慢性肢体严重缺血患者的血运重建延迟。
Delays to revascularization for patients with chronic limb-threatening ischaemia.
机构信息
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
出版信息
Br J Surg. 2022 Jul 15;109(8):717-726. doi: 10.1093/bjs/znac109.
BACKGROUND
Vascular services in England are organized into regional hub-and-spoke models, with hubs performing arterial surgery. This study examined time to revascularization for chronic limb-threatening ischaemia (CLTI) within and across different care pathways, and its association with postrevascularization outcomes.
METHODS
Three inpatient and four outpatient care pathways were identified for patients with CLTI undergoing revascularization between April 2015 and March 2019 using Hospital Episode Statistics data. Differences in times from presentation to revascularization across care pathways were analysed using Cox regression. The relationship between postoperative outcomes and time to revascularization was evaluated by logistic regression.
RESULTS
Among 16 483 patients with CLTI, 9470 had pathways starting with admission to a hub or spoke hospital, whereas 7013 (42.5 per cent) were first seen at outpatient visits. Among the inpatient pathways, patients admitted to arterial hubs had shorter times to revascularization than those admitted to spoke hospitals (median 5 (i.q.r. 2-10) versus 12 (7-19) days; P < 0.001). Shorter times to revascularization were also observed for patients presenting to outpatient clinics at arterial hubs compared with spoke hospitals (13 (6-25) versus 26 (15-35) days; P < 0.001). Within most care pathways, longer delays to revascularizsation were associated with increased risks of postoperative major amputation and in-hospital death, but the effect of delay differed across pathways.
CONCLUSION
For patients with CLTI, time to revascularization was influenced by presentation to an arterial hub or spoke hospital. Generally, longer delays to revascularization were associated with worse outcomes, but the impact of delay differed across pathways.
背景
英国的血管服务组织采用区域枢纽-辐射模型，其中枢纽医院进行动脉手术。本研究考察了慢性肢体威胁性缺血（CLTI）患者在不同的护理路径内和之间进行血运重建的时间及其与血运重建后结局的关系。
方法
使用医院病例统计数据，确定了 2015 年 4 月至 2019 年 3 月期间接受血运重建的 CLTI 患者的三种住院和四种门诊护理路径。使用 Cox 回归分析了不同护理路径之间从就诊到血运重建时间的差异。使用逻辑回归评估术后结局与血运重建时间之间的关系。
结果
在 16483 例 CLTI 患者中，有 9470 例患者的护理路径始于枢纽或辐射医院的入院，而 7013 例（42.5%）首先在门诊就诊。在住院护理路径中，与入住辐射医院的患者相比，入住动脉枢纽医院的患者血运重建时间更短（中位数 5（IQR 2-10）天与 12（7-19）天；P<0.001）。与入住辐射医院的患者相比，在动脉枢纽医院就诊的门诊患者的血运重建时间也更短（13（6-25）天与 26（15-35）天；P<0.001）。在大多数护理路径中，血运重建时间延迟与术后主要截肢和住院死亡风险增加相关，但延迟的影响在不同路径中存在差异。
结论
对于 CLTI 患者，血运重建时间受到就诊于动脉枢纽或辐射医院的影响。通常，血运重建时间延迟与结局较差相关，但延迟的影响在不同路径中存在差异。
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