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Callegari S, Smolderen KG, Cleman J, Mena-Hurtado C, Romain G. Competing risk analysis to estimate amputation incidence and risk in lower-extremity peripheral artery disease. Vasc Med 2024:1358863X241268727. [PMID: 39219174 DOI: 10.1177/1358863x241268727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Background: Patients with peripheral artery disease face high amputation and mortality risk. When assessing vascular outcomes, consideration of mortality as a competing risk is not routine. We hypothesize standard time-to-event methods will overestimate major amputation risk in chronic limb-threatening ischemia (CLTI) and non-CLTI. Methods: Patients undergoing peripheral vascular intervention from 2017 to 2018 were abstracted from the Vascular Quality Initiative registry and stratified by mean age (⩾ 75 vs < 75 years). Mortality and amputation data were obtained from Medicare claims. The 2-year cumulative incidence function (CIF) and risk of major amputation from standard time-to-event analysis (1 - Kaplan-Meier and Cox regression) were compared with competing risk analysis (Aalen-Johansen and Fine-Gray model) in CLTI and non-CLTI. Results: A total of 7273 patients with CLTI and 5095 with non-CLTI were included. At 2-year follow up, 13.1% of patients underwent major amputation and 33.4% died without major amputation in the CLTI cohort; 1.3% and 10.7%, respectively, in the non-CLTI cohort. In CLTI, standard time-to-event analysis overestimated the 2-year CIF of major amputation by 20.5% and 13.7%, respectively, in patients ⩾ 75 and < 75 years old compared with competing risk analysis. The standard Cox regression overestimated adjusted 2-year major amputation risk in patients ⩾ 75 versus < 75 years old by 7.0%. In non-CLTI, the CIF was overestimated by 7.1% in patients ⩾ 75 years, and the adjusted risk was overestimated by 5.1% compared with competing risk analysis. Conclusions: Standard time-to-event analysis overestimates the incidence and risk of major amputation, especially in CLTI. Competing risk analyses are alternative approaches to estimate accurately amputation risk in vascular outcomes research.
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Affiliation(s)
- Santiago Callegari
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Jacob Cleman
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Gaëlle Romain
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
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Li Q, Birmpili P, Atkins E, Johal AS, Waton S, Williams R, Boyle JR, Harkin DW, Pherwani AD, Cromwell DA. Illness Trajectories After Revascularization in Patients With Peripheral Artery Disease: A Unified Approach to Understanding the Risk of Major Amputation and Death. Circulation 2024; 150:261-271. [PMID: 39038089 DOI: 10.1161/circulationaha.123.067687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 05/08/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND The aim of this study was to investigate the illness trajectories of patients with peripheral artery disease (PAD) after revascularization and estimate the independent risks of major amputation and death (from any cause) and their interaction. METHODS Data from Hospital Episode Statistics Admitted Patient Care were used to identify patients (≥50 years of age) who underwent lower limb revascularization for PAD in England from April 2013 to March 2020. A Markov illness-death model was developed to describe patterns of survival after the initial lower limb revascularization, if and when patients experienced major amputation, and survival after amputation. The model was also used to investigate the association between patient characteristics and these illness trajectories. We also analyzed the relative contribution of deaths after amputation to overall mortality and how the risk of mortality after amputation was related to the time from the index revascularization to amputation. RESULTS The study analyzed 94 690 patients undergoing lower limb revascularization for PAD from 2013 to 2020. The majority were men (65.6%), and the median age was 72 years (interquartile range, 64-79). One-third (34.8%) of patients had nonelective revascularization, whereas others had elective procedures. For nonelective patients, the amputation rate was 15.2% (95% CI, 14.4-16.0) and 19.9% (19.0-20.8) at 1 and 5 years after revascularization, respectively. For elective patients, the corresponding amputation rate was 2.7% (95% CI, 2.4-3.1) and 5.3% (4.9-5.8). Overall, the risk of major amputation was higher among patients who were younger, had tissue loss, diabetes, greater frailty, nonelective revascularization, and more distal procedures. The mortality rate at 5 years after revascularization was 64.3% (95% CI, 63.2-65.5) for nonelective patients and 33.0% (32.0-34.1) for elective patients. After major amputation, patients were at an increased risk of mortality if they underwent major amputation within 6 months after the index revascularization. CONCLUSIONS The illness-death model provides an integrated framework to understand patient outcomes after lower limb revascularization for PAD. Although mortality increased with age, the study highlights patients <60 years of age were at increased risk of major amputation, particularly after nonelective revascularization.
