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Vascular surgeons have better outcomes than non-vascular surgeons in key index open vascular procedures
VASCULAR SURGERY performed to analyze the primary endpoint: in-hospital mortality. After adjusting for patient characteristics, multivariable logistic regression models were used to evaluate the association of surgeon specialty with mortality, stroke, myocardial infarction (MI), and other complications.
Unchecking the box: beta blocker associated harm in carotid endarterectomy James C Iannuzzi, MD, Fergal Fleming, MD, Ankur Chandra, MD, Katia Noyes, PhD, MPH, John RT Monson, MD, FACS, Michael C Stoner, MD, FACS University of Rochester Medical Center, Rochester, NY
RESULTS: The analysis included 85,054 procedures. Patients undergoing open AAA repair by vascular surgeons had significantly lower in-hospital mortality than those treated by non-vascular surgeons (8% vs 11.2%;p¼0.005). A similar trend was noted for CEA (0.7% vs 1%;p¼0.119) and LEB (2.3% vs 2.5%;p¼0.601). Multivariable models of AAA repair showed decreased odds of mortality (odds ratio [OR] 0.68, 95% confidence interval [CI]0.51-0.91; p¼0.009), mortality/stroke/MI (OR 0.64, 95% CI 0.49-0.83; p¼0.001), and unplanned return to the operating room (OR 0.73;95% CI 0.57-0.93;p¼0.013) when performed by vascular surgeons. CEA performed by vascular surgeons had significantly lower odds of stroke (OR 0.68, 95% CI 0.50-0.92;p¼0.012), mortality/stroke (OR 0.67, 95% CI 0.52-0.87;p¼0.003), mortality/ stroke/MI (OR 0.75, 95% CI 0.59-0.96;p¼0.02), and overall complications (OR 0.70, 95% CI 0.57-0.86;p¼0.001). Surgeon specialty had no significant effect on LEB outcomes.
INTRODUCTION: Surgical Care Improvement Project (SCIP) has recently incorporated beta-blocker usage, however the impact of perioperative beta-blocker in carotid endarterectomy remains unclear. This study aimed to elucidate the impact of beta-blockers on myocardial infarction (MI) following carotid endarterectomy. METHODS: The vascular procedure specific American College of Surgeons National Surgical Quality Improvement Program database for 2011-2012 was queried for carotid endarterectomy (CEA). Univariate statistics were performed to identify factors associated with MI and pre-procedural beta-blockers. A propensity score was created for beta-blocker use, accounting for selection bias. A forward stepwise multivariable analysis was undertaken for the primary endpoint using factors meeting criteria of p<0.01. RESULTS: Overall 5524 CEA cases were included in analysis. Prior to CEA, 57.6% patients were asymptomatic (n¼3181) 6.9% had amaurosis fugax, 16.2% had transient ischemic attack (TIA), and 17.5% had preoperative stroke. Beta-blockers (BB) were used prior to 55.6% of cases (n¼3073). Mortality was 0.2% (n¼9) and not associated with BB (p>0.999). Stroke/TIA rate was 3.3% (n¼185), without evidence of BB associated benefit (p¼0.461). BB was not associated with the composite outcome (MI, stroke/TIA, and Death) (p¼0.346). MI occurred in 2.1% of cases (n¼118). After propensity score adjustment BB use was associated with 52% increased odds of MI compared to non-BB use. Other factors associated with MI on multivariable analysis following CEA include hypoalbuminemia, dependent functional status, increased operative time, and post-operative stroke.
CONCLUSIONS: In relation to common morbidities and overall mortality, vascular surgeons have better outcomes than nonvascular surgeons for open AAA and CEA. Hospitals should consider evaluating and utilizing this specialty-specific information to identify potential quality improvement initiatives. Analysis of optimal initial and subsequent interventions in the treatment of critical limb ischemia Ann D Smith, MD, Joel T Adler, MD, Louis L Nguyen, MD, MBA, MPH, FACS Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, MA INTRODUCTION: Critical limb ischemia (CLI) impacts the elderly with significant morbidity and mortality. Initial treatments, open vascular intervention (OVI) or percutaneous vascular intervention (PVI), require reintervention in 30% of cases. Little evidence exists for reintervention decisions. Our study assesses outcomes of amputation, death, and reintervention by initial and subsequent intervention for CLI.
