Vascular Surgery Patients Research Articles

The Benefit of Cost-Transparency Calculators Does Not Extend to Vascular Surgery Patients

In 2021, the Centers for Medicare & Medicaid Services (CMS) mandated that every hospital create a publicly available webtool for pricing various medical services in an effort to give patients transparency in regard to their health care expenses and allow patients to "shop around" to receive the care most fitting their budget. Our objective is to investigate the utility this mandate provides for vascular surgery patients. Standardized searches were performed to find patient cost calculators for Newsweek's Top 50 Hospitals in the United States. If the webtool was found, a list of standardized searches were performed to investigate whether the tool listed prices for the following vascular procedures: Arteriovenous fistula (AVF), varicose vein procedures, and Endovascular Aneurysm Repair (EVAR). Of the 50 hospitals included, all had an easily accessible web-based cost estimator tool. The average time to find the cost estimator was 33.27sec. Of these 50 hospitals, 10% provided cost information on AVF surgery, 12% provided cost information on varicose vein procedures, and 0% provided information on EVAR. There was no difference in the hospital's likelihood to report a price based on region of the United States. Average preinsurance price for AVF surgery was $11,933.61 and $22,191 for vein procedures. In conclusion, despite good adherence to the CMS mandate requiring a publicly available pricing tool, these tools provide little to no information for vascular surgery patients. Overall, this discrepancy places vascular surgery patients at a significant disadvantage. As such, vascular patients do not have access to the knowledge necessary to financially prepare for surgery, and furthermore, they are not afforded the luxury to choose where to have procedures performed based on price variability. Hopefully this research will encourage hospitals to broaden the scope of their cost calculators to allow it to benefit all patients.

“A breach in the protocol for no good reason”: a surgical antimicrobial prophylaxis experience in an Ethiopian academic medical center

BackgroundAn appropriately administered surgical antimicrobial prophylaxis decreases the rate of surgical site infections. Although evidence-based clinical practice guidelines have been published on surgical antimicrobial prophylaxis, the rate of adherence to the protocol and the impact of extending antimicrobial prophylaxis postoperatively is yet to be well elucidated.MethodA total of general surgery and vascular surgery patients with clean and clean contaminated wound undergoing elective surgical procedures were included in the study. The rate of surgical antimicrobial prophylaxis utilization, the proportion of patients whom had their antimicrobial prophylaxis extended beyond 24 h and the rate of surgical site infections across groups were evaluated.ResultsThe surgical antimicrobial prophylaxis utilization rate was 90.5%. Of these patients, 12.6% were unnecessarily administered with antibiotics. An “extended” antibiotics administration beyond 24 h after the surgery was found in 40.2%. Gastrointestinal and hepato-pancreatico-biliary surgery patients had 7.9-fold rate of “extended” surgical antimicrobial prophylaxis beyond 24 h, AOR 7.89 (95% CI 3.88–20.715.62, p value < 0.0001). The overall rate of surgical site infection was 15(6.8%). The “extended” regimen of prophylactic antibiotics had no effect on the rate of surgical site infections.ConclusionLess than half of the patients included here had surgical antimicrobial prophylaxis regimen in accordance with the existing guidelines. The most common protocol violation was noted as extension of antimicrobial prophylaxis for more than 24 h after surgery. The extension of antimicrobial prophylaxis did not decrease the rate of surgical site infections, reaffirming the evidence that prophylactic extension of surgical antimicrobial prophylaxis is unnecessary.

Palliative Care Consults and Frailty Screening in High-Risk Vascular Surgery Patients

