Cardiac Surgical Care Research Articles

Grundvoraussetzungen herzchirurgischer Einheiten zur Behandlung von Patienten mit angeborenen Herzfehlern.

This document defines fundamental structures of congenital cardiac surgery departments in Germany. It has been developed by the executive boards of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) and the German Society of Pediatric Cardiology (GSPC) in collaboration with the working group for Congenital and Pediatric Heart Surgery of the GSTCVS.This updated consensus paper is based on a previous publication of the European Association for Cardiothoracic Surgery (EACTS) and is a refinement and adaptation of its initial version published by the GSTCVS in 2005. In Germany, pediatric cardiology and cardiac surgery facilities caring for patients with congenital cardiac defects are subject to certain regulations. For example, in 2010 the Federal Joint Committee implemented the resolution on Quality Assurance Measures in the Provision of Cardiac Surgical Care for Children and Adolescents (directive congenital cardiac surgery) which regulates structural and process quality compulsorily. To date, fundamental and considerable differences of the respective departments persist.Congenital cardiac surgery departments have to provide the whole spectrum of the cardiac surgical therapy from the neonate to the adult with congenital cardiac defects (with the exception of heart transplantation) continuously and with the appropriate experience. Furthermore, the departments have to prove their constant scientific activity and ensure that they facilitate education and training for the specialty certification in cardiac surgery. The responsible surgeons of all congenital cardiac surgery departments commit to participate in the currently voluntary national quality assurance for congenital cardiac defects of the GSTCVS and the GSPC and perform an individual surgical outcome assessment and risk stratification. This is supplemented by the willingness for external certification specific to the individual and the facilitation of peer review procedures for quality assurance purposes. Additional measures, such as collaboration in clinical research and ongoing interdisciplinary education and training, are preferable.

The Chinese Cardiac Surgery Registry: Design and Data Audit

In light of the burgeoning volume and certain variation of in-hospital outcomes of cardiac operations in China, a large patient-level registry was needed. We generated the Chinese Cardiac Surgery Registry (CCSR) database in 2013 to benchmark, continuously monitor, and provide feedback of the quality of adult cardiac operations. We report on the design of this database and provide an overview of participating sites and quality of data. We established a network of participating sites with an adult cardiac surgery volume of more than 100 operations per year for continuous web-based registry of in-hospital and follow-up data of coronary artery bypass grafting (CABG) and valve operations. After a routine data quality audit, we report the performance and quality of care back to the participating sites. In total, 87 centers participated and submitted 46,303 surgical procedures from January 2013 to December 2014. The timeliness rates of the short-list and in-hospital data submitted were 73.6% and 70.2%, respectively. The completeness and accuracy rates of the in-hospital data were 97.6% and 95.1%, respectively. We have provided 2 reports for each site and 1 national report regarding the performance of isolated CABG and valve operations. The newly launched CCSR with a national representativeness network and good data quality has the potential to act as an important platform for monitoring and improving cardiac surgical care in mainland China, as well as facilitating research projects, establishing benchmarking standards, and identifying potential areas for quality improvements (ClinicalTrials.gov No. NCT02400125).

Abstract 17272: Regionalization of Pediatric Cardiac Surgery Lowers Mortality, Re-operation, and Healthcare Costs

Introduction: The mortality of infants requiring cardiac surgery is related to center and surgeon case volume. One solution for increasing case volume is to regionalize pediatric cardiac surgical care. Hypothesis: We hypothesized that the regionalization of pediatric cardiac surgical care from two medical centers would lower mortality, rate of re-operation, and subsequent health care costs. Methods: Infants undergoing a biventricular repair were divided into two groups: pre-regionalization when operations were performed in two separate hospitals (1991-2000) and post-regionalization when all operations were performed in one regional hospital (2001-2010). Operative survival, midterm mortality, need for re-operation, and subsequent healthcare costs were compared between the groups. Results: There were 508 infants in the pre-regionalization group, and 479 infants in the post-regionalization group. There were no significant differences in pre-operative age, weight, or gender between groups. Pre-regionalization operative survival was significantly lower than the state average. Post-regionalization operative survival was significantly greater than pre-regionalization and was similar to the state average (Figure 1). Five and 10 year survival remained significantly greater in the post-regionalization group (5 year: 96.8% vs 90.6%, 10 year: 96.8% vs. 89.9%, p<0.01). Five and ten year freedom from re-operation was significantly higher in the post-regionalization group (5 year: 88.8 vs 79.5 %, 10 year: 82.7 vs 73.3%, p=0.001). Subsequent health care costs were significantly lower in the post-regionalization group ($20,233 ± 53596 vs. 37,516 ± 82,947, p<0.001).Conclusions: Regionalization of pediatric cardiac surgical care lowered operative and 10 year mortality, rate of re-operation, and subsequent costs of health care.

