BACKGROUND To describe short and long-term survival of patients with descending thoracic aortic aneurysms (TAA) following open and endovascular repair (TEVAR). METHODS AND RESULTS Using Medicare claims from 1998–2007, we analyzed patients who underwent repair of intact and ruptured TAA, identified using a combination of procedural and diagnostic ICD-9 codes. Our main outcome measure was mortality, defined as peri-operative mortality (death occurring before hospital discharge or within 30 days), and five year survival, using life-table analysis. We examined outcomes across repair type (open repair. or TEVAR) in crude, adjusted (age, sex, race, procedure year, and Charlson comorbidity score), and propensity-matched cohorts. Overall, we studied 12,573 Medicare patients who underwent open repair, and 2,732 patients who underwent TEVAR. Peri-operative mortality was lower in patients undergoing TEVAR as compared to open repair for both intact (6.1% versus 7.1%, p=0.07) and ruptured TAA (28% versus 46%, p<0.0001). However, patients with intact TAA selected for TEVAR had significantly worse survival than open patients at one year (87% open, 82% TEVAR, p=0.001) and five years (72% open, 62% TEVAR, p= 0.001). Further, in adjusted and propensity-matched cohorts, patients selected for TEVAR had worse 5-year survival than patients selected for open repair. CONCLUSIONS While peri-operative mortality is lower with TEVAR, Medicare patients selected for TEVAR have worse long-term survival than patients selected for open repair. The results of this observational study suggest that higher risk patients are being offered TEVAR, and that some do not benefit based on long-term survival. Future work is needed to identify TEVAR candidates unlikely to benefit from repair.

Background Many believe that variation in vascular practice may affect limb salvage rates in patients with severe PAD. However, the extent of variation in procedural vascular care obtained by patients with critical limb ischemia (CLI) remains unknown. Methods and Results Using Medicare 2003–2006, we identified all patients with CLI who underwent major lower extremity amputation in the 306 hospital referral regions (HRRs) described in the Dartmouth Atlas of Healthcare. For each patient, we studied the use of lower extremity vascular procedures (open surgery or endovascular intervention) in the year prior to amputation. Our main outcome measure was the intensity of vascular care, defined as the proportion of patients in the HRR undergoing vascular procedure in the year before amputation. Overall, 20,464 patients with CLI underwent major lower extremity amputations during the study period, and collectively underwent 25,800 vascular procedures in the year prior to undergoing amputation. However, these procedures were not distributed evenly − 54% of patients had no vascular procedures performed in the year prior to amputation, 14% underwent 1 vascular procedure, and 21% underwent more than one vascular procedure. In the regions in the lowest quintile of vascular intensity, vascular procedures were performed in 32% of patients. Conversely, in the regions in the highest quintile of vascular intensity, revascularization was performed in 58% of patients in the year prior to amputation (p<0.0001). In analyses accounting for differences in age, sex, race, and comorbidities, patients in high intensity regions were 2.4 times as likely to undergo revascularization in the year prior to amputation than patients in low intensity regions (adjusted OR=2.4, 95% CI 2.1–2.6, p<0.001). Conclusions Significant variation exists in the intensity of vascular care provided to patients in the year prior to major amputation. In some regions, patients receive intensive care, while in other regions, far less vascular care is provided. Future work is needed to determine the association between intensity of vascular care and limb salvage.

Objective:To test effectiveness of the Early Detection, Intervention, and Prevention of Psychosis Program in preventing the onset of severe psychosis and improving functioning in a national sample of at-risk youth.Methods:In a risk-based allocation study design, 337 youth (age 12–25) at risk of psychosis were assigned to treatment groups based on severity of positive symptoms. Those at clinically higher risk (CHR) or having an early first episode of psychosis (EFEP) were assigned to receive Family-aided Assertive Community Treatment (FACT); those at clinically lower risk (CLR) were assigned to receive community care. Between-groups differences on outcome variables were adjusted statistically according to regression-discontinuity procedures and evaluated using the Global Test Procedure that combined all symptom and functional measures.Results:A total of 337 young people (mean age: 16.6) were assigned to the treatment group (CHR + EFEP, n = 250) or comparison group (CLR, n = 87). On the primary variable, positive symptoms, after 2 years FACT, were superior to community care (2 df, p < .0001) for both CHR (p = .0034) and EFEP (p < .0001) subgroups. Rates of conversion (6.3% CHR vs 2.3% CLR) and first negative event (25% CHR vs 22% CLR) were low but did not differ. FACT was superior in the Global Test (p = .0007; p = .024 for CHR and p = .0002 for EFEP, vs CLR) and in improvement in participation in work and school (p = .025).Conclusion:FACT is effective in improving positive, negative, disorganized and general symptoms, Global Assessment of Functioning, work and school participation and global outcome in youth at risk for, or experiencing very early, psychosis.

