Outcomes for critical limb ischemia are driven by lower extremity revascularization volume, not distance to hospital
Abstract Objective The objective of this study was to identify relationships among geographic access to care, vascular procedure volume, limb preservation, and survival in patients diagnosed with critical limb ischemia (CLI). Methods Using New York State administrative data from 2000 to 2013, we ide...
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| Veröffentlicht in: | Journal of vascular surgery 2017-08, Vol.66 (2), p.476-487.e1 |
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| creator | Medhekar, Ankit N., BS Mix, Doran S., MD Aquina, Christopher T., MD Trakimas, Lauren E., DO Noyes, Katia, PhD Fleming, Fergal J., MBBCh Glocker, Roan J., MD Stoner, Michael C., MD |
| description | Abstract Objective The objective of this study was to identify relationships among geographic access to care, vascular procedure volume, limb preservation, and survival in patients diagnosed with critical limb ischemia (CLI). Methods Using New York State administrative data from 2000 to 2013, we identified a patient's first presentation with CLI defined by International Classification of Diseases, Ninth Revision diagnosis and procedure codes. Distance from the patient's home to the index hospital was calculated using the centroids of the respective ZIP codes. A multivariable logistic regression model was employed to estimate the impact of distance, major lower extremity amputation (LEA) volume, and lower extremity revascularization (LER) volume on major amputation and 30-day mortality. Volumes and distances were analyzed in quintiles. The farthest distance quintile and the highest procedure volume quintiles were used as references for generating odds ratios (ORs). Results There were 49,576 patients identified with an initial presentation of CLI. The median age was 73 years, 35,829 (73.2%) had Medicare as a primary insurer, 11,395 (23.0%) had a major amputation, and 4249 (8.6%) died within 30 days of admission. Patients in the closest distance quintile were more likely to undergo amputation (OR, 1.53 [1.39-1.68]; P |
| doi_str_mv | 10.1016/j.jvs.2017.01.062 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_1888679469</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><els_id>S0741521417303749</els_id><sourcerecordid>1888679469</sourcerecordid><originalsourceid>FETCH-LOGICAL-c451t-240958bc888e488b05a820275c1a63917ecb4f9bcc60d6daa3d68e89a8d509153</originalsourceid><addsrcrecordid>eNp9kc2O1DAQhCMEYoeFB-CCfORAQnfiJLaQkFYr_qSV9gCcLcfp0Xpw4sF2AsPT42gWDhw49aGrSqqviuI5QoWA3etDdVhjVQP2FWAFXf2g2CHIvuwEyIfFDnqOZVsjvyiexHgAQGxF_7i4qAUHgS3fFel2ScZPFNneB2aCTdZox5ydBmajuaPJaqYDsTHYlWY2nJjzPygw-plCfqYTC7TqaBang_2lk_UzW71bJnrFZp_YaGPSsyGWPLvz8WiTdk-LR3vtIj27v5fF1_fvvlx_LG9uP3y6vropDW8xlTUH2YrBCCGICzFAq0UNdd8a1F0jsScz8L0cjOlg7Eatm7ETJKQWYwsS2-ayeHnOPQb_faGY1JQ7kXN6Jr9EhTm56yXvZJbiWWqCjzHQXh2DnXQ4KQS1wVYHlWGrDbYCVBl29ry4j1-Gica_jj90s-DNWUC55GopqGgsZRijDWSSGr39b_zbf9zG2Xmb5xudKB78EuZMT6GKtQL1eVt7Gxv7Bpqey-Y3WymmeQ</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1888679469</pqid></control><display><type>article</type><title>Outcomes for critical limb ischemia are driven by lower extremity revascularization volume, not distance to hospital</title><source>MEDLINE</source><source>Elsevier ScienceDirect Journals</source><source>EZB-FREE-00999 freely available EZB journals</source><creator>Medhekar, Ankit N., BS ; Mix, Doran S., MD ; Aquina, Christopher T., MD ; Trakimas, Lauren E., DO ; Noyes, Katia, PhD ; Fleming, Fergal J., MBBCh ; Glocker, Roan J., MD ; Stoner, Michael C., MD</creator><creatorcontrib>Medhekar, Ankit N., BS ; Mix, Doran S., MD ; Aquina, Christopher T., MD ; Trakimas, Lauren E., DO ; Noyes, Katia, PhD ; Fleming, Fergal J., MBBCh ; Glocker, Roan J., MD ; Stoner, Michael C., MD</creatorcontrib><description>Abstract Objective The objective of this study was to identify relationships among geographic access to care, vascular procedure volume, limb preservation, and survival in patients diagnosed with critical limb ischemia (CLI). Methods Using New