Lack of Postoperative Follow-up After Bypass Is Associated With Race and Insurance and Is Highly Predictive of Improved Survival

Our goal was to analyze the association of adherence to follow-up on survival in patients undergoing infrainguinal bypass and evaluate predictors of compliance. We queried the Vascular Quality Initiative infrainguinal bypass database from 2011 to 2018. The cohort was restricted at 2018 to allow adequate time for patients to follow-up and potential survival differences to be observed. Patients were divided into two groups: those with any recorded in-person or telemedicine follow-up (LTF) and those without follow-up (NLTF). For the LTF group, this encounter could include either immediate postoperative or long-term follow-up. The primary outcome was long-term survival. A multivariate logistic regression model was used to determine associated factors with lack of follow-up and survival. From 2011 to 2018, there were 44,304 patients in the Vascular Quality Initiative infrainguinal module, of whom 39,379 had follow-up forms available. Of 39,379 patients, 4916 (12.48%) were in NLTF. Patients in NLTF were more likely to be non-White minority, transferred to index hospital for their bypass, underwent emergent procedures, and had more comorbid conditions (Table). These patients were frailer than patients with follow-up (mean frailty score of 43.89 for NLTF vs 38.35 for LTF, P < .001). These patients were also more likely to be residents of a nursing facility, nonambulatory, and have Medicare coverage. Patients in the LTF group were more likely to be using statins and aspirin. Unadjusted Kaplan-Meier survival analysis revealed that LTF had better long-term survival at 3 years compared with NLTF (88.02% ± 0.0038% vs 50.33% ± 0.0075%, P < .001) (Fig). In an adjusted Cox proportional hazard model (adjusted for comorbid conditions and patient functional status), LTF was an independent protective factor against mortality (hazards ratio [HR]: 0.229 [0.216, 0.243], P < .001). To account for survivorship bias, we conducted a sensitivity analysis including only patients who survived the initial 9 months. LTF continued to have a protective effect against mortality (HR: 0.403 [0.368, 0.44], P < .001). Factors independently associated with lack of follow-up included minority race, hospital transfer, discharge to nursing facilities, urgent procedures, postoperative complications, history of chronic obstructive pulmonary disease, and congestive heart failure. Meanwhile, ambulatory status, Medicare coverage, home discharge, and preoperative usage of aspirin and statins were associated with better follow-up. Compliance with follow-up and medication is associated with a significant survival advantage but varies with insurance coverage and race. Efforts to mitigate barriers to follow-up and medication noncompliance should be prioritized after lower extremity bypass to improve survival.TablePatient characteristics and multivariate predictors of no long-term follow-up (NLTF)LTF (N = 34,463)NLTF (N = 4916)Multivariate predictor NLTFP valueOR (CI)P valueAge, years66.13 (10.89)68.86 (11.70)