- Email: [email protected]
PC156 Variation in Emergency Department Treatment of Patients With Critical Limb Ischemia
182S
Journal of Vascular Surgery
Abstracts
June Supplement 2017
PC156. Variation in Emergency Department Treatment of Patients With Critical Limb Ischemia Julia Glaser, Paul J. Foley, Grace J. Wang, Benjamin M. Jackson, Ronald M. Fairman, Scott M. Damrauer. University of Pennsylvania Health System, Philadelphia, Pennsylvania Objectives: Regional variation has been shown to exist in the treatment of lower extremity disease. Additionally, lower socioeconomic status is associated with later presentation and worse outcomes in vascular surgery. The decision to admit or discharge a patient with critical limb ischemia (CLI) from the emergency department (ED) depends on many factors. This study examined patient and hospital characteristics associated with disposition from the ED. Methods: Data from the Nationwide Emergency Department Sample, a stratified sample of 20% of EDs nationwide, was used. Patients presenting with rest pain, ischemic ulceration, or ischemic gangrene were selected. Patient and hospital characteristics associated with admission or discharge were calculated. Weighted logistic regression was used to determine predictors of admission to the hospital. Results: A total of 59,005 patients presented to the ED with CLI: 13.2% (n ¼ 7772) with rest pain, 32.0% (n ¼ 18,903) with ulceration, and 54.8% (n ¼ 32,330) with gangrene. Patients were an average age of 69.7 years, and 42.3% (n ¼ 24,942) were female. The overall admission rate was 96.2% (n ¼ 56,788). The rate of admission was significantly higher for gangrene (98.9% [n ¼ 31,640]) than for ulceration (95.0% [n ¼ 17,498]) and rest pain (92.7% [n ¼ 7201]; P < .01). Uninsured patients had the lowest rate of admission (91.0% [n ¼ 1749]); 96.5% (n ¼ 41,782) of Medicare, 95.7% (n ¼ 6014), and 96.4% (n ¼ 5807) of privately insured patients were admitted (P < .01). Admission rates were not significantly different between patients in the highest (96.1% [n ¼ 18,448]) and lowest (96.5% [n ¼ 11,536]) zip code income quartiles (P ¼ .88). Admission rates varied significantly by region (98.1%, Northeast; 95.6%, Northwest; 96.4%, South; 94.1%, West; P < .01). Urban hospitals were more likely to admit (96.7%) than micropolitan or rural EDs (90.5%; P < .01). On multivariate analysis, ulceration (odds ratio [OR], 1.47; confidence interval [CI], 1.08-2.00; P ¼ .01) and gangrene (OR, 3.69; CI, 2.515.44; P < .01) were predictive of admission (referent to rest pain). Lack of insurance (OR, 0.39; CI, 0.24-0.62; P < .01), region (Northwest: OR, 0.51; CI, 0.28-0.91; P ¼ .024; South: OR, 0.53; CI, 0.29-0.97; P ¼ .04; West: OR, 0.27; CI, 0.13-0.55; P < .01; referent to Northeast), and metropolitan teaching hospital (OR, 0.62; CI, 0.41-0.94; P ¼ .24) or nonmetropolitan (OR, 0.21; CI, 0.11-0.42; P < .01; referent to metropolitan nonteaching hospital) were associated with a decreased likelihood of admission. Conclusions: The majority of patients who present to the ED with CLI are admitted to the hospital from the ED. Admission rates are lower for uninsured patients, possibly reflecting a disparity in care. Author Disclosures: S. M. Damrauer: Nothing to disclose; R. M. Fairman: Nothing to disclose; P. J. Foley: Nothing to disclose; J. Glaser: Nothing to disclose; B. M. Jackson: Nothing to disclose; G. J. Wang: Nothing to disclose.
PC158. Long-Term Outcomes After Endovascular Stent Placement for Symptomatic, Long-Segment Superficial Femoral Artery Lesions Nader Zamani, Sherene Sharath, Rocky Browder, Neal R. Barshes, Houssam Younes, Jonathan Braun, Panos Kougias. Baylor College of Medicine, Houston, Tex Objectives: Endovascular intervention is commonly pursued for the treatment of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare-metal stents (BMS), covered stents (CS), and drug-eluting (DES) stents for long-segment SFA lesions remain uncertain.
