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In response to the pandemic, an abrupt pivot of Vascular Quality Initiative physician members away from standard clinical practice to a restrictive phase of emergent and urgent vascular procedures occurred. The Society for Vascular Surgery Patient Safety Organization queried both data managers and physicians in May 2020. Approximately three-fourths (74%) of physicians adopted restrictive operating policies for urgent and emergent cases only, whereas one-half proceeded with "time sensitive" elective cases as urgent. Data manager case entry was negatively affected by both low case volumes and staffing due to reassignment or furlough. Venous registry volumes were reduced fivefold in the first quarter of 2020 compared with a similar period in 2019. The consequences of delaying vascular procedures for ambulatory venous practice remain unknown with increased morbidity likely. Challenges to determine venous thromboembolism mortality impact exist given difficulty in verifying "in home and extended care facility" deaths. Further ramifications of a pandemic shutdown will likely be amplified if postponement of elective vascular care extends beyond a short window of time. It will be important to monitor disease progression and case severity as a result of policy shifts adopted locally in response to pandemic surges., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

In the present report, we have described the abrupt pivot of Vascular Quality Initiative physician members away from standard clinical practice to a restrictive phase of emergent and urgent vascular procedures in response to the coronavirus disease 2019 (COVID-19) pandemic. The Society for Vascular Surgery Patient Safety Organization queried both data managers and physicians in May 2020 to discern the effects of the COVID-19 pandemic. Approximately three fourths of physicians (74%) had adopted a restrictive operating policy for urgent and emergent cases only. However, one half had considered "time sensitive" elective cases as urgent. Data manager case entry was affected by both low case volumes and low staffing resulting from reassignment or furlough. A sevenfold reduction in arterial Vascular Quality Initiative case volume entry was noted in the first quarter of 2020 compared with the same period in 2019. The downstream consequences of delaying vascular procedures for carotid artery stenosis, aortic aneurysm repair, vascular access, and chronic limb ischemia remain undetermined. Further ramifications of the COVID-19 pandemic shutdown will likely be amplified if resumption of elective vascular care is delayed beyond a short window of time., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

The Vascular Implant Surveillance and Interventional Outcomes Network (VISION) is a Coordinated Registry Network (CRN) a member of Medical Device Epidemiology Network, a U.S. Food and Drug Administration (FDA)-supported global public-private partnership that seeks to advance the collection and use of real-world data to improve patient outcomes. The VISION CRN began in September 2015 and held its first strategic meeting on September 10, 2018, at the FDA headquarters in Silver Spring, Maryland. VISION is a collaboration of the Vascular Quality Initiative (VQI), the FDA, and other stakeholders. At this annual meeting, leaders from the FDA, VQI, industry representatives, population health researchers, and regulatory science experts gathered to discuss strategic goals and opportunities for VISION. One of the key focus areas for VISION is linkage of VQI registry data to Medicare, longitudinal data sources maintained by various states, and other relevant data sources, as a model for efficient, cost-saving, and effectual evidence generation and appraisal. This would provide the means to expand data collection, assess long-term procedural outcomes across the carotid, lower extremity, aortic, and venous intervention datasets, and execute registry-based trials through the CRN structure in an efficient, cost-effective manner. Looking forward, VISION strives to validate long-term outcome data in the VQI using industry datasets, in hopes of using CRNs to make device regulatory decisions. With the guidance of a steering committee, VISION will provide vascular surgeons, industry, and regulators the appropriate data to improve care for patients with vascular disease., (Copyright © 2020. Published by Elsevier Inc.)

Objective: Professional societies publish clinical practice guidelines to provide evidence-based recommendations to improve care and to reduce practice variation. However, the degree of compliance with the guidelines and its impact on outcomes have not been well defined. This study used the Vascular Quality Initiative (VQI) abdominal aortic aneurysm (AAA) registries to determine current compliance with and impact of recent Society for Vascular Surgery (SVS) AAA guidelines., Methods: Recommendations from the SVS AAA guidelines were reviewed and assessed as to whether they could be evaluated with current VQI data sets. The degree of compliance with these individual recommendations was calculated by center and correlated with clinical outcomes. Data were analyzed by univariate analysis and mixed effects multivariable logistic regression. Statistical significance was measured at P < .05., Results: Of the 111 SVS recommendations, 10 could be evaluated using VQI registries. The mean center-specific compliance rate ranged from 40% (smoking cessation 2 weeks before open AAA [OAAA] repair) to 99% (preservation of flow to one internal iliac artery during endovascular aneurysm repair [EVAR]). Some recommendations were associated with improved outcomes (eg, cell salvage for OAAA repair and antibiotic prophylaxis), whereas others were not (eg, EVAR at a center with >10 cases per year or door-to-intervention time <90 minutes for ruptured AAA). With multivariable analysis, compliance with preservation of flow to the internal iliac artery decreased major adverse cardiac events in EVAR and marginally decreased in-hospital and 1-year mortality in OAAA repair. Antibiotic administration decreased surgical site infection, major adverse cardiac events, and in-hospital mortality and marginally decreased