title: Variation in the use of lower extremity vascular procedures for critical limb ischemia.
abstract: BACKGROUND
  Many believe that variation in vascular practice may affect limb salvage rates in patients with severe peripheral arterial disease. However, the extent of variation in procedural vascular care obtained by patients with critical limb ischemia (CLI) remains unknown.
  
  
  RESULTS
  By using Medicare 2003 to 2006 data, we identified all patients with CLI who underwent major lower extremity amputation in the 306 hospital referral regions described in the Dartmouth Atlas of Healthcare. For each patient, we studied the use of lower extremity vascular procedures (open surgery or endovascular intervention) in the year before amputation. Our main outcome measure was the intensity of vascular care, defined as the proportion of patients in the hospital referral region undergoing a vascular procedure in the year before amputation. Overall, 20,464 patients with CLI underwent major lower extremity amputations during the study period, and collectively underwent 25,800 vascular procedures in the year before undergoing amputation. However, these procedures were not distributed evenly: 54% of patients had no vascular procedures performed in the year before amputation, 14% underwent 1 vascular procedure, and 32% underwent >1 vascular procedure. In the regions in the lowest quintile of vascular intensity, vascular procedures were performed in 32% of patients. Conversely, in the regions in the highest quintile of vascular intensity, revascularization was performed in 58% of patients in the year before amputation (P<0.0001). In analyses accounting for differences in age, sex, race, and comorbidities, patients in high-intensity regions were 2.4 times as likely to undergo revascularization in the year before amputation than patients in low-intensity regions (adjusted odds ratio, 2.4; 95% CI, 2.1-2.6; P<0.001).
  
  
  CONCLUSIONS
  Significant variation exists in the intensity of vascular care provided to patients in the year before major amputation. In some regions, patients receive intensive care, whereas in other regions, far less vascular care is provided. Future work is needed to determine the association between intensity of vascular care and limb salvage.
authors.affiliation: Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA. philip.goodney@hitchcock.org
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.forename: Lori L
authors.initials: LL
authors.lastname: Travis
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.forename: Kerianne
authors.initials: K
authors.lastname: Holman
authors.forename: Bjoern
authors.initials: B
authors.lastname: Suckow
authors.forename: Peter K
authors.initials: PK
authors.lastname: Henke
authors.forename: F Lee
authors.initials: FL
authors.lastname: Lucas
authors.forename: David C
authors.initials: DC
authors.lastname: Goodman
authors.forename: John D
authors.initials: JD
authors.lastname: Birkmeyer
authors.forename: Elliott S
authors.initials: ES
authors.lastname: Fisher
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D003695:Delivery of Health Care; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D007511:Ischemia / Q000453:epidemiology* / Q000601:surgery*; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians'; D012307:Risk Factors; D014656:Vascular Surgical Procedures / Q000706:statistics & numerical data*