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Goodney PP. Invited commentary. J Vasc Surg 2018; 67:1715-1716. [DOI: 10.1016/j.jvs.2017.11.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/21/2017] [Indexed: 10/16/2022]
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Kang R, Columbo JA, Kunkel ST, Stucke RS, Sabatino MJ, Tang A, Goodney PP, Rosenkranz KM. Residents' Impressions of the Impact of Advanced Practice Providers on Surgical Training. J Am Coll Surg 2018; 226:1036-1043. [PMID: 29224796 PMCID: PMC10723757 DOI: 10.1016/j.jamcollsurg.2017.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/16/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND To ensure that residents are appropriately trained in the era of the 80-hour work-week, training programs have restructured resident duties and hired advanced practice providers (APPs). However, the effect of APPs on surgical training remains unknown. STUDY DESIGN We created a survey using a modified Delphi technique to examine the interaction between residents and APPs across practice settings (inpatient, outpatient, and operating room). We identified the following domains: administrative tasks, clinical experience, operative experience, and overall impressions. We administered the survey to residents across 7 surgical training programs at a single institution and assessed internal reliability with Cronbach's α. RESULTS Fifty residents responded (77% participation rate). The majority reported APPs reduced the time spent on administrative tasks, such as completing documentation (96%) and answering pages (88%). For clinical experience, 62% of residents thought that APPs had no impact on the amount of time spent evaluating consult patients, and 80% reported no difference in the number of bedside procedures performed. However, 77% of residents reported a reduction in the time spent counseling patients. When APPs worked in the inpatient setting, 90% of residents reported leaving the operating room less frequently to manage patients. When APPs were present in the operating room, 34% of residents thought they were less likely to perform key parts of the case. Cronbach's α showed excellent to good reliability for the administrative tasks (0.96), clinical experience (0.76), operative experience (0.69), and overall impressions (0.66) domains. CONCLUSIONS Most residents report that the integration of APPs has decreased the administrative burden. The reduction in patient counseling might be an unrecognized and unintended consequence of implementing APPs. The perceived effect on operative experience is dependent on the role of the APPs.
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Arya S, Khakharia A, Binney ZO, DeMartino RR, Brewster LP, Goodney PP, Wilson PWF. Association of Statin Dose With Amputation and Survival in Patients With Peripheral Artery Disease. Circulation 2018; 137:1435-1446. [PMID: 29330214 PMCID: PMC5882502 DOI: 10.1161/circulationaha.117.032361] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 11/20/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Statin dose guidelines for patients with peripheral artery disease (PAD) are largely based on coronary artery disease and stroke data. The aim of this study is to determine the effect of statin intensity on PAD outcomes of amputation and mortality. METHODS Using an observational cohort study design and a validated algorithm, we identified patients with incident PAD (2003-2014) in the national Veterans Affairs data. Highest statin intensity exposure (high-intensity versus low-to-moderate-intensity versus antiplatelet therapy but no statin use) was determined within 1 year of diagnosis of PAD. Outcomes of interest were lower extremity amputations and death. The association of statin intensity with incident amputation and mortality was assessed with Kaplan-Meier plots, Cox proportional hazards modeling, propensity score-matched analysis, and sensitivity and subgroup analyses, as well, to reduce confounding. RESULTS In 155 647 patients with incident PAD, more than a quarter (28%) were not on statins. Use of high-intensity statins was lowest in patients with PAD only (6.4%) in comparison with comorbid coronary/carotid disease (18.4%). Incident amputation and mortality risk declined significantly with any statin use in comparison with the antiplatelet therapy-only group. In adjusted Cox models, the high-intensity statin users were associated with lower amputation risk and mortality in comparison with antiplatelet therapy-only users (hazard ratio, 0.67; 95% confidence interval, 0.61-0.74 and hazard ratio, 0.74; 95% confidence interval, 0.70-0.77, respectively). Low-to-moderate-intensity statins also had significant reductions in the risk of amputation and mortality (hazard ratio amputation, 0.81; 95% confidence interval, 0.75- 0.86; hazard ratio death, 0.83; 95% confidence interval, 0.81-0.86) in comparison with no statins (antiplatelet therapy only), but effect size was significantly weaker than the high-intensity statins (P<0.001). The association of high-intensity statins with lower amputation and death risk remained significant and robust in propensity score-matched, sensitivity, and subgroup analyses. CONCLUSIONS Statins, especially high-intensity formulations, are underused in patients with PAD. This is the first population-based study to show that high-intensity statin use at the time of PAD diagnosis is associated with a significant reduction in limb loss and mortality in comparison with low-to-moderate-intensity statin users, and patients treated only with antiplatelet medications but not with statins, as well.
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Weiss S, Sen I, Huang Y, Killian JM, Harmsen WS, Mandrekar J, Chamberlain AM, Goodney PP, Roger VL, DeMartino RR. Abstract 204: Cardiovascular Mortality and Non-fatal Cardiovascular Events After Diagnosis of Acute Aortic Syndrome. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Acute aortic syndrome (AAS) includes aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU) and confers high rates of aortic related events. However, the risk of cardiovascular (CV) events in this patient group is unknown. The aim of this study was to define the rates of CV events in an incident cohort of AAS patients.
