Operations, total hospital stay and costs of critical leg ischemia. A population-based longitudinal outcome study of 321 patients

Impact of the Timing of Foot Tissue Resection on Outcomes in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia

The objective of this study is to describe utilization of revascularization and tissue resection in patients with chronic limb-threatening ischemia (CLTI) and determine whether the timing of resection impacts outcomes. Revascularizations for CLTI were queried (ACS-NSQIP 2011-2015). Outcomes included 30-day major adverse limb events (MALE), major adverse cardiac events (MACE), length of stay (LOS), operative time, 30-day readmissions, and wound infections. Groups included revascularization alone, revascularization/tissue resection during the same procedure (concurrent), or revascularization/delayed tissue resection (delayed). Resections were debridement or transmetatarsal amputations. Multivariate logistic regression determined risk-adjusted effects of tissue resection on outcomes. There was no difference in overall 30-day MACE or MALE between groups (P = .70 and P = .35, respectively). Length of stay (6.1 days revascularization alone vs 7.8 days concurrent vs 8.7 days delayed, P < .0001) was longer in patients who underwent any tissue resection. Highest 30-day readmission and operative time was the concurrent group (P = .02 and P < .0001, respectively). Wound infection was highest in the delayed group (1.4% revascularization alone vs 1.3% concurrent vs 6.2% delayed, P < .0001). After risk adjustment, timing of resection did not impact LOS for concurrent and delayed groups compared to revascularization alone (both P < .0001). Debridement and minor amputations can be done concurrently in patients undergoing revascularization for CLTI.

A Comparative Cost-Effectiveness Analysis of Percutaneous Transluminal Angioplasty With Optional Stenting and Femoropopliteal Bypass Surgery for Medium-Length TASC II B and C Femoropopliteal Lesions

Purpose: To evaluate the total midterm costs and cost-effectiveness of percutaneous transluminal angioplasty with optional stenting (PTA/S) as initial treatment compared with femoropopliteal bypass (FPB) surgery in patients with medium-length TransAtlantic Inter-Society Consensus II (TASC) B and C femoropopliteal lesions. Materials and Methods: Over a period of 3 years, all hospital health care costs for 226 consecutive patients were calculated: 170 patients with a TASC B lesion and 56 patients with a TASC C lesion. In the 135-patient PTA/S group (mean age 69.9±10.9 years; 83 men), 108 (63.5%) patients had TASC B lesions and 27 (48.2%) patients had TASC C lesions. Ninety-one patients (mean age 68.4±10.9 years; 60 men) were treated with FPB for 62 TASC B and 29 TASC C femoropopliteal lesions. The main outcome measure was the primary patency rate at 3-year follow-up. Multiple imputation and bootstrapping techniques were used to analyze the data. The adjusted incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in total costs by the difference in 3-year primary patency rate. Costs were expressed in euros (€), and cost differences are presented with the 95% confidence interval (CI). Results: Mean total costs per patient were €29,058 in the PTA/S treatment group vs €42,437 in the FPB group (mean adjusted difference –€14,820, 95% CI –€29,044 to −€5976). Differences in 3-year primary patency between PTA/S and FPB were small and nonsignificant (68.9% and 70.3%, respectively). An ICER of 563,716 was found, indicating that FPB costs €563,716 more per one extra patient reaching 3-year primary patency in comparison with PTA/S treatment. Conclusion: FPB in medium-length femoropopliteal lesions involved higher total costs when evaluated over a 3-year follow-up period. An endovascular-first approach is recommended, as this will result in cost minimization for patients with medium-length femoropopliteal disease.

Cost Analysis of Initial Treatment With Endovascular Revascularization, Open Surgery, or Primary Major Amputation in Patients With Peripheral Artery Disease

