Prioritizing Quality Improvement in Vascular Surgery

Background: Despite growing interest in quality improvement, there remains uncertainty about which procedures offer the most room for improvement in vascular surgery. To inform ongoing quality improvement initiatives, this study assessed the relative contribution of different procedures to overall morbidity, mortality, and excess length of stay in vascular surgery. Study design: Using data from ACS-NSQIP, all patients undergoing a vascular surgery operation in 2005 and 2006 (N = 16 096) were identified. Patients were placed in 29 distinct procedure categories based on CPT codes. First, we examined the procedures according to their relative contribution to overall morbidity and mortality. Then the procedures were assessed according to their contribution to overall excess length of stay. Results: Four procedure types alone accounted for 72% of adverse events, 68% of excess hospital days, and 77% of the cases in the cohort. Lower extremity bypass graft accounted for the greatest share of adverse events (29%), followed by abdominal aortic reconstruction (20%), lower extremity amputation (16%), and carotid endarterectomy (8%). The remaining 25 procedure categories accounted for only 28% of adverse events and 23% of the cases in the cohort. Conclusions: A small number of procedure types account for a disproportionately large share of morbidity, mortality, and excess hospital stay in vascular surgery, primarily because top ranked procedure types are also the most commonly performed operations in the field. These procedure types represent obvious targets for ACS-NSQIP and other efforts aimed at measuring and improving the quality of vascular surgery.