York State administrative data from 2000 to 2013, we identified a patient's first presentation with CLI defined by International Classification of Diseases, Ninth Revision diagnosis and procedure codes. Distance from the patient's home to the index hospital was calculated using the centroids of the respective ZIP codes. A multivariable logistic regression model was employed to estimate the impact of distance, major lower extremity amputation (LEA) volume, and lower extremity revascularization (LER) volume on major amputation and 30-day mortality. Volumes and distances were analyzed in quintiles. The farthest distance quintile and the highest procedure volume quintiles were used as references for generating odds ratios (ORs). Results There were 49,576 patients identified with an initial presentation of CLI. The median age was 73 years, 35,829 (73.2%) had Medicare as a primary insurer, 11,395 (23.0%) had a major amputation, and 4249 (8.6%) died within 30 days of admission. Patients in the closest distance quintile were more likely to undergo amputation (OR, 1.53 [1.39-1.68]; P < .0001). Patients who visited hospitals in the lowest LER volume quintile with at least one procedure per year faced higher 30-day mortality rates (OR, 2.05 [1.67-2.50]; P < .0001) and greater odds of amputation (OR, 9.94 [8.5-11.63]; P < .0001). Patients who visited hospitals in the lowest LEA volume quintile had lower odds of 30-day mortality (OR, 0.66 [0.50-0.87]; P = .0033) and lower odds of amputation (OR, 0.180 [0.142-0.227]; P < .0001). Conclusions Rates of major amputation are inversely associated with distance from the index hospital, whereas rates of both major amputation and mortality are inversely associated with LER volume. Rates of major amputation and mortality are directly associated with LEA volume. We believe that unless it is otherwise contraindicated, these data support consideration for selective referral of CLI patients to high-volume centers for LER regardless of distance. 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.</description><identifier>ISSN: 0741-5214</identifier><identifier>EISSN: 1097-6809</identifier><identifier>DOI: 10.1016/j.jvs.2017.01.062</identifier><identifier>PMID: 28408154</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Aged ; Aged, 80 and over ; Amputation ; Catchment Area (Health) ; Chi-Square Distribution ; Critical Illness ; Female ; Health Services Accessibility ; Healthcare Disparities ; Hospitals, High-Volume ; Hospitals, Low-Volume ; Humans ; Ischemia - diagnostic imaging ; Ischemia - mortality ; Ischemia - physiopathology ; Ischemia - surgery ; Limb Salvage ; Logistic Models ; Lower Extremity - blood supply ; Male ; Middle Aged ; Multivariate Analysis ; New York ; Odds Ratio ; Peripheral Arterial Disease - diagnostic imaging ; Peripheral Arterial Disease - mortality ; Peripheral Arterial Disease - physiopathology ; Peripheral Arterial Disease - surgery ; Postal Service ; Process Assessment (Health Care) ; Retrospective Studies ; Risk Factors ; Socioeconomic Factors ; Surgery ; Time Factors ; Treatment Outcome ; Vascular Surgical Procedures - adverse effects ; Vascular Surgical Procedures - mortality</subject><ispartof>Journal of vascular surgery, 2017-08, Vol.66 (2), p.476-487.e1</ispartof><rights>Society for Vascular Surgery</rights><rights>2017 Society for Vascular Surgery</rights><rights>Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c451t-240958bc888e488b05a820275c1a63917ecb4f9bcc60d6daa3d68e89a8d509153</citedby><cites>FETCH-LOGICAL-c451t-240958bc888e488b05a820275c1a63917ecb4f9bcc60d6daa3d68e89a8d509153</cites><orcidid>0000-0002-4682-3526</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://dx.doi.org/10.1016/j.jvs.2017.01.062$$EHTML$$P50$$Gelsevier$$Hfree_for_read</linktohtml><link.rule.ids>314,777,781,3537,27905,27906,45976</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/28408154$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Medhekar, Ankit N., BS</creatorcontrib><creatorcontrib>Mix, Doran S., MD</creatorcontrib><creatorcontrib>Aquina, Christopher T., MD</creatorcontrib><creatorcontrib>Trakimas, Lauren