Higher regional spending on vascular care does not result in a reduction in amputation rates, according to the authors of a study published in the November 20 online issue of JAMA Surgery.
“Healthcare costs attributable to critical limb ischemia [CLI]…have been estimated at $5 billion annually for Medicare patients,” wrote the researchers, led by Philip Goodney, MD, MS, of the Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. “With the advent of less-invasive endovascular techniques, the use of revascularization procedures for [CLI] has increased fourfold since 2003.” However, they added that the relationship between spending on vascular care and regional amputation rates remains unclear.
The objective of their study, therefore, was to test the hypothesis that higher regional spending on vascular care is associated with lower amputation rates for patients with severe peripheral artery disease (PAD).
The researchers performed a retrospective study of 18,463 Medicare patients who underwent a major PAD-related amputation between 2003 and 2010. Patients had a mean age of 78 years, and 51 percent of the patients were male. Forty-nine percent of the patients had a history of diabetes, 35 percent had a history of heart failure, and 14 percent had a history of coronary disease. The researchers focused on costs associated with the inpatient care received in the year prior to amputation and the amputation procedure itself.
The mean cost of care was $22,405, but it varied widely from region to region-from $11,077 in Bismarck, North Dakota, to $42,613 in Salinas, California. Costs were adjusted for regional differences in Medicare payments as well as for inflation given the year of the procedure.
Upon examination of risk-adjusted relationships between spending and amputation risk, the researchers found that while “revascularization was associated with higher spending, higher spending was not associated with higher regional amputation rates.” In fact, the regions that used the most aggressive endovascular interventions “were the most likely to have…high amputation rates.”
Two other heart experts interviewed for a HealthDay news article caution that this study may not tell the whole story.
“This study should not suggest that leg revascularizations are useless,” Jeffrey Berger, MD, a cardiologist at New York University (NYU) Langone Medical Center, New York, New York, is quoted as saying. “A leg revascularization could have other beneficial outcomes that this study did not investigate, such as improvement in quality of life, or [it could] affect the type of amputation that might be required.”
Maja Zaric, MD, an interventional cardiologist at Lenox Hill Hospital, New York, was quoted as saying the study “looks only into the Medicare population and analyzes only inpatient cost, which underestimates real and overall costs.”
CLI, the most severe form of lower-limb PAD, results in about 150,000 amputations annually in the United States, according to an article in the August 2011 issue of Endovascular Today.