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Affiliation(s)
- Qiuju Li
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom (Q.L., D.A.C.)
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
| | - Panagiota Birmpili
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
- Hull York Medical School, Heslington, United Kingdom (P.B., E.A.)
| | - Eleanor Atkins
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
- Hull York Medical School, Heslington, United Kingdom (P.B., E.A.)
| | - Amundeep S Johal
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
| | - Sam Waton
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
| | - Robin Williams
- Department of Interventional Radiology, Freeman Hospital, Newcastle-upon-Tyne Hospitals, United Kingdom (R.W.)
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals, National Health Services Foundation Trust and Department of Surgery, University of Cambridge, United Kingdom (J.R.B.)
| | - Denis W Harkin
- Belfast Health and Social Care Trust, United Kingdom (D.W.H.)
- The Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, Dublin, Ireland (D.W.H.)
| | - Arun D Pherwani
- Keele University School of Medicine and University Hospitals of North Midlands National Health Services Trust, Stoke-On-Trent, United Kingdom (A.D.P.)
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom (Q.L., D.A.C.)
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
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Rosen MN, Mor R, Roberts DJ, McIsaac DI. Contraindications to use of neuraxial anesthesia for lower limb revascularization surgery in adults: a cross-sectional study. Can J Anaesth 2024; 71:808-817. [PMID: 37498443 DOI: 10.1007/s12630-023-02546-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 07/28/2023] Open
Abstract
PURPOSE Nonrandomized and some randomized data suggest neuraxial anesthesia may improve outcomes after lower limb revascularization surgery. Nevertheless, the prevalence of contraindications to neuraxial anesthesia in vascular surgery patients is unknown. We aimed to identify the prevalence of patients with contraindications to neuraxial anesthesia, and to derive and validate a case ascertainment algorithm identifying individuals likely to have contraindications. METHODS We conducted a historical cross-sectional study of open lower limb revascularization surgeries performed between 2019 and 2021 at The Ottawa Hospital. Medical records were reviewed for demographic data, admission, procedural characteristics, and presence of contraindications to neuraxial anesthesia. Case ascertainment algorithms to predict the presence of absolute contraindications to neuraxial anesthesia were derived and internally validated. RESULTS We identified 340 cases. General anesthesia was used in 219 (64.4%) cases, isolated neuraxial (spinal and/or epidural) in 106 (31.2%) cases, and general plus neuraxial in 15 (4.4%) cases. Seventy-eight (22.9%; 95% confidence interval [CI], 18.8 to 27.7) patients had absolute contraindications to neuraxial anesthesia, primarily because of anticoagulation or antiplatelet medication (89.4%); 21 (6.2%; 95% CI, 4.1 to 9.3) had relative contraindications, primarily long anticipated duration of surgery (16/21, 76.2%). We derived and validated three nested case-ascertainment algorithms. Using admission and procedure variables, discrimination was moderate with moderately explained variance, and calibration was inadequate for reliable use. Patient comorbidity and laboratory data did not improve algorithm performance. CONCLUSION Most patients undergoing lower limb revascularization surgery did not have absolute contraindications to neuraxial anesthesia. When present, contraindications typically related to anticoagulation. Admission, procedure, comorbidity, and laboratory data did not provide adequate accuracy to ascertain contraindication status.
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Affiliation(s)
- Michael N Rosen
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Rahul Mor
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Daniel I McIsaac
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Room B311, 1053 Carling Ave., Ottawa, ON, K1Y 4E9, Canada.
