Study Evaluates Inpatient and Outpatient Outcomes and Costs After Revascularization for CLTI

December 15, 2023—In a study published online in BJS Open, Saratzis and colleagues evaluated postoperative outcomes and postprocedural health care resources and costs after revascularization for chronic limb-threatening ischemia (CLTI), finding that revascularization is not associated with more postprocedural appointments or increased costs as compared with primary amputation.¹

Investigators used patient data from the United Kingdom Kent Integrated Dataset (1.6 million people) and included patients aged ≥ 18 years who presented with a new diagnosis of CLTI (Rutherford class 4-6) from January 2016 to January 2019 and underwent a first intervention during that presentation.

Patients underwent any of the following as an index procedure: major lower limb amputation, bypass surgery, endarterectomy, angioplasty with or without stenting or other endovascular adjunctive procedure, and thromboembolectomy of any lower limb artery.

One-year inpatient (duration of inpatient stay, in-hospital mortality) and outpatient outcomes (number of primary care appointments, secondary care readmissions, mortality and major cardiovascular events, and major limb amputations after revascularization) and costs of postoperative care based on the number of primary care appointments and secondary care admissions were analyzed. The independent association between postoperative activities, index procedure, and Charlson comorbidity index (CCI) were analyzed using multivariable logistic and linear regression models.

Overall, 4,252 patients were identified and included in the study (65% men; mean age, 73 years). In total, 579 (14%) underwent some type of procedure: 6.9% (296) underwent angioplasty, 1.7% (75) underwent bypass surgery, 3.3% (141) had a major lower limb amputation, 1.3% (56) underwent endarterectomy, and 0.3% (11) had a thromboembolectomy. Comorbidities of interest included current smoking in 3.6%, diabetes in 3.5%, and chronic pulmonary disease in 1.8% of patients.

Of 579 patients who underwent intervention, 206 patients died during their inpatient stay. Median inpatient stay was highest for bypass surgery (15 days; range, 0-103 days), followed by major lower limb amputation (13 days; range, 0-159 days), thromboembolectomy (11 days; range, 2-119 days), angioplasty (7 days; range, 0-225 days), and endarterectomy (6 days; range, 0-117 days).

There were no statistically significant differences in the number of community and primary care appointments within 1 year between groups; however, patients who underwent primary amputation had the highest number of appointments (median, 27), followed by angioplasty (median, 20).

The number of median outpatient hospital appointments was higher at 1 year than angioplasty and major lower limb amputation (5 vs 4 each; P = .002), but types of index procedures for a number of readmissions, duration of stay during readmission, or community care appointments were not statistically significantly different. Patients who underwent major lower limb amputation had the highest number of cardiovascular events within 1 year (mean, 3.9). Over 1 year, 11.6% of patients who underwent revascularization had a major amputation. The type of procedure and CCI score were not predictors of the number of outpatient appointments or readmissions per a linear regression model.

At 1 year, major lower limb amputation had the highest postprocedural community care costs, while thromboembolectomy had the highest postprocedural primary care costs.

Investigators outlined several limitations of the study, including the observational (nonrandomized) data collection; that it was not a prospective study; use of the Kent Integrated Dataset, which does not include the entirety of the National Health Service; absence of distinct coding for hybrid procedures, which were coded as open surgery in this data set; and lack of more detailed cost data, which would have provided a more complete picture of the economic impact of each procedure. In addition, information for patients who did not undergo an intervention upon receiving a new diagnosis of CLTI was not captured.

The take-home message of this study was that revascularization was not associated with more postprocedural or primary care/community care appointments or increased postprocedural costs versus a primary amputation strategy, noted the investigators.

1.  Saratzis A, Musto L, Kumar S, et al. Outcomes and use of healthcare resources after an intervention for chronic limb-threatening ischaemia. BJS Open. Published online November 3, 2023. https://doi.org/10.1093/bjsopen/zrad112