Impact of outcomes research on the management of vascular surgery patients.

Vascular surgery has traditionally relied on prospective, randomized clinical trials, case-control series from single institutions of excellence, and case studies to guide clinical decision-making. However, the use of a number of new clinical research tools has allowed the vascular surgeon to more critically assess the indications for particular operations, the costs of various procedures from both a monetary and quality-of-life standpoint, and the "real world" outcomes that can be expected from practitioners across the United States, not just from centers of excellence. Decision analysis with modeling of cohorts with desired characteristics and vascular disease has allowed for the objective determination of procedural cost-effectiveness and evaluation of patient quality-of-life issues surrounding vascular procedures. The use of large national administrative databases has yielded important information concerning factors associated with improved outcomes after several vascular procedures across the entire United States, especially after relatively uncommon operations, such as thoracoabdominal aortic aneurysm repair. Administrative data have also enabled us to learn that access to various new endovascular procedures is somewhat limited, especially for the uninsured or poor. Hospital and surgeon volume, as a surrogate marker for quality, has been directly correlated with lower morbidity and mortality as well as differences in perioperative complications after multiple vascular procedures. A certificate of added qualification in General Vascular Surgery has also been shown to improve outcomes in patients undergoing vascular procedures. Finally, pioneered by the Veteran's Affairs administration and championed by the American College of Surgeons, prospectively collected data (National Surgery Quality Improvement Program) from the Veteran's Affairs and private sector hospitals is providing high-quality, risk-adjusted feedback about multiple vascular procedures to the hospital and the individual practitioner. Importantly, the body of literature generated using these new clinical research tools is being monitored by insurers and patients, as well as by the surgeons providing the care. This ultimately will have a direct impact on practice and referral patterns. It is therefore mandatory that vascular surgeons understand these new tools so that we can police our own practices before others, such as insurance companies and hospital administrators, do it for us.