Abstract
Introduction
The need for multidisciplinary care of patients with advanced limb threat is well
established. We examined patient reported outcomes and health-related quality of life
(HR-QoL) for those who completed a multidisciplinary extremity preservation program
(EPP) at our institution.
Methods
Patients with advanced limb threat, who had previously failed standard management
at a tertiary-care center, were referred to EPP for evaluation by a multidisciplinary
panel of vascular, plastic, orthopedic and podiatric surgeons, along with infectious
disease, prosthetics, orthotics, imaging, palliative care, social work and wound nursing
specialists. HR-QoL was quantified before and after EPP participation with the RAND-36
questionnaire. The validated RAND-36 assesses physical function, role limitations
caused by physical and emotional health problems, social functioning, emotional well-being,
energy, pain and general health perceptions.
Results
From 2018 to 2020, 185 patients were referred to EPP. After review by the multidisciplinary
panel, 120 were accepted into the program, 63 of whom completed their course of care;
9 were one-time consultations. The median number of EPP in-person care visits was
23 (13-54) per participant; 87.3% of patients received one or more surgical procedure,
including operative debridement (73%), revascularization (44%), soft tissue reconstruction
or transplantation (46%), as well as hyperbaric oxygen therapy (11%) during their
course of treatment.
85.7% of patients achieved complete wound healing, 41.5% occurring within 6 months.
Ultimately, 14.3% required a major amputation. Graduates noted improvement in all
categories of the HR-QoL upon completion, including those undergoing major amputation.
On adjusted multivariate regression analysis, patients with immunocompromised status
were more likely to show greater improvement in their social function (OR: 10.1; P<0.044)
and emotional role limitation (OR:8.1; P=0.042), while patients with larger wound
volume at presentation were more likely to have greater improvement in their general
health (OR: 1.1; P<0.049). Conversely, patients with a smoking history had less improvement
in energy level (OR:0.4; P=0.044) and patients with dialysis-dependence had less improvement
in social function (OR:0.2; P=0.034).
Conclusion
Coordinated, multidisciplinary extremity preservation program improves HR-QoL of patients
with complex limb threat, including those who are immunocompromised with impaired
social function and emotional role limitations. Further study is warranted to better
characterize the generalizability of this approach, including considerations of cost-effectiveness,
wound recidivism, and limiting the number of in-person visits required to achieve
complete healing.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Annals of Vascular SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Benefit of multidisciplinary wound care center on the volume and outcomes of a vascular surgery practice.Journal of Vascular Surgery. 2019; 70: 1612-1619
- Reduction of amputation rates in multidisciplinary foot clinics - a systematic review.Cambridge Publishing. 2014; : 155-162
- The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers: a systematic review.J Wound Care. 2017; 26: 324-339
- Effectiveness of multidisciplinary care teams in reducing major amputation rate in adults with diabetes: A systematic review & meta-analysis.Diabetes Res Clin Pract. 2020; 161107996
- A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers.J Vasc Surg. 2020; 71 (e3): 1433-1446
- Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis.Journal of Foot and Ankle Research. 2020; 13: 15
- Global vascular guidelines on the management of chronic limb-threatening ischemia.Journal of Vascular Surgery. 2019; 69 (e40): 3S-125S
- History of the Team Approach to Amputation Prevention: Pioneers and Milestones.Journal of the American Podiatric Medical Association. 2010; 100: 317-334
- A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration.Journal of Vascular Surgery. 2020; 71 (e2): 669-681
- Burden of diabetic foot disorders, guidelines for management and disparities in implementation in Europe: a systematic literature review.Diabetes Metab Res Rev. 2014; 30: 635-645
- The role of interdisciplinary team approach in the management of the diabetic foot: a joint statement from the Society for Vascular Surgery and the American Podiatric Medical Association.J Vasc Surg. 2010; 51: 1504-1506
- Quantifying Improvement in Symptoms, Functioning, and Quality of Life After Peripheral Endovascular Revascularization.Circulation. 2007; 115: 569-575
- The quality of life in patients after peripheral bypass surgery deteriorates at long-term follow-up.Journal of Vascular Surgery. 2011; 53: 643-650
- Quality of life after infrainguinal bypass grafting surgery.Journal of Vascular Surgery. 1999; 29: 913-919
- Functional outcomes in limb salvage vascular surgery.The American Journal of Surgery. 1994; 168: 188-191
- Validation of a Method to Identify Immunocompromised Patients with Severe Sepsis in Administrative Databases.Ann Am Thorac Soc. 2016; 13: 253-258
- The role of public values in setting health care priorities.Social Science & Medicine. 1991; 32: 773-781
- The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.Med Care. 1992; 30: 473-483
- A shorter form health survey: can the SF-12 replicate results from the SF-36 in longitudinal studies?.Journal of Public Health. 1997; 19: 179-186
- The Impact of a Limb Preservation Service on the Incidence of Major Amputations for All Indications at a Level I Trauma Center.Annals of Vascular Surgery. 2021; 70: 43-50
Death NCEiPOa. Lower limb amputation: working together 2014 [Available from: http://www.ncepod.org.uk/2014report2/downloads/WorkingTogetherFullReport.pdf.
- The Lower Extremity Amputation Protocol (LEAP): A Pathway to Successful Ambulation.Journal of Vascular Surgery. 2021; 74: e279
- Smoking, chronic wound healing, and implications for evidence-based practice.J Wound Ostomy Continence Nurs. 2014; 41 (E2): 415
- Relationship of smoking status, energy balance, and body weight: Analysis of the Second National Health and Nutrition Examination Survey.Journal of Consulting and Clinical Psychology. 1991; 59: 899-905
- Depression in Chronic Kidney Disease and End-Stage Renal Disease: Similarities and Differences in Diagnosis, Epidemiology, and Management.Kidney Int Rep. 2016; 2: 94-107
- The Psychosocial Experience of Patients with End-Stage Renal Disease and Its Impact on Quality of Life: Findings from a Needs Assessment to Shape a Service.ISRN Nephrology. 2013; 2013308986
- The current and future landscape of dialysis.Nature Reviews Nephrology. 2020; 16: 573-585
Article Info
Publication History
Accepted:
May 23,
2022
Received in revised form:
May 14,
2022
Received:
April 3,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Disclosure: The authors have no financial disclosures.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.