Methods:
Medical records and death certificates of all Olmsted County, MN residents with a diagnosis of AAS from 1995-2015 were reviewed and compared to age- and sex- matched population controls. Primary outcome was non-aortic CV mortality. Secondary outcome was overall mortality and first time non-fatal CV event (myocardial infarction (MI), heart failure (HF) or stroke). Events were analyzed using Cox proportional hazards regression adjusting for comorbidities.
Results:
Of 133 patients with AAS (77 AD, 21 IMH, 35 PAU) 57% were male, median age was 72 (SD 14) and median follow-up was 10 years. Overall survival in AAS cases and controls was 62% versus 83% at 5 years and 44% versus 60% at 10 years (adj HR 1.8, p<.001, 95% CI 1.3-2.4). CV death occurred in 21 (29%) of 73 AAS decedents due to HF (9), MI (5), other cardiac causes (5), stroke (1) and peripheral vascular disease (1). CV-related survival at 5 and 10 years after AAS diagnosis (91% and 81%) was not significantly different from controls (95% and 86%) after adjustment for comorbidities (adj HR 1.8, p=.1, 95% CI 0.9-3.6). AAS was associated with an increased risk of any first time CV event (adj HR 2.6, p<.001, 95% CI 1.6-4.4; Figure), first time diagnosis of MI (adj HR 2.8, p<.001, 95% CI 1.7-4.7) and HF (adj HR 3.2, p<.001, 95% CI 1.6-6.2) but not stroke. When excluding acute events within 14 days of diagnosis, AAS was still associated with a significantly higher mortality (adj HR 1.6, p=.011, 95% CI 1.1-2.4) and an increased risk of any first time CV event (adj HR 2.2, p=.018, 95% CI 1.1-4.1), first time MI (adj HR 2.2, p=.012, 95% CI 1.2-4.1) and HF (adj HR 2.9, p=.006, 95% CI 1.4-6.2) but not stroke.
Conclusions:
AAS is associated with a higher overall mortality and an increased risk of any first time CV event, first time MI and HF that persists beyond the acute phase. These data highlight the risk of CV events among those with AAS and implicate the need for long-term cardiovascular management in these patients.
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Suckow BD, Ramkumar N, Brown JR, Sedrakyan AS, Stone DH, Cronenwett JL, Goodney PP. Sex and Lesion Complexity Are Associated with Choice of Treatment Modality for Peripheral Vascular Interventions. Ann Vasc Surg 2018. [DOI: 10.1016/j.avsg.2018.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Columbo JA, Davies L, Kang R, Barnes JA, Leinweber KA, Suckow BD, Goodney PP, Stone DH. Patient Experience of Recovery After Major Leg Amputation for Arterial Disease. Vasc Endovascular Surg 2018; 52:262-268. [DOI: 10.1177/1538574418761984] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: To date, studies of vascular amputees primarily examine quantitative outcomes following limb loss. Less is known about the patient’s perspective after major lower limb amputation. Here, we define and describe the postamputation recovery period. Methods: Qualitative study using purposive, maximum variation sampling on the variables of amputation level and times since surgery. We first conducted structured interviews with 20 participants (median age: 65 years, range: 45-88 years; 85% male; below knee amputation n = 14; above knee amputation n = 6; median time from amputation to interview = 16 months, range: 4-51 months). Findings were validated via a focus group with 5 amputees. Data were coded, analyzed, and interpreted by 2 reviewers. Results: All participants expressed the desire to have an active role in the decision to undergo amputation, even while acknowledging that limb salvage options were exhausted. Following amputation, participants described a 6-month recovery period when they learned to modify daily activities to accommodate their new functional and psychological needs. Participants defined recovery as when they had regained functional independence, which was described as a level of mobility that allowed them to perform daily activities with minimal assistance. Concerns that participants felt were poorly addressed included uncontrolled pain, feeling unprepared to live with an amputation, and questions about prosthetics. Two of the 5 focus group participants stated a preference for amputation earlier in the treatment course. Conclusions: Postamputation recovery has an early (up to 6 months) and late phase (after 6 months) and concludes when amputees regain what they perceive as independence. Patients desire to participate in amputation decision-making; in this study, some would have preferred amputation earlier in their clinical course. Attention to the domains that impact quality of life, and fostering a shared decision-making process, are opportunities to enhance postamputation recovery.
