The Association Between Frailty and Outcomes Following Ruptured Abdominal Aortic Aneurysm Repair

BACKGROUND

Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysm (AAA). Early postoperative outcomes are associated with both patients' physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAA (rAAA).

STUDY DESIGN

Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI; robust≤20, normal 21-29, frail 30-39, very frail≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHR) with 95% confidence intervals (95%CI). Interaction terms evaluated the association's moderation.

RESULTS

We identified 5,806 patients (age 72±9 years; 77% male; EVAR 65%; robust 6%; normal 48%; frail 36%; very frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR [aHR = 1.43 (95%CI 1.19-1.73)] was associated with increased 1-year mortality when compared to EVAR. Increasing frailty status [frail aHR = 1.26 (95%CI 1.00-1.59); very frail aHR =1.64 (95%CI 1.26-2.13)] was associated with increased 1-year mortality, which was moderated by repair type (P-interaction<.05). OSR was associated with increased 1-year mortality in normal [aHR = 1.49 (95%CI 1.20-1.87)] and frail [aHR = 1.51 (95%CI 1.20-1.89)], but not among robust [aHR = 0.88 (95%CI 0.59-1.32)] and very frail [aHR = 1.29 (95%CI 0.97-1.72)] patients.

CONCLUSION

Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared to EVAR. However, there was no difference between OSR and EVAR among robust patients who can well-tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.

Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings

Importance

Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking.

Objective

To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals.

Design, Setting, and Participants

This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older.

Exposures

Surgical care in VA or private-sector hospitals.

Main Outcomes and Measures

Postoperative 30-day mortality and failure to rescue (FTR).

Results

Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures.

Conclusions and Relevance

Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.

Preoperative proteinuria is independently associated with mortality after fenestrated endovascular aneurysm repair

OBJECTIVE

Fenestrated endovascular aneurysm repair (FEVAR) has become a mainstay in treating complex aortic aneurysms, though baseline patient factors predicting long-term outcomes remain poorly understood. Proteinuria is an early marker for chronic kidney disease and associated with adverse cardiovascular outcomes, but its utility in patients with aortic aneurysms is unknown. We aimed to determine whether preoperative proteinuria impacts long-term survival after FEVAR.

METHODS

A single-institution, retrospective review of all elective FEVAR was performed. Preoperative proteinuria was assessed by urinalysis: negative (0-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-299 mg/dL), and 3+ (≥300 mg/dL). The cohort was stratified by patients with proteinuria (≥30 mg/dL) vs those without (<30 mg/dL). Baseline, perioperative, and long-term outcomes were compared. The primary outcome, all-cause mortality, was evaluated by Kaplan-Meier analysis and independent predictors with Cox proportional hazards modeling.

RESULTS

Among 181 patients who underwent standard FEVAR from 2012 to 2022 (mean follow-up 33 months), any proteinuria was noted in 30 patients (16.6%). Patients with proteinuria were more likely to be Black (10.0% vs 1.3%) with a lower estimated glomerular filtration rate (eGFR) (52.7 ± 24.7 vs 67.7 ± 20.5 mL/min/1.73 m2), higher Society for Vascular Surgery comorbidity score (10.9 ± 4.3 vs 8.2 ± 4.7) and calcium channel blocker therapy (50.0% vs 29.1%), and larger maximal aneurysm diameter (67.2 ± 16.9 vs 59.8 ± 9.8 mm) (all P < .05). Thirty-day mortality was higher in the proteinuria group (10.0% vs 1.3%; P = .03). Overall survival at 1 and 5 years was significantly lower for those with proteinuria (71.5% vs 92.3% and 29.5% vs 68.1%; log-rank P < .001). On multivariable analysis, preoperative proteinuria was independently associated with over threefold higher hazard of mortality (hazard ratio [HR]: 3.21, 95% confidence interval [CI]: 1.66-6.20; P < .001), whereas preoperative eGFR was not predictive (HR: 0.99, 95% CI: 0.98-1.01; P = .28). Additional significant predictors included chronic obstructive pulmonary disease (HR: 2.04), older age (HR: 1.05), and larger maximal aneurysm diameter (HR: 1.03; all P < .05).

CONCLUSIONS

In our 10-year experience with FEVAR, preoperative proteinuria was observed in 17% of patients and was significantly associated with worse survival. In this cohort, proteinuria was independently associated with all-cause mortality, whereas eGFR was not, suggesting that urinalysis may provide an additional simple metric for risk-stratifying patients before FEVAR.

A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty

INTRODUCTION

The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers.

METHODS

We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality.

RESULTS

Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality.

CONCLUSIONS

While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.

Comprehensive framework of factors accounting for worse aortic aneurysm outcomes in females: A scoping review

Sex-based outcome studies have consistently documented worse results for females undergoing care for abdominal aortic aneurysms. This review explores the underlying factors that account for worse outcomes in the females sex. A scoping review of studies reporting sex-based disparities on abdominal aortic aneurysms was performed. The review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews. Factors that account for worse outcomes in the females sex were identified, grouped into themes, and analyzed. Key findings of each study are reported and a comprehensive framework of these factors is presented. A total of 35 studies were identified as critical in highlighting sex-based disparities in care of patients with aortic aneurysms. We identified the following 10 interrelated themes in the chain of aneurysm care that account for differential outcomes in females: natural history, risk factors, pathobiology, biomechanics, screening, morphology, device design and adherence to instructions for use, technique, trial enrollment, and social determinants. Factors accounting for worse outcomes in the care of females with aortic aneurysms were identified and described. Some factors are immediately actionable, such as screening criteria, whereas device design improvement will require further research and development. This comprehensive framework of factors affecting care of aneurysms in females should serve as a blueprint to develop education, outreach, and future research efforts to improve outcomes in females.

Sex differences in outcomes among adults undergoing abdominal aortic aneurysm repair

OBJECTIVE

Although the differences in short-term outcomes between male and female patients in abdominal aortic aneurysm (AAA) repair have been well studied, it remains unclear if these sex disparities extend to other long-term adverse outcomes after AAA repair, such as reintervention and late rupture.

METHODS

We performed a retrospective cohort study of 13,007 patients who underwent either endovascular (EVAR) or open AAA repair (OAR) between 2003 and 2015 using data from the Vascular Quality Initiative registries. Eligible patients were linked to fee-for-service Medicare claims to identify late outcomes of rupture and aneurysm-specific reintervention.