respiratory complications and 1-year mortality in EVAR. Cell salvage for OAAA repair decreased 1-year mortality. Tobacco cessation before EVAR or OAAA repair decreased respiratory complications and 1-year mortality., Conclusions: The VQI registry is a valuable tool that can be used to measure compliance with SVS AAA guidelines. Compliance with recommendations was associated with improved outcomes and should be encouraged for providers. Participation in the VQI registry provides an objective assessment of performance and compliance with guidelines. VQI provider and center reports may be used as a focus for quality improvement efforts., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Transcarotid artery revascularization (TCAR) with flow reversal was recently introduced as a novel technique for carotid artery stenting (CAS). We examined the learning curve of surgeons adopting TCAR based on data from the Vascular Quality Initiative (VQI-TCAR Surveillance Project; TSP)., Study Design: We identified all patients in the TSP who underwent TCAR from September 2016 to December 2018. Cases were numbered in chronological order for each unique surgeon. Patients were then divided into 4 levels based on surgeon case number for comparison: cases 1 to 5 (novice), cases 6 to 20 (intermediate), cases 20 to 30 (advanced), and cases >30 (expert)., Results: During the study period, 3,456 TCAR procedures were performed by 417 unique surgeons from 178 centers. Of all procedures, 1,426 (41%) were performed at the novice level, 1,375 (40%) at the intermediate level, 307 (8.9%) at the advanced level, and 348 (10%) at the expert level. Cases performed at more advanced levels had lower operative times (novice 82 vs intermediate 73 vs advanced 62 vs expert 60 minutes, p < 0.001), fluoroscopy time (7 vs 6 vs 5 vs 5 minutes, p < 0.001), and flow reversal time (12 vs 11 vs 10 vs 10 minutes, p < 0.001). Cases done at more advanced levels had decreases in bleeding (3.9% vs 3.4% vs 1.6% vs 1.2%, p = 0.03). No differences in major in-hospital outcomes were found regardless of experience level including stroke (p = 0.99), death (p = 0.39), and composite stroke/death/myocardial infarction (p = 0.84)., Conclusions: Transcarotid artery revascularization is being performed with excellent stroke and mortality rates in the TSP, even in the early stages of the surgeons' learning curve. Bleeding complications, operative, fluoroscopy, and flow reversal times all decrease with increasing TCAR experience., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Importance: Several trials have observed higher rates of perioperative stroke following transfemoral carotid artery stenting compared with carotid endarterectomy. Transcarotid artery revascularization with flow reversal was recently introduced for carotid stenting. This technique was developed to decrease stroke risk seen with the transfemoral approach; however, its outcomes, compared with transfemoral carotid artery stenting, are not well characterized., Objective: To compare outcomes associated with transcarotid artery revascularization and transfemoral carotid artery stenting., Design, Setting, and Participants: Exploratory propensity score-matched analysis of prospectively collected data from the Vascular Quality Initiative Transcarotid Artery Surveillance Project and Carotid Stent Registry of asymptomatic and symptomatic patients in the United States and Canada undergoing transcarotid artery revascularization and transfemoral carotid artery stenting for carotid artery stenosis, from September 2016 to April 2019. The final date for follow-up was May 29, 2019., Exposures: Transcarotid artery revascularization vs transfemoral carotid artery stenting., Main Outcomes and Measures: Outcomes included a composite end point of in-hospital stroke or death, stroke, death, myocardial infarction, as well as ipsilateral stroke or death at 1 year. In-hospital stroke was defined as ipsilateral or contralateral, cortical or vertebrobasilar, and ischemic or hemorrhagic stroke. Death was all-cause mortality., Results: During the study period, 5251 patients underwent transcarotid artery revascularization and 6640 patients underwent transfemoral carotid artery stenting. After matching, 3286 pairs of patients who underwent transcarotid artery revascularization or transfemoral carotid artery stenting were identified (transcarotid approach: mean [SD] age, 71.7 [9.8] years; 35.7% women; transfemoral approach: mean [SD] age, 71.6 [9.3] years; 35.1% women). Transcarotid artery revascularization was associated with a lower risk of in-hospital stroke or death (1.6% vs 3.1%; absolute difference, -1.52% [95% CI, -2.29% to -0.75%]; relative risk [RR], 0.51 [95% CI, 0.37 to 0.72]; P < .001), stroke (1.3% vs 2.4%; absolute difference, -1.10% [95% CI, -1.79% to -0.41%]; RR, 0.54 [95% CI, 0.38 to 0.79]; P = .001), and death (0.4% vs 1.0%; absolute difference, -0.55% [95% CI, -0.98% to -0.11%]; RR, 0.44 [95% CI, 0.23 to 0.82]; P = .008). There was no statistically significant difference in the risk of perioperative myocardial infarction between the 2 cohorts (0.2% for transcarotid vs 0.3% for the transfemoral approach; absolute difference, -0.09% [95% CI, -0.37% to 0.19%]; RR, 0.70 [95% CI, 0.27 to 1.84]; P = .47). At 1 year using Kaplan-Meier life-table estimation, the transcarotid approach was associated with a lower risk of ipsilateral stroke or death (5.1% vs 9.6%; hazard ratio, 0.52 [95% CI, 0.41 to 0.66]; P < .001). Transcarotid artery revascularization was associated with higher risk of access site complication resulting in interventional treatment (1.3% vs 0.8%; absolute difference, 0.52% [95% CI, -0.01% to 1.04%]; RR, 1.63 [95% CI, 1.02 to 2.61]; P = .04), whereas transfemoral carotid artery stenting was associated with more radiation (median fluoroscopy time, 5 minutes [interquartile range {IQR}, 3 to 7] vs 16 minutes [IQR, 11 to 23]; P < .001) and more contrast (median contrast used, 30 mL [IQR, 20 to 45] vs 80 mL [IQR, 55 to 122]; P < .001)., Conclusions and Relevance: Among patients undergoing treatment for carotid stenosis, transcarotid artery revascularization, compared with transfemoral carotid artery stenting, was significantly associated with a lower risk of stroke or death.

