Improving major amputation rates in the multicomplex diabetic foot patient: focus on the severity of peripheral arterial disease

Brechow, Andrej; Slesaczeck, Torsten; Münch, Dirk; Nanning, Thomas; Paetzold, Hartmut; Schwanebeck, Uta; Bornstein, Stefan R.; Weck, M

doi:10.1177/2042018813489719

Cited by 38 publications

(61 citation statements)

References 43 publications

(79 reference statements)

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“…In patients undergoing amputations, decreased ABI and transcutaneous oxygen pressure (both measurements of severity of PVD) have been shown to predict poor wound healing and increased level of primary amputation or reamputation. 17,18 Though our data only demonstrated a trend towards statistical significance, diabetes adversely affects wound healing and resistance to infection and also may contribute to readmissions in this patient population. Although it has been suggested that efforts to improve mobility may help to lower readmission rates, it is unclear the degree to which this strategy can overcome the inherent limitations of chronic comorbid conditions.…”

Section: Discussionmentioning

confidence: 52%

Rates and predictors of readmission after minor lower extremity amputations

Beaulieu

Grimm

Lyu

et al. 2015

Journal of Vascular Surgery

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OBJECTIVES One goal of the Patient Protection and Affordable Care Act is to reduce hospital readmissions, with financial penalties applied for excessive rates of unplanned readmissions within 30 days among Medicare beneficiaries. Recent data indicate that as many as 24% of Medicare patients require readmission following vascular surgery, although the rate of readmission following limited digital amputations has not been specifically examined. The present study was therefore undertaken to define the rate of unplanned readmission among patients following digital amputations, and to identify the factors associated with these readmissions to allow the clinician to implement strategies to reduce readmission rates in the future. METHODS The electronic medical and billing records of all patients undergoing minor amputations (defined as toe or transmetatarsal (TMA) amputations using ICD-9 codes from January 2000 through July 2012 were retrospectively reviewed. Data was collected for procedure, hospital-related variables, level of amputation, length of stay, time to readmission, level of re-amputation, and patient demographics including hypertension, diabetes, hyperlipidemia, smoking history, and history of myocardial infarction, congestive heart failure, PAD, COPD, and CVA. RESULTS Minor amputations were performed in 717 patients (62.2% male), including toe amputations in 565 (72.8%) and TMAs in 152 (19.5%). Readmission occurred in 100 (13.9 %) patients, including 28 within 30 days (3.9%), 28 between 30 and 60 days (3.9%) and 44 (6.1%) more than 60 days after the index amputation. Multivariable analysis revealed that elective admission (P<.001), PAD (P<.001) and chronic renal insufficiency (P=.001) were associated with readmission. The reasons for readmission were infection (49%), ischemia (29%), and non-healing wound (19%) and indeterminate (4%). Reamputation occurred in 95 (95%) of the readmitted patients, including limb amputation in 64 (64%) patients (below knee in 58, through knee in 2, and above knee in 4). CONCLUSION Readmission following minor amputation was associated with limb amputation in the majority of cases. Readmission following minor lower extremity amputation was affected by chronic renal insufficiency, history of peripheral artery bypass and manner of presentation, calling into question the ability of the surgeon to acutely mitigate readmission rates. As nearly half of the readmissions were for infection, this may represent an area for multi-disciplinary management to reduce readmission and subsequent reamputation rates. Further research is needed to establish evidence-based guidelines for acceptable readmission rates, especially in the era of increasing financial scrutiny for such occurrences.

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Section: Discussionmentioning

confidence: 52%

Rates and predictors of readmission after minor lower extremity amputations

Beaulieu

Grimm

Lyu

et al. 2015

Journal of Vascular Surgery

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“…From 9476 titles and abstracts, 156 articles were selected for full‐text review (Figure ). Of these, a total of 11 studies reporting on 5890 patients met the inclusion criteria and were included in the qualitative data synthesis (online Table 1, Appendix of the online data supplement). Most studies ( n = 7) were prospective; the remainder were retrospective ( n = 1), or did not specify ( n = 3) .…”

Section: Resultsmentioning

confidence: 99%

“…The mean or median age of cohorts studied ranged between 61 and 76 years; the proportion of men ranged between 59% and 74%. Seven studies reported on purely ulcerated patients, while two studies included patients with either active ulceration or gangrene at baseline . One study investigated the prognostic performance of PAD measures in patients with foot infection and/or ischemia (Fontaine III/IV).…”

Section: Resultsmentioning

confidence: 99%

“…One study investigated the prognostic performance of PAD measures in patients with foot infection and/or ischemia (Fontaine III/IV). Among studies involving patients with diabetic foot ulceration, a severity assessment was reported in five, and the proportion of patients with Wagner grade ≥3 ranged from 16% to 61% (median 51%). Five studies failed to report any indication of ulcer severity.…”

Section: Resultsmentioning

confidence: 99%

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Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review

Brownrigg

Hinchliffe

Apelqvist

et al. 2016

Diabetes Metabolism Res

115

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Prediction of wound healing and major amputation in patients with diabetic foot ulceration is clinically important to stratify risk and target interventions for limb salvage. No consensus exists as to which measure of peripheral artery disease (PAD) can best predict outcomes. To evaluate the prognostic utility of index PAD measures for the prediction of healing and/or major amputation among patients with active diabetic foot ulceration, two reviewers independently screened potential studies for inclusion. Two further reviewers independently extracted study data and performed an assessment of methodological quality using the Quality in Prognostic Studies instrument. Of 9476 citations reviewed, 11 studies reporting on 9 markers of PAD met the inclusion criteria. Annualized healing rates varied from 18% to 61%; corresponding major amputation rates varied from 3% to 19%. Among 10 studies, skin perfusion pressure ≥40 mmHg, toe pressure ≥30 mmHg (and ≥45 mmHg) and transcutaneous pressure of oxygen (TcPO 2 ) ≥25 mmHg were associated with at least a 25% higher chance of healing. Four studies evaluated PAD measures for predicting major amputation. Ankle pressure <70 mmHg and fluorescein toe slope <18 units each increased the likelihood of major amputation by around 25%. The combined test of ankle pressure <50 mmHg or an ankle brachial index (ABI) <0.5 increased the likelihood of major amputation by approximately 40%. Among patients with diabetic foot ulceration, the measurement of skin perfusion pressures, toe pressures and TcPO 2 appear to be more useful in predicting ulcer healing than ankle pressures or the ABI. Conversely, an ankle pressure of <50 mmHg or an ABI <0.5 is associated with a significant increase in the incidence of major amputation.

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“…Foot ulcers are one of the major health concerns and hospitalization among patients with diabetes, worldwide. In the USA, the yearly price of foot ulcers is estimated at US$11 billion (Brechow et al, 2013). In Brazil, the population 30 years old and over with type 2 diabetes is calculated at 6.5 million.…”

Section: Diabetic Foot Infectionsmentioning

confidence: 99%