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Verhagen MJ, de Vos MS, van Schaik J, van der Vorst JR, Schepers A, Marang-van de Mheen PJ, Hamming JF. Surgical team dynamics in a reflective team meeting to improve quality of care: qualitative analysis of a shared mental model. Br J Surg 2023; 110:1271-1275. [PMID: 37190915 PMCID: PMC10480032 DOI: 10.1093/bjs/znad111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/27/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Merel J Verhagen
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marit S de Vos
- Directorate of Quality and Patient Safety, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jan van Schaik
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joost R van der Vorst
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Abbey Schepers
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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de Vos MS, Verhagen MJ, Hamming JF. The Morbidity and Mortality Conference: A Century-Old Practice with Ongoing Potential for Future Improvement. Eur J Pediatr Surg 2023; 33:114-119. [PMID: 36720246 PMCID: PMC10023258 DOI: 10.1055/s-0043-1760836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To discuss practical strategies to consider for morbidity and mortality conferences (M&M). MATERIALS AND METHODS This article reflects on (i) insights that can be drawn from the M&M literature, (ii) practical aspects to consider when organizing M&M, and (iii) possible future directions for development for this long-standing practice for routine reflection. RESULTS M&M offers the opportunity to learn from past cases in order to improve the care delivered to future patients, thereby serving both educational and quality improvement purposes. For departments seeking to implement or improve local M&M practice, it is difficult that a golden standard or best practice for M&M is nonexistent. This is partly because comparative research on different formats is hampered by the lack of objective outcome measures to evaluate the effectiveness of M&M. Common practical suggestions include the use of (i) a skillful and active moderator; (ii) structured formats for case presentation and discussion; and (iii) a dedicated committee to guide improvement plans that ensue from the meeting. M&M practice is affected by various sociological factors, for which qualitative research methods seem most suitable, but in the M&M literature these are sparsely used. Moreover, aspects influencing an open and blame-free atmosphere underline how local teams should tailor the format to best fit the local context and culture. CONCLUSION This article presents practice guidance on how to organize and carry out M&M This practice for routine reflection needs to be tailored to the local setting, with attention for various sociological factors that are at play.
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Affiliation(s)
- Marit S. de Vos
- Directorate of Quality and Patient Safety, Leiden University Medical Center, Rotterdam, the Netherlands
- Address for correspondence Marit S. de Vos, MD, PhD Directorate of Quality and Patient Safety, Leiden University Medical CenterAlbinusdreef 2, 2333 ZA Leidenthe Netherlands
| | - Merel J. Verhagen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jaap F. Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Verhagen MJ, de Vos MS, Smaggus A, Hamming JF. Measuring What Matters at Morbidity and Mortality Conferences: A Scoping Review of Effectiveness Measures. J Patient Saf 2022; 18:e760-e768. [PMID: 35617601 DOI: 10.1097/pts.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Efforts to study morbidity and mortality conferences (M&MC) are hampered by the lack of rigorous instruments to assess the effectiveness of the conferences for the purpose of quality improvement and medical education. This might limit further advancement of the practice. The aim of this scoping review was to determine commonly used effectiveness measures of M&MC in the literature. METHOD A scoping review was performed of quantitative, qualitative, and mixed methods studies of M&MC, using databases from PubMed, Emcare, Embase, Web of Science, and the Cochrane library. Studies were included if an outcome was described after a general evaluation or an intervention to M&MC. Study quality was assessed with the Quality Assessment Tool for Studies with Diverse Designs. RESULTS A total of 43 articles were included in the review. The majority used a quantitative (n = 23) or mixed (n = 17) design, with surveys as the most frequent method used for data collection (n = 29). The overall Quality Assessment Tool for Studies with Diverse Designs scores were modest (64%). Outcome measures used to evaluate the effectiveness of M&MC were clustered in the following categories: "participant experiences," "characteristics of the meeting," "medical knowledge," "actions for improvement," and "clinical outcomes." CONCLUSIONS This review found a wide variety of effectiveness measures for M&MC. Rather than using isolated measures, approaches that combine multiple effectiveness measures could offer a more comprehensive assessment of M&MC. Although there was a preference for quantitative metrics, this fails to seize the opportunity of qualitative methods to yield insights into sociological purposes of M&MC, such as building professional identities and safety culture.
