Current status of patient-reported outcome measures in vascular surgery

A Patient-Centered Textbook Outcome Measure Effectively Discriminates Contemporary Elective Open Abdominal Aortic Aneurysm Repair Quality

INTRODUCTION

There is persistent controversy surrounding the merit of surgical volume benchmarks being used solely as a sufficient proxy for assessing the quality of open abdominal aortic aneurysm (AAA) repair. Importantly, operative volume quotas may fail to reflect a more nuanced and comprehensive depiction of surgical outcomes most relevant to patients. Accordingly, we herein propose a patient-centered "textbook outcome" (TO) for AAA repair that is analogous to other large magnitude extirpative operations performed in other surgical specialties, and test its feasibility to discriminate hospital performance using Society for Vascular Surgery (SVS) volume guidelines.

METHODS

All elective open infrarenal AAA repairs (OAR) in the SVS-Vascular Quality Initiative were examined (2009-2022). The primary end-point was a TO, defined as a composite of no in-hospital complication or re-intervention/re-operation, length of stay ≤ 10-days, home discharge and 1-year survival. The discriminatory ability of the TO measure was assessed by comparing centers that did or did not meet the SVS annual OAR volume threshold recommendation (high-volume ≥ 10 OARs/year; low-volume <10 OARs/year). Logistic regression and multivariable models adjusted for patient and procedure-related differences.

RESULTS

A total of 9,657 OARs across 198 centers were analyzed (mean age-69.5±8.4, female-26%, non-white-12%). A TO was identified in 44% (N = 4,293) of the overall cohort. The incidence of individual TO components included: no in-hospital complication (61%), no in-hospital re-intervention/re-operation (92%), LOS ≤ 10-days (78%), home discharge (76%), and 1-year survival (91%). Median annual center volume was 6 [IQR 3, 10] and a majority of centers did not meet the SVS volume suggested threshold (<10 OARs/year: N = 148 [74%]). However, most patients (N = 6,265 of 9,657 [65%]) underwent OAR in high-volume hospitals. When comparing high and low-volume centers, a TO was more likely to occur in high-volume institutions: ≥10 OARs/year, 46% vs. <10 OARs/year, 42%; P=.0006. The association of a protective effect for higher center volume remained after risk adjustment: OR 1.1, 95%CI 1.05-1.26; P=.003.

CONCLUSIONS

Textbook outcomes for elective OAR reflect a more nuanced and comprehensive patient centered proxy to measure care delivery consistent with other surgical specialties. Surprisingly, a TO was achieved in < 50% of elective AAA cases nationally. Though the likelihood of a TO appears to correlate with SVS center volume recommendations, it more importantly reflects elements which may be prioritized by patients and thus offers insights into further improving real-world AAA care.

Comparing Post-operative Pain and Other Outcomes in Carotid Endarterectomy Versus Transcarotid Artery Revascularization

BACKGROUND

Transcarotid artery revascularization (TCAR) is growing in popularity. Although major clinical end-points such as stroke rate and mortality are well-known, patient reported outcomes such as pain, and length of stay are among the purported benefits that are as yet untested. We sought to determine if there are differences in pain and other clinical outcomes when comparing carotid endarterectomy (CEA) and TCAR.

METHODS

We performed a retrospective review of 326 patients undergoing TCAR (n = 50) or CEA (n = 276) from 2019-2023. Primary outcomes of interest were maximum pain numeric rating scales (NRS) reported in the post-anesthesia care unit (PACU) and on postoperative days (POD) zero and 1, and oral morphine milligram equivalents (OMMEs) received intraoperatively through POD1. Secondary outcomes included length of stay (LOS), complications, and 30-day emergency department (ED) returns/readmissions.

RESULTS

Fifty TCAR and 150 CEA patients were included in the propensity score matched cohorts. TCAR patients reported lower pain-NRS in PACU (P < .001) and on POD0 (P = .002), but similar pain scores on POD1 (P = .112). Postoperatively, TCAR patients were less likely to receive opioids (52% vs 75.3%, P = .003) and received less OMME from PACU through POD1 (12.8 ± 16.2 vs 23.2 ± 27.2, P = .001). After adjusting for age, sex, BMI, prior chronic opioid use, and prior carotid surgery, TCAR patients were approximately 70% less likely to receive post-operative opioids. No significant differences in LOS, 30-day ED returns/readmissions, or complications were observed between groups.