Objective To examine the relationship between the intensity of vascular care and population-based rate of major lower extremity amputation (above-or below-knee) from vascular disease. Background Because patient-level differences do not fully explain the variation in amputation rate across the United States, we hypothesized that variation in intensity of vascular care may also affect regional rates of amputation. Methods Intensity of vascular care was defined as the proportion of Medicare patients who underwent any vascular procedure in the year prior to amputation, calculated at the regional level (2003–2006), using the 306 hospital referral regions in the Dartmouth Atlas of Healthcare. We examined relationship between intensity of vascular care and major amputation rate, at the regional level, between 2007–2009. Results Amputation rates varied widely by region, from 1 to 27 per 10,000 Medicare patients. Compared to regions in the lowest quintile of amputation rate, patients in the highest quintile were commonly African American (50% versus 13%) and diabetic (38% versus 31%). Intensity of vascular care also varied across regions: fewer than 35% of patients underwent revascularization in the lowest quintile of intensity, while nearly 60% of patients underwent revascularization in the highest quintile. Overall, there was an inverse correlation between intensity of vascular care and amputation rate ranging from R= −0.36 for outpatient diagnostic and therapeutic procedures, to R= −0.87 for inpatient surgical revascularizations. In analyses adjusting for patient characteristics and socioeconomic status, patients in high vascular care regions were significantly less likely to undergo amputation without an antecedent attempt at revascularization (OR 0.37, 95% CI 0.34–0.37, p<0.001). Conclusions The intensity of vascular care provided to patients at risk for amputation varies, and regions with the most intensive vascular care have the lowest amputation rate, although the observational nature of associations do not impart causality. High-risk patients, especially African-American diabetic patients residing in low-intensity vascular care regions, represent an important target for systematic efforts to reduce amputation risk.

Objectives Successful surgical management of thoracic aortic aneurysms (TAA) and thoracoabdominal aortic aneurysms (TAAA) has historically relied upon open surgical repair (OSR). More recently, the advent and application of thoracic endovascular stent graft aneurysm repair (TEVAR) permutations have become increasingly performed in contemporary practice. To better determine the effect of TEVAR techniques on OSR, we examined national and regional trends in treatment use. Methods All Medicare patients from 1998 through 2007 undergoing isolated TAA and TAAA repair were analyzed using a clinically validated algorithm using diagnostic International Classification of Disease 9th revision (ICD-9; 441.1, 441.2, 441.6, 441.7, 441.9) codes and procedural (ICD-9 OSR: 38.35, 38.45 and TEVAR: 39.73, 39.79) codes. Differential rates of OSR and TEVAR were compared across census tract regions during the study interval. Results Total complex aortic repairs increased by 60%, from 10.8 to 17.8/100,000, between 1998 and 2007 (P <.001). A dramatic increase occurred in TEVAR (not performed in 1998, 5.8/100,000 in 2007) during the study period, but OSR rates remained stable during the same interval (10.7 to 12.0/100,000 in 2007, P < NS). There was substantial regional variation for both OSR and TEVAR. This regional variation was greater in OSR (range, 8.8–16.7/100,000) than in TEVAR (range, 4.5–6.9/100,000). Conclusions Degenerative TAA and TAAA aneurysms are being repaired in the United States at an increasing rate. This reflects the rapid acceptance of TEVAR, which apparently supplements rather than supplants OSR. There appears to be greater regional variation in OSR compared with TEVAR. These data may have significant implications for those interested in the effect of new technologies on health care and cost containment.

Background To describe geographic variation in population-based rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed in Medicare beneficiaries. Methods and Results Medicare claims and enrollment data were used to calculate age, sex, and race-adjusted rates of CAS and CEA for Medicare beneficiaries in each of 306 hospital referral regions between 1998 and 2007. Procedures were identified using a combination of Current Procedural Terminology codes as well as diagnostic and procedural ICD-9 codes. Overall, the rate of carotid revascularization has fallen slightly over the last decade (3.8 procedures per 1000 in 1998, 3.1 procedures per 1000 in 2007; P<0.0001). Although the use of CEA decreased, from 3.6 to 2.5 procedures per 1000 beneficiaries in 2007 (P<0.0001), the use of CAS has increased >4-fold between 1998 and 2007, growing from 0.1 to 0.6 CAS procedures per 1000 beneficiaries (P<0.0001). Further, CAS rapidly disseminated across the country over the last decade. In 1998, 66% of hospital referral regions had a hospital that performed CAS; however, by 2007, nearly all (95%) hospital referral regions performed CAS (P<0.0001). Last, in regions with the highest utilization rates of CAS, it appeared that CAS was performed as a substitute for CEA. There was little evidence that CAS was being performed in addition to CEA, as no correlation existed between regional rates of CAS and CEA (r=0.06). Conclusions Even though CEA was used less frequently in 2007 than 1998, the use of CAS has grown significantly. Although regional variation in the use of CEA has remained fairly constant, regional variation has increased in the use of CAS. Given these changes in practice patterns, careful examination of the efficacy and cost-effectiveness of CAS is necessary.

