Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA.
Ann Vasc Surg. 2022 Nov;87:302-310. doi: 10.1016/j.avsg.2022.05.047. Epub 2022 Jul 6.
The need for multidisciplinary care of patients with advanced limb threat is well established. We examined patient reported outcomes and health-related quality of life (HR-QoL) for those who completed a multidisciplinary extremity preservation program (EPP) at our institution.
Patients with advanced limb threat, who had previously failed standard management at a tertiary-care center, were referred to EPP for evaluation by a multidisciplinary panel of vascular, plastic, orthopedic and podiatric surgeons, along with infectious disease, prosthetics, orthotics, imaging, palliative care, social work and wound nursing specialists. HR-QoL was quantified before and after EPP participation with the RAND-36 questionnaire. The validated RAND-36 assesses physical function, role limitations caused by physical and emotional health problems, social functioning, emotional well-being, energy, pain and general health perceptions.
From 2018 to 2020, 185 patients were referred to EPP. After review by the multidisciplinary panel, 120 were accepted into the program, 63 of whom completed their course of care; 9 were one-time consultations. The median number of EPP in-person care visits was 23 (13-54) per participant; 87.3% of patients received one or more surgical procedure, including operative debridement (73%), revascularization (44%), soft-tissue reconstruction or transplantation (46%), as well as hyperbaric oxygen therapy (11%) during their course of treatment. 85.7% of patients achieved complete wound healing, 41.5% occurring within 6 months. Ultimately, 14.3% required a major amputation. Graduates noted improvement in all categories of the HR-QoL upon completion, including those undergoing major amputation. On adjusted multivariate regression analysis, patients with immunocompromised status were more likely to show greater improvement in their social function (OR: 10.1; P < 0.044) and emotional role limitation (OR: 8.1; P = 0.042), while, patients with larger wound volume at presentation were more likely to have greater improvement in their general health (OR: 1.1; P < 0.049). Conversely, patients with a smoking history had less improvement in energy level (OR: 0.4; P = 0.044) and patients with dialysis-dependence had less improvement in social function (OR: 0.2; P = 0.034).
Coordinated, multidisciplinary extremity preservation program improves HR-QoL of patients with complex limb threat, including those who are immunocompromised with impaired social function and emotional role limitations. Furthermore, study is warranted to better characterize the generalizability of this approach, including considerations of cost-effectiveness, wound recidivism, and limiting the number of in-person visits required to achieve complete healing.
为患有晚期肢体威胁的患者提供多学科护理的需求已得到充分证明。我们研究了那些在我们机构完成多学科肢体保留计划（EPP）的患者的患者报告结果和健康相关生活质量（HR-QoL）。
在三级医疗中心接受过标准治疗但先前失败的晚期肢体威胁患者，由血管、整形、骨科和足科外科医生、传染病、假肢、矫形器、影像学、姑息治疗、社会工作和伤口护理专家组成的多学科小组进行 EPP 评估。在参加 EPP 前后，使用 RAND-36 问卷对 HR-QoL 进行量化。经过验证的 RAND-36 评估身体功能、身体和情绪健康问题引起的角色限制、社会功能、情绪健康、能量、疼痛和一般健康感知。
2018 年至 2020 年，有 185 名患者被转介至 EPP。在多学科小组审查后，有 120 名患者被纳入该计划，其中 63 名完成了治疗过程；9 名是一次性咨询。每位参与者接受 EPP 面对面护理访问的中位数为 23 次（13-54 次）；87.3%的患者接受了一次或多次手术，包括清创术（73%）、血运重建术（44%）、软组织重建或移植术（46%）以及高压氧治疗（11%）。85.7%的患者实现了完全的伤口愈合，41.5%在 6 个月内发生。最终，14.3%的患者需要进行大截肢。毕业生在完成治疗后，所有类别的 HR-QoL 都有所改善，包括接受大截肢的患者。在调整后的多变量回归分析中，免疫功能低下的患者在社会功能（OR：10.1；P <0.044）和情绪角色限制（OR：8.1；P =0.042）方面更有可能出现更大的改善，而就诊时伤口体积较大的患者更有可能在一般健康方面有更大的改善（OR：1.1；P <0.049）。相反，有吸烟史的患者在能量水平上的改善较小（OR：0.4；P =0.044），而需要透析的患者在社会功能方面的改善较小（OR：0.2；P =0.034）。
协调的多学科肢体保留计划可提高患有复杂肢体威胁的患者的 HR-QoL，包括免疫功能低下、社会功能受损和情绪角色限制的患者。此外，还需要进行研究以更好地描述这种方法的普遍性，包括考虑成本效益、伤口复发以及减少实现完全愈合所需的面对面就诊次数。
