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Evaluation rates for PAD before amputation low
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Rates of evaluation for peripheral arterial disease before amputation were low for Medicare beneficiaries from 2002 to 2010, according to a new analysis.
Researchers found that only 68.4% of 17,463 patients studied who underwent nontraumatic amputation had some sort of arterial testing performed beforehand. The rates varied by patient, provider and regional characteristics.
Sreekanth Vemulapalli, MD, and colleagues at Duke University School of Medicine searched carrier claims submitted between 2002 and 2010 to identify patients who underwent lower-extremity amputation. Cases also were searched for these forms of testing performed up to 12 months before the amputation: ankle-brachial index (ABI) measurement, lower-extremity arterial duplex ultrasound, lower-extremity CTA, lower-extremity MR angiography and lower-extremity angiography. In a sensitivity analysis, the search was widened to tests performed up to 24 months before amputation. The mean age of the cohort was 73.8 years, and 49% were women and 71.8% were white.
Of the patients who underwent some form of testing, 47.5% had ABI measurement, 38.7% had duplex ultrasound, 31.1% had invasive angiography, 6.7% had CTA and 5.6% had MR angiography. In the 12 to 24 months before amputation, 54.1% of patients were known to have PAD, 47% had ischemic heart disease, 35.4% had HF, 62.8% had diabetes and 27.7% had renal disease.
The rate of those undergoing some form of testing increased from 65.7% in 2002 to 69.2% in 2010 (P<.001). However, Vemulapalli and colleagues wrote, rates for foot, above-knee and below-knee amputations remained lower than 80% during the study period despite guidelines suggesting that at-risk patients be screened for PAD with arterial testing. “The change … was clinically negligible,” the researchers wrote.
Patients undergoing foot amputations (n=7,343) had pre-amputation testing performed 62.5% of the time vs. 76.7% for those undergoing below-knee amputations (n=4,804) and 69% for those undergoing above-knee amputations (n=5,316; P<.001).
After multivariable adjustment, the following factors were associated with greater rates of pre-amputation arterial testing: age 65 years or older, male sex, black race, renal disease, diabetes, known PAD, evaluation by a vascular specialist and living in the East North Central region.
According to the researchers, alternative treatment options for PAD cannot be explored until a PAD diagnosis has been made, and therefore “the threshold for measurement with ABI should be low,” although ABI is not specifically validated as a screening tool.
It is unclear how generalizable the findings are outside the population of patients enrolled in fee-for-service Medicare. It also is possible that unbilled bedside Doppler or ABI exams were missed, the researchers wrote.
Disclosure: See the full study for a list of the researchers’ relevant financial disclosures.
Perspective
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Gary M. Ansel, MD, FACC
The study reaffirms that many patients with nontraumatic limb problems undergo amputation without formal vascular perfusion evaluation. The study is consistent with earlier studies that evaluated this at an earlier time point. Although there are many more options for patients with limb-threatening ischemia, it does not appear on the surface that we have increased our screening for this etiology.
When looking at this on a local scale, we have found multiple factors that affected the rate of arterial testing. We are doing better, but I do not think the number will get to an 80% rate for many reasons. The major reasons in my experience are as follows:
One, physicians trust their physical exams as much as most noninvasive studies. In the past, this seemed reasonable, but with the improved reperfusion technologies and surgical procedures coupled with the realization that revascularizing a specific angiosome improves the chance of healing, physician exam alone by a nonvascular specialist physician can no longer be justified. Not all patients may need a formal study after being seen by a vascular specialist, but documentation for many of these patients’ current vascular status seems reasonable in my view.
Two, the limb is too far gone to be salvaged. Certainly, not all patients with advanced limb gangrene that is not salvageable need further testing.
Three, pain control. Again, not all patients will need a formal vascular test if there are good pulses.
What can help is continued education of the surgeons that perform these procedures, as well as the wound care physicians and primary care physicians. There is such a need for education. Since the majority of these patients are diabetic, it might be reasonable to get the American Diabetes Association involved with educating the patients so that they are empowered to get the message out to the patients as well. Often, it is the delay in vascular consultation and improving the perfusion of the patient with limb ischemia that can lead to worsening of a wound and potential amputation. Many of the reperfusion techniques can be completed percutaneously at very low risk. Even open surgery can be completed with acceptable risk in many of these patients.
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