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Affiliation(s)
| | - Marit S de Vos
- Directorate of Quality and Patient Safety, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew Smaggus
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
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Verhagen MJ, de Vos MS, Sujan M, Hamming JF. The problem with making Safety-II work in healthcare. BMJ Qual Saf 2022; 31:402-408. [PMID: 35304422 DOI: 10.1136/bmjqs-2021-014396] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/25/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Merel J Verhagen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marit S de Vos
- Directorate of Quality and Patient Safety, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark Sujan
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Human Factors Everywhere, Woking, UK
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Damen NL, de Vos MS, Moesker MJ, Braithwaite J, de Lind van Wijngaarden RAF, Kaplan J, Hamming JF, Clay-Williams R. Preoperative Anticoagulation Management in Everyday Clinical Practice: An International Comparative Analysis of Work-as-Done Using the Functional Resonance Analysis Method. J Patient Saf 2021; 17:157-165. [PMID: 29994818 DOI: 10.1097/pts.0000000000000515] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Preoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to study how complex processes usually go right at the frontline (labeled Safety-II) and how this relates to predefined procedures. This study aimed to assess PAM in everyday practice and explore the usability and utility of FRAM. METHODS The study was conducted at an Australian and European Cardiothoracic Surgery Department. A FRAM model of work-as-imagined was developed using (inter)national guidelines. Semistructured interviews with 18 involved professionals were used to develop models reflecting work-as-done at both sites, which were presented to staff for validation. Workload in hours was estimated per process step. RESULTS In both centers, work-as-done differed from work-as-imagined, such as in the division of tasks among disciplines (e.g., nurses/registrars rather than medical specialists), but control mechanisms had been developed locally to ensure safe care (e.g., crosschecking with other clinicians). Centers had organized the process differently, revealing opportunities for improvement regarding patient information and clustering of clinic visits. Presenting FRAM models to staff initiated discussion on improvement of functions in the model that are vital for success. Overall workload was estimated at 47 hours per site. CONCLUSIONS This FRAM analysis provided insight into PAM from the perspective of frontline clinicians, revealing essential functions, interdependencies and variability, and the relation with guidelines. Future studies are warranted to study the potential of FRAM, such as for guiding improvements in complex systems.
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Affiliation(s)
- Nikki L Damen
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Marit S de Vos
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marco J Moesker
- Amsterdam Public Health Research Institute, Department of Public and Occupational Health, VU University Medical Centre, Amsterdam
| | - Jeffrey Braithwaite
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | | | - Jason Kaplan
- Faculty of Medicine and Health Sciences, Macquarie University Hospital, Sydney, Australia
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Robyn Clay-Williams
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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de Vos MS, Hamming JF, Marang-van de Mheen PJ. Learning From Morbidity and Mortality Conferences: Focus and Sustainability of Lessons for Patient Care. J Patient Saf 2021; 17:231-238. [PMID: 29087979 DOI: 10.1097/pts.0000000000000440] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE It remains unclear to what extent the morbidity and mortality conference (M&M) meets the objective of improving quality and safety of patient care. It has been suggested that M&M may be too focused on individual performance, hampering system-level improvement. The aim of this study was to assess focus and sustainability of lessons for patient care that were derived from M&M. METHODS This is an observational study of routinely collected data on evaluated complications and identified lessons at surgical M&M for 8 years, assessing type and recurrence of lessons and cases from which these were drawn. Semistructured interviews with clinicians were qualitatively analyzed to explore factors contributing to lesson focus and recurrence. RESULTS Three hundred eighteen lessons were drawn from 10,883 evaluated complications, primarily for those that were more severe, related to surgical or other treatment, and occurring in nonemergent, lower risk cases (all P < 0.001). Most lessons targeted intraoperative (43%) rather than preoperative or postoperative care as well as specifically technical (87%) and individual-level issues (74%). There were 43 recurring lessons (14%), mostly about postoperative care (47%) and medication management (50%). Interviewed clinicians attributed the intraoperative, technical focus primarily to greater appeal and control but identified an array of factors contributing to lesson recurrence, such as typical staff turnover in teaching hospitals. CONCLUSIONS This study provided empirical evidence that learning at M&M has a tendency to focus on intraoperative, technical performance, with challenges to sustain lessons for more system-level issues. Morbidity and mortality conference formats need to anticipate these tendencies to ensure a wide focus for learning with lasting and wide impact.
