Proposed public policies to improve outcomes in vascular surgery: an experts’ forum

Wolosker, Nelson; Louzada, Andressa Cristina Sposato; Portela, Felipe Soares Oliveira; Silva, Marcelo Fiorelli Alexandrino da; Schettino, Guilherme de Paula Pinto; Corrêa, Lucas Hernandes; Juniordata, Edson Amaro; Teivelis, Marcelo Passos

doi:10.31744/einstein_journal/2023AE0241

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SPECIAL ARTICLE • einstein (São Paulo) 21 • 2023 • https://doi.org/10.31744/einstein_journal/2023AE0241 copy

Proposed public policies to improve outcomes in vascular surgery: an experts’ forum

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

To evaluate outcomes of vascular surgeries and identify strategies to improve public vascular care.

Methods

This was a descriptive, qualitative, and cross-sectional survey involving 30 specialists of the Hospital Israelita Albert Einstein via Zoom. The outcomes of vascular procedures performed in the Public Health System extracted through Big Data analysis were discussed, and 53 potential strategies to improve public vascular care to improve public vascular care.

Results

There was a consensus on mandatory reporting of some key complications after complex arterial surgeries, such as stroke after carotid revascularization and amputations after lower limb revascularization. Participants agreed on the recommendation of screening for diabetic feet and infrarenal abdominal aortic aneurysms. The use of Telemedicine as a tool for patient follow-up, auditing of centers for major arterial surgeries, and the concentration of complex arterial surgeries in reference centers were also points of consensus, as well as the need to reduce the values of endovascular materials. Regarding venous surgery, it was suggested that there should be incentives for simultaneous treatment of both limbs in cases of varicose veins of the lower limbs, in addition to the promotion of ultrasound-guided foam sclerotherapy in the public system.

Conclusion

After discussing the data from the Brazilian Public System, proposals were defined for standardizing measures in population health care in the area of vascular surgery.

Big Data; Vascular surgical procedures; Carotid artery diseases; Peripheral arterial disease; Endovascular procedures; Vascular diseases; Amputation, surgical; Public Policy; Health Policy

Highlights

Notification of complications of arterial surgeries is essential in identifying strategies to improve surgical outcomes.

Screening of prevalent and/or morbid diseases allows early intervention and prevention of complications.

Use of telemedicine in vascular follow-up allows optimizing the use of resources and reducing the burden on health services.

Concentrating complex cases in reference hospitals leads to improved surgical outcomes.

