Regional variation in patient selection and treatment for lower extremity vascular disease in the Vascular Quality Initiative

Abstract

Introduction Prior studies on the cause and effect of surgical variation have been limited by utilization of administrative data. The Vascular Quality Initiative (VQI), a robust national clinical registry, provides anatomic and perioperative details allowing a more robust analysis of variation in surgical practice. Methods The VQI was used to identify all patients undergoing infrainguinal open bypass or endovascular intervention from 2009 to 2014. Asymptomatic patients were excluded. The 16 regional groups of the VQI were used to compare variation in patient selection, operative indication, technical approach, and process measures. χ2 analysis was used to assess for differences across regions where appropriate. Results A total of 52,373 interventions were included (31%). Of the 16145 bypasses, 5% were performed for asymptomatic disease, 26% for claudication, 56% for chronic limb threatening ischemia (CLI) (61% of these for tissue loss), and 13% for acute limb ischemia (ALI). Of the 35,338 endovascular procedures, 4% were for asymptomatic disease, 40% for claudication, 46% for CLI (73% tissue loss), and 12% for ALI. Potentially unwarranted variation included proportion of prosthetic conduit for infrapopliteal bypass in claudication (13–41%, median 29% P<.001), isolated tibial endovascular intervention for claudication (0.0–5.0%, median 3.0% P<.001), discharge on antiplatelet and statin (Bypass: 62–84%, P<.001; Endo: 63–89%, P<.001), and ultrasound guidance for percutaneous access (Claudication: range 7–60%, P<.001; CLI: 5–65%, P<.001). Notable areas needing further research with significant variation include proportion of CLI vs. claudication treated by bypass (38–71%, P < .001) and endovascular intervention (28- 63%, P < .001), and use of closure devices in percutaneous access (claudication 26–76%, P < .001; CLI 30–78%, P < .001). Conclusion Significant variation exists both in areas where evidence exists for best practice and therefore potentially unwarranted variation, and in areas of clinical ambiguity. Quality improvement efforts should be focused on reducing unwarranted variation. Further research should be directed at identifying best practice where no established guidelines and high variation exists.

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

“…We previously reported on the significant variation in prescribing antiplatelet and statin medications at discharge across the VQI. [11] In this analysis we found significant variation between regions in one-year survival and AFS after endovascular intervention but not bypass for claudication, although this lack of significance may well be due to differences in sample size. Furthermore, prior work has established that few patients with claudication go on to develop CLI and therefore the decision to operate on claudication should be predicated on a very low probability of mortality.…”

“…[10] In brief, 16,145 bypasses were included, 5% for asymptomatic PAD (54% of these for aneurysmal disease), 26% for claudication, 56% for chronic limb-threatening ischemia (61% of these for tissue loss), and 13% for acute limb ischemia. For endovascular procedures, 35,338 interventions were included, 4% were asymptomatic (19% aneurysmal disease), 40% for claudication, 46% for CLI (73% tissue loss), and 12% for acute limb ischemia.…”

“…[24] The VQI has identified chlorhexadine prep as an important quality metric for reduction of SSI’s, which we previously reported to significantly vary but there are likely additional factors contributing to SSI and the VQI offers a unique opportunity to identify high-performing regions/centers to further study what best practice should be in the bypass patient and to reduce the variation currently reported. [11, 20, 25, 26]…”

“…The VQI is a national clinical registry, set up as collaboration between regional quality groups, as described previously. [11] More information about the VQI can be found at www.vascularqualityinitiative.org/. The Institutional Review Board at Beth Israel Deaconess Medical Center approved this study and informed consent was waived.…”

“…This is a follow-up to our initial study evaluating variation in patient selection, treatment type, and process measures for lower extremity vascular disease across the same population. [10] In this mansucript we will focus on perioperative and select long-term outcomes following lower extremity intervention, including those in Table I. This report is meant to serve as a description of current outcomes related to the treatment of peripheral artery disease and we hope will serve as a tool for future quality improvement projects.…”