Purpose: To compare the total initial treatment costs for open surgery, endovascular revascularization, and primary major amputation within a single-payer healthcare system. Methods: A multicenter, retrospective analysis was undertaken to evaluate 1138 patients with symptomatic peripheral artery disease (PAD) who underwent 1017 endovascular procedures, 86 open surgeries, and 35 major amputations between 2013 and 2016. A cost-mix analysis was performed on individual patient data generated for selected diagnosis-related groups. Mean costs are presented with the 95% confidence interval (CI). Results: There was no intergroup difference in demographics or private health insurance status. However, the amputation group had a higher proportion of emergency procedures (68.6% vs 13.3% vs 27.9%, p<0.001) and critical limb ischemia (88.6% vs 35.9% vs 37.2%, p<0.001) compared with the endovascular therapy and open surgery groups, respectively. The endovascular revascularization group spent less time in hospital and used fewer intensive care unit (ICU) resources compared with the open surgery and major amputation groups (hospital length of stay: 3.4 vs 10.0 vs 20.2 days, p<0.01; ICU: 2.4 vs 22.6 vs 54.6 hours, p<0.01), respectively. While mean prosthetic and device costs were higher in the endovascular group [AUD$2770 vs AUD$1658 (open) and AUD$1219 (amputation), p<0.01], substantial disparities were observed in costs associated with longer operating theater times, length of stay, and ICU utilization, which resulted in significantly higher costs in the open and amputation groups. After adjusting for confounders, the AUD$18,396 (95% CI AUD$16,436 to AUD$20,356) mean cost per admission for the endovascular revascularization group was significantly less (p<0.001) than the open surgery (AUD$31,908, 95% CI AUD$28,285 to AUD$35,530) and major amputation groups (AUD$43,033, 95% CI AUD$37,706 to AUD$48,361). Conclusion: Endovascular revascularization procedures for PAD cost the health payer less compared with open surgery and primary amputation. While devices used to deliver contemporary endovascular therapy are more expensive, the reduction in bed days, ICU utilization, and related hospital resources results in a significantly lower mean total cost per admission for the initial treatment.

Regional variation in the cost of infrainguinal lower extremity bypass surgery in the United States

BACKGROUND

Lower extremity bypass (LEB) remains the gold standard revascularization procedure in patients with peripheral arterial disease. The cost of LEB substantially varies based on patient's characteristics and comorbidities. The aim of this study was to assess regional variation in infrainguinal LEB cost and to identify the specific health care expenditures per service that are associated with the highest cost in each region.

METHODS

We identified adult patients who underwent infrainguinal LEB in the Premier database between June 2009 and March 2015. Generalized linear regression models were used to report differences between regions in total in-hospital cost and service-specific cost adjusting for patient's demographics, clinical characteristics, and hospital factors.

RESULTS

A total of 50,131 patients were identified. The median in-hospital cost was $13,259 (interquartile range, $9308-$19,590). The cost of LEB was significantly higher in West and Northeast regions with a median cost of nearly $16,000. The high cost in the Northeast region was driven by the fixed (indirect) cost, whereas the driver of the high cost in the West region was the variable (direct) cost. The adjusted total in-hospital cost was significantly higher in all regions compared with the South (mean difference, West, $3752 [95% confidence interval (CI), 3477-4027]; Northeast, $2959 [95% CI, 2703-3216]; Midwest, 1586 [95% CI, 1364-1808]).

CONCLUSIONS

In this study, we show the marked regional variability in LEB costs. This disparity was independent from patient clinical condition and hospital factors. Cost inequality across the US represents a financial burden on both the patient and the health system.

Cell therapy of peripheral arterial disease: from experimental findings to clinical trials

The age-adjusted prevalence of peripheral arterial disease in the US population was estimated to approach 12% in 1985, and as the population ages, the overall population having peripheral arterial disease is predicted to rise. The clinical consequences of occlusive peripheral arterial disease include intermittent claudication, that is, pain with walking, and critical limb ischemia (CLI), which includes pain at rest and loss of tissue integrity in the distal limbs, which may ultimately lead to amputation of a portion of the lower extremity. The risk factors for CLI are similar to those linked to coronary artery disease and include advanced age, smoking, diabetes mellitus, hyperlipidemia, and hypertension. The worldwide incidence of CLI was estimated to be 500 to 1000 cases per million people per year in 1991. The prognosis is poor for CLI subjects with advanced limb disease. One study of >400 such subjects in the United Kingdom found that 25% required amputation and 20% (including some subjects who had required amputation) died within 1 year. In the United States, ≈280 lower-limb amputations for ischemic disease are performed per million people each year. The first objective in treating CLI is to increase blood circulation to the affected limb. Theoretically, increased blood flow could be achieved by increasing the number of vessels that supply the ischemic tissue with blood. The use of pharmacological agents to induce new blood vessel growth for the treatment or prevention of pathological clinical conditions has been called therapeutic angiogenesis. Since the identification of the endothelial progenitor cell in 1997 by Asahara and Isner, the field of cell-based therapies for peripheral arterial disease has been in a state of continuous evolution. Here, we review the current state of that field.

