Bring Your Specialty to the Team: Reaching the Best Outcomes for Patients

by Mia DeFino

CHICAGO, IL—The 9th annual Amputation Prevention Symposium (AMP) kicked off Wednesday at the Hilton Chicago with the Critical Limb Ischemia (CLI) in 2019 #LeaveYourSpecialtyAtTheDoor session. Founder and Course Director Jihad Mustapha, MD, of Advanced Cardiac & Vascular Centers for Amputation Prevention, welcomed attendees to the conference and urged each individual to share what they learn these next few days with their colleagues. Dr. Mustapha emphasized the severity of CLI mortality, as there are more individuals that die over 5 years after a CLI diagnosis than with any type of cancer, except for lung cancer. While there have been national government initiatives to target pancreatic and colorectal cancer to reduce mortality rates, there is still a lack of awareness of the severity of CLI mortality.

There are several approaches to improve CLI mortality that were presented during the session. Richard Neville, MD, Associate Director, INOVA Heart and Vascular Institute, focused on how innovation and multi-disciplinary teams can advance the treatment for patients with CLI during the Alan T. Hirsch Memorial Keynote Address. Dr. Neville encouraged the attendees to “bring the talents your specialty can offer to the team rather than leaving it at the door,” suggesting that finding ways to share expertise and collaborating can lead to better patient outcomes and increased satisfaction with treatment. Attendees can find additional information about communicating between specialties in his recent editorial. This focus translated directly into how specialists will be evaluated in the future, where physicians and health care providers will need to optimize patient quality of life with financial responsibility, thus providing high quality care with low costs.

Dr. Neville also presented on a recent study by the CLI Global Society that has helped gather more statistics about the burden and unmet needs of CLI patients, with less than one-third of patients with CLI being prescribed optimal medical therapy. The population-based study evaluated the outcomes and associated costs following an initial diagnosis of CLI. Of the 36.5 million Medicare beneficiaries considered, there were 116,031 with a CLI diagnosis and 72,199 incident cases of primary CLI. After initial diagnosis, there was a 46% survival rate at a median of 3.5 years, with 87% freedom from amputation. Revascularization led to increased survival compared with amputation over 4 years. Costs per patient per year after CLI diagnosis increased by 30%, with the majority of cost attributed to inpatient hospital stay (62%) and the average per patient cost the highest when patients presented with gangrene. Overall, there were extremely high health care costs and poor prognosis, and major amputation led to decreased survival, higher rate of subsequent amputation, and higher annual healthcare cost in CLI patients.

Dr. Mustapha presented on recent findings from the CLI Global Society, regarding the determinants of long-term outcomes and costs in the management of CLI, to encourage attendees to be part of the considerable effort needed to raise disease awareness and implement coding to better define and identify CLI disease. “Without awareness we are not going to be able to achieve the goal that we want,” said Dr. Mustapha. Currently, CLI prevalence is estimated from administrative claims databases using ICD clinical diagnosis codes that yield high sensitivity when patients with a CLI diagnosis code likely have the disease. However, there is a loss of specificity when patients without a CLI diagnosis code may actually have the disease—leading to underdiagnosis. Proper diagnosis, proper imaging, and increased awareness is needed to address the underdiagnosis and undertreatment of CLI. The CLI Global Society has brought together representatives from SCAI, SVS, SVM, and SIR to form a Coalition that has developed a submitted proposal to differentiate CLI disease from PAD in the medical coding and billing nomenclature, beginning with the ICD-10 diagnosis codes. The submission is currently under review by the Centers for Disease Control and Prevention ICD-10 CM Coordination & Management Committee for addition to the 2021 update.

R. Kevin Rogers, MD, from University of Colorado, Denver, provided an update on the COMPASS trial that was stopped early because of robust results in improvements in limb outcomes in the low dose rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg) daily group compared with aspirin alone and rivaroxaban 5 mg twice daily alone. This is encouraging, as the study was done specifically in PAD patients. Other pharmacologic therapies, such as aspirin, statins, and PSK-9 inhibitors, were discussed by Mahmood Razavi, MD, and Lawrence Garcia, MD, but much of the existing research is not in PAD patients and needs to be extrapolated from other cardiovascular disease populations. Dr. Ido Weinberg from Harvard urged more dedicated studies to be performed in CLI patients so that physicians can have better evidence for which medications are most effective for their patients.