title: Targeting the most important complications in vascular surgery.
abstract: OBJECTIVE
  This study was conducted to identify the most clinically relevant and costly perioperative complications occurring in vascular surgery patients.
  
  
  METHODS
  The analysis included patients in the 2012 to 2014 National Surgical Quality Improvement Program database undergoing one of four high-risk vascular procedures. The procedures-aortic reconstruction, lower extremity bypass, lower extremity amputation, and carotid endarterectomy (CEA)-were selected because they have been established as high risk in the literature, rendering them natural targets for quality improvement initiatives. Population-attributable fractions (PAFs) were used to estimate the impact of seven prespecified complications on 30-day outcomes in the study population. The PAF predicts the reduction in outcome anticipated if a particular complication were to be prevented across the study population. Unadjusted and adjusted PAFs were reported. CEA was analyzed separately from the other procedures.
  
  
  RESULTS
  The analysis included 72,805 National Surgical Quality Improvement Program patients. Pneumonia had the largest impact on the incidence of end-organ dysfunction in CEA patients (adjusted PAF, 24.4%; 95% confidence interval, 20.6-28.1), and cerebrovascular accident had the largest impact on mortality in these patients (adjusted PAF, 23.1%; 95% confidence interval, 18.5-27.3). In patients undergoing abdominal or lower extremity vascular surgery, bleeding and pneumonia had the largest impact on clinical outcomes and need for prolonged hospitalization, and surgical site infection had the largest impact on hospital readmission. In contrast, prevention of venous thromboembolism, urinary tract infection, and myocardial infarction do not demonstrate substantial impact on patient outcomes or resource utilization in either group of vascular surgery patients.
  
  
  CONCLUSIONS
  Quality initiatives that can successfully reduce the occurrence of postoperative stroke, bleeding, and pneumonia will have the greatest clinical impact on the outcomes of vascular surgery patients. Initiatives that target complications such as venous thromboembolism, urinary tract infection, or myocardial infarction will have little impact on this patient population.
authors.affiliation: Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc. Electronic address: bennett@surgery.wisc.edu.
authors.forename: Kyla M
authors.initials: KM
authors.lastname: Bennett
authors.affiliation: Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
authors.forename: K Craig
authors.initials: KC
authors.lastname: Kent
authors.affiliation: Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
authors.forename: Jessica
authors.initials: J
authors.lastname: Schumacher
authors.affiliation: Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
authors.forename: Caprice C
authors.initials: CC
authors.lastname: Greenberg
authors.affiliation: Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
authors.forename: John E
authors.initials: JE
authors.lastname: Scarborough
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000009:adverse effects; D001011:Aorta / Q000601:surgery; D017046:Cost Savings; D016208:Databases, Factual; D016894:Endarterectomy, Carotid / Q000009:adverse effects; D005260:Female; D017048:Health Care Costs; D006801:Humans; D015994:Incidence; D035002:Lower Extremity / Q000098:blood supply; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000601:surgery; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D058017:Vascular Grafting / Q000009:adverse effects; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000191:economics / Q000401:mortality / Q000639:trends