Locating Errors Through Networked Surveillance

The objectives were to develop a scientifically sound and feasible peer-to-peer assessment model that allows health-care organizations to evaluate patient safety in cardiovascular operating rooms and to establish safety priorities for improvement. The locating errors through networked surveillance study was conducted to identify hazards in cardiac surgical care. A multidisciplinary team, composed of organizational sociology, organizational psychology, applied social psychology, clinical medicine, human factors engineering, and health services researchers, conducted the study. We used a transdisciplinary approach, which integrated the theories, concepts, and methods from each discipline, to develop comprehensive research methods. Multiple data collection was involved: focused literature review of cardiac surgery-related adverse events, retrospective analysis of cardiovascular events from a national database in the United Kingdom, and prospective peer assessment at 5 sites, involving survey assessments, structured interviews, direct observations, and contextual inquiries. A nominal group methodology, where one single group acts to problem solve and make decisions was used to review the data and develop a list of the top priority hazards. The top 6 priority hazard themes were as follows: safety culture, teamwork and communication, infection prevention, transitions of care, failure to adhere to practices or policies, and operating room layout and equipment. We integrated the theories and methods of a diverse group of researchers to identify a broad range of hazards and good clinical practices within the cardiovascular surgical operating room. Our findings were the basis for a plan to prioritize improvements in cardiac surgical care. These study methods allowed for the comprehensive assessment of a high-risk clinical setting that may translate to other clinical settings.

Contemporary bloodletting in cardiac surgical care.

Contemporary bloodletting in cardiac surgical care.

Contemporary Bloodletting in Cardiac Surgical Care

Health care providers are seldom aware of the frequency and volume of phlebotomy for laboratory testing, bloodletting that often leads to hospital-acquired anemia. Our objectives were to examine the frequency oflaboratory testing in patients undergoing cardiac surgery, calculate cumulative phlebotomy volume from time of initial surgical consultation to hospital discharge, and propose strategies to reduce phlebotomy volume. From January 1, 2012 to June 30, 2012, 1,894 patients underwent cardiac surgery at Cleveland Clinic; 1,867 had 1 hospitalization and 27 had 2. Each laboratory test was associated with a test name and blood volume. Phlebotomy volume was estimated separately for the intensive care unit (ICU), hospital floors, and cumulatively. A total of 221,498 laboratory tests were performed, averaging 115 tests per patient. The most frequently performed tests were 88,068 blood gas analyses, 39,535 coagulation tests, 30,421 complete blood counts, and 29,374 metabolic panels. Phlebotomy volume differed between ICU and hospital floors, with median volumes of 332 mL and 118 mL, respectively. Cumulative median volume for the entire hospital stay was 454 mL. More complex procedures were associated with higher overall phlebotomy volume than isolated procedures; eg, combined coronary artery bypass grafting (CABG) and valve procedure median volume was 653 mL (25th/75th percentiles, 428 of 1,065 mL) versus 448 mL (284 of 658 mL) for isolated CABG and 338 mL (237 of 619) for isolated valve procedures. We were astonished by the extent of bloodletting, with total phlebotomy volumes approaching amounts equivalent to 1 to 2 red blood cell units. Implementation of process improvement initiatives can potentially reduce phlebotomy volumes and resource utilization.

Blood volumes in cardiac surgery with cardiopulmonary bypass.

