RESUMO
OBJECTIVE: The aim of this study was to explore local practices and perceptions of effective nurse-resident communication during shifts. Subsequently, effective communication was sought to be reinforced by implementing an initiative for improvement. DESIGN: A mixed-methods study was performed, combining a questionnaire with focus groups. Following qualitative analysis, 3 initiatives for improvement of nurse-resident communication were scrutinized, after which 1 initiative was implemented. Overall contentment with the implementation and effectiveness of communication was reassessed through a questionnaire at 3 months postimplementation. SETTING: This study took place between 2022 and 2023 at the Department of Surgery of the Leiden University Medical Center, a tertiary center in the Netherlands. PARTICIPANTS: All surgical nurses (nâ¯=â¯150) and residents (nâ¯=â¯20) were invited to participate, by responding to the questionnaire and take part in the focus groups. A total of 38 nurses (response rate 25.3%) and 12 residents (60%) completed the questionnaire, and 31 nurses and 13 residents participated in the focus groups. RESULTS: The themes "clarity," "mutual respect," "accessibility" and "approach" were critical for effective communication, in which there were interdisciplinary differences in the interpretation and needs regarding "clarity." In response, structured moments for interdisciplinary consultation during shifts were implemented, which were foremostly useful according to nurses (73.9%), compared to residents (40.0%). A majority of the nurses agreed that communication during shifts improved through fixed moments (60.9%). CONCLUSION: Differences in the perception of critical elements for efficient nurse-resident communication during shifts can be found, which could possibly be explained by differences in training and culture. Mutual awareness for each other's tasks, responsibilities and background seems vital for the ability to deliver good patient care during shifts. To improve interprofessional practice and overcome concerns of quality of care, attention for local practices is imperative. Practical arrangements, such as fixed moments for peer communication, can strengthen partnership during shift work.
Assuntos
Grupos Focais , Internato e Residência , Humanos , Países Baixos , Masculino , Inquéritos e Questionários , Feminino , Comunicação , Adulto , Relações Interprofissionais , Jornada de Trabalho em Turnos , Recursos Humanos de Enfermagem Hospitalar/psicologia , Atitude do Pessoal de Saúde , Pesquisa QualitativaRESUMO
OBJECTIVE: To discuss practical strategies to consider for morbidity and mortality conferences (M&M). MATERIALS AND METHODS: This article reflects on (i) insights that can be drawn from the M&M literature, (ii) practical aspects to consider when organizing M&M, and (iii) possible future directions for development for this long-standing practice for routine reflection. RESULTS: M&M offers the opportunity to learn from past cases in order to improve the care delivered to future patients, thereby serving both educational and quality improvement purposes. For departments seeking to implement or improve local M&M practice, it is difficult that a golden standard or best practice for M&M is nonexistent. This is partly because comparative research on different formats is hampered by the lack of objective outcome measures to evaluate the effectiveness of M&M. Common practical suggestions include the use of (i) a skillful and active moderator; (ii) structured formats for case presentation and discussion; and (iii) a dedicated committee to guide improvement plans that ensue from the meeting. M&M practice is affected by various sociological factors, for which qualitative research methods seem most suitable, but in the M&M literature these are sparsely used. Moreover, aspects influencing an open and blame-free atmosphere underline how local teams should tailor the format to best fit the local context and culture. CONCLUSION: This article presents practice guidance on how to organize and carry out M&M This practice for routine reflection needs to be tailored to the local setting, with attention for various sociological factors that are at play.
