With also known to be a heavy smoker prior

With reference to the
supporting evidence base, appraise the clinical and/or cost effectiveness of
an investigative method, procedure, treatment or management approach utilized
in this case.
 
One U.K study5 investigated the breakdown
of cost for the different management options over a period of 12 months:
revascularisation equalled £3,970, angioplasty £6,611, reconstruction £6,766
and amputation £10,162. The reason behind the increased cost for amputation is
ultimately due to the longer inpatient care requirements and the necessity for
support in the community. With the average cost of amputation being close to double10
that of limb salvage procedures, this may well justify an aggressive
revascularisation scheme.
However, in order to maintain this lower
expenditure, it will require continuous long-term monitoring to ensure the
graft remains patent11. Yet, in the non-compliant patient such as
Mr A with the addition of extensive co-morbidities, failure will likely ensue
and the cost of repeated salvage procedures will inevitably overshadow
amputation cost. Thus meaning treatment cost effectiveness is better
determined on a case-by-case basis, exploring factors that may increase the
risk of repeat procedures3. Furthermore, earlier amputation may
allow patients to keep more of their limb in the long-term if repeated
revascularisation attempts fail, thus leading to eventual loss of more of the
limb.
As aforementioned, Mr A had a failed bypass graft
and was also known to be a heavy smoker prior to his amputation. One study12
explored the relationship of smoking and graft patency and found a threefold
increase of graft failure in current smokers. Cost effectiveness, purely in
isolation, could argue that certain lifestyle factors should influence alternative
management pathways in the prevention of irresponsible financial expenditure
i.e. earlier amputation.
On
the other hand, major amputation is strongly associated with high rates of
perioperative mortality and morbidity, increasing the cost of treatment. In
comparison to revascularization, a retrospective study13 found that
amputation carried a 20-37% rate of complications whereas revascularization
only accounted for a rate of 5-9% in the same time frame. The most significant
complication was wound infection at a rate of 10-30%, potentially leading to
secondary amputation, especially in diabetic and/or patients who smoke.
Furthermore, amputation carries the financial strain of potentially long-term
community care, rehabilitation and the cost of prosthetic limb fitting. Successful
revascularisation might be more cost effective toward society, in terms of
returning to employment, but this could also be said for successful limb
fitting post amputation. In summary, cost and clinical effectiveness can generally
only be measured retrospectively on an individual basis.

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