title: Perioperative Optimization of Geriatric Lower Extremity Bypass in the Era of Increased Performance Accountability.
abstract: BACKGROUND
  The initiation of bundled payment for care improvement by Centers for Medicare and Medicaid Services (CMS) has led to increased financial and performance accountability. As most vascular surgery patients are elderly and reimbursed via CMS, improving their outcomes will be critical for durable financial stability. As a first step in forming a multidisciplinary pathway for the elderly vascular patients, we sought to identify modifiable perioperative variables in geriatric patients undergoing lower extremity bypass (LEB).
  
  
  METHODS
  The 2011-2013 LEB-targeted American College of Surgeons National Surgical Quality Improvement Program database was used for this analysis (n = 5316). Patients were stratified by age <65 (n = 2171), 65-74 (n = 1858), 75-84 (n = 1190), and ≥85 (n = 394) years. Comparisons of patient- and procedure-related characteristics and 30-day postoperative outcomes stratified by age groups were performed with Pearson χ2tests for categorical variables and Wilcoxon rank-sum tests for continuous variables.
  
  
  RESULTS
  During the study period, 5316 total patients were identified. There were 2171 patients aged <65 years, 1858 patients in the 65-74 years age group, 1190 patients in the 75-84 years age group, and 394 patients in the ≥85 years age group. Increasing age was associated with an increased frequency of cardiopulmonary disease (P < 0.001) and a decreased frequency of diabetes, tobacco use, and prior surgical intervention (P < 0.001). Only 79% and 68% of all patients were on antiplatelet and statin therapies, respectively. Critical limb ischemia occurred more frequently in older patients (P < 0.001). Length of hospital stay, transfusion requirements, and discharge to a skilled nursing facility increased with age (P < 0.001). Thirty-day amputation rates did not differ significantly with age (P = 0.12).
  
  
  CONCLUSIONS
  Geriatric patients undergoing LEB have unique and potentially modifiable perioperative factors that may improve postoperative outcomes. These modifiers will be the basis of a multidisciplinary care path targeting the geriatric vascular surgery patients.
authors.affiliation: Medical Scientist Training Program, Duke University School of Medicine, Durham, NC.
authors.forename: Shaunak S
authors.initials: SS
authors.lastname: Adkar
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address: ryan.turley@dm.duke.edu.
authors.forename: Ryan S
authors.initials: RS
authors.lastname: Turley
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Ehsan
authors.initials: E
authors.lastname: Benrashid
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Sandhya
authors.initials: S
authors.lastname: Lagoo
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Cynthia K
authors.initials: CK
authors.lastname: Shortell
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Leila
authors.initials: L
authors.lastname: Mureebe
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D001803:Blood Transfusion; D016009:Chi-Square Distribution; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007902:Length of Stay; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D016491:Peripheral Vascular Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology; D017064:Process Assessment, Health Care / Q000592:standards; D058996:Quality Improvement / Q000592:standards; D019984:Quality Indicators, Health Care / Q000592:standards; D012086:Reoperation; D012307:Risk Factors; D012866:Skilled Nursing Facilities; D012941:Social Responsibility; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000592:standards