Assuntos
Melhoria de Qualidade , Humanos , Morbidade , Estudos LongitudinaisRESUMO
OBJECTIVES: Preoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to study how complex processes usually go right at the frontline (labeled Safety-II) and how this relates to predefined procedures. This study aimed to assess PAM in everyday practice and explore the usability and utility of FRAM. METHODS: The study was conducted at an Australian and European Cardiothoracic Surgery Department. A FRAM model of work-as-imagined was developed using (inter)national guidelines. Semistructured interviews with 18 involved professionals were used to develop models reflecting work-as-done at both sites, which were presented to staff for validation. Workload in hours was estimated per process step. RESULTS: In both centers, work-as-done differed from work-as-imagined, such as in the division of tasks among disciplines (e.g., nurses/registrars rather than medical specialists), but control mechanisms had been developed locally to ensure safe care (e.g., crosschecking with other clinicians). Centers had organized the process differently, revealing opportunities for improvement regarding patient information and clustering of clinic visits. Presenting FRAM models to staff initiated discussion on improvement of functions in the model that are vital for success. Overall workload was estimated at 47 hours per site. CONCLUSIONS: This FRAM analysis provided insight into PAM from the perspective of frontline clinicians, revealing essential functions, interdependencies and variability, and the relation with guidelines. Future studies are warranted to study the potential of FRAM, such as for guiding improvements in complex systems.
Assuntos
Anticoagulantes , Anticoagulantes/efeitos adversos , Austrália , HumanosRESUMO
OBJECTIVE: To explore possibilities to improve morbidity and mortality conferences using advancing insights in safety science. SUMMARY BACKGROUND DATA: Mortality and Morbidity conferences (M&M) are the golden practice for case-based learning. While learning from complications is useful, M&M does not meet expectations for system-wide improvement. Resilience engineering principles may be used to improve M&M. METHODS: After a review of the shortcomings of traditional M&M, resilience engineering principles are explored as a new way to evaluate performance. This led to the development of a new M&M format that also reviews successful outcomes, rather than only complications. This "quality assessment meeting" (QAM) is presented and the first experiences are evaluated using local observations and a survey. RESULTS: During the QAM teams evaluate all discharged patients, addressing team resilience in terms of surgeons' ability to respond to irregularities and to monitor and learn from experiences. The meeting was feasible to implement and well received by the surgical team. Observations reveal that reflection on both complicated and uncomplicated cases strengthened team morale but also triggered reflection on the entire clinical course. The QAM serves as a tool to identify how adapting behavior led to success despite challenging conditions, so that this resilient performance can be supported. CONCLUSIONS: The resilience engineering concept can be used to adjust M&M, in which learning is focused not only on complications but also on how successful outcomes were achieved despite ever-present challenges. This reveals the actual ratio between successful and unsuccessful outcomes, allowing to learn from both to reinforce safety-enhancing behavior.
Assuntos
Complicações Pós-Operatórias , Especialidades Cirúrgicas/educação , Procedimentos Cirúrgicos Operatórios/educação , Procedimentos Cirúrgicos Operatórios/normas , Humanos , Complicações Pós-Operatórias/mortalidade , Melhoria de QualidadeRESUMO
BACKGROUND AND OBJECTIVE: Incident, adverse event (AE) and complaint data are typically used separately, but may be related at the patient level with one event triggering a cascade of events, ultimately resulting in a complaint. This study examined relations between incidents, AEs and complaints that co-occurred in admissions. METHODS: Independently and routinely collected incident, AE and complaint data were retrospectively linked for surgical admissions in an academic centre (2008-2014). Two investigators reviewed whether incidents/AEs in admissions were clinically related and in what sequence (incident preceding vs following AE). Likelihood of occurrence of AEs and AE cascades (ie, ≥3 AEs) was studied using logistic regression analyses. RESULTS: Complaints were filed for 33 (0.1%) of 26 383 admissions. Complaints filed by patients with incidents and/or AEs (n=13) mostly addressed quality/safety problems, whereas other complaints mostly addressed relationship problems. Incidents and AEs co-occurred in 730 (2.8%) admissions, which seemed clinically related in 34% of these cases. Incidents with related AEs preceded as well as followed AEs (56.6%/44.4%). Patients with incidents were at greater risk of AEs than patients without incidents, even for seemingly unrelated AEs (OR 1.4; 95% CI 1.3 to 1.6). Risk of AE cascades was greater when patients with AEs also had incidents, regardless of whether these seemed related (unrelated: OR 2.0; 95% CI 1.6 to 2.5; related: OR 5.7; 95% CI 4.3 to 7.4) or whether incidents preceded or followed AEs in these admissions (53% vs 52%, P>0.05). CONCLUSIONS: Patient-level linkage of incident, AE and complaint data can reveal relations between events that otherwise remain obscured, such as incidents that trigger as well as follow AEs, introducing event cascades, regardless of whether clinical relations seem present.
