Vascular Quality Initiative Assessment of Compliance with Society for Vascular Surgery Clinical Practice Guidelines on the Management of Extracranial Cerebrovascular Disease

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Journal of Vascular Surgery


OBJECTIVES: Compliance with SVS clinical practice guidelines (CPGs) is associated with improved outcomes for treatment of abdominal aortic aneurysm, but this has not been assessed for carotid artery disease. The VQI registry was used to examine compliance with the SVS CPGs for management of extracranial cerebrovascular disease and its impact on outcomes. METHODS: The 2021 SVS extracranial cerebrovascular disease CPGs were reviewed for evaluation by VQI data. Compliance rates by center and provider were calculated, and the impact of compliance on outcomes was assessed using logistic regression with inverse probability-weighted risk adjustment for each CPG recommendation, allowing for clustering by center. Our primary outcome was a composite endpoint of in-hospital stroke/death. As a secondary analysis, compliance with the 2021 SVS carotid Implementation Document recommendations and associated outcomes were also assessed. RESULTS: Of the 11 carotid CPG recommendations, 4 (36%) could be evaluated using VQI registry data. Median center-specific CPG compliance ranged from 38-95%, and mean provider-specific compliance ranged from 36-100%. After adjustment, compliance with 2 of the recommendations was associated with lower rates of in-hospital stroke/death: first, use of best medical therapy (antiplatelet and statin therapy) in low/standard surgical risk patients undergoing CEA for >70% asymptomatic stenosis (event rate in compliant vs non-compliant cases 0.59% vs 1.3%; adjusted odds ratio[aOR] 0.44, 95% confidence interval 0.29-0.66); and second, CEA over tfCAS in low/standard surgical risk patients with >50% symptomatic stenosis (1.9% vs 3.4%; aOR 0.55, 0.43-0.71). Of the 132 Implementation Document recommendations, only 10 (7.6%) could be assessed using VQI data, with median center- and provider-specific compliance rates ranging from 67-100%. The impact of compliance on outcomes could only be assessed for 6 (4.5%) of these recommendations, and compliance with 6 of the recommendations was associated with lower stroke/death. CONCLUSION: Few SVS recommendations could be assessed in the VQI due to incongruity between the recommendations and the VQI data variables collected. While guideline compliance was extremely variable among VQI centers and providers, compliance with most of these recommendations was associated with improved outcomes after carotid revascularization. This finding confirms the value of guideline compliance, which should be encouraged for centers and providers. Optimization of VQI data to promote evaluation of guideline compliance and distribution of these findings to VQI centers and providers will help facilitate quality improvement efforts in the care of vascular patients.