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Ramirez JL, Wang K, Sung E, Hernandez S, Le M, Avra TD, Talutis S, Iannuzzi JC, Ulloa JG. Readability of Spanish-Language Online Patient Educational Materials for Peripheral Artery Disease Do Not Meet Recommended Standards and Represent a Literacy Barrier to Care. Ann Vasc Surg 2024; 101:157-163. [PMID: 38154492 DOI: 10.1016/j.avsg.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/28/2023] [Accepted: 10/21/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Online resources are a valuable source of information for patients and have been reported to improve engagement and adherence to medical care. However, readability of online patient educational materials (OPEMs) is crucial for them to serve their intended purpose. The American Medical Association (AMA) recommends that OPEM be written at or below the sixth grade reading level. To avoid disparities in access to comprehensible health information on peripheral artery disease (PAD), it is imperative that the readability of PAD OPEM is appropriate for both English-speaking and Spanish-speaking patients. The aim of this study is to evaluate the readability of PAD OPEM in Spanish and compare to English-language OPEM. METHODS We conducted a Google search in English and Spanish using "peripheral arterial disease" and "enfermedad arterial periferica", respectively, and the top 25 patient-accessible articles were collected for each. Articles were categorized by source type: hospital, professional society, or other. Readability of English-language OPEM was measured using the Flesch Reading Ease Readability Formula, Automated Readability Index, Coleman-Liau Index, Flesch-Kincaid Grade Level, Gunning Fog, Linsear Write Formula, and the Simple Measure of Gobbledygook Index. Readability of Spanish OPEM was measured using the Fernández-Huerta Index and Índice Flesch-Szigriszt Scale. Readability of the articles was compared to the AMA recommendation, between English- and Spanish-language, and across sources using statistical tests appropriate to the data. RESULTS OPEM from professional societies represented the fewest number of English- (n = 7, 28%) and Spanish-language (n = 6, 24%) articles. Most English-speaking (n = 18, 72%) and Spanish-language (n = 20, 80%) OPEM were considered difficult as measured by the Flesch Reading Ease Readability Formula and Fernández-Huerta Index, respectively, but did not significantly differ between languages (P = 0.59). There were no significant differences in the average readability of all readability measurements across sources (hospital, professional society, or other). All the average readability grade levels for English-speaking and Spanish-language OPEM was significantly higher than the sixth grade reading level (P < 0.01). Only 3 (6%) OPEM met the AMA recommended reading level and there was no significant difference between English-language and Spanish-language OPEM (P = 1.0). CONCLUSIONS Nearly all Spanish-language and English-language PAD OPEM assessed were written at a reading grade level higher than recommended by the AMA. There was no significant difference in the readability of materials from hospitals or professional societies. To prevent further widening of health disparities related to literacy, health content creators, particularly hospitals and professional societies, should prioritize, develop, and ensure that English-language and Spanish-language patient education materials are written at a level appropriate for the public.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA; Chan Zuckerberg Biohub, San Francisco, CA
| | - Karissa Wang
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Eric Sung
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | | | - Monica Le
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Tucker D Avra
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Stephanie Talutis
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jesus G Ulloa
- David Geffen School of Medicine, University of California, Los Angeles, CA; West Los Angeles Veterans Health Administration, Los Angeles, CA.
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Gutierrez RD, Smith EJT, Matthay ZA, Gasper WJ, Hiramoto JS, Conte MS, Finlayson E, Walter LC, Iannuzzi JC. Risk factors and associated outcomes of postoperative delirium after open abdominal aortic aneurysm repair. J Vasc Surg 2024; 79:793-800. [PMID: 38042511 DOI: 10.1016/j.jvs.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Open abdominal aortic aneurysm repair (OAR) is a major vascular procedure that incurs a large physiologic demand, increasing the risk for complications such as postoperative delirium (POD). We sought to characterize POD incidence, identify delirium risk factors, and evaluate the effect of delirium on postoperative outcomes. We hypothesized that POD following OAR would be associated with increased postoperative complications and resource utilization. METHODS This was a retrospective study of all OAR cases from 2012 to 2020 at a single tertiary care center. POD was identified via a validated chart review method based on key words and Confusion Assessment Method assessments. The primary outcome was POD, and secondary outcomes included length of stay, non-home discharge, 90-day mortality, and 1-year survival. Bivariate analysis as appropriate to the data was used to assess the association of delirium with postoperative outcomes. Multivariable binary logistic regression was used to identify risk factors for POD and Cox regression for variables associated with worse 1-year survival. RESULTS Overall, 198 OAR cases were included, and POD developed in 34% (n = 67). Factors associated with POD included older age (74 vs 69 years; P < .01), frailty (50% vs 28%; P < .01), preoperative dementia (100% vs 32%; P < .01), symptomatic presentation (47% vs 27%; P < .01), preoperative coronary artery disease (44% vs 28%; P = .02), end-stage renal disease (89% vs 32%; P < .01) and Charlson Comorbidity Index score >4 (42% vs 26%; P = .01). POD was associated with 90-day mortality (19% vs 5%; P < .01), non-home discharge (61% vs 30%; P < .01), longer median hospital length of stay (14 vs 8 days; P < .01), longer median intensive care unit length of stay (6 vs 3 days; P < .01), postoperative myocardial infarction (7% vs 2%; P = .045), and postoperative pneumonia (19% vs 8%; P = .01). On multivariable analysis, risk factors for POD included older age, history of end-stage renal disease, lack of epidural, frailty, and symptomatic presentation. A Cox proportional hazards model revealed that POD was associated with worse survival at 1 year (hazard ratio, 3.8; 95% confidence interval, 1.6-9.0; P = .003). CONCLUSIONS POD is associated with worse postoperative outcomes and increased resource utilization. Future studies should examine the role of improved screening, implementation of delirium prevention bundles, and multidisciplinary care for the most vulnerable patients undergoing OAR.
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Affiliation(s)
- Richard D Gutierrez
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Eric J T Smith
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zachary A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Louise C Walter
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA
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Graham LA, Illarmo S, Gray CP, Harris AHS, Wagner TH, Hawn MT, Iannuzzi JC, Wren SM. Mapping the Discharge Process After Surgery. JAMA Surg 2024; 159:438-444. [PMID: 38381415 PMCID: PMC10882508 DOI: 10.1001/jamasurg.2023.7539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/28/2023] [Indexed: 02/22/2024]
Abstract
Importance Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process. Objective To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery. Design, Setting, and Participants This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide. Exposure Postoperative hospital discharge. Main Outcomes and Measures Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings. Results At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination. Conclusions and Relevance These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Caroline P. Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Alex H. S. Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Mary T. Hawn
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - James C. Iannuzzi
- Department of Surgery, San Francisco VA Medical Center, San Francisco, California
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco
| | - Sherry M. Wren
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
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Matthay ZA, Pace WA, Smith EJ, Gutierrez RD, Gasper WJ, Hiramoto JS, Reilly LM, Conte MS, Iannuzzi JC. Predictors of amputation-free survival and wound healing after infrainguinal bypass with alternative conduits. J Vasc Surg 2024:S0741-5214(24)00269-6. [PMID: 38310981 DOI: 10.1016/j.jvs.2024.01.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE Inadequate vein quality or prior harvest precludes use of autologous single segment greater saphenous vein (ssGSV) in many patients with chronic limb-threatening ischemia (CLTI). Predictors of patient outcome after infrainguinal bypass with alternative (non-ssGSV) conduits are not well-understood. We explored whether limb presentation, bypass target, and conduit type were associated with amputation-free survival (AFS) after infrainguinal bypass using alternative conduits. METHODS A single-center retrospective study (2013-2020) was conducted of 139 infrainguinal bypasses performed for CLTI with cryopreserved ssGSV (cryovein) (n = 71), polytetrafluoroethylene (PTFE) (n = 23), or arm/spliced vein grafts (n = 45). Characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, and outcomes were recorded. Multivariable Cox proportional hazards and classification and regression tree analysis modeled predictors of AFS. RESULTS Within 139 cases, the mean age was 71 years, 59% of patients were male, and 51% of cases were nonelective. More patients undergoing bypass with cryovein were WIfI stage 4 (41%) compared with PTFE (13%) or arm/spliced vein (27%) (P = .04). Across groups, AFS at 2 years was 78% for spliced/arm, 79% for PTFE, and 53% for cryovein (adjusted hazard ratio for cryovein, 2.5; P = .02). Among cases using cryovein, classification and regression tree analysis showed that WIfI stage 3 or 4, age >70 years, and prior failed bypass were predictive of the lowest AFS at 2 years of 36% vs AFS of 58% to 76% among subgroups with less than two of these factors. Although secondary patency at 2 years was worse in the cryovein group (26% vs 68% and 89% in arm/spliced and PTFE groups; P < .01), in patients with tissue loss there was no statistically significant difference in wound healing in the cryovein group (72%) compared with other bypass types (72% vs 87%, respectively; P = .12). CONCLUSIONS In patients with CLTI lacking suitable ssGSV, bypass with autogenous arm/spliced vein or PTFE has superior AFS compared with cryovein, although data were limited for PTFE conduits for distal targets. Despite poor patency with cryovein, wound healing is achieved in a majority of cases, although it should be used with caution in older patients with high WIfI stage and prior failed bypass, given the low rates of AFS.