E., DO</creatorcontrib><creatorcontrib>Noyes, Katia, PhD</creatorcontrib><creatorcontrib>Fleming, Fergal J., MBBCh</creatorcontrib><creatorcontrib>Glocker, Roan J., MD</creatorcontrib><creatorcontrib>Stoner, Michael C., MD</creatorcontrib><title>Outcomes for critical limb ischemia are driven by lower extremity revascularization volume, not distance to hospital</title><title>Journal of vascular surgery</title><addtitle>J Vasc Surg</addtitle><description>Abstract Objective The objective of this study was to identify relationships among geographic access to care, vascular procedure volume, limb preservation, and survival in patients diagnosed with critical limb ischemia (CLI). Methods Using New York State administrative data from 2000 to 2013, we identified a patient's first presentation with CLI defined by International Classification of Diseases, Ninth Revision diagnosis and procedure codes. Distance from the patient's home to the index hospital was calculated using the centroids of the respective ZIP codes. A multivariable logistic regression model was employed to estimate the impact of distance, major lower extremity amputation (LEA) volume, and lower extremity revascularization (LER) volume on major amputation and 30-day mortality. Volumes and distances were analyzed in quintiles. The farthest distance quintile and the highest procedure volume quintiles were used as references for generating odds ratios (ORs). Results There were 49,576 patients identified with an initial presentation of CLI. The median age was 73 years, 35,829 (73.2%) had Medicare as a primary insurer, 11,395 (23.0%) had a major amputation, and 4249 (8.6%) died within 30 days of admission. Patients in the closest distance quintile were more likely to undergo amputation (OR, 1.53 [1.39-1.68]; P < .0001). Patients who visited hospitals in the lowest LER volume quintile with at least one procedure per year faced higher 30-day mortality rates (OR, 2.05 [1.67-2.50]; P < .0001) and greater odds of amputation (OR, 9.94 [8.5-11.63]; P < .0001). Patients who visited hospitals in the lowest LEA volume quintile had lower odds of 30-day mortality (OR, 0.66 [0.50-0.87]; P = .0033) and lower odds of amputation (OR, 0.180 [0.142-0.227]; P < .0001). Conclusions Rates of major amputation are inversely associated with distance from the index hospital, whereas rates of both major amputation and mortality are inversely associated with LER volume. Rates of major amputation and mortality are directly associated with LEA volume. We believe that unless it is otherwise contraindicated, these data support consideration for selective referral of CLI patients to high-volume centers for LER regardless of distance. 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.</description><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Amputation</subject><subject>Catchment Area (Health)</subject><subject>Chi-Square Distribution</subject><subject>Critical Illness</subject><subject>Female</subject><subject>Health Services Accessibility</subject><subject>Healthcare Disparities</subject><subject>Hospitals, High-Volume</subject><subject>Hospitals, Low-Volume</subject><subject>Humans</subject><subject>Ischemia - diagnostic imaging</subject><subject>Ischemia - mortality</subject><subject>Ischemia - physiopathology</subject><subject>Ischemia - surgery</subject><subject>Limb Salvage</subject><subject>Logistic Models</subject><subject>Lower Extremity - blood supply</subject><subject>Male</subject><subject>Middle Aged</subject><subject>Multivariate Analysis</subject><subject>New York</subject><subject>Odds Ratio</subject><subject>Peripheral Arterial Disease - diagnostic imaging</subject><subject>Peripheral Arterial Disease - mortality</subject><subject>Peripheral Arterial Disease - physiopathology</subject><subject>Peripheral Arterial Disease - surgery</subject><subject>Postal Service</subject><subject>Process Assessment (Health Care)</subject><subject>Retrospective Studies</subject><subject>Risk Factors</subject><subject>Socioeconomic Factors</subject><subject>Surgery</subject><subject>Time Factors</subject><subject>Treatment