Quality of care among patients undergoing lower extremity revascularization

Abstract

Background: Compliance with guidelines for treating patients with peripheral artery disease (PAD) lags compliance for treating patients with coronary artery disease. We assessed the gap between guidelines and practice for patients with PAD who underwent lower extremity revascularization (LER) at our institution from 2007 to 2010. Methods: Quality of care (QoC) was calculated by measuring provider performance on four indicators (antiplatelet therapy, dyslipidemia management, control of hypertension, and diabetes) derived from the ACCF/AHA PAD guidelines. The QoC score was calculated at the time of admission and at time of discharge for each patient, and reflects the proportion of indicated treatments received. Results: Patients (n = 734, mean age 70±11, female 51%) were followed for a mean of 2.0±1.4 years (range 0-5.7) following LER. The indication for LER was claudication (24.8%), rest pain (16.7%), and tissue loss (58.4%). The percentage of patients with a perfect QoC score increased significantly during hospital admission (11% to 21%, p < 0.001). Significant multivariate predictors of perfect QoC score included race/ethnicity, Charlson score, severity of LE ischemia, and observation period (admission, discharge). Multivariate analysis demonstrated that age>75 years, heart failure, chronic kidney disease, rest pain, and tissue loss-but not compliance with four guideline-based therapies-were associated with decreased freedom from the composite endpoint of major amputation, repeat revascularization, and death. Conclusions: Although adherence to guidelines improved over time, we found a significant gap between guidelines and practice for this cohort of patients at increased risk for adverse cardiovascular events.

Long-term outcomes in patients with critical limb ischemia and heart failure with preserved or reduced ejection fraction

“…Previous studies evaluating the impact of heart failure on short-term mortality and limb outcomes in CLI patients have demonstrated that heart failure is associated with increased mortality. 13,17,[30][31][32][33] However, mortality data extending beyond 1-year post-intervention is scarce and many have focused only on reduced ejection fraction as a risk factor for increased mortality. 11,14,15 The study by Meltzer and colleagues is the only other to our knowledge that directly compared the outcomes of PAD patients with heart failure based on ejection fraction.…”

Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use is associated with reduced major adverse cardiovascular events among patients with critical limb ischemia

“…Among patients with claudication or CLI undergoing lower extremity revascularization, Slovut et al recently reported a 48% rate of ACEI use at both admission and discharge. 43 In a study analyzing data from a general PAD population, Pande et al 44 reported trends of secondary preventive therapies using the National Health and Nutrition Examination Survey and found a 21% rate of ACEI use. This substantial difference may be due in part to our inclusion of a higher-risk group of CLI patients who often present with more severe PAD symptoms and comorbidities, such as diabetes and HTN.…”

Vascular specialist response to Medicare Evidence Development Coverage Advisory Committee (MEDCAC) panel on peripheral artery disease of the lower extremities

“…21 A number of observational and single center studies have shown that patients with PAD and CLI are under-treated with guideline-recommended therapies (anti-platelet therapy, statins, and antihypertensive therapies). 22 Furthermore, under-treatment with guideline-recommended therapies was associated with increased repeat revascularization and amputation in patients undergoing revascularization. 23…”

“…21 A number of observational and single center studies have shown that patients with PAD and CLI are under-treated with guideline-recommended therapies (anti-platelet therapy, statins, and antihypertensive therapies). 22 Furthermore, under-treatment with guideline-recommended therapies was associated with increased repeat revascularization and amputation in patients undergoing revascularization. 23 The role of supervised exercise training is limited in patients with CLI, given the extent of disease, associated ulcers or gangrene, and the fact that arterial perfusion is inadequate for basal metabolic requirements and not sufficient to improve the metabolic efficiency of exercising muscles.…”