CONCLUSIONS: In a propensity score and risk-adjusted model, beta-blocker usage was associated with increased risk of MI following CEA. These findings strongly suggest current trends towards ubiquitous beat-blocker use, and blind adherence to protocols about perioperative usage warrants reevaluation. Vascular surgeons have better outcomes than nonvascular surgeons in key index open vascular procedures Carla C Moreira, MD, Denis Rybin, MS, Gheorghe Doros, PhD, Jeffrey A Kalish, MD, Mohammad Eslami, MD, Alik Farber, MD Boston University School of Medicine, Boston, MA
METHODS: The California State Inpatient Database 2007-2009 was queried for patients with CLI and at least one revascularization procedure. Reintervention, overall survival and amputation-free survival outcomes were assessed using bivariate and multivariate analysis based on treatment and patient factors.
INTRODUCTION: The purpose of this study was to determine the impact of surgeon specialty on outcome after carotid endarterectomy (CEA), lower extremity bypass (LEB), and open abdominal aortic aneurysm repair (AAA).
RESULTS: Of 4762 patients, 1956 (41.1%) received OVI first and 2806 (58.9%) received PVI first. At two years, PVI-first patients had greater odds of receiving revision (odds ratio 2.042, CI 1.699e2.456, p<0.0001), but similar amputation (odds ratio 1.058, 95% CI 0.837e1.336, p¼0.507) and in-hospital mortality (odds ratio 0.882, 95% CI 0.610 e 1.274, p¼0.5037) odds compared to OVI-first patients. For those
METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset (20052011) was queried to identify patients who underwent open AAA, LEB, and CEA. Stratification by surgeon specialty was
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
e57
http://dx.doi.org/10.1016/j.jamcollsurg.2014.07.534 ISSN 1072-7515/14
Unchecking the box: beta blocker associated harm in carotid endarterectomy James C Iannuzzi, MD, Fergal Fleming, MD, Ankur Chandra, MD, Katia Noyes, PhD, MPH, John RT Monson, MD, FACS, Michael C Stoner, MD, FACS University of Rochester Medical Center, Rochester, NY
RESULTS: The analysis included 85,054 procedures. Patients undergoing open AAA repair by vascular surgeons had significantly lower in-hospital mortality than those treated by non-vascular surgeons (8% vs 11.2%;p¼0.005). A similar trend was noted for CEA (0.7% vs 1%;p¼0.119) and LEB (2.3% vs 2.5%;p¼0.601). Multivariable models of AAA repair showed decreased odds of mortality (odds ratio [OR] 0.68, 95% confidence interval [CI]0.51-0.91; p¼0.009), mortality/stroke/MI (OR 0.64, 95% CI 0.49-0.83; p¼0.001), and unplanned return to the operating room (OR 0.73;95% CI 0.57-0.93;p¼0.013) when performed by vascular surgeons. CEA performed by vascular surgeons had significantly lower odds of stroke (OR 0.68, 95% CI 0.50-0.92;p¼0.012), mortality/stroke (OR 0.67, 95% CI 0.52-0.87;p¼0.003), mortality/ stroke/MI (OR 0.75, 95% CI 0.59-0.96;p¼0.02), and overall complications (OR 0.70, 95% CI 0.57-0.86;p¼0.001). Surgeon specialty had no significant effect on LEB outcomes.