Palliative care has increasingly been integrated into the management of high-risk surgery because of the beneficial effect on patient quality of life. However, the utilization of palliative care in vascular surgery remains unclear due to a lack of data. The purpose of this study was to determine the palliative care consult rate in high-risk vascular surgery patients. A retrospective chart review was performed at a single Veteran Affairs Medical Center from 2013 to 2021. High-risk vascular surgery patients were identified by using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) risk score of >4%, which predicted 30-day mortality. Patient demographics, operative procedures, and clinical outcomes were collected. A total of 126 patients underwent a high-risk vascular surgery operation. The surgical procedures consisted of 78 amputations, 19 bypasses, 18 endovascular aneurysm repair/stents, and 11 thrombectomy/arterial repair. Palliative care was consulted in 44 patients (35%) during the hospitalization: 8 patients (18%) had preoperative consults, whereas 36 patients (82%) had postoperative consults. The overall 30-day mortality was 15%, and the 1-year mortality rate was 34%. The 30-day and 1-year mortality rates were higher in those patients who received palliative care consultation (36% and 64%, respectively) compared with those without consult (0% and 21%, respectively). The palliative care consults had a higher referral rate in more frail patients, by Revised Analysis Index (RAI): n = 13 of 57 (23%) nonfrail (RAI <20), n = 14 of 44 (32%) frail (RAI = 21-32), and n = 17 of 25 (68%) very frail (RAI >33). The majority of the palliative care consults were obtained for goals of care discussion (80%) compared with withdrawal of care (20%). Palliative care is generally underused for vascular surgery patients, but our data demonstrated a palliative care consult rate of 35% in high-risk vascular surgery patients. A frailty screening program can further stratify high-risk vascular surgery patients who would benefit from an early palliative care consult.

Reducing Surgical Site Infections with Silver-impregnated Dressings in Lower Extremity Bypass Patients

Surgical site infection (SSI) after lower extremity (LE) bypass surgery is associated with longer length of stay, higher hospital cost, increased morbidity, and even graft loss. Silver-impregnated dressings have been used by other surgical subspecialties to decrease SSI with reported success. The National Surgical Quality Improvement Program (NSQIP) published a national expected rate of 7.9% for SSI after LE bypass surgery. In 2018, our institutional SSI rate was 12.8%. To reduce this rate, we transitioned to silver-impregnated dressings for all LE bypass procedures and studied the subsequent impact on SSIs. We used NSQIP data to retrospectively study two consecutive cohorts of vascular surgery patients at a single institution who underwent LE bypasses. Patients in 2019 underwent the standard of care surgery with standard sterile gauze postoperative dressings. Patients in 2020 underwent standard of care surgery and were treated with silver-impregnated dressings. NSQIP criteria were used to determine if patients developed SSIs within 30 days of surgery. The Fischer exact and χ2 tests were used to compare groups before and after the intervention. A total of 282 patients underwent LE bypass in 2019 and 2020. The standard of care cohort had 168 patients with sterile gauze dressings, whereas the cohort after intervention had 114 patients with silver-impregnated dressings. The groups were similar in terms of demographics and comorbidities (Table). When considering all classifications of SSI, there were significantly fewer infections in the silver dressing group compared with the sterile gauze group (9.6 % vs 20.8%; P = .014). There was a non-statistically significant reduction in readmissions and unplanned return to the operating room in the silver dressing group. This study demonstrated a significantly lower rate of SSIs in patients undergoing LE bypass with use of a silver-impregnated dressing when compared with a sterile gauze dressing. Although our study does not demonstrate a causal relationship, this relatively inexpensive and low-risk intervention's association with a significant decrease in an otherwise very serious postoperative complication argues for a change in clinical practice or prospective confirmatory studies to optimize patient outcomes after LE bypass.TableDemographic and comorbidity differences between groups of patients who underwent lower extremity (LE) bypass surgery using sterile gauze dressing (2019) and silver-impregnated dressing (2020), and NSQIP-collected outcomes regarding postoperative surgical site infection (SSI), wound dehiscence, unplanned return to operating room, and readmission within 30 daysSterile gauze (n = 168)Silver dressing (n = 114)P-valueMale gender109 (64.8)79 (69.3).5Age, years67.1 (10.8)66.0 (11.2).4Race.7 Asian1 (0.6)2 (1.8) Black or African American25 (14.9)13 (11.4) Unknown11 (6.5)7 (6.1) White131 (78.0)92 (80.7)Emergent surgery10 (5.9)4 (3.5).4Active smoker78 (46.4)52 (45.6).9Diabetes.4 Yes, insulin-dependent47 (28.0)39 (34.2) Yes, non-insulin-dependent32 (19.1)23 (20.2) No89 (53.0)52 (45.6)Hypertension133 (79.2)93 (81.6).6Chronic obstructive pulmonary disease26 (15.5)15 (13.2).6Dialysis10 (5.9)10 (8.8).4Superficial SSI35 (20.8)11 (9.7).014Deep SSI5 (3.0)2 (1.8).7Organ space SSI2 (1.2)6 (5.3).07Wound dehiscence6 (3.6)5 (4.4).8Unplanned return to operating room43 (25.6)32 (28.1).7Readmission39 (23.2)30 (26.3).2Data are presented as mean (standard deviation) or number (%). Open table in a new tab

