Vascular-POPS: evidence for a new standard of care in the management of chronic limb-threatening Ischaemia

Abstract Objective Patients with chronic limb-threatening ischaemia (CLTI) are often admitted emergently with significant comorbidity and frailty, and little time for pre-optimisation, resulting in longer hospital stays and worse outcomes. Our unit implemented a POPS (Perioperative Medicine for the Older Person undergoing Surgery) service, incorporating the comprehensive geriatric assessment (CGA) to optimise patients. This study assesses its effect on non-elective CLTI inpatients. Methods This is a prospective observational cohort study at a single vascular centre, analysing outcomes in non-elective CLTI patients over three different periods: one year prior to POPS (‘Pre-POPS’); during the initial delivery when it was nurse-led (‘POPS v1’); and after it became physician-led (‘POPS v2’). The primary outcome was length of stay (LoS), with 30-day and 12-month secondary outcomes. Cohorts were compared using propensity-score weighted statistical analysis. Economic analysis was undertaken. Results Six hundred and two patients were included. LoS reduced sequentially with greater POPS input (17 days vs. 13 days vs. 11 days, P .001). There was a significant reduction in 30-day acute kidney injury (33% vs. 37% vs. 8%, P .001), myocardial infarction (15% vs. 2% vs. 2% P .001) and hospital-acquired pneumonia (17% vs. 10% vs. 9%, P = .048). Cox survival regression found a reduction in 12-month mortality of 37% for the POPS v1 HR 0.628 (95% CI 0.481–0.891) P = .013 and 40% for the POPS v2 HR 0.598 (95% CI 0.431–0.913) P = .001 cohorts, respectively. Economic analysis found that handling more medically complex patients with a shorter LoS negated its operational costs. Conclusion A Vascular-POPS collaborative service has resulted in major improvements in LoS, adverse events and survival in this most vulnerable of vascular patient cohorts and is a financially sustainable initiative.