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Li A, Dreksler H, Nagpal SK, Brandys T, Jetty P, Dubois L, Parsons Leigh J, Stelfox HT, McIsaac DI, Roberts DJ. Outcomes After Neuraxial or Regional Anaesthesia Instead of General Anaesthesia for Lower Limb Revascularisation Surgery: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Studies. Eur J Vasc Endovasc Surg 2023; 65:379-390. [PMID: 36336286 DOI: 10.1016/j.ejvs.2022.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether receipt of neuraxial or regional anaesthesia instead of general anaesthesia for lower limb revascularisation surgery affects patient outcomes. DATA SOURCES MEDLINE, EMBASE, Evidence Based Medicine Reviews, and Google Scholar. REVIEW METHODS After protocol registration, the data sources were searched for randomised and non-randomised studies comparing neuraxial or regional anaesthesia with general anaesthesia for lower limb revascularisation surgery in adults. Two investigators independently selected articles, extracted data, and assessed risks of bias. Data were pooled using random effects models. GRADE was used to assess certainty in cumulative evidence. RESULTS From 10 755 citations identified, five randomised (n = 970) and 13 non-randomised (n = 96 800) studies were included. Use of neuraxial instead of general anaesthesia for lower limb revascularisation surgery was associated with no statistically significant reduction in short term (in hospital or 30 day) mortality in randomised studies (pooled odds ratio [OR] 0.77; 95% confidence interval [CI] 0.33 - 1.81; low certainty) and a statistically significant reduction in adjusted short term mortality in non-randomised studies (pooled OR 0.67; 95% CI 0.56 - 0.81; low certainty). Adults allocated to neuraxial anaesthesia in randomised studies had fewer pulmonary complications (pooled OR 0.35; 95% CI 0.16 - 0.76; low certainty). In non-randomised studies, neuraxial instead of general anaesthesia was associated with a lower adjusted odds of any morbidity (pooled OR 0.66; 95% CI 0.52 - 0.84), cardiac complications (pooled OR 0.68; 95% CI 0.58 - 0.79), pneumonia (pooled OR 0.81; 95% CI 0.64 - 1.02), prolonged mechanical ventilation (OR 0.09; 95% CI 0.002 - 0.55), and bypass graft thrombosis (OR 0.70; 95% CI 0.59 - 0.85), as well as a shorter operative duration (low certainty for all). Use of a nerve block instead of general anaesthesia was associated with a lower adjusted odds of delirium (OR 0.16; 95% CI 0.06 - 0.42) and a shorter operative duration (low certainty for both). CONCLUSION Randomised and non-randomised data suggest that neuraxial anaesthesia for lower limb revascularisation surgery reduces morbidity and possibly mortality. Until randomised trials with a low risk of bias become available, this study supports use of neuraxial anaesthesia for these procedures where appropriate.
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Affiliation(s)
- Allen Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Hannah Dreksler
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, Ontario, Canada; ICES, Ontario, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Alberta, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; ICES, Ontario, Canada; Department of Anaesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; O'Brien Institute for Public Health, University of Calgary, Alberta, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Birmpili P, Atkins E, Li Q, Johal AS, Waton S, Williams R, Pherwani AD, Cromwell DA. Evaluation of the ICD-10 system in coding revascularisation procedures in patients with peripheral arterial disease in England: A retrospective cohort study using national administrative and clinical databases. EClinicalMedicine 2023; 55:101738. [PMID: 36386037 PMCID: PMC9661515 DOI: 10.1016/j.eclinm.2022.101738] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Many studies evaluating care in hospitals in England use the Hospital Episode Statistics (HES) administrative database. The aim of this study was to explore whether the International Classification of Diseases 10th Revision (ICD-10) system used by HES supported the evaluation of care received by patients with peripheral arterial disease (PAD) who had revascularisation. METHODS This retrospective cohort study used records on patients who had revascularisation for PAD between 1st January 2017 and 31st December 2019 in England, collected prospectively in the National Vascular Registry (NVR) and linked to HES. Patients were excluded if their NVR record did not have a match in HES, due to lack of consent or different admission and procedure dates. Agreement between different presentations of PAD recorded in the NVR and the ICD-10 diagnostic codes recorded in HES was evaluated using the unweighted Kappa statistic and sensitivity and specificity. Agreement between the NVR and HES was also assessed for gender, age, comorbidities, mode of admission, and procedure type and side. FINDINGS In total, 20,603 patients who had 24,621 admissions were included in the study. Agreement between NVR and HES on patient gender (Kappa = 0.98), age (Kappa = 0.98), mode of admission (Kappa = 0.80), and procedure type and side (Kappa = 0.92 and 0.87, respectively) was excellent. When all diagnostic fields in HES were explored, substantial agreement was observed for chronic ischaemia with tissue loss (Kappa = 0.63), but it was lower for chronic ischaemia without tissue loss (Kappa = 0.32) and acute limb ischaemia (Kappa = 0.15). Agreement on comorbidities was mixed; excellent for diabetes (Kappa = 0.82), moderate for chronic lung disease (Kappa = 0.56), chronic kidney disease (Kappa = 0.56), and ischaemic heart disease (Kappa = 0.45) and fair for chronic heart failure (Kappa = 0.35). INTERPRETATION The diagnostic ICD-10 codes currently used in HES cannot accurately differentiate between stages of PAD. Therefore, studies using HES to examine patterns of care and outcomes for patients with PAD are likely to suffer from misclassification bias. Adopting an extended ICD-10 system or the ICD-11 version released to the World Health Organisation member states in 2022, may overcome this problem. FUNDING Healthcare Quality Improvement Partnership (HQIP).
