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 PVSS20. High-Quality Outpatient Diabetic Care Improves Amputation-Free Survival after Lower Extremity Revascularization for Critical Limb Ischemia

Benjamin S. Brooke1, David H. Stone1, Brian Nolan1, Randall R. De Martino1, David C. Goodman2, Jack L. Cronenwett1, Philip P. Goodney1
1Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; 2Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH.
OBJECTIVES: The impact of outpatient diabetic care on the outcome of lower extremity revascularization (LER) for critical limb ischemia (CLI) is unknown. We hypothesized that outcomes following LER in diabetics with CLI might be improved by high-quality outpatient diabetic care, as indexed by the annual rate of cholesterol (CHOL) and HbA1c testing
METHODS: We studied 84,653 diabetic patients with CLI (52% male, 15% black, mean age 76 years) who underwent open and endovascular LER using Medicare claims (2004-2007). The Healthcare Effectiveness Data & Information Set (HEDIS) quality indicators for annual CHOL and HbA1C testing were used as a proxy for quality of diabetic care. We examined relationships between frequency of diabetic testing, amputation-free survival (AFS), and major adverse limb events (MALE) across all U.S. hospital referral regions.
RESULTS: There was significant regional variation in annual HbA1C and CHOL testing across the U.S. (84% highest quartile vs. 60% lowest quartile, p<0.01). Compared with the lowest quartile of diabetic testing, patients undergoing LER in regions with the highest quartile of diabetic testing had significantly better AFS, MALE and mortality (Table 1). These benefits persisted more than 2 years after LER, even after adjusting for gender, age, race and comorbidities (Table 1).
CONCLUSIONS: Diabetic patients undergoing LER for CLI in regions with more frequent outpatient testing have significantly better long-term AFS and MALE. Our study underscores the importance of optimal outpatient medical management in diabetics and provides a novel strategy for improving outcomes after LER.
AUTHOR DISCLOSURES: B. S. Brooke: Nothing to disclose; J. L. Cronenwett: Nothing to disclose; R. R. De Martino: Nothing to disclose; D. C. Goodman: Nothing to disclose; P. P. Goodney: Nothing to disclose; B. Nolan: Nothing to disclose; D. H. Stone: Nothing to disclose
Association between diabetic care quality and 2-year outcomes following LE revascularization for CLI

2 Year Outcomes​

​High-Quality Diabetic Care Low-Quality Diabetic Care ​ ​Adjusted Hazard Ratio 95% Confidence Interval​ P-value
​Amputation 9% 11% ​0.95 ​0.93-0.98
​ <0.01
 Mortality ​ ​29% ​31% ​0.96 ​0.93-0.98 ​ <0.01
​Reintervention ​24% ​25% 0.95 ​0.93-0.98 ​<0.01
​MALE ​29% ​31% ​0.95 ​0.92-0.98 ​<0.01
Amputation or Mortality ​ ​34% ​37% ​0.96 ​0.93-0.99 ​<0.01
Posted April 2013      

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