Patient Well-Being is No Longer the Priority in America's Unbalanced Medical Care Environment.

There is growing evidence that America is experiencing a Medical Care Crisis where patient well-being is no longer the priority. When we define "patient well-being" as the patient's positive experience while receiving medical care (meeting the shared health goals between the doctor and patient), we find that while America has the world's best and most resourced hospitals, doctors and universities, it paradoxically has the lowest patient satisfaction rate (12%-27% satisfaction). The Crisis is manifested by a lack of availability (even when there is access) to clinical services, clinical burnout/loss of doctor autonomy, corporatization of medical care (financial profit motives supersede patient well-being), depersonalization, non-clinicians performing clinical care and inadequate communication. Evidence suggests the cause of the Crisis to be an imbalance in our medical care environment; doctors, hospitals, payors and universities/innovators no longer work in concert to prioritize patient well-being. It calls for leaders to address burnout, communication, academic unawareness, and industry partner engagement. We must reestablish the reason for medical care: patient well-being.

A Regional Experience With Vascular Surgery Mock Oral Examinations.

INTRODUCTION: In 2006 the Southern Association for Vascular Surgery (SAVS) implemented a mock oral examination program to prepare trainees for the Vascular Surgery Certifying Examination (VCE). METHODS: Participating examinees and examiners were identified from SAVS Recorder records and contacted via e-mail with a request to participate in an anonymous online survey. Examinees were asked about passage on American Board of Surgery examinations and perceptions of the mock oral program. Examiners were asked for their perceptions of the examination, applicant performance, and perceived areas for training improvement. Board passage rates for the group and national comparison data were provided in a de-identified fashion by American Board of Surgery. RESULTS: From 2006 to 2014, 158 examinees and 86 examiners participated in the SAVS mock orals program. In all, 33% of examinees and 35% of examiners completed the anonymous survey. Of the examinees, 27 (60%) reported passage of the mock oral examination on their first attempt and 7 of 9 (78%) reported passage on the second attempt. Second year in training was significantly associated with passage of the mock oral (p = 0.002). Of the examinees questioned, 100% "would recommend" the SAVS mock oral examinations to future trainees. Of the responding examiners, 90% felt that the SAVS mock oral examinations were "comparable" to the VCE and 87% "strongly agreed" that the exercise was a valuable preparatory tool. Examiners identified "ability to describe technical aspects of open vascular techniques" and "management of complications associated with vascular disease processes and operations" as commonly displayed deficits among examinees (80% and 77%, respectively). In all, 115 examinee participants from the SAVS mock orals had taken the VCE between 2006 and 2014. Of them, 90 (78%) passed the VCE on their first attempt. During the same time interval, the national first-time pass rate for the VCE was 86%. CONCLUSIONS: Although participation in the SAVS mock orals was overwhelmingly assessed as a positive preparatory experience by examinees and examiners, no incremental advantage in VCE passage was observed. Explanations for the worse-than-average performance on the VCE are not clear but likely involve numerous factors, including participation bias. Importantly, examiners in the SAVS mock oral process felt that the exercise closely simulated the VCE and uniformly reported pervasive deficits in the areas of demonstrated understanding of open surgical techniques and management of complications. This investigation guides further examination of VCE simulation exercises to assist in guiding the use of educational resources at both institutional and professional society levels.

An early validation of the Society for Vascular Surgery lower extremity threatened limb classification system.

