Monday, April 30, 2007

What Works -- Part 7 -- Vascular Surgery Successes


This is one of the posts in which I simply brag about the excellent clinical work I see at this hospital.

We see many, many patients here with diabetes. Notwithstanding improved care of diabetic patients, one of the unfortunate problems they face is vascular disease, particularly in the lower extremities. So patients sometimes show up with the prospect of needing a foot or limb amputation.

It turns out that our vascular surgeons are extremely competent at fixing malfunctioning blood vessels, either by grafting new ones or inserting stents to reopen the original ones. There have been many cases where patients have learned that they could retain their foot after this surgery. I have had a chance to watch these procedures, and you really have to marvel at the ability of surgeons to repair extremely tiny blood vessels in the lower leg.

Here is a summary of activity in our Vascular Surgery division. Over 4000 revascularizations have been performed since 1990. The overall mortality rate is 1.1 %, which is substantially less than reported across the country at high volume centers (4.9%) .

The effectiveness of graft surgery is measured by patency, "the state or quality of being open, expanded, or unblocked." The first chart above shows the record for our hospital for bypass grafts to the foot. (On the chart, primary -- meaning no further intervention necessary -- is shown below; secondary -- meaning some revisit for clotting or another problem, is the line above above). Randomized trials elsewhere show one year patency of about 60%. We show similar results five years after surgery.

Another measure of success is the ability to save limbs over an extended period of time. The second chart above shows the results on this score for our surgeons. Many other institutions show 50 to 80% limb salvage after one year. Our place shows 78% after five years.

3 comments:

Alana said...

Paul,
On a personal level, this information was very useful to me! My father has diabetes, though it is completely under control right now, I worry that someday he might have a problem. It's good to know that there is a hospital in Boston with such a great sucess rate in saving limbs. As my father lives in Boston, I will probably be referring him to your institution based on this post!
I also wanted to say how helpful I've been finding your blog. The Wednesday student questions have especially been useful to me as they are questions I've been too shy to ask myself!! I just started working in the healthcare industry about a year ago and have found it difficult to pick up much of the language and inner workings of the industry. Your blog has been an enjoyable way to keep up to date with the constant changes. Thank you very much!

Emily DeVoto, Ph.D., said...

Nice, but how about prevention? Can BIDMC do anything about the perverse incentives that discourage preventive care for diabetes, which is highly effective, in favor of the high-ticket items (i.e., greater reimbursement) downstream like vascular surgery and amputation? Is the Joslin diabetes clinic still part of the Harvard system?

Paul Levy said...

Yes, Emily, in fact we have a joint venture with the Joslin diabetes center for exactly that reason. Management of the disease is highly preferable to tertiary level care. However, there remain lots of people who need the latter.

Thanks, Alana. We are ready to help as you need it. And thanks for the kind words about the blog.