Background: Patients undergoing vascular operations face high rates of intraoperative and postoperative complications and delayed return to baseline. Enhanced recovery after surgery (ERAS), with its aim of delivering high-quality perioperative care and accelerating recovery, appears well suited to address the needs of this population., Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review to characterize the use and effectiveness of ERAS in all types of vascular and endovascular operations. We queried MEDLINE (through PubMed), Embase, Web of Science, Scopus, ProQuest Dissertations and Theses Global, Cochrane Central Register of Controlled Trials, Prospero, and Google Scholar. Two reviewers independently completed screening, review, and quality assessment. Eligible articles described the use of ERAS pathways for vascular operations from January 1, 1997, through December 7, 2017. Details regarding patients' demographics and use of the ERAS pathway or selected ERAS components were extracted. When available, results including perioperative morbidity, mortality, and in-hospital length of stay were collected. The studies with control groups that evaluated ERAS-like pathways were meta-analyzed using random-effects meta-analysis., Results: In the final analysis, 19 studies were included: four randomized controlled trials and 15 observational studies. By Let Evidence Guide Every New Decision (LEGEND) criteria, the two good-quality studies are randomized controlled trials that evaluated a specific part of an ERAS pathway. All other studies were considered poor quality. Meta-analysis of the five studies describing ERAS-like pathways demonstrated a reduction in length of stay by 3.5 days (P = .0012)., Conclusions: Based on systematic review, the use of ERAS pathways in vascular surgery is limited, and existing evidence of their feasibility and effectiveness is low quality. There is minimal poor- to moderate-quality evidence describing the use of ERAS pathways in open aortic operations. There is scarce, poor-quality evidence related to ERAS pathways in lower extremity operations and no published evidence related to ERAS pathways in endovascular operations. Although the risk of bias is high in most of the studies done to date, all of them observed improvements in length of stay, postoperative diet, and ambulation. It is reasonable to consider the implementation of ERAS pathways in the care of vascular surgery patients, specifically those undergoing open aortic operations, but many of the details will be based on limited data and extrapolation from other surgical specialties until further research is done., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Recent evidence from the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial in high-risk patients undergoing transcarotid artery stenting with dynamic flow reversal reported the lowest stroke rate compared with any prospective trial of carotid artery stenting. However, clinical trials have selection criteria that exclude many patients from enrollment and are highly selective of operators performing the procedures, which limit generalizability. The aim of this study was to compare in-hospital outcomes after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) as reported in the Vascular Quality Initiative (VQI)., Methods: The Society for Vascular Surgery VQI TCAR Surveillance Project (TSP) was designed to evaluate the safety and effectiveness of TCAR in real-world practice. Data from the initial 646 patients enrolled in the TSP from March 2016 to December 2017 were analyzed and compared with those of patients who underwent TFCAS between 2005 and 2017. Patients with tandem, traumatic, or dissection lesions were excluded. Multivariable logistic regression and 1:1 coarsened exact matching were used to analyze neurologic adverse events (stroke and transient ischemic attacks [TIAs]) and in-hospital mortality. Patients in the two procedures were matched on age, ethnicity, coronary artery disease, congestive heart failure, prior coronary artery bypass graft or percutaneous coronary intervention, chronic kidney disease, degree of ipsilateral stenosis, American Society of Anesthesiologists class, symptomatic status, restenosis, anatomic and medical risk, and urgency of the procedure., Results: Compared with patients undergoing TFCAS (n = 10,136), those undergoing TCAR (n = 638) were significantly older, had more cardiac comorbidities, were more likely to be asymptomatic, and were less likely to have a recurrent stenosis. The rates of in-hospital TIA/stroke as well as of TIA/stroke/death were significantly higher in TFCAS compared with TCAR (3.3% vs 1.9% [P = .04] and 3.8% vs 2.2% [P = .04], respectively). In both procedures, symptomatic patients had higher rates of TIA/stroke/death compared with asymptomatic patients (TCAR, 3.7% vs 1.4% [P = .06]; TFCAS, 5.3% vs 2.7% [P < .001]). After multivariable adjustment, there was a trend of increased stroke or death rates in TFCAS compared with TCAR, but it was not statistically significant (2.5% vs 1.7%; P = .25; odds ratio, 1.75, 95% confidence interval, 0.85-3.62). However, TFCAS was associated with twice the odds of in-hospital adverse neurologic events and TIA/stroke/death compared with TCAR (odds ratio, 2.10; 95% confidence interval, 1.08-4.08; P = .03), independent of symptom status. Coarsened exact matching showed similar results., Conclusions: Compared with patients undergoing TFCAS, patients undergoing TCAR had significantly more medical comorbidities but similar stroke/death rates and half the risk of in-hospital TIA/stroke/death. These results persisted despite rigorous adjustment and matching of potential confounders. This initial evaluation of the VQI TSP demonstrates the ability to rapidly monitor new devices and procedures using the VQI. Although it is preliminary, this is the first study to demonstrate the benefit of TCAR compared with TFCAS in real-world practice. These results need to be confirmed by a clinical trial., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Performing lower extremity bypass (LEB) in actively smoking claudicants remains controversial. Whereas some surgeons advocate a strict nonoperative approach to active smokers, citing perceived inferior outcomes, others will proceed with surgical bypass if the patient is anatomically suited and medical management has failed. The purpose of this study was to determine the impact of active smoking on LEB outcomes among claudicants., Methods: All patients undergoing infrainguinal LEB for claudication in the Vascular Study Group of New England from 2003 to 2016 were analyzed. Smoking was defined as active tobacco use within 1 month of surgery. End points included in-hospital outcomes; long-term primary, assisted primary, and secondary patency; and mortality. Univariate, Cox multivariable, and Kaplan-Meier methods were used to determine the impact of smoking. Propensity score matching was performed to control for intergroup differences., Results: Of 1789 LEBs, 971 (54%) were performed in nonsmokers and 818 (46%) in smokers. The follow-up