More than half of patients with critical limb ischemia (CLI) who undergo amputation have not had any surgical or endovascular interventions over the previous year, according to research that shows drastic variability in the frequency of such procedures across the country. The findings were published online December 6, 2011, ahead of print, in Circulation: Cardiovascular Quality and Outcomes.
Researchers led by vascular surgeon Philip P. Goodney, MD, MS, of Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, reviewed Medicare data from 20,464 patients with peripheral arterial disease (PAD) who underwent major leg amputations between 2003 and 2006. More than half (54 percent) received no vascular intervention in the year prior to amputation. Of the 46 percent who did, over one-third (37.4 percent) received diagnostic endovascular intervention alone, 24.2 percent received therapeutic endovascular intervention alone, 6.2 percent received open surgery alone, and 7 percent received both endovascular intervention and open surgery.
Overall, 25,800 vascular procedures were performed. Patients were more likely to undergo three or more procedures in the year before amputation if they underwent therapeutic endovascular intervention as opposed to open surgery. In addition, patients older than 90 were less likely to undergo a vascular procedure than patients less than 70 (21 percent vs. 41 percent; P < 0.001), while African American patients were less likely to undergo any revascularization procedure prior to amputation than Caucasian patients (32 percent vs. 37 percent; P = 0.001). In addition, in regions of high frequency of care, patients were 71 to 80 percent more like to receive vascular intervention in the year prior to amputation than patients in low-frequency regions (< 12 percent. High-frequency regions were widely scattered across the country, which did not demonstrate geographic patterns and were not explained by age or race. This was true for both open surgery and endovascular intervention.
The researchers conclude that “our analyses demonstrate that aggressive vascular care for patients at risk for amputation has been unevenly applied across the United States. In many regions,…most patients with severe PAD undergo amputation without even a diagnostic arteriogram performed in the year before.” In contrast, they write, “in other regions, patients with a similar extent of PAD undergo a multitude of vascular procedures, especially therapeutic endovascular interventions.” These variations, the authors note, must be due to differences in regional practice patterns since all patients in the analysis are over age 65 and, therefore, insured by Medicare, eliminating cost as a potential contributing factor.
