Abstract 338: High Quality Medical Care: A Key Component in Access to Vascular Care for Patients with Lower Extremity PAD

Abstract

Objectives: Prior work has demonstrated that patients at risk for amputation often have limited access to vascular care. We hypothesized that patients at risk for amputation may also have poor access to medical care related to their peripheral arterial disease (PAD). Therefore, we studied the intensity of medical care provided to patients at risk for amputation, and its relationship to access to vascular care. Methods: We identified a cohort of 52,505 Medicare patients at risk for amputation (pre-existing diabetes, PAD, and foot ulceration) who required hospital admission for leg or foot cellulitis. Using the 307 hospital referral regions defined in the Dartmouth Atlas, we determined the proportion of patients that received appropriate, high quality medical care within 1 year (before or after) hospital admission. High-quality medical care was defined as evidence of (1) hemoglobin A1C testing (2) podiatric care, and (3) non-invasive vascular testing. Then, using regression analysis at the regional level, we assessed relationships between the use of high quality of medical care and access to diagnostic or therapeutic lower extremity vascular procedures. Results: Across the United States, only 36% of diabetic patients with PAD and tissue loss received all three components of high quality medical care; 76% received 2 of 3 components. A non-invasive vascular study was absent in 41%. Provision of high-quality medical care varied across regions, from 4% of patients in Mason City, Iowa to 58% of patients in Sun City, Arizona. Regions that provided high quality medical care were significantly more likely to provide vascular care (R=0.30, p<0.001). Across quintiles of medical care quality, those regions most likely to provide high quality medical care were 24% more likely to provide invasive vascular care and revascularization (p<0.001, Figure). Conclusions: Fewer than 4 out of 10 Medicare diabetics with PAD and tissue loss receive high-quality, appropriate medical care. Quality improvement efforts at limiting amputation need to incorporate multidisciplinary strategies and involve primary care providers, as high quality medical care is an important determinant of access to vascular care and limb preservation.