RESULTS

The mean age of our cohort was 76 ± 6.7 years, 22% were female, 94% were White, and 77% underwent EVAR. The 10-year rupture incidence was slightly higher for women at 4.8 per 1000 person-years, vs 3.9 for men, but this difference was not statistically significant after risk adjustment (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 0.74-1.73). Likewise, we found no sex difference in reintervention rates (5.1 vs 4.8 in women per 1000 person-years) even after risk adjustment (HR = 0.95, 95% CI: 0.83-1.09). Regression models suggest effect modification by repair type for reintervention, where women who underwent index EVAR had a higher risk of reintervention than men (HR = 1.08, 95% CI: 0.93-1.26), whereas women who underwent OAR were at a lower risk of reintervention than men (HR = 0.79, 95% CI: 0.58-1.08); however, neither effect reached statistical significance within each subgroup. In addition, we found that the risk of reintervention for women vs men varied by clinical presentation, where women were less likely to undergo reintervention after an elective or symptomatic AAA repair but were more likely to undergo reintervention after a repair for AAA rupture (HR = 1.70, 95% CI: 1.05-2.75).

CONCLUSIONS

Male and female patients who underwent AAA repair had similar rates of reintervention and late aneurysm rupture in the 10 years after their procedure. However, our findings suggest that repair type and clinical presentation may affect the role of sex in clinical outcomes and warrant further exploration in these subgroups.

Evaluation of Lower Extremity Calcium Score as a Measure of Peripheral Arterial Disease Burden and Amputation Risk

BACKGROUND

The ankle-brachial pressure index (ABI) and toe-brachial pressure index (TBI) are commonly used diagnostic tools for peripheral artery disease (PAD) that are unreliable in the presence of calcified vessels. In this study, we aimed to demonstrate the utility of the lower extremity calcium score (LECS) in addition to ABI and TBI in measuring disease burden and predicting the risk of amputation in patients with PAD.

METHODS

Patients who were evaluated in the vascular surgery clinic at Emory University for PAD and who underwent noncontrast computed tomography of the aorta and lower extremities were included in the study. Aortoiliac, femoral-popliteal, and tibial calcium scores were measured using the Agatston method. ABI and TBI that were obtained within 6 months of the computed tomography scan were noted and divided into categories of PAD severity. Associations between ABI, TBI, and LECS of each anatomic segment were evaluated. Univariate and multivariate ordinal regression analyses were performed to predict the outcome of amputation. Receiver operating characteristic analysis was performed to compare LECS with other variables in its ability to predict amputation.

RESULTS

Fifty patients included in the study cohort were divided into LECS quartiles, with 12-13 patients in each quartile. The highest quartile tended to be older (P = 0.016), had a higher percentage of diabetics (P = 0.034), and had a higher frequency of major amputations (P = 0.004) compared to the other quartiles. Patients in the highest quartile of tibial calcium score were more likely to have stage 3 chronic kidney disease (CKD) or greater (P = 0.011) and also had a higher frequency of amputation (P < 0.005) and mortality (P = 0.041). We found no significant association between each anatomic LECS and ABI/TBI categories. On univariate analysis, CKD (Odds Ratio [OR] 12.92 (95% CI 2.01 to 82.83), P = 0.007), diabetes mellitus (OR 5.47 (95% CI 1.27 to 23.64), P = 0.023), tibial calcium score (OR 6.62 (95% CI 1.79 to 24.54), P = 0.005), and total bilateral calcium score (OR 6.32 (95% CI 1.18 to 33.78), P = 0.031) were associated with increased risk of amputation. On multivariate stepwise ordinal regression, TBI and tibial calcium score were identified as important predictors of amputation, with hyperlipidemia and CKD increasing the overall prediction of the model. On Receiver operating characteristic analysis, the addition of the tibial calcium score (area under the curve 0.94, standard error 0.048) significantly improved the prediction of amputation compared to hyperlipidemia, CKD, and TBI alone (area under the curve 0.82, standard error 0.071, P = 0.022).

CONCLUSIONS

The addition of tibial calcium score to other known PAD risk factors may improve the prediction of amputation in patients with PAD.

Artificial intelligence in clinical workflow processes in vascular surgery and beyond

In the past decade, artificial intelligence (AI)-based applications have exploded in health care. In cardiovascular disease, and vascular surgery specifically, AI tools such as machine learning, natural language processing, and deep neural networks have been applied to automatically detect underdiagnosed diseases, such as peripheral artery disease, abdominal aortic aneurysms, and atherosclerotic cardiovascular disease. In addition to disease detection and risk stratification, AI has been used to identify guideline-concordant statin therapy use and reasons for nonuse, which has important implications for population-based cardiovascular disease health. Although many studies highlight the potential applications of AI, few address true clinical workflow implementation of available AI-based tools. Specific examples, such as determination of optimal statin treatment based on individual patient risk factors and enhancement of intraoperative fluoroscopy and ultrasound imaging, demonstrate the potential promise of AI integration into clinical workflow. Many challenges to AI implementation in health care remain, including data interoperability, model bias and generalizability, prospective evaluation, privacy and security, and regulation. Multidisciplinary and multi-institutional collaboration, as well as adopting a framework for integration, will be critical for the successful implementation of AI tools into clinical practice.

Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-Level Frailty Burden Rather Than Comorbidities

BACKGROUND

Failure to rescue (FtR), or inpatient death following complication, is a publicly reported hospital quality measure. Previous work has demonstrated significant variation in the proportion of frail patients across hospitals. However, frailty is not incorporated into risk-adjustment algorithms for hospital quality comparisons and risk adjustment is made by comorbidity scores. Our aim was to assess the impact of frailty on FtR quality measurement and as a means of risk adjustment.

METHODS

Patients undergoing open or endovascular aneurysm repair or lower extremity bypass in the Vascular Quality Initiative (VQI) at centers performing ≥ 25 vascular procedures annually (2003-2019) were included. Multivariable logistic regression evaluated in-hospital death using scaled hierarchical modeling clustering at the center level. Center FtR observed/expected ratios were compared with expected values adjusted for either standard comorbidity profiles or frailty as measured by the VQI Risk Analysis Index. Centers were divided into quartiles using VQI-linked American Hospital Association data to describe the hospital characteristics of centers whose ranks changed.

