Costing report - Nice

National costing report: Lower limb peripheral arterial disease (August 2012) 1 of 24

Costing report

Lower limb peripheral arterial disease

Implementing NICE guidance

NICE clinical guideline 147

August 2012


This costing report accompanies the clinical guideline: ‘Lower limb peripheral arterial disease: diagnosis and management’ (available online at www.nice.org.uk/guidance/CG147).

Issue date: August 2012

This guidance is written in the following context

This report represents the view of NICE, which was arrived at after careful consideration of the available data and through consulting with healthcare professionals. It should be read in conjunction with the NICE guideline. The report is an implementation tool and focuses on the recommendations that were considered to have a significant impact on national resource utilisation.

Assumptions used in the report are based on assessment of the national average. Local practice may be different from this, and the impact should be estimated locally.

Implementation of the guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement this guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in the costing assessment should be interpreted in a way that would be inconsistent with compliance with those duties

National Institute for Health and Clinical Excellence Level 1A City Tower Piccadilly Plaza Manchester M1 4BT

www.nice.org.uk

© National Institute for Health and Clinical Excellence, 2012. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE.


Contents

Executive summary .......................................................................................... 4

Potential resource-impact recommendations .......................................... 4

Costs and savings ................................................................................... 4

1 Introduction .............................................................................................. 5

1.1 Supporting implementation ........................................................... 5

1.2 What is the aim of this report? ...................................................... 5

1.3 Epidemiology of lower limb peripheral arterial disease ................. 5

1.4 Current service provision .............................................................. 7

2 Costing methodology ............................................................................... 8

2.1 Process ........................................................................................ 8

2.2 Scope of the cost-impact analysis ................................................ 9

3 Analysis of the potential resource impact .............................................. 10

3.1 Secondary prevention of cardiovascular disease in people with

peripheral arterial disease ..................................................................... 11

3.2 Imaging for revascularisation ..................................................... 14

3.3 Supervised exercise programmes .............................................. 16

3.4 Major amputation of a lower limb................................................ 18

3.5 Benefits and savings .................................................................. 21

4 Impact of guidance for commissioners .................................................. 21

5 Conclusion ............................................................................................. 21

Appendix A. Approach to costing guidelines .................................................. 23

Appendix B. References ................................................................................ 24


Executive summary

This costing report looks at the resource impact of implementing the NICE

guideline ‘Lower limb peripheral arterial disease: diagnosis and management’

in England.

The costing method adopted is outlined in appendix A; it uses the most

accurate data available, was produced in conjunction with key clinicians, and

reviewed by clinical and financial professionals.

Potential resource-impact recommendations

This report focuses on the recommendations that are likely to have the

greatest resource impact and therefore require the most additional resources

to implement or can potentially generate the biggest savings. They are:

secondary prevention of cardiovascular disease in people with peripheral

arterial disease

imaging for revascularisation

supervised exercise programmes

major amputation of a lower limb.

Because of the variation in current practice and insufficient data, a national

resource impact is not provided. This report discusses the potential costs and

savings that need to be considered at a local level. A local costing template

has been developed to help organisations calculate the local resource impact.

Costs and savings

A national estimate of costs or savings of implementing the guideline is not

provided due to the degree of uncertainty. However, any initial costs

associated with interventions aimed at secondary prevention of cardiovascular

disease and supervised exercise programmes may be exceeded by savings

from increased management in primary care, fewer amputations and a

reduction in cardiovascular episodes such as myocardial infarction and stroke.


1 Introduction

1.1 Supporting implementation

1.1.1 The NICE clinical guideline on lower limb peripheral arterial disease

is supported by the following implementation tools available on our

website www.nice.org.uk/CG147:

a costing report; this document

a local costing template

shared learning examples

online learning module for GPs

baseline assessment tool; assess your baseline against the

recommendations in the guidance in order to prioritise

implementation activity, including clinical audit

clinical audit tool; measure current practice against the guidance

recommendations and identify areas in which practice can be

improved.