Abstract 409: Statin Dose Is Associated With Improved HDL Anti-inflammatory Capacity In Cardiac And Vascular Surgery Patients; Possible Mechanism For Statin Mediated Enhancement Of The Association Between Higher HDL And Less Kidney Injury After Surgery

Introduction: Postoperative acute kidney injury (AKI) is associated with chronic kidney disease (CKD) development and advancement. A higher preoperative high-density lipoprotein (HDL) concentration is associated with less postoperative AKI. Statin exposure, especially long-term exposure, strengthens the association between higher HDL and less postoperative AKI. However, three randomized trials of perioperative statin treatment did not prevent AKI. In animal models, HDL prevents AKI primarily by suppressing renal endothelial intercellular adhesion molecule-1 (ICAM-1). We hypothesized that HDL from surgery patients on higher long-term statin doses would have improved capacity to suppress endothelial ICAM-1 expression. Further, we hypothesized that patients with higher in vitro HDL capacity to suppress ICAM-1 would have lower plasma sICAM-1 concentrations after surgery and less AKI. Methods: We recruited 100 adults undergoing major surgery on the heart or large blood vessels. ApoB-depleted serum was incubated with HUVEC cells for 30min. Then, 8 ng/mL TNF-α was added for 5hr. RT-PCR quantified HUVEC ICAM-1 mRNA. An ELISA assay measured sICAM-1 concentrations. AKI was defined by KDIGO serum creatinine-based criteria. Results: HDL-C did not correlate with HDL ICAM-1 suppression (Spearman’s R=0.05, p=0.64). Apolipoprotein A-I concentration did correlate with HDL ICAM-1 suppression (Spearman’s R= 0.29, p=0.004). Higher HDL capacities to suppress ICAM-1 in vitro were correlated with lower plasma sICAM-1 (Spearman’s R= -0.30, p=0.003). After adjustment for AKI risk factors, higher HDL-C was not associated with AKI (OR 1.03 (95% CI 0.98-1.08), p=0.19). In contrast, a higher HDL capacity to suppress ICAM-1 was independently associated with lower odds of AKI (OR 0.88 (95% CI 0.80-0.98), p=0.016). Further, higher long-term statin dose was associated with higher HDL capacity to suppress ICAM-1 (p=0.045). Conclusions: Cardiac and vascular surgery patients with higher HDL capacity to suppress endothelial ICAM-1 have lower plasma sICAM concentrations after surgery and a lower risk of postoperative AKI. Higher long-term statin dose is associated with higher HDL endothelial cell ICAM-1 suppression capacity in these patients.

A Quality Improvement Initiative to Decrease the Incidence of Post Operative Wound Complications Following Minor Level Amputations

atient education is important for improving the ability to manage one’s health and optimize clinical outcomes. We identified a paucity in educational materials for patients who undergo a partial foot amputation at our institution and developed an educational brochure to address this deficit as part of a quality improvement initiative. Our aim was to increase the proportion of patients receiving pre- operative education and improve the preparation of vascular surgery patients who will undergo partial foot amputations. We produced an educational brochure to improve patient knowledge and address any preoperative concerns. The effectiveness of this educational material was assessed with a questionnaire in a cohort of patients followed since January 2023. One Plan-Do-Study-Act (PDSA) cycle has been completed thus far. To date, five patients have completed the questionnaire. Three patients provided verbal responses. Sixty-six percent of patients found that the information in the brochure improved their knowledge and that the language of the brochure was easy to understand. Seventy-five percent of patients were confident with caring for their wound in the post-operative period. Educational materials are an important pillar of patient care, particularly in helping to prepare patients for minor amputations where there is a high failure rate and conversion to major amputations. Our brochure was effective in improving patient awareness and knowledge before surgery.

Perceived shared decision-making among patients undergoing lower-limb amputation and their care teams: A qualitative study.