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Saab F, Jaff MR, Diaz-Sandoval LJ, Engen GD, McGoff TN, Adams G, Al-Dadah A, Goodney PP, Khawaja F, Mustapha JA. Chronic Total Occlusion Crossing Approach Based on Plaque Cap Morphology: The CTOP Classification. J Endovasc Ther 2018; 25:284-291. [DOI: 10.1177/1526602818759333] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose: To present the chronic total occlusion (CTO) crossing approach based on plaque cap morphology (CTOP) classification system and assess its ability to predict successful lesion crossing. Methods: A retrospective analysis was conducted of imaging and procedure data from 114 consecutive symptomatic patients (mean age 69±11 years; 84 men) with claudication (Rutherford category 3) or critical limb ischemia (Rutherford category 4–6) who underwent endovascular interventions for 142 CTOs. CTO cap morphology was determined from a review of angiography and duplex ultrasonography and classified into 4 types (I, II, III, or IV) based on the concave or convex shape of the proximal and distal caps. Results: Statistically significant differences among groups were found in patients with rest pain, lesion length, and severe calcification. CTOP type II CTOs were most common and type III lesions the least common. Type I CTOs were most likely to be crossed antegrade and had a lower incidence of severe calcification. Type IV lesions were more likely to be crossed retrograde from a tibiopedal approach. CTOP type IV was least likely to be crossed in an antegrade fashion. Access conversion, or need for an alternate access, was commonly seen in types II, III, and IV lesions. Distinctive predictors of access conversion were CTO types II and III, lesion length, and severe calcification. Conclusion: CTOP type I lesions were easiest to cross in antegrade fashion and type IV the most difficult. Lesion length >10 cm, severe calcification, and CTO types II, III, and IV benefited from the addition of retrograde tibiopedal access.
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Bostock IC, Zarkowsky DS, Hicks CW, Stone DH, Malas MB, Goodney PP. Outcomes and Risk Factors Associated with Prolonged Intubation after EVAR. Ann Vasc Surg 2018; 50:167-172. [PMID: 29481928 DOI: 10.1016/j.avsg.2017.11.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/01/2017] [Accepted: 11/19/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Time to discharge has decreased for aortic surgery since the advent of endovascular aortic aneurysm repair (EVAR), partially due to improved perioperative management. We aimed to investigate outcomes and risk factors associated with prolonged intubation following EVAR. METHODS The Vascular Study Group of New England (VSGNE) database was queried to select all patients who underwent elective EVAR between January 2003 and December 2014. Patients who were not extubated in the operating room were classified as having prolonged intubation. Patients requiring prolonged intubation were compared with those extubated in the operating room using t-test and chi-square statistics. Kaplan-Meier survival analyses estimated all-cause mortality. Independent predictors associated with prolonged intubation, including postoperative pneumonia or respiratory failure, were examined using multivariable logistic regression. RESULTS A total of 3,979 patients were identified within the elective EVAR VSGNE data set, among whom 5.2% required prolonged intubation. Patients with prolonged intubation were older, more frequently female, non-Hispanic, had larger aneurysms, and had a more frequent diagnoses of diabetes, congestive heart failure, coronary artery disease, ejection fraction < 50%, and chronic obstructive pulmonary disease (all P < 0.05). Respiratory complications occurred in 25.5% of patients with prolonged intubation vs. 1.8% of patients who were extubated in the operating room (P < 0.001). Kaplan-Meier survival estimates suggested patients requiring prolonged intubation after EVAR had significantly lower survivals than those who extubated in the operating room (P < 0.05). On multivariable analysis, independent risk factors associated with prolonged intubation included subjective lack of fitness for open procedure (OR: 4.8, 95% confidence interval [CI]: 3.5-8.7), ejection fraction < 50% (1.8, 1.3-2.8), and ASA class >3 (1.5, 1.1-1.7). CONCLUSIONS Prolonged intubation following EVAR is associated with increased risk of postoperative respiratory complications, as well as decreased long-term survival. High-risk patients for prolonged intubation, including those deemed subjectively unfit for an open procedure, ejection fraction < 50% and ASA class >3, may not benefit from an elective EVAR.
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Wang GJ, Goodney PP, Sedrakyan A. Conceptualizing treatment of uncomplicated type B dissection using the IDEAL framework. J Vasc Surg 2018; 67:662-668. [PMID: 29389429 DOI: 10.1016/j.jvs.2017.10.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 10/10/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to introduce a new framework, called IDEAL (idea, development, exploration, assessment, and long-term study), to guide physicians, investigators, and regulatory agencies through the life cycle of device development and procedural refinement. METHODS This review describes the IDEAL framework and illustrates its application for treatment of uncomplicated type B dissection (uTBD) as an example of this process. RESULTS Components of IDEAL are summarized and applied to devices used to treat uTBD. Treatment of uTBD is currently in the exploration phase, with concurrent assessment and long-term study being facilitated by detailed registries. CONCLUSIONS The application of IDEAL to the development and monitoring of technologies standardizes the nomenclature, facilitates evidence-based practice, and enhances the innovation process.