OBJECTIVE: The Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic, Ischemia, and foot Infection (WIfI) to stratify the risk for limb amputation at 1 year. Although intuitive in nature, this new system has not been validated. The purpose of the following study was to determine whether the WIfI system is predictive of limb amputation and wound healing. METHODS: Between 2007 and 2010, we prospectively obtained data related to wound characteristics, extent of infection, and degree of postrevascularization ischemia in 139 patients with foot wounds who presented for lower extremity revascularization (158 revascularization procedures). After adapting those data to the WIfI classifications, we analyzed the influence of wound characteristics, extent of infection, and degree of ischemia on time to wound healing; empirical Kaplan-Meier survival curves were compared with theoretical outcomes predicted by WIfI expert consensus opinion. RESULTS: Of the 158 foot wounds, 125 (79%) healed. The median time to wound healing was 2.7 months (range, 1-18 months). Factors associated with wound healing included presence of diabetes mellitus (P = .013), wound location (P = .049), wound size (P = .007), wound depth (P = .004), and degree of ischemia (P < .001). The WIfI clinical stage was predictive of 1-year limb amputation (stage 1, 3%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and wound nonhealing (stage 1, 8%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and correlated with the theoretical outcome estimated by the SVS expert panel. CONCLUSIONS: The theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified.

Radiation safety education in vascular surgery training.

OBJECTIVE: Endovascular volume during vascular surgery training has increased profoundly over recent decades, providing heavy exposure to ionizing radiation. The study purpose was to examine the radiation safety training and practices of current vascular surgery trainees. METHODS: An anonymous survey was distributed to all current U.S. trainees. Responses were compared according to the presence of formal radiation safety training and also the trainees' perception of their attendings' adherence to As Low As Reasonably Achievable (ALARA) strategies. RESULTS: The response rate was 14%. Forty-five percent had no formal radiation safety training, 74% were unaware of the radiation safety policy for pregnant females, 48% did not know their radiation safety officer's contact information, and 43% were unaware of the yearly acceptable levels of radiation exposure. Trained residents knew more basic radiation safety information, and more likely wore their dosimeter badges (P < .05). Trained residents found their radiation safety officer helpful in developing safety habits; untrained residents relied on other residents (P < .05). Trainees who felt their attendings consistently practiced ALARA strategies more likely practiced ALARA themselves (P < .05). CONCLUSIONS: The lack of formal radiation safety training in respondents may reflect an inadequate state of radiation safety education and practices among U.S. vascular surgery residents.

The influence of a Vascular Surgery Hospitalist program on physician and patient satisfaction, resident education, and resource utilization.

A number of surgery practice models have been developed to address general and trauma surgeon workforce shortages and on-call issues and to improve surgeon satisfaction. These include the creation of acute or urgent care surgery services and "surgical hospitalist" programs. To date, no practice models corresponding to those developed for general and trauma surgeons have been proposed to address these same issues among vascular surgeons or other surgical subspecialists. In 2003, our practice established a Vascular Surgery Hospitalist program. Since its inception nearly a decade ago, it has undergone several modifications. We reviewed hospital administrative databases and surveys of faculty, residents, and patients to evaluate the program's impact. Benefits of the Vascular Surgery Hospitalist program include improved surgeon satisfaction, resource utilization, timeliness of patient care, communication among referring physicians and ancillary staff, and resident teaching/supervision. Elements of this program may be applicable to a variety of surgical subspecialty settings.

SESC Practice Committee survey: surgical practice in the duty-hour restriction era.

Debate continues as to the relevance of Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions in actual practice and the adequacy of resident training in surgery. A survey of the membership of the Southeastern Surgical Congress using an Internet-based questionnaire was conducted: adherence to duty-hour restrictions, evidence of sleepiness and fatigue, opinions regarding the training, and clinical performance of surgeons who had trained after the institution of duty-hour restrictions in 2003 (termed "recently trained surgeons"). One hundred seventy-seven members respondents out of 1008 (18%). Most (101 of 170 [59%]) worked more than 80 hours in a week and half (86 of 174 [49%]) more than 24 hours consecutively once or more a month. Falling asleep inappropriately was reported by 6 to 12 per cent. Forty per cent (71 of 176) thought that graduates of residencies today are prepared for clinical practice. Those who had hired a recently trained surgeon believed the latter was sufficiently trained (61 of 123 [50%]) more often than those who had not hired one (10 of 51 [20%]; P = 0.006). Those with a new colleague gave first assistant help in 75 per cent (91 of 121) during the first year. Surgeons in practice regularly violate ACGME duty-hour restrictions. Many surgeons have doubts whether new graduates of residency training programs have adequate training to practice surgery. Those who have hired a new surgeon trained under duty-hour restrictions are more likely to be satisfied with the latter's training. Most new trainees receive direct assistance from their practice partners, continuing their training beyond residency.

