Community Wide Feasibility Of The Lower Extremity Amputation Protocol Among Vascular Amputees
Heather Matheny, MD1, Karen Woo, MD, PhD2, Sammy Siada, DO1, Yazen Qumsiyeh, MD1, Leigh Ann O'Banion, MD1.
1UCSF Fresno, Fresno, CA, USA, 2UCLA, Los Angeles, CA, USA.
Objectives: The Lower Extremity Amputation Protocol (LEAP) is a multidisciplinary enhanced recovery after surgery pathway for vascular amputees. The objective of this study was to examine feasibility and outcomes of community-wide implementation of LEAP. Methods: LEAP was implemented within three tertiary safety net hospitals for patients with peripheral artery disease or diabetes requiring major lower extremity amputation. Patients who underwent LEAP (LEAP) were matched 1:1 on hospital location, need for initial guillotine amputation, and final amputation type (above vs below knee) with retrospective controls (Control). Primary endpoint was post-operative hospital length of stay (PO-LOS). Results: A total of 63 matched pairs were included with no difference between baseline demographics and co-morbidities between LEAP and Control (Table 1). There was no difference in amputation level between LEAP and Control (76% BKA vs 24% AKA). LEAP patients had shorter durations of bed rest (p=0.003) and were more likely to receive limb protectors (100% vs 40%, P=<0.001), prosthetic counseling (100% vs 14%, P=<0.001), perioperative nerve blocks (75% vs 25%, P=<0.001) and postoperative gabapentin(79% vs 50%, P=<0.001). LEAP patients were more likely to be discharged to an acute rehabilitation facility (70% vs 44%) and less likely to be discharged to a skilled nursing facility (14% vs 35%, p=0.009). The median PO-LOS for the overall cohort was 4 days. LEAP patients had a shorter median PO-LOS (3 [IQR2-5] vs 5 [IQR4-9] days, p<0.001). On multivariable logistic regression, LEAP decreased the odds of a PO-LOS of ³4 days by 77% (OR 0.23, 95% CI 0.09, 0.63). Overall, LEAP patients had less phantom limb pain (5% vs 21%, p=0.02), and were more likely to receive a prosthesis (81% vs 40%, p=<0.001). In a multivariable cox proportional hazards model, LEAP was associated with an 84% reduction in time to receipt of prosthesis (HR 0.16, P<0.001). Conclusions: Community wide implementation of LEAP significantly improved outcomes for vascular amputees demonstrating thatutilization of core ERAS principles in vascular patients leads to decreased PO-LOS and improved pain control. LEAP also affordsthis socioeconomically disadvantaged population the opportunity to receive a prosthesis and return to the community as a functional ambulator.
|LEAP (n=63)||Control (n=63)||P-value|
|Age||63 + 12.5||61 + 12.8||0.60|
|Male Sex||46 (73%)||44 (70%)||0.69|
|Body Mass Index||27.1 + 6.5||28.2 + 7.2||0.38|
|Hispanic Ethnicity||35 (56%)||27 (43%)||0.47|
|State Area Deprivation Index||9.3||9.7||0.27|
|Prior Extremity Bypass or Endovascular Intervention||32 (51%)||24 (38%)||0.15|
|Prior Minor Amputation/Debridement of Foot||45 (71%)||40 (63%)||0.34|
|Diabetes Mellitus||51 (81%)||51 (81%)||1.00|
|Guillotine Amputation||9 (14%)||9 (14%)||1.00|
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