Vascular Surgery In-Training Examination performance following implementation of the Vascular Surgical Council on Resident Education curriculum.

OBJECTIVE: The Vascular Surgery Surgical Council on Resident Education (VSCORE) program is a standardized curriculum intended to prepare Vascular Surgery trainees for the annual Vascular Surgery In-Training Examination (VSITE). This study evaluated the performance of 0+5 and 5+2 Vascular Surgery trainees on the VSITE prior to and following implementation of the VSCORE curriculum. METHODS: VSITE scores, measured as percentage of questions correct, were collected for Vascular Surgery trainees at a United States academic medical center between 2015 and 2022. The VSITE scores were compared for the periods prior to (2015-2021) and following (2022) implementation of the VSCORE curriculum. RESULTS: Fifty-seven VSITE scores were evaluated, including 46 examinations completed prior to and 11 after the implementation of the VSCORE curriculum. The mean VSITE score across all training levels (post-graduate year [PGY] 1-7) increased significantly from 68.4% ± 1.5% prior to implementation of VSCORE curriculum to 76.5% ± 3.1% following implementation (P = .03). Two-way analysis of variance identified pre- and post-VSCORE implementation as a statistically significant categorical variable when residents were stratified into junior (PGY 1-2), senior (PGY 3-5), and fellow (PGY 6-7) training levels (P < .001). The mean change in score between consecutive years also increased following VSCORE implementation (14.1% ± 2.3%) compared with the pre-VSCORE era (5.7% ± 1.7%; P = .002) CONCLUSIONS: The implementation of the VSCORE curriculum at an academic medical center improved VSITE scores across vascular surgery trainees at all levels.

Cause-specific mortality of type B aortic dissection and assessment of competing risks of mortality.

OBJECTIVE: Natural history studies of type B aortic dissection (TBAD) commonly report all-cause mortality. Our aim was to determine cause-specific mortality in TBAD and to evaluate the clinical characteristics associated with aorta-related and nonaorta-related mortality. METHODS: Clinical and administrative records were reviewed for patients with acute TBAD between 1995 and 2017. Demographics, comorbidities, presentation, and initial imaging findings were abstracted. Cause of death was ascertained through a multimodality approach using electronic health records, obituaries, social media, Social Security Death Index, and state mortality records. Causes of death were classified as aorta related, nonaorta related, or unknown. A Fine-Gray multivariate competing risk regression model for subdistribution hazard ratio was employed to analyze the association of clinical characteristics with aorta-related and nonaorta-related mortality. RESULTS: A total of 275 individuals met inclusion criteria (61.1 ± 13.7 years, 70.9% male, 68% white). Mean survival after discharge was 6.3 ± 4.7 years. Completeness of follow-up Clark C index was 0.87. All-cause mortality was 50.2% (n = 138; mean age, 70.1 ± 14.6 years) including an in-hospital mortality of 8.4%. Cause-specific mortality was aorta related, nonaorta related, and unknown in 51%, 43%, and 6%, respectively. Compared with patients with nonaorta-related mortality, patients with aorta-related mortality were younger at acute TBAD (69.5 ± 11.2 years vs 61.6 ± 15.5 years; P = .001), underwent more descending thoracic aortic repairs (19.4% vs 45.8%; P = .002), and had a shorter survival duration (5.7 ± 3.9 vs 3.4 ± 4.5 years; P = .002). There was clear variation in cause of death by each decade of life, with higher aorta-related mortality among those younger than 50 years and older than 70 years and a stepwise increase in nonaorta-related mortality with each increasing decade (P < .001). All-cause mortality at 1 year, 3 years, and 10 years was 15%, 24%, and 57%, respectively. After accounting for competing risks, the cumulative incidence of aorta-related mortality at 1 year, 3 years, and 10 years was 8.9%, 16.5%, and 27.2%, respectively, and that of nonaorta-related mortality was 2.7%, 7.2%, and 29%, respectively. A maximum descending thoracic aortic diameter >4 cm was associated with an increase in hazard of aorta-related mortality by 84% (subdistribution hazard ratio, 1.84; 95% confidence interval, 1.03-3.28) on multivariate competing risk regression analysis. CONCLUSIONS: TBAD is associated with high 10-year mortality. Those at risk for aorta-related mortality have a clinical phenotype different from that of individuals at risk for nonaorta-related mortality. This information is important for building risk prediction models that account for competing mortality risks and to direct optimal and individualized surgical and medical management of TBAD.