Total blood volume (TBV) estimation potentially impacts various aspects of cardiac surgical care, including pharmacological and transfusion interventions, hemodynamic and volume management and perfusion equipment selection. TBV is commonly computed during cardiopulmonary bypass (CPB), using standardized formulae. We hypothesized that these equations fail to accurately predict individual blood volume variability. The aim of this study was to determine TBV with a dilution technique and compare the results to commonly utilized TBV calculations. After institutional review board approval, data was prospectively collected and analyzed for 101 patients undergoing open-heart surgery. Hematocrits (Hct) just prior to and immediately after the initiation of CPB were used to calculate the TBV. Results were compared to (1) the Allen formula and (2) weight-based standards (70 ml/kg for males (SM); 65 ml/kg for females (SF)). The average dilution TBV (male: 4684 ± 1641 ml; female: 3027 ± 1067 ml; total: 4175 ± 1617 ml) was significantly smaller (p<0.05) than TBV estimated by Allen's formula (male: 6328 ± 973 ml; female: 4167 ± 643 ml; total: 5665 ± 1134 ml) and weight-based standards (male: 6278 ± 1256 ml; female: 4924 ± 1064 ml; total: 5862 ± 1350 ml). Allen's formula and the weight-based standards correlated strongly (R(2) = 0.821, p<0.001), suggesting similar estimates of TBV when using these methods. In contrast, hemodilution correlated poorly with the estimates by Allen (R(2) = 0.221, p<0.001) and weight-based formulae (R(2) = 0.122, p<0.001), suggesting different TBV computation. The dilution method during CPB for TBV estimation is applicable and reproducible in the cardiac surgical arena and can be utilized to calculate TBV. Our results suggest that traditional TBV assessment in cardiac surgical patients by Allen's and weight-based formulae lacks the desired accuracy in estimating true TBV.

Acute Risk Change for Cardiothoracic Admissions to Intensive Care (ARCTIC index): A new measure of quality in cardiac surgery

Quality of cardiac surgical care may vary between institutions. Mortality is low and large numbers are required to discriminate between hospitals. Measures other than mortality may provide better comparisons. To develop and assess the Acute Risk Change for Cardiothoracic Admissions to Intensive Care (ARCTIC) index, a new performance measure for cardiothoracic admissions to intensive care units (ICUs). The Australian and New Zealand Society of Cardiac and Thoracic Surgeons database and Australian and New Zealand Intensive Care Society Adult Patient Database were linked. Logistic regression was used to generate a predicted risk of death first from preoperative data using the previously validated Allprocscore and second on admission to an ICU using Acute Physiology and Chronic Health Evaluation III score. Change in risk as a percentage (ARCTIC) was calculated for each patient. The validity of ARCTIC as a marker of quality was assessed by comparison with intraoperative variables and postoperative morbidity markers. Sixteen thousand six hundred eighty-seven patients at 21 hospitals from 2008 to 2011 were matched. An increase in ARCTIC score was associated with prolonged cardiopulmonary bypass time (P = .001), intraoperative blood product transfusion (P < .001), reoperation (P < .0001), postoperative renal failure (P < .0001), prolonged ventilation (P < .0001), and stroke (P = .001). The ARCTIC index is associated with known markers of perioperative performance and postoperative morbidity. It may be used as an overall marker of quality for cardiac surgery. Further work is required to assess ARCTIC as a method to discriminate between cardiac surgical units.

“Risk Change”: A New Method to Compare Cardiac Surgical Units

Introduction: Quality of cardiac surgical care may vary between institutions. Mortality is low and large numbers are required to discriminate between hospitals. Measures other than mortality may provide better comparisons.

The Changing Face of Cardiac Surgery: Practice Patterns and Outcomes 2001-2010

BackgroundAdvances in cardiac surgical care have allowed for successful surgery in high-risk elderly patients. Advances in percutaneous coronary intervention (PCI) techniques and expanded indications for PCI have resulted in a decrease in referrals for coronary artery bypass grafting (CABG). Our objective was to document changes in practice patterns and outcomes in a single tertiary cardiac surgery centre serving a large geographic area. MethodsFor all cardiac surgery cases performed from 2001-2010 we examined its use, patient clinical characteristics, and outcomes. Frailty was assessed using a measure we have previously demonstrated to be associated with adverse outcomes. ResultsDuring the study period, annual case volume decreased by 13%. The number of isolated CABG cases declined, and valve surgery and other complex procedures increased. The proportion of patients aged ≥ 80 years rose from 7%-12%, and the proportion of frail patients increased from 4%-10%. Although unadjusted in-hospital mortality remained relatively unchanged, intensive care unit (ICU) stays and prolonged institutional care increased. Older age and frailty were associated with mortality, prolonged ICU stays, prolonged institutional care, and a composite of mortality and major morbidities. ConclusionsOur findings showed a decline in CABG, an increase in more complex operations, and an increase in prolonged ICU stays and prolonged institutional care. The proportion of frail and elderly patients increased over time and these patient groups were at higher risk of adverse postoperative outcomes. Particular attention is required in the decision for surgery and perioperative management of these patients.

