Emily L. Spangler

Variation in thromboembolic complications among patients undergoing commonly performed cancer operations

OBJECTIVE There is widespread evidence that cancer confers an increased risk of deep venous thrombosis (DVT). This risk is thought to vary among different cancer types. The purpose of this study is to better define the incidence of thrombotic complications among patients undergoing surgical treatment for a spectrum of prevalent cancer diagnoses in contemporary practice. METHODS All patients undergoing one of 11 cancer surgical operations (breast resection, hysterectomy, prostatectomy, colectomy, gastrectomy, lung resection, hepatectomy, pancreatectomy, cystectomy, esophagectomy, and nephrectomy) were identified by Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes using the American College of Surgeons National Surgical Quality Improvement Program database (2007-2009). The study endpoints were DVT, pulmonary embolism (PE), and overall postoperative venous thromboembolic events (VTE) within 1 month of the index procedure. Multivariate logistic regression was utilized to calculate adjusted odds ratios for each endpoint. RESULTS Over the study interval, 43,808 of the selected cancer operations were performed. The incidence of DVT, PE, and total VTE within 1 month following surgery varied widely across a spectrum of cancer diagnoses, ranging from 0.19%, 0.12%, and 0.28% for breast resection to 6.1%, 2.4%, and 7.3%, respectively, for esophagectomy. Compared with breast cancer, the incidence of VTE ranged from a 1.31-fold increase in VTE associated with gastrectomy (95% confidence interval, 0.73-2.37; P = .4) to a 2.68-fold increase associated with hysterectomy (95% confidence interval, 1.43-5.01; P = .002). Multivariate logistic regression revealed that inpatient status, steroid use, advanced age (≥60 years), morbid obesity (body mass index ≥35), blood transfusion, reintubation, cardiac arrest, postoperative infectious complications, and prolonged hospitalization were independently associated with increased risk of VTE. CONCLUSIONS The incidence of VTE and thromboembolic complications associated with cancer surgery varies substantially. These findings suggest that both tumor type and resection magnitude may impact VTE risk. Accordingly, such data support diagnosis and procedural-specific guidelines for perioperative VTE prophylaxis and can be used to anticipate the risk of potentially preventable morbidity.

Cost-Effectiveness of Guidelines for Insertion of Inferior Vena Cava Filters in High-Risk Trauma Patients

BACKGROUND Inferior vena cava filters (IVCFs) can prevent pulmonary embolism (PE); however, indications for use vary. The Eastern Association for the Surgery of Trauma (EAST) 2002 guidelines suggest prophylactic IVCF use in high-risk patients, but the American College of Chest Physicians (ACCP) 2008 guidelines do not. This analysis compares cost-effectiveness of prophylactic vs therapeutic retrievable IVCF placement in high-risk trauma patients. METHODS Markov modeling was used to determine incremental cost-effectiveness of these guidelines in dollars per quality-adjusted life-years (QALYs) during hospitalization and long-term follow-up. Our population was 46-year-old trauma patients at high risk for venous thromboembolism (VTE) by EAST criteria to whom either the EAST (prophylactic IVCF) or ACCP (no prophylactic IVCF) guidelines were applied. The analysis assumed the societal perspective over a lifetime. For base case and sensitivity analyses, probabilities and utilities were obtained from published literature and costs calculated from Centers for Medicare & Medicaid Services fee schedules, the Healthcare Cost & Utilization Project database, and Red Book wholesale drug prices for 2007. For data unavailable from the literature, similarities to other populations were used to make assumptions. RESULTS In base case analysis, prophylactic IVCFs were more costly (

Amputation Rates for Patients with Diabetes and Peripheral Arterial Disease: The Effects of Race and Region

37,700 vs

Preventive Measures for Patients at Risk for Amputation From Diabetes and Peripheral Arterial Disease

