Characteristics of Multidisciplinary Limb Preservation Teams and their Impact on Outcomes in the BEST-CLI Trial.

OBJECTIVE

Multidisciplinary care of chronic limb threatening ischemia (CLTI) through specialized CLTI teams has been associated with improved outcomes, including decreased major amputations. Our goal was to characterize CLTI teams and examine their association with outcomes in the Best Endovascular versus Surgical Therapy in Patients with CLTI (BEST-CLI) trial.

METHODS

Responses from a previously described post-trial electronic survey were used to describe CLTI care providers and characterize centers based on the presence of a "formally defined team dedicated to the care of CLTI patients". Patient-level data were analyzed to determine the association of CLTI teams with outcomes. Primary outcomes were: (1) Major (above-ankle) amputation and (2) Major adverse limb event (MALE) or death from any cause. Secondary outcome was the High-Low amputation ratio (ratio of major amputations/minor amputations). Cox multivariable models were used to control for patient demographics, limb stage and revascularization type.

RESULTS

The overall survey response rate was 20.2% with at least 1 response from 75% of enrolling sites. Among survey respondents, specialties identified most frequently as being among those primarily responsible for CLTI care at centers with CLTI teams were: revascularization specialists (vascular surgery, interventional cardiology or interventional radiology, 92%), podiatry (32%) and wound care (22%). Compared to centers without CLTI teams, podiatrists at CLTI team centers were more likely to have a primary role (32% vs 11%) and less likely to be unavailable (4% vs 22%) (P<0.001). Similarly, at centers with CLTI teams, wound care specialists were more likely to have a primary role (22% vs 8%) and less likely to be unavailable (4% vs 11%) (P=0.02). Effectiveness of teamwork among CLTI providers was described as "highly effective" in 71% of respondents with a CLTI team vs 29% without a team (P<0.001). In BEST-CLI, 110 centers (73%) could be classified based on availability of a CLTI team (31% team vs 69% no team), representing 83% of all enrolled patients (n=1,520). Patients treated at centers with a CLTI team had similar rates of unadjusted 1-year above-ankle amputation (7.9% team [95% CI 5.7%-10.7%] vs 12.1% no team [95% CI 10.1%-14.4%], P=0.07) and MALE or death (29% team [95% CI 25.1% -33.3%] vs 33% no team [95% CI 30.1% -36.2%], P=0.07). On multivariable analysis, presence of a CLTI team was independently associated with decreased major amputation (HR 0.60 [95% CI 0.42-0.86], p=0.005) but no significant difference in MALE or death (HR 0.89 [95% CI 0.74-1.06], p=0.2). The High-Low amputation ratio was lower at centers with CLTI teams (0.20, [95% CI 0.14-0.28]) compared to centers with no team (0.31 [95% CI 0.25-0.38]) (P=0.03) CONCLUSIONS: In the BEST-CLI trial, formally defined CLTI teams were associated with decreased risk of major amputation. This may be partially attributable to more effective communication and closer involvement between vascular specialists, podiatry and wound care providers.