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Comparative Study
. 2017 Sep;66(3):810-818.
doi: 10.1016/j.jvs.2017.01.061. Epub 2017 Apr 24.

Regional variation in outcomes for lower extremity vascular disease in the Vascular Quality Initiative

Peter A Soden  1 , Sara L Zettervall  1 , Katie E Shean  1 , Ageliki G Vouyouka  2 , Philip P Goodney  3 , Joseph L Mills  4 , John W Hallett Jr  5 , Marc L Schermerhorn  6 ; Society for Vascular Surgery Vascular Quality Initiative
Affiliations
Comparative Study

Regional variation in outcomes for lower extremity vascular disease in the Vascular Quality Initiative

Peter A Soden et al. J Vasc Surg. 2017 Sep.

Abstract

Background: Increased focus has been placed on perioperative and long-term outcomes in the treatment of peripheral artery disease (PAD), both for purposes of quality improvement and for assessment of performance at a surgeon and institutional level. This study evaluates regional variation in outcomes after treatment for PAD within the Vascular Quality Initiative (VQI). By describing the variation in practice patterns and outcomes across regions, we hope that each regionally based quality group can select which areas are most important for them to focus on as they will have access to their regional data to compare.

Methods: We identified all patients in the VQI who had infrainguinal bypass or endovascular intervention from 2009 to 2014. We compared variation in perioperative and 1-year outcomes stratified by symptom status and revascularization type among the 16 regional groups of the VQI. We analyzed variation in perioperative end points using χ2 analysis, and 1-year end points were analyzed using Kaplan-Meier and life-table analysis.

Results: We identified 15,338 bypass procedures for symptomatic PAD: 27% for claudication, 59% for chronic limb-threatening ischemia (CLI; 61% of these for tissue loss), and 14% for acute limb ischemia. We identified 33,925 endovascular procedures for symptomatic PAD: 42% for claudication, 48% for CLI (73% of these for tissue loss), and 10% for acute limb ischemia. Thirty-day mortality varied significantly after endovascular intervention for CLI (0.5%-3%; P < .001) but not for claudication (0.0%-0.5%, P = .77) or for bypass for claudication (0.0%-2.6%; P = .37) or CLI (0.0%-5.0%; P = .08). After bypass, rates of >2 units transfused red blood cells (claudication, 0.0%-13% [P < .001]; CLI, 6.9%-27% [P < .001]) varied significantly. In-hospital major amputation was variable after bypass for CLI (0.0%-4.3%; P = .004) but not for claudication (0.0%-0.6%; P = .98), as was postoperative myocardial infarction (claudication, 0.0%-4% [P = .36]; CLI, 0.8%-6% [P = .001]). One-year survival varied significantly for endovascular interventions for claudication (92%-100%; P < .001), bypass for CLI (85%-94% [P < .001]), and endovascular interventions for CLI (77%-96%; P < .001) but not after bypass for claudication (95%-100%; P = .57).

Conclusions: In this real-world comparison among VQI regions, we found significant variation in perioperative and 1-year end points for patients with PAD undergoing bypass or endovascular intervention. This study highlights opportunities for quality improvement efforts to reduce variation and to improve outcomes.

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Figures

Figure 1
Figure 1
Perioperative outcomes after Bypass for Claudication. All variation significantly different (P < .05). Each symbol on a line represents a region with a vertical line for median value.
Figure 2
Figure 2
Perioperative outcomes after Endovascular intervention for Claudication. All variation significantly different (P < .05). Each symbol on a line represents a region with a vertical line for median value. AOut of those admitted from home.
Figure 3
Figure 3
Perioperative outcomes after Bypass for CLI. All variation significantly different (P < .05) exceptA. BOut of Elective cases only.
Figure 4
Figure 4
Perioperative outcomes after Endovascular intervention for CLI. All variation significantly different (P < .05). AOut of those admitted from home.
Figure 5
Figure 5
Perioperative death (in-hospital or 30-day) for patients with Claudication and CLI. Region numbers are de-identified.
Figure 6
Figure 6
One-year survival by symptom and intervention type. * Significant variation (P < .05).
See this image and copyright information in PMC

Comment in

  • Invited commentary.
    Abularrage CJ. Abularrage CJ. J Vasc Surg. 2017 Sep;66(3):818-819. doi: 10.1016/j.jvs.2017.02.024. J Vasc Surg. 2017. PMID: 28842072 No abstract available.

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