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Affiliation(s)
- Zachary A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - William A Pace
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Eric J Smith
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Richard D Gutierrez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Linda M Reilly
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
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5
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Ramirez JL, Matthay ZA, Lancaster E, Smith EJT, Gasper WJ, Zarkowsky DS, Doyle AJ, Patel VI, Schanzer A, Conte MS, Iannuzzi JC. Decreasing prevalence of centers meeting the Society for Vascular Surgery abdominal aortic aneurysm guidelines in the United States. J Vasc Surg 2024; 79:240-249. [PMID: 37774990 DOI: 10.1016/j.jvs.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/14/2023] [Accepted: 09/03/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE Based on data supporting a volume-outcome relationship in elective aortic aneurysm repair, the Society of Vascular Surgery (SVS) guidelines recommend that endovascular aortic repair (EVAR) be localized to centers that perform ≥10 operations annually and have a perioperative mortality and conversion-to-open rate of ≤2% and that open aortic repair (OAR) be localized to centers that perform ≥10 open aortic operations annually and have a perioperative mortality ≤5%. However, the number and distribution of centers meeting the SVS criteria remains unclear. This study aimed to estimate the temporal trends and geographic distribution of Centers Meeting the SVS Aortic Guidelines (CMAG) in the United States. METHODS The SVS Vascular Quality Initiative was queried for all OAR, aortic bypasses, and EVAR from 2011 to 2019. Annual OAR and EVAR volume, 30-day elective operative mortality for OAR or EVAR, and EVAR conversion-to-open rate for all centers were calculated. The SVS guidelines for OAR and EVAR, individually and combined, were applied to each institution leading to a CMAG designation. The proportion of CMAGs by region (West, Midwest, South, and Northeast) were compared by year using a χ2 test. Temporal trends were estimated using a multivariable logistic regression for CMAG, adjusting by region. RESULTS Overall, 67,865 patients (49,264 EVAR; 11,010 OAR; 7591 aortic bypasses) at 336 institutions were examined. The proportion of EVAR CMAGs increased nationally by 1.7% annually from 51.6% (n = 33/64) in 2011 to 67.1% (n = 190/283) in 2019 (β = .05; 95% confidence interval [CI], 0.01-0.09; P = .02). The proportion of EVAR CMAGs across regions ranged from 27.3% to 66.7% in 2011 to 63.9% to 72.9% in 2019. In contrast, the proportion of OAR CMAGs has decreased nationally by 1.8% annually from 32.8% (n = 21/64) in 2011 to 16.3% (n = 46/283) in 2019 (β = -.14; 95% CI, -0.19 to -0.10; P < .01). Combined EVAR and OAR CMAGs were even less frequent and decreased by 1.5% annually from 26.6% (n = 17/64) in 2011 to 13.1% (n = 37/283) in 2019 (β = -.12; 95% CI, -0.17 to -0.07; P < .01). In 2019, there was no significant difference in regional variation of the proportion of combined EVAR and OAR CMAGs (P = .82). CONCLUSIONS Although an increasing proportion of institutions nationally meet the SVS guidelines for EVAR, a smaller proportion meet them for OAR, with a concerning downward trend. These data question whether we can safely offer OAR at most institutions, have important implications about sufficient OAR exposure for trainees, and support regionalization of OAR.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA; Chan Zuckerberg Biohub, San Francisco, CA
| | - Zachary A Matthay
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Elizabeth Lancaster
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Eric J T Smith
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Devin S Zarkowsky
- Division of Vascular Surgery, Department of Surgery, Scripps Clinic, La Jolla, CA
| | - Adam J Doyle
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Virendra I Patel
- Division of Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Andres Schanzer
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Ramirez JL, Sung E, Jaramillo E, Gasper WJ, Conte MS, Boitano L, Iannuzzi JC. Development and Validation of a Novel Preoperative Risk Score to Identify Patients at Risk for Nonhome Discharge after Elective Endovascular Aortic Aneurysm Repair (EVAR). Ann Vasc Surg 2024; 99:341-348. [PMID: 37852368 DOI: 10.1016/j.avsg.2023.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after elective endovascular aortic repair (EVAR) is uncommon. However, NHD after surgery has an important impact on patient quality of life and postdischarge outcomes. Understanding factors that put patients undergoing EVAR at high risk for NHD is essential to providing adequate preoperative counseling and shared decision making. This study aimed to identify independent predictors of NHD following elective EVAR and to create a clinically useful preoperative risk score. METHODS Elective EVAR cases were queried from the Society for Vascular Surgery Vascular Quality Initiative 2014-2018. A risk score was created by splitting the data set into two-thirds for development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. The score was then validated, and model performance assessed. RESULTS Overall, 24,426 patients were included and 932 (3.8%) required NHD. Multivariable analysis in the development group identified independent predictors of NHD, which were used to create a 20-point risk score. Patients were stratified into 3 groups based upon their risk score: low risk (0-7 points; n = 16,699) with an NHD rate of 1.8%, moderate risk (8-13 points; n = 7,315) with an NHD rate of 7.3%, and high risk (≥14 points; n = 412) with an NHD rate of 21.8%. The risk score had good predictive ability with c-statistic = 0.75 for model development and c-statistic = 0.73 in the validation dataset. CONCLUSIONS This novel risk score can predict NHD following EVAR using characteristics that can be identified preoperatively. Utilization of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA; Chan Zuckerberg Biohub, San Francisco, CA
| | - Eric Sung
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Emanual Jaramillo
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Geiger JT, Fleming F, Iannuzzi JC, Stoner M, Doyle A. Guideline Compliant Minimum Asymptomatic Carotid Endarterectomy Surgeon and Hospital Volume Cutoffs. Ann Vasc Surg 2023; 97:129-138. [PMID: 37454899 DOI: 10.1016/j.avsg.2023.07.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND There is a known association between volume and outcomes after carotid endarterectomy (CEA). A recent analysis suggested rates of stroke and death do not significantly reduce after a surgeon volume cutoff of 20 CEAs per year. However, these results would severely limit access. The objective here is to identify a lower optimal cutpoint for surgeon and hospital volume for asymptomatic CEA. METHODS We evaluated asymptomatic CEA patients using The New York Statewide Planning and Research Cooperative System database from 2000-2014. The relationship of 3-year averaged volumes for surgeons and hospitals to 30-day stroke was assessed using multiple logistic regression and included both hospital and surgeon volume in all analyses. Optimized cut points were the lowest significant volume cutoff that minimized the adjusted odds ratio of stroke. RESULTS We studied 32,549 CEAs performed by 271 surgeons in 136 centers by vascular surgeons. The median surgeon volume was 26.3 (interquartile range: 12.3-51.7) and the median hospital volume was 67 (interquartile range: 36.3-119.3). The surgeon volume cut point was 3 and the hospital volume cut point was 6 cases per year. There were 756 (2.3%) procedures performed by surgeons with a volume < 3 and 560 (1.7%) procedures performed by hospitals with a volume < 6. Perioperative stroke and death rates were 2.0% (95% confidence interval [CI]: 1.8-2.1) and 3.8% (95% CI: 2.6-5.5) for an average yearly surgeon volume ≥ 3 and < 3 (P = 0.070), respectively. The combined stroke and death rate was 2.0% (95% CI: 1.8-2.1) and 4.8% (95% CI: 3.2-7.0) for an average yearly center volume ≥ 6 and < 6 (P = 0.007), respectively. A combined surgeon and hospital volume variable also predicted outcomes and low-volume procedures did not meet previously proposed American Heart Association and Society for Vascular Surgery quality measures. CONCLUSIONS These data demonstrate an improvement in outcomes at a lower volume threshold than previously reported. These modest cutoff values should be used for asymptomatic CEA volume guideline formation and for future studies, after accounting for the impact of other important factors that may be driving volume-outcome relationships in asymptomatic CEA.
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Affiliation(s)
- Joshua T Geiger
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Fergal Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - James C Iannuzzi
- Division of Vascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
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Ramirez JL, Govsyeyev N, Sorber R, Iannuzzi JC, Schanzer AS, Hicks CW, Malas MB, Zarkowsky DS. Proximal Instructions for Use Violations in Elective Endovascular Aneurysm Repair in the Vascular Quality Initiative: Retrospective Analysis. J Am Coll Surg 2023; 237:633-643. [PMID: 37288832 PMCID: PMC10788874 DOI: 10.1097/xcs.0000000000000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) is often attempted in patients with marginal anatomy. These patients' midterm outcomes are available in the Vascular Quality Initiative for analysis. STUDY DESIGN Retrospective analysis of prospectively collected data in the Vascular Quality Initiative from patients who underwent elective infrarenal EVAR between 2011 and 2018. Each EVAR was identified as either on- or off-instructions for use (IFU) based on aortic neck criteria. Multivariable logistic regression models were used to assess associations between aneurysm sac enlargement, reintervention, and type Ia endoleak with IFU status. Kaplan-Meier time-to-event models estimated reintervention, aneurysm sac enlargement, and overall survival. RESULTS We identified 5,488 patients with at least 1 follow-up recorded. Those treated off-IFU included 1,236 patients ([23%] mean follow-up 401 days) compared with 4,252 (77%) treated on-IFU (mean follow-up 406 days). There was no evidence of significant differences in crude 30-day survival (96% vs 97%; p = 0.28) or estimated 2-year survival (97% vs 97%; log-rank p = 0.28). Crude type Ia endoleak frequency was greater in patients treated off IFU (2% vs 1%; p = 0.03). Off-IFU EVAR was associated with type Ia endoleak on multivariable regression model (odds ratio 1.84 [95% CI 1.23 to 2.76]; p = 0.003). Patients treated off IFU vs on IFU experienced had increased risk of reintervention within 2 years (7% vs 5%; log-rank p = 0.02), a finding consistent with results from the Cox modeling (hazard ratio 1.38 [95% CI 1.06 to 1.81]; p = 0.02). CONCLUSIONS Patients treated off IFU were at greater risk for type Ia endoleak and reintervention, although they had similar 2-year survival compared with those treated on IFU. Patients with anatomy outside IFU should be considered for open surgery or complex endovascular repair to reduce the probability for revision.
