Emerging national trends in the management and outcomes of lower extremity peripheral arterial disease

Abstract

Background: In this study, we sought to analyze emerging national trends in the treatment of lower extremity peripheral arterial disease and associated outcomes.

Methods: The Nationwide Inpatient Sample was queried between 2001 and 2007. Patients diagnosed with lower extremity atherosclerosis were selected by using the International Classification of Diseases, 9th Revision codes 440.20-440.24, resulting in an average of 307,000 annual hospitalizations. Within this group, we determined the annual number of lower extremity bypasses, endovascular interventions, and major and/or minor amputations (below-the- and/or above-the-knee amputation versus toe and/or foot amputation). Chi-square analysis was performed on discharge-weighted data to compare two periods (2001-2003 and 2004-2007) to determine changes in management and differences in outcome. Multivariate logistic regression was used to identify predictors of amputation.

Results: Comparing the two periods, it was found that the average annual number of endovascular interventions increased by 78% (37,692 vs. 67,248, p < 0.001), and open lower extremity bypasses decreased by 20% (68,326 vs. 54,348, p < 0.001). Annually, the total number of interventions increased by 15% (106,018 vs. 121,596, p < 0.001), whereas the number of total amputations (59,693 vs. 50,254, p < 0.001), major amputations (39,543 vs. 31,043, p < 0.001), and minor amputations (20,150 vs. 19,211, p < 0.001) performed all significantly decreased. Diabetes was the leading predictor of amputation, especially those involving the toe and forefoot. After adjusting for age and comorbidities, African Americans were found to have a 2.4 times odds of amputation as compared with Caucasians, whereas those with Medicare or Medicaid had a 1.5 times odds as compared with those having private insurance or Health Maintenance Organization.

Conclusions: Between the periods examined, we observed that the treatment of lower extremity peripheral arterial disease has evolved with increased use of lesser invasive endovascular techniques and fewer open lower extremity bypasses. These trends are associated with fewer major lower extremity amputations. Significant socioeconomic disparities persist in amputation rates, with racial minorities and those with Medicare or Medicaid having higher odds of amputation.