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Geographical Variation in the Management of Peripheral Arterial Occlusive Disease: A Nationwide Danish Cohort Study
Rikke Søgaard1, Louise S Londero2, Jes Lindholt3
1Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Department of Public Health, Aarhus University, Denmark.
Insights
Healthcare costs and amputation risks for peripheral arterial occlusive disease vary significantly across Danish vascular centers. This suggests unequal treatment and efficiency, warranting further investigation into optimizing patient care.
Area of Science:
- Vascular Surgery
- Health Economics
- Public Health Policy
Background:
- Healthcare systems aim for equal access based on need, but geographical variations in care are common, particularly outside vascular surgery.
- Peripheral arterial occlusive disease (PAOD) management is a key area where such variations may impact patient outcomes and healthcare expenditure.
- Understanding cost and outcome variations in PAOD revascularization is crucial for healthcare system efficiency and equity.
Purpose of the Study:
- To assess variations in healthcare costs and patient outcomes (amputation rates) for first-time revascularization procedures in specialized vascular centers within the Danish healthcare system.
- To identify efficient providers and quantify the cost associated with reducing amputation risk across different centers.
- To evaluate the relationship between healthcare costs and the quality of care in managing PAOD.
Main Methods:
- A national study analyzing 10,300 first-time revascularizations for PAOD in Denmark (2009-2014) using data from the Danish Vascular Registry.
- One-year follow-up data on specialized healthcare costs and amputation status were obtained from national registers.
- Statistical analyses included generalized gamma and logit regressions to adjust for patient heterogeneity and cost-effectiveness frontiers to identify efficient centers.
Main Results:
- One-year amputation risks varied significantly across centers for chronic limb-threatening ischemia (11-16%) and acute limb ischemia, but not for intermittent claudication.
- Healthcare costs also showed significant variation across centers for all PAOD indications.
- Three of seven centers demonstrated poorer quality of care (higher amputation rates) at higher costs, with exponentially increasing costs for maximal amputation risk reduction.
Conclusions:
- Substantial variation exists in the clinical management of PAOD across the Danish healthcare system, leading to significant differences in efficiency and potentially unequal treatment.
- The findings highlight the need for further research to address these variations and ensure equitable and cost-effective care for PAOD patients.
- Optimizing care pathways and resource allocation is essential to reduce amputation rates and improve overall system performance.
Objective:
Equal access for equal needs is a key goal for many healthcare systems but geographical variation research has shown that this is often not the case in areas other than vascular surgery. This study assessed the variation across specialised vascular centres of an entire healthcare system in the costs and outcomes for patients having first time revascularisation for peripheral arterial occlusive disease.
Methods:
This was a national study of all first time revascularisations performed in the Danish healthcare system between 2009 and 2014. Episodes were identified in the Danish Vascular Registry (n = 10 300) and data on one year follow up in terms of the costs of specialised healthcare (€) and amputation status were acquired from national registers. Generalised gamma and logit regressions were used to predict margins between centres while adjusting for population heterogeneity (age, sex, education, smoking, hypertension, diabetes, use of prophylactic pharmacological therapy, indication and type of revascularisation). Cost effectiveness frontiers were used to identify efficient providers and to illustrate the cost of reducing the system level risk of amputation.
Results:
For each of the indications of chronic limb threatening and acute limb ischaemia, the one year amputation risks varied from 11% to 16% across centres (p = .003, p = .006) whereas for intermittent claudication there was no significant difference across centres. The corresponding costs of care varied across centres for all indications (p = .027, p = .028, p = .030). Linking costs and outcomes, three of seven centres were observed to provide poorer quality at higher costs. Exponentially increasing costs to obtain the maximum reduction of the amputation risk were observed.
Conclusion:
The results suggest that there is substantial variation in the clinical management of peripheral arterial occlusive disease across the Danish healthcare system and that this results in very different levels of efficiency - on top of potentially unequal treatment for equal needs. Further research is warranted.
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