	Consensual Proposals	Agreement* (%)
Carotid SP	1. Should the costs associated with carotid angioplasty material (stent and filter) be reduced to make it more financially viable?	90
	2. Should centers be audited regarding indications and outcomes (mortality and stroke) of carotid stenosis treatment to have better results?	100
	3. Should stroke during hospitalization and after carotid revascularization be of compulsory notification and thus included in DATASUS?	86
Carotid BR	4. Should the costs associated with carotid angioplasty material (stent and filter) be reduced to make it more financially viable?	93
	5. Should centers be audited regarding indications and outcomes of carotid stenosis treatment (mortality and stroke) to have better results?	100
	6. Should stroke during hospitalization and after carotid revascularization be of compulsory notification and thus included in DATASUS?	89
PAD SP	7. Should angioplasty remain the most commonly used technique in São Paulo, since it has the same cost and lower mortality?	81
	8. Should centers be audited on the outcomes of PAD treatment (mortality, limb salvage, and re-intervention) so that the results improve?	96
	9. Should telemedicine consulting services provided by vascular surgeons to physicians in cities with low numbers of specialists be planned?	93
	10. Should amputation be a mandatory reporting outcome after lower limb revacularization in DATASUS?	81
PAD BR	11. Should centers be audited on the outcomes of PAD treatment (mortality, limb salvage, and re-intervention) so that the results improve?	96
PAD BR	12. Should amputation be a mandatory reporting outcome after lower limb revascularization in DATASUS?	81
AMPUT SP	13. Should there be a statewide program to encourage lower limb revascularization to reduce major amputation rates?	85
	14. Should there be a statewide diabetic foot screening and education program for patients and health care professionals?	100
	15. Should there be a statewide multidisciplinary care program for diabetic feet with ulcers?	100
	16. Should there be a statewide foot care education program for patients with PAD and diabetes mellitus during the fall to avoid the spikes in amputations seen in winter?	85
TEVAR SP	17. Should there be a follow-up control program for patients with acute aortic syndrome who were clinically treated in the emergency room?	88
	18. Should centers be audited on the outcomes of thoracic aortic treatment (mortality and re-intervention) so that the results improve?	100
	19. Should referral centers for TEVAR be created in other states, so patients are treated closer to their residence?	92
TEVAR BR	20. Should there be a follow-up control program for patients with acute aortic syndrome who were clinically treated in the emergency department?	92
TEVAR BR	21. Should centers be audited on the outcomes of thoracic aortic treatment (mortality and re-intervention) so that the results improve?	100
IRAAA SP	22. Should there be any effort to reduce the cost of endovascular materials?	96
	23. Should centers be audited for IRAAA treatment outcomes (mortality and re-intervention) to improve results?	100
	24. Should there be a telemedicine follow-up program for IRAAA?	84
	25. Should there be a screening program for abdominal aneurysmal disease to decrease the number of emergency surgeries in São Paulo?	88
IRAAA BR	26. Should there be a national screening program for abdominal aneurysmal disease to decrease the number of emergency surgeries in Brazil?	88
	27. Should centers be audited on the outcomes of AAAIR repair (mortality and re-interventions) so that the results are increasingly better?	96
	28. Should there be any effort to reduce the cost of endovascular materials?	96
TAA SP	29. Should there be a program to control the follow-up of thoraco-abdominal aneurysmal disease to reduce the number of emergency surgeries in São Paulo?	100
	30. Should there be more centers outside the city of São Paulo to treat this type of disease?	85
	31. Should there be a concentration of surgical cases (especially elective) in specialized centers to improve outcomes for elective surgery?	100
	32. Should there be a telemedicine follow-up program for thoracoabdominal aneurysmal disease?	85
	33. Should centers be audited on the outcomes of TAA treatment (mortality) so that the results are increasingly better?	100
TAA BR	34. Should there be a program of follow-up control of thoracoabdominal aneurysmal disease to reduce the number of emergency surgeries in Brazil?	100
	35. Should there be a telemedicine follow-up program for thoracoabdominal aneurysmal disease?	92
	36. Should centers be audited on the outcomes of TAA repair (mortality) so that the results are increasingly better?	100
	37. Should public hospitals offer endovascular treatment for thoracoabdominal aneurysms paid for by SUS?	84
CVD SP	38. Should the Unified Health System also invest in other techniques, such as echoguided sclerotherapy?	88
CVD SP	39. Should there be a greater incentive to operate on varicose veins of both limbs in the same anesthetic-surgical procedure?	85
CVD BR	40. Should the Brazilian Public Health System also invest in other techniques, such as the use of echoguided sclerotherapy?	96

	Non-consensual proposals	Agreement* (%)
CAROTID SP	1. Should carotid endarterectomy be the most commonly used technique in São Paulo, since it is cheaper, has similar results and the same mortality with other procedures?	72
CAROTID BR	2. Should carotid endarterectomy be Brazil’s most commonly used technique since it is cheaper, despite the higher mortality?	63
PAD BR	3. Should angioplasty remain the most commonly used technique for lower limb revascularization in Brazil since the mortality is lower, despite the higher costs?	77
TEVAR SP	4. Should there be a city and state screening program for thoracic aortic diseases to reduce the number of emergency surgeries?	58
TEVAR BR	5. Should there be a national screening program for thoracic aortic diseases to reduce the number of emergency surgeries?	65
IRAAA SP	6. If the price of endovascular materials were reduced to 30% of what they cost today, should endovascular technique be the technique of choice in São Paulo for all IRAAA with favorable anatomies?	68
IRAAA BR	7. If the price of endovascular materials were reduced to 30% of what they cost today, should the endovascular technique be the technique of choice in Brazil for all IRAAAs with favorable anatomies?	71
IRAAA BR	8. Should there be a telemedicine follow-up program for IRAAA?	79
TAA SP	9. Should there be a municipal and state screening program for thoracoabdominal aneurysmal disease to reduce the number of emergency TAA repairs in São Paulo?	73
TAA BR	10. Should there be a national screening program for thoracoabdominal aneurysmal disease to reduce the number of emergency TAA repairs in Brazil?	68
CVD SP	11. Should the Brazilian Public Health System also invest in endovenous thermoablation for the treatment of varicose veins?	58
CVD BR	12. Should the Brazilian Public Health System also invest in other techniques, such as thermoablative techniques for the treatment of varicose veins?	54
CVD BR	13. Should there be a program to encourage the surgical treatment of varicose veins on a national level?	79

Instituto Israelita de Ensino e Pesquisa Albert Einstein Avenida Albert Einstein, 627/701 , 05651-901 São Paulo - SP, Tel.: (55 11) 2151 0904 - São Paulo - SP - Brazil
E-mail: revista@einstein.br

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[1] Corresponding author: Felipe Soares Oliveira PortelaAvenida Albert Einstein, 627, building A1,room 423 - MorumbiZip code: 05652-900 - São Paulo, SP, BrazilPhone: (55 11) 2151-5423E-mail: fsoaresportela@gmail.com