Bariatric surgery is associated with a reduction in major macrovascular and microvascular complications in moderately to severely obese patients with type 2 diabetes mellitus.

BACKGROUND: Bariatric surgery (BAR) has been established as an effective treatment for type 2 diabetes mellitus (T2DM) in obese patients. However, few studies have examined the mid- to long-term outcomes of bariatric surgery in diabetic populations. Specifically, no comparative studies have broadly examined major macrovascular and microvascular complications in bariatric surgical patients vs similar, nonbariatric surgery controls. STUDY DESIGN: We conducted a large, population-based, retrospective cohort study of adult obese patients with T2DM, from 1996 to 2009, using UB-04 administrative data and vital records. Eligible patients undergoing bariatric surgery (BAR [n = 2,580]) were compared with nonbariatric surgery controls (CON [n = 13,371]) for the outcomes of any first major macrovascular event (myocardial infarction, stroke, or all-cause death) or microvascular event (new diagnosis of blindness, laser eye or retinal surgery, nontraumatic amputation, or creation of permanent arteriovenous access for hemodialysis), assessed in combination and separately, as well as other vascular events (carotid, coronary or lower extremity revascularization or new diagnosis of congestive heart failure or angina pectoris). RESULTS: Bariatric surgery was associated with favorable unadjusted 5-year event-free survival estimates for the combined primary outcome (95% ± 1% vs 81% ± 1%, log-rank p < 0.01) and each secondary outcome (log-rank p < 0.01). Multivariate-adjusted and propensity-based relative risk estimates showed BAR to be associated with a 60% to 70% reduction (adjusted hazard ratio [HR] 0.36, 95% CI 0.27 to 0.47) in the combined primary outcome and 60% to 80% risk reductions for each secondary outcome (macrovascular events [adjusted HR 0.39, 95% CI 0.29 to 0.51]; microvascular events [adjusted HR 0.22, 95% CI 0.09 to 0.49]; and other vascular events [adjusted HR 0.25, 95% CI 0.19 to 0.32]). CONCLUSIONS: Bariatric surgery is associated with a 65% reduction in major macrovascular and microvascular events in moderately and severely obese patients with T2DM.

Aortobiiliac bypass to the distal external iliac artery versus aortobifemoral bypass: a matched cohort study.

Vascular bypass has long been the standard surgical treatment for symptomatic aortoiliac occlusive disease (AIOD). Conventional wisdom has been that aortobifemoral bypass (ABF) be performed for AIOD because of the inevitable progression of iliac atherosclerosis leading to bypass thrombosis. However, ABF is prone to significant groin incision complications such as infection and lymphocele. The purpose of this study was to determine if aortobiiliac bypass (ABI) to the distal external iliac artery performs similarly to ABF in cases in which minimal atherosclerosis is present in the distal iliac arteries. Of patients undergoing aortic reconstruction for symptomatic AIOD between July 1998 and December 2008, 37 were found to have minimal atherosclerosis in the distal external iliac arteries and underwent ABI. These were compared with patients undergoing ABF using a retrospective matched cohort design. The indication for ABI was claudication in 86.5 per cent and critical limb ischemia in 13.5 per cent. There was no difference found in overall bypass patency. The 1-, 3-, and, 5-year patencies were 97, 92, and 79 per cent in the ABI group and 93, 85, and 76 per cent in the ABF group, respectively (P = 0.8). The incidence of groin wound complications in the ABF group was 14.6 per cent. ABI to the distal external iliac artery achieves equivalent graft patencies to ABF without added risk of associated groin wound complications. These data suggest that ABI be preferentially considered to ABF in situations when the very distal external iliac arteries are patent and free of significant atherosclerotic disease.