Meta-analysis of redo stenting versus endarterectomy for in-stent stenosis after carotid artery stenting.

OBJECTIVE: The development of in-stent restenosis (ISR) hinders the long-term patency of carotid artery stenting (CAS), yet no optimal treatment has been established. In the present study, we compared the outcomes of redo CAS (rCAS) and carotid endarterectomy (CEA) for ISR. METHODS: A systematic search using the terms "in-stent restenosis," "carotid endarterectomy," and "carotid artery stenting" was conducted in the PubMed, Embase, and Cochrane databases. Studies reporting perioperative stroke, death, and other important complications of rCAS or CEA for ISR after previous CAS with four or more patients were included. Pooled and sensitivity analyses were conducted to synthesize and compare estimates of the outcomes. RESULTS: A total of 11 studies with 1057 patients who had undergone rCAS (n = 894) or CEA (n = 163) met the inclusion criteria. The CEA group had a significantly greater proportion of symptomatic patients (rCAS vs CEA, 30.4% vs 42.1%; P < .01). The duration from primary CAS to reintervention was relatively longer in the CEA group (rCAS vs CEA, median, 8.8 months [range, 3-26 months] vs 19.9 months [range, 0-54 months]). In the rCAS group, a greater proportion of patients had hypertension, hypercholesterolemia, and coronary artery disease and had received antiplatelet therapy before reintervention. Because of insufficient data or a low incidence, the only complications feasible for further analysis were restenosis, myocardial infarction, cranial nerve injury, and neck hematoma. No significant differences were found in the primary end point of mortality/stroke event-free rate (rCAS vs CEA, 99% vs 98%; P > .05) or other secondary end points (event-free restenosis, 100% vs 100%; event-free myocardial infarction, 100% vs 98%; event-free cranial nerve injury, 100% vs 98%; event-free neck hematoma, 100% vs 100% for rCAS vs CEA; P > .05 for all). CONCLUSIONS: rCAS is commonly used to treat patients with severe and/or symptomatic ISR after primary CAS. Although the endovascular approach is less invasive, both rCAS and CEA can be performed safely with similar short- and midterm outcomes of stroke, death, and surgery-related complications.

Fenestrated endovascular aneurysm repair is financially viable at a high-volume medical center with positive hospital contribution margins and physician payment.

