Outcomes and perspectives on treatment for critical limb ischemia in patients with end-stage renal disease

终末期肾病患者严重肢体缺血治疗的结果和前景

• 批准号: 10673924
• 负责人: Samir Kaushik Shah
• 金额: $ 14.4万
• 依托单位: UNIVERSITY OF FLORIDA
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-08-01 至 2027-07-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10673924
• 关键词: Affect; Aftercare; American; Amputation; Biology; Blood Vessels; Bypass; Cardiology; Cardiovascular system; Caring; Catheters; Clinical Research; Complement 3; Conflict (Psychology); Data; Decision Aid; Decision Making; Development; Diagnosis; Dialysis procedure; Disease; End stage renal failure; Environment; Fee-for-Service Plans; Florida; Foundations; Gangrene; Geography; Goals; Grant; Guidelines; Health Personnel; Health Services Research; Hemodialysis; Hospital Referrals; Incidence; Intervention; Kidney Failure; Knowledge; Leadership; Learning; Length of Stay; Life; Limb structure; Literature; Managed Care; Medicare; Medicare claim; Medicine; Mentors; Mentorship; Methods; Morbidity - disease rate; Nephrology; Operative Surgical Procedures; Outcome; Outcomes Research; Pain; Pain management; Patient-Centered Care; Patient-Focused Outcomes; Patients; Peripheral arterial disease; Persons; Physicians; Population; Population Heterogeneity; Positioning Attribute; Procedures; Process; Provider; Recommendation; Research; Research Personnel; Research Priority; Resources; Rest; Risk Factors; Sample Size; Selection for Treatments; Societies; Stents; Symptoms; Techniques; Training; Treatment Factor; Treatment outcome; Universities; Vascular Diseases; Writing; accountable care organization; beneficiary; care outcomes; career; career development; clinical care; college; comorbidity; critical limb Ischemia; experience; follow-up; improved; large datasets; limb loss; mortality; multidisciplinary; non-healing wounds; preference; programs; risk sharing; satisfaction; shared decision making; skill acquisition; skills; treatment as usual; treatment choice; wound care

Project Summary/Abstract Amputation and mortality rates are extraordinarily high for patients living with both advanced peripheral arterial disease, or critical limb ischemia (CLI), and end-stage renal disease (ESRD). Treatment choices for patients with CLI include catheter-based procedures (e.g. vascular stenting), surgery (e.g. bypass), primary amputation, or symptom control alone (e.g. pain management and wound care). Overall, CLI has dismal outcomes with a 25% mortality and a 30% major amputation rate at one year from diagnosis. Limited data suggest even worse outcomes for patients with ESRD – for example, approximately 50% mortality at 18 months. The existing literature on outcomes is limited by small sample sizes, short follow-up, and a focus on only two of the treatment options, catheter-based interventions and surgery. Patients with ESRD and CLI are often faced with difficult treatment decisions that are complicated by a lack of 1) robust real-world evidence on outcomes and 2) clinical care guidelines. Shared decision-making often relies on these types of information. ESRD is a life-limiting disease and treatment of CLI is resource-intensive. Nevertheless, there are no existing cardiovascular or nephrology society guidelines regarding CLI treatment in patients with ESRD. Knowledge of outcomes of CLI treatment in patients with ESRD, factors affecting CLI treatment selection, and guidelines to direct care would unequivocally improve care by helping to align patient values and preferences with treatment decisions. Owing to these gaps in knowledge, I propose a mixed methods approach using the national Medicare data 2017-2019 to understand 1) factors affecting treatment selection, and 2) traditional and patient-centered outcomes after treatment of CLI in patients with ESRD, complemented by 3) a Delphi panel of expert health care providers and patients to help inform the establishment of care guidelines and identification of research priorities. In addition to helping develop critical data on patients with ESRD and CLI, this proposal will be an essential step in my development as an independent investigator. My long-term career goals are to develop a research program focusing on outcomes of treatment and decision-making surrounding peripheral arterial disease. I hope to advance the field of vascular surgery health services research to improve patient outcomes and aid physicians and patients in aligning decision-making with patient goals and values. This proposal will immediately contribute to my short-term career objectives: increasing expertise with use of Medicare fee-for- service claims data, understanding the practice of nephrology as it applies to ESRD and comorbid conditions such as CLI, learning relevant advanced quantitative and qualitative techniques, and improving grant writing, leadership, and other career development skills. This proposal will take place in the resource-rich environment of the University of Florida College of Medicine under the guidance of an expert mentoring team.

项目概要/摘要 对于患有晚期外周血管疾病的患者来说，截肢率和死亡率非常高。 动脉疾病或严重肢体缺血 (CLI) 和终末期肾病 (ESRD)。治疗选择 CLI 患者包括基于导管的手术（例如血管支架置入术）、手术（例如搭桥术）、初次手术 截肢，或单独控制症状（例如疼痛管理和伤口护理）。总体而言，CLI 的表现令人沮丧 诊断后一年死亡率为 25%，大截肢率为 30%。数据有限 表明 ESRD 患者的结局更糟 – 例如，18 岁时死亡率约为 50% 几个月。现有关于结果的文献受到样本量小、随访时间短以及关注 只有两种治疗选择：基于导管的干预措施和手术。患有 ESRD 和 CLI 的患者是 经常面临困难的治疗决策，由于缺乏 1) 强有力的现实证据，这些决策变得复杂 结果和 2) 临床护理指南。共同决策通常依赖于这些类型的信息。 ESRD 是一种限制生命的疾病，CLI 的治疗需要消耗大量资源。尽管如此，没有 现有心血管或肾病学会关于 ESRD 患者 CLI 治疗的指南。 了解 ESRD 患者的 CLI 治疗结果、影响 CLI 治疗选择的因素，以及 直接护理指南将通过帮助调整患者的价值观和偏好来明确改善护理 与治疗决定。由于这些知识差距，我提出了一种混合方法，使用 2017-2019 年国家医疗保险数据，了解 1) 影响治疗选择的因素，以及 2) 传统和 ESRD 患者接受 CLI 治疗后以患者为中心的结果，并辅以 3) Delphi 小组 专家医疗保健提供者和患者帮助制定护理指南和识别 研究重点。 除了帮助开发 ESRD 和 CLI 患者的关键数据外，该提案还将成为 我作为一名独立调查员的发展过程中至关重要的一步。我的长期职业目标是发展 研究项目重点关注周围动脉周围的治疗结果和决策 疾病。我希望推进血管外科健康服务研究领域，以改善患者的治疗效果 帮助医生和患者根据患者的目标和价值观做出决策。该提案将 立即为我的短期职业目标做出贡献：通过使用 Medicare 按次付费提高专业知识 服务索赔数据，了解肾脏病学实践，因为它适用于 ESRD 和合并症 例如 CLI，学习相关的高级定量和定性技术，以及改进资助写作， 领导力和其他职业发展技能。本提案将在资源丰富的环境中进行 佛罗里达大学医学院的专家指导团队的指导下。

项目成果

National Institutes of Health funding among vascular surgeons is rare.

美国国立卫生研究院对血管外科医生的资助很少。

• DOI: 10.1016/j.jvs.2023.05.052
• 发表时间: 2023
• 期刊: Journal of vascular surgery
• 影响因子: 4.3
• 作者: Mirzaie,AminA;Cooper,MicholA;Weaver,MLibby;Jacobs,ChristopherR;Cox,MorganL;Berceli,ScottA;Scali,SalvatoreT;Back,MartinR;Huber,ThomasS;Upchurch,GilbertR;Shah,SamirK
• 通讯作者: Shah,SamirK