INTRODUCTION: Surgical Care Improvement Project (SCIP) has recently incorporated beta-blocker usage, however the impact of perioperative beta-blocker in carotid endarterectomy remains unclear. This study aimed to elucidate the impact of beta-blockers on myocardial infarction (MI) following carotid endarterectomy. METHODS: The vascular procedure specific American College of Surgeons National Surgical Quality Improvement Program database for 2011-2012 was queried for carotid endarterectomy (CEA). Univariate statistics were performed to identify factors associated with MI and pre-procedural beta-blockers. A propensity score was created for beta-blocker use, accounting for selection bias. A forward stepwise multivariable analysis was undertaken for the primary endpoint using factors meeting criteria of p<0.01. RESULTS: Overall 5524 CEA cases were included in analysis. Prior to CEA, 57.6% patients were asymptomatic (n¼3181) 6.9% had amaurosis fugax, 16.2% had transient ischemic attack (TIA), and 17.5% had preoperative stroke. Beta-blockers (BB) were used prior to 55.6% of cases (n¼3073). Mortality was 0.2% (n¼9) and not associated with BB (p>0.999). Stroke/TIA rate was 3.3% (n¼185), without evidence of BB associated benefit (p¼0.461). BB was not associated with the composite outcome (MI, stroke/TIA, and Death) (p¼0.346). MI occurred in 2.1% of cases (n¼118). After propensity score adjustment BB use was associated with 52% increased odds of MI compared to non-BB use. Other factors associated with MI on multivariable analysis following CEA include hypoalbuminemia, dependent functional status, increased operative time, and post-operative stroke.
CONCLUSIONS: In relation to common morbidities and overall mortality, vascular surgeons have better outcomes than nonvascular surgeons for open AAA and CEA. Hospitals should consider evaluating and utilizing this specialty-specific information to identify potential quality improvement initiatives. Analysis of optimal initial and subsequent interventions in the treatment of critical limb ischemia Ann D Smith, MD, Joel T Adler, MD, Louis L Nguyen, MD, MBA, MPH, FACS Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, MA INTRODUCTION: Critical limb ischemia (CLI) impacts the elderly with significant morbidity and mortality. Initial treatments, open vascular intervention (OVI) or percutaneous vascular intervention (PVI), require reintervention in 30% of cases. Little evidence exists for reintervention decisions. Our study assesses outcomes of amputation, death, and reintervention by initial and subsequent intervention for CLI.
CONCLUSIONS: In a propensity score and risk-adjusted model, beta-blocker usage was associated with increased risk of MI following CEA. These findings strongly suggest current trends towards ubiquitous beat-blocker use, and blind adherence to protocols about perioperative usage warrants reevaluation. Vascular surgeons have better outcomes than nonvascular surgeons in key index open vascular procedures Carla C Moreira, MD, Denis Rybin, MS, Gheorghe Doros, PhD, Jeffrey A Kalish, MD, Mohammad Eslami, MD, Alik Farber, MD Boston University School of Medicine, Boston, MA
METHODS: The California State Inpatient Database 2007-2009 was queried for patients with CLI and at least one revascularization procedure. Reintervention, overall survival and amputation-free survival outcomes were assessed using bivariate and multivariate analysis based on treatment and patient factors.
INTRODUCTION: The purpose of this study was to determine the impact of surgeon specialty on outcome after carotid endarterectomy (CEA), lower extremity bypass (LEB), and open abdominal aortic aneurysm repair (AAA).
RESULTS: Of 4762 patients, 1956 (41.1%) received OVI first and 2806 (58.9%) received PVI first. At two years, PVI-first patients had greater odds of receiving revision (odds ratio 2.042, CI 1.699e2.456, p<0.0001), but similar amputation (odds ratio 1.058, 95% CI 0.837e1.336, p¼0.507) and in-hospital mortality (odds ratio 0.882, 95% CI 0.610 e 1.274, p¼0.5037) odds compared to OVI-first patients. For those
METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset (20052011) was queried to identify patients who underwent open AAA, LEB, and CEA. Stratification by surgeon specialty was
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
e57
http://dx.doi.org/10.1016/j.jamcollsurg.2014.07.534 ISSN 1072-7515/14