Delays to revascularization for patients with chronic limb-threatening ischaemia

Abstract

Background Vascular services in England are organized into regional hub-and-spoke models, with hubs performing arterial surgery. This study examined time to revascularization for chronic limb-threatening ischaemia (CLTI) within and across different care pathways, and its association with postrevascularization outcomes. Methods Three inpatient and four outpatient care pathways were identified for patients with CLTI undergoing revascularization between April 2015 and March 2019 using Hospital Episode Statistics data. Differences in times from presentation to revascularization across care pathways were analysed using Cox regression. The relationship between postoperative outcomes and time to revascularization was evaluated by logistic regression. Results Among 16 483 patients with CLTI, 9470 had pathways starting with admission to a hub or spoke hospital, whereas 7013 (42.5 per cent) were first seen at outpatient visits. Among the inpatient pathways, patients admitted to arterial hubs had shorter times to revascularization than those admitted to spoke hospitals (median 5 (i.q.r. 2–10) versus 12 (7–19) days; P < 0.001). Shorter times to revascularization were also observed for patients presenting to outpatient clinics at arterial hubs compared with spoke hospitals (13 (6–25) versus 26 (15–35) days; P < 0.001). Within most care pathways, longer delays to revascularizsation were associated with increased risks of postoperative major amputation and in-hospital death, but the effect of delay differed across pathways. Conclusion For patients with CLTI, time to revascularization was influenced by presentation to an arterial hub or spoke hospital. Generally, longer delays to revascularization were associated with worse outcomes, but the impact of delay differed across pathways.

Evaluation of the ICD-10 system in coding revascularisation procedures in patients with peripheral arterial disease in England: a retrospective cohort study using national administrative and clinical databases

“…To overcome the lack of specific diagnostic codes for CLTI, studies using HES data to evaluate outcomes after revascularisation procedures have used a combination of the urgency of admission variable and codes relating to PAD overall or signs of the disease, such as ulcers and gangrene, as a proxy for the severity of the disease in risk-adjustment models. 3 Our study found that using the emergency mode of admission and ICD-10 codes corresponding to PAD had high specificity but low sensitivity of diagnosing chronic limb-threatening ischaemia. This approach has two important limitations.…”

“…Data about the care received by patients with PAD are available within the Hospital Episode Statistics (HES) Admitted Patient Care (APC) database, an administrative database that contains information about all admissions to National Health Service (NHS) hospitals in England. 2 HES has been used by various studies to evaluate patterns of care for patients with PAD who undergo revascularisation, such as time to surgery 3 and postoperative outcomes. 4 , 5 A benefit of HES is its comprehensive coverage and its linkage with the Office for National Statistics (ONS) death registry.…”

Health Related Quality of Life in patients undergoing Lower Limb Amputation secondary to Peripheral Arterial Disease

“…Interestingly, only thirty percent of interviewed patients had a secondary amputation indicating delayed presentation to medical facilities demonstrating the paucity of awareness regarding vascular diseases. This is concerning since delayed revascularization has been associated with a higher chance of postoperative amputation 29 . A cohort study of limb ischemia from Aga Khan University demonstrates that non-referral by primary physician is the main reason for late presentation 30 .…”

The symptom to assessment pathway for suspected chronic limb-threatening ischaemia (CLTI) affects quality of care: a process mapping exercise

“…CLTI is associated with an increased risk of major limb amputation and mortality2–4 and urgent treatment is required for an optimal prognosis. However, studies examining the care pathway from first symptom to intervention have described how delays can occur at each stage of the process,5 starting with the identification and referral of patients with CLTI6 and also at the time of assessment by vascular services 7.…”