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de Vos MS, Hamming JF, Boosman H, Marang-van de Mheen PJ. The Association Between Complications, Incidents, and Patient Experience: Retrospective Linkage of Routine Patient Experience Surveys and Safety Data. J Patient Saf 2021; 17:e91-e97. [PMID: 30865163 DOI: 10.1097/pts.0000000000000581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Linkage of safety data to patient experience data may provide information to improve surgical care. This retrospective observational study aimed to assess associations between complications, incidents, patient-reported problems, and overall patient experience. METHODS Routinely collected data from safety reporting on complications and incidents, as well as patient-reported problems and experience on the Picker Patient Experience Questionnaire 15, covering seven experience dimensions, were linked for 4236 surgical inpatients from an academic center (April 2014-December 2015, 41% response). Associations between complication and/or incident occurrence and patient-reported problems, regarding risk of nonpositive experience (i.e., grade of 1-5 of 10), were studied using multivariable logistic regression. RESULTS Patient-reported problems were associated with occurrence of complications/incidents among patients with nonpositive experiences (odds ratio [OR] = 2.8, 95% confidence interval [CI] = 1.6-4.9), but not among patients with positive experiences (OR = 1.0, 95% CI = 0.6-1.5). For each experience dimension, presence of patient-reported problems increased risk of nonpositive experience (OR range = 2.7-4.4). Patients with complications or incidents without patient-reported problems were at lower risk of a nonpositive experience than patients with neither complications/incidents nor reported problems (OR = 0.5; 95% CI = 0.3-0.9). Occurrence of complications/incidents only increased risk of nonpositive experience when patients also had problems on "continuity and transition" or "respect for patient preferences" dimensions. CONCLUSIONS Linking safety data to patient experience data can reveal ways to optimize care. Staff seem able to ensure positive patient experiences despite complications or incidents. Increased attention should be paid to respecting patient preferences, continuity, and transition, particularly when complications or incidents occur.
