Variation in the Use of Lower Extremity Vascular Procedures for Critical Limb Ischemia

Abstract

Background Many believe that variation in vascular practice may affect limb salvage rates in patients with severe PAD. However, the extent of variation in procedural vascular care obtained by patients with critical limb ischemia (CLI) remains unknown. Methods and Results Using Medicare 2003–2006, we identified all patients with CLI who underwent major lower extremity amputation in the 306 hospital referral regions (HRRs) described in the Dartmouth Atlas of Healthcare. For each patient, we studied the use of lower extremity vascular procedures (open surgery or endovascular intervention) in the year prior to amputation. Our main outcome measure was the intensity of vascular care, defined as the proportion of patients in the HRR undergoing vascular procedure in the year before amputation. Overall, 20,464 patients with CLI underwent major lower extremity amputations during the study period, and collectively underwent 25,800 vascular procedures in the year prior to undergoing amputation. However, these procedures were not distributed evenly − 54% of patients had no vascular procedures performed in the year prior to amputation, 14% underwent 1 vascular procedure, and 21% underwent more than one vascular procedure. In the regions in the lowest quintile of vascular intensity, vascular procedures were performed in 32% of patients. Conversely, in the regions in the highest quintile of vascular intensity, revascularization was performed in 58% of patients in the year prior to amputation (p<0.0001). In analyses accounting for differences in age, sex, race, and comorbidities, patients in high intensity regions were 2.4 times as likely to undergo revascularization in the year prior to amputation than patients in low intensity regions (adjusted OR=2.4, 95% CI 2.1–2.6, p<0.001). Conclusions Significant variation exists in the intensity of vascular care provided to patients in the year prior to major amputation. In some regions, patients receive intensive care, while in other regions, far less vascular care is provided. Future work is needed to determine the association between intensity of vascular care and limb salvage.

Worth an Arm and a Leg: The Critical Importance of Limb Ischemia

“…Prior data suggest that a substantial number of individuals with CLI do not undergo any revascularization attempt before amputation,17 confirmed in the present analysis. Education about the importance of revascularization for limb salvage among primary care practitioners and ancillary services, like podiatry, are critical to improve outcomes for this condition.…”

Determinants of Long‐Term Outcomes and Costs in the Management of Critical Limb Ischemia: A Population‐Based Cohort Study

“…Allie et al23 reported that 51% of CLI patients had no diagnostic vascular evaluation preceding primary amputation. Goodney et al10 reported that 54% of patients with CLI had no vascular procedures in the year before undergoing amputation. In the current study, 51% of patients undergoing primary major amputation received no previous revascularization.…”

“…Patients were included if CLI diagnosis was made between January 1, 2011 and December 31, 2011, they had continuous coverage from January 1, 2010 to December 31, 2011, and they did not have a CLI diagnosis code in 2010 (eg, patients had no CLI diagnosis during at least the past 12 months). Utilization of a 12‐month stable diagnosis period is common in Medicare claims analyses of CLI patients 9, 10. Patients were followed through September 30, 2015, which corresponds to the date of the transition from ICD‐9‐CM to International Classification of Diseases, Tenth Revision, Clinical Modification ( ICD‐10‐CM ) codes.…”

A perifériás verőérbetegséggel és a cukorbetegséggel összefüggő alsó végtagi amputációk. Epidemiológiai adatok bemutatása és a megelőző stratégia lehetőségeinek elemzése

“…Egy, a 2000-es évek második felében végzett vizsgálat azt mutatta, hogy nemcsak az alsó végtagi amputációk incidenciája külön-bözik jelentősen az egy országon belüli régiók összeha-sonlításában, hanem az elszenvedett amputációs esemé-nyeket megelőző egy évben, végtagmentés céljából végzett revascularisatiós beavatkozások előfordulása is jelentősen eltér. Az egyes régiókat tekintve e beavatkozá-sok gyakorisága 32-58% között volt [41]. Az amputációs trendek és a revascularisatiós beavatkozások gyakorisága között inverz kapcsolatot találtak.…”

“…Ezt az anatómiai helyzet technikai aspektusán túl a kiterjedt szövetelhalás és a fennálló társbetegségek indokolhatják [37]. A primer amputációk számarányára vonatkozóan kevés adat áll rendelkezésre, ezek tartománya széles (33-71,5%), a magyar adatok kiugróan magasak [13,41,44]. A helyzet értékelését nehezíti, hogy nem tudhatjuk, a primer amputáció melletti döntést az irány-elveknek megfelelő mérlegelés (revascularisatio nem lehetséges) vagy az érbeavatkozás tárgyi, személyi feltéte-leinek hiánya, elérhetősége határozta meg.…”