Does training paradigm matter? A comparison of outcomes of frail patients treated by integrated vascular surgery residency and vascular surgery fellowship-trained surgeons.

BACKGROUND: It is unclear whether shortened training of integrated vascular surgery residencies (IVSR) has detrimental effects on graduates' performance. We sought to investigate whether there is a difference in frail patient outcomes based on the training paradigm completed by their surgeon. METHODS: IVSR and vascular surgery fellowship (VSF)-trained surgeons were identified in the American Board of Surgery database and linked to the Vascular Quality Initiative registry (2013-2019) to evaluate provider-specific patient outcomes for frail patients following vascular procedures using mixed-effects logistic regression. RESULTS: 105 IVSR graduates (31%) and 233 VSF graduates (69%) were included. Composite 1-year outcomes of frail patients were comparable between IVSR and VSF-trained surgeons following carotid endarterectomy (16%-IVSR vs 25%-VSF; p = 0.76), lower extremity revascularization (37%-IVSR vs 36%-VSF; p = 0.83), and aortic aneurysm repair (25%-IVSR vs 23%-VSF; p = 0.89). CONCLUSIONS: The type of training paradigm completed by vascular surgeons was not associated with differences in their post-operative outcomes in frail patients.

Index atherectomy peripheral vascular interventions performed for claudication are associated with more reinterventions than nonatherectomy interventions.

OBJECTIVE: Despite limited evidence supporting atherectomy alone over stenting/angioplasty as the index peripheral vascular intervention (PVI), the use of atherectomy has rapidly increased in recent years. We previously identified a wide distribution of atherectomy practice patterns among US physicians. The aim of this study was to investigate the association of index atherectomy with reintervention. METHODS: We used 100% Medicare fee-for-service claims to identify all beneficiaries who underwent elective first-time femoropopliteal PVI for claudication between January 1, 2019, and December 31, 2019. Subsequent PVI reinterventions were examined through June 30, 2021. Kaplan-Meier curves were used to compare rates of PVI reinterventions for patients who received index atherectomy versus nonatherectomy procedures. Reintervention rates were also described for physicians by their overall atherectomy use (by quartile). A hierarchical Cox proportional hazard model was used to evaluate patient and physician-level characteristics associated with reinterventions. RESULTS: A total of 15,246 patients underwent an index PVI for claudication in 2019, of which 59.7% were atherectomy. After a median of 603 days (interquartile range, 77-784 days) of follow-up, 41.2% of patients underwent a PVI reintervention, including 48.9% of patients who underwent index atherectomy versus 29.8% of patients who underwent index nonatherectomy (P < .001). Patients treated by high physician users of atherectomy (quartile 4) received more reinterventions than patients treated by standard physician users (quartiles 1-3) (56.8% vs 39.6%; P < .001). After adjustment, patient factors association with PVI reintervention included receipt of index atherectomy (adjusted hazard ratio [aHR], 1.33; 95% confidence interval [CI], 1.21-1.46), Black race (vs White; aHR; 1.18; 95% CI, 1.03-1.34), diabetes (aHR, 1.13; 95% CI, 1.07-1.21), and urban residence (aHR, 1.11; 95% CI, 1.01-1.22). Physician factors associated with reintervention included male sex (aHR, 1.52; 95% CI, 1.12-2.04), high-volume PVI practices (aHR, 1.23; 95% CI, 1.10-1.37), and physicians with a high use of index atherectomy (aHR, 1.49; 95% CI, 1.27-1.74). Vascular surgeons had a lower risk of PVI reintervention than cardiologists (vs vascular; aHR, 1.22; 95% CI, 1.09-1.38), radiologists (aHR, 1.55; 95% CI, 1.31-1.83), and other specialties (aHR, 1.59; 95% CI, 1.20-2.11). The location of services delivered was not associated with reintervention (P > .05). CONCLUSIONS: The use of atherectomy as an index PVI for claudication is associated with higher PVI reintervention rates compared with nonatherectomy procedures. Similarly, high physician users of atherectomy perform more PVI reinterventions than their peers. The appropriateness of using atherectomy for initial treatment of claudication needs critical reevaluation.