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Affiliation(s)
- Joel L Ramirez
- From the Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA (Ramirez, Zarkowsky)
- Chan Zuckerberg Biohub, San Francisco, CA (Rmairez)
| | | | - Rebecca Sorber
- Johns Hopkins University School of Medicine, Baltimore, MD (Sorber, Hicks)
| | | | - Andres S Schanzer
- University of Massachusetts Medical School, Worcester, MA (Schanzer)
| | - Caitlin W Hicks
- Johns Hopkins University School of Medicine, Baltimore, MD (Sorber, Hicks)
| | | | - Devin S Zarkowsky
- From the Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA (Ramirez, Zarkowsky)
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9
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Smith EJT, Gasper WJ, Schneider PA, Finlayson E, Walter LC, Covinsky KE, Conte MS, Iannuzzi JC. Cognitive Impairment is Common in a Veterans Affairs Population with Peripheral Arterial Disease. Ann Vasc Surg 2023; 91:210-217. [PMID: 36581154 DOI: 10.1016/j.avsg.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite the shared pathogenesis of peripheral arterial disease (PAD) and vascular dementia, there are little data on cognitive impairment in PAD patients. We hypothesized that cognitive impairment will be common and previously unrecognized. METHODS Cognitive impairment screening was prospectively performed for veterans presenting to a single Veterans Affairs outpatient vascular surgery clinic from 2020-2021 for PAD consultation or disease surveillance. Overall, 125 Veterans were screened. Cognitive impairment was defined as a score of <26 on the Montreal Cognitive Assessment (MoCA) survey. A multivariable logistic regression assessed for independent risk factors for cognitive impairment. RESULTS Overall, 77 (61%) had cognitive impairment, 92% was previously unrecognized. Cognitive impairment was associated with increased age (74.4 vs. 71.8 years, P = 0.03), Black versus White race (94% vs. 54%, P < 0.01), hypertension (66% vs. 31%, P = 0.01), prior stroke/TIA (79% vs. 58%, P = 0.03), diabetes treated with insulin (79% vs. 58%, P = 0.05), and post-traumatic stress disorder (PTSD) (80% vs. 57%, P = 0.04). On multivariable analysis, risk factors for newly diagnosed cognitive impairment included age ≥70 years, diabetes treated with insulin, PTSD, and Black race. CONCLUSIONS Many veterans with PAD have evidence of cognitive impairment and is overwhelmingly underdiagnosed. This study suggests cognitive impairment is an unrecognized issue in a VA population with PAD, requiring more study to determine cognitive impairment's impact on surgical outcomes, and how it can be mitigated and incorporated into clinical care.
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Affiliation(s)
- Eric J T Smith
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Peter A Schneider
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA and Veterans Affairs, San Francisco, CA
| | - Ken E Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA and Veterans Affairs, San Francisco, CA
| | | | - James C Iannuzzi
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA.
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10
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Jaramillo EA, Smith EJT, Matthay ZA, Sanders KM, Hiramoto JS, Gasper WJ, Conte MS, Iannuzzi JC. Racial and ethnic disparities in major adverse limb events persist for chronic limb threatening ischemia despite presenting limb threat severity after peripheral vascular intervention. J Vasc Surg 2023; 77:848-857.e2. [PMID: 36334848 DOI: 10.1016/j.jvs.2022.10.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Racial and ethnic disparities have been well-documented in the outcomes for chronic limb threatening ischemia (CLTI). One purported explanation has been the disease severity at presentation. We hypothesized that the disparities in major adverse limb events (MALE) after peripheral vascular intervention (PVI) for CLTI would persist despite controlling for disease severity at presentation using the WIfI (Wound, Ischemia, foot Infection) stage. METHODS The Vascular Quality Initiative PVI dataset (2016-2021) was queried for CLTI. Patients were excluded if they were missing the WIfI stage. The primary end point was the incidence of 1-year MALE, defined as major amputation (through the tibia or fibula or more proximally) or reintervention (endovascular or surgical) of the initial treatment limb. A multivariate hierarchical Fine-Gray analysis was performed, controlling for hospital variation, competing risk of death, and presenting WIfI stage, to assess the independent association of Black/African American race and Latinx/Hispanic ethnicity with MALE. A Cox proportional hazard regression model was used for the 1-year survival analysis. RESULTS Overall, 47,830 patients (60%) had had WIfI scores reported (73% White, 20% Black, and 7% Latinx). The 1-year unadjusted cumulative incidence of MALE was 13.1% (95% confidence interval [CI], 12.6%-13.5%) for White, 14.3% (95% CI, 13.5%-15.3%) for Black, and 17.0% (95% CI, 15.3%-18.9%) for Latinx patients. On bivariate analysis, the occurrence of MALE was significantly associated with younger age, Black race, Latinx ethnicity, coronary artery disease, cerebrovascular disease, congestive heart failure, hypertension, diabetes, dialysis, intervention level, any prior minor or major amputation, and WIfI stage (P < .001). The cumulative incidence of 1-year MALE increased by increasing WIfI stage: stage 1, 11.7% (95% CI, 10.9%-12.4%); stage 2, 12.4% (95% CI, 11.8%-13.0%); stage 3, 14.8% (95% CI, 13.8%-15.8%); and stage 4, 15.4% (95% CI, 14.3%-16.6%). The cumulative incidence also increased by intervention level: inflow, 10.7% (95% CI, 9.8%-11.7%), femoropopliteal, 12.3% (95% CI, 11.7%-12.9%); and infrapopliteal, 14.1% (95% CI, 13.5%-14.8%). After adjustment for WIfI stage only, Black race (subdistribution hazard ratio [SHR], 1.30; 95% CI, 1.17-1.44; P < .001) and Latinx ethnicity (SHR, 1.58; 95% CI, 1.37-1.81; P < .001) were associated with an increased 1-year hazard of MALE compared with White race. On adjusted multivariable analysis, MALE disparities persisted for Black/African American race (SHR, 1.12; 95% CI, 1.01-1.25; P = .028) and Latinx/Hispanic ethnicity (SHR, 1.34; 95% CI, 1.16-1.54; P < .001) compared with White race. CONCLUSIONS Black/African American and Latinx/Hispanic patients had a higher associated hazard of MALE after PVI for CLTI compared with White patients despite an adjustment for WIfI stage at presentation. These results suggest that disease severity at presentation does not account for disparities in outcomes. Further work should focus on better understanding the underlying mechanisms for disparities in historically marginalized racial and ethnic groups presenting with CLTI.
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Affiliation(s)
- Emanuel A Jaramillo
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA; Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Eric J T Smith
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zachary A Matthay
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Katherine M Sanders
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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11
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Jaramillo EA, Sanders KM, Lancaster EM, Gomez-Sanchez C, Hiramoto JS, Gasper WJ, Conte MS, Iannuzzi JC. Sex-based Disparities In Major Adverse Limb Events Highest For Femoropopliteal Intervention After Accounting For Presenting Wifi Stage For Chronic Limb Threatening Ischemia. Ann Vasc Surg 2023. [DOI: 10.1016/j.avsg.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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12
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Yin K, Willie-Permor D, Zarrintan S, Dakour-Aridi H, Ramirez JL, Iannuzzi JC, Naazie I, Malas MB. Anemia is associated with higher mortality and morbidity after thoracic endovascular aortic repair. J Vasc Surg 2023; 77:357-365.e1. [PMID: 36087831 DOI: 10.1016/j.jvs.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND It is uncertain whether preoperative anemia is independently associated with thoracic endovascular aortic repair (TEVAR) outcomes. Using a national vascular surgery database, we evaluated the associations between preoperative anemia and 30-day mortality, postoperative complications, and 1-year survival for patients undergoing TEVAR. METHODS We retrospectively analyzed all patients in the Vascular Quality Initiative who had undergone TEVAR for aortic dissection, aortic aneurysm, penetrating aortic ulcer, hematoma, or thrombus between January 2011 and December 2019. We excluded patients with a ruptured aneurysm, traumatic dissection, emergent repair, treated aorta distal to zone 5, polycythemia, transfusion of >4 U of packed red blood cells intraoperatively or postoperatively, and missing data on hemoglobin level or surgical indications. The final study cohort was dichotomized into two groups: normal/mild anemia (women, ≥10 g/dL; men, ≥12 g/dL) and moderate/severe anemia (women, <10 g/dL; male, <12 g/dL). Propensity scores by stratification were used to control for confounding in the analysis of the association between the outcomes of 30-day mortality, postoperative complications, and 1-year survival and a binary indicator variable of moderate/severe anemia vs normal/mild anemia. Kaplan-Meier analysis and log-rank tests were used to compare the 1-year survival between the two groups. A Cox regression model was fitted to assess the associations between anemia and survival outcomes. RESULTS A total of 3391 patients were analyzed, 958 (28.3%) of whom had had moderate/severe anemia. After adjustment for multiple clinical factors using propensity score stratification, moderate/severe anemia was associated with a 141% increased odds of 30-day mortality (adjusted odds ratio [aOR], 2.41; 95% confidence interval [CI], 1.15-5.05; P = .019), 58% increased odds of any in-hospital complication (aOR, 1.58; 95% CI, 1.17-2.13; P = .003), 281% increased odds of intraoperative transfusion (aOR, 3.81; 95% CI, 2.68-5.53; P < .001). In addition, moderate/severe anemia was associated with significantly worse survival within the first year after TEVAR (log-rank P < .001; 1-year survival rate using Kaplan-Meier estimates, 86.4% ± 1.3% standard error vs 92.5% ± 0.6% standard error) and with an increased risk of mortality in the first postoperative year (adjusted hazard ratio, 1.81; 95% CI, 1.16-2.82; P = .009). CONCLUSIONS We found that moderate or severe anemia is associated with significantly increased odds of mortality, postoperative complications, and worse 1-year survival after TEVAR. Future studies are needed to evaluate the effect of anemia correction on the outcomes of TEVAR.
