Incentives and individualized coaching improves completion rates of supervised exercise therapy for claudication.

OBJECTIVE: Supervised exercise therapy (SET) provides clinical benefit for patients suffering from intermittent claudication and has been widely recommended as first-line therapy before endovascular or surgical intervention. However, published rates of SET program completion range from 5% to 55%, with historic completion of 54% at our own institution. As such, we sought to identify if targeted patient-supportive interventions improve SET completion rates while still maintaining efficacious SET programming. METHODS: Patients who were diagnosed with intermittent claudication, as defined by ankle-brachial index (ABI) <0.9 without rest pain, were offered enrollment in a prospective quality improvement protocol for our 12-week SET for peripheral artery disease program. Program completion was defined as ≥24 of 36 offered sessions over 12 weeks. A three-pronged approach was utilized to improve completion during the study, including financial incentives up to $180, scheduled coaching with our advanced practitioner staff, and informational materials on the importance of SET programming and lifestyle modification. Patient-reported improvements in walking symptoms were tracked via regularly administered questionnaires. Functional measures of SET programming including total walking duration and distance, metabolic equivalent of task, and ABIs; vascular intervention within 12-months after enrollment was also collected and compared using univariate paired analysis. RESULTS: In total, seventy-three patients were enrolled in SET for peripheral artery disease programming over the study period. Utilizing our three-pronged coaching approach, 56 patients completed SET programming, increasing our SET completion rate to 76.7% over a 2-year study period. Compared with pre-SET baseline, patients who completed SET noted less pain, aching, cramps in calves when walking (P = .004), and less difficulty walking 1 block (P = .038). Additionally, patients significantly increased their metabolic equivalent of task (3.1 vs 2.6; P < .001), total walking duration (30 mins vs 13.5 mins; P < .001), and total walking distance (0.7 vs 0.3 miles; P < .001) from their pre-SET baseline. There were no changes in participant ABIs from enrollment to completion in participants. Patients who completed SET programming also delayed vascular intervention compared with those who did not complete SET or declined participation (213.5 vs 122.5 days from enrollment; P = .041). CONCLUSIONS: Targeted incentives, including cost-coverage vouchers and personalized coaching with instructional materials, successfully improved patient completion of a prescribed SET program. Patients who completed SET programming reported subjective improvement in walking symptoms and objective walking benefits. In addition, these patients had delayed time to vascular intervention, supporting current vascular guidelines advocating for effective SET therapy prior to offering vascular intervention for intermittent claudication.

Patient Reported Barriers for Participation in Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease.

BACKGROUND: Supervised exercise therapy (SET) provides clinical benefit for patients suffering from intermittent claudication due to peripheral artery disease (PAD). However, enrollment in programs when offered remains low. We sought to identify patient-reported barriers to enrollment in SET as part of a prospective quality improvement program. METHODS: Patients who presented to clinic and were diagnosed with claudication were offered enrollment in a prospective quality improvement protocol, offered at 9 regional offices throughout our health system. Both patients who enrolled and declined enrollment were offered a 12-question questionnaire to identify potential barriers to enrollment. Additional data including gender, smoking status, ankle-brachial index (ABI), proximity to the nearest regional office, and disadvantage levels of neighborhoods (low: 1-3, medium: 4-7, and high: 8-10 area deprivation index [ADI]) was collected and compared by program participation using univariate analysis. RESULTS: Patients enrolled in the SET program (n = 66 patients) versus those who declined (n = 84 patients) were of similar age (medium age: 71.4 vs. 69.7 years, P = 0.694), baseline ABI (0.6 vs. 0.6, P = 0.944), smoking status (former 56.1% vs. 53.6%, P = 0.668), distance away from outpatient center (8.2 mi vs. 8.4 mi, P = 0.249), and had similar Connecticut state ADIs (2021 high-disadvantage: 35.4% vs. 33.3%, P = 0.549). Patients participating in the SET program were more likely to be male (78.8% vs. 56.0%, P = 0.003). Top self-reported barriers for patients who declined participation included transportation/distance (39.3%), preference for independent walking (56.0%), inability to commit to 3 sessions per week (52.4%), and lack of interest (20.2%). In addition, a higher proportion of patients who declined participation identified severe barriers of preference for independent walking (39.3% vs. 1.5%, P < 0.001), inability to commit to 3 sessions per week (26.2% vs. 3.0% P < 0.001), transportation/distance issues (23.8% vs. 7.6% P = 0.008), and cost (27.4% vs. 9.1%, P = 0.005) as significant barriers for participation in SET. CONCLUSIONS: Patients who declined participation in SET for PAD had similar disease status and access to care than participating counterparts. Top reported barriers to enrollment include a preference for independent walking, transportation/distance, commitment to 3x/week program, and cost, which highlight areas of focus for equitable access to these limb-saving services.