Comparison of Patient Outcomes Among Integrated Residency Versus Fellowship-trained Vascular Surgeons.

OBJECTIVE: This study aims to evaluate whether graduates of integrated vascular surgery residency (IVSR) programs achieve similar surgical outcomes in clinical practice as compared to graduates of vascular surgery fellowships (VSF). SUMMARY OF BACKGROUND DATA: Early sub-specialization through IVSR programs decreases the total years of surgical training. However, it is unclear whether IVSR graduates achieve comparable outcomes to fellowship-trained surgeons once in clinical practice. METHODS: We identified all vascular surgeons who finished IVSR and VSF programs between 2013-2017 using American Board of Surgery data, which was linked to the Vascular Quality Initiative registry (2013-2019) to evaluate provider-specific clinical outcomes following carotid, lower extremity, and aortic aneurysm repair procedures. The association between training models and the composite outcome of 1-year mortality, major adverse cardiac events and/or other major complications were analyzed using mixed-effects logistic regression models. RESULTS: A total of 338 surgeons (31% IVSR, 69% VSF) submitted cases into the Vascular Quality Initiative registry, including 8155 carotid, 21,428 lower extremity, and 5800 aortic aneurysm repair procedures. Composite 1-year outcome rates were comparable between IVSR and VSF-trained surgeons following carotid endarterectomy (8%-IVSR vs 7%-VSF), lower extremity revascularization (19%-IVSR vs 16%-VSF), and aortic aneurysm repair (13%-IVSR vs 13%-VSF) procedures. These findings among IVSR-trained surgeons persisted following risk adjustment for severity of patient disease and indications for undertaking carotid [aOR: 1.04 (0.84-1.28)], lower extremity [aOR: 1.03 (0.84-1.26)], and aortic [aOR: 0.96 (0.76-1.21)] procedures when compared to VSF-trained surgeons. CONCLUSIONS: Despite fewer total years of training, graduates of IVSR programs achieve equivalent surgical outcomes as fellowship-trained vascular surgeons once in practice. These results suggest that concerns about differential competence among integrated residency graduates are not warranted.

Race and socioeconomic differences associated with endovascular peripheral vascular interventions for newly diagnosed claudication.

BACKGROUND: Despite guidelines cautioning against the use of endovascular peripheral vascular interventions (PVI) for claudication, more than 1.3 million PVI procedures are performed annually in the United States. We aimed to describe national rates of PVI for claudication, and identify patient and county-level risk factors associated with a high rate of PVI. METHODS: We used the Medicare claims database to identify all Medicare beneficiaries with a new diagnosis of claudication between January 2015 and June 2017. A hierarchical logistic regression model accounting for patient age, sex, comorbidities; county region and setting; and a patient race-county median income interaction was used to assess the associations of race and income with a high PVI rate. RESULTS: We identified 1,201,234 patients with a new diagnosis of claudication for analysis. Of these, 15,227 (1.27%) underwent a PVI. Based on hierarchical logistic regression accounting for patient and county-level factors, black patients residing in low-income counties had a significantly higher odds of undergoing PVI than their white counterparts (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.20-1.40), whereas the odds of PVI for black versus white patients was similar in high-income counties (OR, 1.06; 95% CI, 0.99-1.14). PVI rates were higher for low versus high-income counties in both the black (OR, 1.46; 95% CI, 1.31-1.64) and white (OR, 1.19; 95% CI, 1.12-1.27) groups. There were no significant associations of Hispanic, Asian, North American native, or other races with PVI in either low- or high-income counties after risk adjustment (all P ≥ .09). CONCLUSIONS: In the Medicare population, the mean rate of PVI of 12.7 per 1000 claudication patients varies significantly based on race and income. Our data suggest there are racial and socioeconomic differences in the treatment of claudication across the United States.

Mortality variability after endovascular versus open abdominal aortic aneurysm repair in a large tertiary vascular center using a Medicare-derived risk prediction model.