rate was 87% at a mean of 382 days (standard error, ±6.8 days). Smokers were younger (60 vs 68 years; P < .001) and were less likely to have multiple comorbidities, including hypertension, coronary artery disease, congestive heart failure, diabetes, and chronic renal insufficiency (P ≤ .05); they were more likely to have an above-knee popliteal bypass target (52% vs 43%; P = .001). Smokers also had lower rates of postoperative major cardiac events (2.4% vs 5.3%; P = .002) and perioperative blood transfusion (5.6% vs 11%; P < .001) compared with nonsmokers, but there was no difference in respiratory complications, wound complications, or mortality. At 2-year follow-up, smokers demonstrated inferior primary patency (48% vs 61%; P = .03) and assisted primary patency (59% vs 74%; P = .01), with comparable rates of secondary patency and overall mortality. Propensity matching yielded two similar groups (n = 450 for each). Propensity-matched smokers had significantly decreased 2-year primary patency (43% vs 58%; P = .02), assisted primary patency (54% vs 71%; P = .03), and 10-year survival (69% vs 76%; P < .01). Cox multivariable analysis confirmed that smoking was an independent predictor of diminished primary patency (hazard ratio [HR], 1.3; 95% confidence interval [CI], 1.0-1.6; P = .03), assisted primary patency (HR, 1.4; 95% CI, 1.1-1.8; P = .004), and overall survival (HR, 1.3; 95% CI, 1.1-1.5; P < .001)., Conclusions: Despite the fact that smokers are younger and have fewer comorbidities than nonsmokers, active smoking at the time of LEB for claudication is associated with decreased long-term patency and decreased overall survival. Surgeons should consider smoking an important risk factor for worse LEB outcomes in smokers compared with nonsmokers., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Lower extremity bypass (LEB) operations have high rates of surgical site infections (SSI). Phenylephrine is a commonly used vasoconstrictor which may reduce skin blood flow and increase the likelihood of SSI in these patients. We studied the potential effect of phenylephrine infusion during LEB surgery on SSI., Methods: LEB cases and their demographic data were identified through the Vascular Quality Initiative registry. SSI in this population was identified using the hospital epidemiology surveillance database. Phenylephrine use in this population was identified through chart review., Results: We identified 699 patients who underwent LEB; 82 (11.7%) developed an SSI, and 244 of 698 (35.0%) were treated with phenylephrine infusion. In bivariate analysis, higher body mass index (28.8 kg/m 2 vs 27.3 kg/m 2 ; P = .034), diabetes (14.6% vs 9.4%; P = .035), hypertension (12.6% vs 4.7%; P = .038), groin incision (13.2 vs 5.4%; P = .013) and longer procedure times (17.1% for >220 minutes and 8.9% for ≤220 minutes; P = .003) were associated with higher rates of SSI. Whereas phenylephrine infusion exhibited a trend toward a higher rate (14.8% vs 9.9%; P = .057). In the logistic regression model, diabetes (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.0-3.2; P = .032), total procedure time (OR, 1.85; 95% CI, 1.1-3.1; P = .026) and vertical groin incision (OR, 2.6; 95% CI, 1.1-6.5; P = .035) were independent predictors of increased SSI rates, whereas body mass index (OR, 1.04; 95% CI, 0.99-1.08; P = .09), hypertension (OR, 2.5; 95% CI, 0.6-10.9; P = .22), and phenylephrine infusion (OR, 1.08; 95% CI, 0.63-1.85; P = .78) were not independent predictors of increased SSI rates., Conclusions: Phenylephrine infusion did not increase the risk of SSI in patients who underwent LEB., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to develop and to validate the Vascular Quality Initiative (VQI) Cardiac Risk Index (CRI) for prediction of postoperative myocardial infarction (POMI) after vascular surgery., Methods: We developed risk models for in-hospital POMI after 88,791 nonemergent operations from the VQI registry, including carotid endarterectomy (CEA; n = 45,340), infrainguinal bypass (INFRA; n = 18,054), suprainguinal bypass (SUPRA; n = 2678), endovascular aneurysm repair (EVAR; n = 18,539), and open abdominal aortic aneurysm repair (OAAA repair; n = 4180). Multivariable logistic regression was used to create an all-procedure and four procedure-specific risk calculators based on the derivation cohort from 2012 to 2014 (N = 61,236). Generalizability of the all-procedure model was evaluated by applying it to each procedure subtype. The models were validated using a cohort (N = 27,555) from January 2015 to February 2016. Model discrimination was measured by area under the receiver operating characteristic curve (AUC), and performance was validated by bootstrapping 5000 iterations. The VQI CRI calculator was made available on the Internet and as a free smart phone app available through QxCalculate., Results: Overall POMI incidence was 1.6%, with variation by procedure type as follows: CEA, 0.8%; EVAR, 1.0%; INFRA, 2.6%; SUPRA, 3.1%; and OAAA repair, 4.3% (P < .001). Predictors of POMI in the all-procedure model included age, operation type, coronary artery disease, congestive heart failure, diabetes, creatinine concentration >1.8 mg/dL, stress test status, and body mass index (AUC, 0.75; 95% confidence interval [CI], 0.73-0.76). The all-procedure model demonstrated only minimally reduced accuracy when it was applied to each procedure, with the following AUCs: CEA, 0.65 (95% CI, 0.59-0.70); INFRA, 0.69 (95% CI, 0.64-0.73); EVAR, 0.72 (95% CI, 0.65-0.80); SUPRA, 0.62 (95% CI, 0.52-0.72); and OAAA, 0.63 (95% CI, 0.56-0.70). Procedure-specific models had unique predictors and showed improved prediction compared with the all-procedure model, with the following AUCs: CEA, 0.69 (95% CI, 0.66-0.72); INFRA, 0.75 (95% CI, 0.73-0.78); EVAR, 0.76 (95% CI, 0.73-0.80); and OAAA, 0.72 (95% CI, 0.69-0.77). Bias-corrected AUC (95% CI) from internal validation for the models was as follows: all procedures, 0.75 (0.73-0.76); CEA, 0.68 (0.65-0.71); INFRA, 0.74 (0.72-0.76); EVAR, 0.73 (0.70-0.78); and OAAA repair, 0.68 (0.65-0.73)., Conclusions: The VQI CRI is a useful and valid clinical decision-making tool to predict POMI after vascular surgery. Procedure-specific models improve accuracy when they include unique risk factors., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Heart rate (HR) parameters are known indicators of cardiovascular complications after cardiac surgery, but there is little evidence of their role in predicting outcome after major vascular surgery. The purpose of this study was to determine whether arrival HR (AHR) and highest intraoperative HR are associated with mortality or major adverse cardiac events (MACEs) after elective vascular surgery in the Vascular Quality Initiative (VQI)., Methods: Patients undergoing elective lower extremity bypass (LEB), aortofemoral bypass (AFB), and open abdominal aortic aneurysm (AAA) repair in the VQI were analyzed. MACE was defined as any postoperative myocardial infarction, dysrhythmia, or congestive heart failure. Controlled HR was defined as AHR <75 beats/min on