Surgery News - November 2008 - (Page 18)

OPINION POINT/COUNTERPOINT SURGERY NEWS • N O V E M B E R 2 0 0 8 Which approach is best for claudication? Greater use of intervention is warranted. 60-year-old man with bilateral claudication is referred to a surgeon. He is a smoker who has experienced a recent mild MI and seeks relief for ambulatory leg pain. His right leg has an ankle-brachial index of 0.5 and a distal superficial femoral artery stenosis. His left leg has a normal vascular exam but severe osteoarthritis of the knee. He is advised to have a total knee replacement for the left leg, and to stop smoking and adopt a walking regimen for the right leg. When the patient asks about current methods available to open his blocked leg artery, the surgeon says that guidelines dictate nonoperative therapy, thus squelching the reality that outpatient angioplasty could easily be performed using local anesthesia. This scenario represents the current state of treatment for both conditions, but is our approach to vasculogenic claudication antiquated? Neither condition frequently progresses to limb amputation, yet an open operation is recommended for one patient and the other patient is told to walk through the pain. Despite advances in perioperative management and endovascular technology, noninterventional therapy continues to be dogmatically declared the best initial approach for claudication. Although there is an abundance of literature supporting the medical triad of smoking cessation, supervised walking, and pharmacologic intervention for the treatment of claudication, there is equally abundant literature demonstrating that compliance with these therapies is rarely achieved. Smoking cessation is successful long term in as few as 6% of patients. As many as 34% of patients with claudication have another condition that precludes walking therapy, and an additional 30% refuse to walk regularly. The best Food and Drug Administration–approved drug for claudication has been shown to increase walking distance, but its side effects often offset its clinical benefit. Thus, Conservative treatment is more cost effective. nonoperative therapy for claudication is effective, at best, for only 25%-30% of patients. Contrast this to the findings of a recently published contemporary interventional series of 1,000 limbs treated for claudication ( J. Am. Coll. Surg. 2008; 206:1053-64). In this series, patients with critical limb ischemia were excluded, because this group is known to have poorer outcomes. Prior to publication of this report, the authors observed that conventional treatment recommendations for claudication had been based on results from interventional trials that blended claudication and critical limb ischemia. When intervention for claudication was examined independently, more than 60% of cases were treated by endovascular means. Intervention was safe (with less than 1% periprocedural mortality), effective (with symptom resolution in 78%), and durable (with a symptom recurrence rate of less than 20%). Major limb amputation occurred in 1.2%, and long-term interventional patency was more than 90% at 5 years. Admittedly, these findings are from a single series at one institution, but they suggest that a reappraisal of our approach to vasculogenic claudication is warranted. Couple these findings with a separate report from the same institution showing that one-third of patients with critical limb ischemia fail to receive functional benefit despite successful revascularization ( J. Vasc. Surg. 2006;44:747-56), and one might conclude that we are squandering an opportunity to achieve the greater good: to revascularize more patients with claudication and primarily amputate more patients with critical limb ischemia. That, however, is a discussion for another day (Am. Surg. 2008;74:27584). ■ DR. SPENCE M. TAYLOR is chair and clinical professor of surgery at the University of South Carolina, Greenville. M edicare data presented in 2007 at the International Symposium on Endovascular Therapy show an increase in the incidence of peripheral vascular disease, a trend that is likely to continue. Greater awareness of peripheral vascular disease (PVD) and early detection should lead to the use of the best medical therapy, but it may also result in revascularization followed by complications and possible loss of limb or life. The assessment of a patient with intermittent claudication (IC) is not always easy because symptoms can be affected by many comorbid conditions. Patients with IC alone infrequently require intervention, and most have been managed conservatively. IC is now commonly treated with endovascular intervention (EVI). Unfortunately, interventionalists with minimal or no clinical training in PVD management perform most EVIs, and as a result, more liberal indications for EVI are being advocated. When EVI is used to treat IC, operative mortality should be at or near zero, the percentage of amputations should be less than 5% in 5 years, the intervention should have an acceptably high initial success rate, and success