Basisstandards einer Fachabteilung für Herzchirurgie

Current evolutions and substantial amendments of the German health care system in combination with distinguished progress in cardiac surgery over the past years require both a reflection of principles in patient-centered care and an update of basic standard requirements for a department of cardiac surgery in Germany. In due consideration of the data from the voluntary registry of the German Society for Thoracic and Cardiovascular Surgery, this article accurately defines core requirements for a cardiac surgical department (cardiac surgery on-site), subdivided into facilities, staff and processes. If based on these standards, one may anticipate that cardiac surgical care is performed under appropriate conditions leading to an intrinsic benefit for patients.

Assessment of coronary artery disease risk in 5463 patients undergoing cardiac surgery: When is preoperative coronary angiography necessary?

We sought to critically analyze the routine use of conventional coronary angiography (CCA) before noncoronary cardiac surgery and to assess clinical prediction models that might allow more selective use of CCA in this setting. We studied 5463 patients undergoing aortic valve surgery, mitral valve surgery, or septal myectomy with or without coronary artery bypass grafting from 2001 to 2010. Preoperative CCAs were evaluated for the presence of significant coronary artery disease (CAD). Random forests and logistic regression methods were used to determine the predictors of significant (≥50%) coronary stenosis. Preoperative CCA was performed in 4711 patients (86%). Two thirds of those with angina, previous myocardial infarction, or percutaneous coronary intervention had significant CAD found on CCA, versus one third of patients free of these risk factors (P<.001). Among 3019 patients without angina, previous myocardial infarction or percutaneous coronary intervention, older age, male gender, diabetes, and peripheral vascular disease independently predicted significant CAD (P<.001 for all; C-index=0.74). Specifically, a multivariate model with these variables identified 10% (301 of 3019) of patients as having a low (≤10%) probability ofcoronary stenosis, of whom fewer than 5% had significant CAD and fewer than 1% had left main or triple-vessel coronary disease. In the absence of angina, previous myocardial infarction, or percutaneous coronary intervention, preoperative CCA identified significant CAD in only one third of patients. Our clinical prediction models could enhance the identification of patients at low risk of significant CAD for whom CCA might potentially be avoided before cardiac surgery. This strategy may improve the efficiency of cardiac surgical care delivery by diminishing procedure-related morbidity and offering significant cost savings.

The European Association for Cardio-Thoracic Surgery (EACTS) database: an introduction

Continuous monitoring of surgical outcomes through benchmarking and the identification of best practices has become increasingly important. A structured approach to data collection, coupled with validation, analysis and reporting, is a powerful tool in these endeavours. However, inconsistencies in standards and practices have made comparisons within and between European countries cumbersome. The European Association for Cardio-Thoracic Surgery (EACTS) has established a large international database with the goals of (i) working with other organizations towards universal data collection and creating a European-wide repository of information on the practice of cardio-thoracic surgery, and (ii) disseminating that information in scientific, peer-reviewed articles. We report on the process of data collection, as well as on an overview of the data in the database. The EACTS Database Committee met for the first time in Monaco, September 2002, to establish the ground rules for the process of setting up the database. Subsequently, data have been collected and merged by Dendrite Clinical Systems Ltd. As of December 2008, the database included 1,074,168 patient records from 366 hospitals located in 29 countries. The latest submission from the years 2006-08 included 404,721 records. The largest contributors were the UK (32.0%), Germany (20.9%) and Belgium (7.3%). Isolated coronary bypass surgery was the most frequently performed operation; the proportion of surgical workload that comprised isolated coronary artery bypass grafting varied from country to country: 30% in Spain and almost 70% in Denmark. Isolated valve procedures constituted 12% of all procedures in Norway and 32% in Spain. Baseline demographics showed an increase in the mean age and the percentage of patients that were female over time. Remarkably, the mortality rates for all procedures declined over the period analysed, to 2.2% (95% confidence interval [CI] 2.2-2.3%) for isolated coronary bypass, 3.4% (95% CI 3.3-3.5%) for isolated valve and 6.2% (95% CI 6.0-6.5%) for bypass + valve procedures. The EACTS database has proven to be an important step forward in providing opportunities for monitoring cardiac surgical care across Europe. As the database continues to expand, it will facilitate research projects, establish benchmarking standards and identify potential areas for quality improvements.