operating room arrival. Delta HR (DHR) was defined as highest intraoperative HR - AHR. Procedure-specific MACE models were derived for risk stratification, and generalized estimating equations were used to account for clustering of center effects. HR, beta-blocker exposure, cardiac risk, and their interactions were explored to determine association with MACE or 30-day mortality. A Bonferroni correction with P < .004 was used to declare significance., Results: There were 13,291 patients reviewed (LEB, n = 8155 [62%]; AFB, n = 2629 [18%]; open AAA, n = 2629 [20%]). Rates of any preoperative beta-blocker exposure were as follows: LEB, 66.5% (n = 5412); AFB, 57% (n = 1342); and open AAA, 74.2% (n = 1949). AHR and DHR outcome association was variable across patients and procedures. AHR <75 beats/min was associated with increased postoperative myocardial infarction risk for LEB patients across all risk strata (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.03-1.9; P = .03), whereas AHR <75 beats/min was associated with decreased dysrhythmia risk (OR, 0.42; 95% CI, 0.28-0.63; P = .0001) and 30-day death (OR, 0.50; 95% CI, 0.33-0.77; P = .001) in patients at moderate and high cardiac risk. These HR associations disappeared in controlling for beta-blocker status. For AFB and open AAA repair patients, there was no significant association between AHR and MACE or 30-day mortality, irrespective or cardiac risk or beta-blocker status. DHR and extremes of highest intraoperative HR (>90 or 100 beats/min) were analyzed among all three operations, and no consistent associations with MACE or 30-day mortality were detected., Conclusions: The VQI AHR and highest intraoperative HR variables are highly confounded by patient presentation, operative variables, and beta-blocker therapy. The discordance between cardiac risk and HR as well as the lack of consistent correlation to outcome makes them unreliable predictors. The VQI has elected to discontinue collecting AHR and highest intraoperative HR data, given insufficient evidence to suggest their importance as an outcome measure., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Medical management (MM) with antiplatelet (AP) and statin therapy is recommended for most patients undergoing vascular surgery and has been advocated by the Vascular Quality Initiative (VQI). We analyzed the effect of VQI participation on perioperative (preoperative and postoperative) MM use over time and the effect of discharge MM on patient survival., Methods: We studied VQI patients treated with MM preoperatively and at discharge from 2005 to 2014, including all elective carotid endarterectomy/carotid stenting (n = 28,092), suprainguinal/infrainguinal bypass (n = 11,362), peripheral vascular interventions (n = 24,476), open/endovascular abdominal aortic aneurysm repair (n = 13,503), and thoracic endovascular aneurysm repair (n = 702). We examined trends of MM use over time, as well as the effect of duration of VQI participation on MM use. Multivariable logistic regression analysis was performed to identify factors associated with MM use. In addition, the Cox proportional hazards model was used to identify factors associated with 5-year survival., Results: MM with AP and statin preoperatively and postoperatively across VQI centers improved from 55% in 2005 to 68% in 2009, with a subsequent overall decline to 62% by 2014, coincident with many new centers with lower MM rates joining VQI in 2010. Longer center participation in VQI was associated with improved perioperative MM overall. This was also noted across all procedure types, with MM increasing from 47% to 82% for aneurysm repairs and 69% to 83% for carotid procedures from 1 to 12 years of participation in VQI. After multivariable adjustment, centers in VQI ≥3 years were 30% more likely to have patients on MM (odds ratio, 1.3, 95% confidence interval [CI], 1.3-1.4). Importantly, discharge on AP and statin therapy was associated with improved 5-year survival, compared with discharge on neither medication (82% [95% CI, 81%-83%] vs 67% [95% CI, 62%-72%]), and an adjusted hazard ratio for death of 0.6 (95% CI, 0.5-0.7; P < .001). Discharge on a single medication was associated with intermediate survival at 5 years (AP only: 77% [95% CI, 75%-79%]; statin only: 73% [95% CI, 68%-77%])., Conclusions: These data demonstrate that MM is associated with improved survival after a number of vascular procedures. Importantly, VQI participation improves the use of MM, demonstrating that involvement in an organized quality effort can affect patient outcomes., (Copyright © 2015 Society for Vascular Surgery. All rights reserved.)

Objective: Many patients undergoing vascular surgical procedures are not on appropriate medical therapy. This study sought to examine the variation and impact of antiplatelet (AP) and statin therapy on early and late mortality in patients undergoing vascular surgery in our region., Methods: We studied all patients (n = 14,489) undergoing elective carotid endarterectomy (n = 6978), carotid stenting (n = 524), and suprainguinal (n = 763) and infrainguinal bypass (n = 3053), as well as patients with known coronary risk factors undergoing open (n = 1044) and endovascular (n = 2127) abdominal aortic aneurysm repair from 2005 to 2012 in the Vascular Study Group of New England. Optimal medical management was defined as treatment with both AP and statin agents, preoperatively and at discharge. We analyzed temporal, procedural, and center variation of medication use. Multivariable analyses were used to determine the adjusted impact of AP and statin therapy on 30-day mortality and 5-year survival., Results: Optimal medical management improved over the study interval (55% in 2005 to 68% in 2012; P trend < .01) with carotid interventions having the highest rates of optimal medications use (carotid artery stenting, 78%; carotid endarterectomy, 74%) and abdominal aortic aneurysm repair in patients with known cardiac risk factors having the lowest (open, 57%; endovascular aneurysm repair, 56%). Optimal medication use varied by center as well (range, 40%-86%). Preoperative AP and statin use was associated with reduced 30-day mortality (odds ratio, 0.76; 95% confidence interval [CI], 0.5-1.05; P = .09). AP and statin prescription at discharge was additive in survival benefit with improved 5-year survival (hazard ratio, 0.5; 95% CI, 0.4-0.7; P < .01) that was consistent across procedure types. Patients prescribed AP and statin at discharge had 5-year survival of 79% (95% CI, 77%-81%) compared with only 61% (95% CI, 52%-68%; P < .001) for patients on neither medication., Conclusions: AP and statin therapy preoperatively and at discharge was associated with reduced 30-day mortality and an absolute 18% improved 5-year survival after vascular surgery. However, one-third of patients are suboptimally managed in real world practice. This demonstrates an opportunity for quality improvement that can substantially improve survival after vascular surgery., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Smoking is the most important modifiable risk