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Variation in the use of lower extremity vascular procedures for critical limb ischemia
Philip P Goodney1, Lori L Travis, Brahmajee K Nallamothu
1Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA. philip.goodney@hitchcock.org
Insights
Vascular care intensity varies significantly for patients with critical limb ischemia (CLI) before amputation. Patients in high-intensity regions were more likely to receive revascularization procedures, highlighting disparities in care.
Area of Science:
- Vascular Surgery
- Health Services Research
- Peripheral Arterial Disease
Background:
- Variation in vascular practice may impact limb salvage rates for severe peripheral arterial disease.
- The extent of variation in procedural vascular care for critical limb ischemia (CLI) is not well understood.
Purpose of the Study:
- To investigate the variation in vascular care intensity among patients with CLI.
- To determine the proportion of CLI patients receiving vascular procedures before major lower extremity amputation.
Main Methods:
- Analysis of Medicare data from 2003-2006 for patients with CLI undergoing major lower extremity amputation.
- Examined the utilization of lower extremity vascular procedures (open or endovascular) in the year preceding amputation.
- Defined vascular care intensity by the proportion of patients within a hospital referral region undergoing a vascular procedure.
Main Results:
- Over 20,000 CLI patients underwent major amputations; 54% received no vascular procedures in the prior year.
- Vascular procedure rates varied by region, with 32% in low-intensity regions and 58% in high-intensity regions.
- Patients in high-intensity regions were 2.4 times more likely to undergo revascularization before amputation.
Conclusions:
- Significant geographic variation exists in the intensity of vascular care for CLI patients awaiting amputation.
- Some regions provide intensive vascular care, while others offer substantially less.
- Further research is necessary to link vascular care intensity with limb salvage outcomes.
Background:
Many believe that variation in vascular practice may affect limb salvage rates in patients with severe peripheral arterial disease. However, the extent of variation in procedural vascular care obtained by patients with critical limb ischemia (CLI) remains unknown.
Methods And Results:
By using Medicare 2003 to 2006 data, we identified all patients with CLI who underwent major lower extremity amputation in the 306 hospital referral regions 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 before amputation. Our main outcome measure was the intensity of vascular care, defined as the proportion of patients in the hospital referral region undergoing a 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 before undergoing amputation. However, these procedures were not distributed evenly: 54% of patients had no vascular procedures performed in the year before amputation, 14% underwent 1 vascular procedure, and 32% underwent >1 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 before 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 before amputation than patients in low-intensity regions (adjusted odds ratio, 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 before major amputation. In some regions, patients receive intensive care, whereas 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.
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