RESULTS

A total of 63,143 patients (213 centers) were included; 1,630 patients (2.58%) were classified as FtR. After accounting for center-level variability, frailty was associated with FtR [scaled odds ratio 1.9 (1.8-2.0), P < 0.001]. The comorbidity-centric and frailty-based models performed similarly in predicting FtR with C-statistics of 0.85 (0.84-0.86) and 0.82 (0.82-0.84), respectively. Overall changes in ranking based on observed/expected ratios were not statistically significant (P = 0.48). High and low performing centers had similar ranking using comorbidity-centric and frailty-based methods; however, centers in the middle of the performance spectrum saw more variability in ranking alterations. Forty nine (23%) of hospitals improved their ranking by five or more positions when using frailty versus comorbidity risk adjustment. The centers in Quartile 4, those who performed the highest number of vascular procedures annually, experience on average a significant improvement in hospital ranking when frailty was used for risk adjustment, whereas centers performing the fewest number of vascular procedures and the lowest proportion of vascular surgery cases annually (Quartile 1) saw a significant worsening of ranking position (all P < 0.05). However, total number of surgical procedures annually, total hospital beds, for-profit status, and teaching hospital status were not significantly associated with changes in rank.

CONCLUSIONS

A simple frailty-adjusted model has similar predictive abilities as a comorbidity-focused model for predicting a common quality metric that influences reimbursement. In addition to distilling the risk-adjustment algorithm to a few variables, frailty can be assessed preoperatively to develop quality improvement efforts for rescuing frail patients. Centers treating a greater proportion of frail patients and those who perform higher volumes of vascular surgery benefit from a risk adjustment strategy based on frailty.

A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

Evaluation of the impact of continuous Kangaroo Mother Care (KMC) initiated immediately after birth compared to KMC initiated after stabilization in newborns with birth weight 1.0 to < 1.8 kg on neurodevelopmental outcomes: Protocol for a follow-up study

BACKGROUND

Preterm birth or low birth weight is the single largest cause of death in newborns, however this mortality can be reduced through newborn care interventions, including Kangaroo Mother Care (KMC). Previously, a multi-country randomized controlled trial, coordinated by the World Health Organization (WHO), reported a significant survival advantage with initiation of continuous KMC immediately after birth compared with initiation of continuous KMC a few days after birth when the baby is considered clinically stable. Whether the survival advantage would lead to higher rates of neurodevelopmental morbidities, or the immediate KMC will also have a beneficial effect on cognitive development also, has not been investigated. We therefore propose to test the hypothesis that low-birth-weight infants exposed to immediate KMC will have lower rates of neurodevelopmental impairment in comparison to traditional KMC-treated infants, by prospectively following up infants already enrolled in the immediate KMC trial for the first 2 years of life, and assessing their growth and neurodevelopment.

METHODS

This prospective cohort study will enroll surviving neonates from the main WHO immediate KMC trial. The main trial as well as this follow-up study are being conducted in five low- and middle-income countries in South Asia and sub-Saharan Africa. The estimated sample size for comparison of the risk of neurodevelopmental impairment is a total of 2200 children. The primary outcome will include rates of cerebral palsy, hearing impairment, vision impairment, mental and motor development, and epilepsy and will be assessed by the age of 3 years. The analysis will be by intention to treat.

DISCUSSION

Immediate KMC can potentially reduce low-birth-weight-associated complications such as respiratory disease, hypothermia, hypoglycemia, and infection that can result in impaired neurocognitive development. Neuroprotection may also be mediated by improved physiological stabilization that may lead to better maturation of neural pathways, reduced risk of hypoxia, positive parental impact, improved sleep cycles, and improved stress responses. The present study will help in evaluating the overall impact of KMC by investigating the long-term effect on neurodevelopmental impairment in the survivors.

TRIAL REGISTRATION

Clinical Trials Registry-India CTRI/2019/11/021899. Registered on 06 November 2019. Trials registration of parent trial: ACTRN12618001880235; Clinical Trials Registry-India: CTRI/2018/08/015369.

Racial, ethnic, and socioeconomic inequities in amputation risk for patients with peripheral artery disease and diabetes

Peripheral artery disease and diabetes are highly prevalent diseases and the leading cause of limb loss. Despite advances in medical and surgical techniques, there are stark differences in delivery and outcomes of lower extremity amputation among populations when stratified by race, ethnicity, and socioeconomic status. We reviewed studies from the last 2 decades (1999-2022) to provide a comprehensive assessment of the current impact of disparities on the risk for, and management of, lower extremity amputation and offer action items that can optimize health outcomes.

Transfusion trigger after operations in high cardiac risk patients (TOP) trial protocol. Protocol for a multicenter randomized controlled transfusion strategy trial

BACKGROUND

There is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events.

METHODS

A two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants. Postoperative transfusions in the liberal arm commence when Hb is <10 g/ dL and continue until Hb is greater than or equal to 10 g/dL. In the restrictive arm, transfusions begin when Hb is <7 g/dL and continue until Hb is greater than or equal to 7 g/dL. Study duration is estimated to be 5 years including a 3-month start-up period and 4 years of recruitment. Each randomized participant will be followed for 90 days after randomization with a mortality assessment at 1 year.

RESULTS

The primary outcome is a composite endpoint of all-cause mortality, myocardial infarction (MI), coronary revascularization, acute renal failure, or stroke occurring up to 90-days after randomization. Events rates will be compared between restrictive and liberal transfusion groups.

CONCLUSIONS

The TOP Trial is uniquely positioned to provide high quality evidence comparing transfusion strategies among patients with high cardiac risk. Results will clarify the effect of postoperative transfusion strategies on adverse outcomes and inform postoperative management algorithms.

TRIAL REGISTRATION

http://clinicaltrials.gov identifier: NCT03229941.

A Vascular Quality Initiative frailty assessment predicts postdischarge mortality in patients undergoing arterial reconstruction

BACKGROUND

Frailty assessment adds important prognostic information during preoperative decision-making but can be cumbersome to implement into routine clinical care. We developed and tested an abbreviated method of frailty assessment using variables routinely collected by the Vascular Quality Initiative (VQI) registry.

