Society for Vascular Surgery appropriate use criteria for management of intermittent claudication

Woo, Karen; Siracuse, Jeffrey J.; Klingbeil, Kyle D.; Kraiss, Larry W.; Osborne, Nicholas H.; Singh, Niten; Tan, Tze-Woei; Arya, Shipra; Banerjee, Subhash; Bonaca, Marc P.; Brothers, Thomas E.; Conte, Michael S.; Dawson, David L.; Erben, Young; Lerner, Benjamin M.; Lin, Judith C.; Mills, Joseph L.; Mittleider, Derek; Nair, Deepak G.; O’Banion, Leigh Ann; Patterson, Robert B.; Scheidt, Matthew J.; Simons, Jessica P.

doi:10.1016/j.jvs.2022.04.012

Cited by 57 publications

(22 citation statements)

References 39 publications

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“…To test the association between physician implicit bias and procedure performance, we assessed the outcome of below the knee procedures for claudication because these have been identified as carrying high risk with questionable benefit. 21,22 We defined below-knee as arteries inclusive of the below-knee popliteal and arteries more distal (tibial, pedal, etc). Because these procedures often lead to major adverse vascular events, we used this as our primary outcome.…”

Section: Primary Outcome: Risk>benefit Proceduresmentioning

confidence: 99%

Implicit Bias And Unintentional Harm In Vascular Care: The Case For Intervention

Kalbaugh,

Beidelman,

Howard

et al. 2024

Preprint

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Introduction. Implicit (or unconscious) bias may influence physician treatment decisions and contribute to Black-White health disparities. While implicit bias has been linked with low quality care via clinical vignettes, some worry that these studies are not representative of the 'real world.' There is limited data that has attempted to link implicit bias with actual care delivery and outcomes. We sought to understand if implicit bias is associated with potentially harmful surgical treatment selection in a cohort of patients with peripheral artery disease (PAD)-related claudication undergoing below-knee lower extremity revascularization as captured in a 'real world' procedural registry. Methods. We invited vascular specialists from the Vascular Quality Initiative (VQI) to take the race Implicit Association Test (IAT). The IAT asks participants to associate images of Black and White Americans with either positive or negative attributes. Based on reaction time differences across sequential tests, participants were grouped into race-based implicit bias categories: pro-White bias, no bias, or pro-Black bias. Our provider-level implicit bias results were linked to patient-level registry data of peripheral revascularization procedures performed for claudication. We measured the adjusted odds of performance of below knee procedures by specialist implicit bias and patient race via mixed effects logistic regression models. We assessed implicit bias as a moderator of the association of below-knee procedures and patient race with 1-yr amputation. Results. 218 vascular specialists in the United States completed the IAT and 157 (72%) had a pro-White bias. Black patients treated by a physician with pro-White bias had a 74% increase in the odds of receiving a below-knee procedure compared to the total sample (aOR: 1.74, 95% CI: 1.33-2.15). When treated by a specialist with pro-White bias, Black patients had 3 times the odds of 1-yr amputation – regardless of anatomic location treated – compared to White patients (aOR: 3.04, 95% CI: 1.68-5.51). Conversely, Black patients treated by a specialist with no bias had similar odds of a below-knee procedure (aOR: 0.99, 95% CI: 0.67-1.30) and 1-year amputation (aOR: 1.31, 95% CI: 0.35-4.96) as the full patient sample. Conclusions. Implicit bias is associated with potentially harmful below-knee procedures for Black patients and contributes to Black-White outcome disparities in the United States. These results suggest the need for system-level interventions that transparently identify and warn of procedures not aligned with best practices to reduce the negative effect of implicit bias.

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Section: Primary Outcome: Risk>benefit Proceduresmentioning

confidence: 99%

Implicit Bias And Unintentional Harm In Vascular Care: The Case For Intervention

Kalbaugh,

Beidelman,

Howard

et al. 2024

Preprint

View full text Add to dashboard Cite

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“…Furthermore, technical failure, restenosis, and multiple reinterventions may lead to adverse outcomes after invasive treatment. Reflecting this ongoing debate regarding the optimal management of IC, the Society for Vascular Surgery Appropriateness Committee is engaged in better defining the nuances of treatment approaches 15,16 …”