Helicobacter pylori is not the predominant etiology for peptic ulcers requiring operation.

As the number of patients requiring operation for peptic ulcer disease (PUD) declines, presumed contemporary ulcer etiology has largely been derived from medically treated patients not subjected to surgery. The purpose of this study was to examine the specific causes of PUD in patients requiring surgery. Our Acute Care Surgical Service registry was reviewed for patients operated on for complications of PUD from 2004 to 2009. Emphasis was placed on individual etiologic factors for PUD. There were 128 patients (52% male, 81% white) who underwent emergency operation including: simple patch closure (n = 61, 48%); gastric resection (n = 22, 17%); gastric resection with vagotomy (n = 21, 16%); vagotomy and pyloroplasty (n = 18, 14%); or other procedures (n = 6, 5%). Complications necessitating operation were perforation (n = 79, 62%); bleeding (n = 29, 23%); obstruction (n = 12, 9%); and intractability (n = 8, 6%). Perioperative mortality was 12.5 per cent. Risk factors for PUD included tobacco use (50%), alcohol abuse (34%), and steroids (21%). Nonsteroidal anti-inflammatory use was confirmed in 68 (53%) patients. Of the 128 patients, 82 (64%) were tested for Helicobacter pylori, 33 (40%) of which were positive and 49 (60%) negative. Helicobacter pylori, thus, was the confirmed ulcer etiology in only 26 per cent of cases. Unlike contemporary series of medically treated PUD, Helicobacter pylori may not be the predominant etiologic factor in patients who experience complications requiring surgery. A "traditional" surgical approach with liberal use of vagotomy, not antibiotic triple therapy, may well be the preferred treatment consideration in such cases.

The value of a carotid duplex surveillance program for stroke prevention.

BACKGROUND: Although duplex ultrasonography (DU) can readily identify progression of carotid stenosis, controversy regarding the natural history of asymptomatic carotid stenosis as well as the need and appropriate interval for carotid DU surveillance still exists. Furthermore, consensus has not yet been made in the surgical literature regarding the usefulness, cost-effectiveness, or timing of DU surveillance after carotid endarterectomy (CEA). The purpose of this study was to determine how often DU surveillance for asymptomatic carotid disease or postintervention stenosis resulted in any change in the patient's clinical management, how many strokes were prevented by DU surveillance, and the cost of such a DU surveillance program per stroke prevented. METHODS: We reviewed a 9-year vascular surgical database to identify all patients enrolled in a carotid DU surveillance program for asymptomatic carotid stenosis or following CEA between January 1, 2000, and December 31, 2008. The number of duplex scans and CEAs performed in those patients through March 2010 was also determined. The results of the Asymptomatic Carotid Atherosclerosis Study were then used to estimate the number of strokes prevented by CEA in the study population. Reimbursement data were assessed to calculate the average cost of each DU and the cost of the DU surveillance program for each stroke prevented. RESULTS: During the study period, there were 11,531 carotid duplex scans performed on 3,003 patients (mean: 3.84 scans per patient) who had been enrolled in the DU surveillance program. CEA for asymptomatic carotid stenosis was performed on 225 (7.5%) patients. The DU surveillance program prevented approximately 13 strokes (871 carotid duplex scans per stroke prevented). The mean cost of each duplex scan was $332 ± 170. The total cost of the DU surveillance program was approximately $3,830,000 or $290,000 per stroke prevented. CONCLUSIONS: Although a carotid DU surveillance program generates substantial revenue for a vascular surgery practice, it is costly and inefficient. A reappraisal of the "value" of carotid DU surveillance in stroke prevention is warranted. Consideration should be given to eliminating routine surveillance of postendarterectomy carotids in the absence of contralateral disease and limiting the number of DU surveillance studies for asymptomatic carotid disease.

Contemporary management of diabetic neuropathic foot ulceration: a study of 917 consecutively treated limbs.