Assuntos
Segurança do Paciente , Qualidade da Assistência à Saúde , Adulto , Sistemas de Notificação de Reações Adversas a Medicamentos , Idoso , Bases de Dados Factuais , Feminino , Cirurgia Geral , Humanos , Modelos Logísticos , Masculino , Erros Médicos/estatística & dados numéricos , Pessoa de Meia-Idade , Admissão do Paciente , Estudos RetrospectivosRESUMO
OBJECTIVE: To assess formats for surgical morbidity and mortality conferences (M&M) for strengths and challenges. DESIGN: A mixed methods approach with local observations to assess key domains of M&M practice (i.e., goals, structure, and process/content) and surveys to assess participants' expectations and experiences. SETTING: Surgical departments of two teaching hospitals (Boston, USA and Leiden, Netherlands). PARTICIPANTS: Participants of surgical M&M, including attending surgeons, residents, physician assistants, and medical students (total n = 135). RESULTS: Surgical M&M practices at both hospitals had education as its overarching goal, but varied in structure and process/content. Expectations were similar at both sites with ≥80% of participants (n = 90; 67% response) expecting M&M to be focused on education as well as quality improvement (QI), blame-free, mandatory for both residents and attendings, and to lead to changes in clinical practice. However, compared to expectations, significantly fewer participants at both sites experienced: a QI focus (both p < 0.001); mandatory faculty attendance (p = 0.004; p < 0.001) and changes to practice (both p < 0.001). In comparison, at the site where an active moderator and QI committee are present, respondents seemed more positive about experiencing a QI focus (73% vs 30%) and changes to practice (44% vs 16%). CONCLUSION: Despite variation in M&M practice, the same (unmet) expectations existed at both hospitals, indicating that certain challenges may be more universal. M&M was reported to be well-focused on education, and certain aspects (e.g., active moderator and QI committee) seemed beneficial, but expectations were not met for the conference's focus and function for QI. Greater exchange of "best practices" for M&M may enhance the conference's value for improving surgical care.
Assuntos
Cirurgia Geral/educação , Pesquisas sobre Atenção à Saúde/métodos , Mortalidade/tendências , Equipe de Assistência ao Paciente/organização & administração , Procedimentos Cirúrgicos Operatórios/mortalidade , Boston , Competência Clínica , Congressos como Assunto , Feminino , Humanos , Internato e Residência/organização & administração , Masculino , Morbidade , Países Baixos , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Operatórios/métodos , Inquéritos e QuestionáriosRESUMO
OBJECTIVES: To explore barriers and facilitators to successful morbidity and mortality conferences (M&M), driving learning and improvement. DESIGN: This is a qualitative study with semistructured interviews. Inductive, thematic content analysis was used to identify barriers and facilitators, which were structured across a pre-existing framework for change in healthcare. SETTING: Dutch academic surgical department with a long tradition of M&M. PARTICIPANTS: An interview sample of surgeons, residents and physician assistants (n=12). RESULTS: A total of 57 barriers and facilitators to successful M&M, covering 18 themes, varying from 'case type' to 'leadership', were perceived by surgical staff. While some factors related to M&M organisation, others concerned individual or social aspects. Eight factors, of which four were at the social level, had simultaneous positive and negative effects (eg, 'hierarchy' and 'team spirit'). Mediating pathways for M&M success were found to relate to available information, staff motivation and realisation processes. CONCLUSIONS: This study provides leads for improvement of M&M practice, as well as for further research on key elements of successful M&M. Various factors were perceived to affect M&M success, of which many were individual and social rather than organisational factors, affecting information and realisation processes but also staff motivation. Based on these findings, practical recommendations were formulated to guide efforts towards best practices for M&M.