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Soden PA, Zettervall SL, Deery SE, Hughes K, Stoner MC, Goodney PP, Vouyouka AG, Schermerhorn ML. Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention. J Vasc Surg 2018; 67:549-556.e3. [PMID: 28951156 PMCID: PMC5794625 DOI: 10.1016/j.jvs.2017.06.089] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 06/07/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although many studies have demonstrated racial disparities after major vascular surgery, few have identified the reasons for these disparities, and those that did often lacked clinical granularity. Therefore, our aim was to evaluate differences in initial vascular intervention between black and white patients. METHODS We identified black and white patients' initial carotid, abdominal aortic aneurysm (AAA), and infrainguinal peripheral artery disease (PAD) interventions in the Vascular Quality Initiative (VQI) registry from 2009 to 2014. We excluded nonblack or nonwhite patients as well as those with Hispanic ethnicity, asymptomatic PAD, or a history of prior ipsilateral interventions. We compared baseline characteristics and disease severity at time of intervention on a national and regional level. RESULTS We identified 76,372 patients (9% black), including 35,265 carotid (5% black), 17,346 AAA (5% black), and 23,761 PAD interventions (18% black). For all operations, black patients were younger, more likely female, and had more insulin-dependent diabetes, hypertension, congestive heart failure, renal dysfunction, and dialysis dependence. Black patients were less likely to be on a statin before AAA (62% vs 69%; P < .001) or PAD intervention (61% vs 67%; P < .001) and also less likely to be discharged on an antiplatelet and statin regimen after these procedures (AAA, 60% vs 64% [P = .01]; PAD, 64% vs 67% [P < .001]). Black patients presented with more severe disease, including higher proportions of symptomatic carotid disease (36% vs 31%; P < .001), symptomatic or ruptured AAA (27% vs 16%; P < .001), and chronic limb-threatening ischemia (73% vs 62%; P < .001). Black patients more often presented with concurrent iliac artery aneurysms at the time of AAA repair (elective open AAA repair, 46% vs 26% [P < .001]; elective endovascular aneurysm repair, 38% vs 23% [P < .001]). CONCLUSIONS Black patients present with more advanced disease at the time of initial major vascular operation. Efforts to control risk factors, identify and treat arterial disease in a timely fashion, and optimize medical management among black patients may provide opportunity to improve current disparities.
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Suckow BD, Goodney PP, Columbo JA, Kang R, Stone DH, Sedrakyan A, Cronenwett JL, Fillinger MF. National trends in open surgical, endovascular, and branched-fenestrated endovascular aortic aneurysm repair in Medicare patients. J Vasc Surg 2017; 67:1690-1697.e1. [PMID: 29290495 DOI: 10.1016/j.jvs.2017.09.046] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 09/24/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Open repair effectively prevents rupture for patients with abdominal aortic aneurysm (AAA) and is commonly studied as a metric reflecting hospital and surgeon expertise in cardiovascular care. However, given recent advances in endovascular aneurysm repair (EVAR), such as branched-fenestrated EVAR, it is unknown how commonly open surgical repair is still used in everyday practice. METHODS We analyzed trends in open AAA repair, EVAR, and branched-fenestrated EVAR for AAA in Medicare beneficiaries from 2003 to 2013. We used Medicare Part B claims to ascertain counts of these repair types annually during the study period. We assessed regional and national trends in characteristics of the patients and procedure volume. RESULTS Between 2003 and 2013, the total number of AAA repairs performed in fee-for-service Medicare patients declined by 26% from 31,582 to 23,421 (P < .001), after a peak number of 32,540 was performed in 2005 (28% decline since 2005). The number of open AAA repairs steadily declined by a total of 76%, from 20,533 in 2003 to 4916 in 2013 (P < .001). Whereas the number of EVARs increased from 11,049 in 2003 to 19,247 in 2011 (P < .001), it has since declined a total of 15% to only 16,362 repairs in 2013 (P < .001). After its introduction in 2011, the number of branched-fenestrated EVAR cases continuously rose from 335 procedures in 2011 to 2143 procedures in 2013 (P < .001). By 2013, virtually all hospital referral regions in the United States had rates of open AAA repair that would have been in the lowest quintile of volume in 2003. CONCLUSIONS The number of open AAA repairs fell by nearly 80% during the last decade, whereas traditional EVAR declined slightly and branched-fenestrated EVAR rapidly disseminated into national practice. These results suggest that open AAA repair is now performed too infrequently to be used as a metric in the assessment of hospital and surgeon quality in cardiovascular care. Furthermore, surgical training paradigms will need to reflect the changing dynamics necessary to ensure that surgeons and interventionists can safely perform these high-risk surgical procedures.
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Schroeck FR, Patterson OV, Alba PR, Pattison EA, Seigne JD, DuVall SL, Robertson DJ, Sirovich B, Goodney PP. Development of a Natural Language Processing Engine to Generate Bladder Cancer Pathology Data for Health Services Research. Urology 2017; 110:84-91. [PMID: 28916254 PMCID: PMC5696035 DOI: 10.1016/j.urology.2017.07.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/13/2017] [Accepted: 07/25/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To take the first step toward assembling population-based cohorts of patients with bladder cancer with longitudinal pathology data, we developed and validated a natural language processing (NLP) engine that abstracts pathology data from full-text pathology reports. METHODS Using 600 bladder pathology reports randomly selected from the Department of Veterans Affairs, we developed and validated an NLP engine to abstract data on histology, invasion (presence vs absence and depth), grade, the presence of muscularis propria, and the presence of carcinoma in situ. Our gold standard was based on an independent review of reports by 2 urologists, followed by adjudication. We assessed the NLP performance by calculating the accuracy, the positive predictive value, and the sensitivity. We subsequently applied the NLP engine to pathology reports from 10,725 patients with bladder cancer. RESULTS When comparing the NLP output to the gold standard, NLP achieved the highest accuracy (0.98) for the presence vs the absence of carcinoma in situ. Accuracy for histology, invasion (presence vs absence), grade, and the presence of muscularis propria ranged from 0.83 to 0.96. The most challenging variable was depth of invasion (accuracy 0.68), with an acceptable positive predictive value for lamina propria (0.82) and for muscularis propria (0.87) invasion. The validated engine was capable of abstracting pathologic characteristics for 99% of the patients with bladder cancer. CONCLUSION NLP had high accuracy for 5 of 6 variables and abstracted data for the vast majority of the patients. This now allows for the assembly of population-based cohorts with longitudinal pathology data.