Fig 1.
Fig 2. Methods: A retrospective cohort study identified consecutive patients with symptomatic SFA occlusions measuring at least 15 cm who received an endovascular stent (BMS, CS, or DES). The primary outcome of interest was patency, while secondary outcomes included postoperative presentation with acute limb ischemia (ALI), number of reoperations, and limb salvage. Patency rates were compared using time-to-event analysis and log-rank tests. Results: From 186 patients that were identified, a total of 215 procedures were analyzed (BMS: 113 [52%]; CS: 75 [35%]; DES: 27 [13%]) with a median follow-up time of 56 months (although the follow-up for DES was less: median, 10 months; P < .001). There were no significant differences among the groups with respect to mean age, diabetes status, renal dysfunction, and lower extremity runoff (mean 2.0 6 0.7 vessels). The mean length of the SFA lesion being treated in this series was 27 6 8 cm (also similar across all groups, P ¼ .165). Although primary and secondary patency rates were not significantly different among the stent types, DES is associated with an improved short-term primary-assisted patency, with 6-, 12-, and 24-month rates of 92%, 92%, and 83%, respectively. This is compared to 80%, 57%, and 47% for BMS, and 80%, 49%, and 41% for CS, respectively (log-rank test: P ¼ .009; Fig 1). In comparing only BMS with CS, 5- and 8-year primary-assisted patency rates are also higher among BMS: 60% and 60% vs 33% and 33% for CS, respectively (P ¼ .011; Fig 2). Zero DES patients have presented postoperatively with ALI compared to 3% of BMS patients and 13% of CS patients (P ¼ .004). Similarly, the CS group had a higher rate of subsequent open revascularization (32%) compared with BMS (24%) and DES (7%; P ¼ .038). Conclusions: Although long-term primary-assisted patency is greater in BMS as compared to CS, primary and secondary patency rates among all
Journal of Vascular Surgery
Abstracts
June Supplement 2017
PC156. Variation in Emergency Department Treatment of Patients With Critical Limb Ischemia Julia Glaser, Paul J. Foley, Grace J. Wang, Benjamin M. Jackson, Ronald M. Fairman, Scott M. Damrauer. University of Pennsylvania Health System, Philadelphia, Pennsylvania Objectives: Regional variation has been shown to exist in the treatment of lower extremity disease. Additionally, lower socioeconomic status is associated with later presentation and worse outcomes in vascular surgery. The decision to admit or discharge a patient with critical limb ischemia (CLI) from the emergency department (ED) depends on many factors. This study examined patient and hospital characteristics associated with disposition from the ED. Methods: Data from the Nationwide Emergency Department Sample, a stratified sample of 20% of EDs nationwide, was used. Patients presenting with rest pain, ischemic ulceration, or ischemic gangrene were selected. Patient and hospital characteristics associated with admission or discharge were calculated. Weighted logistic regression was used to determine predictors of admission to the hospital. Results: A total of 59,005 patients presented to the ED with CLI: 13.2% (n ¼ 7772) with rest pain, 32.0% (n ¼ 18,903) with ulceration, and 54.8% (n ¼ 32,330) with gangrene. Patients were an average age of 69.7 years, and 42.3% (n ¼ 24,942) were female. The overall admission rate was 96.2% (n ¼ 56,788). The rate of admission was significantly higher for gangrene (98.9% [n ¼ 31,640]) than for ulceration (95.0% [n ¼ 17,498]) and rest pain (92.7% [n ¼ 7201]; P < .01). Uninsured patients had the lowest rate of admission (91.0% [n ¼ 1749]); 96.5% (n ¼ 41,782) of Medicare, 95.7% (n ¼ 6014), and 96.4% (n ¼ 5807) of privately insured patients were admitted (P < .01). Admission rates were not significantly different between patients in the highest (96.1% [n ¼ 18,448]) and lowest (96.5% [n ¼ 11,536]) zip code income quartiles (P ¼ .88). Admission rates varied significantly by region (98.1%, Northeast; 95.6%, Northwest; 96.4%, South; 94.1%, West; P < .01). Urban hospitals were more likely to admit (96.7%) than micropolitan or rural EDs (90.5%; P < .01). On multivariate analysis, ulceration (odds ratio [OR], 1.47; confidence interval [CI], 1.08-2.00; P ¼ .01) and gangrene (OR, 3.69; CI, 2.515.44; P < .01) were predictive of admission (referent to rest pain). Lack of insurance (OR, 0.39; CI, 0.24-0.62; P < .01), region (Northwest: OR, 0.51; CI, 0.28-0.91; P ¼ .024; South: OR, 0.53; CI, 0.29-0.97; P ¼ .04; West: OR, 0.27; CI, 0.13-0.55; P < .01; referent to Northeast), and metropolitan teaching hospital (OR, 0.62; CI, 0.41-0.94; P ¼ .24) or nonmetropolitan (OR, 0.21; CI, 0.11-0.42; P < .01; referent to metropolitan nonteaching hospital) were associated with a decreased likelihood of admission. Conclusions: The majority of patients who present to the ED with CLI are admitted to the hospital from the ED. Admission rates are lower for uninsured patients, possibly reflecting a disparity in care. Author Disclosures: S. M. Damrauer: Nothing to disclose; R. M. Fairman: Nothing to disclose; P. J. Foley: Nothing to disclose; J. Glaser: Nothing to disclose; B. M. Jackson: Nothing to disclose; G. J. Wang: Nothing to disclose.
PC158. Long-Term Outcomes After Endovascular Stent Placement for Symptomatic, Long-Segment Superficial Femoral Artery Lesions Nader Zamani, Sherene Sharath, Rocky Browder, Neal R. Barshes, Houssam Younes, Jonathan Braun, Panos Kougias. Baylor College of Medicine, Houston, Tex Objectives: Endovascular intervention is commonly pursued for the treatment of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare-metal stents (BMS), covered stents (CS), and drug-eluting (DES) stents for long-segment SFA lesions remain uncertain.
Fig 1.
Fig 2. Methods: A retrospective cohort study identified consecutive patients with symptomatic SFA occlusions measuring at least 15 cm who received an endovascular stent (BMS, CS, or DES). The primary outcome of interest was patency, while secondary outcomes included postoperative presentation with acute limb ischemia (ALI), number of reoperations, and limb salvage. Patency rates were compared using time-to-event analysis and log-rank tests. Results: From 186 patients that were identified, a total of 215 procedures were analyzed (BMS: 113 [52%]; CS: 75 [35%]; DES: 27 [13%]) with a median follow-up time of 56 months (although the follow-up for DES was less: median, 10 months; P < .001). There were no significant differences among the groups with respect to mean age, diabetes status, renal dysfunction, and lower extremity runoff (mean 2.0 6 0.7 vessels). The mean length of the SFA lesion being treated in this series was 27 6 8 cm (also similar across all groups, P ¼ .165). Although primary and secondary patency rates were not significantly different among the stent types, DES is associated with an improved short-term primary-assisted patency, with 6-, 12-, and 24-month rates of 92%, 92%, and 83%, respectively. This is compared to 80%, 57%, and 47% for BMS, and 80%, 49%, and 41% for CS, respectively (log-rank test: P ¼ .009; Fig 1). In comparing only BMS with CS, 5- and 8-year primary-assisted patency rates are also higher among BMS: 60% and 60% vs 33% and 33% for CS, respectively (P ¼ .011; Fig 2). Zero DES patients have presented postoperatively with ALI compared to 3% of BMS patients and 13% of CS patients (P ¼ .004). Similarly, the CS group had a higher rate of subsequent open revascularization (32%) compared with BMS (24%) and DES (7%; P ¼ .038). Conclusions: Although long-term primary-assisted patency is greater in BMS as compared to CS, primary and secondary patency rates among all