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Affiliation(s)
- Kanhua Yin
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Daniel Willie-Permor
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Sina Zarrintan
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA.
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13
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Sanders KM, Nacario JH, Smith EJT, Jaramillo EA, Lancaster EM, Hiramoto JS, Conte MS, Iannuzzi JC. Structured discharge documentation reduces sex-based disparities in statin prescription in vascular surgery patients. J Vasc Surg 2023; 77:1504-1511. [PMID: 36682597 DOI: 10.1016/j.jvs.2023.01.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Perioperative statin use has been shown to improve survival in vascular surgery patients. In 2018, the Northern California Vascular Study Group implemented a quality initiative focused on the use of a SmartText in the discharge summary. We hypothesized that structured discharge documentation would decrease sex-based disparities in evidence-based medical therapy. METHODS A retrospective analysis was conducted using Vascular Quality Initiative eligible cases at a single institution. Open or endovascular procedures in the abdominal aorta or lower extremity arteries from 2016 to 2021 were included. Bivariate analysis identified factors associated with statin use and sex. Multivariate logistic regression was performed with the end point of statin prescription at discharge and aspirin prescription at discharge. An interaction term assessed the differential impact of the initiative on both sexes. Analysis was then stratified by prior aspirin or statin prescription. An interrupted time series analysis was used to evaluate the trend in statin prescription over time. RESULTS Overall, 866 patients were included, including 292 (34%) female and 574 (66%) male patients. Before implementation, statins were prescribed in 77% of male and 62% of female patients (P < .01). After implementation, there was no statistically significant difference in statin prescription (91% in male vs 92% in female patients, P = .68). Female patients saw a larger improvement in the adjusted odds of statin prescription compared with male patients (odds ratio: 3.1, 95% confidence interval: 1.1-8.6, P = .04). For patients not prescribed a statin preoperatively, female patients again saw an even larger improvement in the odds of being prescribed a statin at discharge (odds ratio: 6.4, 95% confidence interval: 1.8-22.7, P < .01). Interrupted time series analysis demonstrated a sustained improvement in the frequency of prescription for both sexes over time. The unadjusted frequency of aspirin prescription also improved by 3.5% in male patients vs 5.5% in female patients. For patients not prescribed an aspirin preoperatively, we found that the frequency of aspirin prescription significantly improved for both male (19% increase, P = .006) and female (31% increase, P = .001) patients. There was no significant difference in the perioperative outcomes between male and female patients before and after standardized discharge documentation. CONCLUSIONS A simple, low-cost regional quality improvement initiative eliminated sex-based disparities in statin prescription at a single institution. These findings highlight the meaningful impact of regional quality improvement projects. Future studies should examine the potential for structured discharge documentation to improve patient outcomes and reduce disparities.
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Affiliation(s)
- Katherine M Sanders
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Joyce H Nacario
- Heart and Vascular Services, Department of Quality & Patient Safety, University of California, San Francisco, CA
| | - Eric J T Smith
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Emanuel A Jaramillo
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Elizabeth M Lancaster
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Jade S Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA.
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14
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Matthay ZA, Smith EJ, Flanagan CP, Wu B, Malas MB, Hiramoto JS, Conte MS, Iannuzzi JC. Association of Intraoperative and Perioperative Transfusions with Postoperative Cardiovascular Events and Mortality after Infrainguinal Revascularization. Ann Vasc Surg 2022; 88:70-78. [PMID: 35872210 DOI: 10.1016/j.avsg.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/23/2022] [Accepted: 07/03/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients undergoing open or endovascular infrainguinal revascularization are at elevated risk for postoperative cardiovascular complications due to high rates of comorbidities and the physiologic stress of surgery. Transfusions are known to be associated with adverse events, but knowledge of specific risks associated with transfusion timing, product type, and long-term outcomes while accounting for preoperative cardiovascular risk factors is not well understood in this population. AIM This study aimed to characterize the association of intraoperative and perioperative transfusion, anemia, and cardiovascular risk factors with cardiovascular events and mortality in patients undergoing infrainguinal revascularization. METHODS A single-center retrospective study was performed on 564 infrainguinal revascularization procedures, including both open (n=250) and endovascular (n=314) approaches (2016-2020). Comprehensive clinical data were collected including patient demographics, cardiovascular risk factors, preoperative hemoglobin, and detailed transfusion data. Multivariable logistic regression tested the association of transfusions with composite 30-day outcomes of cardiac complications (postoperative myocardial infarction [postop-MI], congestive heart failure [CHF], or dysrhythmia) and with major adverse cardiovascular events (MACE- postop-MI or death). Kaplan-Meier analysis and cox-proportional hazard modeling examined the association of transfusions, anemia, and cardiovascular risk factors with mortality up to 1 year. RESULTS Intraoperative transfusion was performed in 15% of cases and 13% underwent transfusion in the early postoperative period. Intraoperative transfusion was associated with higher Revised Cardiac Risk Index (RCRI), lower preoperative hemoglobin, increased blood loss and open procedures (all p<0.05). Within each RCRI score, intraoperative transfusion was associated with 2-4 fold increased MACE at 30 days. Intraoperative pRBC transfusion and early postoperative pRBC transfusion was associated with more than 2-fold adjusted odds of any cardiovascular complication and intraoperative transfusion was also associated with MACE (all p<0.05). Intraoperative transfusion was associated with mortality at one year on unadjusted analysis, but after adjustment for RCRI, age, and preoperative hemoglobin, only RCRI scores of 2 and 3+ and preoperatively hemoglobin remained significant risk factors for mortality. CONCLUSIONS Intraoperative and early perioperative transfusions are strongly associated with worse cardiovascular outcomes after infrainguinal revascularization. These findings may have prognostic value for further risk stratifying patients perioperatively at high risk for complications. However, prospective studies are needed to elucidate whether optimizing transfusion strategies mitigates these risks.
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Affiliation(s)
- Zachary A Matthay
- Department of Surgery, University of California, San Francisco, California.
| | - Eric J Smith
- Department of Surgery, University of California, San Francisco, California
| | - Colleen P Flanagan
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, California
| | - Bian Wu
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, California; Department of Vascular Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Diego, California
| | - Jade S Hiramoto
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, California
| | - Michael S Conte
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, California
| | - James C Iannuzzi
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, California
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15
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Gutierrez RD, Matthay ZA, Smith EJT, Linderman K, Gasper WJ, Hiramoto JS, Conte MS, Iannuzzi JC. Clinical Predictors and Outcomes Associated with Postoperative Delirium Following Infrainguinal Bypass Surgery. Ann Vasc Surg 2022; 87:254-262. [PMID: 35803458 DOI: 10.1016/j.avsg.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/29/2022] [Accepted: 06/12/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Postoperative delirium (POD) is common yet often underdiagnosed following vascular surgery. Elderly patients with advanced peripheral artery disease may be at particular risk for POD yet understanding of the clinical predictors and impact of POD is incomplete. We sought to identify POD predictors and associated resource utilization after infrainguinal lower extremity bypass. METHODS This single center retrospective analysis included all infrainguinal bypass cases performed for peripheral arterial disease from 2012-2020. The primary outcome was inpatient post-operative delirium. Delirium sequelae were also evaluated. Key secondary outcomes were length of stay, non-home discharge, readmission, 30-day amputation, postoperative myocardial infarction, mortality, and 2-year survival. Regression analysis was used to evaluate risk factors for delirium in addition to association with 2-year survival and amputation free survival. RESULTS Among 420 subjects undergoing infrainguinal lower extremity bypass, 105 (25%) developed POD. Individuals with POD were older and more likely to have non-elective surgery (p<0.05). On multivariable analysis, independent predictors of POD were age 60-89 years old, chronic limb threatening ischemia, female sex, and non-elective procedure. Consultations for POD took place for 25 cases (24%); 13 (52%) were with pharmacists, and only 4 (16%) resulted in recommendations. The average length of stay for those with POD was higher (17 days vs 9 days; p<.001). POD was associated with increased non-home discharge (61.8% vs 22.1%; p<.001), 30-day major amputation (6.7% vs 1.6%; p<0.01), 30-day postoperative myocardial infarction (11.4% vs 4.1%; p<0.01), and 90-day mortality (7.6% vs 2.9%; p=0.03). Survival at 2 years was lower in those with delirium (89% vs 75%; p<.001). In a Cox proportional hazards model, delirium was independently associated with decreased survival (HR=2.0; 95% CI=1.15-3.38; p=0.014) and decreased major-amputation free survival (HR=1.9; 95% CI=1.18-2.96; p=0.007). CONCLUSIONS Postoperative delirium is common following infrainguinal lower extremity bypass and is associated with other adverse post-operative outcomes and increased resource utilization, including increased hospital length of stay, non-home discharge, and worse 2-year survival. Future studies should evaluate the role of routine multidisciplinary care for high-risk patients to improve perioperative outcomes for vulnerable older adults undergoing infrainguinal lower extremity bypass.