Assuntos
Atitude do Pessoal de Saúde , Cirurgia Geral/educação , Aprendizagem , Motivação , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Mortalidade Hospitalar , Humanos , Entrevistas como Assunto , Morbidade , Mortalidade , Países Baixos , Pesquisa QualitativaRESUMO
OBJECTIVE: Despite patent vein bypass grafts, some patients with critical limb ischemia (CLI) receive major amputations. We analyzed the predictive factors leading to major amputation in the presence of patent lower extremity bypass (LEB) grafts. METHODS: Data from the Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III), a large prospective randomized trial of 1404 patients who underwent LEB with vein graft for CLI, were queried for outcomes. The primary outcome was major amputation with patent (PMA) LEB compared with patients with patent LEB who achieved limb salvage (PLS). The population excluded those who received amputation for occluded grafts. A Cox proportional hazard model identified independent predictors. RESULTS: Of 1404 LEB patients, 162 (11.5%) had major amputation: 89 (6.3%) with patent and 73 (5.2%) with occluded LEB. For PMA, 21 of 89 (23.6%) developed critical stenosis and 11 of 21 (52.4%) were revised. For PLS, 460 of 1242 (37.0%) developed critical stenosis and 351 of 460 (76.3%) were revised. Predictive patient factors included having preoperative gangrene (vs rest pain; hazard ratio [HR], 3.504; 95% confidence interval [CI], 1.533-8.007; P = .0029), diabetes (HR, 1.800; 95% CI, 1.006-3.219; P = .0477), black (vs white) race (HR, 1.779; 95% CI, 1.051-3.011; P = .0321), baseline creatinine clearance <25 mL/min (vs >65 mL/min; HR, 1.759; 95% CI, 1.016-3.048; P = .0439), prior history of coronary artery bypass grafting (HR, 1.702; 95% CI, 1.080-2.683; P = .0221), and lower baseline activity quality of life score (HR, 1.401; 95% CI, 1.105-1.778; P = .0054). Postoperative wound factors included gangrenous changes (HR, 5.830; 95% CI, 1.647-20.635; P = .0063), surgical wound necrosis (HR, 5.319; 95% CI, 1.478-19.146; P = .0105), deep (vs superficial) wound infection (HR, 3.815; 95% CI, 1.220-11.927; P = .0213), and wound healing abnormally (HR, 3.754; 95% CI, 1.061-13.278; P = .0402). Associated postoperative consequences leading to PMA included having recurrent CLI symptoms (HR, 2.915; 95% CI, 1.816-4.681; P < .0001), a severe (vs mild) adverse event (HR, 2.751; 95% CI, 1.391-5.443; P = .0036), fewer percutaneous revisions (HR, 2.425; 95% CI, 1.573-3.740; P < .0001), discharge on low-molecular-weight heparin (HR, 2.087; 95% CI, 1.309-3.326; P = .0020), and decreasing days to critical stenosis/occlusion/revision/amputation (HR, 1.010; 95% CI, 1.007-1.012; P < .0001). CONCLUSIONS: Whereas a patent vein graft is important to all vascular surgeons, additional factors should be considered in trying to attain limb salvage for patients with CLI. These factors include intervening surgically before CLI has progressed to a state of gangrene or limited activity and optimizing nutrition, diabetes control, cardiac conditions, and activity level. Revision offers hope for clinical improvement but may be delayed when there is no graft lesion identified. The absence of a graft lesion to revise may also portend amputation despite a patent graft because of nongraft-related factors such as infection. Finally, the experience of a severe (vs mild) adverse event may also result in limb loss despite a patent graft. Systematic efforts to reduce severe adverse events among patients may also lead to increased limb salvage.
