Division of Vascular and Endovascular Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.
J Vasc Surg. 2013 Mar;57(3):784-90. doi: 10.1016/j.jvs.2012.09.035. Epub 2013 Jan 9.
Major amputation is associated with increased short-term healthcare resource utilization (RU), early mortality, and socioeconomic status (SES) disparities. Our objective is to study patient-specific and SES-related predictors of long-term RU and survival after amputation.
This retrospective analysis identified 364 adult patients who underwent index major amputation for critical limb ischemia from January 1995 through December 2000 at two tertiary centers with outcomes through December 2010. Age, gender, SES (race, income, insurance, and marital status), comorbidities (congestive heart failure [CHF], diabetes, diabetes with complications, and renal failure [RF]), subsequent procedures, cumulative length of stay (cLOS), and mortality were analyzed. Bivariate and multivariate Poisson regression for subsequent procedures and cLOS and Cox proportional hazard modeling for all-cause mortality were undertaken.
During a mean follow-up of 3.25 years, amputation patients had mean cLOS of 71.2 days per person-year (median, 17.6), 19.5 readmissions per person-year (median, 2.1), 0.57 amputation-related procedures (median, 0), and 0.31 cardiovascular procedures (median, 0). Below-knee amputation as the index procedure was performed in 70% of patients, and 25% had additional amputation procedures. Of readmissions at ≤ 30 days, 52% were amputation-related. Overall mortality during follow-up was 86.9%; 37 patients (10.2%) died within 30 days. Among patients surviving >30 days, multivariate Poisson regression demonstrated that younger age (incidence rate ratio [IRR], 0.98), public insurance (IRR, 1.63), CHF (IRR, 1.60), and RF (IRR, 2.12) were associated with increased cLOS. Diabetes with complications (IRR, 1.90) and RF (IRR, 2.47) affected subsequent amputation procedures. CHF (IRR, 1.83) and RF (IRR, 3.67) were associated with a greater number of cardiovascular procedures. Cox proportional hazard modeling indicated older age (hazard ratio [HR], 1.04), CHF (HR, 2.26), and RF (HR, 2.60) were risk factors for decreased survival. Factors associated with SES were not significantly related to the outcomes.
This study found that RU is high for amputees, and increased RU persists beyond the perioperative period. Results were similar across SES indices, suggesting higher SES may not be protective against poor outcomes when limb salvage is no longer attainable. These findings support the hypothesis that SES disparities may be more modifiable during earlier stages of care for critical limb ischemia.
大截肢与短期医疗资源利用（RU）增加、早期死亡率和社会经济地位（SES）差异有关。我们的目的是研究与患者特定和 SES 相关的预测因素，以预测截肢后的长期 RU 和生存。
本回顾性分析确定了 1995 年 1 月至 2000 年 12 月期间在两个三级中心接受主要大截肢治疗严重肢体缺血的 364 名成年患者，其结果截至 2010 年 12 月。年龄、性别、SES（种族、收入、保险和婚姻状况）、合并症（充血性心力衰竭[CHF]、糖尿病、糖尿病合并并发症和肾功能衰竭[RF]）、后续程序、累积住院时间（cLOS）和死亡率进行了分析。进行了后续程序和 cLOS 的双变量和多变量泊松回归，以及所有原因死亡率的 Cox 比例风险模型。
在平均 3.25 年的随访期间，截肢患者的人均 cLOS 为每年 71.2 天（中位数，17.6），每年 19.5 次再入院（中位数，2.1），每年 0.57 次截肢相关程序（中位数，0），每年 0.31 次心血管程序（中位数，0）。70%的患者接受了膝下截肢作为主要手术，25%的患者接受了额外的截肢手术。在 30 天内的再入院中，52%与截肢有关。随访期间的总死亡率为 86.9%；37 名患者（10.2%）在 30 天内死亡。在存活超过 30 天的患者中，多变量泊松回归表明年龄较小（发病率比[IRR]，0.98）、公共保险（IRR，1.63）、CHF（IRR，1.60）和 RF（IRR，2.12）与 cLOS 增加相关。糖尿病合并并发症（IRR，1.90）和 RF（IRR，2.47）影响后续截肢手术。CHF（IRR，1.83）和 RF（IRR，3.67）与更多的心血管程序相关。Cox 比例风险模型表明，年龄较大（HR，1.04）、CHF（HR，2.26）和 RF（HR，2.60）是降低生存率的危险因素。与 SES 相关的因素与结果没有显著关系。
本研究发现，截肢者的 RU 较高，并且 RU 在围手术期后仍持续增加。SES 指数之间的结果相似，这表明当肢体保存不再可行时，较高的 SES 可能并不能保护患者免受不良结局的影响。这些发现支持 SES 差异可能在严重肢体缺血的早期治疗阶段更为可改变的假设。
