title: Outcomes in Critical Limb Ischemia Compared by Distance from Referral Center.
abstract: BACKGROUND
  Little data exist regarding the effect of referral distance on outcomes after revascularization for critical limb ischemia (CLI). We tested the assumption that patients who travel longer distances for revascularization procedures have worse outcomes.
  
  
  METHODS
  We identified a retrospective cohort of 300 CLI patients who underwent revascularization between January 1, 2000 and December 31, 2010 at a single academic medical center. Patients were stratified into 2 groups based on distance greater than or less than 100 miles from the referral center. The association between travel distance and outcome measures including length of stay (LOS), postoperative functional status, hospital disposition, patient follow-up, and amputation-free survival (AFS) were evaluated using Cox proportional hazard models controlling for patient comorbidities and type of revascularization procedure.
  
  
  RESULTS
  One hundred eighteen (39%) patients travelled >100 miles for CLI revascularization. The 2 groups had similar baseline characteristics. Overall, 211 (70%) patients underwent an open revascularization, 60 (20%) an endovascular, and 29 (10%) a hybrid procedure. Those living >100 miles away less commonly underwent an endovascular procedure (14% vs. 24%, P = 0.05). LOS was similar between near and far groups (7.3 vs. 8.9 days, P = 0.1), as was postoperative functional status (ambulatory 73% vs. 68%, P = 0.34) and discharge to home (68% vs. 74%, P = 0.34). Long-term follow-up (mean 2.07 years) was similar between distance groups (P = 0.6). Five-year AFS (73% vs. 56%, P = 0.02) was superior in the distance >100 group. In the multivariate analysis, distance >100 miles (hazard ratio [HR] 0.6, P = 0.05), preoperative warfarin use (HR 0.5, P = 0.02), and independent ambulatory status (HR 0.5, P = 0.002) were associated with improved AFS.
  
  
  CONCLUSIONS
  Patient referral distance did not adversely affect AFS or long-term follow-up after revascularization for CLI. Patients traveling from rural settings for revascularization can expect similar outcomes as patients located near tertiary centers.
authors.affiliation: Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City, UT. Electronic address: peter.bartline@gmail.com.
authors.forename: Peter B
authors.initials: PB
authors.lastname: Bartline
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Bjoern D
authors.initials: BD
authors.lastname: Suckow
authors.affiliation: Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Benjamin S
authors.initials: BS
authors.lastname: Brooke
authors.affiliation: Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Larry W
authors.initials: LW
authors.lastname: Kraiss
authors.affiliation: Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Michelle T
authors.initials: MT
authors.lastname: Mueller
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D002391:Catchment Area, Health; D016638:Critical Illness; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology; D016016:Proportional Hazards Models; D020127:Recovery of Function; D012017:Referral and Consultation; D012086:Reoperation; D012111:Residence Characteristics; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014186:Transportation; D016896:Treatment Outcome; D014589:Utah; D014656:Vascular Surgical Procedures / Q000009:adverse effects