Veterans Study Shows Areas of Need for CLI Care

In the Veterans Administration system, patients with critical limb ischemia (CLI) are more likely to receive revascularization than they were in the past, with an accompanying decline in death and major amputations, new data show. However, the findings suggest a lack of uniformity in how patients are managed that remains to be addressed.

"Among the 100 or so hospitals that were included in our study, rates of revascularization varied by more than fourfold across the sites,” said Saket Girotra, MD, MSc (University of Iowa Carver College of Medicine, Iowa City), the study’s senior author. “We need to do more work to make certain that regardless of which hospital a veteran presents [at], that they have the ability to access specialty care for this condition. If they are a candidate for revascularization, they should have that treatment."

In an interview with TCTMD, Girotra said it is possible that in some instances, patients are not referred for revascularization due to a lack of vascular expertise at the location where they present. “We need to think innovatively,” he continued. “Perhaps there needs to be telehealth, or collaboration between larger medical centers that could serve as referral sites [for] hospitals where vascular expertise is not available.”

Disparities at Facility Level

For the study, Girotra and colleagues, led by Amgad Mentias, MD, MSc (University of Iowa Carver College of Medicine), examined Veterans Health Administration data on 20,938 patients with CLI who were hospitalized between 2005 and 2014. Over the study period, there was a modest but statistically significant decline in rates of CLI. Rates of revascularization within 90 days of hospitalization increased from 41.1% in 2005 to 57.9% in 2014 (P < 0.01 for trend). Surgery was the primary modality, followed by endovascular and hybrid procedures.

We need to do more work to make certain that regardless of which hospital a veteran presents [at], that they have the ability to access specialty care for this condition. Saket Girotra

Compared with patients who underwent revascularization for CLI, those who did not were more likely to be black, diabetic, and to have kidney disease or heart failure.

In-hospital and 90-day mortality both declined over time. The decrease in 90-day mortality was driven by use of revascularization and statin prescription. The rate of major amputation during hospitalization and at 90 days also decreased over time. In risk-adjusted analyses, 90-day major amputation declined from 19.8% in 2005 to 12.9% in 2014 (P < 0.01 for trend), driven by revascularization.

Of those who underwent a major amputation, the authors found that 59% never had a pre-amputation angiogram or an attempted revascularization in the previous 90 days. Proceeding directly to amputation was associated with a greater incidence of diabetes, kidney disease, and heart failure, and a lower incidence of CAD, hypertension, and guideline-recommended medications such as statins.

As Girotra pointed out, rates of any revascularization at the facility level ranged from 12.5% to 53.2%, and did not appear to be related to variations in patient characteristics. Older age, black race, and comorbidities (except CAD) were most associated with lower odds of receiving revascularization.

Unanswered Questions

To TCTMD, Girotra said the finding of surgical bypass being the predominant revascularization strategy in this population was surprising and bears further study. Whether it signals the VA being out of step is unclear, but in their paper, the researchers note that a recent study of National Inpatient Sample data showed a doubling of endovascular revascularization for CLI between 2003 and 2011, with a concomitant decline of 25% for surgical revascularization during the same period.

While Girotra said he cannot be certain of the reason for the high incidence of surgery in the VA population, lack of ready access to interventionalists who perform endovascular procedures is likely a factor in some facilities and in certain areas of the country. But he noted that in an exploratory analysis, 90% of the VA sites that were included had both surgical and endovascular capability.

Another possibility is that reimbursement issues within the VA system may play a role. Additionally, despite data showing equipoise between surgery and endovascular options, not everyone is convinced that endovascular-first is the way to go. Girotra said the ongoing BEST-CLI trial, which is enrolling patients who are candidates for either procedure, may ultimately impact revascularization trends in the VA and elsewhere depending on what it shows.

Lastly, Girotra said the findings of the current study also highlight underprescribing of key medications in the CLI population. Rates of statin prescription at discharge increased over the study period from 47.4% to 60.9%, and high-intensity statins increased from 16.5% to 29.4%. Still, Girotra said statins remain underutilized “and that's an important area for us to try to understand why it's happening and figure out what we can do to improve the medication rates.”