OBJECTIVE: To examine hospital finances and physician payment associated with fenestrated endovascular aneurysm repair (FEVAR) for complex aortic disease at a high-volume center and to compare the costs and reimbursements for FEVAR with open repair, and their trends over time. METHODS: Clinical and financial data were collected retrospectively from electronic medical and administrative records. Data for each patient included inpatient and outpatient encounters 3 months before and 12 months after the primary aneurysm operation. RESULTS: Between 2007 and 2017, 157 and 71 patients were treated with physician-modified endograft (PMEG) and Cook Zenith Fenestrated (ZFEN) repair, respectively. Twenty-one patients who were evaluated for FEVAR underwent open repair instead. The 228 FEVAR patients provided a total positive contribution margin (reimbursements minus direct costs) of $2.65 million. The index encounter (the primary aneurysm operation and hospitalization) accounted for the majority (90.6%) of the total contribution margin. The largest component (50.3%) of direct cost for FEVAR from the index encounter was implant/graft expenses. The average direct costs for FEVAR and for open repair from the index encounter were $34,688 and $35,020, respectively. The average contribution margins for FEVAR and for open repair were approximately $10,548 and $21,349, respectively, attributable to differences in reimbursement. The average direct cost for FEVAR trended down over time as cumulative experience increased. Average reimbursement for FEVAR increased after Centers for Medicare and Medicaid Services approved payments with the Investigational Device Exemption (IDE) trial for PMEG in 2011, and a new technology add-on payment for ZFEN in 2012. These factors transitioned the average contribution margin from negative to positive in 2012. The average physician payments for PMEG increased from $128 to $5848 after the start of the IDE trial. The average physician payments for ZFEN and for open repair between 2011 and 2017 were $7597 and $7781, respectively. CONCLUSIONS: FEVAR can be performed at a high-volume medical center with positive contribution margins and with comparable physician payments to open repair. At this institution, hospital reimbursement and physician payments improved for PMEG with participation in an IDE trial, while hospital direct costs decreased for both PMEG and ZFEN with accumulated experience.

Outcome Comparison of TEVAR with and without Left Subclavian Artery Revascularization from Analysis of Nationwide Inpatient Sample Database.

BACKGROUND: The purpose of this study was to compare the outcomes of thoracic endovascular aortic repair (TEVAR) without and with left subclavian artery (LSA) revascularization using the Nationwide Inpatient Sample (NIS) database. METHODS: NIS records from 2005 to 2013 were retrospectively analyzed to identify patients undergoing TEVAR without and with LSA revascularization. Perioperative outcomes were compared between the two groups. The LSA revascularization group was further subdivided to compare perioperative outcomes if the revascularization was performed pre- or post-TEVAR or if the revascularization was performed open versus endovascular. Comparisons were examined using univariable analysis and multivariable logistic regression. Multivariable models were constructed using a forward selection approach with P < 0.05 required for model entry. Odds ratios are expressed per standard deviation change for continuous covariates. Continuous variables were compared between different groups using t-test, and categorical variables were compared using the chi-squared test. All statistical analyses were performed using R (cran.r-project.org). RESULTS: 7,773 TEVAR patients were included in this study. 6,411 (82.5%) were performed without and 1,362 (17.5%) with LSA revascularization. The rate of revascularization for LSA coverage during TEVAR doubled after the Society for Vascular Surgery Guidelines recommending revascularization were published in 2009. Groups were not significantly different in age (65.5 ± 15.8 and 66.1 ± 14.4 years old, respectively), gender, or race. Multivariable analysis showed that although rates of spinal cord ischemia and upper extremity ischemia were similar, perioperative cardiac complications (OR 1.5, 95% CI [1.2, 1.9], P = 0.025), stroke (OR 2.1, 95% CI [1.6, 2.8], P = 0.001), and pulmonary complications (OR 1.9, 95% CI [1.7, 2.3], P < 0.001) were significantly higher in the patients undergoing TEVAR with LSA revascularization than those without. Of the 1,362 patients with LSA revascularization, 1,251 (91.9%) were performed pre-TEVAR and 111 (8.1%) were performed post-TEVAR. Among the 1,251 patients with pre-TEVAR LSA revascularization, 583 had open surgery and 553 had stenting. In 115 patients, LSA revascularization was coded as both open and endovascular. Compared with pre-TEVAR revascularization, post-TEVAR revascularization was associated with higher risks of pulmonary complications and spinal cord ischemia. Endovascular LSA revascularization had lower pulmonary and stroke morbidity versus open LSA revascularization. The perioperative outcomes for the LSA revascularization subgroups are summarized. CONCLUSIONS: TEVAR with LSA revascularization is associated with significantly increased rates of perioperative stroke and cardiopulmonary complications. LSA revascularization before TEVAR, compared with post-TEVAR revascularization, had lower perioperative complications. In high-risk patients, endovascular LSA revascularization may be recommended over open surgery.