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Affiliation(s)
- Panagiota Birmpili
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
- Corresponding author. Clinical Effectiveness Unit, The Royal College of Surgeons of England, Holborn, London, WC2A 3PE, UK.
| | - Eleanor Atkins
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Qiuju Li
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amundeep S. Johal
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Sam Waton
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Robin Williams
- Department of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Arun D. Pherwani
- Staffordshire & South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - David A. Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Zeller T, Brodmann M, Ansel GM, Scheinert D, Choi D, Tepe G, Menk J, Micari A. Paclitaxel-coated balloons for femoropopliteal peripheral arterial disease: final five-year results of the IN.PACT Global Study. EUROINTERVENTION 2022; 18:e940-e948. [PMID: 35635160 PMCID: PMC9743239 DOI: 10.4244/eij-d-21-01098] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/22/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Numerous randomised controlled trials (RCTs) have demonstrated the superiority of paclitaxel drug-coated balloons (DCBs) over non-coated angioplasty balloons for treatment of femoropopliteal peripheral arterial disease (PAD). There is a paucity of clinical evidence in more complex patients who are often excluded from RCTs and long-term data up to 5 years are very limited in PAD revascularisation studies. AIMS This is a report of the 5-year outcomes from the prospective, single-arm, international IN.PACT Global Study. The IN.PACT Admiral DCB was evaluated for femoropopliteal atherosclerotic disease treatment in a real-world patient population. METHODS In total, 1,535 patients were enrolled at 64 international sites. The prespecified clinical cohort included 1,406 patients with claudication or rest pain. Patients were evaluated up to 5 years for the occurrence of adverse events and clinically driven target lesion revascularisations (CD-TLR). RESULTS The mean lesion length was 12.1±9.5 cm in 1,774 lesions, 18.0% had in-stent restenosis, 35.5% were total occlusions and 68.7% were calcified. Per independent clinical events committee adjudication, the Kaplan-Meier estimate of freedom from CD-TLR up to 5 years was 69.4%, and the restricted mean survival time to first CD-TLR was 1,470.1 days. Outcomes were similar for males and females; freedom from CD-TLR was 69.1% in females and 69.6% in males (p=0.602). The cumulative incidence of major adverse events for the clinical cohort was 45.9% and freedom from all-cause mortality with the vital status update was 78.9% up to 5 years. CONCLUSIONS The IN.PACT Admiral DCB demonstrated safe and durable outcomes in real-world participants with complex femoropopliteal disease. CLINICALTRIALS gov: NCT01609296.
