Humphries Misty D, Brunson Ann, Li Chin-Shang, Melnikow Joy, Romano Patrick S
Division of Vascular Surgery, Department of Surgery, University of California, Davis Medical Center, Sacramento, Calif.
Division of Hematology-Oncology, Department of Medicine, University of California, Davis Medical Center, Sacramento, Calif.
J Vasc Surg. 2016 Dec;64(6):1747-1755.e3. doi: 10.1016/j.jvs.2016.06.096. Epub 2016 Sep 23.
This study reports all-payer amputation rates using state-based administrative claims data for high-risk patients with lower extremity (LE) ulcers and concomitant peripheral artery disease (PAD), diabetes mellitus (DM), or combination PAD/DM. In addition, we characterize patient factors that affect amputation-free survival. We also attempted to create a measure of a patient's ability to manage chronic diseases or to access appropriate outpatient care for ulcer management by accounting for hospital and emergency department (ED) visits in the preceding 60 days to determine how this also affects amputation-free survival.
Patients admitted to nonfederal hospitals, seen in an ED, or treated in an eligible ambulatory surgery center within California from 2005 through 2013 with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a disease-specific LE ulcer were identified in the California Office of Statewide Health Planning and Development database. All subsequent hospital, ED, and ambulatory surgery center visits and procedures are captured to identify whether a patient underwent major amputation. Yearly amputation rates were determined to analyze trends. Amputation-free survival for the PAD, DM, and PAD/DM groups was determined. Cox modeling was used to evaluate the effect of patient characteristics.
There were 219,547 patients identified with an incident LE ulcer throughout the state. Of these, 131,731 were DM associated, 36,193 were PAD associated, and 51,623 were associated with both PAD and DM. From 2005 to 2013, the number of patients with LE ulcers who required inpatient admission, presented to the ED, or had outpatient procedures was stable. However, there was a statistically significant increase in overall disease-associated amputation rates from 5.1 in 2005 to 13.5 in 2013 (P < .001). Patients with PAD/DM had the greatest increase in amputation rates from 10 per 100 patients with LE ulcers in 2005 to 28 per 100 patients in 2013 (P < .001). Despite that patients with PAD/DM were 8 years younger than patients with PAD only, they had similar amputation-free survival. Within all age groups, men had worse amputation-free survival than women did. Race did not predict amputation-free survival, but having multiple prior ED or hospital admissions was a significant predictor of worse amputation-free survival.
Potentially preventable amputations associated with high-risk diseases are increasing among patients who require inpatient hospital admission, present to the ED, or require outpatient interventional treatment. This trend is most notable among patients with a combination of PAD and DM. Patients with repeated hospitalizations before admission for the LE ulcer had the highest risk of amputation.
本研究使用基于州的行政索赔数据，报告下肢（LE）溃疡合并外周动脉疾病（PAD）、糖尿病（DM）或PAD/DM组合的高危患者的全支付方截肢率。此外，我们描述了影响无截肢生存期的患者因素。我们还试图通过考虑前60天内的住院和急诊科（ED）就诊情况，创建一种衡量患者管理慢性病或获得适当门诊溃疡治疗能力的指标，以确定这如何影响无截肢生存期。
在加利福尼亚州全州卫生规划与发展办公室数据库中，识别出2005年至2013年期间在加利福尼亚州非联邦医院住院、在急诊科就诊或在符合条件的门诊手术中心接受治疗且具有疾病特异性LE溃疡的国际疾病分类第九版临床修订版诊断代码的患者。记录所有后续的住院、急诊科和门诊手术中心就诊及手术情况，以确定患者是否接受了大截肢手术。确定年度截肢率以分析趋势。确定PAD、DM和PAD/DM组的无截肢生存期。使用Cox模型评估患者特征的影响。
全州共识别出219,547例新发LE溃疡患者。其中，131,731例与DM相关，36,193例与PAD相关，51,623例与PAD和DM均相关。从2005年到2013年，需要住院、到急诊科就诊或接受门诊手术的LE溃疡患者数量稳定。然而，总体疾病相关截肢率从2005年的5.1%显著增加到2013年的13.5%（P <.001）。PAD/DM患者的截肢率增加最大，从2005年每100例LE溃疡患者中的10例增加到2013年每100例患者中的28例（P <.001）。尽管PAD/DM患者比仅患PAD的患者年轻8岁，但他们的无截肢生存期相似。在所有年龄组中，男性的无截肢生存期比女性差。种族不能预测无截肢生存期，但之前多次到急诊科或住院是无截肢生存期较差的重要预测因素。
在需要住院、到急诊科就诊或需要门诊介入治疗的患者中，与高危疾病相关的潜在可预防截肢数量正在增加。这种趋势在PAD和DM合并的患者中最为明显。入院前因LE溃疡多次住院的患者截肢风险最高。