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Affiliation(s)
- Richard D Gutierrez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zachary A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Eric J T Smith
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Kurt Linderman
- University of Utah, School of Medicine, Salt Lake City, UT
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Iannuzzi JC, Conte MS, Rebrin K, Lozano MM, Menke L, Cheng D, Smith E, Schneider P, Vartanian S. Monitoring Tissue Oxygen Dynamics with a Novel Implantable Hydrogel Sensor in Patients with Peripheral Arterial Disease. JVS Vasc Sci 2022. [DOI: 10.1016/j.jvssci.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Patel PB, Marcaccio CL, O'Donnell TF, Rao A, Iannuzzi JC, Siracuse JJ, Garg K, Schermerhorn ML, Takayama H, Patel V. Thoracic Aortic Aneurysm Sac Remodeling After Thoracic Endovascular Aortic Repair Affects Late Outcomes After Repair. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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18
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Smith E, Matthay ZA, Liu IH, Ramirez J, Patel V, Gasper WJ, Hiramoto JS, Conte MS, Iannuzzi JC. High-Risk Clinical Predictors and Associated Morbidity of Acute Kidney Injury Following Thoracic Endovascular Aortic Repair for Aortic Aneurysm. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Jaramillo EA, Smith E, Matthay ZA, Sanders KM, Hiramoto JS, Gasper WJ, Conte MS, Iannuzzi JC. Presenting Severity of Limb Threat Does Not Account for Racial and Ethnic Disparities in Major Adverse Limb Events After Peripheral Vascular Intervention for Chronic Limb-Threatening Ischemia. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Rao A, Patel P, Mehta A, Bajakian D, Morrissey N, Schermerhorn ML, Siracuse JJ, Iannuzzi JC, Garg K, Takayama H, Patel V. Factors Associated With Large-Bore Access Complications in Patients Undergoing TEVAR. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Iannuzzi JC, Conte MS, Rebrin K, Lozano MM, Menke L, Cheng D, Smith E, Schneider P, Vartanian S. Abstract 303: Monitoring Tissue Oxygen Dynamics With A Novel Implantable Hydrogel Sensor In Patients With Pad. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Objective:
Tissue perfusion measurement remains a fundamental challenge in management of peripheral arterial disease (PAD) patients. Better measurement of baseline and dynamic changes after revascularization would aid clinical judgement. The Wireless Lumee® Oxygen System represents a novel approach to tracking tissue oxygen via a subcutaneous hydrogel that provides noninvasive optical oxygen measurements. This study’s objective was to assess the correlation of the Lumee sensor with transcutaneous oximetry (tcpO2) in PAD patients.
Methods:
The Lumee® Oxygen System is a subcutaneously placed hydrogel (0.5x0.5x5mm). Optical signals are captured with a skin surface reader sensing extravascular oxygenation. A pilot study assessed in vivo performance with inclusion criteria of peripheral arterial disease (Rutherford I-IV). Sensors were injected in the arm and foot and oxygenation measured before, during, and after proximal blood pressure cuff inflation (Figure) and Buerger’s Test modulation. The correlation (R) of oxygenation between tcpO2 and Lumee® was assessed following sensor placement at 2, 10, 90, 180, and 365 days.
Results:
Eleven subjects had 148 occlusion modulations over 199 days. Mean age was 67 years (range: 55-88), with 9% females, 45% White and 55% Black Race, Rutherford class I: 36%, II: 36%, III:27%. The median ABI was 0.83 (IQR0.69-1.14). In the arm, modulation was 56.9±24.6% (Lumee) and 84.7±9.2% (tcpO2), R:0.81. In the foot, modulation was 63.4±22.7% (Lumee) and 80.4±15.5% (tcpO2), R:0.79. No injection related adverse events occurred.
Conclusion:
Occlusion related changes in tissue oxygen can be detected by both tcpO2 and the Lumee sensor which strongly correlate in both the arm and foot. This pilot phase study supports expansion of the trial. The Lumee sensor shows promise for future evaluation of tissue oxygenation in PAD patients, which could be used to assess changes in tissue oxygenation over time and following revascularization.
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Affiliation(s)
| | | | | | | | | | - David Cheng
- San Francisco VA Med Cntr, San Francisco, CA
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22
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Gutierrez RD, Matthay ZA, Smith EJT, Linderman K, Gasper WJ, Hiramoto JS, Conte MS, Iannuzzi JC. Delirium Associated Adverse Events And Resource Use After Infrainguinal Lower Extremity Bypass. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2021.12.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Smith EJ, Gasper WJ, Schneider P, Finlayson E, Walter LC, Covinsky KE, Conte MS, Iannuzzi JC. Unrecognized Cognitive Impairment Is Common In A VA Population With Peripheral Arterial Disease. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2021.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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24
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Sanders KM, Schneider PA, Conte MS, Iannuzzi JC. Endovascular treatment of high-risk peripheral vascular occlusive lesions: a review of current evidence and emerging applications of intravascular lithotripsy, atherectomy, and paclitaxel-coated devices. Semin Vasc Surg 2021; 34:172-187. [PMID: 34911623 DOI: 10.1053/j.semvascsurg.2021.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/11/2022]
Abstract
Endovascular treatment of peripheral arterial disease has evolved and expanded rapidly over the last 20 years. New technologies have increased the diversity of devices available and have made it possible to approach even the most challenging and high-risk lesions using endovascular techniques. In this review, we examine the clinical evidence available for several categories of endovascular devices available to treat peripheral arterial disease, including intravascular lithotripsy, atherectomy, and drug-coated devices. The best application for some technologies, such as intravascular lithotripsy and atherectomies, have yet to be identified. In contrast, drug-coated devices have an established role in patients at high risk for long-term failure, but have been the subject of much controversy, given recent concerns about possible adverse effects of paclitaxel. Future investigation should further assess these technologies in patients with complex disease using updated staging systems and outcomes with direct clinical relevance, such as functional improvement, wound healing, and freedom from recurrent symptoms.
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Affiliation(s)
- Katherine M Sanders
- Division of Vascular and Endovascular Surgery, 400 Parnassus Avenue, A-501, San Francisco, CA, 94143-0957
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, 400 Parnassus Avenue, A-501, San Francisco, CA, 94143-0957
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, 400 Parnassus Avenue, A-501, San Francisco, CA, 94143-0957
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, 400 Parnassus Avenue, A-501, San Francisco, CA, 94143-0957.
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25
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Vervoort D, Canner JK, Haut ER, Black JH, Abularrage CJ, Zarkowsky DS, Iannuzzi JC, Hicks CW. Racial Disparities Associated With Reinterventions After Elective Endovascular Aortic Aneurysm Repair. J Surg Res 2021; 268:381-388. [PMID: 34399360 PMCID: PMC8678173 DOI: 10.1016/j.jss.2021.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/18/2021] [Accepted: 07/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND There are substantial racial and socioeconomic disparities underlying endovascular abdominal aortic aneurysm repair (EVAR) in the United States. To date, race-based variations in reinterventions following elective EVAR have not been studied. Here, we aim to examine racial disparities associated with reinterventions following elective EVAR in a real-world cohort. MATERIALS AND METHODS We used the Vascular Quality Initiative EVAR dataset to identify all patients undergoing elective EVAR between January 2009 and December 2018 in the United States. We compared the association of race with reinterventions after EVAR and all-cause mortality using Welch two-sample t-tests, multivariate logistic regression, and Cox proportional hazards analyses adjusting for baseline differences between groups. RESULTS At median follow-up of 1.1 ± 1.1 y (1.3 ± 1.4 y Black, 1.1 ± 1.1 y White; P = 0.02), a total of 1,164 of 42,481 patients (2.7%) underwent reintervention after elective EVAR, including 2.7% (n = 1,096) White versus 3.2% (n = 68) Black (P = 0.21). Black patients requiring reintervention were more frequently female, more frequently current or former smokers, and less frequently insured by Medicare/Medicaid (P < 0.05). After adjusting for baseline differences, the risk of reintervention after elective EVAR was significantly lower for Black versus White patients (HR 0.74, 95% CI 0.55-0.99; P = 0.04). All-cause mortality was comparable between groups (HR 0.81, 95% CI 0.33-2.00, P = 0.65). CONCLUSIONS There are significant differences between Black and White patients in the risk of reintervention after elective EVAR in the United States. The etiology of this difference deserves investigation.
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Affiliation(s)
- Dominique Vervoort
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine; The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado School of Medicine, Aurora, Colorado
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, California
| | - Caitlin W Hicks
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Vascular and Endovascular Surgery, University of California, San Francisco, California.