The economic burden of diabetic foot and ankle disorders

Physicians specializing in the care of patients with lower extremity disorders are acutely aware of the many adverse effects of diabetes mellitus and its secondary complications on all body systems. However, the disease has a devastating socioeconomic impact, as well. An estimated $98 billion in direct and indirect medical costs was spent on diabetes in 1997 in the United States. With a growing older population, cases of diabetes mellitus will certainly increase. The economic impact and clinical effectiveness of patient evaluation, preventive strategies, and treatment options are discussed.

From major amputation to prosthetic outcome: a prospective study of 190 patients in a defined population

In this prospective study, the overall treatment and outcome of patients that underwent major lower limb amputation in a defined population is described. The study was performed over a five year period in the Health Care District of North-East Skåne, Sweden. Some 190 patients, permanent inhabitants of the Health Care District, underwent major lower limb amputation. Sixteen (16) of these patients had amputations before the study started and went through late second leg amputation during the period. One hundred and seventy four (174) patients had primary major amputation. Seventy nine (79) were men and 95 were women, with a median age of 81. The re-amputation rate was 17% although the primary knee preservation ratio was as high as 3.0:1. Rigid dressing was the standard method following trans-tibial amputation and was used for 5-7 days. ICEROSS silicone liner was used for compression therapy in 90% of all cases that resulted in delivery of a prosthesis. Prostheses were delivered to 43% of all patients with primary amputations. These patients spent a median of 13 days at the orthopaedic clinic. 55 days at the rehabilitation unit. Pressure casting was used as a standard method in the production of the prosthetic socket. ICEX carbon-fibre socket was used in 52%. New procedures, treatments and techniques were introduced, standardised and evaluated whilst the routines in the hospital were reorganised. In this way, a system has been implemented that better guarantees the outcome of the whole procedure and the service received by this category of patients.

Adenoviral-mediated gene transfer of vascular endothelial growth factor in critical limb ischemia: safety results from a phase I trial

Critical limb ischemia (CLI) is typified by rest pain and/or tissue necrosis secondary to advanced peripheral arterial disease (PAD) and is characterized by diminution in limb perfusion at rest. We tested the safety of an angiogenic strategy with CI-1023 (Ad(GV)VEGF121.10), a replication-deficient adenovirus encoding human vascular endothelial growth factor isoform 121 in patients with CLI as part of a phase I trial. Fifteen subjects >35 years of age with CLI and angiographic disease involving the infra-inguinal vessels underwent intramuscular injection of CI-1023 (4 x 10(8) to 4 x 10(10) particle units, n = 13) or placebo (n = 2). All of the patients tolerated the injection well and there were no serious complications related to the procedure. Transient edema was noted in one patient. A total of 79 adverse events were reported over the course of one year. One death (day 136) and one malignancy (day 332) occurred in the CI-1023 group. CI-1023 appears to be well tolerated and safe for single-dose administration in patients with critical limb ischemia due to PAD. Further studies are needed to determine the efficacy of this form of therapeutic angiogenesis.

Causes, investigation and treatment of leg ulceration

Chronic ulceration of the lower leg is a frequent condition, with a prevalence of 3-5% in the population over 65 years of age. The incidence of ulceration is rising as a result of the ageing population and increased risk factors for atherosclerotic occlusion such as smoking, obesity and diabetes. Ulcers can be defined as wounds with a 'full thickness depth' and a 'slow healing tendency'. In general, the slow healing tendency is not simply explained by depth and size, but caused by an underlying pathogenetic factor that needs to be removed to induce healing. The main causes are venous valve insufficiency, lower extremity arterial disease and diabetes. Less frequent conditions are infection, vasculitis, skin malignancies and ulcerating skin diseases such as pyoderma gangrenosum. But even rarer conditions exist, such as the recently discovered combination of vasculitis and hypercoagulability. For a proper treatment of patients with leg ulcers, it is important to be aware of the large differential diagnosis of leg ulceration.