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Affiliation(s)
| | | | - Hileen Boosman
- Quality and Patient Safety, Leiden University Medical Centre, Leiden, the Netherlands
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de Vos MS, Hamming JF, Chua-Hendriks JJC, Marang-van de Mheen PJ. Connecting perspectives on quality and safety: patient-level linkage of incident, adverse event and complaint data. BMJ Qual Saf 2018; 28:180-189. [DOI: 10.1136/bmjqs-2017-007457] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 06/02/2018] [Accepted: 06/19/2018] [Indexed: 11/04/2022]
Abstract
Background and objectiveIncident, adverse event (AE) and complaint data are typically used separately, but may be related at the patient level with one event triggering a cascade of events, ultimately resulting in a complaint. This study examined relations between incidents, AEs and complaints that co-occurred in admissions.MethodsIndependently and routinely collected incident, AE and complaint data were retrospectively linked for surgical admissions in an academic centre (2008–2014). Two investigators reviewed whether incidents/AEs in admissions were clinically related and in what sequence (incident preceding vs following AE). Likelihood of occurrence of AEs and AE cascades (ie, ≥3 AEs) was studied using logistic regression analyses.ResultsComplaints were filed for 33 (0.1%) of 26 383 admissions. Complaints filed by patients with incidents and/or AEs (n=13) mostly addressed quality/safety problems, whereas other complaints mostly addressed relationship problems. Incidents and AEs co-occurred in 730 (2.8%) admissions, which seemed clinically related in 34% of these cases. Incidents with related AEs preceded as well as followed AEs (56.6%/44.4%). Patients with incidents were at greater risk of AEs than patients without incidents, even for seemingly unrelated AEs (OR 1.4; 95% CI 1.3 to 1.6). Risk of AE cascades was greater when patients with AEs also had incidents, regardless of whether these seemed related (unrelated: OR 2.0; 95% CI 1.6 to 2.5; related: OR 5.7; 95% CI 4.3 to 7.4) or whether incidents preceded or followed AEs in these admissions (53% vs 52%, P>0.05).ConclusionsPatient-level linkage of incident, AE and complaint data can reveal relations between events that otherwise remain obscured, such as incidents that trigger as well as follow AEs, introducing event cascades, regardless of whether clinical relations seem present.
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Abstract
'The Problem with…' series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.
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Affiliation(s)
- Marit S de Vos
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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de Vos MS, Marang-van de Mheen PJ, Smith AD, Mou D, Whang EE, Hamming JF. Toward Best Practices for Surgical Morbidity and Mortality Conferences: A Mixed Methods Study. J Surg Educ 2018; 75:33-42. [PMID: 28720425 DOI: 10.1016/j.jsurg.2017.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 06/28/2017] [Accepted: 07/02/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To assess formats for surgical morbidity and mortality conferences (M&M) for strengths and challenges. DESIGN A mixed methods approach with local observations to assess key domains of M&M practice (i.e., goals, structure, and process/content) and surveys to assess participants' expectations and experiences. SETTING Surgical departments of two teaching hospitals (Boston, USA and Leiden, Netherlands). PARTICIPANTS Participants of surgical M&M, including attending surgeons, residents, physician assistants, and medical students (total n = 135). RESULTS Surgical M&M practices at both hospitals had education as its overarching goal, but varied in structure and process/content. Expectations were similar at both sites with ≥80% of participants (n = 90; 67% response) expecting M&M to be focused on education as well as quality improvement (QI), blame-free, mandatory for both residents and attendings, and to lead to changes in clinical practice. However, compared to expectations, significantly fewer participants at both sites experienced: a QI focus (both p < 0.001); mandatory faculty attendance (p = 0.004; p < 0.001) and changes to practice (both p < 0.001). In comparison, at the site where an active moderator and QI committee are present, respondents seemed more positive about experiencing a QI focus (73% vs 30%) and changes to practice (44% vs 16%). CONCLUSION Despite variation in M&M practice, the same (unmet) expectations existed at both hospitals, indicating that certain challenges may be more universal. M&M was reported to be well-focused on education, and certain aspects (e.g., active moderator and QI committee) seemed beneficial, but expectations were not met for the conference's focus and function for QI. Greater exchange of "best practices" for M&M may enhance the conference's value for improving surgical care.