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Smith EJT, Matthay E, Matthay Z, Seligman H, Wick EC, Finlayson EVA, Iannuzzi JC. Living in a Food Desert Increases Wound Complication Risk after Colorectal Surgery. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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27
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Matthay ZA, Flanagan CP, Sanders K, Smith EJ, Lancaster EM, Gasper WJ, Kornblith LZ, Hiramoto JS, Conte MS, Iannuzzi JC. Risk Factors for Venous Thromboembolism after Vascular Surgery and Implications for Chemoprophylaxis Strategies. J Vasc Surg Venous Lymphat Disord 2021; 10:585-593.e2. [PMID: 34637952 PMCID: PMC9056001 DOI: 10.1016/j.jvsv.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/03/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is an important cause of postoperative morbidity and mortality, but the reported incidence after major vascular surgery ranges from as low as 1% to upwards of 10%. Further, little is known about optimal chemoprophylaxis regimens or rates of post-discharge VTE in this population. This study aimed to better characterize in-hospital and post-discharge VTE after major vascular surgery, the role of chemoprophylaxis timing, and the association of VTE with mortality. METHODS A single center retrospective study of 1,449 major vascular operations (2013-2020) was performed, and included 189 EVARs (13%), 169 TEVARs (12%), 318 open aortic operations (22%), 640 lower extremity bypasses (44%), and 133 femoral endarterectomies (9%). Baseline characteristics, anticoagulant/antiplatelet medications, and outcomes were abstracted from an electronic data warehouse with medical chart auditing. Post-operative VTE (pulmonary embolism [PE] and deep vein thrombosis [DVT]) within 90-days of surgery was classified based on location, symptoms, and treatment. Cut point analysis using Youden's index identified the most VTE discriminating timing of chemoprophylaxis (including therapeutic/prophylactic anticoagulant and antiplatelet medications) and Caprini score. Multivariable logistic regression tested the association of VTE with chemoprophylaxis timing, Caprini score, and additional risk factors. Cox proportional hazard modeling measured the association between VTE and mortality. RESULTS Overall VTE incidence was 3.4% (65% DVTs, 25% PEs, 10% both) and 37% were post-discharge. The rate of symptomatic VTE was 2.4%, which was lowest for EVAR (0.0%) and highest for open aortic operations (4.1%, p=0.02). Individuals who developed VTE had longer length of stay, higher rates of end-stage renal disease, prior VTE, and higher Caprini scores (8 vs 5 points) (all p<0.01). Individuals who developed VTE were also more likely to receive >2 units of blood postoperatively, have an unplanned return to the operating room, have delayed chemoprophylaxis/anticoagulation/antiplatelet initiation >4 days postoperatively, and had increased 90-day mortality (all p<0.01). Caprini score >7 (29% of patients) was associated with post-discharge VTE (2.6% vs 0.7%, p=0.01), and chemoprophylaxis/anticoagulation/antiplatelet timing >4 days was associated with increased adjusted odds of VTE (odds ratio 2.4 [1.1-4.9]). Although no fatal VTEs were identified, VTE was an independent predictor of 90-day mortality (adjusted hazard ratio 2.7 [1.3-5.9]). CONCLUSIONS These data highlight that patients undergoing major vascular surgery are particularly prone to VTE with frequent hypercoagulable comorbidities and earlier initiation of chemoprophylaxis is associated with reduced risk of development of VTE. Furthermore, post-discharge VTE rates may reach thresholds warranting post-discharge chemoprophylaxis, particularly for patients with Caprini scores >7.
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Affiliation(s)
- Zachary A Matthay
- Department of Surgery, University of California, San Francisco. San Francisco, CA, USA.
| | - Colleen P Flanagan
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco. San Francisco, CA, USA
| | - Katherine Sanders
- Department of Surgery, University of California, San Francisco. San Francisco, CA, USA
| | - Eric J Smith
- Department of Surgery, University of California, San Francisco. San Francisco, CA, USA
| | - Elizabeth M Lancaster
- Department of Surgery, University of California, San Francisco. San Francisco, CA, USA
| | - Warren J Gasper
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco. San Francisco, CA, USA
| | - Lucy Z Kornblith
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Jade S Hiramoto
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco. San Francisco, CA, USA
| | - Michael S Conte
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco. San Francisco, CA, USA
| | - James C Iannuzzi
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco. San Francisco, CA, USA
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28
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El Khoury R, Woodford C, Ramirez JL, Lancaster EM, Nacari J, Hiramoto JS, Eichler CM, Reilly LM, Iannuzzi JC, Conte MS. Capturing the Complexity of Open Abdominal Aortic Surgery in the Endovascular Era. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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29
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Flanagan CP, Matthay ZA, Smith EJ, Conte MS, Iannuzzi JC. In-Network Primary Care: An Important Augmentation To Preoperative Workup For Patients Undergoing Infrainguinal Bypass. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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30
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Kim T, Schneider PA, Iannuzzi JC, Ochoa Chaar CI. High-Risk Characteristics for Clinical Failure After Isolated Femoropopliteal Peripheral Vascular Interventions. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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31
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Zarkowsky DS, Govseyeyev N, Ramirez JL, Bonaca M, Iannuzzi JC, Hicks CW, Powell R, Nehler MR. Variable National Prescribing Patterns After Suprainguinal Bypass to Treat Acute Limb Ischemia. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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32
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Matthay ZA, Flanagan CP, Sanders K, Smith EJ, Lancaster E, Gasper W, Kornblith LZ, Hiramoto J, Conte MS, Iannuzzi JC. Venous Thromboembolism After Vascular Surgery: Is More Aggressive Chemoprophylaxis Warranted? J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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33
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Mehta A, Patel P, Garg K, Siracuse JJ, Iannuzzi JC, Schwartz SI, Schermerhorn ML, Patel VI. Effect of Preoperative Pulmonary Status on Open Aortic Aneurysm Repairs. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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34
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Smith EJ, Matthay ZA, Ramirez JL, Covinsky K, Seligman H, Conte MS, Hiramoto J, Iannuzzi JC. Food Deserts Associated With Increased Wound Complications After Major Vascular Procedures. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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35
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Ramirez JL, Matthay ZA, Lancaster E, Smith EJ, Gasper W, Doyle AJ, Patel VI, Schanzer A, Conte MS, Iannuzzi JC, Zarkowsky DS. Decreasing Prevalence of Centers Meeting the Society for Vascular Surgery Abdominal Aortic Aneurysm Guidelines in the United States. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Zarkowsky DS, Sorber R, Ramirez JL, Goodney PP, Iannuzzi JC, Wohlauer M, Hicks CW. Aortic Neck IFU Violations During EVAR for Ruptured Infrarenal Aortic Aneurysms are Associated with Increased In-Hospital Mortality. Ann Vasc Surg 2021; 75:12-21. [PMID: 33951521 PMCID: PMC9843606 DOI: 10.1016/j.avsg.2021.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Vascular surgeons treating patients with ruptured abdominal aortic aneurysm must make rapid treatment decisions and sometimes lack immediate access to endovascular devices meeting the anatomic specifications of the patient at hand. We hypothesized that endovascular treatment of ruptured abdominal aortic aneurysm (rEVAR) outside manufacturer instructions-for-use (IFU) guidelines would have similar in-hospital mortality compared to patients treated on-IFU or with an infrarenal clamp during open repair (ruptured open aortic aneurysm repair [rOAR]). METHODS Vascular Quality Initiative datasets for endovascular and open aortic repair were queried for patients presenting with ruptured infrarenal AAA between 2013-2018. Graft-specific IFU criteria were correlated with case-specific proximal neck dimension data to classify rEVAR cases as on- or off-IFU. Univariate comparisons between the on- and off-IFU groups were performed for demographic, operative and in-hospital outcome variables. To investigate mortality differences between rEVAR and rOAR approaches, coarsened exact matching was used to match patients receiving off-IFU rEVAR with those receiving complex rEVAR (requiring at least one visceral stent or scallop) or rOAR with infrarenal, suprarenal or supraceliac clamps. A multivariable logistic regression was used to identify factors independently associated with in-hospital mortality. RESULTS 621 patients were treated with rEVAR, with 65% classified as on-IFU and 35% off-IFU. The off-IFU group was more frequently female (25% vs. 18%, P = 0.05) and had larger aneurysms (76 vs. 72 mm, P= 0.01) but otherwise was not statistically different from the on-IFU cohort. In-hospital mortality was significantly higher in patients treated off-IFU vs. on-IFU (22% vs. 14%, P= 0.02). Off-IFU rEVAR was associated with longer operative times (135 min vs. 120 min, P= 0.004) and increased intraoperative blood product utilization (2 units vs. 1 unit, P= 0.002). When off-IFU patients were matched to complex rEVAR and rOAR patients, no baseline differences were found between the groups. Overall in-hospital complications associated with off-IFU were reduced compared to more complex strategies (43% vs. 60-81%, P< 0.001) and in-hospital mortality was significantly lower for off-IFU rEVAR patients compared to the supraceliac clamp group (18% vs. 38%, P= 0.006). However, there was no significantly increased mortality associated with complex rEVAR, infrarenal rOAR or suprarenal rOAR compared to off-IFU rEVAR (all P> 0.05). This finding persisted in a multivariate logistic regression. CONCLUSIONS Off-IFU rEVAR yields inferior in-hospital survival compared to on-IFU rEVAR but remains associated with reduced in-hospital complications when compared with more complex repair strategies. When compared with matched patients undergoing rOAR with an infrarenal or suprarenal clamp, survival was no different from off-IFU rEVAR. Taken together with the growing available evidence suggesting reduced long-term durability of off-IFU EVAR, these data suggest that a patient's comorbidity burden should be key in making the decision to pursue off-IFU rEVAR over a more complex repair when proximal neck violations are anticipated preoperatively.