Purpose Clinical pathways aimed at reducing hospital length of stay following vascular surgery have been broadly implemented to reduce costs. However, early hospital discharge may adversely affect the risk of readmission or mortality. To address this question, we examined the relationship between early discharge and 30-day outcomes among patients undergoing a high-risk vascular surgery procedure, thoracic aortic aneurysm (TAA) repair. Methods Using Medicare claims from 2000 to 2007, we identified all patients who were discharged home following elective thoracic endovascular aneurysm repair (TEVAR) and open repair for nonruptured TAAs. For each procedure, we examined the correlation between early discharge (<3 days for TEVAR, <7 days for open TAA repair) and 30-day readmission, 30-day mortality, and hospital costs. Predictors of readmission were evaluated using logistic regression models controlling for patient comorbidities, perioperative complications, and discharge location. Results Our sample included 9764 patients, of which 7850 (80%) underwent open TAA repair, and 1914 (20%) underwent TEVAR. Patients discharged to home early were more likely to be female (66% early vs 56% late), Caucasian (94% early vs 91% late), younger (73 years early vs 74 years late), and have fewer comorbidities (mean Charlson score: 0.7 early vs 1.0 late) than patients discharged home late (all P < .01). As compared with patients who were discharged late, patients discharged home early following uncomplicated open TAA repair and TEVAR had significantly lower 30-day readmission rates ([open: 17% vs 24%; P < .001] [TEVAR: 12% vs 23%; P < .001]) and hospital costs ([open: $73,061 vs $136,480; P < .001] [TEVAR: $58,667 vs $128,478; P < .001]), without an observed increase in 30-day postdischarge mortality. In multivariable analysis, early hospital discharge was associated with a significantly lower likelihood of readmission following both open TAA repair (odds ratio, 0.70; 95% confidence interval, 0.57–0.85; P < .001) and TEVAR (odds ratio, 0.57; 95% confidence interval, 0.38–0.85; P < .01) procedures. Conclusions Discharging patients home early following uncomplicated TEVAR or open TAA repair is associated with reduced hospital costs without adversely impacting 30-day readmission or mortality rates. These data support the safety and cost-effectiveness of programs aimed at early hospital discharge in selected vascular surgery patients.

Importance While lower extremity revascularization is effective in preventing amputation, the relationship between spending on vascular care and regional amputation rates remains unclear. Objective To test the hypothesis that higher regional spending on vascular care is associated with lower amputation rates in patients with severe peripheral arterial disease (PAD). Design Retrospective cohort study. Setting United States Medicare patients, 2003-2010 Participants 18,463 patients who underwent major PAD-related amputation. Exposures Price-adjusted Medicare spending on revascularization procedures and related vascular care in the year before lower extremity amputation, across hospital referral regions. Main Outcome Measure(s) Correlation coefficient between regional spending on vascular care and regional rates of PAD-related amputation. Results Among patients ultimately subject to amputation, 64% were admitted to the hospital in the year prior to amputation for revascularization, wound-related care, or both; 36% were admitted only for their amputation. The mean cost of inpatient care in the year before amputation, including the amputation itself, was $22,405, but varied from $11,077 (Bismarck, North Dakota) to $42,613 (Salinas, California) (p<0.001). Patients in high-spending regions were more likely to undergo vascular procedures in crude analyses (12.0 procedures per 10,000 patients in the lowest quintile of spending, 20.4 procedures per 10,000 patients in the highest quintile of spending, p<0.0001), as well as in risk-adjusted analyses (adjusted OR for receiving a vascular procedure in highest quintile of spending = 3.5, 95 % CI 3.2-3.8, p<0.0001). While revascularization was associated with higher spending (R=0.38, p<0.001), higher spending was not associated with lower regional amputation rates (R=0.10, p=0.06). Regions most aggressive in the use of endovascular interventions which most likely to have high spending (R=0.42, p=0.002) and high amputation rates (R=0.40, p=0.004). Conclusions Regions that spend the most on vascular care is highest perform the most procedures, especially endovascular interventions, in the year before amputation. However, there is little evidence that higher regional spending is associated with lower amputation rates. This suggests an opportunity to limit costs in vascular care without compromising quality.