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Affiliation(s)
- Marit S de Vos
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands; Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | | | - Ann D Smith
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danny Mou
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Abstract
OBJECTIVES To explore barriers and facilitators to successful morbidity and mortality conferences (M&M), driving learning and improvement. DESIGN This is a qualitative study with semistructured interviews. Inductive, thematic content analysis was used to identify barriers and facilitators, which were structured across a pre-existing framework for change in healthcare. SETTING Dutch academic surgical department with a long tradition of M&M. PARTICIPANTS An interview sample of surgeons, residents and physician assistants (n=12). RESULTS A total of 57 barriers and facilitators to successful M&M, covering 18 themes, varying from 'case type' to 'leadership', were perceived by surgical staff. While some factors related to M&M organisation, others concerned individual or social aspects. Eight factors, of which four were at the social level, had simultaneous positive and negative effects (eg, 'hierarchy' and 'team spirit'). Mediating pathways for M&M success were found to relate to available information, staff motivation and realisation processes. CONCLUSIONS This study provides leads for improvement of M&M practice, as well as for further research on key elements of successful M&M. Various factors were perceived to affect M&M success, of which many were individual and social rather than organisational factors, affecting information and realisation processes but also staff motivation. Based on these findings, practical recommendations were formulated to guide efforts towards best practices for M&M.
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Affiliation(s)
- Marit S de Vos
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Smith AD, Hawkins AT, Schaumeier MJ, de Vos MS, Conte MS, Nguyen LL. Predictors of major amputation despite patent bypass grafts. J Vasc Surg 2016; 63:1279-88. [PMID: 26860641 DOI: 10.1016/j.jvs.2015.10.101] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/30/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Despite patent vein bypass grafts, some patients with critical limb ischemia (CLI) receive major amputations. We analyzed the predictive factors leading to major amputation in the presence of patent lower extremity bypass (LEB) grafts. METHODS Data from the Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III), a large prospective randomized trial of 1404 patients who underwent LEB with vein graft for CLI, were queried for outcomes. The primary outcome was major amputation with patent (PMA) LEB compared with patients with patent LEB who achieved limb salvage (PLS). The population excluded those who received amputation for occluded grafts. A Cox proportional hazard model identified independent predictors. RESULTS Of 1404 LEB patients, 162 (11.5%) had major amputation: 89 (6.3%) with patent and 73 (5.2%) with occluded LEB. For PMA, 21 of 89 (23.6%) developed critical stenosis and 11 of 21 (52.4%) were revised. For PLS, 460 of 1242 (37.0%) developed critical stenosis and 351 of 460 (76.3%) were revised. Predictive patient factors included having preoperative gangrene (vs rest pain; hazard ratio [HR], 3.504; 95% confidence interval [CI], 1.533-8.007; P = .0029), diabetes (HR, 1.800; 95% CI, 1.006-3.219; P = .0477), black (vs white) race (HR, 1.779; 95% CI, 1.051-3.011; P = .0321), baseline creatinine clearance <25 mL/min (vs >65 mL/min; HR, 1.759; 95% CI, 1.016-3.048; P = .0439), prior history of coronary artery bypass grafting (HR, 1.702; 95% CI, 1.080-2.683; P = .0221), and lower baseline activity quality of life score (HR, 1.401; 95% CI, 1.105-1.778; P = .0054). Postoperative wound factors included gangrenous changes (HR, 5.830; 95% CI, 1.647-20.635; P = .0063), surgical wound necrosis (HR, 5.319; 95% CI, 1.478-19.146; P = .0105), deep (vs superficial) wound infection (HR, 3.815; 95% CI, 1.220-11.927; P = .0213), and wound healing abnormally (HR, 3.754; 95% CI, 1.061-13.278; P = .0402). Associated postoperative consequences leading to PMA included having recurrent CLI symptoms (HR, 2.915; 95% CI, 1.816-4.681; P < .0001), a severe (vs mild) adverse event (HR, 2.751; 95% CI, 1.391-5.443; P = .0036), fewer percutaneous revisions (HR, 2.425; 95% CI, 1.573-3.740; P < .0001), discharge on low-molecular-weight heparin (HR, 2.087; 95% CI, 1.309-3.326; P = .0020), and decreasing days to critical stenosis/occlusion/revision/amputation (HR, 1.010; 95% CI, 1.007-1.012; P < .0001). CONCLUSIONS Whereas a patent vein graft is important to all vascular surgeons, additional factors should be considered in trying to attain limb salvage for patients with CLI. These factors include intervening surgically before CLI has progressed to a state of gangrene or limited activity and optimizing nutrition, diabetes control, cardiac conditions, and activity level. Revision offers hope for clinical improvement but may be delayed when there is no graft lesion identified. The absence of a graft lesion to revise may also portend amputation despite a patent graft because of nongraft-related factors such as infection. Finally, the experience of a severe (vs mild) adverse event may also result in limb loss despite a patent graft. Systematic efforts to reduce severe adverse events among patients may also lead to increased limb salvage.