Reliability of evaluating hospital quality by colorectal surgical site infection type.

OBJECTIVE: To determine whether risk-adjusted colorectal SSI rates are statistically reliable as hospital quality measures. BACKGROUND: Policymakers use surgical site infections (SSI) for public reporting of hospital quality and pay-for-performance because they are a relatively common and costly cause of patient morbidity. METHODS: Patients who underwent a colorectal procedure in 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program. We developed hierarchical multivariate logistic models for (1) superficial SSI, (2) deep/organ-space SSI, and (3) "any SSI" and compared how each model ranked hospital-level risk-adjusted performance. Statistical reliability of hospital quality measurements was estimated on a scale from 0 to 1; with 0 indicating that apparent variation between a hospital's quality measurement and the average hospital is statistically unreliable, and 1 indicating that any observed variation is due to a real difference in performance. RESULTS: Mean reliability of hospital-level quality measurements was 0.650 for superficial, 0.404 for deep/organ-space, and 0.586 for "any SSI." Lower reliability was accounted for by relatively little variation in risk-adjusted SSI rates between hospitals and insufficient numbers of colorectal cases submitted by individual hospitals. In 2009, we estimate that 22.1% of all US hospitals performed a sufficient number of colorectal cases to report superficial SSI rates at a high standard of statistical reliability and 1.0% did for deep/organ-space SSI. CONCLUSIONS: As currently constructed, colorectal SSI quality measures might not meet a high standard of statistical reliability for most hospitals, limiting their ability to confidently differentiate high and low performance. Despite an expectation of improving statistical power, combining superficial and deep/organ-space SSI into an "any SSI" measure worsens reliability.

Validity and feasibility of the american college of surgeons colectomy composite outcome quality measure.

OBJECTIVE: To develop a reliable, robust, parsimonious, risk-adjusted 30-day composite colectomy outcome measure. BACKGROUND: A fundamental aspect in the pursuit of high-quality care is the development of valid and reliable performance measures in surgery. Colon resection is associated with appreciable morbidity and mortality and therefore is an ideal quality improvement target. METHODS: From 2010 American College of Surgeons National Surgical Quality Improvement Program data, patients were identified who underwent colon resection for any indication. A composite outcome of death or any serious morbidity within 30 days of the index operation was established. A 6-predictor, parsimonious model was developed and compared with a more complex model with more variables. National caseload requirements were calculated on the basis of increasing reliability thresholds. RESULTS: From 255 hospitals, 22,346 patients were accrued who underwent a colon resection in 2010, most commonly for neoplasm (46.7%). A mortality or serious morbidity event occurred in 4461 patients (20.0%). At the hospital level, the median composite event rate was 20.7% (interquartile range: 15.8%-26.3%). The parsimonious model performed similarly to the full model (Akaike information criterion: 19,411 vs 18,988), and hospital-level performance comparisons were highly correlated (R = 0.97). At a reliability threshold of 0.4, 56 annual colon resections would be required and achievable at an estimated 42% of US and 69% of American College of Surgeons National Surgical Quality Improvement Program hospitals. This 42% of US hospitals performed approximately 84% of all colon resections in the country in 2008. CONCLUSIONS: It is feasible to design a measure with a composite outcome of death or serious morbidity after colon surgery that has a low burden for data collection, has substantial clinical importance, and has acceptable reliability.

Effect of histologic subtype on treatment and outcomes for esophageal cancer in the United States.

