Objectives: To analyze the cost-effectiveness of early endovenous ablation of superficial venous reflux in patients with venous leg ulcer (VLU) over 65 from a U.S. payer perspective.

Methods: A Markov model was constructed to simulate the progression of VLU for patients receiving compression therapy with early ablation vs. deferred ablation over 3 years from the U.S. payer perspective. The early intervention group receives compression therapy with endovenous ablation performed within two weeks. Patients receiving deferred ablation would have compression therapy alone, and defer the ablation until the ulcer heals, or after 6 months if the ulcer does not heal. The model inputs were sourced from the Early Venous Reflux Ablation trial, published literature, and data from U.S. Medicare. We considered probability of healing, probability of recurrence, direct medical costs, and quality-adjusted life years (QALY) impacted by VLU. We calculated the incremental net monetary benefit (NMB) at a willingness-to-pay threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses tested model uncertainty.

Results: Early ablation was a dominant strategy at a per-patient cost of $12,527 and 2.01 QALYs gained, whereas compression therapy with deferred ablation resulted in $15,208 and 1.98 QALYs gained per patient. At $100,000/QALY, the incremental NMB was $5,226 per-patient. Probability of healing, followed by the probability of recurrence, were the parameters with greatest impact on model uncertainty. The probabilistic sensitivity analysis showed that early ablation was cost-effective in 59.2% simulations at a threshold $100,000/QALY.

Conclusions: Compression therapy with early endovenous ablation was the dominating strategy as it was cost-saving while generating greater QALYs over a 3-year time horizon from the U.S. payer perspective. Payers should consider prioritizing early ablation on their formulary to prevent VLU complications rather than treat a costly outcome that also reduces patient health-related quality of life.