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Background: Wound complications after open infrainguinal revascularization are a frequent cause of patient morbidity, resulting in increased healthcare costs. The purpose of the present study was to assess the effects of closed incision negative pressure therapy (ciNPT) on groin wound complications after infrainguinal bypass and femoral endarterectomy., Methods: A total of 242 patients who had undergone infrainguinal bypass (n = 124) or femoral endarterectomy (n = 118) at five academic medical centers in New England from April 2015 to August 2019 were randomized to ciNPT (PREVENA; 3M KCI, St Paul, Minn; n = 118) or standard gauze (n = 124). The primary outcome measure was a composite endpoint of groin wound complications, including surgical site infections (SSIs), major noninfectious wound complications, or graft infections within 30 days after surgery. The secondary outcome measures included 30-day SSIs, 30-day noninfectious wound complications, readmission for wound complications, significant adverse events, and health-related quality of life using the EuroQoL 5D-3L survey., Results: The ciNPT and control groups had similar demographics (age, 67 vs 67 years, P = .98; male gender, 71% vs 70%, P = .86; white race, 93% vs 93%, P = .97), comorbidities (previous or current smoking, 93% vs 94%, P = .46; diabetes, 41% vs 48%, P = .20; renal insufficiency, 4% vs 7%, P = .31), and operative characteristics, including procedure type, autogenous conduit, and operative time. No differences were found in the primary composite outcome at 30 days between the two groups (ciNPT vs control: 31% vs 28%; P = .55). The incidence of SSI at 30 days was similar between the two groups (ciNPT vs control: 11% vs 12%; P = .58). Infectious (13.9% vs 12.6%; P = .77) and noninfectious (20.9% vs 17.6%; P = .53) wound complications at 30 days were also similar for the ciNPT and control groups. Wound complications requiring readmission also similar between the two groups (ciNPT vs control: 9% vs 7%; P = .54). The significant adverse event rates were not different between the two groups (ciNPT vs control: 13% vs 16%; P = .53). The mean length of the initial hospitalization was the same for the ciNPT and control groups (5.2 vs 5.7 days; P = .63). The overall health-related quality of life was similar at baseline and at 14 and 30 days postoperatively for the two groups. Although not powered for stratification, we found no differences among the subgroups in gender, obesity, diabetes, smoking, claudication, chronic limb threatening ischemia, bypass, or endarterectomy. On multivariable analysis, no differences were found in wound complications at 30 days for the ciNPT vs gauze groups (odds ratio, 1.4; 95% confidence interval, 0.8-2.6; P = .234)., Conclusions: In contrast to other randomized studies, our multicenter trial of infrainguinal revascularization found no differences in the 30-day groin wound complications for patients treated with ciNPT vs standard gauze dressings. However, the SSI rate was lower in the control group than reported in other studies, suggesting other practice patterns and processes of care might have reduced the rate of groin infections. Further study might identify the subsets of high-risk patients that could benefit from ciNPT., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Major adverse event (MAE) rates are used as an outcome measure after surgical procedures. Although MAE rates summarize the occurrences of adverse events, they do not reflect differences in severity of these events. We propose that a measure of complication severity could provide a more accurate assessment about the quality of care. We aimed to analyze and to describe the regional variation in elective endovascular aneurysm repair (EVAR) MAE rates across centers in the Vascular Study Group of New England and to create an index for describing complication severity., Methods: Patients undergoing elective EVAR (n = 4731) at 30 Vascular Study Group of New England centers between 2003 and 2016 were studied. The MAE composite end point was defined as the occurrence of any of the following postoperative events: myocardial infarction, dysrhythmia, congestive heart failure, leg ischemia, renal insufficiency, bowel complication, reoperation, surgical site infection, stroke, respiratory complication, and no home discharge. An adjustment factor (complication severity index) was calculated as a ratio of length of stay for complicated to uncomplicated cases. Multivariate logistic regression was used to calculate predicted MAE rates. The observed and predicted MAE rates as well as complication severity index rates were compared among centers and across quintiles of center volume., Results: Observed MAE rates varied widely, ranging from 0% to 39%. Multivariate predictors of MAE included abdominal aortic aneurysm diameter >6 cm (odds ratio [OR], 2.1; 95% confidence interval [CI], 2.0-2.3), female sex (OR, 2.0; 95% CI, 1.8-2.2), chronic renal insufficiency (OR, 1.9; 95% CI, 1.7-2.1), age >75 years (OR, 1.9; 95% CI, 1.8-2.1), congestive heart failure (OR, 1.7; 95% CI, 1.5-1.9), chronic obstructive pulmonary disease (OR, 1.5; 95% CI, 1.4-1.6), diabetes (OR, 1.4; 95% CI, 1.1-1.7), positive stress test result (OR, 1.2; 95% CI, 1.1-1.4), preoperative beta blocker (OR, 1.2; 95% CI, 1.1-1.3), and no preoperative statin (OR, 1.2; 95% CI, 1.1-1.3). Predicted MAE rates had little variation (range, 21%-29%). In comparing observed MAE rates and complication severity, there was an inverse relation between the two, suggesting that although certain centers had a greater number of MAEs, the complications were less severe., Conclusions: MAE rates after elective EVAR vary widely. However, centers with higher MAE rates tended to have less severe complications, suggesting that observed MAE rates may not be a good measure of outcomes assessment after elective EVARs., (Published by Elsevier Inc.)