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Affiliation(s)
- Devin S. Zarkowsky
- Divison of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Joel L. Ramirez
- Division of Vascular Surgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Philip P. Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - James C. Iannuzzi
- Division of Vascular Surgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Max Wohlauer
- Divison of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
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Ramirez JL, Lopez J, Sanders K, Schneider PA, Gasper WJ, Conte MS, Sosa JA, Iannuzzi JC. Understanding value and patient complexity among common inpatient vascular surgery procedures. J Vasc Surg 2021; 74:1343-1353.e2. [PMID: 33887430 DOI: 10.1016/j.jvs.2021.03.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Vascular surgery patients are highly complex, second only to patients undergoing cardiac procedures. However, unlike cardiac surgery, work relative value units (wRVU) for vascular surgery were undervalued based on an overall patient complexity score. This study assesses the correlation of patient complexity with wRVUs for the most commonly performed inpatient vascular surgery procedures. METHODS The 2014 to 2017 National Surgical Quality Improvement Program Participant Use Data Files were queried for inpatient cases performed by vascular surgeons. A previously developed patient complexity score using perioperative domains was calculated based on patient age, American Society of Anesthesiologists class of ≥4, major comorbidities, emergent status, concurrent procedures, additional procedures, hospital length of stay, nonhome discharge, and 30-day major complications, readmissions, and mortality. Procedures were assigned points based on their relative rank and then an overall score was created by summing the total points. An observed to expected ratio (O/E) was calculated using open ruptured abdominal aortic aneurysm repair (rOAAA) as the referent and then applied to an adjusted median wRVU per operative minute. RESULTS Among 164,370 cases, patient complexity was greatest for rOAAA (complexity score = 128) and the least for carotid endarterectomy (CEA) (complexity score = 29). Patients undergoing rOAAA repair had the greatest proportion of American Society of Anesthesiologists class of ≥IV (84.8%; 95% confidence interval [CI], 82.6%-86.8%), highest mortality (35.5%; 95% CI, 32.8%-38.3%), and major complication rate (87.1%; 95% CI, 85.1%-89.0%). Patients undergoing CEA had the lowest mortality (0.7%; 95% CI, 0.7%-0.8%), major complication rate (8.2%; 95% 95% CI, 8.0%-8.5%), and shortest length of stay (2.7 days; 95% CI, 2.7-2.7). The median wRVU ranged from 10.0 to 42.1 and only weakly correlated with overall complexity (Spearman's ρ = 0.11; P < .01). The median wRVU per operative minute was greatest for thoracic endovascular aortic repair (0.25) and lowest for both axillary-femoral artery bypass (0.12) and open femoral endarterectomy, thromboembolectomy, or reconstruction (0.12). After adjusting for patient complexity, CEA (O/E = 3.8) and transcarotid artery revascularization (O/E = 2.8) had greater than expected O/E. In contrast, lower extremity bypass (O/E = 0.77), lower extremity embolectomy (O/E = 0.79), and open abdominal aortic repair (O/E = 0.80) had a lower than expected O/E. CONCLUSIONS Patient complexity varies substantially across vascular procedures and is not captured effectively by wRVUs. Increased operative time for open procedures is not adequately accounted for by wRVUs, which may unfairly penalize surgeons who perform complex open operations.
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Affiliation(s)
- Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Jose Lopez
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Katherine Sanders
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Peter A Schneider
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, Calif.
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Ramirez JL, Smith EJ, Zarkowsky DS, Lopez J, Hicks CW, Schneider PA, Conte MS, Iannuzzi JC. Closure Device Use For Common Femoral Artery Antegrade Access Is Higher Risk Than Retrograde Access. Ann Vasc Surg 2021. [DOI: 10.1016/j.avsg.2021.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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39
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Ramirez JL, Zarkowsky DS, Ramirez FD, Gasper WJ, Cohen BE, Conte MS, Grenon SM, Iannuzzi JC. Depression Predicts Non-Home Discharge After Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2021; 74:131-140. [PMID: 33503503 DOI: 10.1016/j.avsg.2020.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mental health's impact on vascular surgical patients has long been overlooked. While outside the expertise of most surgeons, understanding the role that depression plays in the postoperative course could provide additional insight into opportunities to improve surgical outcomes and healthcare value. Additionally, non-home discharge (NHD) to a rehabilitation or skilled nursing facility after surgery is associated with impaired quality of life and higher postdischarge complications, readmissions, and mortality. We hypothesized that depression would be associated with an increased risk for NHD following abdominal aortic aneurysm (AAA) repair. METHODS Nonruptured AAA repair cases were identified from the National Inpatient Sample (NIS) using ICD-9 codes between 2005 and 2014. Depression, comorbidities, postoperative complications, and discharge destination were evaluated using statistical tests as appropriate to the data. A hierarchical multivariable logistic regression controlling for hospital level variation was used to examine the independent association between depression, and the primary outcome of NHD controlling for median income and confounders meeting P < 0.05 on univariate analysis. RESULTS There were 99,934 total cases analyzed, of which 4,755 (4.8%) were diagnosed with depression and 10,618 (11.9%) required NHD. Patients with depression were younger, more likely to be women, white, have diabetes, chronic obstructive pulmonary disease, hypertension, tobacco use, and more likely to experience a postoperative complication. On adjusted multivariable analysis, patients with depression were more likely to require NHD (odds ratio [OR] 1.87, 95% confidence interval [CI]: 1.68-2.08, c-statistic = 0.82). On stratified analysis by operative approach, depression had a larger effect estimate in endovascular repair (OR 2.19; 95% CI: 1.90-2.52) versus open repair (OR 1.60; 95% CI: 1.38-1.87). CONCLUSIONS In a nationally representative sample, patients with depression were more likely to require NHD after AAA repair. This study highlights the importance that depression plays in postoperative outcomes after AAA repair. Furthermore, addressing mental health preoperatively has the potential to improve outcomes in patients undergoing AAA repair.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO
| | - Faustine D Ramirez
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - S Marlene Grenon
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Ramirez JL, Zahner GJ, Arya S, Grenon SM, Gasper WJ, Sosa JA, Conte MS, Iannuzzi JC. Patients with depression are less likely to go home after critical limb revascularization. J Vasc Surg 2020; 74:178-186.e2. [PMID: 33383108 DOI: 10.1016/j.jvs.2020.12.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although often overlooked during the preoperative evaluation, recent evidence has suggested that depression in patients with peripheral artery disease is associated with increased postoperative complications, including decreased primary and secondary patency after revascularization and an increased risk of major amputation and mortality. Postoperative nonhome discharge (NHD) is an important outcome for patients and has also been associated with other adverse outcomes; however, the effect that depression has on NHD after vascular surgery has remained unexplored. We hypothesized that depression would be associated with an increased risk of NHD after revascularization for chronic limb threatening ischemia (CLTI). METHODS Endovascular, open, and hybrid (combined open and endovascular) cases of revascularization for CLTI were identified from the 2012 to 2014 National (Nationwide) Inpatient Sample. CLTI, diagnoses of depression, and medical comorbidities were defined using the corresponding International Classification of Diseases, Ninth Revision, Clinical Modification codes. A hierarchical multivariable binary logistic regression controlling for hospital level variation and for confounders meeting P <.01 on bivariate analysis was used to examine the association between depression and NHD. A sensitivity analysis after coarsened exact matching for baseline characteristics that differed between the two groups was performed to reduce any imbalance. RESULTS A total of 64,817 cases were identified, of which 5472 (8.4%) included a diagnosis of depression and 16,524 (25.5%) NHD. The patients with depression were younger and more likely to be women and white, have multiple comorbidities and a nonelective admission, and experience a postoperative complication (P <.05). On unadjusted analyses, patients with depression had an 8% absolute increased risk of requiring NHD (32.1% vs 24.9%; P <.001). On multivariable analysis, patients with depression had an increased odds for NHD (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.40-1.61; c-statistic, 0.81) compared with those without depression. After stratification by operative approach, depression had a larger effect estimate in endovascular revascularization (OR, 1.57; 95% CI, 1.42-1.74) compared with open (OR, 1.45; 95% CI, 1.30-1.62). A test for interaction between depression and gender identified that men with depression had greater odds of NHD compared with women with depression (OR, 1.68; 95% CI, 1.51-1.88; vs OR, 1.37; 95% CI, 1.25-1.51; interaction P <.01). A sensitivity analysis after coarsened exact matching confirmed these findings. CONCLUSIONS To the best of our knowledge, the present study is the first to identify an association between depression and NHD after revascularization for CLTI. These results provide further evidence of the negative effects that comorbid depression has on patients undergoing revascularization for CLTI. Future studies should examine whether treating depression can improve the outcomes in this patient population.
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Affiliation(s)
- Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Greg J Zahner
- Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Shipra Arya
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, Calif
| | - S Marlene Grenon
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, Calif.