Current status of mind-body interventions for vascular complications of diabetes

Impaired peripheral blood flow causes complications, disabilities, expenses, and deaths among persons with diabetes mellitus. Many individuals suffer from lower-extremity pain, reduced functional status, and impaired quality of life. Current conventional treatments include lifestyle modification, exercise, medication, and surgery. However, these approaches are often impractical or insufficient. Thermal biofeedback, however, alone or in conjunction with other mind-body techniques, improves peripheral circulation, pain, neuropathy, ulcer healing, ambulatory activity, and quality of life. It is noninvasive, inexpensive, and consistent with community-based approaches to diabetes self-management. As an adjunct to the medical management of diabetes, thermal biofeedback may help ameliorate some of the vascular complications.

Management of chronic critical limb ischemia

The patient with CLI is challenging and requires a multi-disciplinary approach to effective management that involves a team of individuals proficient in various aspects of vascular disease. Fig. 4 details the approach at the University of Michigan's comprehensive vascular medicine program.

A bibliography of cost-effectiveness practices in physical medicine and rehabilitation: AAPM&R white paper

Cost-effectiveness studies attempt to determine the ratio of costs to outcomes of a particular intervention or treatment and to compare a standard intervention with an alternative intervention to determine if the alternative is more cost effective. The goal is to establish priorities for the resources allocation and to decide among alternative interventions for the same medical condition. The global process of rehabilitation does not usually lend itself to cost-effective analysis (due to the complex set of treatments provided) but rather to specific interventions and specific aspects of outcome. The American Academy of Physical Medicine and Rehabilitation has published a cost effectiveness annotated bibliography on the Internet (http://www.aapmr.org/memphys/cebfinala.htm) that identifies 132 studies in the literature that meet specified criteria and are related to the field of rehabilitation. This White Paper attempts to interpret and synthesize the studies in that bibliography that relate to stroke, spinal cord injury (SCI), orthopedic conditions, pain syndromes, amputations, and traumatic brain injury (TBI). Most studies support the cost effectiveness of care for stroke and SCI in dedicated units or centers rather than in a general medical unit. Studies also support back programs and revascularization procedures in limb ischemia. Studies in TBI underscore the significant financial resources for the care of these patients as well as the potential benefit from rehabilitation services even in the most severely injured. Further high quality research in this area is needed.

Costing vascular surgery: A review of current reporting practice

OBJECTIVE

The objective of this study was to assess the level of reporting in economic studies in the area of peripheral vascular disease. Adequate reporting of data is necessary to judge the quality of economic studies by means of critical appraisal criteria.

METHODS

A systematic review of the journal literature between 1986 and the first half of 1997 was undertaken. Studies that have attempted to estimate the resource consequences of one or more vascular procedure were the focus of the review. The extent of reporting in each study was assessed by using published guidelines.

RESULTS

The review identified 30 articles from nine different countries for inclusion in the study. Of these, more than half were published in the last 2(1/2) years of the search period, indicating a recent and rapid growth in economic studies in this area. When subjected to the reporting guidelines, the studies performed rather poorly overall.

CONCLUSIONS

Although the vascular studies can be criticized for inadequate reporting of economic data, it appears from the limited evidence from elsewhere that inadequate reporting is a problem in other clinical areas. In view of the importance of reporting to the ability to critically assess studies-and thus separate the "good" from the "bad"-there is a need for reporting to improve future published studies.

Cost of prostheses in patients with unilateral transtibial amputation for vascular disease. A population-based follow-up during 8 years of 112 patients

We analyzed the cost of prostheses for patients amputated because of vascular disease. During 1 year, 112 patients were treated with a primary unilateral transtibial amputation in Malmöhus county, Sweden, which has 527,000 inhabitants. During the first 6 months after the amputation, 50% (56/112) of the patients had received a prosthesis. At 6 months, 49 patients (7 had died) were examined, 18 had poor and 31 had good prosthetic function. Within 1 year, 71 (63%) patients had been fitted with a prosthesis. During 8 years after the amputation, they received altogether 137 prostheses and 54 exchange sockets; 59% of the prostheses and 26% of the sockets were delivered during the first year. Each patient received a median of 1 prosthesis and 1 extra socket. During the 8-year period, the total cost of prostheses, sockets and maintenance for the 71 patients was USD 228,746, representing a median cost of USD 1,582 per patient. The total cost of maintenance of the prostheses during the same period was USD 37,959, representing 20% of the total cost of all the prostheses and sockets. There was no statistically significant difference in the costs between patients with good or poor function.