Determinants of midterm functional outcomes, wound healing, and resources used in a hospital-based limb preservation program

Bala Ramanan, Ayman Ahmed, Bian Wu, Marlin W. Causey, Warren J. Gasper, Shant M. Vartanian, Alexander M. Reyzelman, Jade S. Hiramoto, Michael S. Conte

Research output: Contribution to journalArticle

7 Citations (Scopus)

Abstract

Objective The objective of this study was to assess midterm functional status, wound healing, and in-hospital resource use among a prospective cohort of patients treated in a tertiary hospital, multidisciplinary Center for Limb Preservation. Methods Data were prospectively gathered on all consecutive admissions to the Center for Limb Preservation from July 2013 to October 2014 with follow-up data collection through January 2016. Limbs were staged using the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification scheme at the time of hospital admission. Patients with nonatherosclerotic vascular disorders, acute limb ischemia, and trauma were excluded. Results The cohort included 128 patients with 157 threatened limbs; 8 limbs with unstageable disease were excluded. Mean age (±standard deviation [SD]) was 66 (±13) years, and median follow-up duration (interquartile range) was 395 (80-635) days. Fifty percent (n = 64/128) of patients were readmitted at least once, with a readmission rate of 20% within 30 days of the index admission. Mean total number of admissions per patient (±SD) was 1.9 ± 1.2, with mean (±SD) cumulative length of stay (cLOS) of 17.1 (±17.9) days. During follow-up, 25% of limbs required a vascular reintervention, and 45% developed recurrent wounds. There was no difference in the rate of readmission, vascular reintervention, or wound recurrence by initial WIfI stage (P >.05). At the end of the study period, 23 (26%) were alive and nonambulatory; in 20%, functional status was missing. On both univariate and multivariate analysis, end-stage renal disease and prior functional status predicted ability to ambulate independently (P <.05). WIfI stage was associated with major amputation (P =.01) and cLOS (P =.002) but not with time to wound healing. Direct hospital (inpatient) cost per limb saved was significantly higher in stage 4 patients (P <.05 for all time periods). WIfI stage was associated with cumulative in-hospital costs at 1 year and for the overall follow-up period. Conclusions Among a population of patients admitted to a tertiary hospital limb preservation service, WIfI stage was predictive of midterm freedom from amputation, cLOS, and hospital costs but not of ambulatory functional status, time to wound healing, or wound recurrence. Patients presenting with limb-threatening conditions require significant inpatient care, have a high frequency of repeated hospitalizations, and are at significant risk for recurrent wounds and leg symptoms at later times. Stage 4 patients require the most intensive care and have the highest initial and aggregate hospital costs per limb saved. However, limb salvage can be achieved in these patients with a dedicated multidisciplinary team approach.

Original languageEnglish (US)
Pages (from-to)1765-1774
Number of pages10
JournalJournal of Vascular Surgery
Volume66
Issue number6
DOIs
StatePublished - Dec 1 2017

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Wound Healing
Extremities
Wounds and Injuries
Ischemia
Hospital Costs
Foot
Blood Vessels
Infection
Length of Stay
Amputation
Tertiary Care Centers
Inpatients
Recurrence
Limb Salvage
Patient Admission
Critical Care
Chronic Kidney Failure
Leg
Hospitalization
Multivariate Analysis

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

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Determinants of midterm functional outcomes, wound healing, and resources used in a hospital-based limb preservation program. / Ramanan, Bala; Ahmed, Ayman; Wu, Bian; Causey, Marlin W.; Gasper, Warren J.; Vartanian, Shant M.; Reyzelman, Alexander M.; Hiramoto, Jade S.; Conte, Michael S.

In: Journal of Vascular Surgery, Vol. 66, No. 6, 01.12.2017, p. 1765-1774.

