Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif; Geisel School of Medicine at Dartmouth, Hanover, NH.
Division of Vascular and Endovascular Surgery, University of California Davis Medical Center, Sacramento, Calif.
J Vasc Surg. 2019 Nov;70(5):1612-1619. doi: 10.1016/j.jvs.2019.01.087. Epub 2019 May 29.
Multidisciplinary care is recommended for the treatment of patients with ischemic and diabetic wounds. In addition to integrating care from multiple specialties, outpatient wound care centers provide an opportunity for continuity and organization of care after revascularization or hospitalization. The purpose of this study was to assess changes in the practice patterns and outcomes of patients treated by a tertiary care vascular surgery practice after the introduction of an affiliated outpatient wound care center.
A prospective institutional database was used to identify patients who underwent lower-extremity revascularization, amputation, or surgical debridement during consecutive 3-year periods before (BWC; n = 735) and after (AWC; n = 1503) the opening of an affiliated wound care center. Patients were included if they underwent intervention for atherosclerotic peripheral arterial disease or diabetic foot ulcers (DFUs). Changes in case volume, surgical indication, and procedural characteristics were assessed. Clinical outcomes included freedom from lower-extremity amputations and mortality.
We identified a total of 1751 procedures performed in 1249 limbs that met inclusion criteria. After the opening of the wound clinic, procedures related to limb salvage represented a greater proportion of overall cases performed by the vascular service (19% vs 26%; P < .0001). The volume of lower-extremity interventions increased by 64%, from 662 procedures in the BWC period to 1085 procedures in the AWC period. There was no difference in type of revascularization performed between the two study periods, although surgical debridements (from 8.9% to 13%; P = .01) and infrapopliteal endovascular interventions (from 21% to 28%; P = .04) significantly increased. Compared with BWC patients, AWC patients more frequently presented with DFUs (7.3% vs 13%; P = .002) and chronic wounds (39% vs 45%; P = .05). At 1 year of follow-up, major amputation rates were significantly lower in the AWC group than in the BWC cohort (5.5% vs 8.8%; P = .04). Treatment during the AWC period was associated with a reduced risk of major amputation (adjusted hazard ratio, 0.41; 95% confidence interval, 0.27-0.62; P < .001), but no difference in all-cause mortality.
The opening of an outpatient wound center affiliated with a tertiary vascular surgical practice was associated with a higher volume of limb salvage patients and procedures. The risk of major amputation decreased following the opening of the wound care center. Integrating vascular surgeons into wound centers may result in a synergistic system that promotes more aggressive and effective limb salvage.
多学科护理被推荐用于治疗缺血性和糖尿病性伤口患者。除了整合来自多个专业的护理外，门诊伤口护理中心还为血管再通或住院后的护理连续性和组织提供了机会。本研究的目的是评估在附属门诊伤口护理中心开设后，三级护理血管外科实践治疗的患者的治疗模式和结果的变化。
使用前瞻性机构数据库，确定了在连续 3 年期间（BWC；n=735）和开设附属伤口护理中心后（AWC；n=1503）接受下肢血运重建、截肢或手术清创术的患者。如果他们接受了治疗动脉粥样硬化外周动脉疾病或糖尿病足溃疡（DFU）的干预，则将患者纳入研究。评估了病例量、手术指征和手术特征的变化。临床结果包括免于下肢截肢和死亡率。
共确定了 1249 条肢体的 1751 例符合纳入标准的手术。在开设伤口诊所后，保肢手术的比例占血管科手术的比例增加（19%对 26%；P<0.0001）。下肢干预的数量增加了 64%，从 BWC 期间的 662 例增加到 AWC 期间的 1085 例。两个研究期间的血运重建类型没有差异，但手术清创术（从 8.9%增加到 13%；P=0.01）和腘下腔内介入治疗（从 21%增加到 28%；P=0.04）明显增加。与 BWC 患者相比，AWC 患者更常患有 DFU（7.3%对 13%；P=0.002）和慢性伤口（39%对 45%；P=0.05）。在 1 年的随访中，AWC 组的主要截肢率明显低于 BWC 组（5.5%对 8.8%；P=0.04）。AWC 期间的治疗与降低主要截肢风险相关（调整后的危险比，0.41；95%置信区间，0.27-0.62；P<0.001），但全因死亡率无差异。
附属三级血管外科实践门诊伤口中心的开设与更多的保肢患者和手术数量增加有关。开设伤口护理中心后，主要截肢风险降低。将血管外科医生纳入伤口中心可能会产生协同系统，从而促进更积极有效的保肢。