Comparison of Social Media Utilization Among Vascular Surgeons, Interventional Cardiologists, and Interventional Radiologists at Academic Training Institutions.

BACKGROUND: Social media platforms, especially Twitter, are increasingly utilized across medical practice, education, and research. However, little is known about differences in social media use among physicians of varying specialties and its impact on recruitment of trainees. Our objective was to describe differences in social media use among vascular interventional proceduralists at academic training institutions. METHODS: We identified institutions with training programs in vascular surgery (VS), interventional radiology (IR), and interventional cardiology (IC). Faculty providers were identified in each specialty at these institutions. A standardized search was used to identify non-anonymous social media profiles on Facebook, Instagram, and Twitter in September 2019. Influencers were defined as physicians with more than 1,000 Twitter followers. Follow ratio was defined as the number of followers divided by the number of accounts followed. Between-specialty differences were analyzed. RESULTS: A total of 1,330 providers (n = 454 VS, n=451 IR, n = 425 IC) were identified across 47 institutions in 27 states. Across all physicians, a minority of providers utilize social media (Facebook: 24.9%, n = 331; Instagram: 10.8%, n = 143; Twitter: 18.0%, n = 240). VS were significantly more likely to use Instagram (P = 0.001) but there was not a significant difference in utilization of Facebook and Twitter. Among Twitter users, VS had fewer followers on average (median 178, inter-quartile range [IQR] 39-555) than IR (median 272, IQR 50-793, P = 0.26) and IC (median 286, IQR 71-1257, P = 0.052). IC were most likely to be influencers (30.9%, n = 25) followed by IR (17.9%, n = 15) and VS (10.7%, n = 8, P = 0.006). On average, interventional cardiologists had the highest follow ratio (mean 4.9 ± 7.1) compared to interventional radiologists (mean 3.2 ± 5.5) and vascular surgeons (mean 2.5 ± 3.3, P < 0.001). CONCLUSION: A minority of academic vascular interventional proceduralists utilize social media in a non-anonymous manner. On Twitter, interventional cardiologists are most likely to be influencers based on number of followers and, on average, have the highest follow ratio. Vascular surgeons could potentially benefit from pursuing greater influence and visibility on social media as a means to recruit trainees.

Society for Vascular Surgery best practice recommendations for use of social media.

The use of social media (SoMe) in medicine has demonstrated the ability to advance networking among clinicians and other healthcare staff, disseminate research, increase access to up-to-date information, and inform and engage medical trainees and the public at-large. With increasing SoMe use by vascular surgeons and other vascular specialists, it is important to uphold core tenets of our commitment to our patients by protecting their privacy, encouraging appropriate consent and use of any patient-related imagery, and disclosing relevant conflicts of interest. Additionally, we recognize the potential for negative interactions online regarding differing opinions on optimal treatment options for patients. The Society for Vascular Surgery (SVS) is committed to supporting appropriate and effective use of SoMe content that is honest, well-informed, and accurate. The Young Surgeons Committee of the SVS convened a diverse writing group of SVS members to help guide novice as well as veteran SoMe users on best practices for advancing medical knowledge-sharing in an online environment. These recommendations are presented here with the goal of elevating patient privacy and physician transparency, while also offering support and resources for infrequent SoMe users to increase their engagement with each other in new, virtual formats.

Patient and institutional factors associated with postoperative opioid prescribing after common vascular procedures.