1.2 What is the aim of this report?

1.2.1 This report aims to help organisations plan for the financial

implications of implementing NICE guidance.

1.2.2 This report does not reproduce the NICE guideline on lower limb

peripheral arterial disease and should be read in conjunction with it

(see www.nice.org.uk/guidance/CG147).

1.3 Epidemiology of lower limb peripheral arterial

disease

1.3.1 Peripheral arterial disease is a condition in which the arteries that

carry blood to the limbs are narrowed or blocked, most often

because of atherosclerosis. This guideline offers recommendations

on lower limb peripheral arterial disease only.

http://www.nice.org.uk/CG147

http://www.nice.org.uk/CG147


1.3.2 The incidence of peripheral arterial disease increases with age.

Other risk factors include smoking, diabetes mellitus, pre-existing

cardiovascular disease, renal insufficiency and a sedentary

lifestyle. Men are more likely to be affected by peripheral arterial

disease.

1.3.3 The symptoms of peripheral arterial disease include pain on

exercise (intermittent claudication), pain while resting (critical limb

ischaemia), skin ulceration and gangrene. All people with

peripheral arterial disease are at increased risk of mortality,

myocardial infarction and stroke.

1.3.4 Table 1 shows the prevalence in England of peripheral arterial

disease, intermittent claudication and critical limb ischaemia among

people aged 60 years or over.

Table 1 Number of people in England aged 60 years and over with peripheral arterial disease

Proportion of people

Number of people

Population of England 51,573,132

People aged 60 years and over 11,536,529

People aged 60 years or over with peripheral arterial diseasea

20% 2,307,306

People with peripheral arterial disease who have symptoms of intermittent claudicationb

25% 576,826

People with intermittent claudication who are likely to develop critical limb ischaemiaa

20% 115,365

a. Taken from ‘Lower limb peripheral arterial disease: diagnosis and management’ (NICE clinical guideline 147). b. Taken from ‘Cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease’ (NICE technology appraisal guidance 223).

1.3.5 As the prevalence of peripheral arterial disease is significantly

greater in people aged 60 years and over, only this group are

considered in this report.

http://guidance.nice.org.uk/CG147

http://guidance.nice.org.uk/TA223



1.3.6 Peripheral arterial disease is a marker for an increased risk of

potentially preventable cardiovascular events even when it is

asymptomatic. Symptomatic peripheral arterial disease can

significantly impair quality of life through reduced mobility, severe

pain, ulceration and gangrene, and is the largest single cause of

lower limb amputation in the UK.

1.4 Current service provision

1.4.1 The management of peripheral arterial disease is subject to

considerable uncertainty and variation in practice.

1.4.2 In recent years the provision of vascular services has changed

because of the development of diagnostic methods, the emergence

of new endovascular treatments and organisational changes.

1.4.3 Current treatments include watchful waiting, medical management,

exercise training, endovascular treatment and surgical

reconstruction. The trend is towards less invasive treatment.

1.4.4 Exercise is often advised for people with intermittent claudication.

However, access to supervised exercise programmes is variable

and many are not funded by the NHS. In addition, the uptake of

such programmes can be low.

1.4.5 Drug treatment is used to treat people with intermittent claudication,

either for secondary prevention or specifically for the treatment of

symptoms. Cilostazol, naftidrofuryl oxalate, pentoxifylline and

inositol nicotinate for the treatment of intermittent claudication in

people with peripheral arterial disease (NICE technology appraisal

guidance 223) includes recommendations on drug treatment.

1.4.6 Mild symptoms are managed in primary care, but people

experiencing more severe symptoms that decrease quality of life

are referred to secondary care to be assessed for endovascular or

surgical treatments.





1.4.7 There has been a move away from invasive investigations for

people who are referred to secondary care, with catheter

angiography being replaced by duplex ultrasonography, magnetic

resonance angiography or computed tomography angiography.

Treadmill walking tests and segmental pressures are other

commonly used investigations.

