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Concerned about the inadequacy of a centralized database and the importance of low morbidity and mortality on carotid endarterectomy efficacy, the South Carolina Vascular Surgical Society prospectively instituted a computer registry for carotid procedures performed by its members, to establish a statewide standard of practice. From January 1994 through December 1997, 23 of the 30 physician members voluntarily registered data on 1652 carotid operations at 14 hospitals into a central database. Blinded results were reviewed biannually. Complete data (1995-1997) were available for 1199 cases. The patients tended to be >64 years old (72%), male (62%), and white (93%). Carotid endarterectomy was the most frequently performed operation (90%). Perioperative complications (< or = 30 days) occurred in 173 patients (14.4%), including stroke (n = 19; 1.6%), death (n = 8; 0.7%), and stroke/death (n = 25; 2.0%). Although 23 surgeons (77% of the society) contributed some data, only 10 surgeons (33%) contributed complete data on >10 patients/year. Despite biannual efforts to boost participation, case entry remained stable (1994, 358; 1995, 347; 1996, 425; and 1997, 427), representing about one-third of the estimated carotid procedures performed in the state during that period. The cost of the registry was approximately $11,500. Audit of 8 surgeons revealed a >95 per cent match against the statewide discharge database and low error rate versus independent medical record review. This experience confirms that excellent outcomes after carotid endarterectomy are not limited to a few select centers and can be accomplished by adequately trained surgeons in a variety of institutional settings. Incomplete physician participation, however, inevitably raises questions about the utility of such efforts. Until volunteer registries induce full participation by heightening perceived physician benefit, their role will remain limited for future outcomes research.

Objective: African Americans, especially African American women, have a greater risk of lower extremity ischemia that necessitates an infrainguinal bypass graft operation and amputation. Because the prevalence of diabetes mellitus is proportionally greater in this ethnic/racial group, the relative contribution of diabetes was compared with other potential risk factors., Methods: This study was designed as a retrospective case control study at the University and Veterans Hospitals. In a 5-year period, 764 consecutive patients who required infrainguinal revascularizations were compared with a statewide population that was described by the 1995 Behavior Risk Factor Surveillance System database. The main outcome measure was the requirement for infrainguinal revascularization., Results: Diabetes mellitus was more common among African American women who underwent bypass graft operation (70%; odds ratio [OR], 24.9; 95% confidence interval [CI], 20.3 to 30.4) than African American men (46%; OR, 11.6; 95% CI, 8.9 to 15.2), white women (49%; OR, 15.9; 95% CI, 13.0 to 19.5), or white men (42%; OR, 14.8; 95% CI, 12.5 to 17.4). Overall, bypass graft operation was associated more strongly with diabetes mellitus for all groups (OR, 15.7; 95% CI, 13.5 to 18. 3) than with smoking (OR, 4.5; 95% CI, 3.8 to 5.2) or hypertension (OR, 4.6; 95% CI, 4.0 to 5.3). Life-table analysis revealed limb salvage to be worse at 3 years among African American patients (64% vs 75%; P <.005) despite similar primary and cumulative secondary graft patency rates., Conclusion: Diabetes mellitus is the dominant risk factor that contributes to the need for bypass graft operation, especially among African American women. A greater prevalence of diabetes mellitus may account for the higher incidence of tissue necrosis and the increased requirement for distal bypass grafting and may contribute to the reduction in long-term limb salvage that was observed with these women.

Continuous quality improvement methods are increasingly being applied to health care systems, yet demonstration of outcome and cost benefits for surgical patients remains sparse. We used continuous quality improvement principles to specifically identify potential opportunities to reduce patient charges for carotid endarterectomy in our academic vascular surgery practice without compromising results. The targeted opportunities included: 1) limitation of laboratory examination, 2) selective cardiac stress testing, 3) discharge on 1st postoperative day, and 4) substitution of outpatient carotid duplex imaging for inpatient angiography. After 1 year, reductions in the average patient charge ($7700 versus $13,900, P < 0.001) and increases in payment/charge ratio (1.2 versus 0.8; P < 0.001) were observed. These changes were primarily due to a reduction in length of stay (2.2 versus 5.7 days; P < 0.001). No significant difference in patient morbidity occurred. Reductions in charges occurred within the targeted areas of laboratory (-77%), cardiac testing (-73%), hospital room (-60%), and radiology (-81%) utilization. Attention to the four factors identified by continuous quality improvement methods significantly reduced total patient charges without detrimental effects on patient outcome.

Operation for non-coronary atherosclerotic peripheral vascular occlusive disease may vary among race and gender groups. Using a state-wide registry, the authors identified all operations performed for infrarenal peripheral vascular disease over a 12-month period in a single south-eastern state. Procedures performed included reconstruction for aortoiliac (n=641) and infrainguinal (n=1129) disease and major amputation (n=1077). The incidence for patients over age 50 was calculated using census data. Operation for aortoiliac disease was significantly more likely for white patients (relative risk 3.79, 95% C.I. 2.84-5.15), but less likely for infrainguinal peripheral vascular disease (relative risk 0.64, 95% C.I. 0.56-0.73) and amputation (relative risk 0.17, 95% C.I. 0.15-0.19). Trends toward lower operative mortality in blacks with aortoiliac disease (10.6% versus 12.0%), PVD (3.2% versus 3.5%), and amputation (5.5 versus 8.7%) failed to attain statistical significance. Patient race was associated with the type and location of operation performed for peripheral vascular disease.