factor for patients with vascular disease. The purpose of this study was to examine smoking cessation rates after vascular procedures and delineate factors predictive of postoperative smoking cessation., Methods: The Vascular Study Group of New England registry was used to analyze smoking status preoperatively and at 1 year after carotid endarterectomy, carotid artery stenting, lower extremity bypass, and open and endovascular abdominal aortic aneurysm repair between 2003 and 2009. Of 10,734 surviving patients after one of these procedures, 1755 (16%) were lost to follow-up and 1172 (11%) lacked documentation of their smoking status at follow-up. The remaining 7807 patients (73%) were available for analysis. Patient factors independently associated with smoking cessation were determined using multivariate analysis. The relative contribution of patient and procedure factors including treatment center were measured by χ-pie analysis. Variation between treatment centers was further evaluated by calculating expected rates of cessation and by analysis of means. Vascular Study Group of New England surgeons were surveyed regarding their smoking cessation techniques (85% response rate)., Results: At the time of their procedure, 2606 of 7807 patients (33%) were self-reported current smokers. Of these, 1177 (45%) quit within the first year of surgery, with significant variation by procedure type (open abdominal aortic aneurysm repair, 50%; endovascular repair, 49%; lower extremity bypass, 46%; carotid endarterectomy, 43%; carotid artery stenting, 27%). In addition to higher smoking cessation rates with more invasive procedures, age >70 years (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.30-2.76; P < .001) and dialysis dependence (OR, 2.38; 95% CI, 1.04-5.43; P = .04) were independently associated with smoking cessation, whereas hypertension (OR, 1.23; 95% CI, 1.00-1.51; P = .051) demonstrated a trend toward significance. Treatment center was the greatest contributor to smoking cessation, and there was broad variation in smoking cessation rates, from 28% to 62%, between treatment centers. Cessation rates were higher than expected in three centers and significantly lower than expected in two centers. Among survey respondents, 78% offered pharmacologic therapy or referral to a smoking cessation specialist, or both. The smoking cessation rate for patients of these surgeons was 48% compared with 33% in those who did not offer medications or referral (P < .001)., Conclusions: Patients frequently quit smoking after vascular surgery, and multiple patient-related and procedure-related factors contribute to cessation. However, we note significant influence of treatment center on cessation as well as broad variation in cessation rates between treatment centers. This variation indicates an opportunity for vascular surgeons to impact smoking cessation at the time of surgery., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

The Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) is designed to improve the quality, safety, effectiveness, and cost of vascular health care. The SVS VQI is uniquely organized as a distributed network of regional quality improvement groups across the United States. The regional approach allows for the involvement of a variety of health care professionals, the pooling of available resources and expertise, and serves as a motivating factor for each participating institution. Regional quality group sizes, administrative structure, and meeting logistics vary according to geography and regional needs. This review describes the process of forming, growing, and maintaining a regional quality improvement group of the SVS VQI., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Some patients who undergo lower extremity bypass (LEB) for critical limb ischemia ultimately require amputation. The functional outcome achieved by these patients after amputation is not well known. Therefore, we sought to characterize the functional outcome of patients who undergo amputation after LEB, and to describe the pre- and perioperative factors associated with independent ambulation at home after lower extremity amputation., Methods: Within a cohort of 3,198 patients who underwent an LEB between January, 2003 and December, 2008, we studied 436 patients who subsequently received an above-knee (AK), below-knee (BK), or minor (forefoot or toe) ipsilateral or contralateral amputation. Our main outcome measure consisted of a "good functional outcome," defined as living at home and ambulating independently. We calculated univariate and multivariate associations among patient characteristics and our main outcome measure, as well as overall survival., Results: Of the 436 patients who underwent amputation within the first year following LEB, 224 of 436 (51.4%) had a minor amputation, 105 of 436 (24.1%) had a BK amputation, and 107 of 436 (24.5%) had an AK amputation. The majority of AK (75 of 107, 72.8%) and BK amputations (72 of 105, 70.6%) occurred in the setting of bypass graft thrombosis, whereas nearly all minor amputations (200 of 224, 89.7%) occurred with a patent bypass graft. By life-table analysis at 1 year, we found that the proportion of surviving patients with a good functional outcome varied by the presence and extent of amputation (proportion surviving with good functional outcome = 88% no amputation, 81% minor amputation, 55% BK amputation, and 45% AK amputation, p = 0.001). Among those analyzed at long-term follow-up, survival was slightly lower for those who had a minor amputation when compared with those who did not receive an amputation after LEB (81 vs. 88%, p = 0.02). Survival among major amputation patients did not significantly differ compared with no amputation (BK amputation 87%, p = 0.14, AK amputation 89%, p = 0.27); however, this part of the analysis was limited by its sample size (n = 212). In multivariable analysis, we found that the patients most likely to remain ambulatory and live independently despite undergoing a lower extremity amputation were those living at home preoperatively (hazard ratio [HR]: 6.8, 95% confidence interval [CI]: 0.94-49, p = 0.058) and those with preoperative statin use (HR: 1.6, 95% CI: 1.2-2.1, p = 0.003), whereas the presence of several comorbidities identified patients less likely to achieve a good functional outcome: coronary disease (HR: 0.6, 95% CI: 0.5-0.9, p = 0.003), dialysis (HR: 0.5, 95% CI: 0.3-0.9, p = 0.02), and congestive heart failure (HR: 0.5, 95% CI: 0.3-0.8, p = 0.005)., Conclusions: A postoperative amputation at any level impacts functional outcomes following LEB surgery, and the extent of amputation is directly related to the effect on functional outcome. It is possible, based on preoperative patient characteristics, to identify patients undergoing LEB who are most or least likely to achieve good functional outcomes even if a major amputation is ultimately required. These findings may assist in patient education and surgical decision making in patients who are poor candidates for lower extremity bypass., (Published by Elsevier Inc.)