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Affiliation(s)
- Ann D Smith
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Alexander T Hawkins
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Maria J Schaumeier
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Marit S de Vos
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif
| | - Louis L Nguyen
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Hawkins AT, Schaumeier MJ, Smith AD, de Vos MS, Ho KJ, Semel ME, Nguyen LL. Concurrent venography during first rib resection and scalenectomy for venous thoracic outlet syndrome is safe and efficient. J Vasc Surg Venous Lymphat Disord 2014; 3:290-4. [PMID: 26992308 DOI: 10.1016/j.jvsv.2014.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 09/24/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Surgical treatment of acute axillosubclavian vein thrombosis from venous thoracic outlet syndrome (VTOS) traditionally involves first rib resection and scalenectomy (FRRS) followed by interval venography and balloon angioplasty. This approach can lead to an extended need for anticoagulation and a separate anesthesia session. We present outcomes for FRRS with concurrent venography. METHODS Retrospective chart review was performed for consecutive patients undergoing FRRS with concurrent venography for VTOS from February 2007 to April 2014. Venography was performed immediately after FRRS with the arm in neutral and provocative positions. The primary outcomes of this study were primary and primary-assisted patency. Secondary outcomes included whether concurrent venography resulted in modification of the procedure, postoperative anticoagulation use, and postoperative complications. RESULTS Thirty patients underwent first rib resection with venography with a mean follow-up time of 24.4 months. The mean age was 29.5 years (range, 17-52 years), and 17 (56.7%) were female. All were maintained on anticoagulation before the procedure. Concurrent venography resulted in modification of the procedure in 28 patients (93.3%). Of these, 27 patients (96.4%) underwent balloon angioplasty and two patients (7.1%) underwent further rib resection. Twenty patients (66.7%) were discharged after the procedure with no anticoagulation. For those receiving postoperative anticoagulation for persistent minor thrombus, median time for anticoagulation duration was 5.0 months (range, 0.8 and 16.7 months). Two patients (6.7%) had postoperative bleeding requiring thoracentesis or video-assisted thoracoscopic evacuation of hemothorax. One patient (3.3%) suffered rethrombosis and was successfully lysed open, resulting in a 2-year subclavian vein (SCV) primary patency of 96.7% and primary-assisted patency of 100%. No patients required reoperation for VTOS, and all reported improvements in symptoms. Three patients (10.0%) later underwent prophylactic first rib resection on the contralateral side for symptoms and SCV stenosis. CONCLUSIONS FRRS with concurrent venography is a safe procedure for VTOS that allows effective intraoperative modification of the surgical plan, resulting in excellent patency of the SCV, early cessation of anticoagulation, and durable relief of symptoms.