Shared decision-making (SDM) is increasingly advocated in the care of vascular surgery patients. The goal of this investigation was to gain a greater understanding of the patient and provider experience of SDM during clinical decision-making around the need for lower-extremity amputation and amputation level related to chronic limb-threatening ischemia (CLTI) in the Veterans Health Administration. Semistructured interviews in male Veterans with CLTI, vascular surgeons, physical medicine and rehabilitation physicians, and podiatric surgeons. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. We interviewed 22 patients and 21 surgeons and physicians and identified 4 themes related to SDM: (1) providers recognize the importance of incorporating patient preferences into amputation-level decisions and strive to do so; (2) patients do not perceive that they are included as equal partners in decisions around amputation or amputation level; (3) providers perceive several obstacles to including patients in amputation level decisions; and (4) patients describe facilitators to their involvement in SDM. Despite the recognized importance SDM in amputation decision-making, patients often perceived that their opinion was not solicited. This may result from provider perception of significant challenges to SDM posed by the clinical context of amputation. Patients identified key features that might enhance SDM including presentation of clear, concise information, and the importance of communicating concern during the discussion. These findings point to gaps in the provision of patient-centric care through SDM discussions at the time of amputation.

Vascular surgery patients with elevated neutrophil-to-lymphocyte ratios have downregulated neutrophil complement RNA expression.

Elevated neutrophil-to-lymphocyte ratio (NLR) in patients who undergo elective vascular surgery (EVS) have increased mortality independent of perioperative surgical outcome. To understand why high NLR is associated with higher mortality, we investigated neutrophil and lymphocyte transcriptome expression in patients undergoing EVS. Blood samples were collected from patients undergoing EVS and healthy donors for NLR calculation. RNA samples were isolated from patients' neutrophils and lymphocytes and divided into NLR_Low (<3) and NLR_High (≥3) groups (n= 6 each). Paired samples with the highest RNA integrity number (mean= 9.8± 0.4) were sequenced and analyzed for differential expression. Normalized data were inputted for downstream analysis using iPathwayGuide (AdvaitaBio) and gene set enrichment analysis using GenePattern and MSigDB (Broad Institute). There was no clinical difference between the patient groups with regard to clinical diagnosis, age, sex, history of hypertension, lipid abnormalities, diabetes mellitus, smoking, or statin use. The mean NLR was 4.37± 0.27 SEM in the NLR_High and 1.88± 0.16 for the NLR_Low groups. Significantly differentially expressed gene sets identified in the RNA sequence data were enriched highly (P= 1E-24) in the humoral immunity and complement systems. Neutrophils from NLR_High patients downregulated complement genes (C1QA, C1QB, C1QC, C1S, C2, CR2, C3AR1, C3, C8G, and C9 and complement regulatory genes CD59, SERPING1, C4BPA, CFH, and CFI). Downregulation of gene expressions of humoral immunity and complement within the neutrophils are associated with elevated NLR. It remains to be determined whether and how these changes contribute to increased late mortality previously observed in patients undergoing EVS.

Postoperative complications and disposition for vascular surgery.

Among all surgical specialties, vascular surgery has the greatest proportion of patients with unplanned admissions to the intensive care unit postoperatively. Therefore, current clinical pathways for the postoperative management of vascular surgery patients may need to be revised. We aimed to compare the prevalence of postoperative deterioration in the high and standard risk cohorts of patients through several markers: medical emergency team activations and unplanned intensive care unit admissions. This was a single-centre, retrospective cohort study of all vascular surgical patients, emergency and elective, between 1 January and 31 December 2020 at Fiona Stanley Hospital, a tertiary hospital located in Perth, Western Australia. Patients (n = 680) were risk stratified using the surgical outcome risk tool into standard-risk (30-day mortality risk <5%; n = 475, 69.9%) and high-risk (30-day mortality risk ≥5%; n = 205, 30.1%). There were 43 unplanned intensive care unit admissions (6.3%) in total. Furthermore, surgical outcome risk tool 5% or greater risk patients were approximately eight times more likely to experience an unplanned intensive care unit admission compared with their surgical outcome risk tool less than 5% risk counterparts (relative risk 7.65, 95% confidence interval 3.84-15.21). There were 87 medical emergency team calls (12.8%) in total. In addition, surgical outcome risk tool 5% or greater risk patients were approximately five times more likely to experience a medical emergency team activation than their surgical outcome risk tool less than 5% risk counterparts (relative risk 5.15, 95% confidence interval 3.37-7.86). Our findings highlight the need for a revision of the inpatient journey for surgical outcome risk tool 5% or greater risk vascular patients, given their increased rates of unfavourable postoperative outcomes such as unplanned intensive care unit admission and medical emergency team activation. Ideally this can be addressed through appropriate postoperative triage, thus allowing this vulnerable population group early access to higher acuity care.

