1. Trends in Hospitalization of patients with Peripheral Vascular Disorders in Public Hospitals, 2000-08 Class 18 Alice Brás, Ana Filipa Mendes, António Carujo, Bernardo Cruz, Mafalda Costa, Mariana Fernandes, Marisa Barros, Marta Dantas, Pedro Gonçalves, Sara Salvador, Sara Araújo, Susana Merim, Tomás Fontes e Vanessa Nunes Introdução à Medicina II 25 th May 2012

2. Clinical case of reduction of the size of blood vessels in both the lower and upper limb, which causes pain in the affected parts of body. Affects 12-14% of the population in general Clinical case of reduction of the size of blood vessels in both the lower and upper limb, which causes pain in the affected parts of body. Affects 12-14% of the population in general Peripheral Vascular Disease 2 Peripheral Vascular Disease FMUP

3. There are several risk factors associated with peripheral vascular disease (PVD), including: Smoking High blood pressure (hypertension) High cholesterol Diabetes Family history of heart or vascular disease Being overweight Lack of exercise or physical activity Age over 50 There are several risk factors associated with peripheral vascular disease (PVD), including: Smoking High blood pressure (hypertension) High cholesterol Diabetes Family history of heart or vascular disease Being overweight Lack of exercise or physical activity Age over 50 Risk Factors 3 Peripheral Vascular Disease FMUP

4. Which are the trends in Hospitalizations for Peripheral Vascular Disorders in portuguese public hospitals between 2000-2008? 4 Peripheral Vascular Disease FMUP

5. Aims By making an analytical study of PVD patients’ hospitalizations in Portuguese hospitals, we want to: 1.Study the evolution of the disease between 2000 and 2008, according to different variables: Number of admissions; Type of admission; Hospital mortality and type of admission; Clinical outcome; 2.Compare the influence in the number of hospitalizations between 2000 and 2008 of some factors: Gender; Age group; Month; Patient’s residency according to the geographic subregion where the patient lives. 3.Analyze the success of different types of programmed surgeries according to Hospital mortality. By making an analytical study of PVD patients’ hospitalizations in Portuguese hospitals, we want to: 1.Study the evolution of the disease between 2000 and 2008, according to different variables: Number of admissions; Type of admission; Hospital mortality and type of admission; Clinical outcome; 2.Compare the influence in the number of hospitalizations between 2000 and 2008 of some factors: Gender; Age group; Month; Patient’s residency according to the geographic subregion where the patient lives. 3.Analyze the success of different types of programmed surgeries according to Hospital mortality. 5 Peripheral Vascular Disease FMUP

6. Methods Target population: Patients hospitalized with Peripheral Vascular Disorders (PVD) in Portuguese mainland public hospitals between 2000 and 2008 – 116236 hospitalizations. Source: The administrative database managed by ACSS (Administração Central do Sistema de Saúde – Portuguese Central Authority for Health Services) which contains an index of all hospitalizations in Portuguese public acute care hospitals. This is a retrospective observational cohort clinical study. Target population: Patients hospitalized with Peripheral Vascular Disorders (PVD) in Portuguese mainland public hospitals between 2000 and 2008 – 116236 hospitalizations. Source: The administrative database managed by ACSS (Administração Central do Sistema de Saúde – Portuguese Central Authority for Health Services) which contains an index of all hospitalizations in Portuguese public acute care hospitals. This is a retrospective observational cohort clinical study. 6 Peripheral Vascular Disease FMUP

7. Index of Diseases and Injuries 250.7 Diabetes with peripheral circulatory disorders 440.2 Atherosclerosis; Of native arteries of the extremities 440.3 Atherosclerosis; Of bypass graft of the extremities 440.4 Chronic total occlusion of artery of the extremities 443 Other peripheral vascular disease 444.2 Arterial embolism and thrombosis; Of arteries of the extremities 444.81 Arterial embolism and thrombosis; Of Iliac artery Index of Diseases and Injuries 250.7 Diabetes with peripheral circulatory disorders 440.2 Atherosclerosis; Of native arteries of the extremities 440.3 Atherosclerosis; Of bypass graft of the extremities 440.4 Chronic total occlusion of artery of the extremities 443 Other peripheral vascular disease 444.2 Arterial embolism and thrombosis; Of arteries of the extremities 444.81 Arterial embolism and thrombosis; Of Iliac artery ICD-9-CM “International Statistical Classification of Diseases and Related Health Problems” ICD-9-CM “International Statistical Classification of Diseases and Related Health Problems” 7 Peripheral Vascular Disease FMUP