Cardiac Surgical ICU Care: Eliminating “Preventable” Complications

The goal of this article is to provide an outline of the latest advances in critical care that pertain to the open heart surgery patient, pinpointing initiatives that would enable physicians and institutions to successfully implement guidelines, protocols, checklists, and initiatives that have been shown to improve patient safety.

Invited Commentary

Invited Commentary

Invited Commentary

Quality of life as an outcome variable has ascended to a level of importance second only to survival in many decision algorithms allocating complex medical and surgical therapies in the current era of advanced heart failure management. This analysis by Farmer and colleagues [1Farmer S.A. Grady K.L. Wang E. McGee Jr, E.C. Cotts W.G. McCarthy P.M. Demographic, psychosocial, and behavioral factors associated with survival after heart transplantation.Ann Thorac Surg. 2013; 95: 876-883Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar] supports the findings of prior studies on quality of life and its impact after heart and other solid organ transplantation, which emphasize the importance of education and compliance to achieve long-term survival. The issue of compliance is particularly challenging in young adults and older teenagers, who are especially prone to rejection with hemodynamic compromise [2George J.F. Tallaj J.A. Melby S.J. Kirklin J.K. Pamboukian S.V. Opportunities for improvement in heart transplantation outcomes for young adults 18 to 35 years of age.J Heart Lung Transplant. 2012; 31: 903-904Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar], and at the same time are susceptible to lapses in compliance as they gain greater independence from parental influence. Comprehensive quality-of-life analyses such as this have set the standard for other complex cardiovascular therapies that require major patient involvement in surveillance and self-care. The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) and the National Heart, Lung, and Blood Institute have emphasized the importance of quality of life in the long-term evaluation of ventricular assist devices as long-term “destination” therapy [3Grady K.L. Warner Stevenson L. Pagani F.D. et al.Beyond survival: recommendations from INTERMACS for assessing function and quality of life with mechanical circulatory support.J Heart Lung Transplant. 2012; 31: 1158-1164Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. Clearly, quality-of-life indicators will play a major role in determining which complex therapies are recommended to patients with advanced heart failure who are listed for heart transplantation but are eligible for triage to alternative therapies [4Kirklin J.K. Naftel D.C. Pagani F.D. et al.Long-term mechanical circulatory support (destination therapy): on track to compete with heart transplantation?.J Thorac Cardiovasc Surg. 2012; 144 (discussion 597–8): 584-603Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar]. The necessary team components to optimize and evaluate quality of life after complex cardiac procedures that involve several surgical and medical options (such as the Fontan pathway versus cardiac transplantation for some anatomic subsets of single ventricle, the application of transcutaneous aortic valve replacement, catheter versus surgically based mitral valve repair, and robotic versus open cardiothoracic operations) will be increasingly mandated as part of the necessary institutional platform of care for large patient cohorts considered for cardiac surgical care. Further refinement of quality-of-life assessment tools and rigorous quality-of-life statistical analyses will increasingly become an obligatory component of any serious evaluation of these complex cardiovascular applications. Demographic, Psychosocial, and Behavioral Factors Associated With Survival After Heart TransplantationThe Annals of Thoracic SurgeryVol. 95Issue 3PreviewHeart transplantation requires substantial personal, financial, and psychosocial resources. Using an existing multisite data set, we examined predictors of mortality at 5 to 10 years after heart transplantation. Full-Text PDF

Heart surgery programs innovation using surgical risk stratification at the São Paulo State Public Healthcare System: SP-SCORE-SUS STUDY