CONCLUSIONS

Compared with CEA, patients undergoing TCAR reported lower pain scores and consumed fewer narcotics overall. However, the absolute difference was modest, and pain scores were low in both cohorts. Differences in pain and post-operative narcotic use may be of less importance when deciding between TCAR and CEA. Total non-opioid protocols may be feasible in both approaches.

Patient reported outcome measures (PROMs) in zygomatic fracture surgery

Attitudes towards healthcare in the NHS and in other Western healthcare systems have been changing dramatically in recent years. There is a significant movement calling for a shift from the traditional paternalistic model, with patients as passive recipients of treatments that are supported by objective and observable evidence, towards a more holistic approach, in which patients have agency, and treatments are tailored to the individual needs of a particular patient. Whilst patient safety and clinical effectiveness remain intrinsic to the traditional measurement of successful healthcare, Patient Reported Outcome Measures (PROMs) are increasingly being advocated as an important tool to uphold patient-centric care in the NHS.The aim of this study is to complete the first evaluation of PROMs that we know of in patients receiving surgical management of zygomatic fractures, by comparing two interventions commonly used in this condition: the zygomaticomaxillary complex open reduction and internal fixation (ZMC ORIF), and the Gillies approach to zygomatic elevation. We demonstrate high levels of patient satisfaction across all domains, irrespective of surgical approach, but that mood and anxiety remain an issue after surgery.

Long-term limb salvage and functional outcomes for patients undergoing partial calcanectomy

INTRODUCTION

Partial calcanectomy (PC) can be performed to treat chronic heel ulcers in patients with calcaneal osteomyelitis. Patients undergoing PC often have multiple comorbidities, limited mobility, and face high risk of major limb amputation. This study examined the extent of vascular diagnostic testing and interventions as well as long-term outcomes in patients undergoing PC.

METHODS

A retrospective analysis was performed on patients who underwent PC for non-healing calcaneal ulcer over a ten-year period. Demographics, comorbidities, vascular testing, and procedural data were recorded. Additional subgroup analysis was performed according to presence or absence of peripheral arterial disease (PAD). Primary outcomes were major limb amputation (above or below the knee) and mortality. Secondary outcomes included successful wound healing, time to complete wound healing, re-interventions, and change in ambulatory status.

RESULTS

A total of 157 patients underwent partial calcanectomies on 162 limbs. 78.3% of patients had diabetes mellitus and 47.8% were diagnosed with PAD. Ankle brachial index with pulse volume recording (ABI/PVR) was performed for 46.5% (73/157) of patients, arterial duplex in 44.6% (70/157), and 19.7% (31/157) had a computed tomography angiogram. Lower extremity revascularization was performed in 28.4% of limbs (46/162). Independent ambulatory status was reported in 40.1% prior to PC and decreased to 17.9% by the time of last recorded follow-up (p < .00001). Long-term amputation-free survival was significantly higher in patients without PAD at 7 years (78.4% vs 57.1%, p = .02). Multivariate logistic regression analysis demonstrated that PAD and end-stage renal disease (ESRD) increased the odds of major limb amputation (OR 3.5 and 2.8, respectively), whereas ESRD and adjuvant podiatric procedures were associated with increased mortality (OR 4.8 and 4.8, respectively).

CONCLUSION

Non-invasive vascular testing should be obtained in all patients undergoing PC, in order to stratify risk of amputation and identify candidates for revascularization. Over the long-term, patients undergoing PC face significant risk of prolonged wound healing, decline in ambulatory status, and major limb amputation.

Longitudinal assessment of health-related quality of life and clinical outcomes with at home advanced pneumatic compression treatment of lower extremity lymphedema

OBJECTIVE

This prospective, longitudinal, pragmatic study describes at home treatment with a proprietary advanced pneumatic compression device (APCD) for patients with lower extremity lymphedema (LED).

