Quality of care among patients undergoing lower extremity revascularization

BACKGROUND

Compliance with guidelines for treating patients with peripheral artery disease (PAD) lags compliance for treating patients with coronary artery disease. We assessed the gap between guidelines and practice for patients with PAD who underwent lower extremity revascularization (LER) at our institution from 2007 to 2010.

METHODS

Quality of care (QoC) was calculated by measuring provider performance on four indicators (antiplatelet therapy, dyslipidemia management, control of hypertension, and diabetes) derived from the ACCF/AHA PAD guidelines. The QoC score was calculated at the time of admission and at time of discharge for each patient, and reflects the proportion of indicated treatments received.

RESULTS

Patients (n = 734, mean age 70±11, female 51%) were followed for a mean of 2.0±1.4 years (range 0-5.7) following LER. The indication for LER was claudication (24.8%), rest pain (16.7%), and tissue loss (58.4%). The percentage of patients with a perfect QoC score increased significantly during hospital admission (11% to 21%, p < 0.001). Significant multivariate predictors of perfect QoC score included race/ethnicity, Charlson score, severity of LE ischemia, and observation period (admission, discharge). Multivariate analysis demonstrated that age>75 years, heart failure, chronic kidney disease, rest pain, and tissue loss-but not compliance with four guideline-based therapies-were associated with decreased freedom from the composite endpoint of major amputation, repeat revascularization, and death.

CONCLUSIONS

Although adherence to guidelines improved over time, we found a significant gap between guidelines and practice for this cohort of patients at increased risk for adverse cardiovascular events.

Laparoscopic sleeve gastrectomy for obesity: can it be considered a definitive procedure?

BACKGROUND

Providing bariatric surgery services to an inner-city population is a challenge. Laparoscopic sleeve gastrectomy (LSG) is an effective operation for morbid obesity with a relatively low complication rate. LSG appears to be a suitable alternative procedure for this group of patients.

METHODS

This is a retrospective review and analysis of the experience with 185 consecutive LSGs that had completed at least 6 months follow-up. Eleven conversions from LSG to laparoscopic Roux-en-Y gastric bypass were excluded, leaving 174 patients for outcome analysis. Data collected were patient demographics, body mass index (BMI), comorbid conditions, operating time, length of hospital stay, and perioperative complications. Weight loss and resolution/improvement of comorbidities were analyzed.

RESULTS

Mean patient age was 39.58 years and mean BMI was 48.97 kg/m(2). The percentage of patients with BMI > 50 kg/m(2) was 37.94%. Mean excess weight loss (EWL) was 44.76, 55.52, 59.22, and 58.92% at 6, 12, 24, and 36 months, respectively. Six patients (3.24%) lost less than 25% EWL. Thirteen patients (7.02%) regained an average of 13 lb after reaching a plateau. Resolution/improvement of comorbidities was 84% for diabetes mellitus, 49.99% for hypertension, 90% for asthma, 90.74% for obstructive sleep apnea, and 45.92% for gastroesophageal reflux disease symptoms (GERD). The mortality rate was zero in this series. Perioperative complications occurred in 26 patients (14.05%): four staple-line leaks (2.16%), four bleeds (2.16%), four obstructions (2.16%), five vomiting/dehydration (2.70%), six new onset of GERD symptoms (3.24%), two with pneumonia (1.08%), and one with pulmonary embolism (0.54%).

CONCLUSION

LSG results in stable and adequate weight loss with resolution/improvement in comorbidities in a high percentage of patients. It can be considered a definitive operation for morbid obesity.