Cardiovascular diseases represent the greatest burden of morbidity and mortality for the health system and cardiac surgery has an important impact on their resolutivity. The association and correlation of patients' demographic and clinical relevant information with the resources required for each stratum represent the possibility to adapt, improve and innovate into the healthcare programs. This project aims to remodel the "InsCor" risk score for the formulation of the SP-SCORE (Sao Paulo System for Cardiac Operative Risk Evaluation) in order to better reflects the complexity of cardiac surgical care. The participating hospitals include the Health Technology Assessment Centers in of the Health Secretariat' HTA Network of São Paulo State (HTA-NATSs / SES-SP). The SP-SCORE will use 10 variables of the InsCor model and others 8 variables with presumed influence in Brazil. The primary endpoints are morbidity and mortality. Bootstrap technique besides automated selection of variables (stepwise) will be used to develop a parsimonious model by multiple logistic regression. This project will contribute for the SUS-SP regionalized health-care (RRAS) sustainability and financing of the CABG and/or heart valve surgery programs promoting equitable allocation, increasing access and effectiveness, as well as characterizing the magnitude of available resources and its impact.

Evaluation of supply-side initiatives to improve access to coronary bypass surgery

BackgroundGuided by the evidence that delaying coronary revascularization may lead to symptom worsening and poorer clinical outcomes, expansion in cardiac surgery capacity has been recommended in Canada. Provincial governments started providing one-time and recurring increases in budgets for additional open heart surgeries to reduce waiting times. We sought to determine whether the year of decision to proceed with non-emergency coronary bypass surgery had an effect on time to surgery.MethodsUsing records from a population-based registry, we studied times between decision to operate and the procedure itself. We estimated changes in the length of time that patients had to wait for non-emergency operation over 14 calendar periods that included several years when supplementary funding was available. We studied waiting times separately for patients who access surgery through a wait list and through direct admission.ResultsDuring two periods when supplementary funding was available, 1998–1999 and 2004–2005, the weekly rate of undergoing surgery from a wait list was, respectively, 50% and 90% higher than in 1996–1997, the period with the longest waiting times. We also observed a reduction in the difference between 90th and 50th percentiles of the waiting-time distributions. Forty percent of patients in the 1998, 1999, 2004 and 2005 cohorts (years when supplementary funding was provided) underwent surgery within 16 to 20 weeks following the median waiting time, while it took between 27 and 37 weeks for the cohorts registered in the years when supplementary funding was not available. Times between decision and surgery were shorter for direct admissions than for wait-listed patients. Among patients who were directly admitted to hospital, time between decision and surgery was longest in 1992–1993 and then has been steadily decreasing through the late nineties. The rate of surgery among these patients was the highest in 1998–1999, and has not changed afterwards, even for years when supplementary funding was provided.ConclusionsWaiting times for non-emergency coronary bypass surgery shortened after supplementary funding was granted to increase volume of cardiac surgical care in a health system with publicly-funded universal coverage for the procedure. The effect of the supplementary funding was not uniform for patients that access the services through wait lists and through direct admission.

The Canadian Society of Cardiac Surgeons Perspective on the Cardiac Surgery Workforce in Canada

As the professional society representing cardiac surgeons in Canada, the Canadian Society of Cardiac Surgeons (CSCS) recognizes the importance of maintaining a stable cardiac surgical workforce. The current reactive approach to health human resource management in cardiac surgery is inadequate and may result in significant misalignment of cardiac surgeon supply and demand. The availability of forecasting models and high quality, consistent data on productivity, workload, utilization, and demand is a prerequisite for our profession's capacity to predict and plan for changes in health human resources. The CSCS recognizes that improved workforce management is a key component to providing optimal cardiac surgical care for Canadians in the future and has developed the recommendations in this document as a call to action to interested stakeholders and policymakers to bring substantial improvements to health human resource management in cardiac surgery.

Developing strategies for predicting and preventing readmissions in vascular surgery

The escalating cost burden of hospital readmission has prompted recent nationwide efforts aimed at reducing the incidence of this important quality measure. Because patients undergoing vascular surgery account for a significant proportion of readmissions, vascular surgeons may face reduced reimbursements in the near future if these trends continue. However, risk factors associated with readmission remain poorly defined, and further research is needed to identify interventions that will prevent readmission following vascular procedures. Accordingly, this manuscript will (1) propose a conceptual model to explain the driving forces behind readmissions in vascular surgery, (2) review current evidence directed at identifying risk factors and evaluating interventions to reduce readmissions across different medical and surgical specialties, and (3) identify key areas in patient care where targeted research or interventions may be implemented in vascular surgery.