Outcome</subject><subject>Vascular Surgical Procedures - adverse effects</subject><subject>Vascular Surgical Procedures - mortality</subject><issn>0741-5214</issn><issn>1097-6809</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2017</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kc2O1DAQhCMEYoeFB-CCfORAQnfiJLaQkFYr_qSV9gCcLcfp0Xpw4sF2AsPT42gWDhw49aGrSqqviuI5QoWA3etDdVhjVQP2FWAFXf2g2CHIvuwEyIfFDnqOZVsjvyiexHgAQGxF_7i4qAUHgS3fFel2ScZPFNneB2aCTdZox5ydBmajuaPJaqYDsTHYlWY2nJjzPygw-plCfqYTC7TqaBang_2lk_UzW71bJnrFZp_YaGPSsyGWPLvz8WiTdk-LR3vtIj27v5fF1_fvvlx_LG9uP3y6vropDW8xlTUH2YrBCCGICzFAq0UNdd8a1F0jsScz8L0cjOlg7Eatm7ETJKQWYwsS2-ayeHnOPQb_faGY1JQ7kXN6Jr9EhTm56yXvZJbiWWqCjzHQXh2DnXQ4KQS1wVYHlWGrDbYCVBl29ry4j1-Gica_jj90s-DNWUC55GopqGgsZRijDWSSGr39b_zbf9zG2Xmb5xudKB78EuZMT6GKtQL1eVt7Gxv7Bpqey-Y3WymmeQ</recordid><startdate>20170801</startdate><enddate>20170801</enddate><creator>Medhekar, Ankit N., BS</creator><creator>Mix, Doran S., MD</creator><creator>Aquina, Christopher T., MD</creator><creator>Trakimas, Lauren E., DO</creator><creator>Noyes, Katia, PhD</creator><creator>Fleming, Fergal J., MBBCh</creator><creator>Glocker, Roan J., MD</creator><creator>Stoner, Michael C., MD</creator><general>Elsevier Inc</general><scope>6I.</scope><scope>AAFTH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-4682-3526</orcidid></search><sort><creationdate>20170801</creationdate><title>Outcomes for critical limb ischemia are driven by lower extremity revascularization volume, not distance to hospital</title><author>Medhekar, Ankit N., BS ; Mix, Doran S., MD ; Aquina, Christopher T., MD ; Trakimas, Lauren E., DO ; Noyes, Katia, PhD ; Fleming, Fergal J., MBBCh ; Glocker, Roan J., MD ; Stoner, Michael C., MD</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c451t-240958bc888e488b05a820275c1a63917ecb4f9bcc60d6daa3d68e89a8d509153</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2017</creationdate><topic>Aged</topic><topic>Aged, 80 and over</topic><topic>Amputation</topic><topic>Catchment Area (Health)</topic><topic>Chi-Square Distribution</topic><topic>Critical Illness</topic><topic>Female</topic><topic>Health Services Accessibility</topic><topic>Healthcare Disparities</topic><topic>Hospitals, High-Volume</topic><topic>Hospitals, Low-Volume</topic><topic>Humans</topic><topic>Ischemia - diagnostic imaging</topic><topic>Ischemia - mortality</topic><topic>Ischemia - physiopathology</topic><topic>Ischemia - surgery</topic><topic>Limb Salvage</topic><topic>Logistic Models</topic><topic>Lower Extremity - blood supply</topic><topic>Male</topic><topic>Middle Aged</topic><topic>Multivariate Analysis</topic><topic>New York</topic><topic>Odds Ratio</topic><topic>Peripheral Arterial Disease - diagnostic imaging</topic><topic>Peripheral Arterial Disease - mortality</topic><topic>Peripheral Arterial Disease - physiopathology</topic><topic>Peripheral Arterial Disease - surgery</topic><topic>Postal Service</topic><topic>Process Assessment (Health Care)</topic><topic>Retrospective Studies</topic><topic>Risk Factors</topic><topic>Socioeconomic Factors</topic><topic>Surgery</topic><topic>Time Factors</topic><topic>Treatment Outcome</topic><topic>Vascular Surgical Procedures - adverse effects</topic><topic>Vascular Surgical Procedures - mortality</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Medhekar, Ankit N., BS</creatorcontrib><creatorcontrib>Mix, Doran S., MD</creatorcontrib><creatorcontrib>Aquina, Christopher T., MD</creatorcontrib><creatorcontrib>Trakimas, Lauren E., DO</creatorcontrib><creatorcontrib>Noyes, Katia, PhD</creatorcontrib><creatorcontrib>Fleming, Fergal J., MBBCh</creatorcontrib><creatorcontrib>Glocker, Roan J., MD</creatorcontrib><creatorcontrib>Stoner, Michael C., MD</creatorcontrib><collection>ScienceDirect Open Access Titles</collection><collection>Elsevier:ScienceDirect:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of vascular surgery</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Medhekar, Ankit N., BS</au><au>Mix, Doran S., MD</au><au>Aquina, Christopher T., MD</au><au>Trakimas, Lauren E., DO</au><au>Noyes, Katia, PhD</au><au>Fleming, Fergal