Variation in CLI Vascular Care Before Amputation Studied

December 6, 2011—Significant variation exists in the intensity of vascular care provided to patients in the year before major amputation, according to a study by Philip P. Goodney, MD, et al, which was published online ahead of print in Circulation: Cardiovascular Quality and Outcomes.

The investigators found that in some regions, patients receive intensive care, whereas in other regions, far less vascular care is provided. They advised that future work is needed to determine the association between the intensity of vascular care and limb salvage.

The study was conducted because the extent of variation in vascular care for patients with critical limb ischemia (CLI) remains unknown and many believe that variation in vascular practice may affect limb salvage rates in patients with severe peripheral arterial disease.

As detailed in Circulation: Cardiovascular Quality and Outcomes, the investigators used Medicare data from 2003 to 2006 to identify 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, the investigators studied the use of lower extremity vascular procedures (open surgery or endovascular intervention) in the year before amputation. The 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.

The investigators stated that 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 one vascular procedure, and 32% underwent more than one vascular procedure.

The investigators found that in the regions within the lowest quintile of vascular care, vascular procedures were performed in 32% of patients. Conversely, in the regions within the highest quintile of vascular care, revascularization was performed in 58% of patients in the year before amputation (P < .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% confidence interval, 2.1–2.6; P < .001), reported the investigators.