Improving Outcomes for Diabetic Patients Undergoing Revascularization for Critical Limb Ischemia: Does the Quality of Outpatient Diabetic Care Matter?
Improving Outcomes for Diabetic Patients Undergoing Revascularization for Critical Limb Ischemia: Does the Quality of Outpatient Diabetic Care Matter?
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DOI：
10.1016/j.avsg.2014.05.009
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发表时间：
2014-10-01
影响因子：
1.5
通讯作者：
Goodney, Philip P.
中科院分区：
文献类型：
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作者：
Brooke, Benjamin S.;Kraiss, Larry W.;Goodney, Philip P.
背景：因严重肢体缺血（CLI）而接受下肢外科血运重建术的糖尿病患者即使住院手术成功，其截肢或死亡的风险也很高。我们假设，在CLI糖尿病患者接受更频繁的高质量门诊治疗的地区，术后结果可能会得到改善。方法：一项回顾性队列研究对172134例CLI患者（52%男性，15%黑人，平均年龄76岁）进行了回顾性队列研究，这些患者使用医疗保险索赔（2004-2007）接受了开放和血管内下肢血管重建术，其中包括84653例（49%）糖尿病患者。使用年度血清胆固醇和糖化血红蛋白检测的地区利用率来评估门诊糖尿病护理的质量。我们研究了美国所有医院转诊地区糖尿病检测频率与无截肢生存（AFS）、主要肢体不良事件（MALE）和再入院率之间的关系。结果：美国每年的血清胆固醇和血红蛋白A1c检测存在显著的地区差异（最高四分位数为87%，最低四分位数为59%，P < 0.01）。与最低四分位数的糖尿病检测相比，在糖尿病检测最高四分位数的地区，接受下肢血运重建术的糖尿病患者在下肢血运重建术后持续2年的AFS（风险比[HR]: 0.94, 95%可信区间[CI]: 0.90-0.97; P < 0.01）和MALE（风险比：0.92,95% CI: 0.89-0.96; P < 0.01）显著改善，即使在调整手术类型、性别、年龄、种族和合共病后也是如此。此外，在糖尿病检测最高和最低四分位数的地区，30天再入院的风险显著降低（优势比：0.91,95% CI: 0.85-0.97; P < 0.01）。相比之下，在有高质量门诊糖尿病护理的地区，非糖尿病的CLI患者接受血运重建术并没有同样程度的获益。结论：在糖尿病护理质量措施使用率较高的地区，接受下肢血运重建术的糖尿病患者有明显更好的长期肢体保留和再入院结果。我们的研究强调了为血管手术后的糖尿病患者提供最佳门诊护理的重要性，并概述了提高这些高危患者质量的潜在策略。
Background: Diabetic patients who undergo lower extremity surgical revascularization for critical limb ischemia (CLI) are at high risk for amputation or death, even when their inpatient procedures are successful. We hypothesized that postoperative outcomes might be improved in regions where diabetics with CLI receive more frequent high-quality outpatient care.Methods: A retrospective cohort study was performed among 172,134 patients with CLI (52% male, 15% black, mean age 76 years) who underwent open and endovascular lower extremity revascularization procedures using Medicare claims (2004-2007), which included 84,653 (49%) beneficiaries who were diabetic. Regional utilization of annual serum cholesterol and hemoglobin A1c testing were used to assess the quality of outpatient diabetic care. We examined relationships between frequency of diabetic testing with amputation-free survival (AFS), major adverse limb events (MALE), and rates of readmission across all US hospital referral regions.Results: There was significant regional variation in annual serum cholesterol and hemoglobin A1c testing across the United States (87% highest quartile vs. 59% lowest quartile, P < 0.01). Compared with the lowest quartile of diabetic testing, diabetic patients undergoing lower extremity revascularization in regions with the highest quartile of diabetic testing had significantly improved AFS (hazards ratio [HR]: 0.94, 95% confidence interval [CI]: 0.90-0.97; P < 0.01) and MALE (HR: 0.92, 95% CI: 0.89-0.96; P < 0.01) persisting up to 2 years after lower extremity revascularization, even after adjusting for procedure type, gender, age, race, and comorbidities. Moreover, the risk of 30-day readmission was significantly reduced in regions with the highest versus lowest quartile of diabetic testing (odds ratio: 0.91, 95% CI: 0.85-0.97; P < 0.01). Nondiabetic patients with CLI, in comparison, did not benefit to the same extent from undergoing revascularization in regions with high-quality outpatient diabetic care.Conclusions: Diabetic patients undergoing lower extremity revascularization in regions with higher utilization of diabetic care quality measures have significantly better long-term limb salvage and readmission outcomes. Our study underscores the importance of providing optimal outpatient care to diabetics following vascular surgery and outlines a potential strategy for quality improvement in these high-risk patients.