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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Leonard C, Sayre G, Williams S, Henderson A, Norvell D, Turner AP, Czerniecki J. Perceived shared decision-making among patients undergoing lower-limb amputation and their care teams: A qualitative study. Prosthet Orthot Int 2023; 47:379-386. [PMID: 37079358 DOI: 10.1097/pxr.0000000000000234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/18/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Shared decision-making (SDM) is increasingly advocated in the care of vascular surgery patients. The goal of this investigation was to gain a greater understanding of the patient and provider experience of SDM during clinical decision-making around the need for lower-extremity amputation and amputation level related to chronic limb-threatening ischemia (CLTI) in the Veterans Health Administration. METHODS Semistructured interviews in male Veterans with CLTI, vascular surgeons, physical medicine and rehabilitation physicians, and podiatric surgeons. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. RESULTS We interviewed 22 patients and 21 surgeons and physicians and identified 4 themes related to SDM: (1) providers recognize the importance of incorporating patient preferences into amputation-level decisions and strive to do so; (2) patients do not perceive that they are included as equal partners in decisions around amputation or amputation level; (3) providers perceive several obstacles to including patients in amputation level decisions; and (4) patients describe facilitators to their involvement in SDM. CONCLUSIONS Despite the recognized importance SDM in amputation decision-making, patients often perceived that their opinion was not solicited. This may result from provider perception of significant challenges to SDM posed by the clinical context of amputation. Patients identified key features that might enhance SDM including presentation of clear, concise information, and the importance of communicating concern during the discussion. These findings point to gaps in the provision of patient-centric care through SDM discussions at the time of amputation.
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Affiliation(s)
- Chelsea Leonard
- Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus, and Denver Seattle Center of Innovation, VA Eastern Healthcare System, Aurora, CO, USA
- VA Collaborative Evaluation Center (VACE), Seattle, WA, USA
| | - George Sayre
- VA Puget Sound Health Care System, Seattle, WA, USA
- Qualitative Research Core, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
- VA Collaborative Evaluation Center (VACE), Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Sienna Williams
- VA Puget Sound Health Care System, Seattle, WA, USA
- VA Center for Limb Loss and Mobility (CLiMB), Seattle, WA, USA
| | - Alison Henderson
- VA Puget Sound Health Care System, Seattle, WA, USA
- VA Center for Limb Loss and Mobility (CLiMB), Seattle, WA, USA
| | - Dan Norvell
- VA Puget Sound Health Care System, Seattle, WA, USA
- VA Center for Limb Loss and Mobility (CLiMB), Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | | | - Joseph Czerniecki
- VA Puget Sound Health Care System, Seattle, WA, USA
- VA Center for Limb Loss and Mobility (CLiMB), Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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Henderson AW, Turner AP, Leonard C, Sayre G, Suckow B, Williams SL, Norvell DC, Czerniecki JM. Mortality Conversations Between Male Veterans and Their Providers Prior to Dysvascular Lower Extremity Amputation. Ann Vasc Surg 2023; 92:313-322. [PMID: 36746270 PMCID: PMC10121889 DOI: 10.1016/j.avsg.2023.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND Among patients facing lower extremity amputation due to dysvascular disease, the mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during preoperative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration. METHODS Semistructured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. RESULTS We interviewed 22 patients and 21 surgeons and physicians and identified 3 themes related to conversations around mortality: (1) both patients and providers report that mortality conversations are not common prior to amputation; (2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and (3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation. CONCLUSIONS Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.
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Affiliation(s)
- Alison W Henderson
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA.
| | - Aaron P Turner
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Chelsea Leonard
- VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Denver Seattle COIN, VA Eastern Colorado Healthcare System, Aurora, CO; Health Systems, Management and Policy, University of Colorado, School of Public Health, Aurora, CO
| | - George Sayre
- VA Puget Sound Health Care System, Seattle, WA; Qualitative Research Core, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA; VA Collaborative Evaluation Center (VACE), Seattle, WA; Department of Health Services, University of Washington, Seattle, WA
| | - Bjoern Suckow
- Department of Vascular Surgery, White River Junction VA Medical Center, White River Junction, VT; Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Sienna L Williams
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA
| | - Daniel C Norvell
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Joseph M Czerniecki
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
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Peters L, Stubenrouch F, Thijs J, Klemm P, Balm R, Ubbink D. Predictors of the Level of Shared Decision-Making in Vascular Surgery: A Cross-sectional Study. Eur J Vasc Endovasc Surg 2022; 64:65-72. [DOI: 10.1016/j.ejvs.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/22/2022] [Accepted: 05/01/2022] [Indexed: 12/24/2022]