1.4.8 Endovascular treatments include balloon angioplasty, endovascular

stents and a range of new adjunct or alternative treatments and

techniques such as drug-eluting stents, modified balloons, laser

angioplasty, atherectomy, cryotherapy and brachytherapy.

1.4.9 Surgical reconstruction may be carried out to unblock or bypass

occluded or narrowed arteries.

1.4.10 There has been a recent trend towards increasing

subspecialisation of vascular surgery and this is likely to continue.

The increasing development of multidisciplinary teams is likely to

accompany this, and such teams will already be available in many

of the centres that currently provide a full vascular service. There

will continue to be a small number of centres where there are

general surgeons with a vascular interest working in relative

isolation. These centres may be affected to a greater extent by the

recommendations in the guideline, as more changes to practice are

likely to be needed to allow multidisciplinary working.

2 Costing methodology

2.1 Process

2.1.1 We use a structured approach for costing clinical guidelines (see

appendix A).

2.1.2 We have to make assumptions in the costing report. These are

tested for reasonableness with members of the Guideline


Development Group (GDG) and key clinical practitioners in the

NHS.

2.2 Scope of the cost-impact analysis

2.2.1 The guideline offers best practice advice on the diagnosis and

management of lower limb peripheral arterial disease.

2.2.2 The guideline does not cover:

acute ischaemia of the lower limb

methods of amputation

rehabilitation after amputation

management of diabetic foot problems

use of topical treatments and dressings.

Therefore, these issues are outside the scope of the costing work.

2.2.3 Rather than cost each individual recommendation, costing work

has focused on the areas that will potentially need the most

resources to implement or generate the biggest savings. These

areas were determined in discussion with the clinical guideline

project team and the members of the GDG.


3 Analysis of the potential resource impact

Table 2 Analysis of the potential resource impact of recommendations

Recommendation type

Recommendation numbers

Expected to have a resource impact?

Information requirements

1.1.1–1.1.2 Information provision is expected to form part of routine healthcare practice. Any impact on time and resource use is expected to be minimal and would be likely to be offset by an improvement in quality of life.

Secondary prevention of cardiovascular disease in people with peripheral arterial disease

1.2.1 See section 3.1 below.

Diagnosis 1.3.1–1.3.3 There are not expected to be significant costs associated with implementing the recommendations on diagnosis. Ankle brachial pressure index is typically performed by a practice nurse or podiatrist while taking a clinical history. It may add between 5 and 15 minutes to the time needed for the clinical examination. The Guideline Development Group considered the incremental resource needs associated with measuring ankle brachial pressure index to be small compared with the benefit of accurately identifying people with suspected peripheral arterial disease. Accurate diagnosis would be expected to improve quality of life and reduce costs by ensuring that the person’s condition is managed appropriately.

Imaging for revascularisation

1.4.1–1.4.3 See section 3.2.

Management of intermittent claudication

1.5.1–1.5.8 In general, the recommendations in this section are not expected to be significantly different from current practice. However, there will be some degree of regional variation and there will be differences between larger centres that provide a full vascular service and smaller units. The recommendation on supervised exercise is discussed in section 3.3.

Management of critical limb ischaemia

1.6.1–1.6.11 The recommendations on multidisciplinary teams and revascularisation are not expected to be


significantly different from current practice. However, there will be some variation between larger centres that provide a full vascular service and smaller units. Vascular multidisciplinary teams currently exist in many organisations and therefore it is expected that new teams will not need to be formed to implement the recommendation relating to this. However, more formal network meetings and increased communication between existing staff may be needed. Drug treatment included in the recommendations is not expected to be significantly different from current practice. Chemical sympathectomy is not considered here as it is recommended in the context of clinical trials only.

See section 3.4 for discussion about the costs of major amputation.

3.1 Secondary prevention of cardiovascular disease in

people with peripheral arterial disease

Recommendation 1.2.1

Offer all people with peripheral arterial disease information, advice, support

and treatment regarding the secondary prevention of cardiovascular disease,

in line with published NICE guidance on:

smoking cessation

diet, weight management and exercise

lipid modification and statin therapy

the prevention, diagnosis and management of diabetes

the prevention, diagnosis and management of high blood pressure

antiplatelet therapy.