NAD+ Biosynthesis Impairment and Acute Kidney Injury after Major Vascular Surgery.

Acute kidney injury (AKI) is a serious complication after vascular surgery. Reduced synthesis of nicotinamide adenine dinucleotide (NAD+) from tryptophan is associated with an increased risk of AKI in critically ill patients, patients hospitalized with COVID-19, and cardiac surgery patients, and is marked by elevated urinary quinolinate and quinolinate to tryptophan ratios. We measured quinolinate concentrations in vascular surgery patients to determine if impaired NAD+ synthesis was associated with AKI in this patient population. Eight preoperative and eight postoperative vascular surgery patients who developed AKI were selected from a parent study to participate in this single-center case-control study. They were matched with controls who did not develop AKI based on age, sex, BMI, eGFR, hypertension, and diabetes. Urinary quinolinate and tryptophan concentrations were measured at anesthetic induction and on postoperative day one. Two-sided Mann-Whitney U tests were used to compare quinolinate and quinolinate to tryptophan ratios. Multivariate linear regression modeling was used to estimate the relationship between quinolinate and serum creatinine. There was no difference in preoperative or postoperative urine quinolinate concentrations or the preoperative quinolinate to tryptophan ratio between patients that did and did not develop AKI (p = 0.07, 0.50, and 0.32, respectively). However, postoperative quinolinate to tryptophan ratios were higher in AKI patients (p = 0.04). Further, after adjustment for AKI risk factors, higher preoperative quinolinate concentrations and higher postoperative quinolinate to tryptophan ratios were associated with greater postoperative creatinine increases (p = 0.04 and 0.04, respectively). These data suggest that impaired NAD+ synthesis may contribute to AKI development in vascular surgery patients.

Adding value to routine postoperative troponin testing of vascular surgery patients

Adding value to routine postoperative troponin testing of vascular surgery patients

Optimising Medications in Older Vascular Surgery Patients Through Geriatric Co-management.

Prescribing of potentially inappropriate medications and under-prescribing of guideline-recommended medications for cardiovascular risk modification have both been associated with negative outcomes in older adults. Hospitalisation represents an important opportunity to optimise medication use and may be achieved through geriatrician-led interventions. We aimed to evaluate whether implementation of a novel model of care called Geriatric Comanagement of older Vascular (GeriCO-V) surgery patients is associated with improvements in medication prescribing. We used a prospective pre-post study design. The intervention was a geriatric co-management model, where a geriatrician delivered comprehensive geriatric assessment-based interventions including a routine medication review. We included consecutively admitted patients to the vascular surgery unit at a tertiary academic centre aged ≥65 years with an expected length of stay of ≥2 days and who were discharged from hospital. Outcomes of interest were the prevalence of at least one potentially inappropriate medication as defined by the Beers Criteria at admission and discharge, and rates of cessation of at least one potentially inappropriate medication present on admission. In the subgroup of patients with peripheral arterial disease, the prevalence of guideline-recommended medications on discharge was determined. There were 137 patients in the pre-intervention group (median [interquartile range] age: 80.0 [74.0-85.0] years, 83 [60.6%] with peripheral arterial disease) and 132 patients in the post-intervention group (median [interquartile range] age: 79.0 (73.0-84.0) years, 75 [56.8%] with peripheral arterial disease). There was no change in the prevalence of potentially inappropriate medication use from admission to discharge in either group (pre-intervention: 74.5% on admission vs 75.2% on discharge; post-intervention: 72.0% vs 72.7%, p = 0.65). Forty-five percent of pre-intervention group patients had at least one potentially inappropriate medication present on admission ceased, compared with 36% of post-intervention group patients (p = 0.11). A higher number of patients with peripheral arterial disease in the post-intervention group were discharged on antiplatelet agent therapy (63 [84.0%] vs 53 [63.9%], p = 0.004) and lipid-lowering therapy (58 [77.3%] vs 55 [66.3%], p = 0.12). Geriatric co-management was associated with an improvement in guideline-recommended antiplatelet agent prescribing aimed at cardiovascular risk modification for older vascular surgery patients. The prevalence of potentially inappropriate medications was high in this population, and was not reduced with geriatric co-management.