METHODS

Following institutiona review board approval, four participating Veterans Affairs centers enrolled LED patients from 2016 to 2022. The primary outcome measures were health-related quality of life (HR-QoL) questionnaires (lymphedema quality of life-leg and the generic SF-36v2) obtained at baseline and 12, 24, and 52 weeks. The secondary outcome measures were limb circumference, cellulitis events, skin quality, and compliance with APCD and other compression therapies.

RESULTS

Because a portion of the trial was conducted during the coronavirus disease 2019 pandemic, 179 patients had 52 weeks of follow-up, and 143 had complete measurements at all time points. The baseline characteristics were a mean age of 66.9 ± 10.8 years, 91% were men, and the mean body mass index was 33.8 ± 6.9 kg/m2. LED was bilateral in 92.2% of the patients. Chronic venous insufficiency or phlebolymphedema was the most common etiology of LED (112 patients; 62.6%), followed by trauma or surgery (20 patients; 11.2%). Cancer treatment as a cause was low (4 patients; 2.3%). Patients were classified as having International Society for Lymphology stage I (68.4%), II (27.6%), or III (4.1%). Of the primary outcome measures, significant improvements were observed in all lymphedema quality of life-leg domains of function, appearance, symptoms, and emotion and the overall score after 12 weeks of treatment (P < .0001) and through 52 weeks of follow-up. The SF-36v2 demonstrated significant improvement in three domains at 12 weeks and in the six domains of physical function, bodily pain, physical component (P < .0001), social functioning (P = .0186), role-physical (P < .0006), and mental health (P < .0333) at 52 weeks. An SF-36v2 score <40 indicates a substantial reduction in HR-QoL in LED patients compared with U.S. norms. Regarding the secondary outcome measures at 52 weeks, compared with baseline, the mean limb girth decreased by 1.4 cm (P < .0001). The maximal reduction in mean limb girth was 1.9 cm (6.0%) at 12 weeks in ISL stage II and III limbs. New episodes of cellulitis in patients with previous episodes (21.4% vs 6.1%, P = .001) were reduced. The 75% of patients with skin hyperpigmentation at baseline decreased to 40% (P < .01) at 52 weeks. At 52 weeks, compliance, defined as use for 5 to 7 days per week, was reported for the APCD by 72% and for elastic stockings by 74%.

CONCLUSIONS

This longitudinal study of Veterans Affairs patients with LED demonstrated improved generic and disease-specific HR-QoL through 52 weeks with at home use of an APCD. Limb girth, cellulitis episodes, and skin discoloration were reduced, with excellent compliance.

Daly/Cost comparison in the management of peripheral arterial disease at 17 Belgian hospitals

OBJECTIVE

Peripheral arterial disease (PAD) is a manifestation of atherosclerosis that affects the lower extremities and afflicts more than 200 million people worldwide. Because of limited resources, the need to provide quality care associated with cost control is essential for health policies. Our study concerns an interhospital comparison among seventeen Belgian hospitals that integrates the weighting of quality indicators and the costs of care, from the hospital perspective, for a patient with this pathology in 2018.

METHODS

The disability-adjusted life years (DALYs) were calculated by adding the number of years of life lost due to premature death and the number of years of life lost due to disability for each in-hospital stay. The DALY impact was interpreted according to patient safety indicators. We compared the hospitals using the adjusted values ​​of costs and DALYs for their case mix index, obtained by relating the observed value to the predicted value obtained by linear regression.

RESULTS

We studied 2,437 patients and recorded a total of 560.1 DALYs in hospitals. The in-hospital cost average [standard deviation (SD)] was €8,673 (€10,893). Our model identified the hospitals whose observed values were higher than predicted; six needed to reduce the costs and impacts of DALYs, six needed to improve one of the two factors, and four seemed to have good results. The average cost (SD) for the worst performing hospitals amounted to €27,803 (€28,358).

CONCLUSIONS

Studying the costs of treatment according to patient safety indicators permits us to evaluate the entire chain of care using a comparable unit of measurement.