Background

3.1.1 Peripheral arterial disease is strongly associated with

cardiovascular disease, and the modifiable and non-modifiable risk

factors are the same for both conditions. Many people with

peripheral arterial disease will have evidence of cardiovascular


disease, and people diagnosed with peripheral arterial disease are

at high risk of further cardiovascular events such as stroke and

myocardial infarction.

3.1.2 Treatments for secondary prevention of cardiovascular disease are

less commonly offered to people with peripheral arterial disease

than to people with other cardiac and cerebrovascular risk factors.

3.1.3 The GDG recognised that there are existing NICE

recommendations covering the secondary prevention of

cardiovascular disease that are relevant for people with peripheral

arterial disease. These recommendations should be applied when

treating people with peripheral arterial disease to avoid

inconsistency.

3.1.4 Appropriate and consistent implementation of NICE

recommendations on the secondary prevention of cardiovascular

disease may have a high impact on patient outcomes and help to

reduce variations in care and outcome.

Potential costs

3.1.5 There may be additional costs associated with providing the

infrastructure for information, advice, support and treatment

because of staff time, materials, drug costs and other services.

3.1.6 The approximate numbers of people likely to need information,

advice, support and treatment for the secondary prevention of

cardiovascular disease in line with existing NICE guidance in each

of the recommended areas is shown in table 3.


Table 3 Prevalence of peripheral arterial disease and number of people who would be affected by the recommendation on secondary prevention of cardiovascular disease

Risk factor Prevalence for people with peripheral arterial disease based on data from 2011/12a (%)

Approximate number of people aged 60 years or over with peripheral arterial disease plus risk factorb

Smoker 9.7 55,952

Obesity 28.3 163,242

Raised cholesterol 20.0 115,365

Statin therapy 68.3 393,972

Type 2 diabetes 53.9 310,909

High blood pressure 62.9 362,824

Antiplatelet therapy 51.2 295,335 a Prevalence data, based on the ICD-10 definition of peripheral arterial disease, were taken

from the IMS disease Analyzer (Information Centre: unpublished data 2012), which collects data from a sample of GP practice systems. Around 100 are currently delivering data and the database has about 2.7 million patient records, around 0.85 million of which were registered for the whole of the study year (2011/12). b Percentage prevalence applied to the number of people aged 60 years or over with

symptoms of intermittent claudication (576,826 people, taken from table 1).

3.1.7 Some elements of these interventions could be provided in primary

care, reducing costs associated with referring people to vascular

surgical units in secondary care for advice and support. Table 4

shows that an outpatient appointment in secondary care costs

significantly more than an appointment in primary care.

Table 4 Costs of appointments for people with peripheral arterial disease in primary and secondary care

Appointment Cost (£)

Primary care

Surgery appointment with a GP lasting 11.7 minutes 36a

Clinic appointment with a GP lasting 17.2 minutes 53a

Secondary care – Vascular surgery treatment function 107

WF01B first attendance 234b

WF01A follow-up attendance 116b

a From personal social services research unit – unit costs of health and social care 2011

(Curtis, 2011). Includes qualification costs. b From payment by results tariff for 2012/3.


3.1.8 The cost of implementing the recommendation about secondary

prevention of cardiovascular disease is not quantified in this report.

Some people with peripheral arterial disease are likely to be

receiving such information, advice, support and treatment already,

but for many people this could represent a change to current

practice. Local commissioners and providers are advised to

consider current provision of services for secondary prevention of

cardiovascular disease and the varying needs of people with

peripheral arterial disease in order to assess the potential costs of

implementing the recommendation.

3.2 Imaging for revascularisation

Recommendations 1.4.1–1.4.3

Offer duplex ultrasound as first-line imaging to all people with peripheral

arterial disease for whom revascularisation is being considered.

