Contemporary Indications for Vascular Surgery Fail to Achieve Desired Patient-Centered Outcomes When Applied to Critical Limb Ischemia

Background: The purpose of this analysis is to examine desired patient outcomes after vascular surgery and to measure the achievement of these outcomes when applied to a large cohort of patients undergoing intervention for critical limb ischemia (CLI). Methods: To understand patient expectations after vascular intervention, 102 consecutive patients undergoing elective operations were prospectively administered a standardized preoperative questionnaire regarding the characteristics of a successful outcome. The following were identified: 1) maintenance of living independence, 2) maintenance of ambulatory status, 3) control/relief of pain, 4) no additional/nonroutine physician visits, and 5) survival for 1 year. These outcomes were then applied retrospectively to a cohort of 954 consecutive patients with CLI (37% rest pain, 37% ischemic ulceration, 26% gangrene) undergoing planned intervention (57% open, 41% endo, 2% both) to analyze patient-centered success. Results: While 12-month overall success for maintenance of independence was 89% (n = 849), maintenance of ambulation 84% (n = 802), control/relief of pain 48% (n = 461), no additional physician visits 36% (n = 340), and 1-year survival 79% (n = 755), overall patient-entered success (achievement of all 5 patient-centered success outcomes) was accomplished in only 23% (n = 218) of patients. Of 20 variables examined, end-stage renal disease (OR [95%CI] 2.21[1.26-3.88]; P = .006) and impaired ambulatory status preoperatively (OR [95%CI] 1.76 [1.12-2.79]; P = .015) were independent predictors of failure. The probability of experiencing patient-centered failure was 93% in patients with both end-stage renal disease and impaired ambulatory status preoperatively. Conclusions: If patients alone are allowed to define their outcomes after vascular intervention, success is infrequent. These data suggest that successful overall outcome may best be achieved when physicians and patients mutually target specific attainable goals and strive to achieve them. W hen planning intervention for their patients, surgeons are trained to achieve the best outcome possible. Typically, that outcome is defined by evidence accumulated through medical research from surgical investigators who often focus on postoperative goals they deem as important. In the case of vascular disease, surgeons define treatment success referencing parameters such as survival, intervention patency rate, 30-day complication rate, and freedom from comorbid vascular event. Though important, these definitions of success GHS Proc. May 2016; 1 (1): 13-21 Figure 1 The questionnaire utilized when determining patient-centered outcomes for 102 patients undergoing elective vascular surgery. RESEARCH STAFF: Check the line below if patient refused to participate and save this questionnaire as if patient completed it Patient Refused:_________ RESEARCH STAFF: ASK THE QUESTIONS BELOW AND WRITE THE RESPONSES IN THE SPACES BY OR UNDER THE QUESTIONS: (1) What is the reason you are having surgery? (2) Is there anything that helped you decide surgery was the best choice for you? (3) What will surgery allow you to do that you cannot do now? (4) What do you consider a successful surgery outcome? (5) Is there anything you will need to do to help you get better after surgery? (6) How long do you think it will take you to recover after your surgery? (7a) Do you think the surgery may keep you from doing things you want? [if “yes” to above question] (7b) What are the things you think surgery will keep you from doing? (8) How many times do you think you will have to come back to the doctor for “follow up”? (9) We listed some things that some people hope surgery improves. I’ll put a check by any items you hope your surgery improves. I can check as many or as few as you like. Pain Relief_________ Daily functioning (washing, shopping)_________ Work attendance_________ Avoiding repeat doctor visits for the same problem_________ Hobbies_________ Mobility_________ Anything not listed, but important to you? [IF YES, RESEARCH STAFF WRITE IN “OTHER”]_________ (10) Thinking about what you checked above. Help me order them by how important they are to you; I’ll number the item you think most important with a “1”, the item you think is second most important with a “2”, the item you think is third most important with a “3”. I’ll continue numbering until rank all items you checked. Pain Relief_________ Improve daily functioning(washing, shopping)_________ Work attendance_________ Avoiding repeat doctor visits for the same problem_________ Hobbies_________ Mobility_________ “Other” item patient identified above_________ (11) What is your gender Male _________ Female_________ (12) How old were you on your last birthday Age_________ (13) Are you Hispanic, Latino, or Spanish Origin? No, not Hispanic, Latino or Spanish Origin_________ Yes, Mexican, Mexican American, Chicano_________ Yes, Puerto Rican_________ Yes, Cuban_________ Yes, another Hispanic Latino or Spanish origin_________ (14) What is your Race? Check All that Apply White_________ Black (African American)_________ American Indian or Alaskan Native_________ Asian_________ RESEARCH STAFF: READ THE STATEMENT BELOW TO THE PATIENT: THERE ARE NO MORE QUESTIONS FOR YOU TO ANSWER! THANK YOU FOR SHARING WITH US!