OBJECTIVE: Overprescription of postoperative opioid medication is a major contributor to the opioid abuse epidemic in the United States. Research into prescribing practices has suggested that patients be limited to 7 days or <200 morphine milligram equivalents (MME) after surgical procedures. Our aim was to identify patient or institutional factors associated with increased opioid prescriptions. METHODS: Opioid naive patients from an integrated health system undergoing one of nine surgical and endovascular procedures tracked within the Vascular Quality Initiative from 2015 to 2017 were identified and matched to their discharge and refill opioid prescriptions. Discharge opioid prescriptions were converted to MME. The primary outcome was discharge MME >200, and secondary outcomes were procedure-specific top-quartile opioid prescription and medication refills. Multivariable logistic regression was used to assess patient and perioperative factors associated with each outcome. RESULTS: Among 1546 opioid naive patients, 739 (48%) received a discharge opioid prescription; median MME was 0 (interquartile range, 0-150), and 349 (23%) had >200 MME. Among those with a discharge prescription, median MME was 180 (interquartile range, 150-300). MME varied by procedure (P < .001), with highest MME after suprainguinal bypass (median, 225) and infrainguinal bypass (200) and lowest MME after carotid artery stenting, carotid endarterectomy, and percutaneous peripheral vascular intervention (all medians of 0). On multivariable analysis, factors associated with MME >200 included younger patient age (<65 vs ≥ 80 years; odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.6; P < .001), treating institution B vs A (OR, 3.50; 95% CI, 2.42-5.07; P < .001) and C vs A (OR, 3.90; 95% CI, 2.66-5.74; P < .001), procedure-specific top-quartile length of stay (OR, 1.45; 95% CI, 1.01-2.08; P = .047), and prior tobacco use (OR, 1.60; 95% CI, 1.07-2.37; P = .02). The same variables along with current tobacco use and lack of preoperative aspirin were associated with procedure-specific top-quartile MME at discharge. Chronic beta-blocker use was protective of top-quartile MME. Based on the observed variability, an institutional standard for opioid prescribing has been developed for standardization. CONCLUSIONS: Opioid prescriptions at discharge vary with the invasiveness of vascular surgical procedures. Less than 25% of patients receive >200 MME. Variation by center represents a lack of standardization in prescribing practices and an opportunity for further improvement based on developed guidelines. Patient factors and procedure type can alert clinicians to patients at risk of higher than recommended MME.

General Anesthesia Is Not Necessary for Hemodialysis Access Surgery.

Chronic kidney disease has been identified as a risk factor for mortality after procedures under general anesthesia (GA). However, a recent study showed that 85 per cent of arteriovenous fistulas in the United States are performed under GA. Our aim was to demonstrate that GA can be avoided in patients with chronic kidney disease and end-stage renal disease by using local anesthesia (LA) with monitored anesthesia care or brachial plexus block (BPB) during hemodialysis access surgery. A retrospective review was performed at a single institution. Outcome measures included need for conversion to GA, major perioperative complications, and 30-day mortality. Four hundred and fourteen access procedures were performed by seven vascular surgeons between 2011 and 2014. Arteriovenous fistulas were placed in 379 (92%), arteriovenous grafts were placed in 31 (7%), and four (1%) received unsuccessful extremity exploration. Anesthetic approach was LA in 344 (83%) and BPB in 64 (15%). GA was initially induced in three (0.7%) and three (0.7%) additional patients required conversion to GA from LA. There were no cardiopulmonary events or perioperative deaths. Of the 32 patients who received an arteriovenous graft, only three (10%) required GA. In conclusion, LA and BPB are safe and conversion to GA is rare. GA should be avoided in hemodialysis access surgery.

Variation in the learning curves of general surgery residents performing arteriovenous fistulas.