Offer contrast-enhanced magnetic resonance angiography to people with

peripheral arterial disease who need further imaging (after duplex ultrasound)

before considering revascularisation.

Offer computed tomography angiography to people with peripheral arterial

disease who need further imaging (after duplex ultrasound) if

contrast-enhanced magnetic resonance angiography is contraindicated or not

tolerated.

Background

3.2.1 Assessment by diagnostic imaging is indicated in people with

peripheral arterial disease when interventional treatment is being

considered.

3.2.2 The choice of imaging modality used will be influenced by local

expertise and the availability of imaging equipment. Less invasive

and lower cost strategies are generally preferred.


3.2.3 GDG opinion is that the recommendations are likely to reflect

current practice in some centres, although not all centres will offer

imaging techniques in the order set out in the recommendations.

Potential costs

3.2.4 Implementation of the guideline will not result in a resource impact

for many centres, but for some centres there may be implications

for training and the availability of expertise and experience. Costs

associated with these should be determined locally.

3.2.5 The costs of the imaging techniques included in the

recommendations are shown in Table 5. Costs are taken from the

payment by results tariff for 2012/3.

Table 5 Cost of imaging techniques

HRG description HRG code

Cost (£)

Duplex ultrasound

Ultrasound – less than 20 minutes RA23Z 47

Ultrasound – more than 20 minutes RA24Z 63

Contrast-enhanced magnetic resonance angiography

Magnetic Resonance Imaging Scan, one area, pre and post contrast

RA03Z 207

Magnetic Resonance Imaging Scan, two - three areas, with contrast

RA05Z 213

Computed tomography angiography

Computerised Tomography Scan, one area, pre and post contrast

RA10Z 108

Computerised Tomography Scan, two areas with contrast

RA12Z 130

Computerised Tomography Scan, three areas with contrast

RA13Z 144

3.2.6 For people in whom revascularisation may be beneficial, duplex

ultrasound is the least costly and least invasive method of

determining the location and extent of the lesion, and may provide

sufficient information. If the results of duplex ultrasound are not

suitable for planning an intervention, contrast-enhanced magnetic

resonance imaging or computed tomography angiography can

provide more detailed information.


Potential savings

3.2.7 There may be savings in centres that do not currently use duplex

ultrasound for first-line imaging, as this is the least costly method.

3.2.8 The imaging techniques included in the recommendations are

considered by the GDG to be the most cost-effective. The

avoidance of unnecessary reduplication of imaging will save time

and cash resources.

3.3 Supervised exercise programmes

Recommendations 1.5.1–1.5.2

Offer a supervised exercise programme to all people with intermittent

claudication.

Consider providing a supervised exercise programme for people with

intermittent claudication which involves:

2 hours of supervised exercise a week for a 3-month period

encouraging people to exercise to the point of maximal pain.

Background

3.3.1 Supervised exercise is not defined in the recommendations, but is

likely to be a community-based exercise programme supervised by

healthcare professionals.

3.3.2 The GDG agreed that the risks associated with a supervised

exercise programme for people with peripheral arterial disease are

minimal, while the benefits include an increase in walking distance,

quality of life and a decreased risk of cardiovascular events.

3.3.3 Based on experience of GDG members, no more than 30% of

people with intermittent claudication are currently offered the

opportunity to participate in a supervised exercise programme. Of

those who do have the opportunity, less than half choose to join an

exercise programme.


3.3.4 Based on information provided by GDG members, supervised

exercise programmes aimed at people with peripheral arterial

disease are typically supervised by 2 physiotherapists and have

approximately 10 people per group. The programme consists of

approximately 2 hours of classes per week for 3 months in an

outpatient setting. People exercise until the onset of symptoms,

then rest. They may walk on treadmills or outside, complete

circuits, etc. The details are likely to vary between supervised

exercise programmes.

3.3.5 At the end of a programme, people are then encouraged to

exercise independently.