METHODS

An abbreviated frailty score (the simple Vascular Quality Initiative-Frailty Score [VQI-FS]) was developed using 11 or fewer VQI variables (hypertension, congestive heart failure, coronary artery disease, peripheral vascular disease, diabetes, chronic obstructive pulmonary disease, renal impairment, anemia, underweight, nonhome residence, and nonambulatory status) that map to recognized frailty domains in the Comprehensive Geriatric Assessment and the literature. Nonemergent cases registered in the VQI from 2010 to 2017 (n = 265,632) in seven registries (carotid endarterectomy, n = 77,111; carotid artery stenting, n = 13,215; endovascular abdominal aortic aneurysm repair, n = 29,607; open abdominal aortic aneurysm repair, n = 7442; infrainguinal bypass, n = 33,128; suprainguinal bypass, n = 10,661; and peripheral vascular intervention, n = 94,468) were analyzed using logistic regression models to determine the predictive power of the VQI-FS for perioperative and longer term (9-month) mortality. Nomograms were created using weighted regression coefficients to assist in individualized frailty assessment and estimation of 9-month mortality.

RESULTS

The VQI-FS, using equal weighting of these 11 VQI variables, effectively predicted 9-month mortality with an area under the curve of 0.724 by receiver operating characteristic curve analysis. However, differential weighting of the variables allowed simplification of the model to only seven variables (congestive heart failure, renal impairment, chronic obstructive pulmonary disease, not living at home, not ambulatory, anemia, and underweight status); hypertension, coronary artery disease, peripheral vascular disease, and diabetes had relatively low predictive power. Adding procedure-specific risk further improved performance of the model with a final area under the curve on receiver operating characteristic curve analysis of 0.758. Model calibration was excellent with predicted/observed regression line slope of 0.991 and intercept of 5.449e-04.

CONCLUSIONS

A differentially weighted abbreviated VQI-FS using seven variables in addition to procedure-specific risk has strong correlation with 9-month mortality. Nomograms incorporating patient- and procedure-adjusted risk can effectively predict 9-month mortality. Reliable estimates of longer term mortality should assist in preoperative decision-making for vascular procedures that often carry substantial risk of mortality.

Use of linked registry claims data for long term surveillance of devices after endovascular abdominal aortic aneurysm repair: observational surveillance study

OBJECTIVE

To evaluate long term outcomes (reintervention and late rupture of abdominal aortic aneurysm) of aortic endografts in real world practice using linked registry claims data.

DESIGN

Observational surveillance study.

SETTING

282 centers in the Vascular Quality Initiative Registry linked to United States Medicare claims (2003-18).

PARTICIPANTS

20 489 patients treated with four device types used for endovascular abdominal aortic aneurysm repair (EVAR): 40.6% (n=8310) received the Excluder (Gore), 32.2% (n=6606) the Endurant (Medtronic), 16.0% (n=3281) the Zenith (Cook Medical), and 11.2% (n=2292) the AFX (Endologix). Given modifications to AFX in late 2014, patients who received the AFX device were categorized into two groups: the early AFX group (n=942) and late AFX group (n=1350) and compared with patients who received the other devices, using propensity matched Cox models.

MAIN OUTCOME MEASURES

Reintervention and rupture of abdominal aortic aneurysm post-EVAR; all patients (100%) had complete follow-up via the registry or claims based outcome assessment, or both.

RESULTS

Median age was 76 years (interquartile range (IQR) 70-82 years), 80.0% (16 386/20 489) of patients were men, and median follow-up was 2.3 years (IQR 0.9-4.1 years). Crude five year reintervention rates were significantly higher for patients who received the early AFX device compared with the other devices: 14.9% (95% confidence interval 13.7% to 16.2%) for Excluder, 19.5% (18.1% to 21.1%) for Endurant, 16.7% (15.0% to 18.6%) for Zenith, and early 27.0% (23.7% to 30.6%) for the early AFX. The risk of reintervention for patients who received the early AFX device was higher compared with the other devices in propensity matched Cox models (hazard ratio 1.61, 95% confidence interval 1.29 to 2.02) and analyses using a surgeon level instrumental variable of >33% AFX grafts used in their practice (1.75, 1.19 to 2.59). The linked registry claims surveillance data identified the increased risk of reintervention with the early AFX device as early as mid-2013, well before the first regulatory warnings were issued in the US in 2017.

CONCLUSIONS

The linked registry claims surveillance data identified a device specific risk in long term reintervention after EVAR of abdominal aortic aneurysm. Device manufacturers and regulators can leverage linked data sources to actively monitor long term outcomes in real world practice after cardiovascular interventions.

Management of Cylindrical Battery Ingestion

Presentation A female presented to the Emergency Department following ingestion of an unknown number of cylindrical batteries. Diagnosis Abdominal X-ray confirmed the presence of multiple batteries located throughout the abdomen. Treatment A trial of conservative management was pursued, and five AA batteries were successfully passed per rectum. Serial X-rays over three weeks revealed that the majority of batteries failed to pass. A decision was made to perform a laparotomy, and 46 cylindrical batteries were removed from the stomach through a small gastrotomy. Four batteries located in the colon were milked into the rectum and removed via the transanal route. Discussion Using daily clinical exams and weekly plain films of the abdomen, conservative management is possible if a small number of batteries are ingested and make it to the stomach. However, the potential of cylindrical batteries to result in acute surgical emergencies should not be underestimated.

Effect of a Decision Aid on Agreement Between Patient Preferences and Repair Type for Abdominal Aortic Aneurysm: A Randomized Clinical Trial

Importance

Patients with abdominal aortic aneurysm (AAA) can choose open repair or endovascular repair (EVAR). While EVAR is less invasive, it requires lifelong surveillance and more frequent aneurysm-related reinterventions than open repair. A decision aid may help patients receive their preferred type of AAA repair.

Objective

To determine the effect of a decision aid on agreement between patient preference for AAA repair type and the repair type they receive.

Design, Setting, and Participants

In this cluster randomized trial, 235 patients were randomized at 22 VA vascular surgery clinics. All patients had AAAs greater than 5.0 cm in diameter and were candidates for both open repair and EVAR. Data were collected from August 2017 to December 2020, and data were analyzed from December 2020 to June 2021.

Interventions

Presurgical consultation using a decision aid vs usual care.

Main Outcomes and Measures

The primary outcome was the proportion of patients who had agreement between their preference and their repair type, measured using χ2 analyses, κ statistics, and adjusted odds ratios.