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Ramirez JL, Zarkowsky DS, Boitano LT, Conrad MF, Arya S, Gasper WJ, Conte MS, Iannuzzi JC. A novel preoperative risk score for nonhome discharge after elective thoracic endovascular aortic repair. J Vasc Surg 2020; 73:1549-1556. [PMID: 33065243 DOI: 10.1016/j.jvs.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its large impact on patients. Understanding postsurgical NHD risk is essential to providing adequate preoperative counseling and shared decision making, particularly for elective surgeries. We aimed to identify independent predictors of NHD after elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAA) and to create a clinically useful preoperative risk score. METHODS Elective TEVAR cases for descending TAA were queried from the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2018. A risk score was created by splitting the dataset into two-thirds for model development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. This score was then cross-validated and model performance assessed. RESULTS Overall, 1469 patients were included and 213 (14.5%) required NHD. At baseline, patients who required NHD were more likely to be ≥80 years old (35.2% vs 19.4%), female (58.7% vs 40.6%), functionally dependent (42.3% vs 24.0%), and anemic (46.5% vs 27.8%), and to have chronic obstructive pulmonary disease (41.3% vs 33.4%), congestive heart failure (18.8% vs 11.1%), and American Society of Anesthesiologists class ≥4 (51.6% vs 39.8%; all P < .05). Multivariable analysis in the development group identified independent predictors of NHD that were used to create an 18-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-7 points; n = 563) with an NHD rate of 4.3%, moderate risk (8-11 points; n = 701) with an NHD rate of 17.0%, and high risk (≥12 points; n = 205) with an NHD rate of 34.2%. The risk score had good predictive ability with a c-statistic of 0.75 for model development and a c-statistic of 0.72 in the validation dataset. CONCLUSIONS This novel risk score can predict NHD after TEVAR for TAA using characteristics that can be identified preoperatively. The use of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, Colo
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University, Palo Alto, Calif
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
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Smith EJT, Ramirez JL, Wu B, Zarkowsky DS, Gasper WJ, Finlayson E, Conte MS, Iannuzzi JC. Living in a Food Desert is Associated with 30-day Readmission after Revascularization for Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 70:36-42. [PMID: 32628994 DOI: 10.1016/j.avsg.2020.06.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Living in a food desert has been associated with increased cardiovascular risk; however, its impact on vascular surgery outcomes is unknown. This study hypothesized that living in a food desert would be associated with increased postoperative complications in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI). METHODS This was a single-center retrospective analysis of open and endovascular infrainguinal revascularization for CLTI between April 2013 and December 2015. A food desert was defined using the US Department of Agriculture's Food Access Research Atlas. Bivariate analyses were performed appropriate to the data. Binary logistic regression was performed assessing the association of food desert status with 30-day postoperative complications. RESULTS In total, 152 cases were included, of which 17% (n = 26) resided in food deserts. Patients in the food desert cohort were less likely to be low income (27% vs. 54%, P = 0.01). Living in a food desert was associated with increased 30-day readmission [(39% vs. 20%, P = 0.04), unadjusted OR: 2.5 (CI: 1.0-6.2)]. FD cases also had a higher proportion of wound complications [12 (46%) vs. 28 (22%), P = 0.01)]. The overall wound complication rate was 27% with the majority being due to infections (63%). On multivariable analysis, food desert status remained associated with increased odds of 30-day readmission (OR: 2.7, CI: 1.2-8.4, P = 0.047). Reasons for readmission in the food desert group were all due to wound complications (100% vs. 72%, P = 0.08). CONCLUSIONS Living in a food desert was associated with nearly three times the odds of 30-day readmission after lower extremity revascularization for CLTI. This increase in readmission may be explained through increased wound complications. These findings support considering access to healthy food as a potential modifiable risk factor for adverse outcomes, particularly in CLTI revascularization.
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Affiliation(s)
- Eric J T Smith
- Department of Surgery, University of California, San Francisco, CA
| | - Joel L Ramirez
- Department of Surgery, University of California, San Francisco, CA
| | - Bian Wu
- Department of Surgery, University of California, San Francisco, CA
| | | | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, CA.
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Kim AS, Ramirez JL, Lancaster EM, Zarkowsky D, Patel VI, Conte M, Iannuzzi JC. Thoracic Endovascular Aortic Repair for Aortic Aneurysm Is Safe in Patients With Chronic Kidney Disease, but at a Cost. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ramirez JL, Gasper WJ, Seib CD, Finlayson E, Conte MS, Sosa JA, Iannuzzi JC. Patient complexity by surgical specialty does not correlate with work relative value units. Surgery 2020; 168:371-378. [PMID: 32336468 DOI: 10.1016/j.surg.2020.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/23/2020] [Accepted: 03/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Understanding the differences in how patient complexity varies across surgical specialties can inform policy decisions about appropriate resource allocation and reimbursement. This study evaluated variation in patient complexity across surgical specialties and the correlation between complexity and work relative value units. STUDY DESIGN The 2017 American College of Surgeons National Surgical Quality Improvement Program was queried for cases involving otolaryngology and general, neurologic, vascular, cardiac, thoracic, urologic, orthopedic, and plastic surgery. A total of 10 domains of patient complexity were measured: American Society of Anesthesiologists class ≥4, number of major comorbidities, emergency operation, major complications, concurrent procedures, additional procedures, length of stay, non-home discharge, readmission, and mortality. Specialties were ranked by their complexity domains and the domains summed to create an overall complexity score. Patient complexity then was evaluated for correlation with work relative value units. RESULTS Overall, 936,496 cases were identified. Cardiac surgery had the greatest total complexity score and was most complex across 4 domains: American Society of Anesthesiologists class ≥4 (78.5%), 30-day mortality (3.4%), major complications (56.9%), and mean length of stay (9.8 days). Vascular surgery had the second greatest complexity score and ranked the greatest on the domains of major comorbidities (2.7 comorbidities) and 30-day readmissions (10.1%). The work relative value units did not correlate with overall complexity score (Spearman's ρ = 0.07; P < .01). Although vascular surgery had the second most complex patients, it ranked fifth greatest in median work relative value units. Similarly, general surgery was the fifth most complex but had the second-least median work relative value units. CONCLUSION Substantial differences exist between patient complexity across specialties, which do not correlate with work relative value units. Physician effort is determined largely by patient complexity, which is not captured appropriately by the current work relative value units.
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Affiliation(s)
- Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Carolyn D Seib
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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Zarkowsky DS, Ramirez JL, Holscher CM, Goodney PP, Malas MB, Iannuzzi JC, Wohlauer M, Hicks CW. Ruptured AAA Patients Treated with EVAR Off-IFU Demonstrate Lower In-hospital Survival Than Those With On-IFU Repair. Ann Vasc Surg 2020. [DOI: 10.1016/j.avsg.2020.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Boitano LT, Iannuzzi JC, Tanious A, Chou E, Latz C, Chang DC, Clouse WD, Conrad MF. Hypoalbuminemia Predicts Major Amputation and Death after Revascularization for Tissue Loss. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ramirez JL, Zarkowsky DS, Boitano LT, Conrad MF, Arya S, Gasper WJ, Conte MS, Iannuzzi JC. Novel Preoperative Risk Score to Identify Patients at High Risk for Non-Home Discharge after Elective Thoracic Endovascular Aortic Aneurysm Repair. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ramirez JL, Gasper WJ, Seib CD, Finlayson E, Conte MS, Sosa JA, Iannuzzi JC. Patient Complexity Varies by Surgical Specialty and Does Not Strongly Correlate with Work Relative Value Units. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ramirez JL, Zahner GJ, Arya S, Grenon SM, Gasper WJ, Sosa JA, Conte MS, Iannuzzi JC. Patients with Depression Are Less Likely to Go Home after Critical Limb Revascularization. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Iannuzzi JC, Boitano LT, Cooper MA, Watkins MT, Eagleton MJ, Clouse WD, Conte MS, Conrad MF. Risk score for nonhome discharge after lower extremity bypass. J Vasc Surg 2019; 71:889-895. [PMID: 31519514 DOI: 10.1016/j.jvs.2019.07.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/03/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Patients undergoing lower extremity bypass (LEB) for peripheral artery disease require intensive health care resource utilization including rehabilitation and skilled nursing facilities. However, few studies have evaluated factors that lead to nonhome discharge (NHD) in this population of patients. This study sought to predict NHD by preoperative risk factors in patients undergoing LEB for peripheral artery disease using a novel risk score. METHODS The Vascular Study Group of New England database was queried for elective LEB for peripheral artery disease including claudication and critical limb ischemia from 2003 to 2017. Patients were excluded if the procedure was not elective, if they were not admitted from home, if they were bedridden, or if they died during the index admission. Only preoperative factors were considered in the analysis. The primary end point was NHD including rehabilitation and skilled nursing facilities. Data were split two-thirds for model derivation and one-third for validation. In the derivation cohort, bivariate analysis assessed the association of preoperative factors with NHD. A parsimonious manual stepwise binary logistic regression for NHD aimed at maximizing the C statistic while maintaining model simplicity was performed. A risk score was developed using the β coefficients and applied to the validation data set. The risk score performance was assessed using a C statistic and Hosmer-Lemeshow test for model fit. RESULTS There were 10,145 cases included with an overall NHD rate of 26.4% (n = 2676). Mean age was 66 years (range, 41-90 years). NHD patients were older (72 years vs 64 years; P < .01) and more frequently male (57.2% vs 42.8%; P < .01) and nonwhite (16.1% vs 9.9%; P < .01); they more frequently had tissue loss (54.2% vs 23.0%; P < .01), anemia (16.0% vs 5.3%; P < .01), severe cardiac comorbidity (21.8% vs 10.5%; P < .01), and insulin-dependent diabetes (33.3% vs 18.2%; P < .01). On multivariable analysis, factors associated with NHD included age, sex, nonwhite race, tissue loss, cardiac comorbidity, partial ambulatory deficit, and insulin-dependent diabetes. The C statistic was 0.78 in the derivation group and 0.79 in the validation group, with Hosmer-Lemeshow P > .999. The risk score ranged from 0 to 18, with a mean score of 4 (standard deviation ±3.5). The risk score was divided into low risk (0-4 points; n = 5272 [52%]; NHD = 10.1%]), moderate risk (5-9 points; n = 3663 [36.7%]; NHD = 36.7%), and high risk (≥10 points; n = 1210 [11.9%]; NHD = 66.1%). CONCLUSIONS This novel risk score was highly predictive for NHD after LEB for peripheral artery disease using only preoperative comorbidities. High-risk patients account for 12% of LEB but nearly a third of all patients requiring NHD. This risk score can be used preoperatively to determine high-risk patients for NHD, which may help improve preoperative counseling and hospital efficiency by allocating resources appropriately.
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Affiliation(s)
- James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, Calif.
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Michol A Cooper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Michael T Watkins
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, Calif
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
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