Predictors of health after revascularization for extremity ischemia

Brief report: do patients with poor outcomes regret having had infrainguinal bypass surgery?

BACKGROUND

Retrospection and hindsight bias may lead patients with bad outcomes to regret the choice of infrainguinal bypass surgery.

OBJECTIVE

To assess patients' retrospective evaluations of surgery stratified by common criteria to judge surgical success. SURVEY DESIGN: Cross-sectional phone surveys of 33 patients, an average of 162 d following infrainguinal bypass surgery.

RESULTS

Of the 33 patients evaluated, 26 (79%) experienced undesirable outcomes, including amputation (4, 12%), prolonged hospitalization (8, 24%), wound infection (8, 24%), readmission to the hospital (12, 36%), additional surgery (11, 33%), and other complications (16, 48%). Of the patients surveyed, nearly all (30, 91%) reported that they would still want to have had the surgery if they had a 5-y 50% mortality, and the same proportion reported they would recommend the surgery to someone else with similar medical problems (30, 91%).

CONCLUSIONS

If confirmed in larger populations, these findings suggest that when viewed retrospectively, results traditionally considered poor outcomes may not deter many patients' preferences for surgical management of their infrainguinal vascular disease.

A comparison of patient and physician beliefs about infrainguinal bypass operation: What role should surgical optimism play?

BACKGROUND

Risk and outcomes of infrainguinal bypass operation vary by identifiable patient characteristics. Previously, we found that although patients appear willing to undertake considerable risk, they may have unrealistic expectations for operative benefits. Little is known about whether patients and physicians have similar beliefs regarding the risks and benefits of the operation.

METHODS

Cross-sectional paired surveys of 6 surgeons and 45 of their patients undergoing infrainguinal bypass operation at a large university medical center.

RESULTS

Similar proportions of physicians and patients reported risks associated with the operation. There was moderate agreement within patient-surgeon pairs regarding specific risks such as the likely need for additional operations or for amputation despite the procedure (agreement ranging from 60% to 69% of patient-physician pairs). In nearly two thirds (62%) of cases surgeons provided more optimistic prognostic estimates of 5-year mortality than is suggested by prior research (McNemar test, P < .001). In turn, patients tended to be more optimistic regarding their estimated 5-year survival than their surgeons, with 56% of patients estimating a lesser 5-year mortality than that predicted by their surgeon (McNemar test, P < .01).

CONCLUSIONS

Although surgeons and patients generally agree regarding the risks of infrainguinal bypass operation, both groups appear more optimistic regarding likely 5-year survival than the outcomes suggested by prior research. This optimism may play an important role in the decision to proceed with infraninguinal bypass operation, as well as the preservation of hope regarding the potential long-term benefits of such intervention.

Increased psychiatric morbidity after abdominal aortic surgery: risk factors for stress-related disorders

OBJECTIVE

Research on surgical outcomes has focused on technical results and physical morbidity. However, postoperative psychiatric complications are common and can undermine functional results. High rates of posttraumatic stress disorder and major depressive disorder have been documented after cardiac events or surgery. These complications are also expected after abdominal aortic surgery, but their incidence and relevant risk factors in this population have not been documented.

METHODS

We examined the development of posttraumatic stress and depressive symptoms in patients with aortic aneurysms or occlusive disease, comparing surgical with nonsurgical patients and predicting that surgery and a prolonged intensive care stay would contribute to the development of psychiatric morbidity. A consecutive sample of vascular surgery patients (n = 109) was recruited 6 months to 2 years after surgery. Data were analyzed by using group comparisons, regression, and path analyses.

RESULTS

Rates of objectively determined postoperative psychiatric morbidity were extremely high (32%). Surgical patients were more than four times more likely to develop psychiatric disorders (odds ratio, 4.8; P = .02). Being younger, having increased preoperative blood pressure, and being intubated at the end of surgery were linked to greater rates of psychiatric morbidity (P < .05), but a longer intensive care stay was not.

CONCLUSIONS

New-onset psychiatric symptoms are common after abdominal aortic surgery, and preoperative and surgical factors were more predictive than postoperative complications and stress, as reflected in intensive care unit stays. Prospective examination of vulnerability in this model could identify risk factors for stress-related psychiatric morbidity and help improve surgical outcomes.

Exploring Patient Preferences for Infrainguinal Bypass Operation

BACKGROUND

Surgical risk and outcomes for patients undergoing infrainguinal bypass operation vary by identifiable patient characteristics, yet little is known about whether patients understand the risks, benefits, and alternatives to operation.

STUDY DESIGN

Cross-sectional surveys administered to 50 patients undergoing infrainguinal bypass operation at one institution an average of 7 days (median 4 days) before operations.

RESULTS

Most patients rated their health as fair or poor (53%) or good (35%), and the majority reported their vascular disease was associated with difficulty doing activities they enjoyed (71%), leg pain (86%), and difficulty walking (98%). About one-half of patients (54%) thought they would require additional operations, 21% reported being at risk for postoperative myocardial infarction and 24% believed they would require a major amputation despite operations. Over two-thirds of patients (69%) believed their overall health would improve postoperatively, although more than four-fifths (80% to 86%) believed their ability to perform activities, leg pain, and walking would improve. Eighty-eight percent of patients reported willingness to have the operation even with a 10% postoperative mortality rate and 96% of patients reported a preference for operations if the chance of successful outcomes was only 75%.

CONCLUSIONS

Although patients appear to be willing to undertake considerable postoperative risk, expectations for benefits from infrainguinal bypass operation appear greater than outcomes suggested by earlier research. These findings, if confirmed in larger studies, challenge how patient preferences should optimally be used to inform decisions about whether to undertake infrainguinal bypass operations.

Predictors of health after operation for aortoiliac occlusive and aneurysmal disease

BACKGROUND

We assessed the impact of comorbid conditions and revascularization for aortoiliac occlusive and aneurysmal disease and determined the functional health status of patients with the Medical Outcomes Study SF36 Health Survey.

METHODS

One hundred twenty-five patients were surveyed prospectively, before operation, and at intervals ranging from 2 weeks to 2 years after operation. To identify the factors that influenced functional health, multiple regression analysis was performed to test the hypothesis that age, pulmonary disease, atherosclerotic heart disease, diabetes, aortoiliac occlusive disease (AOD) versus aneurysmal disease, and the preoperative physical summary score affected outcome.

RESULTS

Regression analysis identified that before operation, the physical summary score (PCS) was affected by pulmonary disease, atherosclerotic heart disease, and AOD, and patients with AOD had significantly worse PCS than patients with aneurysmal disease (43.2 +/- 12.6 vs 30.1 +/- 8.3, P <.05). This difference was also present after 3 to 12 months, and the preoperative PCS was the strongest predictor of the postoperative score. For patients followed up between 1 and 2 years, there was no significant difference among the groups, and atherosclerotic heart disease and pulmonary disease were identified to most affect the PCS.

CONCLUSIONS

Patients with AOD have significantly impaired physical function (as compared with patients with aneurysmal disease) that is successfully reversed with a surgical procedure. The functional health of patients after operation for aneurysmal disease returns to baseline after 3 and 12 months. Ultimately, cardiac and pulmonary comorbidities have a continued effect on the functional health of patients.