Results

Of 235 included patients, 234 (99.6%) were male, and the mean (SD) age was 73 (5.9) years. A total of 126 patients were enrolled in the decision aid group, and 109 were enrolled in the control group. Within 2 years after enrollment, 192 (81.7%) underwent repair. Patients were similar between the decision aid and control groups by age, sex, aneurysm size, iliac artery involvement, and Charlson Comorbidity Index score. Patients preferred EVAR over open repair in both groups (96 of 122 [79%] in the decision aid group; 81 of 106 [76%] in the control group; P = .60). Patients in the decision aid group were more likely to receive their preferred repair type than patients in the control group (95% agreement [93 of 98] vs 86% agreement [81 of 94]; P = .03), and κ statistics were higher in the decision aid group (κ = 0.78; 95% CI, 0.60-0.95) compared with the control group (κ = 0.53; 95% CI, 0.32-0.74). Adjusted models confirmed this association (odds ratio of agreement in the decision aid group relative to control group, 2.93; 95% CI, 1.10-7.70).

Conclusions and Relevance

Patients exposed to a decision aid were more likely to receive their preferred AAA repair type, suggesting that decision aids can help better align patient preferences and treatments in major cardiovascular procedures.

Trial Registration

ClinicalTrials.gov Identifier: NCT03115346.

Factors Associated with Preference of Choice of Aortic Aneurysm Repair in the PReference for Open Versus Endovascular repair of AAA (PROVE-AAA) study

OBJECTIVE

Patients can choose between open repair and endovascular repair of abdominal aortic aneurysm (AAA). However, the factors associated with patient preference for one repair type over another are not well characterized. Here we assess the factors associated with preference of choice for open or endovascular AAA repair among veterans exposed to a decision aid to help with choosing surgical treatment.

METHODS

Across 12 VA hospitals, veterans received a decision aid covering domains including patient information sources and understanding preference. Veterans were then given a series of surveys at different timepoints examining their preferences for open versus endovascular AAA repair. Questions from the preference survey were used in analyses of patient preference. Results were analyzed using chi-squared tests. A logistic regression was performed to assess factors associated with preference for open repair or preference for endovascular repair.

RESULTS

A total of 126 veterans received a decision aid informing them of their treatment choices, after which 121 completed all preference survey questions; five veterans completed only part of the instruments. Overall, veterans who preferred open repair were typically younger (70 vs 73, p=0.02), with similar rates of common comorbidities (coronary disease 16% vs 28%, p=0.21), and similar aneurysms compared to those who preferred endovascular repair (6.0 cm versus 5.7 cm, p=0.50). Veterans in both preference categories (28% of veterans preferring EVAR, 48% of veterans preferring open repair) reported "taking their doctor's" advice as the "top-box" response for the single most important factor influencing their decision. When comparing the tradeoff between less invasive surgery and higher risk of long-term complications, more than half of veterans preferring EVAR reported invasiveness as more important compared with approximately one in ten of those preferring open repair (53% versus 12%, p<0.001). Shorter recovery was an important factor for the endovascular repair group (74%) and not important in the open repair group (76%), p=0.5). In multivariable analyses, valuing a short hospital stay (OR=12.4, 95% CI 1.13-135.7) and valuing a shorter recovery (OR15.72, 95% CI 1.03-240.2) were associated with greater odds of preference for endovascular repair, while finding these characteristics not important were associated with greater odds of preference for open repair.

CONCLUSIONS

When faced with the decision of open repair versus endovascular repair, veterans who valued a shorter hospital stay and a shorter recovery were more likely to prefer endovascular repair, while those more concerned about long-term complications preferred open repair. Veterans typically value the advice of their surgeon over their own beliefs and preference. These findings need to be considered by surgeons as they guide their patients to a shared decision.

Trivialization of Aggression Against Women in India: An Exploration of Life Writings and Societal Perception

Purpose

Aggression, or an action that intend to harm, encompasses different forms with varying intensity, impact, and salient features. Globally and in Indian context specifically, aggression against women is often normalized if there is no physical aggression involved as the hurt caused tends to be invisible. The current study explored the perceived intensity of physical, verbal, and sexual aggression among south Indian adults.

Method

Aggressive instances from the life writings of two south Indian women were chosen and were rated by five independent coders to check inter-coder reliability. The select narratives disclose instances of domestic aggression. Ten instances with highest ratings were chosen as the material for data collection. Adults (N = 145) from two southern states had reported the perceived intensity of aggression in each context. Textual analysis and ANOVA were the analytic techniques adopted.

Results

The results indicate trivialization of verbal aggression compared to physical and sexual aggression. Further, the instances of verbal or more subtle aggression were perceived as even more trivial when the respondents got exposed to the instances of explicit physical and sexual aggressions first.

Conclusions

The findings indicate trivialization of verbal and implicit forms of aggression, particularly when exposed along with physical and explicit forms of aggression. Consequences of different forms of aggression were not considered significant by the respondents. Suggestions for further studies, changes in policy-making, and law-enforcement were made based on the current results.

Cardiovascular and Limb Events Following Endovascular Revascularization Among Patients ≥65 Years Old: An American College of Cardiology PVI Registry Analysis

Background We aimed to characterize the occurrence of major adverse cardiovascular and limb events (MACE and MALE) among patients with peripheral artery disease (PAD) undergoing peripheral vascular intervention (PVI), as well as associated factors in patients with chronic limb threatening ischemia (CLTI). Methods and Results Patients undergoing PVI in the American College of Cardiology's (ACC) National Cardiovascular Data Registry's PVI Registry who could be linked to Centers for Medicare and Medicaid Services data were included. The primary outcomes were MACE, MALE, and readmission within 1 month and 1 year following index CLTI-PVI or non-CLTI-PVI. Cox proportional hazards regression was used to identify factors associated with the development of the primary outcomes among patients undergoing CLTI-PVI. There were 1758 (49.7%) patients undergoing CLTI-PVI and 1779 (50.3%) undergoing non-CLTI-PVI. By 1 year, MACE occurred in 29.5% of patients with CLTI (n=519), and MALE occurred in 34.0% of patients with CLTI (n=598). By 1 year, MACE occurred in 8.2% of patients with non-CLTI (n=146), and MALE occurred in 26.1% of patients with non-CLTI (n=465). Predictors of MACE at 1 year in CLTI-PVI included end-stage renal disease on hemodialysis, congestive heart failure, prior CABG, and severe lung disease. Predictors of MALE at 1 year in CLTI-PVI included treatment of a prior bypass graft, profunda femoral artery treatment, end-stage renal disease on hemodialysis, and treatment of a previously treated lesion. Conclusions Patients ≥65 years old undergoing PVI experience high rates of MACE and MALE. A range of modifiable and non-modifiable patient factors, procedural characteristics, and medications are associated with the occurrence of MACE and MALE following CLTI-PVI.