3.3.6 Other exercise programmes also exist and may include different

amounts of support, such as regular telephone calls, an exercise

diary or an education component. The GDG noted that increased

support may encourage people to follow unsupervised exercise

programmes.

Potential costs

3.3.7 Based on information provided by the GDG a typical supervised

exercise programme may have the following costs.

Table 6 Cost of a 3-month supervised exercise programme

Resource Estimated cost for a 1-hour session (£)

Estimated cost for 2 hours a week for 3 months (£)

2 community physiotherapistsa 68 1,768

1 physiotherapist technicianb 22 572

Room hire and rental equipmentc 15 390

Total cost for 10 people 105 2,730

Cost per person 11 273 a From personal social services research unit – unit costs of health and social care 2011

(Curtis, 2011). Includes qualification costs. b. Taken from the health economics section for supervised exercise in the full guideline.

c Based on expert opinion of members of the GDG.

http://guidance.nice.org.uk/CG147/Guidance/pdf/English


3.3.8 The costs included in table 6 are averages. The actual costs of a

supervised exercise programme are likely to vary. The GDG noted

that in some centres only 2 staff members are involved in provision

(1 physiotherapist and 1 physiotherapist technician).

3.3.9 It may also be possible for people with peripheral arterial disease to

participate in community-based cardiac exercise programmes.

However, GDG opinion is that the focus of these programmes is

different from the requirements of people with peripheral arterial

disease, who need to focus on walking problems. There is likely to

be regional variation in the suitability of adapting current cardiac

programmes to meet the needs of people with peripheral arterial

disease. These programmes will also need enough capacity to

accommodate people with peripheral arterial disease. In addition,

some of the cardiac exercise programmes that currently exist are

not funded by the NHS.

Other considerations

3.3.10 People with peripheral arterial disease who are offered access to a

supervised exercise programme should be encouraged to take up

the offer. Consideration should be given to the setting and the

description of the programme, as many people with peripheral

arterial disease may have never participated in cardiovascular

exercise before. It is important that uptake and commitment are

encouraged.

3.4 Major amputation of a lower limb

Recommendation 1.6.11

Do not offer major amputation to people with critical limb ischaemia unless all

options for revascularisation have been considered by a vascular

multidisciplinary team.


Background

3.4.1 Major amputation of a lower limb is defined as amputation of the

leg above the ankle.

3.4.2 Amputation is usually offered when it has been agreed that medical

therapy or revascularisation cannot control critical limb ischaemia.

3.4.3 The decision to amputate and the timing of the procedure depend

upon the wishes of the person and their family. Therefore it is likely

that there will be significant variations in if and when amputation is

performed.

Potential savings

3.4.4 Prompt diagnosis of peripheral arterial disease and then critical

limb ischaemia and referral to a specialist vascular unit that is able

to offer a full range of treatments may avoid the need for

amputation.

3.4.5 After amputation, people will need rehabilitation and limb-fitting

services, for which there are additional costs.

3.4.6 An analysis of hospital episode statistics data for 2010/11 has

shown the number of amputations of the leg during the year. The

OPCS Classification of Interventions and Procedures (OPCS-4)

code specified in the analysis is X09 (‘Amputation of leg’). The

International Classification of Diseases (ICD-10) for peripheral

arterial disease is I73.9 (Peripheral Vascular Disease –

unspecified). Table 7 shows the cost of amputations in the payment

by results tariff for 2012/13 and the number of episodes for each

type of procedure during 2010/11.


Table 7 Costs of amputation procedures

HRG code Description PbR cost (£)

Activity during 2010/11

QZ11A Non-elective amputations with major complications or comorbidities (cc)

16,136 194

QZ11B Non-elective Amputations without cc 10,771 294

QZ11A Elective amputations with cc 15,764 42

QZ11B Elective amputations without cc 8,011 143

Total activity 673

PbR: payment by results.

3.4.7 Based on the data in table 7, the weighted average cost of a leg

amputation is around £12,000.

