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Markov Model Representing The Chronic Limb-threatening Ischemia Patient’S Journey
Cynthia A. Ramazani, BS
1, Adriana Gutierrez, MD
2, Amelia Fogle, BS
1, Alex Mao
1, Yazan Duwayri, MD, MBA
1, Katherine McGinigle, MD, MPH
3, Manuel Garcia-Toca, MD, MS
1, Nader N. Massarweh, MD, MPH
4, Emily Spangler, MD, MS
5, Olamide Alabi, MD, MS
1.
1Emory University School of Medicine, Atlanta, GA, USA,
2Emory University School of Public Health, Atlanta, GA, USA,
3University of North Carolina, Chapel Hill, NC, USA,
4Atlanta VA Medical Center, Decatur, GA, USA,
5University of Alabama, Birmingham, AL, USA.
OBJECTIVES: We created a framework to characterize the journey of patients with chronic limb threatening ischemia (CLTI) (
Figure 1) and evaluated its applicability to clinical practice by applying it to a group of CLTI patients.
METHODS: Patients with an incident CLTI diagnosis (T
d) undergoing index revascularization (T
0) between June-December 2021 at our institution were reviewed. Exclusions included major amputation or death before T
0 and prior revascularization within 1 year. Two groups were defined at the first follow-up after T
0: Group A (achieved resolution of CLTI-defining feature); Group B (did not achieve resolution). Sociodemographic, revascularization method, Wound, Ischemia, Foot Infection (WIfI) stage, and follow-up data (up to 2 years) were compared between groups. A Markov model was constructed to model CLTI-health state transitions and events (i.e., major amputation, reintervention, mortality) with A
0 defined as the goal health state (remission).
RESULTS: Among 228 patients with newly diagnosed CLTI, 95 met inclusion criteria (102 limbs; mean age 71.0(10.3) years, 59.8% male). Baseline presentation included 29.4% ischemic rest pain, 43.1% nonhealing wound, and 27.5% gangrene. Group B had a higher median WIfI stage than Group A (3 vs 2, p=.0013). Revascularization types included open surgical (30.4%), endovascular (62.7%), and hybrid (6.9%). Major amputation was more common within Group B (22.7% vs. 3.7%, p=0.037). Reintervention occurred in 38.2% of limbs, with higher rates in Group B than Group A (45.3% vs 18.5%, p=0.026) and a shorter median days to reintervention (56 vs 222, p=.025). Mortality occurred in 18.9% of the cohort, with no deaths among patients who transitioned to Group A after T
0. Despite no differences between groups during follow up, 37.8% of all patients were lost to follow-up during the study period. At first follow-up after T
0, there was a 30.8% probability of entering Group A and a 69.2% probability of entering Group B. Remission was achieved by 26.5% after T
0 with 43.1% eventually reaching remission by end of follow-up.
CONCLUSIONS: The proposed framework characterizes the CLTI journey after revascularization well and can be used to design a Markov model that may aid in complex decision-making and test the efficacy of future CLTI interventions.
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