Research output: Contribution to journalArticle

Ramanan, B, Ahmed, A, Wu, B, Causey, MW, Gasper, WJ, Vartanian, SM, Reyzelman, AM, Hiramoto, JS & Conte, MS 2017, 'Determinants of midterm functional outcomes, wound healing, and resources used in a hospital-based limb preservation program', Journal of Vascular Surgery, vol. 66, no. 6, pp. 1765-1774. https://doi.org/10.1016/j.jvs.2017.05.102
Ramanan, Bala ; Ahmed, Ayman ; Wu, Bian ; Causey, Marlin W. ; Gasper, Warren J. ; Vartanian, Shant M. ; Reyzelman, Alexander M. ; Hiramoto, Jade S. ; Conte, Michael S. / Determinants of midterm functional outcomes, wound healing, and resources used in a hospital-based limb preservation program. In: Journal of Vascular Surgery. 2017 ; Vol. 66, No. 6. pp. 1765-1774.
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abstract = "Objective The objective of this study was to assess midterm functional status, wound healing, and in-hospital resource use among a prospective cohort of patients treated in a tertiary hospital, multidisciplinary Center for Limb Preservation. Methods Data were prospectively gathered on all consecutive admissions to the Center for Limb Preservation from July 2013 to October 2014 with follow-up data collection through January 2016. Limbs were staged using the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification scheme at the time of hospital admission. Patients with nonatherosclerotic vascular disorders, acute limb ischemia, and trauma were excluded. Results The cohort included 128 patients with 157 threatened limbs; 8 limbs with unstageable disease were excluded. Mean age (±standard deviation [SD]) was 66 (±13) years, and median follow-up duration (interquartile range) was 395 (80-635) days. Fifty percent (n = 64/128) of patients were readmitted at least once, with a readmission rate of 20{\%} within 30 days of the index admission. Mean total number of admissions per patient (±SD) was 1.9 ± 1.2, with mean (±SD) cumulative length of stay (cLOS) of 17.1 (±17.9) days. During follow-up, 25{\%} of limbs required a vascular reintervention, and 45{\%} developed recurrent wounds. There was no difference in the rate of readmission, vascular reintervention, or wound recurrence by initial WIfI stage (P >.05). At the end of the study period, 23 (26{\%}) were alive and nonambulatory; in 20{\%}, functional status was missing. On both univariate and multivariate analysis, end-stage renal disease and prior functional status predicted ability to ambulate independently (P <.05). WIfI stage was associated with major amputation (P =.01) and cLOS (P =.002) but not with time to wound healing. Direct hospital (inpatient) cost per limb saved was significantly higher in stage 4 patients (P <.05 for all time periods). WIfI stage was associated with cumulative in-hospital costs at 1 year and for the overall follow-up period. Conclusions Among a population of patients admitted to a tertiary hospital limb preservation service, WIfI stage was predictive of midterm freedom from amputation, cLOS, and hospital costs but not of ambulatory functional status, time to wound healing, or wound recurrence. Patients presenting with limb-threatening conditions require significant inpatient care, have a high frequency of repeated hospitalizations, and are at significant risk for recurrent wounds and leg symptoms at later times. Stage 4 patients require the most intensive care and have the highest initial and aggregate hospital costs per limb saved. However, limb salvage can be achieved in these patients with a dedicated multidisciplinary team approach.",
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T1 - Determinants of midterm functional outcomes, wound healing, and resources used in a hospital-based limb preservation program

AU - Ramanan, Bala

AU - Ahmed, Ayman

AU - Wu, Bian

AU - Causey, Marlin W.

AU - Gasper, Warren J.

AU - Vartanian, Shant M.

AU - Reyzelman, Alexander M.

AU - Hiramoto, Jade S.

AU - Conte, Michael S.