The experience of hospital care for older surgical patients and their carers: A mixed-methods study.

A growing proportion of older adults are undergoing surgery, but there is a paucity of patient and carer experience research in this group. This study investigated the experience of hospital care in an older vascular surgery population for patients and their carers. This was a mixed-methods convergent design, including simultaneous collection of quantitative and qualitative research strands by combining open-ended questions with rating scales in a questionnaire. Recently hospitalised vascular surgery patients aged ≥65 years at a major teaching hospital were recruited. Carers were also approached to participate. Forty-seven patients (mean age 77 years, 77% male, 20% with a Clinical Frailty Scale score >4) and nine carers participated. The majority of patients reported that their views were listened to (n= 42, 89%), they were kept informed (n= 39, 83%), and were asked about their pain (n= 37, 79%). Among carers, seven reported their views were listened to and that they were kept informed. Thematic analysis of patients' and carers' responses to open-ended questions about their experience of hospital care revealed four themes in terms of what mattered to them: fundamental care including hygiene and nutrition, comfort of the hospital environment such as sleep and meals, being informed and involved in health-care decision-making, and treating pain and deconditioning to help recovery. Older adults admitted to hospital for vascular surgery and their carers, valued highly the care that met both their fundamental needs and facilitated shared decisions for care and recovery. These priorities can be addressed through Age-Friendly Health System initiatives.

Assessment of the Myocardial Stress Biomarker NT-proBNP in Real Clinical Practice

Subjects and Methods. The study involved 35 vascular surgery patients of varying degrees of cardiological risk. Blood specimens were collected from each patient at 3 time-points: 1. prior to surgery (NT-proBNP1), 2 — after the procedure (NT-proBNP2), 3 — before the discharge from the hospital (NT-proBNP3). Each specimen was split into equal aliquots for biomarker quantification using two different techniques (ELISA using domestic reagents — for the 1st series of analyses, and ICLA using an imported kit — for the 2nd series). Perioperative cardiovascular complications were recorded. The consistency of the measurement results obtained by two different methods was evaluated using the Bland–Altman technique. A discrimination ability of independent variables in relation to a binary dependent variable was studied using ROC analysis.Results. In the 1st series, ranges of the biomarker were as follows: NT-proBNP1 — 24–774 pg/ml, NT-proBNP2 — 41.2–889.1 pg/ml, NT-proBNP3 — 39.3–1013.3 pg/ml. In the 2nd series, NT-proBNP1 was 31.2–2087.0 pg/ml, NT-proBNP2 — 32.5–3754.0 pg/ml, NT-proBNP3 — 34.1–2728.0 pg/ml. In the Bland–Altman analysis, 97.03% of the values fell within the lower and upper limits of consistency (±1.96 SD of the average difference), which indicated comparability of the results in the series, but the values of NT-proBNP in the 1st series were lower than in the 2nd ones. Cardiovascular complications were registered in 3 (8.5%) patients. In the 1st series, NT-proBNP1 &gt; 218 pg/ml predicted cardiovascular complications with a sensitivity of 66.7% and a specificity of 81.3% (AUC 0.844, 95% CI 0.681–0.944, P = 0.0003). In the 2nd series, NT-proBNP1 &gt; 315 pg/ml predicted cardiovascular complications with a sensitivity of 66.7% and a specificity of 75.0% (AUC 0.828, 95% CI 0.663–0.934, P = 0.001).Conclusion. The domestic ELISA kit for solid-phase enzyme immunoassay proved its clinical informativeness for quantitation of NT-proBNP demonstrating its value for diagnostic and prognostic purposes, or scientific studies. The novel domestic technique provides consistently reproducible results, although with lower reference values as compared to the standard immunochemiluminescence assay.

Perioperative variable rate intravenous insulin infusion: a quality improvement project on a vascular surgery ward

AimsVariable rate intravenous insulin infusion (VRIII) is used perioperatively to maintain normoglycaemia in patients with diabetes who are undergoing surgery. The aims of this project were as follows: (1) to...

