Study Assesses Impact of Rising PAD Prevalence in Germany

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A population-based analysis of German patients with peripheral arterial disease (PAD) has found a significant rise in the condition over time, particularly in the subset of patients with critical limb ischemia (CLI). The paper, published online July 17, 2013, ahead of print in the European Heart Journal, predicts that despite decreasing rates of major amputation and overall mortality, the burden of PAD hospitalizations and associated costs will increase dramatically as the population ages.

Researchers led by Nasser Malyar, MD, of the University of Muenster (Muenster, Germany), analyzed nationwide data of all hospitalizations in Germany in 2005, 2007, and 2009, looking at the prevalence of PAD, comorbidities, endovascular and surgical revascularizations, major (above the ankle) and minor (below the ankle) amputations, in-hospital mortality, and associated costs.

PAD Rising, Mortality Somewhat Reduced 

Over the study period, total PAD cases increased by 20.7% (from 400,928 to 483,961), with an increase in the CLI subset from 40.6% to 43.5%. In-hospital endovascular procedures rose by 46%, while the number of thrombectomy/embolectomy, endarterectomy, and plastic patch procedures increased by 67%, 42%, and 21%, respectively.

In 2005, 38,415 major (48%) and minor (52%) amputations were performed, and although the overall number was higher in 2009 (n = 41,458), minor amputations clearly predominated (60%).

The crude overall in-hospital mortality rates for claudicants remained the same between 2005 and 2009 (2.2%), while rates for patients with rest pain or Fontaine IV classification declined slightly (from 5.9% to 5.3% and 9.8% to 8.4%, respectively). More than half of all in-hospital deaths occurred among the Fontaine IV patients. Endovascular revascularization reduced mortality compared with those treated by other methods (1.9% vs. 5.9%). In-hospital mortality was higher in CLI patients compared with claudicants (P < 0.001) and remained unchanged over time, while mortality rates among claudicants rose from 2005 to 2009 (P < 0.01). Lastly, women had slightly higher mortality than men in all PAD stages, with the largest gender difference among those with CLI.

Total reimbursement costs for in-hospital PAD treatment rose roughly 21% from 2007 to 2009. Although CLI patients represented 43.5% of all PAD patients, expenditures for these patients accounted for approximately half (52%) of all PAD reimbursement costs.

Missing Outpatient Information Gives False Impression

“Despite all measures to optimize the public awareness for PAD and to implement primary and secondary preventive measures to optimize the underlying atherosclerotic risk factors,

PAD-related hospitalizations and related costs are dramatically increasing,” Dr. Malyar and colleagues write. The “PAD population remains a subset with an extensively high burden of morbidity and mortality, particularly those patients with CLI.”

In a telephone interview with TCTMD, Christopher J. White, MD, of Ochsner Heart and Vascular Institute (New Orleans, LA), expressed surprise at the reported increase in PAD rates. “I don’t think that’s real. I don’t think that all of the sudden a whole bunch of patients have caught PAD. I think what they may be doing is identifying patients who haven’t been identified before because they have this [diagnosis-related group classification],” he said. Another reason, he suggested, might be the relationship between age and PAD, given that people are living longer.

A significant limitation of the study is that only in-patients were analyzed, the authors acknowledge, so the size of the out-patient (ambulatory) PAD population and its economic impact remain unknown, they observe. “However, it is conceivable, that [the] out-patient population and particularly the PAD-related out-of-hospital costs considerably add to the de facto epidemiological and economic burden that is posed by PAD to the German health care system.”

Dr. White focused on this omission, saying that a result is that the majority of claudicants are not included in the analysis. “They notice that the mortality for claudicators went up, but we would never admit a claudicator,” he said. “So if somebody was in the hospital for claudication, there was something else going on to make them sick enough to be in the hospital.”

Including out-patients would have led to a “truer look at the changing risk of mortality,” Dr. White continued. “For example, no out-patient gets an amputation. A lot of people get treated who never need an amputation, so they’re not counted. When you start looking at mortality per procedure, it’s a little bit of a skewed population.”

Minor Amputations Not ‘Relevant’

Regarding amputation rates, Dr. Malyar and colleagues call the increasing trend toward minor amputations “alarming,” saying that it warrants “every effort to reduce these numbers.”

However, Dr. White explained that increasing minor amputations are a direct result of decreasing major amputations. “Most people don’t count minor [amputations because they] are not that relevant, they don’t point to the direction of health care,” he said. “Whereas if you can cut down on major amputations, you keep people walking, you keep people’s knees attached, you are doing a lot of very useful things for your patients. The real goal is [to reduce] major amputation.”

Noting that the most recent study data are already 4 years old, Dr. White estimated that the positive trends seen have been “accelerating” more recently, especially with the advent of DES use in the leg. Also, many vascular surgeons have been trained in endovascular techniques in the last few years, he added. “That makes a big change in how we treat people . . . because the operation itself is morbid.”

All Comes Back to Reimbursement

The authors also cite increasing reimbursement costs as a major issue. “When comparing costs among diverse vascular fields, patients with PAD have been shown to have the highest hospitalization and total annual costs,” they write. “The higher costs in CLI patients compared with claudicants can be attributed to the extensive therapeutic measures in this subset.”

“However, our data alongside . . . previously published data from [US] Medicare databases demonstrate that even patients with asymptomatic PAD create a significant health economic burden, which has been shown to be mainly due to myocardial and cerebral ischemic events,” they continue.

Dr. White likened the German health care setting to that of the United States in that physicians are incentivized to be “more aggressive in the peripheral vasculature.” US surgeons “have learned that if they don’t learn how to put in stents, then the patients all come to the cardiologists,” he said. “That was a tremendous energizing force for the vascular surgeons in the US to train and learn the stenting techniques so now when they see patients they have options. Patients would all really like to avoid surgery.”

Study Details

Compared with asymptomatic patients and claudicants, CLI patients were older—about half were older than 75 years—and were more likely to be female. There was a marked increase in the prevalence of diabetes among all PAD stages, particularly among those with CLI. 

 

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Source:
Malyar N, Fürstenberg T, Wellmann J, et al. Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: A nationwide population-based analysis. Eur Heart J. 2013;Epub ahead of print.

 

 

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