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Stubenrouch FE, Peters LJ, de Mik SML, Klemm PL, Peppelenbosch AG, Schreurs SCWM, Scharn DM, Legemate DA, Balm R, Ubbink DT. Improving shared decision-making in vascular surgery: a stepped-wedge cluster-randomised trial. Eur J Vasc Endovasc Surg 2022; 64:73-81. [PMID: 35483576 DOI: 10.1016/j.ejvs.2022.04.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/25/2022] [Accepted: 04/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND For various vascular surgical disorders different treatment options are available and feasible. Hence, vascular surgery seems an area par excellence for shared decision-making (SDM), in which clinicians incorporate patients' preferences into the final treatment decision. However, current SDM-levels in vascular surgical outpatient clinics is below expectations. To improve this, different decision support tools (DSTs) were developed: online patient decision aids, consultation cards and decision cards. METHODS This stepped-wedge cluster-randomised trial was conducted in 13 Dutch hospitals. Besides the developed DSTs, a training on how to apply SDM during the clinician-patient encounter was used in this study. Data were obtained via questionnaires and audio-recordings. Primary outcome was the OPTION-5 score, an objective tool to assess the level of SDM, expressed as a percentage of exemplary performance. Main secondary outcomes were: patients' disease-specific knowledge, consultation duration, and treatment choice. Factors influencing OPTION-5 scores were studied using linear regression analysis. RESULTS We included 342 patients with an abdominal aortic aneurysm (AAA); n=87, intermittent claudication (IC); n=143, or varicose veins (VV); n=112. Audiotapes of 395 consultations were analysed. Overall mean OPTION-5 score significantly improved from 28.7% to 37.8% (mean difference 9.1%, 95%CI: 6.5-11.8%) after implementation of the DSTs. Also patient knowledge increased significantly (median increase: 13%, effect size: 0.13, p=.025). The number of patients choosing non-surgical treatment choices increased with 21.4% to 28.8% for AAA-patients and doubled (16.0% to 32.0%) among IC-patients. For surgeons, the SDM-training and for patients the decision aid significantly and independently increased OPTION-5 scores (p<.001 and p=.047, respectively). CONCLUSION Introducing DSTs improves the level of shared decision-making in vascular surgery, improves patient knowledge, and shifts their preference towards more non-surgical treatments. The SDM-training for clinicians and the decision aid for patients appeared the most effective means for improving SDM. TRIAL REGISTRATION NTR6487.
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Affiliation(s)
- Fabienne E Stubenrouch
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Department of Radiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Loes J Peters
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.
| | | | - Peter L Klemm
- Department of Surgery, Gelre Hospital, Apeldoorn, The Netherlands
| | - Arnoud G Peppelenbosch
- Department of Vascular Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Operative Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Stella C W M Schreurs
- Department of Vascular Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dick M Scharn
- Department of Surgery, Slingeland Hospital, Doetinchem, The Netherlands
| | - Dink A Legemate
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Dirk T Ubbink
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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Cecchi AC, Drake M, Campos C, Howitt J, Medina J, Damrauer SM, Shalhub S, Milewicz DM. Current state and future directions of genomic medicine in aortic dissection: A path to prevention and personalized care. Semin Vasc Surg 2022; 35:51-59. [PMID: 35501041 PMCID: PMC9258522 DOI: 10.1053/j.semvascsurg.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 12/03/2022]
Abstract
Aortic dissection confers high mortality and morbidity rates despite advances in treatment, impacts quality of life, and contributes immense burden to the healthcare system globally. Efforts to prevent aortic dissection through screening and management of modifiable risk factors and early detection of aneurysms should incorporate genomic information, as it is integral to stratifying risk. However, effective integration of genomic-guided risk assessment into clinical practice will require addressing implementation barriers that currently permeate our healthcare systems. The Aortic Dissection Collaborative was established to define aortic dissection research priorities through patient engagement. Using a collaborative patient-centered feedback model, our Genomic Medicine Working Group identified related research priorities that could be investigated by pragmatic interventional studies aimed at aortic dissection prevention, utilization of genomic information to improve patient outcomes, and access to genomic medicine services. Further research is also needed to identify the genomic, lifestyle, and environmental risk factors that contribute to aortic dissection so these data can be incorporated into future comparative effectiveness studies to prevent aortic dissection.
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de Mik SML, Stubenrouch FE, Balm R, Ubbink DT. Development of three different decision support tools to support shared decision-making in vascular surgery. PATIENT EDUCATION AND COUNSELING 2021; 104:282-289. [PMID: 33277102 DOI: 10.1016/j.pec.2020.11.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Shared decision-making (SDM) is known to improve quality of care. Particularly in vascular surgery treatment options are often preference-sensitive. Unfortunately, vascular surgeons infrequently apply SDM. Decision support tools (DSTs) have been shown to be helpful in SDM. OBJECTIVE This article describes the development process of three different DSTs to help vascular surgeons and patients apply SDM. PATIENT INVOLVEMENT Patients' information needs were obtained via focus group meetings. Fifty-two patients and eighteen vascular surgeons not involved in the development process evaluated the comprehensibility and usability of the DST-prototypes. METHODS A multidisciplinary steering group commissioned the development of the three DSTs according to international standards. RESULTS Digital decision aids and paper-based consultation cards and decision cards were developed for patients with an abdominal aortic aneurysm, carotid artery disease, intermittent claudication or varicose veins. Patients preferred the use of the decision aids followed by consultation cards, whereas vascular surgeons preferred to use decision cards followed by decision aids. DISCUSSION Decision aids, consultation cards and decision cards for four vascular diseases are now available to all vascular surgeons and patients in the Netherlands. The DSTs were well received by both surgeons and patients. English versions are also available.
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Affiliation(s)
- Sylvana M L de Mik
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - Fabienne E Stubenrouch
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - Ron Balm
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - Dirk T Ubbink
- Amsterdam University Medical Centers, Department of Surgery, location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands.
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