By using Medicare 2003 to 2006 data, we identified all patients with CLI who underwent major lower extremity
amputation in the 306 hospital referral regions described in the Dartmouth Atlas of Healthcare. For each patient, we studied the use of lower extremity vascular procedures (open surgery or endovascular intervention) in the year before
amputation. Our main outcome measure was the intensity of vascular care, defined as the proportion of patients in the hospital referral region undergoing a vascular procedure in the year before
amputation. Overall, 20,464 patients with CLI underwent major lower extremity
amputations during the study period, and collectively underwent 25,800 vascular procedures in the year before undergoing
amputation. However, these procedures were not distributed evenly: 54% of patients had no vascular procedures performed in the year before
amputation, 14% underwent 1 vascular procedure, and 32% underwent >1 vascular procedure. In the regions in the lowest quintile of vascular intensity, vascular procedures were performed in 32% of patients. Conversely, in the regions in the highest quintile of vascular intensity, revascularization was performed in 58% of patients in the year before
amputation (P<0.0001). In analyses accounting for differences in age, sex, race, and comorbidities, patients in high-intensity regions were 2.4 times as likely to undergo revascularization in the year before
amputation than patients in low-intensity regions (adjusted odds ratio, 2.4; 95% CI, 2.1-2.6; P<0.001).
CONCLUSIONS: Significant variation exists in the intensity of vascular care provided to patients in the year before major
amputation. In some regions, patients receive
intensive care, whereas in other regions, far less vascular care is provided. Future work is needed to determine the association between intensity of vascular care and
limb salvage.