Trends in annual open abdominal aortic surgical volumes for vascular trainees compared to annual national volumes in the endovascular era

OBJECTIVE

Prior analysis predicted a shortfall in open abdominal aortic repair (OAR) experience for vascular trainees resulting from the rapid adoption of and increased anatomic suitability of endovascular aortic repair (EVAR) technology. We explored how EVAR has transformed contemporary open aortic surgical education for vascular trainees.

METHODS

We examined ACGME case volumes of open abdominal aortic aneurysm (AAA) repair and reconstruction for aorto-iliac occlusive disease (AIOD) via aorto-iliac/femoral bypass (AFB) from integrated vascular surgery residents (VSR) and fellows (VSF) graduating 2006-2017 and compared them to national estimates of total OAR (open AAA repair + AFB) in the Agency for Healthcare Research and Quality National Inpatient Sample based on ICD-9 and ICD-10 procedural codes. Changes over time were assessed using Chi-square test, Student's t-test, and linear regression.

RESULTS

During the twelve-year study period, the national annual total OAR and open AAA repair estimates decreased: total OAR by 72.5% (2006: estimate (standard error) 24,255 (1185) vs. 2017: 6,690 (274); p<0.001) and open AAA repair by 84.7% (2006: 18,619 (924) vs. 2017: 2,850 (168); p<0.001); AFB estimates decreased by 33.0% (p<0.001). The percentage of total OAR, open AAA repair, and AFB performed at teaching hospitals significantly increased from ∼55 to 80% (all p<0.001). There was a 40.9% decrease in open AAA repairs logged by graduating VSF (mean 18.6 vs. 11) but only a 6.9% decrease in total OAR cases (mean 27.6 vs. 25.7) due to increasing AFB volumes (mean 9.0 vs. 14.7). VSR graduates consistently logged an average of ∼10 open AAA repairs and there was a 31.0% increase in total OAR (mean 23.2 vs. 30.4), again secondary to rising AFB volumes (mean 11.4 vs 17.5). Although there was an absolute decrease in open aortic experience for VSF, the rate of decline for total OAR case volumes was not significantly different after VSR programs were established (p=0.40).

CONCLUSIONS

As incidence decreases nationally, OAR is shifting towards teaching hospitals. While open AAA procedures for trainees are declining due to EVAR, open aortic reconstruction for AIOD is rising and plays an important role in ensuring that vascular trainees continue to have satisfactory OAR experience sufficient for meeting minimum graduation requirements. Strategies to maintain and maximize the education and experience from these cases should be top priority for vascular surgery program directors.

Closing the Gaps in Racial Disparities in Critical Limb Ischemia Outcome and Amputation Rates: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel

Minority patients such as Blacks, Hispanics, and Native Americans are disproportionately impacted by critical limb ischemia and amputation due to multiple factors such as socioeconomic status, type or lack of insurance, lack of access to health care, capacity and expertise of local hospitals, prevalence of diabetes, and unconscious bias. The Society of Interventional Radiology Foundation recognizes that it is imperative to close the disparity gaps and funded a Research Consensus Panel to prioritize a research agenda. The following research priorities were ultimately prioritized: (a) randomized controlled trial with peripheral arterial disease screening of at-risk patients with oversampling of high-risk racial groups, (b) prospective trial with the introduction of an intervention to alter a social determinant of health, and (c) a prospective trial with the implementation of an algorithm that requires criteria be met prior to an amputation. This article presents the proceedings and recommendations from the panel.

Ankle- and Toe-Brachial Index for Peripheral Artery Disease Identification: Unlocking Clinical Data Through Novel Methods

BACKGROUND

Despite its high prevalence and clinical impact, research on peripheral artery disease (PAD) remains limited due to poor accuracy of billing codes. Ankle-brachial index (ABI) and toe-brachial index can be used to identify PAD patients with high accuracy within electronic health records.

METHODS

We developed a novel natural language processing (NLP) algorithm for extracting ABI and toe-brachial index values and laterality (right or left) from ABI reports. A random sample of 800 reports from 94 Veterans Affairs facilities during 2015 to 2017 was selected and annotated by clinical experts. We trained the NLP system using random forest models and optimized it through sequential iterations of 10-fold cross-validation and error analysis on 600 test reports and evaluated its final performance on a separate set of 200 reports. We also assessed the accuracy of NLP-extracted ABI and toe-brachial index values for identifying patients with PAD in a separate cohort undergoing ABI testing.

RESULTS

The NLP system had an overall precision (positive predictive value) of 0.85, recall (sensitivity) of 0.93, and F1 measure (accuracy) of 0.89 to correctly identify ABI/toe-brachial index values and laterality. Among 261 patients with ABI testing (49% PAD), the NLP system achieved a positive predictive value of 92.3%, sensitivity of 83.1%, and specificity of 93.1% to identify PAD when compared with a structured chart review. The above findings were consistent in a range of sensitivity analysis.

CONCLUSIONS

We successfully developed and validated an NLP system for identifying patients with PAD within the Veterans Affairs electronic health record. Our findings have broad implications for PAD research and quality improvement.

Comparing Veterans Affairs and Private Sector Perioperative Outcomes After Noncardiac Surgery

Importance

Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking.

Objective

To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals.

Design, Setting, and Participants

This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included.

Exposures

Surgical care in either a VA or private sector setting.

Main Outcomes and Measures

Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication.

Results

Of 3 910 752 operations (3 174 274 from NSQIP and 736 477 from VASQIP), 1 498 984 (92.1%) participants in NSQIP were male vs 678 382 (47.2%) in VASQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P < .001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P < .001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P < .001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P < .001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding.

Conclusions and Relevance

VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.

Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

Perspectives on Home Time and Its Association With Quality of Life After Inpatient Surgery Among US Veterans

IMPORTANCE

Home time, defined as time spent at home after hospital discharge, is emerging as a novel, patient-oriented outcome in stroke recovery and end-of-life care. Longer home time is associated with lower mortality and higher patient satisfaction. However, a knowledge gap exists in the measurement and understanding of home time in the population undergoing surgery.

OBJECTIVES

To examine the association between postoperative home time and quality of life (QoL), functional status, and decisional regret and to identify themes regarding the meaning of time spent at home after surgery.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-methods study including a survey and qualitative interviews used an explanatory sequential design involving 152 quantitative surveys followed by in-depth interviews with 12 participants from February 26, 2020, to December 17, 2020. US veterans older than 65 years who underwent inpatient surgery at a single-center veterans hospital within the prior 6 to 12 months were studied.

EXPOSURES

Quality of life, measured by the Veterans RAND 12-item Health Survey and 19-item Control, Autonomy, Self-realization, and Pleasure scale; functional status, measured by activities of daily living (ADL) and instrumental ADL scales; and regret, measured by the Decision Regret Scale.

MAIN OUTCOMES AND MEASURES

Home time, standardized as percentage of total time spent at home from the time of surgery to the time of survey administration. Associations between home time and QoL, function, and decisional regret in the survey data were analyzed using Spearman correlation in the overall cohort and in operative stress score subcohorts (1-2 [low] vs 3-5 [high]) in a stratified analysis. The 12 semistructured interviews were analyzed to elicit patients' perspectives on home time in postoperative recovery. Qualitative data were coded and analyzed using content and thematic analysis and integrated with quantitative data in joint displays.

RESULTS

A total of 152 patients (mean [SD] age, 72.3 [4.4] years; 146 [96.0%] male) were surveyed, and 12 patients (mean [SD] age, 72.3 [4.8] years; 11 [91.7%] male) were interviewed. The median time to survey completion was 307 days (IQR, 265-344 days). The median home time was 97.8% (IQR, 94.6%-98.6%; range, 22.2%-99.5%). Increased home time was associated with better physical health-related QoL in the Veterans RAND 12-item Health Survey (r = 0.33; 95% CI, 0.18-0.47; P < .001) and higher ADL scores (r = 0.21; 95% CI, 0.06-0.36; P = .008) and instrumental ADL functional scores (r = 0.21; 95% CI, 0.04-0.37; P = .009). Decisional regret was inversely associated with home time in only the high operative stress score subcohort (r = -0.22; 95% CI, -0.47 to -0.04; P = .047). Home was perceived as a safe and familiar environment that accelerated recovery through nurturing support of loved ones.

CONCLUSIONS AND RELEVANCE

In this mixed-methods study including a survey and qualitative interviews, increased home time in the first year after major surgery was associated with improved daily function and physical QoL among US veterans. Interviewees considered the transition to home to be an indicator of recovery, suggesting that home time may be a promising, patient-oriented quality outcome measure for surgical recovery that warrants further study.

Clinical Utility of the Risk Analysis Index as a Prospective Frailty Screening Tool within a Multi-practice, Multi-hospital Integrated Healthcare System

OBJECTIVE

The goal of this project was to first address barriers to implementation of the Risk Analysis Index (RAI) within a large, multi-hospital, integrated healthcare delivery system, and to subsequently demonstrate its utility for identifying at-risk surgical patients.

BACKGROUND

Prior studies demonstrate the validity of the RAI for evaluating preoperative frailty, but they have not demonstrated the feasibility of its implementation within routine clinical practice.

METHODS

Implementation of the RAI as a frailty screening instrument began as a quality improvement initiative at the University of Pittsburgh Medical Center in July 2016. RAI scores were collected within a REDCap survey instrument integrated into the outpatient electronic health record and then linked to information from additional clinical datasets. NSQIP-eligible procedures were queried within 90 days following the RAI, and the association between RAI and postoperative mortality was evaluated using logistic regression and Cox proportional hazards models. Secondary outcomes such as inpatient length of stay and readmissions were also assessed.

RESULTS

RAI assessments were completed on 36,261 unique patients presenting to surgical clinics across five hospitals from July 1 to December 31, 2016, and 8,172 of these underwent NSQIP-eligible surgical procedures. The mean RAI score was 23.6 (SD 11.2), the overall 30-day and 180-day mortality after surgery was 0.7% and 2.6%, respectively, and the median time required to collect the RAI was 33 [IQR 23-53] seconds. Overall clinic compliance with the recommendation for RAI assessment increased from 58% in the first month of the study period to 84% in the sixth and final month. RAI score was significantly associated with risk of death (HR=1.099 [95% C.I.: 1.091 - 1.106], p < 0.001). At an RAI cutoff of ≥37, the positive predictive values for 30- and 90-day readmission were 14.8% and 26.2%, respectively, and negative predictive values were 91.6% and 86.4%, respectively.

CONCLUSIONS

The RAI frailty screening tool can be efficiently implemented within multi-specialty, multi-hospital healthcare systems. In the context of our findings and given the value of the RAI in predicting adverse postoperative outcomes, health systems should consider implementing frailty screening within surgical clinics.

Effect of type 1 tympanoplasty on the quality of life of patients suffering from chronic otitis media (safe type)

Background

Chronic otitis media (COM) remains a major public health issue and is associated with relentless discharge from the ear, pain, significant functional limitation of hearing, leading to communication problems and frequent specialist visits.

Aims

To assess the improvement in quality of life of patients of COM (safe type) and surgical success in terms of graft uptake and improvement in hearing.

Patients and Methods

A prospective questionnaire-based outcome study was directed in 100 patients with COM who were treated with Type I Tympanoplasty at our institution between May 2018 and May 2020. All patients were asked to fill Modified Chronic Otitis Media 4 (COM-4) survey before operation and 3 months after operation. Preoperative and postoperative total ear scores, audiological results, postoperative graft uptake were assessed.

Results

The correlation between preoperative and postoperative assessment by questionnaire was statistically critical (P < 0.001). There was significant improvement in hearing postoperatively (P < 0.001). Effective graft uptake was seen in 80%.

Conclusion

The current study emphasizes that Type 1 Tympanoplasty fundamentally improves quality of life of patients in terms of physical suffering, hearing loss, emotional distress postoperatively.

