Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire2Dartmouth-Hitchcock Medical Center, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
Center for Outcomes Research and Evaluation, Maine Medical Center, Portland4Center for Health Outcomes and Policy, University of Michigan, Ann Arbor.
JAMA Surg. 2014 Jan;149(1):34-42. doi: 10.1001/jamasurg.2013.4277.
Although lower extremity revascularization is effective in preventing amputation, the relationship between spending on vascular care and regional amputation rates remains unclear.
To test the hypothesis that higher regional spending on vascular care is associated with lower amputation rates for patients with severe peripheral arterial disease.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 18,463 US Medicare patients who underwent a major peripheral arterial disease-related amputation during the period between 2003 and 2010.
Price-adjusted Medicare spending on revascularization procedures and related vascular care in the year before lower extremity amputation, across hospital referral regions.
Correlation coefficient between regional spending on vascular care and regional rates of peripheral arterial disease-related amputation.
Among patients who ultimately underwent an amputation, 64% were admitted to the hospital in the year prior to the amputation for revascularization, wound-related care, or both; 36% were admitted only for their amputation. The mean cost of inpatient care in the year before amputation, including costs related to the amputation procedure itself, was $22,405, but it varied from $11,077 (Bismarck, North Dakota) to $42,613 (Salinas, California) (P < .001). Patients in high-spending regions were more likely to undergo vascular procedures as determined by crude analyses (12.0 procedures per 10,000 patients in the lowest quintile of spending and 20.4 procedures per 10,000 patients in the highest quintile of spending; P < .001) and by risk-adjusted analyses (adjusted odds ratio for receiving a vascular procedure in highest quintile of spending, 3.5 [95% CI, 3.2-3.8]; P < .001). Although revascularization was associated with higher spending (R = 0.38, P < .001), higher spending was not associated with lower regional amputation rates (R = 0.10, P = .06). The regions that were most aggressive in the use of endovascular interventions were the regions that were most likely to have high spending (R = 0.42, P = .002) and high amputation rates (R = 0.40, P = .004).
Regions that spend the most on vascular care perform the most procedures, especially endovascular interventions, in the year before amputation. However, there is little evidence that higher regional spending is associated with lower amputation rates. This suggests an opportunity to limit costs in vascular care without compromising quality.
虽然下肢血运重建可有效预防截肢，但血管护理支出与区域性截肢率之间的关系尚不清楚。
检验假设，即血管护理的区域支出较高与严重外周动脉疾病患者的截肢率降低相关。
设计、地点和参与者：这是一项回顾性队列研究，纳入了 2003 年至 2010 年间在美国接受主要外周动脉疾病相关截肢的 18463 名 Medicare 患者。
在下肢截肢前一年，按医院转诊区域调整的血管再通手术和相关血管护理的 Medicare 调整后支出。
血管护理区域支出与外周动脉疾病相关截肢区域率之间的相关系数。
在最终接受截肢的患者中，64%的患者在截肢前一年因血运重建、伤口相关护理或两者入院；36%的患者仅因截肢入院。截肢前一年住院护理的平均费用（包括截肢手术本身的费用）为 22405 美元，但费用从北达科他州俾斯麦的 11077 美元到加利福尼亚州萨利纳斯的 42613 美元不等（P<0.001）。从粗分析（最低五分位支出的每 10000 例患者中有 12.0 例血管手术，最高五分位支出的每 10000 例患者中有 20.4 例血管手术；P<0.001）和风险调整分析（最高五分位支出患者接受血管手术的调整后优势比为 3.5[95%CI，3.2-3.8]；P<0.001）来看，高支出地区更有可能进行血管手术。尽管血管重建与较高的支出相关（R=0.38，P<0.001），但较高的支出与较低的区域截肢率无关（R=0.10，P=0.06）。血管内介入治疗使用最积极的地区也是支出最高（R=0.42，P=0.002）和截肢率最高（R=0.40，P=0.004）的地区。
血管护理支出最多的地区在截肢前一年进行的手术最多，尤其是血管内介入治疗。然而，几乎没有证据表明较高的区域支出与较低的截肢率相关。这表明在不影响质量的情况下限制血管护理成本的机会。
