Identifying Potentially Avoidable Femoral to Popliteal ePTFE Bypass for Claudication Using Cross Site Blinded Peer Review.

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Journal of vascular surgery


OBJECTIVE: The surgical treatment of claudication can be associated with significant morbidity and cost. There are growing concerns that some patients proceed to interventions without first attempting evidence-based nonoperative management. We employed direct, cross-site, blinded expert review to evaluate the appropriateness of the surgical treatment of claudication.

METHODS: We enlisted practicing vascular surgeons to perform retrospective clinical assessments of lower extremity bypass procedures in a statewide clinical registry. Cases were limited to elective, open, infrainguinal bypasses performed for claudication using prosthetic grafts. Reviewing surgeons were randomly assigned 10 cases from a sample of 139 anonymized bypass operations and instructed to evaluate procedural appropriateness based on their expert opinion and evidence-based guidelines for preoperative treatment, namely, antiplatelet, statin, cilostazol, exercise, and smoking cessation therapy as documented in the medical record. Ninety-day episode payments were estimated from a distinct but similar cohort of patients undergoing lower extremity bypass for claudication.

RESULTS: Out of 325 total reviews, surgeons stated they would not have recommended bypass in 134 (41%) reviews and deemed bypass inappropriate in 122 (38%) reviews. The most common reason for inappropriateness was lack of preoperative medical and lifestyle therapy, which was present in 63% of reviews where bypass was deemed appropriate and 39% of reviews where bypass was deemed inappropriate (P

CONCLUSIONS: In this cross-site expert peer review study, 40% of lower extremity bypasses were deemed premature and therefore potentially avoidable, primarily due to lack of medical and lifestyle management before surgery. Reviews deemed inappropriate were associated with approximately $4 million in potentially avoidable costs. This approach could inform performance feedback among surgeons to help align clinical practice with evidence-based recommendations for the treatment of claudication.


Online ahead of print.





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