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Iribarne A, Goodney PP, Flores AM, DeSimone J, DiScipio AW, Austin A, McCullough JN. National Trends and Geographic Variation in Bilateral Internal Mammary Artery Use in the United States. Ann Thorac Surg 2017; 104:1902-1907. [PMID: 29102303 DOI: 10.1016/j.athoracsur.2017.08.055] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 07/12/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The goal of this study was to characterize the adoption rate and regional variation in bilateral internal mammary artery (BIMA) use during coronary artery bypass grafting (CABG) in the United States. METHODS Observational study of 100% sample of fee-for-service Medicare beneficiaries aged 65 years or older, continuously enrolled in Parts A and B from 2009 to 2014 (n = 162,860,439). Rates of beneficiaries receiving a BIMA versus single internal mammary artery (SIMA) during CABG are expressed per 1,000 beneficiaries and aggregated by Hospital Referral Region (HRR). An HRR is a validated unit for quantifying regional variation in health care. RESULTS The absolute national rate of BIMA use declined during the study period from 0.21 claims per 1,000 beneficiaries in 2009 to 0.13 in 2014 (p < 0.001). When indexed to overall CABG volume, no change was seen in the frequency of BIMA use over time (p = 0.883). SIMA use ranged from 1.3 to 8.5 claims per 1,000 Medicare beneficiaries, whereas BIMA use ranged from 0 to 1.5 (p < 0.001). A significant correlation was found between regional volume of SIMA use and likelihood of BIMA use (correlation coefficient 0.673, p < 0.001). Although both SIMA and BIMA use correlated with regional volume of diagnostic cardiac catheterization, the correlation was stronger for SIMA use (correlation coefficient 0.962 versus 0.682, p < 0.001). CONCLUSIONS Over the past 5 years, no growth was seen in BIMA use among Medicare beneficiaries, and the frequency of BIMA use during CABG remained low. There was significant regional variation in BIMA use, however, which demonstrates opportunity for continued growth of BIMA grafting.
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Schroeck FR, Sirovich B, Seigne JD, Robertson DJ, Goodney PP. Assembling and validating data from multiple sources to study care for Veterans with bladder cancer. BMC Urol 2017; 17:78. [PMID: 28877694 PMCID: PMC5585934 DOI: 10.1186/s12894-017-0271-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 08/31/2017] [Indexed: 11/17/2022] Open
Abstract
Background Despite the high prevalence of bladder cancer, research on optimal bladder cancer care is limited. One way to advance observational research on care is to use linked data from multiple sources. Such big data research can provide real-world details of care and outcomes across a large number of patients. We assembled and validated such data including (1) administrative data from the Department of Veterans Affairs (VA), (2) Medicare claims, (3) data abstracted by tumor registrars, (4) data abstracted via chart review from the national electronic health record, and (5) full text pathology reports. Methods Based on these combined data, we used administrative data to identify patients with newly diagnosed bladder cancer who received care in the VA. To validate these data, we first compared the diagnosis date from the administrative data to that from the tumor registry. Second, we measured accuracy of identifying bladder cancer care in VA administrative data, using a random chart review (n = 100) as gold standard. Lastly, we compared the proportion of patients who received bladder cancer care among those who did versus did not have full text bladder pathology reports available, expecting that those with reports are significantly more likely to receive care in VA. Results Out of 26,675 patients, 11,323 (42%) had tumor registry data available. 90% of these patients had a difference of 90 days or less between the diagnosis dates from administrative and registry data. Among 100 patients selected for chart review, 59 received bladder cancer care in VA, 58 of which were correctly identified using administrative data (sensitivity 98%, specificity 90%). Receipt of bladder cancer care was substantially more common among those who did versus did not have bladder pathology available (96% vs. 43%, p < 0.001). Conclusion Merging administrative with electronic health record and pathology data offers new possibilities to validate the use of administrative data in bladder cancer research. Electronic supplementary material The online version of this article (10.1186/s12894-017-0271-x) contains supplementary material, which is available to authorized users.
