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Regions of the country that spend the most money on vascular care perform the most interventions in peripheral artery disease (PAD) patients, but such spending does not translate to any decrease in the rate of eventual amputations, according to a study published online November 20, 2013, ahead of print in the Journal of the American Medical Association: Surgery.

Philip P. Goodney, MD, MS, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), and colleagues analyzed 18,463 Medicare patients who underwent a PAD-related amputation between 2003 and 2010. Of those, 64% were admitted to the hospital in the year leading up to the amputation for revascularization, wound-related care, or both, while 36% were admitted only for their amputation.

The overall mean cost of inpatient vascular care was $22,405 per patient, ranging from $11,077 (Bismarck, ND) to $42,613 (Salinas, CA).

Patients in the highest spending quintile (mean $27,395) underwent more invasive vascular procedures than patients in the lowest spending quintile (mean $17,134; 20.4 vs. 12.0 per 10,000 patients; P < 0.001). This relationship was strengthened after adjustment for age, sex, race, diabetes, cardiac, and renal disease (adjusted OR 3.5; 95% CI 3.2-3.8; P < 0.001).

Even though revascularization was associated with higher spending (P < 0.001), there was no correlation between higher spending and lower regional amputation rates (P = 0.06). Regions reporting the highest use of endovascular interventions were most likely to have high spending (P = 0.002) and high amputation rates (P = 0.004).

Results were divided by region of the country; patients in regions making up the highest quintile of spending underwent more procedures, but saw no reduction in amputation rates.

More Expense, No Benefit?

“Our prior work showed us that getting little or no vascular care is not good for preventing amputation,” Dr. Goodney told TCTMD in an e-mail communication. “What this paper helped us to understand is that more expensive vascular treatments don’t seem to [help more] than less expensive, basic, vascular interventions. . . . There seems to be little measurable benefit to much more expensive strategies using the ‘latest and greatest’ atherectomy catheter or drug-coated balloon.”

Michael R. Jaff, MD, of Massachusetts General Hospital (Boston, MA), said that these results highlight some important opportunities to improve care. “We need better, more effective, and durable revascularization options for patients with critical limb ischemia,” he told TCTMD in an e-mail communication, noting that revascularization strategies should be better linked with wound care.

Dr. Jaff pointed out that the study found a relationship between comorbidities and spending, suggesting “that those who received more expensive care actually were more complex and required more intensive management.” However, the study elucidates the fact that some patients have a very low likelihood of limb salvage, and a primary amputation is likely a better option than expensive procedures that do not correlate with any decrease in amputation rates, he added.

Dr. Goodney concluded that more work is still needed on specific, newer technologies to determine if they are worth the higher cost.

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