OBJECTIVE: Previous reports have documented better outcomes after open abdominal aortic aneurysm (AAA) repair in tertiary centers compared with lower-volume hospitals, but outcome variability for endovascular AAA repair (EVAR) vs open AAA repairs in a large tertiary center using a Medicare-derived mortality risk prediction model has not been previously reported. In the current study, we compared the observed vs predicted mortality after EVAR and open AAA repair in a single large tertiary vascular center. METHODS: We retrospectively analyzed all patients who underwent repair of a nonruptured infrarenal AAA in our center from 2003 to 2012. Univariable and multivariable logistic regression were used to evaluate 30-day mortality. Patients were stratified into low-risk, medium-risk, and high-risk groups, and mortality was predicted for each patient based on demographics and comorbidities according to the Medicare risk prediction model. RESULTS: We analyzed 297 patients (EVAR, 72%; open AAA repair, 28%; symptomatic, 25%). Most of our patients were of high and moderate risk (48% and 28%, respectively). The observed 30-day mortality was 1.9% after EVAR vs 2.4% after open repair (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.14-4.29; P = .67). There was no difference in mortality with EVAR vs open repair after adjusting for predefined patient characteristics (OR, 0.92; 95% CI, 0.16-7.43; P = .93); only preoperative renal disease was predictive of 30-day mortality after AAA repair in our cohort (OR, 8.39; 95% CI, 1.41-67.0). The observed mortality within our study was significantly lower than the Medicare-derived expected mortality for each treatment group within patients stratified as high risk or medium risk (P ≤ .0002 for all). CONCLUSIONS: Despite treating patients with high preoperative risk status, we report a 10-fold decrease in operative mortality for EVAR and open AAA repair in a tertiary vascular center compared with national Medicare-derived predictions. High-risk patients should be considered for aneurysm management in dedicated aortic centers, regardless of approach.

Trends and determinants of costs associated with the inpatient care of diabetic foot ulcers.

OBJECTIVE: The cost of care for diabetic foot ulcers is estimated to be more than $1.5 billion annually. The aim of this study was to analyze inpatient diabetic foot ulcer cost changes over time and to identify factors associated with these costs. METHODS: The Nationwide Inpatient Sample (2005-2010) was queried using the International Classification of Diseases, Ninth Revision codes for a primary diagnosis of foot ulceration. The primary outcomes were changes in adjusted total hospital charges and costs over time. Multivariable analysis was performed to assess relative increases (RIs) in hospital charges per patient in 2005 vs 2010 adjusting for demographic characteristics, income, comorbidities (Charlson Comorbidity Index ≥3), insurance type, hospital characteristics, diagnostic imaging, revascularization, amputation, and length of stay. RESULTS: Overall, 336,641 patients were admitted with a primary diagnosis of diabetic foot ulceration (mean age, 62.9 ± 0.1 years, 59% male, 61% white race). The annual cumulative cost for inpatient treatment of diabetic foot ulcers increased significantly from 2005 to 2010 ($578,364,261 vs $790,017,704; P < .001). More patients were hospitalized (128.6 vs 152.8 per 100,000 hospitalizations; P < .001), and the mean adjusted cost per patient hospitalization increased significantly over time ($11,483 vs $13,258; P < .001). The proportion of nonelective admissions remained stable (25% vs 23%; P = .32) and there were no differences in mean hospital length of stay (7.0 ± 0.1 days vs 6.8 ± 0.1 days; P = .22). Minor (17.9% vs 20.6%; P < .001), but not major amputations (3.9% vs 4.2%; P = .27) increased over time. Based on multivariable analysis, the main factors contributing to the escalating cost per patient hospitalization included increased patient comorbidities (unadjusted mean difference 2005 vs 2010 $3303 [RI, 1.08] vs adjusted $15,220 [RI, 1.35]), open revascularization (unadjusted $15,145 [RI, 1.25] vs adjusted $30,759 [RI, 1.37]), endovascular revascularization (unadjusted $17,662 [RI, 1.29] vs adjusted $28.937 [RI, 1.38]), and minor amputations (unadjusted $9918 [RI, 1.24] vs adjusted $18,084 [RI, 1.33]) (P < .001, all). CONCLUSIONS: Hospital charges and costs related to diabetic foot ulcers have increased significantly over time despite stable hospital length of stay and proportion of emergency admissions. Risk-adjusted analyses suggest that this change might be reflective of increasing charges associated with a progressively sicker patient population and attempts at limb salvage. Despite this, the overall incidence of major amputations remained stable.

