Disparities in CLI Management and Association With Major Limb Amputation Evaluated in Medicare Data

October 5, 2021—The VIVA Foundation announced the presentation of findings from a real-world evaluation of disparities in critical limb ischemia (CLI) management associated with major limb amputation. Eric A. Secemsky, MD, presented the study at VIVA 2021, the annual Vascular InterVentional Advances meeting held October 4-7 in Las Vegas, Nevada.

As noted in the VIVA announcement, well-established disparities in care exist for patients with CLI. The investigators aimed to determine (1) if patient, hospital, and geographic factors are associated with different intensities of vascular care received before major amputation and (2) if the intensity of vascular care received in the year before major amputation is associated with differences in outcomes postamputation. The study was supported by Abbott. 

According to the VIVA summary, the investigators used Medicare claims data from 2016 to 2019 to identify patients with a CLI diagnosis who underwent a major lower limb amputation. To understand the factors associated with the intensity of vascular care received in the year before amputation, intensity was categorized as low (no angiography or revascularization), medium (angiography only), or high (revascularization by any method: surgical, endovascular, or hybrid).

The investigators then examined the association of patient (demographics, comorbidities), hospital, and geographic characteristics with receiving low-intensity (reference group) versus medium-intensity versus high-intensity vascular care before amputation using ordered multivariable logistic regression. Secondary endpoints examined included mortality and readmission.

Of 7,904 Medicare beneficiaries who underwent major amputation, 46% were above-the-knee amputations. Among the study cohort, 5,090 (63.4%) received low-intensity vascular care, 442 (5.5%) received medium-intensity care, and 2,500 (31.1%) received high-intensity vascular care.

After multivariable adjustment, three factors—being male, being low income, or receiving care at a safety-net hospital—were all strongly associated with receiving lower-intensity vascular care before amputation. Patients who received high-intensity care died at a frequency of 19% versus 23% among those who received low-intensity vascular care in the 2 years after amputation.

In addition, by 12 months postamputation, 40%, 50%, and 48% of patients receiving high-, medium-, and low-intensity care, respectively, were readmitted. These data emphasize the importance of vascular care before amputation and the continued disparities that exist in contemporary vascular practice, noted the investigators.

Dr. Secemsky further reported that 69% of patients did not receive a revascularization attempt in the year before amputation, and 92% of those who were not revascularized did not receive an angiogram.

“We need to figure this out,” said Dr. Secemsky, emphasizing the urgent need for greater investment to reduce disparities in care quality and delivery to make the necessary progress toward meaningful reductions in nontraumatic lower extremity amputations.

Exploring the practical implications of these findings, Dr. Secemsky and the VIVA panel reiterated the importance of seeing patients earlier in their disease process and discussed the value of multidisciplinary care teams and peer-review processes to ensure patients with multiple comorbidities have their needs met.