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Affiliation(s)
- Thomas Zeller
- Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | | | | | | | - Donghoon Choi
- Yonsei University, Yongin Severance Hospital, Yongin, Republic of Korea
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Spyrou JM, Minns Lowe C. An exploration of specialist clinicians' experiences and beliefs about inpatient amputee rehabilitation as a pathway option for adult primary amputees. Disabil Rehabil 2022; 44:6710-6721. [PMID: 34465267 DOI: 10.1080/09638288.2021.1970830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE To explore specialist amputee physiotherapists' experiences and subsequent views about specialist inpatient rehabilitation (IPR) as a National Health Service (NHS) pathway option for adult primary amputees and their perceptions and beliefs about the effects of inpatient amputee rehabilitation. MATERIALS AND METHODS A qualitative study using a phenomenological approach. Semi-structured interviews were completed with seven physiotherapists experienced in working in both specialist amputee inpatient and outpatient rehabilitation settings. Interviews were audio-recorded and fully transcribed. Data were analysed using thematic analyses; inductive coding was completed; emerging themes are shown and a conceptual framework was developed. To promote rigour, this study was peer reviewed and coding was done by two people. RESULTS Clinicians believed inpatient amputee rehabilitation to be the preferred model of rehabilitation for the majority of adult primary amputees. A central theme of healthcare inequality within primary amputee rehabilitation provision emerged with four sub-themes: IPR, outpatient rehabilitation, barriers, the ideal world. Geographical variation was described in: type of rehabilitation provided, timescales of prosthetic rehabilitation provision, fitting a prosthesis with wounds, and the availability of community rehabilitation services. CONCLUSIONS Healthcare inequality is a central concern identified by clinicians who work within amputee rehabilitation in the UK. Clinicians interviewed believe NHS specialist amputee inpatient rehabilitation should be a more accessible pathway.Implications for rehabilitationClinicians believe healthcare inequality exists within primary amputee rehabilitation provision in the UK National Health Service (NHS).Geographical variation in type of care provision, fitting a prosthesis with wounds, timescales in prosthetic rehabilitation provision and community rehabilitation services were described.Clinicians believe inpatient amputee rehabilitation to be the preferred model of care for the majority of adult primary amputees and should be a more accessible pathway within the NHS.Inpatient rehabilitation facilities may be a way of compensating for amputee rehabilitation inequalities.
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Affiliation(s)
- Jodie Marie Spyrou
- Department of Allied Health Professions, Midwifery and Social Work, School of Health and Social Work, University of Hertfordshire, Hatfield, UK.,Amputee Rehabilitation Unit, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Catherine Minns Lowe
- Department of Allied Health Professions, Midwifery and Social Work, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
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Weissler EH, Ford CB, Patel MR, Goodney P, Clark A, Long C, Jones WS. Younger patients with chronic limb threatening ischemia face more frequent amputations. Am Heart J 2021; 242:6-14. [PMID: 34371002 DOI: 10.1016/j.ahj.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/02/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Amputations among younger patients with chronic limb threatening ischemia (CLTI) may carry higher personal and societal costs, but younger patients are often not included in CLTI research because of dataset limitations. We aimed to characterize and compare outcomes between younger (<65 years old) and older patients with CLTI. METHODS This retrospective cohort study identified patients with CLTI between July 1, 2014 and December 31, 2017 in the MarketScan commercial claims database, a proprietary set of claims for over 50 million patients with private insurance in the United States. The primary outcome was major adverse limb events (MALE); secondary outcomes included amputations, major adverse cardiovascular events, and statin prescription fills. RESULTS The study cohort included 64,663 people with CLTI, of whom 25,595 (39.6%) were <65 years old. Younger patients were more likely to have diabetes mellitus (54.1% versus 49.9%, P<.001) but less likely to have other comorbidities. A higher proportion of younger patients suffered MALE (31.7% versus 30.2%, P=.002), specifically amputation (11.5% versus 9.3%, P<.001). After adjustment, age <65 years old was associated with a 24% increased risk of amputation (HRadj 1.24, 95%CI 1.18-1.32, P<.001) and a 10% increased risk of MALE (HRadj 1.10, 95%CI 1.07-1.14, P<.001). CONCLUSIONS A significant proportion of commercially insured patients with CLTI are under the age of 65, and younger patients have worse limb-related outcomes. These findings highlight the importance of aggressively treating risk factors for atherosclerosis and intentionally including younger patients with CLTI in future analyses to better understand their disease patterns and outcomes.
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Affiliation(s)
- E Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC.
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Phil Goodney
- Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Amy Clark
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Chandler Long
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC
| | - W Schuyler Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
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Creager MA, Matsushita K, Arya S, Beckman JA, Duval S, Goodney PP, Gutierrez JAT, Kaufman JA, Joynt Maddox KE, Pollak AW, Pradhan AD, Whitsel LP. Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association. Circulation 2021; 143:e875-e891. [PMID: 33761757 DOI: 10.1161/cir.0000000000000967] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.