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Soden PA, Zettervall SL, Shean KE, Vouyouka AG, Goodney PP, Mills JL, Hallett JW, Schermerhorn ML. Regional variation in outcomes for lower extremity vascular disease in the Vascular Quality Initiative. J Vasc Surg 2017; 66:810-818. [PMID: 28450103 PMCID: PMC5572773 DOI: 10.1016/j.jvs.2017.01.061] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 01/31/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Increased focus has been placed on perioperative and long-term outcomes in the treatment of peripheral artery disease (PAD), both for purposes of quality improvement and for assessment of performance at a surgeon and institutional level. This study evaluates regional variation in outcomes after treatment for PAD within the Vascular Quality Initiative (VQI). By describing the variation in practice patterns and outcomes across regions, we hope that each regionally based quality group can select which areas are most important for them to focus on as they will have access to their regional data to compare. METHODS We identified all patients in the VQI who had infrainguinal bypass or endovascular intervention from 2009 to 2014. We compared variation in perioperative and 1-year outcomes stratified by symptom status and revascularization type among the 16 regional groups of the VQI. We analyzed variation in perioperative end points using χ2 analysis, and 1-year end points were analyzed using Kaplan-Meier and life-table analysis. RESULTS We identified 15,338 bypass procedures for symptomatic PAD: 27% for claudication, 59% for chronic limb-threatening ischemia (CLI; 61% of these for tissue loss), and 14% for acute limb ischemia. We identified 33,925 endovascular procedures for symptomatic PAD: 42% for claudication, 48% for CLI (73% of these for tissue loss), and 10% for acute limb ischemia. Thirty-day mortality varied significantly after endovascular intervention for CLI (0.5%-3%; P < .001) but not for claudication (0.0%-0.5%, P = .77) or for bypass for claudication (0.0%-2.6%; P = .37) or CLI (0.0%-5.0%; P = .08). After bypass, rates of >2 units transfused red blood cells (claudication, 0.0%-13% [P < .001]; CLI, 6.9%-27% [P < .001]) varied significantly. In-hospital major amputation was variable after bypass for CLI (0.0%-4.3%; P = .004) but not for claudication (0.0%-0.6%; P = .98), as was postoperative myocardial infarction (claudication, 0.0%-4% [P = .36]; CLI, 0.8%-6% [P = .001]). One-year survival varied significantly for endovascular interventions for claudication (92%-100%; P < .001), bypass for CLI (85%-94% [P < .001]), and endovascular interventions for CLI (77%-96%; P < .001) but not after bypass for claudication (95%-100%; P = .57). CONCLUSIONS In this real-world comparison among VQI regions, we found significant variation in perioperative and 1-year end points for patients with PAD undergoing bypass or endovascular intervention. This study highlights opportunities for quality improvement efforts to reduce variation and to improve outcomes.
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Newhall KA, Stone DH, Goodney PP. Reply. J Vasc Surg 2017; 66:968-969. [DOI: 10.1016/j.jvs.2017.06.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 11/29/2022]
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217
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Deery SE, Ergul EA, Schermerhorn ML, Siracuse JJ, Schanzer A, Goodney PP, Cambria RP, Patel VI. Aneurysm sac expansion is independently associated with late mortality in patients treated with endovascular aneurysm repair. J Vasc Surg 2017; 67:157-164. [PMID: 28865980 DOI: 10.1016/j.jvs.2017.06.075] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/07/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms can exhibit variations in sac behavior ranging from complete regression to expansion. We evaluated the impact of sac behavior at 1-year follow-up on late survival. METHODS We used the Vascular Study Group of New England (VSGNE) registry from 2003 to 2011 to identify EVAR patients with 1-year computed tomography follow-up. Aneurysm sac enlargement ≥5 mm (sac expansion) and decrease ≥5 mm (sac regression) were defined per Society for Vascular Surgery guidelines. Predictors of change in sac diameter and impact of sac behavior on long-term mortality were assessed by multivariable methods. RESULTS Of 2437 patients who underwent EVAR, 1802 (74%) had complete 1-year follow-up data and were included in the study. At 1 year, 162 (9%) experienced sac expansion, 709 (39%) had a stable sac, and 931 (52%) experienced sac regression. Sac expansion was associated with preoperative renal insufficiency (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.5-8.0; P < .01), urgent repair (OR, 2.7; 95% CI, 1.4-5.1; P < .01), hypogastric coverage (OR, 1.7; 95% CI, 1.1-2.7; P = .02), and type I/III (OR, 16.8; 95% CI, 7.3-39.0; P < .001) or type II (OR, 2.9; 95% CI, 2.0-4.3; P < .001) endoleak at follow-up, and sac expansion was inversely associated with smoking (OR, 0.6; 95% CI, 0.4-0.96; P = .03) and baseline aneurysm diameter (OR, 0.7; 95% CI, 0.6-0.9; P < .001). Sac regression (vs expansion or stable sac) was associated with female gender (OR, 1.8; 95% CI, 1.4-2.4; P < .001) and larger baseline aneurysm diameter (OR, 1.4; 95% CI, 1.2-1.5; P < .001) and inversely associated with type I/III (OR, 0.2; 95% CI, 0.1-0.5; P < .01) or type II endoleak at follow-up (OR, 0.2; 95% CI, 0.2-0.3; P < .001). After risk-adjusted Cox regression, sac expansion was independently associated with late mortality (hazard ratio, 1.5; 95% CI, 1.1-2.0; P = .01), even with adjustment for reinterventions and endoleak during follow-up. Sac regression was associated with lower late mortality (hazard ratio, 0.6; 95% CI, 0.5-0.7; P < .001). Long-term survival was lower (log-rank, P < .001) in patients with sac expansion (98% 1-year and 68% 5-year survival) compared with all others (99% 1-year and 83% 5-year survival). CONCLUSIONS These data suggest that an abdominal aortic aneurysm sac diameter increase of at least 5 mm at 1 year, although infrequent, is independently associated with late mortality regardless of the presence or absence of endoleak and warrants close observation and perhaps early intervention.