BACKGROUND: An arteriovenous fistula (AVF), performed for hemodialysis access, provides one of the few remaining opportunities for general surgery residents to perform an open vascular anastomosis (VA). Limited data exist regarding the learning curve of residents performing this procedure. The objective of this study was to determine how residents improve in performance of VA by implementing real-time tracking of anastomosis time as well as technical errors. STUDY DESIGN: From April 2012 to January 2014, we conducted a prospective intraoperative assessment of 9 postgraduate year 3 general surgery residents during the performance of AVFs using a checklist of common errors in VA. Time for AVF anastomosis completion and number and types of technical errors during anastomosis were recorded. Primary end points were the change in anastomosis time and change in technical errors over time. RESULTS: A total of 86 AVFs were performed and assessed intraoperatively. Each resident performed a median of 10 AVFs (interquartile range [IQR]: 7-11). The mean anastomosis time was 18.1 minutes. The mean number of technical errors was 13.8 per case. Overall, for every additional AVF performed, mean anastomosis time decreased by 0.63 minutes (95% CI: 0.45-0.81, p < 0.0001) and the mean number of technical errors decreased by 1.0 (95% CI: 0.7-1.3, p < 0.0001). The greatest improvement in overall errors (mean difference = 7.9, p = 0.03) and time (mean difference = 4.7min, p = 0.03) occurred after the performance of 3 AVFs. However, when analyzed by individual resident, the R(2) value for anastomotic time by number of AVFs performed ranged from 0.01 to 0.69. Similarly, for technical errors, the R(2) value by number of AVFs performed ranged from 0.04 to 0.62. CONCLUSIONS: In novice surgical residents performing AVFs, improvement in VA skill can readily be tracked via anastomosis time and technical errors. Collectively, there is a strong association between number of cases performed and reduction in time and errors. However, individually, the number of cases completed did not correlate well with time and errors. These findings suggest that for VA skills, determining progression from novice to competence cannot rely on case volume but rather needs to be individualized.

Program Factors That Influence American Board of Surgery In-Training Examination Performance: A Multi-Institutional Study.

OBJECTIVE: To determine the influence of program strategies, such as program directors' (PD) attitudes about the American Board of Surgery In-Training Examination (ABSITE) and approach to ABSITE preparation, on residents' ABSITE performance. DESIGN: A 17-item questionnaire was sent to PDs at surgical residency programs. The questions were designed to elicit information regarding the educational curriculum, remediation protocols, and opinions relating to the ABSITE. Main outcome measure was categorical resident ABSITE percentile scores from the January 2014 examination. Statistical analysis was performed using the Student t-test, analysis of variance, and linear regression as appropriate. SETTING: The study was carried out at general surgery residency programs across the country. PARTICIPANTS: In total, 15 general surgery residency PDs participated in the study. RESULTS: The PD response rate was 100%. All 460 resident ABSITE scores from the 15 programs were obtained. In total, 10 programs (67%) identified as university affiliated, 4 programs (27%) as independent academic, and 1 program (7%) as hybrid. The mean number of residents per program was 30.7 (range: 15-57). In total, 14 PDs (93%) indicated that an ABSITE review curriculum was in place and 13 PDs (87%) indicated they had a remediation protocol for residents with low ABSITE scores (with differing thresholds of <30th, <35th, and <40th percentile). The median overall ABSITE score for all residents was 61st percentile (interquartile range = 39.5). The mean ABSITE score for each program ranged from 39th to 75th percentile. Program factors associated with higher ABSITE scores included tracking resident reading throughout the year (median 63rd percentile with tracking vs 59th percentile without, p = 0.040) and the type of remediation (by PD: 77th percentile, by PD and faculty: 57th percentile, faculty only: 64th percentile, with Surgical Education and Self-Assessment Program (SESAP): 63rd percentile, outside review course: 43rd percentile; p < 0.001). Programs with a remediation protocol trended toward higher ABSITE scores compared with programs without remediation protocols (median 61st percentile vs 53rd percentile, p = 0.098). Factors not significantly associated with ABSITE performance included number of structured educational hours per week and frequency of ABSITE review sessions. CONCLUSIONS: Program factors appear to significantly influence ABSITE performance. Programs where the PD was actively involved in remediation mentorship and the tracking of resident reading achieved higher ABSITE percentile scores on the January 2014 examination. Counterintuitively, residents from programs with a lower ABSITE threshold for remediation performed better on the examination.

Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance.

IMPORTANCE: Few large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations. OBJECTIVES: To identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS: An anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide. MAIN OUTCOMES AND MEASURES: Scores from the 2014 ABSITE. RESULTS: A total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), high opinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), daily studying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCAT score (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P = .03) were identified as positive predictors of ABSITE performance. CONCLUSIONS AND RELEVANCE: Most residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.