37,300) and less effective (by 0.139 QALYs) than therapeutic IVCFs. In sensitivity analysis, the EAST strategy of prophylactic filter placement would become the preferred strategy in individuals never having a filter, with either an annual probability of VTE of ≥ 9.6% (base case, 5.9%), or a very high annual probability of anticoagulation complications of ≥ 24.3% (base case, 2.5%). The EAST strategy would also be favored if the annual probability of venous insufficiency was <7.69% (base case, 13.9%) after filter removal or <1.90% with a retained filter (base case, 14.1%). In initial hospitalization only, EAST guidelines were more costly by

Impact of Glucose Control and Regimen on Limb Salvage in Patients Undergoing Vascular Intervention

2988 and slightly more effective by .0008 QALY, resulting in an incremental cost-effectiveness ratio of

Outcomes of carotid endarterectomy versus stenting in comparable medical risk patients

383,638/QALY. CONCLUSIONS Analysis suggests prophylactic IVC filters are not cost-effective in high-risk trauma patients. The magnitude of this result is primarily dependent on probabilities of long-term sequelae (venous thromboembolism, bleeding complications). Even in the initial hospitalization, however, prophylactic IVCF costs for the additional quality-adjusted life years gained did not justify use.

Impact and Duration of Brief Surgeon-Delivered Smoking Cessation Advice on Attitudes Regarding Nicotine Dependence and Tobacco Harms for Patients with Peripheral Arterial Disease

BACKGROUND It remains unknown whether care of high-risk vascular patients with both diabetes and peripheral arterial disease (PAD) is improving. We examined national trends in care of patients with both PAD and diabetes. METHODS A cohort of patients diagnosed with PAD and diabetes between 2007 and 2011 undergoing open or endovascular diagnostic or revascularization procedures was analyzed using Medicare claims data. Main outcome measure was amputation-free survival measured from time of initial revascularization procedure to 24 months, stratified by race and hospital referral region (HRR). RESULTS From 2007 to 2011, 2.3 per 1,000 patients underwent a major amputation with the higher rate among black patients (5.5 per 1,000 vs. 1.9 per 1,000; P < 0.001) compared with nonblack. The rate varied widely by HRR (1.2 per 1,000-6.2 per 1,000), with higher variation in amputation rates in black patients (2.1-16.1 per 1,000). Overall, amputation-free survival was approximately 74.6% at 2 years, 68.4% among black patients, and 75.4% among nonblack patients, with the disparity between the 2 groups increasing over time. CONCLUSIONS Prevalence of concurrent PAD and diabetes is increasing, but amputation rates and amputation-free survival vary significantly by both race and HRR. Prevention and care coordination effort should aim to limit racial disparities in the treatment and outcomes of these high-risk patients.

Smoking cessation counseling in vascular surgical practice using the results of interviews and focus groups in the Vascular Surgeon offer and report smoking cessation pilot trial

When patients with diabetes and peripheral arterial disease (PAD) receive treatment for vascular disease, amputation rates tend to be lower, suggesting that greater utilization of vascular care is associated with lower amputation risk (1). However, procedural care is not provided in isolation. Patients should be engaged in a care system where preventive measures, such as hemoglobin A1c testing, podiatric care, and noninvasive vascular testing are routinely provided (2,3). However, it remains unknown how commonly patients at risk for amputation actually receive preventive measures. Therefore, we studied how commonly patients at risk for amputation actually receive evidence-based preventive measures aimed at limiting amputation. We identified a cohort of 52,505 patients with diabetes and PAD in Medicare claims (2008–2009), who had been admitted to the hospital for an episode of lower …

Design and initial enrollment in the Vascular Physicians Offer and Report (VAPOR) trial

to 39 of 60 (65%) in the usual group (P < .001). The mean hospital length of stay in patients with BTAI at the unusual locations was 8.5 days compared with 20.3 days in the usual location group (P < .004). Mortality occurred in 5 of 14 (36%) in the unusual location group compared with 5 of 60 (8%) in the usual location group. No deaths were related to the BTAI itself in the unusual location group. Conclusions: BTAIs at unusual locations are associated with several characteristics. They are more frequently associated with thoracic spine injuries, are more common in women, tend to be lower grade, are less likely to require intervention, and appear to have a higher mortality due to other traumatic injuries.