Negative Pressure Wound Therapy and Traditional Dressing: An Italian Health Technology Assessment Evaluation.

This evaluation shows the main advantages related to the introduction of negative pressure wound therapy (NPWT) in Italian clinical practice for the management of incisions in vascular surgery in patients suffering from peripheral arterial disease (PAD) and at risk of postoperative complications, compared to treatment with traditional dressings. A health technology assessment (HTA) activity was conducted assuming the hospital perspective, within a 12-month time horizon. The nine EUnetHTA Core Model dimensions were deeply explored, using scientific evidence on the topic, real-life data, and healthcare professionals' perceptions. The evaluation shows that the use of NPWT has had a positive impact in terms of higher clinical effectiveness and safety profile. The process mapping highlights how NPWT allows a reduction of 2.5 hospitalization days compared with standard dressing, with the consequent benefits considering economic, organizational, and social aspects. A significant economic saving per patient emerged, with an overall optimization of the patient's clinical pathway, impacting positively on the hospital's capacity. The budget impact analysis shows that the higher number of patients treated with NPWT, the higher the economic advantages. Furthermore, assuming the patient's perspective, it would generate an overall reduction in social costs of 28%. In conclusion, the results of this study provide helpful evidence-based information to policymakers through examinations of the relative values of intervention, thus supporting the overall hospital and institutional decision-making process to define appropriate areas of investments, leading to the achievement of not only higher clinical outcomes, but also important social, economic, and organizational advantages.

Ability and willingness of vascular surgery patients to use telemedicine

Background/Objectives: This study aims to assess the ability and willingness of vascular surgery patients to use telemedicine (TM), as well as identifying some barriers restricting its use.&#x0D; Methods: An observational, cross-sectional study was conducted among vascular surgery patients in 2022 who visited the clinic from 9/2019 to 12/2019. A telephone survey was used to assess patients’ perceptions and barriers to TM along with mobility. Distance and time traveled to the clinic were evaluated.&#x0D; Results: A total of 107 patients were surveyed. General willingness to use TM for vascular surgery appointments was 3.35 (Likert scale 1-5). 33.6% of patients preferred TM over in-person appointments, 50.5% of patients believed their medical needs could be met using TM, and 57.9% of patients feel comfortable using TM. Positive correlations were found between technology access and willingness to use TM (web camera (M=+1.5, p&lt;0.001), ability operatingweb camera (M=+1.2, p&lt;0.001), stable internet (M=+0.7, p=0.026)), work hours impactscheduling appointments (M=1.0, p=0.007), and believing medical needs could be met using TM (M=+1.7, p&lt;0.001). Negative correlations were found between age and technology access (web camera (M= -7.0, p=0.004) and ability operating web camera (M=-9.4, p&lt;0.001)), preferring TM (M=-7.2, p&lt;0.001), believing medical needs could be met using TM (M =-6.3, p=0.002), and feeling comfortable using TM (M-6.4, p=0.002). Younger patients have work hours that impact appointment scheduling (M=-10.9, p&lt;0.001). Patients were less willing to use TM for initial appointments than follow-ups and long-term surveillance (M=-0.85, M=-0.90, p=&lt;0.001).&#x0D; Conclusion and potential impact: The COVID-19 pandemic caused many vascular surgery clinics to rapidly turn to telemedicine. The results from this study suggest that there is an ability and interest in TM for vascular surgery appointments, but limitations exist in older populations. This study serves to better understand the patient perceptions and limitations to use TM for vascular surgery appointments.

Structured discharge documentation reduces sex-based disparities in statin prescription in vascular surgery patients

