Apr 19, 2017
Among patients with critical limb ischemia, those in hospitals with a high volume of amputation procedures had elevated rates of major amputation and mortality, but those in hospitals with a high volume of revascularization procedures had better outcomes, according to new findings.
“We believe that unless it is otherwise contraindicated, these data support consideration for selective referral of CLI patients to high-volume centers for [lower-extremity revascularization] regardless of distance,” Michael C. Stoner, MD, from the department of vascular surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, and colleagues wrote in the Journal of Vascular Surgery. “Within the context of value-based health care delivery, policy supporting regionalization of CLI care into centers of excellence may improve outcomes for these patients.”
From New York administrative data, Stoner and colleagues identified 49,576 patients presenting with CLI (median age, 73 years) between 2000 and 2013. They stratified patients by distance from home to index hospital and calculated the impact of distance, major lower-extremity amputation volume and lower-extremity revascularization volume on major amputation and 30-day mortality.
During the study period, 23% of patients had a major amputation and 8.6% died within 30 days of admission.
Patients in the quintile of closest distance to index hospital were more likely to undergo amputation compared with patients in the farthest-distance quintile (OR = 1.53; 95% CI, 1.39-1.68), Stoner and colleagues found.
Patients who went to hospitals in the lowest quintile of lower-extremity revascularization volume with at least one procedure per year had higher 30-day mortality rates (OR = 2.05; 95% CI, 1.67-2.5) and greater likelihood of major amputation (OR = 9.94; 95% CI, 8.5-11.63) compared with those who went to hospitals in the highest quintile of lower-extremity revascularization volume, according to the researchers.
Patients who visited hospitals in the lowest quintile of lower-extremity amputation volume had lower odds of 30-day mortality (OR = 0.66; 95% CI, 0.5-0.87) and amputation (OR = 0.18; 95% CI, 0.142-0.227) than those who went to hospitals in the highest quintile of lower-extremity amputation volume, the researchers wrote.
“We initially believed that CLI patients who live closer to the health care facilities at which they sought treatment would fare better in terms of amputation and mortality. We … found that this was not true,” Stoner and colleagues wrote. “Rates of mortality were unaffected by distance to the center at which care was sought. In addition, proximity to a hospital is associated with higher odds of mortality in CLI patients. We additionally hypothesized that [lower-extremity revascularization] volumes would be associated with lower rates of mortality and amputation, whereas [lower-extremity amputation] volumes would be associated with higher rates of mortality and amputation. We found that this was the case. Overall, we believe the creation and expansion of centers of excellence for CLI may improve outcomes in this group of patients.” – by Erik Swain