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Affiliation(s)
- Alexander T Hawkins
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Maria J Schaumeier
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Ann D Smith
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Marit S de Vos
- Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, Mass
| | - Karen J Ho
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Marcus E Semel
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Louis L Nguyen
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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Hawkins AT, Smith AD, Schaumeier MJ, de Vos MS, Hevelone ND, Nguyen LL. The effect of surgeon specialization on outcomes after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2014; 60:590-6. [DOI: 10.1016/j.jvs.2014.03.283] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 03/27/2014] [Indexed: 02/01/2023]
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de Vos MS, Bol BJ, Gravereaux EC, Hamming JF, Nguyen LL. Treatment planning for peripheral arterial disease based on duplex ultrasonography and computed tomography angiography: Consistency, confidence and the value of additional imaging. Surgery 2014; 156:492-502. [DOI: 10.1016/j.surg.2014.03.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 03/19/2014] [Indexed: 12/31/2022]
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de Vos MS, Hawkins AT, Hevelone ND, Hamming JF, Nguyen LL. National variation in the utilization of alternative imaging in peripheral arterial disease. J Vasc Surg 2014; 59:1315-22.e1. [PMID: 24423477 DOI: 10.1016/j.jvs.2013.11.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/07/2013] [Accepted: 11/10/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The value and cost-effectiveness of less invasive alternative imaging (AI) modalities (duplex ultrasound scanning, computed tomography angiography, and magnetic resonance angiography) in the care of peripheral arterial disease (PAD) has been reported; however, there is no consensus on their role. We hypothesized that AI utilization is low compared with angiography in the United States and that patient and hospital characteristics are both associated with AI utilization. METHODS The Nationwide Inpatient Sample (2007-2010) was used to identify patients with an International Classification of Diseases-Ninth Edition diagnosis of claudication or critical limb ischemia (CLI) as well as PAD treatment (surgical, endovascular, or amputation). Patients with AI and those with angiography or expected angiography (endovascular procedures without imaging codes) were selected and compared. Multivariable logistic regression was performed for receiving AI stratified by claudication and CLI and adjusting for patient and hospital factors. RESULTS We identified 290,184 PAD patients, of whom 5702 (2.0%) received AI. Patients with AI were more likely to have diagnosis of CLI (78.8% vs 48.6%; P < .0001) and receive open revascularizations (30.4% vs 18.8%; P < .0001). Van Walraven comorbidity scores (mean [standard error] 5.85 ± 0.22 vs 4.10 ± 0.05; P < .0001) reflected a higher comorbidity burden in AI patients. In multivariable analysis for claudicant patients, AI was associated with large bed size (odds ratio [OR], 3.26, 95% confidence interval [CI], 1.16-9.18; P = .025), teaching hospitals (OR, 1.97; 95% CI, 1.10-3.52; P = .023), and renal failure (OR, 1.52; 95% CI, 1.13-2.05; P = .006). For CLI patients, AI was associated with black race (OR, 1.53; 95% CI, 1.13-2.08; P = .006) and chronic heart failure (OR, 1.29; 95% CI, 1.04-1.60; P = .021) and was negatively associated with renal failure (OR, 0.80; 95% CI, 0.67-0.95; P = .012). The Northeast and West regions were associated with higher odds of AI in claudicant patients (OR, 2.41; 95% CI, 1.23-4.75; P = .011; and OR, 2.59; 95% CI, 1.34-5.02; P = .005, respectively) and CLI patients (OR, 4.31; 95% CI, 2.20-8.36; P < .0001; and OR, 2.18; 95% CI, 1.12-4.22; P = .021, respectively). Rates of AI utilization across states were not evenly distributed but showed great variability, with ranges from 0.31% to 9.81%. CONCLUSIONS National utilization of AI for PAD is low and shows great variation among institutions in the United States. Patient and hospital factors are both associated with receiving AI in PAD care, and AI utilization is subject to significant regional variation. These findings suggest differences in systems of care or practice patterns and call for a clearer understanding and a more unified approach to imaging strategies in PAD care.
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Affiliation(s)
- Marit S de Vos
- Department of Surgery, Division of Endovascular and Vascular Surgery, Brigham & Women's Hospital and Harvard Medical School, Boston, Mass; Department of Surgery, Division of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexander T Hawkins
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Nathanael D Hevelone
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Jaap F Hamming
- Department of Surgery, Division of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Louis L Nguyen
- Department of Surgery, Division of Endovascular and Vascular Surgery, Brigham & Women's Hospital and Harvard Medical School, Boston, Mass; Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, Mass.
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