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Columbo JA, Martinez-Camblor P, MacKenzie TA, Staiger DO, Kang R, Goodney PP, O'Malley AJ. Long-Term Survival After Carotid Endarterectomy and Carotid Stenting: A Propensity-Matched Analysis. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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219
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Audu CO, Columbo JA, Sun SJ, Perri JL, Goodney PP, Stone DH, Nolan BW, Suckow BD. Variation in Timing and Type of Groin Wound Complications Highlights the Need for Uniform Reporting Standards. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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220
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Koo K, Zubkoff L, Sirovich BE, Goodney PP, Robertson DJ, Seigne JD, Schroeck FR. The Burden of Cystoscopic Bladder Cancer Surveillance: Anxiety, Discomfort, and Patient Preferences for Decision Making. Urology 2017; 108:122-128. [PMID: 28739405 DOI: 10.1016/j.urology.2017.07.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/19/2017] [Accepted: 07/13/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine discomfort, anxiety, and preferences for decision making in patients undergoing surveillance cystoscopy for non-muscle-invasive bladder cancer (NMIBC). METHODS Veterans with a prior diagnosis of NMIBC completed validated survey instruments assessing procedural discomfort, worry, and satisfaction, and were invited to participate in semistructured focus groups about their experience and desire to be involved in surveillance decision making. Focus group transcripts were analyzed qualitatively, using (1) systematic iterative coding, (2) triangulation involving multiple perspectives from urologists and an implementation scientist, and (3) searching and accounting for disconfirming evidence. RESULTS Twelve patients participated in 3 focus groups. Median number of lifetime cystoscopy procedures was 6.5 (interquartile range 4-10). Based on survey responses, two-thirds of participants (64%) experienced some degree of procedural discomfort or worry, and all participants reported improvement in at least 2 dimensions of overall well-being following cystoscopy. Qualitative analysis of the focus groups indicated that participants experience preprocedural anxiety and worry about their disease. Although many participants did not perceive themselves as having a defined role in decision making surrounding their surveillance care, their preferences to be involved in decision making varied widely, ranging from acceptance of the physician's recommendation, to uncertainty, to dissatisfaction with not being involved more in determining the intensity of surveillance care. CONCLUSION Many patients with NMIBC experience discomfort, anxiety, and worry related to disease progression and not only cystoscopy. Although some patients are content to defer surveillance decisions to their physicians, others prefer to be more involved. Future work should focus on defining patient-centered approaches to surveillance decision making.
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Perri JL, Nolan BW, Goodney PP, DeMartino RR, Brooke BS, Arya S, Conrad MF, Cronenwett JL. Factors affecting operative time and outcome of carotid endarterectomy in the Vascular Quality Initiative. J Vasc Surg 2017; 66:1100-1108. [PMID: 28712813 DOI: 10.1016/j.jvs.2017.03.426] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/18/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Prior studies have suggested a relationship between operative (Op) time and outcome after major vascular procedures. This study analyzed factors associated with Op time and outcome after carotid endarterectomy (CEA) in the Vascular Quality Initiative (VQI) registry. METHODS Elective, primary CEAs without high anatomic risk or concomitant procedures from 2012 to 2015 in the VQI were analyzed (N = 26,327, performed by 1188 surgeons from 249 centers). Multivariable analysis was used to identify patient, procedure, and surgeon factors associated with Op time and major adverse events (MAEs), categorized as either technical (ipsilateral stroke, cranial nerve injury, reoperation) or cardiac (myocardial infarction, congestive heart failure, dysrhythmia requiring treatment, surgical site infection, and death). RESULTS The mean CEA Op time in the VQI was 114 minutes, with the mean Op time for individual surgeons ranging from 37 to 305 minutes. Procedural factors and the surgeon's volume were responsible for much of the variation in overall Op time (patient factors that reflected demographics and comorbidities each added 5.9 to 6.8 minutes; procedural factors, such as patch angioplasty and completion duplex ultrasound, each added 5.5 to 16.4 minutes; the lowest quartile of the surgeon's annual case volume added 24 minutes). Chi-pie analysis demonstrated that patient factors accounted for 17% of variability in Op time; procedural factors, 44%; and the surgeon's annual volume, 39%. Increasing Op time was highly associated with increased rates of MAEs (P < .001 for cardiac, technical, and death rates). Based on hierarchical multiple logistic regression, cardiac complications were independently associated with increased Op time (comparing surgeons in highest quartile of Op time with those in the lowest: odds ratio, 2.16 for cardiac MAE; 95% confidence interval, 1.59-2.95; P < .001) but not with the surgeon's annual volume. Technical complications were independently associated with a surgeon's low volume (comparing surgeons with the highest annual case volume by quartile against the lowest: odds ratio, 1.25 for technical MAE; 95% confidence interval, 1.06-1.48; P < .001) but not with Op time. CONCLUSIONS Op time for elective, primary CEAs varies substantially across surgeons in the VQI. Increased Op time is associated with a surgeon's lower annual CEA volume in addition to patient variables and techniques employed. Cardiac complications after CEA are associated with longer Op time, whereas technical complications are associated with a surgeon's low annual volume.
