1. Background:
 Despite being associated with substantial clinical
and economic burdens, as well as adverse effects
on quality of life, lower extremity amputations
(LEAs) are quite common in the United States
(US).1-2
 Nearly 85% of LEAs are above the foot and/or
ankle.3
 Peripheral Artery Disease (PAD) is responsible for
the majority of these amputations.4 Critical limb
ischemia (CLI) is the most advanced form of PAD
with the average amputation rate among PAD-CLI
patients estimated at 25%.5
 Even with multiple endovascular strategies as
alternative options, many CLI patients receive a
LEA as first-line treatment.6
 Limb salvage programs provide an alternative
treatment care pathway for PAD-CLI patients
aimed at preventing LEAs. Moreover, limb salvage
procedures may reduce costs while improving
patient outcomes.
Objective:
 To estimate the potential lifetime economic
savings to a third party payer from the
implementation of a limb salvage program in
the US.
Methods:
 A simulation model was developed in MS Excel to
estimate the direct healthcare cost of
implementing a limb salvage program in the US
for all CLI patients.
 The model was from a third party payer
perspective.
 It was assumed that all the patients undergoing
amputation will be eligible for the limb salvage
program.
 Clinical endpoints were as follows:
– Number of amputations performed
annually1-2 and
– LEA reduction rate associated with a limb
salvage program.
 Cost parameters included:
– Lifetime direct amputation burden and
– Limb salvage program cost estimates.
 All parameter values were obtained from the
published literature and adjusted to 2016 dollars
using the Medical Care Component of the
Consumer Price Index.
Impact of a Limb Salvage Program on the Economic
Burden of Amputation in the United States
Swetha R. Palli, MS1; Candace Gunnarsson, EdD1; Harry Kotlarz, MBA2; Brad J. Martinsen, PhD2; Ruizhi Zhao PhD Candidate2;
John A. Rizzo, PhD3
[1] CTI Clinical Trial and Consulting Services, Cincinnati, OH; [2] Cardiovascular Systems, Inc., St Paul, MN; [3] Stony Brook University, Stony Brook, NY
Figure 1: Comprehensive Limb Salvage Program
Conclusion:
 The lifetime economic burden of amputees is
substantial. A national limb salvage program
may reduce this burden by $55.3 ($31.5 to
$79.2) billion.
 Policy efforts aimed at limb sparing treatments
for PAD patients may lead to substantial cost
savings while enhancing patients’ quality of life.
References:
1. Wier LM, Steiner CA, Owens PL. Surgeries in Hospital-Owned Outpatient Facilities,
2012. Health Care Cost and Utilization Project. Statistical Brief. 2015; 188.
2. Centers for Disease Control. National Diabetes Statistics Report, 2014. Accessed on
March 10, 2016 at: http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-
report-web.pdf.
3. Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs
among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil.
2005; 86(3):480-6.
4. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R.
Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys
Med Rehabil. 2008; 89(3):422-9.
5. Henry AJ, Hevelone ND, Belkin M, Nguyen LL. Socioeconomic and hospital-related
predictors of amputation for critical limb ischemia. J Vasc Surg. 2011; 53(2):330-9.
6. Jindeel A, Narahara KA, Nontraumatic amputation: incidence and cost analysis. Int J
Low Extrem Wounds. 2012; 11(3):177-9.
7. MacKenzie EJ et al. Health-care costs associated with amputation or reconstruction of
a limb-threatening injury. J Bone Joint Surg Am. 2007; 89(8):1685-92.
8. Sanders LJ, Robbins JM, Edmonds ME. History of the team approach to amputation
prevention: pioneers and milestones. J Vasc Surg. 2010 Sep;52(3 Suppl):3S-16S.
Please contact the authors for information on additional references.
• Evaluation (e.g., ankle branchial index tests)
• Imaging
• Angiography
• Ultrasound
• Angioplasty w/without stents or atherectomy
• Follow-up evaluation and management
Pre-procedure
Endovascular procedure
Post-procedure
Figure 2: Model Scaffold and Parameters
# of Amputations
Lifetime Amputee
Burden
Total Burden
Comprehensive Limb
Salvage Program
Cost/Patient
Limb Salvage
Rate
Lifetime Cost
Savings
Limb Salvage
Rate
Lifetime Cost
Savings
120,000
$794,027
$95.2 Bil
36%
$31.5 Bil
86%
$79.2 Bil
$23,152
Study Support: This study was supported by Cardiovascular Systems, Inc., CSI
Poster presented at ISPOR 21st Annual International Meeting, May 21-25, 2016, Washington, DC USA
Results:
 Approximately 120,000 (119,700 to 121,667) LEA
procedures are performed annually in the US.1-2
 The estimated lifetime direct healthcare cost for
an amputee patient is $794,027.7
 When aggregated for the total number of LEA
patients annually, the expected lifetime cost is
estimated at roughly $95.2 billion USD.
 In the published literature, comprehensive limb
salvage programs are shown to reduce the rate
of amputations from 36% to 86%.8
 Using the midpoint of this reduction (61%) and
accounting for the estimated cost of a
comprehensive limb salvage program ($23,152)
yields aggregate cost savings of $55.3 billion.
(Additional details about the limb salvage
program can be found in Figure 1).
 The reduction in amputations from a formal limb
salvage program is expected to save CMS from
$31.5 billion assuming a 36% salvage rate to
$79.2 billion assuming an 86% salvage rate (See
Figure 2 for more information on the model
calculation).