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Published on: September 22, 2020
Gaps in Vascular Evaluation Before Major Lower-Extremity Amputation Among Medicare Beneficiaries With Chronic
Samir K Shah1, Dan Neal2, Khanjan B Shah3
1Division of Vascular Surgery, University of Florida, Gainesville, FL.
Insights
One in six patients undergoing major amputation for chronic limb-threatening ischemia (CLTI) lacked vascular imaging. Patients without evaluation had cognitive or functional issues, not extreme complexity, indicating a need for system-level interventions.
Area of Science:
- Vascular Surgery
- Health Services Research
- Geriatric Medicine
Background:
- Guidelines recommend vascular specialist evaluation before major amputation for chronic limb-threatening ischemia (CLTI).
- National data on pre-amputation vascular workup consistency in CLTI patients is limited.
- Previous studies indicate 50-63% of Medicare patients with CLTI undergo amputation without revascularization, with disparities.
Purpose of the Study:
- To characterize the national rates of pre-amputation vascular specialist evaluation and imaging in CLTI patients.
- To identify patient and system-level factors associated with lack of vascular workup before amputation.
- To compare outcomes across different pre-amputation care pathways.
Main Methods:
- Retrospective cohort study of Medicare beneficiaries (≥66 years) undergoing major lower-extremity amputation for CLTI (2021-2022).
- Classification of patients into four phenotypes based on vascular specialist contact, imaging, and revascularization attempts in the 180 days prior to amputation.
- Mixed-effects multinomial regression to identify predictors of phenotype membership; comparison of post-amputation outcomes.
Main Results:
- Among 10,666 patients, 16.6% had no vascular imaging before amputation (Phenotype A).
- Phenotype A was associated with dementia, paralysis, and dual eligibility, not higher comorbidity burden.
- Phenotype A patients had lower 1-year mortality (40% vs. 51% for revascularization attempted) and fewer readmissions.
- Significant variation in Phenotype A prevalence (3-16%) across hospital referral regions.
Conclusions:
- A substantial proportion of CLTI amputees (1 in 6) do not receive recommended pre-amputation vascular imaging.
- Lack of evaluation is linked to patient cognitive/functional limitations and socioeconomic factors, not solely medical complexity.
- Wide hospital-level variation suggests system-level interventions are needed to improve guideline adherence.
Background:
Guidelines recommend vascular specialist evaluation and revascularization consideration before major amputation in chronic limb-threatening ischemia (CLTI). Whether patients consistently receive pre-amputation vascular workup is poorly characterized nationally.
Methods:
We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries ≥66 years with CLTI undergoing incident major lower-extremity amputation (2021-2022) with ≥12 months continuous enrollment. Using claims in the 180 days preceding hospitalization for amputation, we classified patients into mutually exclusive pathway phenotypes: (A) no specialist, no imaging, no revascularization attempt; (B) specialist only, no revascularization attempt; (C) imaging, no revascularization attempt; or (D) revascularization attempted. Mixed-effects multinomial regression with hospital random intercepts identified predictors of phenotype membership. Post-amputation outcomes were compared across phenotypes.
Results:
Among 10,666 patients (mean age 76.6 years; 35% female; 70% White, 21% Black), phenotype distribution was: A, 9.4%; B, 7.1%; C, 50.7%; D, 32.7%. Thus, 16.6% had no vascular imaging before amputation. Dementia (OR 2.0; 95% CI, 1.61-2.52), paralysis (OR 4.1; 2.62-6.34), and dual eligibility (OR 1.2; 1.01-1.42) were independently associated with phenotype A. Higher comorbidity burden was inversely associated with A (OR 0.49 for >6 vs 0-3 Elixhauser comorbidities). Phenotype A patients had lower 1-year mortality (40% vs 51% for D), fewer readmissions (90-day OR 0.54; 0.47-0.64), and lower costs (adjusted 50% lower at 180 days). Results were robust to acuity adjustment, exclusion of early deaths, and propensity-score matching (n=824 pairs). Phenotype A prevalence varied widely across hospital referral regions, ranging from 3% (Boston, Atlanta) to 16% (Little Rock) among regions with >100 patients.
Conclusions:
One in six CLTI amputees had no vascular imaging before amputation. Patients without evaluation were characterized by cognitive impairment, functional limitation, lower healthcare engagement, and socioeconomic disadvantage rather than extreme medical complexity. Hospital-level variation suggests system-level interventions could address these gaps.
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