Racial and ethnic disparities in the treatment of unruptured thoracoabdominal aortic aneurysms in the United States.

PURPOSE: Previous studies have found increased mortality in minority patients undergoing abdominal aortic aneurysm repair. The goal of this study was to identify racial and ethnic disparities in patients undergoing thoracoabdominal aortic aneurysm repair. MATERIALS AND METHODS: We queried the Nationwide Inpatient Sample (2005-2009) using International Classification of Diseases, Ninth Revision, Clinical Modification codes for repair of unruptured thoracoabdominal aneurysms. The primary outcome was death. Secondary outcomes included postoperative complications. We performed multivariate analysis adjusting for age, gender, race, comorbidities (Charlson index), insurance type, and surgeon and hospital operative volumes and characteristics. RESULTS: Overall, 1541 white, 207 black, and 117 Hispanic patients underwent thoracoabdominal aortic aneurysm repair. White patients tended to be older (P = 0.003), whereas black patients had a higher incidence of diabetes mellitus (P = 0.04). Black and Hispanic patients were less likely to have an elective admission (P < 0.001) and more likely to have repair performed at a hospital with a lower average annual surgical volume (P = 0.04). Postoperative complications were similar among the groups (P = 0.31). On multivariate analysis, increased mortality was independently associated with Hispanic ethnicity (relative ratio [RR], 2.57; 95% confidence interval [CI], 1.25-5.25; P = 0.01), cerebrovascular disease (RR, 1.88; 95% CI, 1.10-3.23; P = 0.02), and age (RR, 1.04; 95% CI, 1.01-1.07; P = 0.004). CONCLUSIONS: Hispanic ethnicity is independently associated with increased mortality after repair of unruptured thoracoabdominal aneurysms. This finding was independent of preoperative comorbidities, postoperative complications, and surgeon and hospital operative volumes. Further studies are necessary to determine whether this mortality difference persists after the index hospitalization.

Disparities in outcomes for Hispanic patients undergoing endovascular and open abdominal aortic aneurysm repair.

BACKGROUND: Previous studies have demonstrated racial and ethnic disparities associated with the outcomes of abdominal aortic aneurysm (AAA) repair, although little is known about the influence of race and ethnicity on the costs associated with these disparities. The current study was undertaken to examine the influence of race and ethnicity on the outcomes of endovascular (EVAR) and open repair (open AAA) of unruptured AAA and its effect on costs in contemporary practice. METHODS: The Nationwide Inpatient Sample (2005 to 2008) was queried using ICD-9-CM codes for unruptured AAA (441.4). The primary outcomes were mortality and total hospital charges. Multivariate analyses were performed adjusting for age, gender, race, comorbidities (Charlson index), year, insurance type, and hospital characteristics. RESULTS: A total of 62,728 patients underwent EVAR and 24,253 patients underwent open AAA. White patients (72%) were more likely to undergo EVAR than Hispanic (69%) or black patients (69%; P = 0.02). On univariate analysis, in-hospital mortality after EVAR was increased in Hispanic patients compared with white patients (1% vs 2%; P = 0.02). There were no differences in mortality after EVAR between white and black patients, and there were no racial or ethnic differences in mortality after open AAA. Hispanic ethnicity remained an independent risk factor for increased mortality after AAA repair on multivariate analysis (RR 1.64; 95% CI [1.05 to 2.57]; P = 0.03). Hispanic ethnicity was associated with increased hospital charges compared with white ethnicity after both EVAR ($108,886 vs $77,748; P < 0.001) and open AAA ($134,356 vs $85,536; P < 0.001) and for black patients after open AAA ($101,168 vs $85,536; P = 0.04). CONCLUSIONS: Hispanic ethnicity is an independent risk factor for mortality after AAA repair independent of insurance type or hospital characteristics. There were dramatic disparities in hospital costs for Hispanic patients undergoing either EVAR or open AAA and for black patients after open AAA compared with white patients. This observation seems unrelated to length of stay, postoperative complications, and admission status. Further studies are needed to determine whether these disparities extend beyond the primary hospitalization.