should be durable. Does EVI fulfill these criteria? Mortality and morbidity are low, but the patency rate is questionable, particularly if the femoropopliteal segment is treated for long lesions. Excellent outcomes were achieved in a series of 1,000 limbs revascularized for claudication (both open and EVI), in which 70% of patients had aortoiliac occlusive disease and only 19% underwent infrainguinal intervention ( J. Am. Coll. Surg. 2008;206:1053-64). However, in our institution, treatment of infrainguinal disease represented nearly two-thirds of all EVIs performed for claudication. In fact, most patients with IC have multilevel or infrainguinal disease. The efficacy and cost-effectiveness of EVI over exercise has not been unequivocally established. According to a recent meta-analysis, functional capacity was significantly higher after EVI than with exercise alone, but quality-of-life scores did not differ significantly (Radiology 2005;235:833-42). Hospital costs for EVI range between $5,714 and $12,278 and vary depending on procedure type, setting (OR vs. radiology suite), and admission status (inpatient vs. ambulatory) ( J. Vasc. Surg. 2008;47:982-7). We found that over a 2year period following EVI for IC, overall expenditures were $13,886, and virtually 40% of limbs required reintervention. We estimated that the costs of supervised exercise and combined pharmacotherapy during that time would be less than onethird of total EVI expenditures. The failure rate for conservative treatment would have to exceed 86% to offset the cost benefit of a policy that requires a trial period of conservative management preceding EVI. However, supervised exercise is needed for optimal results ( JAMA 1995;274:975-80; J. Vasc. Surg. 2007;45 [Suppl.]:S1-S64), and because insurers do not reimburse structured vascular exercise programs, it’s hard for most physicians to recommend such treatment. The expected increase in prevalence of PVD and IC will add significant cost to our health care system. Can or should society bear the financial burden for EVI when there is no level I evidence of its superiority over conservative treatment? We strongly recommend that until the publication of results of the randomized National Institutes of Health–funded CLEVER (Claudication: Exercise Versus Endoluminal Revascularization) study, which compares EVI with supervised exercise, patients should undergo a trial of conservative management prior to intervention for infrainguinal disease ( J. Vasc. Surg. 2008;47:1356-63). ■ DR. MACIEJ DRYJSKI, MS. MONICA S. O’BRIEN-IRR, and DR. LINDA M. HARRIS are with the department of surgery at the State University of New York at Buffalo and Kaleida Health, Buffalo. stracted data from the medical record. The strength of a risk model can be estimated statistically using the C statistic, so the question of which database is “better” should be answered quantitatively. The ultimate measure of a risk adjustment method is how it identifies opportunities for improving care. Informed clinicians understand how approaches to comparative data differ, but are guided by the overarching challenge their main concern is to answer the question, Where are our problems and how can we improve? Debating about which database is better and why distracts us from finding the answer. Steve Meurer, M.B.A., M.H.S., Ph.D. Mark Keroack, M.D., M.P.H . University HealthSystem Consortium Allison Sabel, M.D., Ph.D., M.P.H., CMQ Denver Health LETTERS Risk Adjustment Revisited Differences in the National Surgical Quality Improvement Program’s (NSQIP) and the University HealthSystem Consortium’s (UHC) risk-adjusted predicted mortality for general and vascular surgery patients were described in “Quality Programs Differ on Risk Data” (May 2008, p. 1), but we would like to clarify UHC’s approach to risk adjustment. The article presented the two approaches as very similar, but UHC’s risk adjustment methodology is unique in several ways. It is modeled on patients from only our 102 academic medical center members. Comments from the clinicians and researchers in our member organizations increase the relevance and accuracy of the methodology. Finally, UHC’s models are available in their entirety to our membership, a feature generally not available with other risk adjustment models. NSQIP uses a sampling algorithm to obtain cases and generates models for a sam- LETTERS TO THE EDITOR SURGERY NEWS is your publication, and we’re eager to share your opinions. Please send correspondence, including your name and address, to surgerynews@facs.org or to: American College of Surgeons Communications Office 633 N. St. Clair St. Chicago, IL 60611-3211 Letters may be edited for space and clarity. ple of patients undergoing a select number of surgical procedures in both academic and community hospitals. UHC does not use sampling. Our member hospitals contribute, on average, 31,000 cases annually per institution to our risk

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Surgery News - November 2008

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