Association of Smoking With Postprocedural Complications Following Open and Endovascular Interventions for Intermittent Claudication

Importance

Smoking is a key modifiable risk factor in the development and progression of peripheral artery disease, which often manifests as intermittent claudication (IC). Smoking cessation is a first-line therapy for IC, yet a minority of patients quit smoking prior to elective revascularization.

Objective

To assess if preprocedural smoking is associated with an increased risk of early postprocedural complications following elective open and endovascular revascularization.

Design, Setting, and Participants

This retrospective cohort study used nearest-neighbor (1:1) propensity score matching of 2011 to 2019 data from the Veterans Affairs Surgical Quality Improvement Program, including all cases with a primary diagnosis of IC and excluding emergent cases, primary procedures that were not lower extremity revascularization, and patients with chronic limb-threatening ischemia within 30 days of the intervention. All data were abstracted June 18, 2020, and analyzed from July 26, 2020, to June 30, 2021.

Exposures

Preprocedural cigarette smoking.

Main Outcomes and Measures

Any and organ system-specific (ie, wound, respiratory, thrombosis, kidney, cardiac, sepsis, and neurological) 30-day complications and mortality, overall and in prespecified subgroups.

Results

Of 14 350 included cases of revascularization, 14 090 patients (98.2%) were male, and the mean (SD) age was 65.7 (7.0) years. A total of 7820 patients (54.5%) were smoking within the preprocedural year. There were a total of 4417 endovascular revascularizations (30.8%), 4319 hybrid revascularizations (30.1%), and 5614 open revascularizations (39.1%). A total of 1594 patients (11.1%) had complications, and 57 (0.4%) died. Among 7710 propensity score-matched cases (including 3855 smokers and 3855 nonsmokers), 484 smokers (12.6%) and 34 nonsmokers (8.9%) experienced complications, an absolute risk difference (ARD) of 3.68% (95% CI, 2.31-5.06; P < .001). Compared with nonsmokers, any complication was higher for smokers following endovascular revascularization (26 [4.3%] vs 52 [2.1%]; ARD, 2.19%; 95% CI, 0.77-3.60; P = .003), hybrid revascularization (204 [17.3%] vs 163 [14.1%]; ARD, 3.18%; 95% CI, 0.23-6.13; P = .04), and open revascularization (228 [15.4%] vs 153 [10.3%]; ARD, 5.18%; 95% CI, 2.78-7.58; P < .001). Compared with nonsmokers, respiratory complications were higher for smokers following endovascular revascularization (20 [1.7%] vs 6 [0.5%]; ARD, 1.17%; 95% CI, 0.35-2.00; P = .009), hybrid revascularization (33 [2.8%] vs 10 [0.9%]; ARD, 1.93%; 95% CI, 0.85-3.02; P = .001), and open revascularization (32 [2.2%] vs 19 [1.3%]; ARD, 0.89%; 95% CI, 0-1.80; P = .06). Wound complications and graft failure were higher for smokers compared with nonsmokers following open interventions (wound complications: 146 [9.9%] vs 87 [5.8%]; ARD, 4.05%; 95% CI, 2.12-5.99; P < .001; graft failure: 33 [2.2%] vs 11 [0.7%]; ARD, 1.50%; 95% CI, 0.63-2.37; P = .001). In a sensitivity analysis, compared with active smokers (n = 5173; smoking within 2 weeks before the procedure), the risk of any complication was decreased by 65% for never smokers (n = 1197; adjusted odds ratio, 0.45; 95% CI, 0.34-0.59) and 29% for former smokers (n = 4755; cessation more than 1 year before the procedure; adjusted odds ratio, 0.71; 95% CI, 0.61-0.83; P = .001 for interaction).

Conclusions and Relevance

In this cohort study, more than half of patients with IC were smoking prior to elective revascularization, and complication risks were higher across all modalities of revascularization. These findings stress the importance of smoking cessation to optimize revascularization outcomes.

An analysis of gender disparities amongst United States medical students, general surgery residents, vascular surgery trainees, and the vascular surgery workforce

Gender diversity in medicine continues to be a critical topic, and gender diversity within surgical fields remains an overarching challenge. In the following review, we objectively address the data available in terms of training slots for women in general and vascular surgery and within the vascular surgery workforce. Overall, women comprise 36% of active physicians in the 2019 Association of American Medical Colleges data. The number of women in surgical fields is lower representing 22% in general surgery, 9% in neurosurgery, 6% in orthopedic surgery, 17% in plastic surgery, 8% in thoracic surgery, and 15% in vascular surgery. Also notable is the lower academic ranks held by women in surgery. The proportion of women instructors in surgery in 2020 was 61%, assistant professors 30%, associate professors 23%, and full-time professors only 13.5%. There are multiple opportunities across the divisional/institutional/societal domains in which mentorship and sponsorship can promote gender equity and inclusion. Recruitment and retention of women and minorities into the vascular academic and private practices is essential to ensure best patient outcomes and quality of care for our patients. We hope that by shedding light on this topic, there will be greater awareness and improved strategies to address the disparities within institutions.

The Correlation Between Case Total Work Relative Value Unit, Operative Stress, and Patient Frailty: Retrospective Cohort Study

OBJECTIVE

Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions.

SUMMARY OF BACKGROUND DATA

Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity.

METHODS

Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score).

RESULTS

Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases.

CONCLUSIONS

Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.

Family violence during COVID-19 and its impact on mental health of children: A systematic review

Purpose: The COVID-19 pandemic posed unanticipated challenges that could impact how the family system operates across the world. Restrictions imposed to control the rapid spread of the virus substantially increased violence in families. The current study aims to review violence in the family and its impact on the mental health of children during the pandemic.Method: A systematic search was conducted using keywords in the electronic databases PubMed, PsycINFO, and Web of Science, and a manual search was conducted on Google Scholar for articles from January 2020 to January 2021. Of the 50 records identified, seven studies that met eligibility criteria were selected for final analysis.Results: Results revealed that family violence during the pandemic has escalated the mental health problems of children, including aggressive and self-harming behaviours. Lockdown restrictions, social detachment, financial instability, fear of infection, and unemployment led to increased parental stress. Parents with a higher level of stress were more likely to maltreat their children.Conclusions: Exposure to short and long-term family violence can adversely impact the mental health of children and can negatively affect a child's present and future life. Recommendations for researchers, mental health practitioners, public health authorities, and other service providers are also outlined.

Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association

Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.