Cost of inpatient care and its association with hospital competition.

BACKGROUND: Conventional economic principles suggest that increases in competition are associated with price decreases. The purpose of this study is to determine whether this association holds true between objective measures of hospital competition and gross charges, by analyzing standardized operations where variations in costs should be minimal. STUDY DESIGN: Hospital Market Structure file (from Agency for Healthcare Research and Quality, available for years 2000 and 2003) was linked to Nationwide Inpatient Sample database. Appendectomy, carotid endarterectomy, bariatric surgery, radical prostatectomy, and pyloromyotomy were analyzed, after excluding patients with possible complications. Primary outcomes included total hospital charges. Primary independent variable was Herfindahl-Hirschman Index (HHI) calculated by the Agency for Healthcare Research and Quality for each hospital based on its patient-flow market. Higher HHI represents the presence of more dominant hospitals in the market or lower competition. RESULTS: A total of 162,823 patients from 1,492 hospitals (85,791 appendectomies, 38,619 carotid endarterectomies, 18,383 bariatric operations, 16,784 radical prostatectomies, 3,246 pyloromyotomies) were analyzed. Single linear regression analyses demonstrated higher HHI was significantly associated with lower hospital gross charges in all cases. On multivariate analysis, a 1 percentage-point increase on HHI was associated with -$114 for appendectomy, -$163 for carotid endarterectomy, and -$193 for radical prostatectomy (all p ≤ 0.001), and were independent of hospital urbanicity, teaching status, and payer mix. In contrast, no association was found between competition and hospital costs. CONCLUSIONS: Higher level of hospital competition is associated with higher hospital gross charges, although competition intensity is not associated with hospital costs. These data are important as health policy makers consider possible cost-control measures.

Statistical modeling of the volume-outcome effect for carotid endarterectomy for 10 years of a statewide database.

OBJECTIVE: We aimed to achieve accurate statistical modeling of a putative relationship between carotid endarterectomy (CEA) annual surgeon and hospital volume and in-hospital mortality. DESIGN OF STUDY: We performed a secondary data analysis of 10 years (1994-2003) of the Maryland hospital discharge database. Annual volume was defined as the total number of procedures performed for the time in the dataset divided by the total years in the dataset. Non-linear relationships between death and average volumes were explored with logit-transformed lowess smoothing functions, followed by random effect models and inspection of data likelihood under each combination of spline knots. A marginal model with generalized estimating equations was used to represent population-average response as a function of covariates and to account for clustering in the data. Patient comorbidity was assessed using the Deyo modification of the Charlson Index. SETTING: The Maryland hospital discharge database is a 100% sample of all hospitals in the state. SUBJECTS: CEA was identified through ICD-9 and diagnosis codes, using a previously reported algorithm. MAIN OUTCOME MEASURE: Estimated odds ratios predicting in-hospital death, alpha set at 0.05. RESULTS: During the study period, 22,772 patients with surgeon identifiers underwent CEA in Maryland, resulting in 123 in-hospital deaths (0.54%). The crude odds ratio of death for the entire surgeon dataset was 0.9838, meaning that the odds of death decreased by an average of 0.0162 for each additional annual procedure. Surgeon volume of four to 15 CEAs per year was highly significant: for an increase in annual surgeon volume by one procedure per year, the estimated odds of death decreased by 0.065 when controlling for hospital volume, age, and comorbidity (P = .351). Surgeons in other volume categories also demonstrated lower odds of death with increased annual volume, but these odds ratios did not attain statistical significance. Surgeons performing 15 CEAs per year had an odds ratio of 0.997 (P = .485). Hospitals that saw >130 CEAs per year had an odds ratio of death of 0.945 per additional procedure, or 0.055 decrease in the odds of death (P = 0.013), whereas hospitals performing /=130 CEAs per year) showing a statistically significant decrease in the odds ratio of death. As studies on volume-outcome relationships can have important implications for health policy and surgical training, such studies should consider non-linear effects in their modeling of procedural volume.