ObjectivePerioperative statin use has been shown to improve survival in vascular surgery patients. In 2018, the Northern California Vascular Study Group implemented a quality initiative focused on the use of a SmartText in the discharge summary. We hypothesized that structured discharge documentation would decrease sex-based disparities in evidence-based medical therapy. MethodsA retrospective analysis was conducted using Vascular Quality Initiative eligible cases at a single institution. Open or endovascular procedures in the abdominal aorta or lower extremity arteries from 2016 to 2021 were included. Bivariate analysis identified factors associated with statin use and sex. Multivariate logistic regression was performed with the end point of statin prescription at discharge and aspirin prescription at discharge. An interaction term assessed the differential impact of the initiative on both sexes. Analysis was then stratified by prior aspirin or statin prescription. An interrupted time series analysis was used to evaluate the trend in statin prescription over time. ResultsOverall, 866 patients were included, including 292 (34%) female and 574 (66%) male patients. Before implementation, statins were prescribed in 77% of male and 62% of female patients (P < .01). After implementation, there was no statistically significant difference in statin prescription (91% in male vs 92% in female patients, P = .68). Female patients saw a larger improvement in the adjusted odds of statin prescription compared with male patients (odds ratio: 3.1, 95% confidence interval: 1.1-8.6, P = .04). For patients not prescribed a statin preoperatively, female patients again saw an even larger improvement in the odds of being prescribed a statin at discharge (odds ratio: 6.4, 95% confidence interval: 1.8-22.7, P < .01). Interrupted time series analysis demonstrated a sustained improvement in the frequency of prescription for both sexes over time. The unadjusted frequency of aspirin prescription also improved by 3.5% in male patients vs 5.5% in female patients. For patients not prescribed an aspirin preoperatively, we found that the frequency of aspirin prescription significantly improved for both male (19% increase, P = .006) and female (31% increase, P = .001) patients. There was no significant difference in the perioperative outcomes between male and female patients before and after standardized discharge documentation. ConclusionsA simple, low-cost regional quality improvement initiative eliminated sex-based disparities in statin prescription at a single institution. These findings highlight the meaningful impact of regional quality improvement projects. Future studies should examine the potential for structured discharge documentation to improve patient outcomes and reduce disparities.

Impact of Preoperative Anemia on Hospitalization, Death, and Overall Survival in Patients With Peripheral Artery Disease Undergoing Endovascular Therapy: A Retrospective Cohort Study in the United States and Canada

Purpose: Preoperative anemia is associated with adverse outcomes after cardiac and noncardiac surgeries, but outcomes after an endovascular peripheral vascular intervention (PVI) are not well established. We aimed to assess the association of preoperative anemia with 30 day death, hospital length of stay (LOS), and overall (long term) survival in patients undergoing an endovascular PVI for peripheral artery disease. Materials and Methods: In this retrospective, cohort study in the United States and Canada, we queried the national Vascular Quality Initiative database for all endovascular PVIs performed between 2010 and 2019, and outcomes were correlated with patients’ hemoglobin (Hb) levels. Anemia was classified as mild (Hb=10–13 g/dL for men and 10–12 g/dL for women), moderate (Hb=8–9.9 g/dL), and severe (Hb<8 g/dL). Results: A total of 79 707 adult patients who met study criteria underwent endovascular PVI. The mean age was 68 years, and 59% of patients were male. Anemia was documented in 38 543 patients (48%) and was mild in 27 435 (71%), moderate in 9783 (25%), and severe in 1325 (4%). The median follow-up duration was 4 years (range, 1.25–5.78 years). On univariate analysis, 30 day mortality, total LOS, and overall survival were significantly associated with the level of preoperative anemia. These associations persisted in the multivariate models. Kaplan-Meier survival analysis demonstrated an association of death with degree of anemia (p<0.001). Conclusion: The presence and degree of preoperative anemia were independently associated with increased 30 day mortality and LOS and decreased overall survival for patients with peripheral artery disease who had undergone endovascular PVI. Clinical Impact: The findings from this study have many implications for how to approach vascular surgery in patients with variable hemoglobin levels. Our findings will strengthen our ability to conduct accurate preoperative risk stratification for patients undergoing peripheral vascular interventions. This may also mitigate healthcare expenditures if findings are applied in a way that can lower patient length of postoperative stay while also maintaining quality of care and patient safety. Our results will also serve as guidance for clinical trials, and future prospective trials should evaluate the effect of preoperative optimization of hemoglobin as a potentially modifiable risk factor for outcomes.

Novel Electronic Health Records-based Consultation Workflow Improves Time To Operating Room For Vascular Surgery Patients In An Acute Setting

Inefficient clinical workflows can have downstream effects of increased costs, poor resource utilization, and worse patient outcomes. The surgical consultation process can be complex with unclear communication, potentially delaying care for patients requiring time-sensitive intervention in an acute setting. A novel electronic health records (EHR)-based workflow was implemented to improve the consultation process. Post-implementation, we assessed the impact of this initiative in patients requiring vascular surgery consultation.