3.4.8 In addition to the cost of the procedure there are other costs to the

NHS in the year after an amputation that may be around £20,000

(based on information in the health economics section of the full

guideline). These include costs for prosthetic limbs (GDG opinion is

that around 55% of people will have a prosthetic limb after a leg

amputation), rehabilitation and wound care. Therefore the total cost

to the NHS of a leg amputation and care in the first year could be

around £32,000 per person.

3.4.9 Based on GDG opinion, implementing the guideline may result in a

small reduction in the number of amputations performed. It is not

known how many years it would take for such a reduction to occur.

If there was a 5% decrease (34 people) in the number of people

undergoing a major amputation of the leg then there could be an

annual national saving to the NHS of around £1 million. A 10%

decrease (68 people) could result in saving of around £2 million.

Because the number of people affected nationally is small, the local

impact would be variable.

Other considerations

3.4.10 There are a number of other costs associated with the care of a

person after a leg amputation. These include home adaptations,




community care, care homes and wheelchairs. These costs are

likely to be borne by local authority social services departments.

3.5 Benefits and savings

3.5.1 Many people with peripheral arterial disease will have evidence of

cardiovascular disease, and people diagnosed with peripheral

arterial disease are at very high risk of further cardiovascular

events such as stroke and myocardial infarction.

3.5.2 Implementation of the guideline may result in fewer cardiovascular

events for people with peripheral arterial disease. This will provide

savings through a reduced number of admissions.

3.5.3 Quantification of these savings is not provided in this report, as

there are uncertainties around the number of events that may be

avoided and the timescales within which these would occur. Table

8 shows the cost per episode of typical cardiovascular events.

Table 8 Costs of cardiovascular events

HRG code Description Non-elective PbR tariff cost (£)

AA22Z Non-Transient Stroke or Cerebrovascular Accident, Nervous system infections or Encephalopathy

4,208

EB10Z Actual or Suspected Myocardial Infarction 3,436

PbR: payment by results.

4 Impact of guidance for commissioners

4.1.1 The procedures included in the guideline and discussed in this

costing report are included in the payment by results tariff. Costs

fall under budgeting code 10X – Problems of circulation.

5 Conclusion

5.1.1 The guideline offers best practice advice on the care of adults aged

18 years or over with peripheral arterial disease. GDG opinion

suggests there is variation in current practice, and implementation


of the recommendations in the guideline may not result in a

significant change to practice for some centres.

5.1.2 It is not possible to provide a calculation of the national resource

impact of the recommendations with a reasonable degree of

certainty. It is likely that implementing the guideline would result in

some savings overall, although these may take some time to be

realised.

5.1.3 A local costing template has been developed to help organisations

calculate the local resource impact.

5.1.4 Potential areas for additional costs are:

additional time and resources for providing advice, information,

support and treatment for secondary prevention of

cardiovascular disease to an increased number of people

increased provision of supervised exercise programmes.

5.1.5 Potential areas for additional savings are:

changes to imaging techniques used

secondary prevention advice, information and support being

offered in primary care rather than secondary care

reduced number of major amputations of the leg

reduced number of cardiovascular events such as myocardial

infarction and stroke.

5.1.6 NHS organisations and local authorities are advised to assess local

resource implications and the level of costs or savings that may be

expected in their area.


Appendix A. Approach to costing guidelines

Guideline at first consultation stage

Identify key cost drivers – gather information

needed and research cost behaviour

Develop costing report

Internal peer review by qualified accountant

within NICE

Circulate report to cost impact panel and GDG for comments

Update based on feedback and any changes following consultation

Cost-impact review meeting

Final sign-off by NICE

Prepare for publication in conjunction with guideline

Analyse the clinical pathway to identify significant recommendations and population

cohorts affected


Appendix B. References

Curtis L. (2011) Unit Costs of Health & Social Care 2011. The University of

Kent

Department of Health (2011) Payment by Results Guidance 2012–13

National Institute for Health and Clinical Excellence (2011) Cilostazol,

naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of

intermittent claudication in people with peripheral arterial disease. NICE

technology appraisal guidance 223.




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