BACKGROUND: For patients with diabetic neuropathic foot ulceration, the current treatment paradigm is heavily weighted toward limb revascularization; aligning incentives to perform more surgery and less ulcer management/prevention. Our purpose was to perform an analysis of functional outcomes to assess this current treatment paradigm. STUDY DESIGN: Nine hundred and seventeen neuropathic ulcerated feet in 706 patients with diabetes were analyzed. Four hundred and sixty limbs (50.2%) had concomitant ischemia, 219 of which were revascularized (137 angioplasty and 82 open surgery). Outcomes measured included ulcer healing, survival, limb salvage, amputation-free survival, maintenance of ambulation, and independence. Independent predictors of outcomes were measured using an Extended Cox Model. RESULTS: Overall outcomes (n = 917) were: ulcer healed, n = 250 (27%; mean time to healing 33 weeks); functionally healed, n = 488 (53%; mean time to functional healing 29 weeks); 5-year limb salvage, 68%; survival, 38%; amputation-free survival, 30%; maintenance of ambulation, 64%; and maintenance of independence, 74%. There was little difference in ulcer healing rates for patients with or without ischemia (28.5% versus 26%; p = 0.4). However, ischemia was a significant marker of poor outcomes (nonischemic ulcer, ischemic ulcer revascularized, and ischemic ulcer not revascularized: 5-year limb salvage of 80%, 61%, and 51%; p < 0.001); survival (47%, 37%, and 24%; p = 0.03); amputation-free survival (37%, 28%, and 17%; p < 0.001); maintenance of ambulation (74%, 55%, and 55%; p < 0.001); and maintenance of independence (82%, 72%, and 58%; p = 0.01). Wound healing was an independent predictor of survival and amputation-free survival (survival: hazard ratio = 0.58; 95% CI,0.46-0.73; amputation-free survival: hazard ratio = 0.42; 95% CI, 0.33-0.53). CONCLUSIONS: The current treatment paradigm is associated with relatively poor healing rates and substantial late morbidity and mortality. Although revascularization is effective treatment for ischemia, it is probably overvalued when compared with the potential improvement afforded by better medical foot wound management.

Open versus endovascular intervention for critical limb ischemia: a population-based study.

BACKGROUND: Endovascular techniques are considered by many as the first-line treatment for critical limb ischemia (CLI). The purpose of this study is to assess the impact of endovascular therapy on CLI and amputation in South Carolina during the past decade. STUDY DESIGN: This is a retrospective, comparative analysis of treatment outcomes for CLI in the pre-endovascular era and the endovascular era. The South Carolina Office of Research and Statistics database was reviewed using ICD-9 diagnosis and procedure codes to identify patients who underwent limb revascularization in 1996 (pre-endovascular era) and 2005 (endovascular era) for CLI and to determine those who required subsequent limb amputation and additional revascularization. RESULTS: The index limb revascularization procedures increased 33% from 571 in 1996 (420 [74%] open; 151 [26%] endovascular) to 758 in 2005 (373 [49%] open; 385 [51%] endovascular). The demographics and comorbidities for patients who underwent revascularization in 1996 were similar to those in 2005. The amputation rate for patients who underwent a revascularization procedure was 34% at 1 year and 43% at 3 years in 1996, compared with 34% at 1 year and 40% at 3 years in 2005 (p = NS). The percentage of patients who required an additional revascularization in the same calendar year increased from 8% in 1996 to 19% in 2005 (p < 0.001). CONCLUSIONS: Although there has been an absolute increase in the number of revascularization procedures for CLI, with a clear shift toward endovascular therapy, the amputation rates for these patients have not changed. However, the shift to endovascular interventions has increased the number of secondary procedures required to maintain limb-salvage rates equivalent to those of the pre-endovascular era.

Outcome of the use of stent grafts to salvage failed arteriovenous accesses.