A state-of-the-art review of quality-of-life assessment in venous disease

OBJECTIVE

Chronic venous disease is a common condition and has a significant impact on patients' health status. Validated patient-reported outcome measures (PROMs) used to assess health status are needed to measure health status. This state-of-the-art review summarizes the current validation evidence for disease-specific PROMs for chronic venous disease and provides a framework for their use in the clinical setting.

METHODS

A literature search in OVID Embase and Medline was conducted to identify relevant English-language studies of chronic venous disease that used disease-specific PROMs between January 1, 1993, and June 30, 2022. Abstracts and titles from identified studies were screened by four investigators, and full-text articles were subsequently screened for eligibility. Data on validation of disease-specific PROMs was abstracted from each included article. Classical test theory was used as a framework to examine a priori defined validation criteria for content validity, reliability (construct validity, internal reliability, and test-retest reliability), responsiveness, and expansion of the validation evidence base (use in randomized controlled trials and comparative effectiveness research, cultural or linguistic translations, predictive validity, or establishing the minimal clinically important difference threshold, defined as smallest amount an outcome or measure is perceived as a meaningful change to patients). The PROMs were categorized into three groups based on the manifestations of disease of the population for which they were developed. The overall validity of each PROM was assessed across three stages of validation including content validity (phase 1); construct validity, reliability, and responsiveness (phase 2); and expansion of the validation evidence base (phase 3).

RESULTS

Of 2338 unique studies screened, 112 studies (4.8%) met inclusion criteria. The eight disease-specific PROMs identified were categorized into three groups: (1) overall chronic venous disease (C1 to C6); (2) C1 to C4 disease; and (3) C5 to C6 disease. Assessed by group, the Chronic Venous Insufficiency Questionnaire met criteria for validation at all three phases for patients with C1 to C4 disease, and the Charing Cross Venous Ulcer Questionnaire met criteria for validation at all three phases for patients with C5 to C6 disease. There were no PROMs that met all criteria for validation for use in overall chronic venous disease (C1 to C6).

CONCLUSIONS

Of the eight PROMs assessed in this review, only two met prespecified criteria at each phase for validation. The Chronic Venous Insufficiency Questionnaire and Charing Cross Venous Ulcer Questionnaire should be considered for use in patients with chronic venous disease without venous ulcers and with venous ulcers, respectively.

Quality of Life in Chronic Limb Threatening Ischaemia: Systematic Review and Meta-Analysis

OBJECTIVE

To assess the comparative effectiveness and temporal changes in quality of life (QoL) outcomes after revascularisation, major lower extremity amputation (MLEA), and conservative management (CM) in chronic limb threatening ischaemia (CLTI).

DATA SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science.

REVIEW METHODS

A systematic review and meta-analysis were performed on QoL measured by any QoL instrument in adult patients with CLTI after open surgery (OS), endovascular intervention (EVI), MLEA, or CM. Randomised controlled trials and prospective observational studies published in any language between 1 January 1990 and 21 May 2021 were included. There was a pre-specified measurement time point of six months. Random effects meta-analysis was conducted on total scores for each QoL instrument. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach (PROSPERO registration: CRD42021253953).

RESULTS

Fifty-five studies with 8 909 patients were included. There was significant heterogeneity in the methods used to measure QoL, and the study characteristics. In particular, 14 different QoL instruments were used with various combinations of disease specific and generic instruments within each study. A narrative summary is therefore presented. Comparative effectiveness data showed there was reasonable certainty that QoL was similar between OS and EVI at six months. Temporal outcomes suggested small to moderate improvements in QOL six months after OS and EVI compared with baseline. Limited data indicated that QoL can be maintained or slightly improved after MLEA or CM. Treatment effects were overestimated owing to small study effects, selective non-reporting, attrition, and survivorship bias.

CONCLUSION

QoL after OS and EVI appears to be similar. Revascularisation may provide modest QoL benefits, while MLEA or CM can maintain QoL. However, certainty of evidence is generally low or very low, and interpretation is hampered by significant heterogeneity. There is a need for a CLTI specific QoL instrument and methodological standardisation in QoL studies.