How to avoid a huge number of major amputations

 More than 400 Americans undergo major amputation of a leg, either above or below the knee, every day. Many of them suffer from what’s known as chronic limb-threatening ischemia (CLTI), a form of peripheral artery disease that narrows people’s arteries.

At my health system, we perform about 70 major amputations every year for CLTI. Amputation can save the lives of patients with CLTI, but it brings with it a lifetime of disability, emotional distress, social burden, and increased health care costs — burdens that don’t fall equitably. Recent data show evidence of persistent disparities when it comes to major amputation. Residents of rural areas, African-American and Native American patients, and those of low socioeconomic status are all more likely than others to undergo the life-changing surgery.

Plus, the unfortunate truth is that losing a limb often means losing a life. Research shows that nearly half of all patients with CLTI will die within five years of amputation, which is higher than the five-year mortality rates for breast cancer, colon cancer, and prostate cancer.

Fortunately, though, it doesn’t need to be this way. Through greater collaboration among physicians who treat CLTI and some out-of-the-box thinking around the insurance prior authorization process linked to major amputation procedures, I believe it’s possible to dramatically reduce the number of these life-altering amputations across the U.S. The solution to the problem lies in sharing expertise.

At my institution, we’ve established what’s known as the Limb Salvage Advisory Council. We engage diverse medical experts from across our multi-hospital health system to thoroughly and quickly review and discuss each patient slated for amputation. Vascular surgeons, endovascular and vascular medicine specialists, podiatrists, and wound care experts all participate. We discuss every option possible, including potentially attempting revascularization, which restores blood flow by addressing the blockage or narrowing of the arteries in the legs, either surgically or through a minimally invasive procedure to save the limb. Sometimes, the group meets two or three times on a single case, with different specialists lending their expertise. Eventually, either we decide the patient’s limb can be salvaged and the team creates a plan to do so, or the panel recommends the originally scheduled amputation.

Seems like a straightforward approach, right? But we believe that this model is unique in the U.S. In fact, such initiatives that put the patient at the center of care are still relatively uncommon in medicine. We remain too specialty-, department-, and division-centric. That is often dangerous — especially when a patient is about to lose a leg. Patients deserve the best treatment, which means always exhausting all options.

Results published in 2022 show that our approach is working. Data from my institution published in the journal Circulation: Cardiovascular Interventions show that the Limb Salvage Advisory Council approach helped save the limbs of about 75 percent of the people we worked on — people who certainly would have lost their limbs otherwise. Pair this with recent treatment advances for CLTI, and the future looks brighter for these patients. My institution, for example, recently co-led a clinical trial of a new technology that showed a 76 percent success rate in saving limbs in patients with no options at risk of major amputation, with results published in the New England Journal of Medicine. It’s clear both the low-tech, compassionate innovation of the Limb Salvage Advisory Council and the emergence of high-tech disruptive technology around CLTI can create the climate for a careful, deliberative discussion among experts, ultimately bringing the latest technology to save a limb.

The next logical step is to integrate an entity like our advisory council into the insurance prior authorization process for major amputation surgery. Thankfully, we even have guidance and precedent in a minimally invasive heart procedure to replace the aortic valve known as transcatheter aortic valve replacement. Today, every form of insurance, including government payors, mandate that patients undergoing transcatheter aortic valve replacement — which is common in advanced medical centers in the U.S. — have a review of their case that pulls in several different specialists, which is known as a Heart Team review. These insurers further demand that the transcatheter aortic valve replacement procedure be performed by an interventional cardiologist and cardiac surgeon working in tandem. Otherwise, there will be no reimbursement. A similar prior authorization process for such amputations could result in dramatically better outcomes for patients.

What’s clear is that the status quo can’t continue. Our experience shows that collaboration saves limbs. The power of medicine by meeting, it seems, has untapped potential.

Mehdi Shishehbor, DO, MPH, Ph.D., is president of University Hospitals Harrington Heart & Vascular Institute and holds the Angela and James Hambrick chair in innovation.

https://www.statnews.com/2023/04/28/preventing-leg-amputation-research/