BACKGROUND: Esophageal adenocarcinoma (AC) and squamous cell carcinoma (SCC) have distinct clinico-pathologic characteristics; however, it is unclear whether treatment patterns differ by histologic subtype. The objective of this study was to examine differences in treatment use and outcomes by histologic subtype for esophageal cancer in the United States. METHODS: From the National Cancer Data Base, patients with esophageal cancer were identified. Regression models were formulated to assess the influence of histologic subtype on treatment use and overall survival. RESULTS: From 1998 to 2007, 80,961 patients were identified with esophageal cancer in the United States. A higher percentage of patients with nonmetastatic AC underwent surgical resection compared with patients with nonmetastatic SCC (AC, 65.7%; SCC, 36.0%; P<.001), who were more often treated with chemoradiotherapy alone (AC, 25.7%; SCC, 54.1%; P<.001). High-volume academic centers used surgery more frequently for both AC and SCC than did other centers, yet even at high-volume academic centers, surgery was used much less often to treat SCC than AC (AC, 79.3%; SCC, 53.7%; P<.001). The likelihood of operative treatment for nonmetastatic disease was significantly lower in patients with SCC compared with patients with AC (P<.001). Overall survival was lower for patients with stage II/III disease of either histologic subtype treated with chemoradiotherapy alone compared with surgery plus chemoradiotherapy (P<.001). CONCLUSION: A large proportion of patients with esophageal cancer are being treated nonoperatively, and treatment use varies according to tumor histology, particularly by center type.

Use of multimodality neoadjuvant therapy for esophageal cancer in the United States: assessment of 987 hospitals.

BACKGROUND: Consensus guidelines recommend neoadjuvant therapy in locally advanced esophageal cancer; however, whether this recommendation has been widely adopted is unknown. Therefore, we evaluated the utilization of neoadjuvant therapy in esophageal cancer and its association with outcomes in the United States. METHODS: From the National Cancer Data Base all patients with middle and lower third clinical stage I-III esophageal cancers who underwent surgical resection were identified (1998-2007). Multivariable regression models were developed to identify predictors of neoadjuvant therapy use and associated outcomes. RESULTS: We identified 8562 patients who underwent surgical resection for esophageal cancer. In nonmetastatic locally advanced tumors, neoadjuvant therapy use increased (stage II 47.9% to 72.5%; stage III 51.0% to 90.1%; P < 0.001). On multivariable analysis, factors associated with the decreased use of neoadjuvant therapy for stage II and III disease were age ≥75 years, Medicare insurance coverage, Charlson score ≥2, stage II (vs. III) disease, and geographic region. Patients with stage II and III disease who underwent neoadjuvant therapy had a lower risk of positive lymph nodes (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.35-0.55) and positive surgical margins (OR 0.51, 95% CI 0.38-0.69). Thirty-day postoperative mortality rates were not significantly affected by neoadjuvant therapy (OR 0.90, 95% CI 0.66-1.24). A pathologic complete response was observed in 10.8% of patients. The only factor that was predictive of pathologic complete response was squamous cell tumor histology (OR 2.14, 95% CI 1.52-3.02). CONCLUSIONS: In surgically treated patients, the use of neoadjuvant trimodal therapy has increased in the past decade; however, opportunities exist to improve adherence to national guidelines.

Variation in lymph node examination after esophagectomy for cancer in the United States.

OBJECTIVES: To evaluate the quality of lymph node examination after esophagectomy for cancer in the United States based on current treatment guidelines (15 nodes) and to assess the association of patient, tumor, and hospital factors with the adequacy of lymph node examination. DESIGN: Retrospective observational study from 1998 to 2007. SETTING: National cancer database. PATIENTS: Patients with stage I through III esophageal cancer undergoing esophagectomy and not treated with neoadjuvant chemoradiotherapy. MAIN OUTCOME MEASURE: Rate of adequate lymph node examination (15 nodes). RESULTS: A total of 13 995 patients were identified from 639 hospitals. Overall, 4014 patients (28.7%) had at least 15 lymph nodes examined, which increased from 23.5% to 34.4% during the study period. At the hospital level, only 45 centers (7.0%) examined a median of at least 15 lymph nodes. In the most recent period (2005-2007), at least 15 nodes were examined in 38.9% of patients at academic centers vs 28.0% at community hospitals and in 44.1% at high-volume centers vs 29.3% at low-volume centers. On multivariable analysis, hospital type, surgical volume status, and geographic location remained significant predictors of having at least 15 lymph nodes examined. CONCLUSIONS: Fewer than one-third of patients and fewer than 1 in 10 hospitals met the benchmark of examining at least 15 lymph nodes. Hospitals should perform internal process improvement activities to improve guideline adherence.