Objective: Patch angioplasty has been shown to decrease rates of restenosis after carotid endarterectomy (CEA). In 2003, the Vascular Study Group of New England (VSGNE) implemented its first quality initiative aimed at increasing the rates of patch closure after CEA. This study reports the effects of that initiative on the rate of patch closure in the VSGNE and also postoperative and 1-year CEA outcomes., Methods: Patients undergoing CEA (N = 14,636) within the VSGNE between 2003 and 2014 were studied. Rates of in-hospital postoperative events (death, ipsilateral stroke or transient ischemic attack [TIA], and return to the operating room for bleeding) and events during 1 year of follow-up (stroke or TIA and restenosis >70% or occlusion) were compared by repair type-patch closure, primary closure, or eversion. One-year follow-up events were also compared over time and by annualized surgeon volume., Results: During the 12 years studied, patch use increased from 71% to 91% (P < .001). There was no difference in postoperative death or ipsilateral stroke or TIA between the repair types. However, there was a statistically lower rate of return to the operating room for bleeding (P < .001), 1-year stroke or TIA (P < .003), and 1-year restenosis or occlusion (P < .001) with patch closure. Overall, the rates of 1-year stroke or TIA and restenosis decreased over time in the VSGNE. The initiative affected patch closure rates and outcomes of high-volume surgeons (>47 CEAs/y) the most. High-volume surgeons increased patch use from 50% to 90% and decreased their restenosis rates from 9.0% to 1.2% and 1-year stroke or TIA from 4.9% to 1.9% (P < .001)., Conclusions: The VSGNE carotid patch quality initiative successfully increased the rates of CEA patch closure. During the same time, there has been a decrease in postoperative bleeding requiring reoperation and 1-year ipsilateral neurologic events and restenosis or occlusion., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: A postoperative length of stay (LOS) >1 day after elective surgery incurs financial losses for hospitals, given fixed diagnosis-related group-based reimbursement. We sought to identify factors leading to a prolonged LOS (>1 postoperative day) after carotid endarterectomy (CEA)., Methods: Patients undergoing CEA in 23 centers of the Vascular Study Group of New England between 2003 and 2011 (n = 8860) were analyzed. Only elective, primary CEAs were analyzed, leaving a study cohort of 7108 procedures. Hierarchical multivariable logistic regression analysis was performed to identify predictors of a postoperative LOS >1 day. A Knaus-Wagner chi-pie analysis was performed to determine the relative contributions of each significant covariate to a postoperative LOS >1 day., Results: A postoperative LOS >1 day occurred in 17.5% of the sample (n = 1244). The average LOS was 1.4 days (range, 1-91 days; median, 1). There was significant variation in rates of postoperative LOS >1 day across centers (range, 5%-100%; P < .001). Factors independently associated with a postoperative LOS >1 day and their percentage contribution to the prediction model included the need for postoperative intravenous medications for hypertension or hypotension (26%), any major adverse event (MAE) postoperatively (21%), low-volume (<15 CEAs per year) surgeons (28%), increasing age (7%), female gender (4%), positive result on a preoperative stress test (3%), preoperative major stroke ≤30 days (2%), medication-dependent diabetes (1%), severe chronic obstructive pulmonary disease (1%), history of congestive heart failure (1%), and CEA performed on Friday (2%)., Conclusions: Certain patient characteristics predispose to a postoperative LOS >1 day after elective CEA. However, patient characteristics play only a modest (17%) role in determining LOS. The need for postoperative blood pressure control and MAEs are the biggest drivers of postoperative LOS >1 day, but system factors, such as low operative volume, contribute substantially to postoperative LOS >1 day, independent of MAEs. These findings can be used to guide quality improvement efforts designed to reduce LOS after elective CEA., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. 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: 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.