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Risk factors for amputation are influenced by competing risk of death in patients with critical limb ischemia. J Vasc Surg 2020; 71:1305-1314.e5. [DOI: 10.1016/j.jvs.2019.07.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/15/2019] [Indexed: 12/22/2022]
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Dake MD, Ansel GM, Bosiers M, Holden A, Iida O, Jaff MR, Lottes AE, O'Leary EE, Saunders AT, Schermerhorn M, Yokoi H, Zeller T. Paclitaxel-Coated Zilver PTX Drug-Eluting Stent Treatment Does Not Result in Increased Long-Term All-Cause Mortality Compared to Uncoated Devices. Cardiovasc Intervent Radiol 2019; 43:8-19. [PMID: 31502026 PMCID: PMC6940321 DOI: 10.1007/s00270-019-02324-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/21/2019] [Indexed: 12/24/2022]
Abstract
Purpose Patient-level data from two large studies of the Zilver PTX drug-eluting stent (DES) with long-term follow-up and concurrent non-drug comparator groups were analyzed to determine whether there was an increased mortality risk due to paclitaxel. Methods Data from the Zilver PTX randomized controlled trial (RCT) and Zilver PTX and bare metal stent (BMS) Japan post-market surveillance studies were analyzed. Five-year follow-up is complete in both DES studies; follow-up for the BMS study was limited to 3 years and is complete. Kaplan–Meier analyses assessed mortality. A Cox proportional hazards model identified significant factors related to mortality. Results In the RCT, there were 336 patients treated with the DES and 143 patients treated with percutaneous transluminal angioplasty (PTA) or BMS. In Japan, there were 904 DES patients and 190 BMS patients. There was no difference in all-cause mortality for the DES compared to PTA/BMS in the RCT (19.1% DES versus 17.1% PTA/BMS through 5 years, p = 0.60) or Japan (15.8% DES versus 15.3% BMS through 3 years, p = 0.89). Cox proportional hazard models revealed that age, tissue loss, and congestive heart failure were significantly associated with mortality in the RCT, and critical limb ischemia, age, renal failure, and gender were significantly associated with mortality in Japan (all p < 0.05). Neither treatment with Zilver PTX (p = 0.46 RCT, p = 0.49 Japan) nor paclitaxel dose (p = 0.86 RCT, p = 0.07 Japan) was associated with mortality. Conclusion Analyses of the Zilver PTX patient-level data demonstrated no increase in long-term all-cause mortality. Level of Evidence Zilver PTX RCT: Level 1, randomized controlled trial; Japan PMS studies: Level 3, post-market surveillance study. Electronic supplementary material The online version of this article (10.1007/s00270-019-02324-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael D Dake
- The University of Arizona, Roy P. Drachman Hall Building, B207, 1295 North Martin Avenue, P.O. Box 210202, Tucson, AZ, 85721-0202, USA.
| | - Gary M Ansel
- Department of Medicine, Ohio Health/Riverside Methodist Hospital, Columbus, OH, USA
| | - Marc Bosiers
- Foundation of Cardiovascular Research and Education, Münster, Germany
| | - Andrew Holden
- Department of Interventional Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | | | | | | | | | - Marc Schermerhorn
- Division of Vascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hiroyoshi Yokoi
- Department of Cardiovascular Medicine, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Thomas Zeller
- Universitaets-Herz-Zentrum Freiburg - Bad Krozingen, Bad Krozingen, Germany
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Baubeta Fridh E, Andersson M, Thuresson M, Nordanstig J, Falkenberg M. Impact of Preoperative Symptoms and Revascularized Arterial Segment in Patients With Chronic Limb-Threatening Ischemia. Vasc Endovascular Surg 2019; 53:365-372. [DOI: 10.1177/1538574419834765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Erik Baubeta Fridh
- Department of Radiology, Ryhov County Hospital, Jönköping, Sweden
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Manne Andersson
- Department of Vascular Surgery, Ryhov County Hospital, Jönköping, Sweden
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | | | - Joakim Nordanstig
- Department of Vascular Surgery and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska University Hospital and Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Mårten Falkenberg
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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