Leg Revascularization
at NYU Medical Center: Pefecting a Limb-Saving Service

Abstract

The peripheral vascular surgeons at NYU Medical Center provide a valuable, often limb-saving service to patients who have serious medical conditions resulting from obstruction in the arteries that supply blood to the legs. When treating the most severely ill patients, they circumvent the arterial blockage by surgically inserting natural or synthetic grafts. However, these grafts may eventually deteriorate or become occluded, and each "leg-bypass" operation entails a protracted, uncomfortable recovery period. Therefore, the physicians employ non-surgical procedures whenever possible. This prudent clinical policy reduces patient discomfort and minimizes the risk of infection.

The average length of stay among the patients who are treated surgically is, understandably, greater at NYU than at medical centers where surgery is frequently performed on patients with less advanced illness. Nonetheless, a team of analysts led by Dr. Patrick Lamparello has recently identified some immediate opportunities to shorten both the pre- and post-operative stays of leg-bypass patients. Dr. Lamparello and his colleagues will also evaluate minimally invasive procedures that could reduce the length of stay dramatically while significantly lessening patients' post-surgical discomfort.

Frequent Use of Non-Invasive Techniques
Maximizes Safety and Minimized Surgical Trauma

With the advice of Dr. Patrick Lamparello, who was asked by Dr. Thomas Riles to oversee the development of guidelines for leg-bypass procedures a team of analysts recently reviewed the medical charts of 50 patients. They concluded that surgical revascularization at NYU Medical Center is usually reserved for patients with advanced chronic ischemia (insufficient oxygenation of tissue due to progressive arterial narrowing). Whenever possible, the physicians at NYU Medical Center use non-surgical techniques (clot-dissolving drugs or balloon angioplasty) to treat peripheral vascular disease. This prudent clinical policy minimizes the possibility of infection and reduces the number of patients who are subjected to the trauma of surgery. In contrast, physicians at other hospitals frequently treat claudication (painful but not limb-threatening partial arterial blockage) surgically.

Severity of Illness Among Patients Treated Surgically
Creates Illusion of Excessively Long Length of Stay

The intensity of the ischemic problems among the relatively few patients who are treated surgically at NYU was underscored by the finding that half of them had been admitted with cellulitis or infected, gangrenous, or non-healing ulcers. The severity of illness among these patients accounts for the relatively long average hospital stay at NYU Medical Center for leg-bypass procedures. The average stay among the 50 patients included in the study was 10.2 days, which is 1.1 days more than the corresponding average for patients treated at the academic medical centers in the University HealthSystem Consortium (UHC). However, because the physicians at NYU Medical Center use surgical techniques (which necessitate some recovery time in the hospital) sparingly, the total cost of treating all patients with lower-extremity peripheral vascular disease may well be lower at NYU Medical Center than at institutions that perform surgery more frequently.

Other Challenges at NYU Medical Center

Any program for improving the quality of care must acknowledge the particular challenges posed by NYU Medical Center's complex patient population. Many patients referred to NYU Medical Center have complicated medical histories, and they frequently come to the hospital with a combination of serious problems. A remarkable number of patients in the leg-bypass study had complicating conditions such as diabetes (60 percent), arteriosclerotic heart disease (54 percent), and hypertension(48 percent). These rates are significantly higher than the corresponding rates for other academic hospitals, based on data from the UHC.

The complexity of illness among the patients at NYU Medical Center is partially related to their advanced age. The average age of the patients in the study was 72 (versus 65 at the UHC), and 20 percent were more than 85 years old (versus four percent at the UHC).