Perspective:

This analysis of the NIS database provides insight into hospitalization, revascularization, and associated outcomes among patients with DM and CLI. The focus on diabetics provides a perspective that complements previously published work based on data from the Centers for Medicare and Medicaid Services.

It is interesting to note that a revascularization procedure was performed during only approximately one third of hospitalizations. The underlying explanation for why the majority of patients were not treated with revascularization is unknown, but may indicate an opportunity for more aggressive treatment both inside and outside the hospital to avoid amputations.

As the authors point out in their discussion, there may have been selection biases underlying the outcomes observed with specific revascularization strategies. For example, the higher rate of amputation observed after endovascular interventions may, in part, reflect greater enthusiasm for endovascular versus surgical approaches to achieve amputation healing when limb salvage was not possible. Because the unit of analysis was defined by a hospitalization in the current study, there is also limited insight into additional procedures that were performed before or after the inpatient stay.

The introduction alludes to a paucity of “real-world” data related to the research question. It is therefore appropriate to consider that the cohort analyzed in the current study was strictly inpatient and did not include hospitalizations after 2015. Given the continuing shift to ambulatory and office-based environments for endovascular procedures over the past decade, the real world in 2021 differs in many ways from 2002 (the first year of the study cohort included in this analysis). Accordingly, inpatient endovascular procedures over time may increasingly consist of patients with greater comorbidity and/or technically challenging anatomy that affected the treatment venue.