Objective: To determine if a regional quality improvement effort can increase beta-blocker utilization prior to vascular surgery and decrease the incidence of postoperative myocardial infarction (POMI)., Methods: A quality improvement effort to increase perioperative beta blocker utilization was implemented in 2003 at centers participating in the Vascular Study Group of New England (VSGNE). A 90% target was set and feedback given at biannual meetings. Beta blocker utilization (<1 month preoperative versus chronic) and POMI rates were prospectively collected for patients undergoing open abdominal aortic aneurysm (AAA) repair (n = 926) and lower extremity bypass (LEB; n = 2,123) from 2003 through 2008. Predictors of POMI were determined using multivariate logistic regression. Rates of beta blocker administration and POMI were analyzed over time, and across strata of patient risk based on a multivariate model., Results: Perioperative beta blocker treatment increased from 68% of patients in the first 3 months of 2005 to 88% by the last 3 months of 2008 (P < .001). In 2003, 44% of patients not on chronic beta blockers were treated with preoperative beta blockers; by 2008, 78% of patients not on chronic beta blockers were started perioperatively on these medications (P < .001). Beta blocker utilization increased across all centers and surgeons participating during the study period, and increased in patients of low, medium, and high cardiac risk. However, the rate of POMI did not change over time (5.2% in 2003, 5.5% in 2008; P = .876), although a trend towards lower POMI rate was seen in patients on preoperative beta blockers (4.4% in 2003-2005, 2.6% in 2006-2008; P = .43). In multivariable modeling we found that age >70 (odds ratio [OR], 2.1), positive stress test (OR, 2.2), congestive heart failure (CHF; OR, 1.7), chronic beta blocker administration (OR, 1.7), resting heart rate <70 (OR, 1.8), and diabetes (OR, 1.6) were associated with POMI. Resting heart rate was similar for patients on chronic (67), preoperative (70), and no beta blockers (70; P = .521)., Conclusions: Our regional quality improvement effort successfully increased perioperative beta blocker utilization. However, this was not associated with reduced rates of POMI or resting heart rate. While this demonstrates the effectiveness of regional quality improvement efforts in changing practice patterns, further work is necessary to more precisely identify those patients who will benefit from beta blockade at the time of vascular surgery., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The Revised Cardiac Risk Index (RCRI) is a widely used model for predicting cardiac events after noncardiac surgery. We compared the accuracy of the RCRI with a new, vascular surgery-specific model developed from patients within the Vascular Study Group of New England (VSGNE)., Methods: We studied 10,081 patients who underwent nonemergent carotid endarterectomy (CEA; n = 5293), lower extremity bypass (LEB; n = 2673), endovascular abdominal aortic aneurysm repair (EVAR; n = 1005), and open infrarenal abdominal aortic aneurysm repair (OAAA; n = 1,110) within the VSGNE from 2003 to 2008. First, we analyzed the ability of the RCRI to predict in-hospital major adverse cardiac events, including myocardial infarction (MI), arrhythmia, or congestive heart failure (CHF) in the VSGNE cohort. Second, we used a derivation cohort of 8208 to develop a new cardiac risk prediction model specifically for vascular surgery patients. Chi-square analysis identified univariate predictors, and multivariate logistic regression was used to develop an aggregate and four procedure-specific risk prediction models for cardiac complications. Calibration and model discrimination were assessed using Pearson correlation coefficient and receiver operating characteristic (ROC) curves. The ability of the model to predict cardiac complications was assessed within a validation cohort of 1873. Significant predictors were converted to an integer score to create a practical cardiac risk prediction formula., Results: The overall incidence of major cardiac events in the VSGNE cohort was 6.3% (2.5% MI, 3.9% arrhythmia, 1.8% CHF). The RCRI predicted risk after CEA reasonably well but substantially underestimated risk after LEB, EVAR, and OAAA for low- and higher-risk patients. Across all VSGNE patients, the RCRI underestimated cardiac complications by 1.7- to 7.4-fold based on actual event rates of 2.6%, 6.7%, 11.6%, and 18.4% for patients with 0, 1, 2, and >or=3 risk factors. In multivariate analysis of the VSGNE cohort, independent predictors of adverse cardiac events were (odds ratio [OR]) increasing age (1.7-2.8), smoking (1.3), insulin-dependent diabetes (1.4), coronary artery disease (1.4), CHF (1.9), abnormal cardiac stress test (1.2), long-term beta-blocker therapy (1.4), chronic obstructive pulmonary disease (1.6), and creatinine >or=1.8 mg/dL (1.7). Prior cardiac revascularization was protective (OR, 0.8). Our aggregate model was well calibrated (r = 0.99, P < .001), demonstrating moderate discriminative ability (ROC curve = 0.71), which differed only slightly from the procedure-specific models (ROC curves: CEA, 0.74; LEB, 0.72; EVAR, 0.74; OAAA, 0.68). Rates of cardiac complications for patients with 0 to 3, 4, 5, and >or=6 VSG risk factors were 3.1%, 5.0%, 6.8%, and 11.6% in the derivation cohort and 3.8%, 5.2%, 8.1%, and 10.1% in the validation cohort. The VSGNE cardiac risk model more accurately predicted the actual risk of cardiac complications across the four procedures for low- and higher-risk patients than the RCRI. When the VSG Cardiac Risk Index (VSG-CRI) was used to score patients, six categories of risk ranging from 2.6% to 14.3% (score of 0-3 to 8) were discernible., Conclusions: The RCRI substantially underestimates in-hospital cardiac events in patients undergoing elective or urgent vascular surgery, especially after LEB, EVAR, and OAAA. The VSG-CRI more accurately predicts in-hospital cardiac events after vascular surgery and represents an important tool for clinical decision making.

Background: Optimal patient selection for lower extremity bypass surgery requires surgeons to predict which patients will have durable functional outcomes following revascularization. Therefore, we examined risk factors that predict amputation or graft occlusion within the first year following lower extremity bypass., Methods: Using our regional quality-improvement initiative in 11 hospitals in northern New England, we studied 2,306 lower extremity bypass procedures performed in 2,031 patients between January 2003 and December 2007. Sixty surgeons contributed to our database, and over 100 demographic and clinical variables were abstracted by trained researchers. Cox proportional hazards models were used to generate hazard ratios and surrounding 95% confidence intervals (CIs) for our combined outcome measure of major amputation (above-knee or below-knee) or permanent graft occlusion (loss of secondary patency) occurring within the first year postoperatively., Results: We found that within our cohort of 2,306 bypass procedures 17% resulted in an amputation or graft occlusion within 1 year of surgery. Of the 143 amputations performed (8% of all limbs undergoing bypasses), 17% occurred in the setting of a patent graft. Similarly, of the 277 graft occlusions (12% of all bypasses), 42% resulted in a major amputation. We identified eight preoperative patient characteristics associated with amputation or graft occlusion in multivariate analysis: age <50, nonambulatory status preoperatively, dialysis dependence, diabetes, critical limb ischemia, need for venovenostomy, tarsal target, and living preoperatively in a nursing home. While patients with no risk factors had 1-year amputation/occlusion rates that were <1%, patients with three or more risk factors had a nearly 30% chance of suffering amputation or graft occlusion by 1 year postoperatively. When