mentioning

confidence: 99%

“…Reflecting this ongoing debate regarding the optimal management of IC, the Society for Vascular Surgery Appropriateness Committee is engaged in better defining the nuances of treatment approaches. 15,16 Taken together, the current meta-analysis aimed to address whether risks of progression to CLTI and amputation are increased by invasive treatment for IC using data from performed randomized control trials (RCTs). Differences in outcomes after invasive versus noninvasive strategies regarding total number of subsequent revascularizations performed and all-cause mortality are also analyzed.…”

mentioning

confidence: 99%

Long-Term Outcomes of Exercise Therapy Versus Revascularization in Patients With Intermittent Claudication

et al. 2023

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Objective: The aim was to analyze the risk of progression to chronic limb-threatening ischemia (CLTI), amputation and subsequent interventions after revascularization versus noninvasive therapy in patients with intermittent claudication (IC). Background: Conflicting evidence exists regarding adverse limb outcomes after each treatment strategy. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. MEDLINE, Web of Science, and Google Scholar were searched aided by a health sciences librarian through August 16, 2022. Randomized control trials (RCTs) comparing invasive (endovascular or surgical revascularization) and noninvasive treatment (exercise and/or medical treatment) were included. PROSPERO registration was completed (CRD42022352831). Results: A total of 9 RCTs comprising 1477 patients (invasive, 765 patients; noninvasive, 712 patients) were eligible. During a mean of 3.6-year follow-up, progression to CLTI after invasive [5 (2–8) per 1000 person-years] and noninvasive treatment [6 (3–10) per 1000 person-years] were not statistically different [rate ratio (RR): 0.77; 95% CI, 0.35–1.69; P=0.51, I 2=0%]. Incidence of amputation (RR: 1.69; 95% CI, 0.54–5.26; P=0.36, I 2=0%) and all-cause mortality (hazard ratio: 1.26; 95% CI, 0.91–1.74; P=0.16, I 2=0%) also did not differ between the groups. However, the invasive treatment group underwent significantly more revascularizations (RR: 4.15; 95% CI, 2.80–6.16; P<0.00001, I 2=83%). The results were not changed by fixed effect or random-effects models, nor by sensitivity analysis. Conclusions: Although there is equivalent risk of progression to CLTI, major amputation and all-cause mortality compared with noninvasive treatment, invasive treatment for patients with IC led to significantly more revascularization procedures and should be used selectively in patients with major lifestyle limitation. Guideline recommendation of noninvasive treatment for first-line IC therapy is supported.

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“… 5 , 12 The initial management of IC is supervised exercise therapy, smoking cessation, and medical optimization rather than procedural intervention. 13 , 14 This is in contrast to CLTI, where treatment is much more aggressive and, in addition to smoking cessation and optimal medical therapy, intervention is performed expeditiously to prevent limb loss. 5 , 12 As described in figure 4 in Brown et al, these OBL peripheral vascular intervention procedures are being done not only for limb salvage for CLTI, but also for IC.…”

mentioning

confidence: 99%

“…The Society for Vascular Surgery appropriate use criteria for managing IC were published in the Journal of Vascular Surgery earlier in 2022. 13 The criteria were created by a multidisciplinary rating panel consisting of 15 volunteers from 3 professional societies (the American College of Cardiology, the Society of Interventional Radiology, and the Society for Vascular Surgery) using the RAND appropriateness method, the only validated method for developing appropriate use criteria and a standardized method that combines the best available evidence from medical literature with expert opinion, using a modified Delphi process, and were published in the Journal of Vascular Surgery earlier in 2022. Key principles described in the article included exercise therapy as a mainstay of treatment; invasive therapy might provide a net benefit for selected patients who are nonsmokers, are taking optimal medical therapy, are considered low physiologic and technical risk, and are experiencing severe lifestyle‐limiting or short‐distance claudication.…”

mentioning

confidence: 99%

Atherectomy Overuse: Do Policy Solutions Exist?

George

Arya

2022

JAHA

Self Cite

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Society for Vascular Surgery appropriate use criteria for management of intermittent claudication

Cited by 57 publications

References 39 publications

Implicit Bias And Unintentional Harm In Vascular Care: The Case For Intervention

Implicit Bias And Unintentional Harm In Vascular Care: The Case For Intervention

Long-Term Outcomes of Exercise Therapy Versus Revascularization in Patients With Intermittent Claudication

Atherectomy Overuse: Do Policy Solutions Exist?

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