J., MBBCh</au><au>Glocker, Roan J., MD</au><au>Stoner, Michael C., MD</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Outcomes for critical limb ischemia are driven by lower extremity revascularization volume, not distance to hospital</atitle><jtitle>Journal of vascular surgery</jtitle><addtitle>J Vasc Surg</addtitle><date>2017-08-01</date><risdate>2017</risdate><volume>66</volume><issue>2</issue><spage>476</spage><epage>487.e1</epage><pages>476-487.e1</pages><issn>0741-5214</issn><eissn>1097-6809</eissn><abstract>Abstract Objective The objective of this study was to identify relationships among geographic access to care, vascular procedure volume, limb preservation, and survival in patients diagnosed with critical limb ischemia (CLI). Methods Using New York State administrative data from 2000 to 2013, we identified a patient's first presentation with CLI defined by International Classification of Diseases, Ninth Revision diagnosis and procedure codes. Distance from the patient's home to the index hospital was calculated using the centroids of the respective ZIP codes. A multivariable logistic regression model was employed to estimate the impact of distance, major lower extremity amputation (LEA) volume, and lower extremity revascularization (LER) volume on major amputation and 30-day mortality. Volumes and distances were analyzed in quintiles. The farthest distance quintile and the highest procedure volume quintiles were used as references for generating odds ratios (ORs). Results There were 49,576 patients identified with an initial presentation of CLI. The median age was 73 years, 35,829 (73.2%) had Medicare as a primary insurer, 11,395 (23.0%) had a major amputation, and 4249 (8.6%) died within 30 days of admission. Patients in the closest distance quintile were more likely to undergo amputation (OR, 1.53 [1.39-1.68]; P < .0001). Patients who visited hospitals in the lowest LER volume quintile with at least one procedure per year faced higher 30-day mortality rates (OR, 2.05 [1.67-2.50]; P < .0001) and greater odds of amputation (OR, 9.94 [8.5-11.63]; P < .0001). Patients who visited hospitals in the lowest LEA volume quintile had lower odds of 30-day mortality (OR, 0.66 [0.50-0.87]; P = .0033) and lower odds of amputation (OR, 0.180 [0.142-0.227]; P < .0001). Conclusions Rates of major amputation are inversely associated with distance from the index hospital, whereas rates of both major amputation and mortality are inversely associated with LER volume. Rates of major amputation and mortality are directly associated with LEA volume. We believe that unless it is otherwise contraindicated, these data support consideration for selective referral of CLI patients to high-volume centers for LER regardless of distance. 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.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>28408154</pmid><doi>10.1016/j.jvs.2017.01.062</doi><orcidid>https://orcid.org/0000-0002-4682-3526</orcidid><oa>free_for_read</oa></addata></record> |
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| subjects | Aged Aged, 80 and over Amputation Catchment Area (Health) Chi-Square Distribution Critical Illness Female Health Services Accessibility Healthcare Disparities Hospitals, High-Volume Hospitals, Low-Volume Humans Ischemia - diagnostic imaging Ischemia - mortality Ischemia - physiopathology Ischemia - surgery Limb Salvage Logistic Models Lower Extremity - blood supply Male Middle Aged Multivariate Analysis New York Odds Ratio Peripheral Arterial Disease - diagnostic imaging Peripheral Arterial Disease - mortality Peripheral Arterial Disease - physiopathology Peripheral Arterial Disease - surgery Postal Service Process Assessment (Health Care) Retrospective Studies Risk Factors Socioeconomic Factors Surgery Time Factors Treatment Outcome Vascular Surgical Procedures - adverse effects Vascular Surgical Procedures - mortality |
| title | Outcomes for critical limb ischemia are driven by lower extremity revascularization volume, not distance to hospital |
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