we compared risk-adjusted rates of amputation/occlusion across centers, we found that one center in our region performed significantly better than expected (observed/expected ratio 0.7, 95% CI 0.6-0.9, p < 0.04)., Conclusion: Preoperative risk factors allow surgeons to predict the risk of amputation or graft occlusion following lower extremity bypass and to more precisely inform patients about their operative risk and functional outcomes. Additionally, our model facilitates comparison of risk-adjusted outcomes across our region. We believe quality-improvement measures such as these will allow surgeons to identify best practices and thereby improve outcomes across centers., (Copyright 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Using 30-day operative mortality reported with lower extremity bypass (LEB) in preoperative decision making may underestimate the actual death rate encountered before patients have truly recovered from surgery, especially in elderly, debilitated patients with significant tissue loss. Therefore, we examined preoperative, patient-level risk factors that predict survival within the first year following LEB., Methods: Using our regional quality improvement initiative in 11 hospitals in Northern New England, we studied 2306 LEB procedures performed in 2031 patients between January 2003 and December 2007. Sixty surgeons contributed to our database, and over 100 demographic and clinical variables were abstracted by trained researchers. Cox proportional hazards models were used to generate hazard ratios (HR) and surrounding 95% confidence intervals (CI) for our combined outcome measure of death occurring within the first year postoperatively., Results: We found that within our cohort of 2306 bypass procedures, 11% of patients died within 1 year of surgery (2% prior to discharge, 9% prior to 1-year follow-up). We identified six preoperative patient characteristics associated with higher risk of death in multivariate analysis: congestive heart failure (HR 1.3, 95% CI 1.0-1.8), diabetes (HR 1.5, 95% CI 1.1-2.1), critical limb ischemia (CLI) (HR 1.7, 95% CI 1.3-2.4), lack of single-segment saphenous vein (HR 1.9, 95% CI 1.5-2/5), age over 80 (HR 2.0, 95% CI 1.5-2.7), dialysis dependence (HR 2.7, 95% CI 1.9-3.6), and emergent nature of the procedure (HR 3.4, 95% CI 1.7-6.8). While patients with no risk factors had 1-year death rates that were less than 5%: patients with three or more risk factors had a 28% chance of dying before 1 year postoperatively. When we compared risk-adjusted survival across centers, we found that one center in our region performed significantly better than expected (observed-to-expected outcome ratio 0.7, 95% CI 0.6-0.9, P = .04)., Conclusions: Preoperative risk factors allow surgeons to predict survival in the first year following LEB, and to more precisely inform patients about their operative risk with LEB. Additionally, our model facilitates benchmarking comparison of risk-adjusted outcomes across our region. We believe quality improvement measures such as these will allow surgeons to identify best practices and thereby improve outcomes with LEB across centers., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Benefit of prophylactic abdominal aortic aneurysm (AAA) repair requires sufficient survival to overcome operative risk. Since death within 1 year of elective open or endovascular (EVAR) infrarenal AAA repair likely indicates ineffective treatment, we developed a prediction model for 1-year mortality to aid clinical decision-making., Methods: We used a prospective registry of 1387 consecutive patients who had undergone elective AAA repair from 2003 to 2007 by 50 surgeons from 11 hospitals in Northern New England. Cox proportional hazards were used to analyze potential risk factors for 1-year mortality, including medical comorbidities, aortic clamp site, preoperative risk factor modification (eg, beta-blockade), and aneurysm diameter., Results: Thirty-day and 1-year mortality after open repair (n = 748) was 2.3% and 5.8%, and after EVAR (n = 639) was 0.5% and 5.7%, respectively. Factors associated with death within 1-year after open repair were: age >/= 70 (P = .007; hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.3-6.3), history of chronic obstructive pulmonary disease (COPD) (P < .0001; HR 3.6, 95% CI 1.9-7.0), chronic renal insufficiency (creatinine >/= 1.8) (P = .008; HR 2.8, 95% CI 1.3-6.2) and suprarenal aortic clamp site (P < .0001; HR 3.8, 95% CI 1.9-7.5). Depending on the number of risk factors present, predicted 1-year mortality after open repair varied from 1% in patients with no risk factors to 67% in patients with four risk factors. Our model demonstrated excellent correlation between observed and expected deaths (r = 0.97). For EVAR, identified risk factors for death within 1 year included a history of congestive heart failure (CHF) (P = .002; HR 3.2, 95% CI 1.6-6.5), and aneurysm diameter >/=6.5 cm (P = .04 95% CI 1.0-4.8). Depending on the number of risk factors present, predicted mortality ranged from 3.6% to 23%. A model using CHF and aneurysm diameter correlated well with actual mortality rates, with an observed to expected ratio of 0.96., Conclusion: Predictors of 1-year mortality can identify patients less likely to benefit from elective AAA repair. These factors differ for open repair vs EVAR and should be considered in individual patient decision-making. Our EVAR model had less impact on 1-year survival, even if CHF and large AAA diameter were present. However, a combination of age, COPD, renal insufficiency, and need for suprarenal clamping have significant impact on 1-year mortality after open AAA repair. Consideration of these variables should assist decision-making for elective AAA repair, especially in borderline cases.

Objective: A regional cooperative data registry was organized for carotid endarterectomy (CEA), lower extremity bypass (LEB), and infrarenal abdominal aortic aneurysm (AAA) repair (open and endovascular) procedures in Northern New England to allow benchmarking among centers for quality assurance and improvement activities., Methods: Since January 2003, 48 vascular surgeons from nine hospitals in Maine, New Hampshire, and Vermont (25 to 615 beds) have prospectively recorded patient, procedure, and in-hospital patient outcome data. Results plus 1-year follow-up data analyzed at a central site are reported anonymously to each center at semiannual meetings where care processes and regional benchmarks are discussed. Mortality and compliance with procedure entry were validated by independent comparison with hospital administrative data. Initial improvement efforts focused on optimizing preoperative medication usage., Results: A total of 6143 operations were entered into the registry through December 2006. In-hospital stroke or death after CEA was 1.0%, major amputation or death after LEB was 3.8%, and mortality was 2.9% after elective open and 0.4% after endovascular repair. Variation in results between centers and surgeons provides opportunity for further quality improvement. Any postoperative complication increased median length of stay by > or =3 days. Process improvement efforts initiated in 2004 increased preoperative beta-blocker administration from 72% to 91%, antiplatelet agents from 73% to 83%, and statins from 54% to 72% (all P < .001). Procedure volume and discharge status validation with administrative data led to 99% of appropriate operations being reported to the registry. Mortality was accurately reported to the data registry for all patients., Conclusion: This validated regional data registry within a quality improvement initiative has been associated with improved preoperative medication usage. It provides a potential vehicle for future public and pay-for-performance reporting and has the potential to improve patient outcomes. It has been sustained for >4 years and is a model that could be adopted by other regions.