Spending on Vascular Care Has Little Effect on Amputations

Researchers find large regional variations in spending, but little evidence to suggest that aggressive, high-cost treatments for leg revascularization translate into lower rates of amputation.

A Dartmouth Atlas study has found similar trends in leg revascularizations as highlighted in a 2009 study of high healthcare costs in Miami and McAllen, TX. The current findings show that regions where doctors performed more expensive procedures incurring higher Medicare spending generally did not prevent more limb amputations than did doctors in regions where less was spent.

In the 2009 study, "we studied costs of care in the last year of life for people who died," explained Philip Goodney, MD, a vascular surgeon at Dartmouth-Hitchcock Medical Center in Lebanon, NH. "With this new study, we looked at spending in the last year for the leg in people who had amputations," that is, people with lower limb vascular disease that was so serious, amputation would be required within the year.

Limb amputations can be a consequence of poor circulation resulting from untreated diabetes or cardiovascular disease. The belief is that better care can save the leg or at least keep it from requiring surgical removal.

But the researchers could not explain why, for example, there was a nearly four-fold difference between total cost of overall inpatient care in Salinas CA, $42,613, and Bismarck, ND, $11,077, but not a corresponding difference in amputations.

In fact, according to the analysis, higher spending "was not associated with lower regional amputation rates." The study is published in the Nov. 20 issue of JAMA Surgery.

The researchers analyzed regional variation through administrative claims for 18,463 Medicare beneficiaries who underwent a disease-related amputation between 2003 and 2010, and tracked healthcare spending by amount and type.

Asked why there is such a big difference, Goodney hypothesized that "some areas of the country are able to deliver vascular care in a pretty cost-effective manner. They stick to straightforward operations or interventional procedures, like plain old angioplasty," to open occlusions in the leg that block circulation.

"But there are places that very commonly use more expensive technology, like multiple atherectomy catheters" to remove plaque instead of pushing it against the artery wall, "or laser catheters, or whatever the newest and fanciest device that tends to come down the road. And they use a lot of them."

"We know that if you [have circulation health issues and] get no vascular care, that's not good. But we wanted to look at those who did, and ask whether, if you got five angioplasties and a leg bypass, did that translate to a better outcome than if you had just a simple operation and an angioplasty."

"If you think about it, if you're in a region that consistently spends more money, and you're likely using more expensive technology, you would think that if that technology worked better, then the amputation risks would be lower; you'd think you're doing something better.

"What we found is that the more aggressive they were, the more procedures were done and the higher the cost… that didn't translate into lower rates of amputation."

Other variations included the difference on regional spending for revascularization or debridement, exclusive of the amputation in the year before these patients underwent amputation.

Regions with the lowest mean spending:

• Muncie IN – $1,277
• Duluth, MN – $3.342
• Topeka, KS – $4199

Regions with the highest mean spending:

• St. Paul, MN – $14,063
• Toledo, OH – $14,107
• Harlingen, TX – $14,120

Goodney emphasized that the variation for the most part "is driven by differences in the types of treatments and frequency of use rather than the differences in patients' health status or other characteristics.

Goodney says that the next step will be to look in detail at areas of the country with low spending on lower limb vascular care and fewer amputations. "That's going to be the place that we want to try to replicate across the country. Instead of spending $42,000 a year in the last year before an amputation, in say, Salinas, you can get similar results by spending a quarter of that. We can learn what they're doing and export it to Salinas."

He added that he and his research team "hope Medicare officials will listen to us, in terms of offering some advice on how to make this better."

About two million people in the U.S. are living with amputations, and slightly more than half of those lost their limbs because of circulatory disease. There are about 180,000 amputations performed a year, a hospital cost of about $8.3 billion annually.