Association between postoperative complications and reoperation for patients undergoing geriatric surgery and the effect of reoperation on mortality.

Elderly patients have greater risk for postoperative adverse events (PAEs). The study examines the rates of reoperation, the association between PAEs and reoperation, and the effect of reoperation on mortality for patients 65 years of age or older undergoing colorectal resections (CRRs), pancreatic resections (PRs), and lower extremity bypass (LEB) in 2010 American College of Surgeons National Surgical Quality Improvement Program. The models evaluating associations between reoperation and preoperative factors, PAEs, and mortality were developed using multiple logistic regression. The reoperation rates were 6.41 per cent for CRR (n=11,084), 6.79 per cent for PR (n=1,606), and 15.04 per cent for LEB (n=4,170). Preoperative factors predicting reoperation included indications for surgery, procedure category, emergency status, and systemic sepsis. The PAEs most strongly associated with reoperation were wound dehiscence for CRR (odds ratio [OR], 15.286; 95% confidence interval [CI], 11.035 to 21.175) and for PR (OR, 19.656; 8.677 to 44.531) and for LEB, graft failure (OR, 28.151; 18.030 to 43.954) and organ space surgical site infection (OR, 15.753; 6.938 to 35.711). Higher rates of mortality occurred with reoperation for patients undergoing CRR (16.88 vs 5.45%, P<0.0001), PR (28.44 vs 2.14%, P<0.0001), and LEB (6.22 vs 3.05%, P<0.0001). For elderly patients undergoing general and vascular surgery, reoperation occurs frequently, is strongly associated with other PAEs, and may elevate risk of mortality for this vulnerable population.

Relevance of the c-statistic when evaluating risk-adjustment models in surgery.

BACKGROUND: The measurement of hospital quality based on outcomes requires risk adjustment. The c-statistic is a popular tool used to judge model performance, but can be limited, particularly when evaluating specific operations in focused populations. Our objectives were to examine the interpretation and relevance of the c-statistic when used in models with increasingly similar case mix and to consider an alternative perspective on model calibration based on a graphical depiction of model fit. STUDY DESIGN: From the American College of Surgeons National Surgical Quality Improvement Program (2008-2009), patients were identified who underwent a general surgery procedure, and procedure groups were increasingly restricted: colorectal-all, colorectal-elective cases only, and colorectal-elective cancer cases only. Mortality and serious morbidity outcomes were evaluated using logistic regression-based risk adjustment, and model c-statistics and calibration curves were used to compare model performance. RESULTS: During the study period, 323,427 general, 47,605 colorectal-all, 39,860 colorectal-elective, and 21,680 colorectal cancer patients were studied. Mortality ranged from 1.0% in general surgery to 4.1% in the colorectal-all group, and serious morbidity ranged from 3.9% in general surgery to 12.4% in the colorectal-all procedural group. As case mix was restricted, c-statistics progressively declined from the general to the colorectal cancer surgery cohorts for both mortality and serious morbidity (mortality: 0.949 to 0.866; serious morbidity: 0.861 to 0.668). Calibration was evaluated graphically by examining predicted vs observed number of events over risk deciles. For both mortality and serious morbidity, there was no qualitative difference in calibration identified between the procedure groups. CONCLUSIONS: In the present study, we demonstrate how the c-statistic can become less informative and, in certain circumstances, can lead to incorrect model-based conclusions, as case mix is restricted and patients become more homogenous. Although it remains an important tool, caution is advised when the c-statistic is advanced as the sole measure of a model performance.