BACKGROUND: Since elements of the Dialysis Outcome Quality Initiative (K/DOQI) were implemented a decade ago, there has been a reduction in mortality for patients on hemodialysis. As patient longevity has increased, AV access site preservation by salvaging failed arteriovenous (AV) accesses has become increasingly important. However, efforts to salvage an AV access must be balanced against futile and expensive procedures. The Viabahn Endoprosthesis is a self-expandable stent graft (SG) that can be used to treat vein rupture or fibrotic lesions with significant elastic recoil following balloon angioplasty. The literature comprising the outcome of the use of SGs in salvaging failed AV accesses is limited. The purpose of this study is to determine the outcome of failed AV accesses treated with SGs and to identify patient or graft factors predictive of success. METHODS: The vascular access database and office, hospital, and dialysis unit records were retrospectively reviewed to identify all patients who underwent placement of an SG for the treatment of a thrombosed AV access between September 2004 and December 2007. Mean patient follow-up was 6 months. The K/DOQI goal for patency following a surgical intervention (6 months or later) was used to determine procedure success or failure. Kaplan-Meier life-table analysis was used to determine patency. Patient demographics and graft factors (location, diameter, length) were analyzed to identify predictors of success. RESULTS: Fifty-five SGs were placed in 48 patients (males, 29%; mean age, 61 years; diabetes mellitus, 47%) with a failed AV access. The indications were to treat significant elastic recoil or vein rupture following balloon angioplasty (47 patients) and to treat an AV graft seroma (1 patient). Cost for the VE ranged from $2337 to $3367 per patient. The procedure was deemed successful (patent at 6 months) in 29 + or - 7% of cases. Procedure success was not influenced by AV access location, endoprosthesis size (diameter or length), or patient demographic factors (p > 0.05). CONCLUSION: Use of the SG to salvage AV accesses falls short of the current K/DOQI clinical outcome goals for successful surgical intervention in the majority of cases. Given these results and the cost of the SG, its use is indicated in cases where AV access salvage will have an impact on long-term survival such as for patients in whom there are few options for new access placement. Further studies are needed to compare the SG to less costly options, such as angioplasty alone or angioplasty with the use of bare metal stents.

The Greenville Hospital System University Medical Center Department of Surgery.

Despite its modest surgical heritage, the Greenville Hospital System University Medical Center Department of Surgery has evolved into a progressive, academic hybrid, well-suited to deliver mission-based surgical care to an expanding regional population. It not only is well positioned clinically, academically, and financially to successfully implement organized processes to improve quality and control cost, but is also well positioned to assume financial accountability for these outcomes in the future.

Changing indications and outcomes for open abdominal aortic aneurysm repair since the advent of endovascular repair.

The indications for open abdominal aortic aneurysm (AAA) repair have changed with the development of endovascular techniques. The purpose of this study is to clarify the indications and outcomes for open repair since endovascular aneurysm repair (EVAR) and to compare contemporary AAA repair with the pre-EVAR era. Patients undergoing open AAA repair were identified; the demographics, outcomes, and indications for open repair were reviewed. Outcomes were compared based on indication for open repair in the EVAR era and between the pre-EVAR and EVAR eras. Open indications in the EVAR era included: age younger than 65 years with minimal comorbidities (AGE, n = 24 [9.8%]), unfavorable anatomy (ANAT, n = 146 [59.3%]), aortoiliac occlusive disease (AIOD, n = 38 [15.4%]), and miscellaneous (OTHER, n = 38 [15.4%]). Mortality (30-day and 5-year) was affected by indication: AGE = 0 and 0 per cent, ANAT = 4.1 and 49.7 per cent, AIOD = 13.5 and 32.3 per cent, and OTHER = 5.3 and 41.8 per cent. Age, sex, race, coronary artery disease, and peripheral artery disease were similar between the pre-EVAR and EVAR eras. EVAR-era patients had more diabetes mellitus, hypertension, and hyperlipidemia and longer operative time. Mortality was not different, but complication rates were lower in the pre-EVAR era (23.7 vs 43.5%, P = 0.025). Patients undergoing open AAA repair in the EVAR era have more comorbidities, longer operative times, and more complications. Outcomes for EVAR-era patients are affected by the indication for open repair. A preference for open repair in younger patients with minimal comorbidities is justified.