Polyvascular Disease is Common in Patients Undergoing Carotid Endarterectomy and Lower Extremity Bypass and is Associated With Worse Outcomes.

INTRODUCTION: Polyvascular disease is strongly associated with increased risk of cardiovascular morbidity and mortality. However, its prevalence in patients undergoing carotid and lower extremity surgical revascularization and its impact on outcomes are unknown. METHODS: The Vascular Quality Initiative was queried for carotid endarterectomy (CEA) or infrainguinal lower extremity bypass (LEB), 2013-2019. Polyvascular disease was defined as presence of atherosclerotic occlusive disease in > 1 arterial bed: carotid, coronary, and infrainguinal. Primary outcomes were: (1) composite perioperative myocardial infarction (MI) or death and (2) 5-year survival. Patient characteristics and perioperative outcomes were evaluated using chi-square test and multivariable logistic regression. Survival was analyzed using Kaplan-Meier method and Cox proportional hazards multivariable models. RESULTS: Polyvascular disease was identified in 47% of CEA (39% 2 arterial beds, 7.6% 3 arterial beds; n = 93,736) and 47% of LEB (41% 2 arterial beds, 5.7% 3 arterial beds; n=25,223). For both CEA and LEB, patients with polyvascular disease had more comorbidities including hypertension, congestive heart disease, chronic obstructive pulmonary disease, smoking, diabetes mellitus, and end-stage renal disease (P<0.0001). Perioperative MI/death rates increased with increasing number of vascular beds affected following CEA (0.9% 1 bed vs 1.5% 2 beds vs 2.7% 3 beds, P<0.001) and LEB (2.2% 1 bed vs 5.3% 2 beds vs 6.6% 3 beds, P<0.001). Polyvascular disease was independently associated with perioperative MI/death after CEA (OR 1.59 (95% CI 1.40-1.81), P<.0001) and LEB (OR 1.78 (95% CI 1.52-2.08), P<.0001). Five-year survival was decreased in patients with polyvascular disease after CEA (82% 3 beds vs 88% 2 beds vs 92% 1 bed, P<0.01) and LEB (72% 3 beds vs 75% 2 beds vs 84% 1 bed, P<0.01) in a dose-dependent manner, with the lowest 5 year survival observed in those with 3 arterial beds involved. Polyvascular disease was independently associated with five-year mortality following CEA (HR 1.33 (95% CI 1.24-1.40), P=0.0001) and LEB (HR 1.30 (95% CI 1.20-1.41), P=0.0001). CONCLUSION: Polyvascular disease is common in patients undergoing CEA and LEB and is associated with higher risk of perioperative MI/death and decreased long-term survival. Following revascularization, polyvascular disease patients may be considered for more aggressive cardioprotective medications and closer follow up.

A Call to Action: Using Curriculum Mapping at Four Medical Schools in Massachusetts to Advance Serious Illness Communication Training in Undergraduate Medical Education.

Background: Practicing physicians require serious illness communication (SIC) skills to ensure high-quality, humanistic care for patients and families as they face life-changing medical decisions. However, a majority of U.S. medical schools do not require formal training in SIC and fail to provide students deliberate practice before graduation. The Massachusetts Medical Schools' Collaborative was created to ensure that students receive foundational SIC training in undergraduate medical education. This Collaborative developed a curriculum-mapping tool to assess SIC at four medical schools. Objective: We aimed to understand existing educational activities across four medical schools and identify opportunities to build longitudinal, developmentally based curricular threads in SIC. Design: From July 2019 to April 2021, faculty, staff, and medical students assessed current educational activities related to five core competencies in SIC, adapted for students from national competencies for palliative medicine fellows, using a curriculum mapping tool. Measurements: The group selected 23 keywords and collected metrics to describe the timing, instruction and assessment for each school's educational activities. Results: On average, there were only 40 hours of required curricula in SIC over four years. Over 80% of relevant SIC hours occurred as elective experiences, mostly during the postclerkship phase, with limited capacity in these elective experiences. Only one school had SIC educational activities during the clerkship phase when students are developing clinical competencies. Assessment methods focused on student participation, and no school-assessed clinical performance in the clerkship or postclerkship phase. Conclusions: Medical schools are failing to consistently train and ensure basic competency in effective, compassionate SIC. Curriculum mapping allows schools to evaluate their current state on a particular topic such as SIC, ensure proper assessment, and evaluate curricular changes over time. Through the deliberate inclusion of SIC competencies in longitudinal curriculum design, we can fill this training gap and create best practices in undergraduate medical education.