Branding of vascular surgery.

The Society for Vascular Surgery surveyed primary care physicians (PCPs) to understand how PCPs make referral decisions for their patients with peripheral vascular disease. Responses were received from 250 PCPs in 44 states. More than 80% of the respondents characterized their experiences with vascular surgeons as positive or very positive. PCPs perceive that vascular surgeons perform "invasive" procedures and refer patients with the most severe vascular disease to vascular surgeons but were more than twice as likely to refer patients to cardiologists, believing they are better able to perform minimally invasive procedures. Nevertheless, PCPs are receptive to the notion of increasing referrals to vascular surgeons. A successful branding campaign will require considerable education of referring physicians about the totality of traditional vascular and endovascular care increasingly provided by the contemporary vascular surgical practice and will be most effective at the local grassroots level.

Cardiac troponin I predicts short-term mortality in vascular surgery patients.

BACKGROUND: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for myocardial injury that predicts outcomes in patients with acute coronary syndromes. Cardiovascular complications are the leading cause of morbidity and mortality in patients who have undergone vascular surgery. However, postoperative surveillance with cardiac enzymes is not routinely performed in these patients. We evaluated the association between postoperative cTnI levels and 6-month mortality and perioperative myocardial infarction (MI) after vascular surgery. METHODS AND RESULTS: Two hundred twenty-nine patients having aortic or infrainguinal vascular surgery or lower extremity amputation were included in this study. Blood samples were analyzed for cTnI immediately after surgery and the mornings of postoperative days 1, 2, and 3. An elevated cTnI was defined as serum concentrations >1.5 ng/mL in any of the 4 samples. Twenty-eight patients (12%) had postoperative cTnI >1.5 ng/mL, which was associated with a 6-fold increased risk of 6-month mortality (adjusted OR, 5.9; 95% CI, 1.6 to 22.4) and a 27-fold increased risk of MI (OR, 27.1; 95% CI, 5.2 to 142.7). Furthermore, we observed a dose-response relation between cTnI concentration and mortality. Patients with cTnI >3.0 ng/mL had a significantly greater risk of death compared with patients with levels < or =0.35 ng/mL (OR, 4.9; 95% CI, 1.3 to 19.0). CONCLUSIONS: Routine postoperative surveillance for cTnI is useful for identifying patients who have undergone vascular surgery who have an increased risk for short-term mortality and perioperative MI. Further research is needed to determine whether intervention in these patients can improve outcome.

A contemporary assessment of carotid body tumor surgery.

Carotid body tumor resection remains a surgical challenge traditionally associated with a 15-30% incidence of cranial nerve injury. The authors reviewed their experience with carotid body tumor surgery to determine whether contemporary awareness of carotid body tumors is leading to earlier detection and operation, resulting in a lower incidence of postoperative cranial nerve injury. Twenty-seven carotid body tumors were resected in 25 patients between 1990 and 2000. No patient died and no patient had postoperative baroreflex failure syndrome. There was 1 stroke (4%) in a patient who required ligation of the internal carotid artery. There were 9 cranial nerve injuries (33%), most commonly to the vagus or hypoglossal nerves, which was not significantly different from the rate of cranial nerve injury (44%) in the 9 patients operated upon between 1984 and 1989 (p=0.37, Fisher's exact test). Multivariate analysis demonstrated that tumor size was the only significant factor predicting cranial nerve injury (p=0.045, logistic regression). Since carotid body tumors with large size or higher Shamblin grades had predictably high operative blood loss and rates of postoperative cranial nerve injury, a high index of suspicion and aggressive surgical management may lead to earlier detection and operation on smaller tumors, ultimately reducing the risk of nerve injury. Nevertheless, carotid body tumor surgery appears to be relatively free of mortality and major morbidity in contemporary practice.