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David RA, Brooke BS, Hanson KT, Goodney PP, Genovese EA, Baril DT, Gloviczki P, DeMartino RR. Early extubation is associated with reduced length of stay and improved outcomes after elective aortic surgery in the Vascular Quality Initiative. J Vasc Surg 2017; 66:79-94.e14. [PMID: 28366307 PMCID: PMC6114133 DOI: 10.1016/j.jvs.2016.12.122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/09/2016] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Timing of extubation after open aortic procedures varies across hospitals. This study was designed to examine extubation timing and determine its effect on length of stay (LOS) and respiratory complications after elective open aortic surgery. METHODS We studied extubation timing for 7171 patients undergoing elective open abdominal aortic aneurysm repair (2687 [37.5%]) or suprainguinal bypass for aortoiliac occlusive disease (4484 [62.5%]) from October 2010 to April 2015 in hospitals participating in the Vascular Quality Initiative (VQI). Our primary outcome was prolonged LOS (>7 days), and the secondary outcome was respiratory complications (pneumonia or reintubation). The association between extubation timing and outcomes was assessed using multivariable logistic regression mixed-effects models that adjusted for confounding factors at the patient and procedure level. A variable importance analysis was conducted using a chi-pie framework to identify factors contributing to the variability of extubation timing. RESULTS The 7171 patients undergoing abdominal aortic surgery were a mean age of 65.4 (standard deviation, 10.2) years, and 63% were male. Extubation occurred (1) in the operating room (76.3%), (2) <12 hours (10.9%), (3) 12 to 24 hours (7.2%), or (4) >24 hours (5.6%) after surgery. Hospitals in the top quartile for case volume had the highest percentage of patients extubated in the operating room (82.8%). Patients least likely to be extubated in the operating room were older, more likely to have chronic obstructive pulmonary disease, require vasopressors, have higher estimated blood loss (EBL), and longer procedure times. After adjustment for patient, procedure, and institutional factors, delayed extubation was associated with prolonged LOS (<12 hours: odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.7; 12-24 hours: OR, 2.1; 95% CI, 1.7-2.7; >24 hours: OR, 5.3; 95% CI, 4.0-6.9), and pulmonary complications (<12 hours: OR, 1.9; 95% CI, 1.4-2.6; 12-24 hours: OR, 2.6; 95% CI, 1.8-3.6; >24 hours: OR, 9.6; 95% CI, 7.1-13.0) compared with those extubated in the operating room. Subset analysis of patients extubated in the operating room or <12 hours showed that extubation out of the operating room was associated with prolonged LOS (OR, 1.4; 95% CI, 1.2-1.7) and pulmonary complications (OR, 1.8; 95% CI, 1.3-2.5). The variable importance analysis demonstrated that EBL (26%) and procedure time (24%) accounted for half of the variation in extubation timing. CONCLUSIONS Extubation in the operating room is associated with shorter LOS and morbidity after open aortic surgery. EBL, procedure time, and center variation account for variability in extubation timing. These data advocate for standardized perioperative respiratory care to reduce variation, improve outcomes, and reduce LOS.
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Perri JL, Zwolak RM, Goodney PP, Rutherford GA, Powell RJ. Reimbursement in hospital-based vascular surgery: Physician and practice perspective. J Vasc Surg 2017; 66:317-322. [DOI: 10.1016/j.jvs.2017.03.417] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/11/2017] [Indexed: 10/19/2022]
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Kang R, Columbo JA, Goodney PP. Assessing the Appropriateness of Carotid Revascularization: In the Eye of the Beholder. JAMA Surg 2017; 152:573. [PMID: 28249068 DOI: 10.1001/jamasurg.2017.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Ramkumar N, Suckow BD, Cronenwett JL, Goodney PP. Abstract 196: Gender-based Differences in Presentation and Treatment of Patients Undergoing Peripheral Vascular Intervention. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
While men and women are at equal risk for peripheral arterial disease (PAD), studies suggest that women present at an older age and with more advanced disease. The purpose of this analysis is to evaluate gender-based differences in disease presentation and its effect on treatment modality among patients who underwent peripheral vascular intervention (PVI) for PAD.
Methods:
Using national registry data from the Vascular Quality Initiative, univariate analysis, of patient-, limb- and artery-specific characteristics were performed by gender for procedures from 2010-2013. Statistical significance was determined by the Student’s T-test or Chi-squared test.
Results:
In this real-world cohort, there were 26,873 eligible procedures for 23,940 patients that had 30,668 limbs and 44,927 arteries treated. Compared to men, women presented at an older age (69 vs 71 years, p<0.001) and with more rest pain and tissue loss than claudication (RR=1.13, 95% CI: 1.10-1.16). Women had more severe lesions than men, as measured by TASC classification (TASC C or D RR= 1.81, 95% CI: 1.74-1.87) (
Table
1
). There were no meaningful gender-based differences in artery treated or treatment modality (
Figure
1
). Treatment modality was determined by disease severity (indication and TASC classification) and artery treated rather than gender.
Conclusion:
Although gender-based differences in PAD presentation exist, these differences do not extend to treatment modality, which is determined by disease severity and artery treated. Further investigation is required to appreciate the effect of disease severity and treatment modality on patient outcomes after PVI.
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