Assuntos
Amputação Cirúrgica , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Enxerto Vascular/métodos , Grau de Desobstrução Vascular , Veias/transplante , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Comorbidade , Estado Terminal , Progressão da Doença , Método Duplo-Cego , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estado Nutricional , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Modelos de Riscos Proporcionais , Estudos Prospectivos , Qualidade de Vida , Reoperação , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Veias/diagnóstico por imagem , Veias/fisiopatologiaRESUMO
BACKGROUND: Text pages can communicate important information but also disrupt workflow, which can affect the safety of patient care. The purpose of this study was to analyze the content, volume, and distribution of text pages received by general surgery residents and physician's assistants (PAs) using natural language processing (NLP). METHODS: We studied text pages received by residents and PAs at a tertiary care teaching hospital from March to May 2012 using NLP. The number and content of pages were stratified by recipient seniority, surgical service, patient census, and patient location. Chi-square tests, t test, and analysis of variance were used to detect statistical significance. RESULTS: We captured 48,202 pages. The average number (mean ± standard deviation) of pages per hour was 3.1 ± 2.2 for postgraduate year (PGY)-1s and 2.8 ± 1.9 for PAs (P < .0001). The greatest number of pages per day by Service was 86.1 ± 37.5 on the acute care surgery service. The most common paging topic was medications (18,444 [38.3%]) and the most common symptom was pain (6,240 pages [12.9%]). On services where patients were located near each other (regionalized), the number of pages per day per recipient per patient on census was almost half that compared with nonregionalized services (1.40 vs 2.43; P < .0001). CONCLUSION: Residents receive a high volume of pages at this tertiary care center, particularly regarding medications and pain. Services with regionalized patients exhibit less paging need per patient. Initiatives to improve pain management and regionalize patients may streamline communication, decrease the number of pages, and increase patient safety.
Assuntos
Cirurgia Geral/educação , Internato e Residência/métodos , Melhoria de Qualidade , Envio de Mensagens de Texto/estatística & dados numéricos , Adulto , Análise de Variância , Atenção , Comunicação , Estudos Transversais , Eficiência , Feminino , Humanos , Incidência , Masculino , Segurança do Paciente , Assistentes Médicos , Centros de Atenção Terciária , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: Surgical treatment of acute axillosubclavian vein thrombosis from venous thoracic outlet syndrome (VTOS) traditionally involves first rib resection and scalenectomy (FRRS) followed by interval venography and balloon angioplasty. This approach can lead to an extended need for anticoagulation and a separate anesthesia session. We present outcomes for FRRS with concurrent venography. METHODS: Retrospective chart review was performed for consecutive patients undergoing FRRS with concurrent venography for VTOS from February 2007 to April 2014. Venography was performed immediately after FRRS with the arm in neutral and provocative positions. The primary outcomes of this study were primary and primary-assisted patency. Secondary outcomes included whether concurrent venography resulted in modification of the procedure, postoperative anticoagulation use, and postoperative complications. RESULTS: Thirty patients underwent first rib resection with venography with a mean follow-up time of 24.4 months. The mean age was 29.5 years (range, 17-52 years), and 17 (56.7%) were female. All were maintained on anticoagulation before the procedure. Concurrent venography resulted in modification of the procedure in 28 patients (93.3%). Of these, 27 patients (96.4%) underwent balloon angioplasty and two patients (7.1%) underwent further rib resection. Twenty patients (66.7%) were discharged after the procedure with no anticoagulation. For those receiving postoperative anticoagulation for persistent minor thrombus, median time for anticoagulation duration was 5.0 months (range, 0.8 and 16.7 months). Two patients (6.7%) had postoperative bleeding requiring thoracentesis or video-assisted thoracoscopic evacuation of hemothorax. One patient (3.3%) suffered rethrombosis and was successfully lysed open, resulting in a 2-year subclavian vein (SCV) primary patency of 96.7% and primary-assisted patency of 100%. No patients required reoperation for VTOS, and all reported improvements in symptoms. Three patients (10.0%) later underwent prophylactic first rib resection on the contralateral side for symptoms and SCV stenosis. CONCLUSIONS: FRRS with concurrent venography is a safe procedure for VTOS that allows effective intraoperative modification of the surgical plan, resulting in excellent patency of the SCV, early cessation of anticoagulation, and durable relief of symptoms.