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N2 - Objective The objective of this study was to assess midterm functional status, wound healing, and in-hospital resource use among a prospective cohort of patients treated in a tertiary hospital, multidisciplinary Center for Limb Preservation. Methods Data were prospectively gathered on all consecutive admissions to the Center for Limb Preservation from July 2013 to October 2014 with follow-up data collection through January 2016. Limbs were staged using the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification scheme at the time of hospital admission. Patients with nonatherosclerotic vascular disorders, acute limb ischemia, and trauma were excluded. Results The cohort included 128 patients with 157 threatened limbs; 8 limbs with unstageable disease were excluded. Mean age (±standard deviation [SD]) was 66 (±13) years, and median follow-up duration (interquartile range) was 395 (80-635) days. Fifty percent (n = 64/128) of patients were readmitted at least once, with a readmission rate of 20% within 30 days of the index admission. Mean total number of admissions per patient (±SD) was 1.9 ± 1.2, with mean (±SD) cumulative length of stay (cLOS) of 17.1 (±17.9) days. During follow-up, 25% of limbs required a vascular reintervention, and 45% developed recurrent wounds. There was no difference in the rate of readmission, vascular reintervention, or wound recurrence by initial WIfI stage (P >.05). At the end of the study period, 23 (26%) were alive and nonambulatory; in 20%, functional status was missing. On both univariate and multivariate analysis, end-stage renal disease and prior functional status predicted ability to ambulate independently (P <.05). WIfI stage was associated with major amputation (P =.01) and cLOS (P =.002) but not with time to wound healing. Direct hospital (inpatient) cost per limb saved was significantly higher in stage 4 patients (P <.05 for all time periods). WIfI stage was associated with cumulative in-hospital costs at 1 year and for the overall follow-up period. Conclusions Among a population of patients admitted to a tertiary hospital limb preservation service, WIfI stage was predictive of midterm freedom from amputation, cLOS, and hospital costs but not of ambulatory functional status, time to wound healing, or wound recurrence. Patients presenting with limb-threatening conditions require significant inpatient care, have a high frequency of repeated hospitalizations, and are at significant risk for recurrent wounds and leg symptoms at later times. Stage 4 patients require the most intensive care and have the highest initial and aggregate hospital costs per limb saved. However, limb salvage can be achieved in these patients with a dedicated multidisciplinary team approach.

AB - Objective The objective of this study was to assess midterm functional status, wound healing, and in-hospital resource use among a prospective cohort of patients treated in a tertiary hospital, multidisciplinary Center for Limb Preservation. Methods Data were prospectively gathered on all consecutive admissions to the Center for Limb Preservation from July 2013 to October 2014 with follow-up data collection through January 2016. Limbs were staged using the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification scheme at the time of hospital admission. Patients with nonatherosclerotic vascular disorders, acute limb ischemia, and trauma were excluded. Results The cohort included 128 patients with 157 threatened limbs; 8 limbs with unstageable disease were excluded. Mean age (±standard deviation [SD]) was 66 (±13) years, and median follow-up duration (interquartile range) was 395 (80-635) days. Fifty percent (n = 64/128) of patients were readmitted at least once, with a readmission rate of 20% within 30 days of the index admission. Mean total number of admissions per patient (±SD) was 1.9 ± 1.2, with mean (±SD) cumulative length of stay (cLOS) of 17.1 (±17.9) days. During follow-up, 25% of limbs required a vascular reintervention, and 45% developed recurrent wounds. There was no difference in the rate of readmission, vascular reintervention, or wound recurrence by initial WIfI stage (P >.05). At the end of the study period, 23 (26%) were alive and nonambulatory; in 20%, functional status was missing. On both univariate and multivariate analysis, end-stage renal disease and prior functional status predicted ability to ambulate independently (P <.05). WIfI stage was associated with major amputation (P =.01) and cLOS (P =.002) but not with time to wound healing. Direct hospital (inpatient) cost per limb saved was significantly higher in stage 4 patients (P <.05 for all time periods). WIfI stage was associated with cumulative in-hospital costs at 1 year and for the overall follow-up period. Conclusions Among a population of patients admitted to a tertiary hospital limb preservation service, WIfI stage was predictive of midterm freedom from amputation, cLOS, and hospital costs but not of ambulatory functional status, time to wound healing, or wound recurrence. Patients presenting with limb-threatening conditions require significant inpatient care, have a high frequency of repeated hospitalizations, and are at significant risk for recurrent wounds and leg symptoms at later times. Stage 4 patients require the most intensive care and have the highest initial and aggregate hospital costs per limb saved. However, limb salvage can be achieved in these patients with a dedicated multidisciplinary team approach.

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