Multidisciplinary Telehealth-Focused Approach to Chronic Limb-Threatening Ischemia Prevents Increased Amputation Rates During COVID-19 Pandemic

Abstract

Introduction and ObjectiveDuring the Coronavirus Disease 2019 (COVID-19) pandemic, global reports have surfaced describing patient- and system-level delays in care secondary to scarcity of resources, fear of exposure, and even reassignment of providers, with subsequent adverse outcomes for patients. After early reports suggested increased major amputation rates among patients with chronic limb-threatening ischemia (CLTI), our healthcare system employed a multidisciplinary strategy to monitor these patients closely. The objective of our study was to evaluate primary amputation rates and disease severity among Veterans who presented with CLTI during the COVID-19 pandemic.MethodsA retrospective cohort study of all patients treated at our Veterans Affairs Medical Center (VAMC) for CLTI was performed. Veterans with CLTI (Rutherford Classification 4-6) who underwent lower extremity revascularization (LER) within the first 7 months of the pandemic (COVID cohort) were compared to those who underwent LER within the same 7-month period one year prior to the pandemic (pre-COVID cohort). Exclusion criteria included acute limb ischemia presentation and LER within 3 months prior to the study period. During the COVID study period, a multidisciplinary team of vascular surgeons, podiatrists, advanced practice providers, and trainees screened all upcoming Veteran appointments for peripheral artery disease or leg wounds. Those with known or suggested CLTI were scheduled for either telehealth or telephone encounters based on access to compatible devices.Table 1Table 1. Comparison of patients undergoing lower extremity revascularization (LER) for chronic limb threatening ischemia (CLTI) before versus during the COVID-19 pandemic.Table 1Image, table 1ResultsThe pre-COVID and COVID cohorts consisted of 32 and 35 patients, respectively. Both displayed similar demographics (Table 1Table 1Comparison of patients undergoing lower extremity revascularization (LER) for chronic limb threatening ischemia (CLTI) before versus during the COVID-19 pandemic.Table 1Image, table 1). Nearly 80% of all patients presented with Rutherford 5-6 disease. WIfI (Wound, Ischemia, and Foot Infection) stage did not significantly differ between the two cohorts. Primary major amputation rate was 15.7% in the pre-COVID cohort compared to 14.3% in the COVID cohort (p=0.980). Based on WIfI score, primary amputation was driven by ischemia (versus infection) in both the pre-COVID and COVID cohorts. During the first 7 months of the pandemic, vascular surgery alone increased monthly telehealth encounters nearly 14-fold, with overall improvement in the number of successful multidisciplinary telehealth visits as the pandemic persisted (Figure 1).Figure 1Progression of successful telehealth visits during the first seven months of the COVID-19 pandemic, by month.Figure 1ConclusionsOur institution did not experience increased amputation rates or advanced disease presentation for patients with CLTI during the COVID-19 pandemic. This may be due to the coordinated approach that has capitalized on continued collaboration between vascular surgery and podiatric surgery, as well as the rapid roll-out of a robust tele-wound program to surveil high-risk Veterans. Further investigation is necessary to determine how telehealth can be leveraged to improve limb outcomes.