Assuntos
Flebografia , Costelas/cirurgia , Síndrome do Desfiladeiro Torácico/cirurgia , Adolescente , Adulto , Angioplastia com Balão , Descompressão Cirúrgica , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Veia Subclávia/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Duplex ultrasonography (DUS) can be used for treatment planning for lower extremity peripheral arterial disease (PAD), but has not replaced contrast-enhanced imaging such as computed tomography angiography (CTA). We assessed DUS-based treatment planning for consistency, confidence, and the value of additional CTA among multinational surgeons. METHODS: Data from 12 patients with PAD were reviewed by 2 American vascular surgeons individually and 1 Dutch vascular department by consensus. Reviewers selected treatment based on DUS first and based on added CTA second. Agreement and consistency of treatment plans was assessed using kappa statistics (κ). Imaging quality and therapeutic confidence were scored (1-5) and assessed with t-tests. RESULTS: Of the 36 treatment plans formulated, additional CTA confirmed 27 (75%), changed 6 (17%), and supplemented 3 (8%) plans. The approach never changed when open revascularization was selected based on DUS (14 plans; 39%). Agreement between DUS- and CTA-based treatment planning was substantial, with a mean kappa (µκ) of 0.68, but agreement between reviewers was fair (µκ DUS, 0.24; µκ CTA, 0.23). CTA received greater average scores than DUS for quality (4.36 vs 3.29; P < .0001) and confidence (4.36 vs 3.26; P < .0001). Reviewers often expressed the need for additional imaging after DUS (mean, 63%). CONCLUSION: PAD treatment planning based on CTA was mostly consistent with DUS-based treatment plans, although CTA was still felt to be needed to increase confidence. This observation suggests that to promote greater use of less invasive DUS imaging, not only improvement of DUS quality but also improvement of clinician confidence is required.
Assuntos
Doença Arterial Periférica/diagnóstico por imagem , Adulto , Idoso , Angiografia , Estudos de Coortes , Extremidades/irrigação sanguínea , Feminino , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/terapia , Isquemia/diagnóstico por imagem , Isquemia/terapia , Masculino , Pessoa de Meia-Idade , Países Baixos , Planejamento de Assistência ao Paciente/estatística & dados numéricos , Doença Arterial Periférica/terapia , Projetos Piloto , Tomografia Computadorizada por Raios X , Ultrassonografia Doppler Dupla , Estados UnidosRESUMO
OBJECTIVE: Although mortality after elective abdominal aortic aneurysm (AAA) repair has steadily declined, operative mortality for a ruptured AAA (rAAA) remains high. Repair of rAAA at hospitals with a higher elective aneurysm workload has been associated with lower mortality rates irrespective of the mode of treatment. This study sought to determine the association between surgeon specialization and outcomes after rAAA repair. METHODS: The American College of Surgeons National Surgical Quality Improvement Project database from 2005 to 2010 was used to examine the 30-day mortality and morbidity outcomes of patients undergoing rAAA repair by vascular and general surgeons. Multivariable logistic regression analysis was performed for each death and morbidity, adjusting for all independently predictive preoperative risk factors. Survival curves were compared using the log-rank test. RESULTS: We identified 1893 repairs of rAAAs, of which 1767 (96.1%) were performed by vascular surgeons and 72 (3.9%) were performed by general surgeons. There were no significant differences between patients operated on by general vs vascular surgeons in preoperative risk factors or method of repair. Overall 30-day mortality was 34.3% (649 of 1893). After risk adjustment, mortality was significantly lower in the vascular surgery group compared with the general surgery group (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.30-0.86; P = .011). The risk of returning to the operating room (OR, 0.58; 95% CI, 0.35-0.97; P = .038), renal failure (OR, 0.54; 95% CI, 0.31-0.95; P = .034), and a cardiac complication (OR, 0.53; 95% CI, 0.28-0.99; P = .047) were all significantly less in the vascular surgery group. CONCLUSIONS: Despite similar preoperative risk factors profiles, patients who were operated on by vascular surgeons had lower mortality, less frequent returns to the operating room, and decreased incidences of postoperative renal failure and cardiac events. These data add weight to the case for further centralization of vascular services.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Cirurgia Geral , Avaliação de Processos e Resultados em Cuidados de Saúde , Especialização , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico , Ruptura Aórtica/mortalidade , Feminino , Cardiopatias/etiologia , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Modelos de Riscos Proporcionais , Insuficiência Renal/etiologia , Reoperação , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidadeRESUMO
OBJECTIVE: The value and cost-effectiveness of less invasive alternative imaging (AI) modalities (duplex ultrasound scanning, computed tomography angiography, and magnetic resonance angiography) in the care of peripheral arterial disease (PAD) has been reported; however, there is no consensus on their role. We hypothesized that AI utilization is low compared with angiography in the United States and that patient and hospital characteristics are both associated with AI utilization. METHODS: The Nationwide Inpatient Sample (2007-2010) was used to identify patients with an International Classification of Diseases-Ninth Edition diagnosis of claudication or critical limb ischemia (CLI) as well as PAD treatment (surgical, endovascular, or amputation). Patients with AI and those with angiography or expected angiography (endovascular procedures without imaging codes) were selected and compared. Multivariable logistic regression was performed for receiving AI stratified by claudication and CLI and adjusting for patient and hospital factors. RESULTS: We identified 290,184 PAD patients, of whom 5702 (2.0%) received AI. Patients with AI were more likely to have diagnosis of CLI (78.8% vs 48.6%; P < .0001) and receive open revascularizations (30.4% vs 18.8%; P < .0001). Van Walraven comorbidity scores (mean [standard error] 5.85 ± 0.22 vs 4.10 ± 0.05; P < .0001) reflected a higher comorbidity burden in AI patients. In multivariable analysis for claudicant patients, AI was associated with large bed size (odds ratio [OR], 3.26, 95% confidence interval [CI], 1.16-9.18; P = .025), teaching hospitals (OR, 1.97; 95% CI, 1.10-3.52; P = .023), and renal failure (OR, 1.52; 95% CI, 1.13-2.05; P = .006). For CLI patients, AI was associated with black race (OR, 1.53; 95% CI, 1.13-2.08; P = .006) and chronic heart failure (OR, 1.29; 95% CI, 1.04-1.60; P = .021) and was negatively associated with renal failure (OR, 0.80; 95% CI, 0.67-0.95; P = .012). The Northeast and West regions were associated with higher odds of AI in claudicant patients (OR, 2.41; 95% CI, 1.23-4.75; P = .011; and OR, 2.59; 95% CI, 1.34-5.02; P = .005, respectively) and CLI patients (OR, 4.31; 95% CI, 2.20-8.36; P < .0001; and OR, 2.18; 95% CI, 1.12-4.22; P = .021, respectively). Rates of AI utilization across states were not evenly distributed but showed great variability, with ranges from 0.31% to 9.81%. CONCLUSIONS: National utilization of AI for PAD is low and shows great variation among institutions in the United States. Patient and hospital factors are both associated with receiving AI in PAD care, and AI utilization is subject to significant regional variation. These findings suggest differences in systems of care or practice patterns and call for a clearer understanding and a more unified approach to imaging strategies in PAD care.