8. ICD-9-CM “International Statistical Classification of Diseases and Related Health Problems” ICD-9-CM “International Statistical Classification of Diseases and Related Health Problems” Index of Procedures 00.55 – Insertion of drug-eluting peripheral vessel stent(s) 38.13 – Endarterectomy, upper limb vessels 38.18 – Endarterectomy, lower limb vessels 39.25 – Aorta-iliac-femoral bypass 39.26 – Other intra-abdominal vascular shunt or bypass 39.29 – Other (peripheral) vascular shunt or bypass 39.90 – Insertion of non-drug-eluting peripheral vessel stent(s) Index of Procedures 00.55 – Insertion of drug-eluting peripheral vessel stent(s) 38.13 – Endarterectomy, upper limb vessels 38.18 – Endarterectomy, lower limb vessels 39.25 – Aorta-iliac-femoral bypass 39.26 – Other intra-abdominal vascular shunt or bypass 39.29 – Other (peripheral) vascular shunt or bypass 39.90 – Insertion of non-drug-eluting peripheral vessel stent(s) 8 Peripheral Vascular Disease FMUP

9. Gender Figure 1 - Percentage of admission of patients diagnosed with PVD, as principal or secondary diagnosis, per gender, in Portuguese public hospitals, from 2000 to 2008. The number of hospitalizations of men was higher than that of women. 9 Peripheral Vascular Disease FMUP

10. Age Group Figure 2 -Percentage of people within each age groups hospitalized with Peripheral Vascular Disease, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008. There were more PVD hospitalizations of older people, which lets us guess that there are more cases of this disease in this age group. 10 Peripheral Vascular Disease FMUP

11. Months Figure 3 - Number of admissions of patients diagnosed with PVD, as principal or secondary diagnosis, per month of admission, in Portuguese public hospitals, from 2000 to 2008. There were less hospitalizations in hotter months (May, June and September) when comparing to colder months (January, February and March). 11 Peripheral Vascular Disease FMUP

12. Regions/Patients Residency Figure 4 – Admission’s rate per a thousand people of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008 according to patient residence: Algarve, Alentejo, Lisboa, Centro and Norte (NUT II) Lisbon and Alentejo had the highest number of hospitalizations according to their population. Algarve, was the region with the lowest. 12 Peripheral Vascular Disease FMUP

13. Regions/Patients Residency Figure 5 – Hospital mortality rate per 1000 hospitalizations of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008 according to patient residence: Algarve, Alentejo, Lisboa, Centro and Norte (NUT II). Lisbon, Alentejo and Algarve had the highest number of hospital deaths according to the number of hospitalizations. 13 Peripheral Vascular Disease FMUP

14. Hospital Mortality Rate Figure 6 – Percentage of hospital fatalities of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008. Between 2000 and 2008 the hospital mortality rate showed no clear trend. 14 Peripheral Vascular Disease FMUP %

15. Vascular surgeries and hospital mortality rate Figure 7 - Hospital mortality associated with treatment procedures on patients who had a programmed admission, diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008. The procedure associated with higher hospital mortality in patients who had a programmed admission was endarterectomy, followed by bypass surgery. The procedure associated with a lower mortality was angioplasty. 15 Peripheral Vascular Disease FMUP

16. Type of admission Table 1 - Type of admission of patients diagnosed with PVD, as principal or secondary diagnosis, per year of discharge, in Portuguese public hospitals, from 2000 to 2008. (p<0.001) Type of admission ScheduledNot scheduled Recovery programs of waiting lists Year of discharge 200025,0%75,0%0,0% 200125,2%74,8%0,0% 200226,9%73,1%0,0% 200326,1%73,8%0,2% 200427,2%72,6%0,1% 200525,9%73,6%0,5% 200627,5%71,1%1,4% 200726,5%72,9%0,6% 200826,2%72,4%1,4% Total26,3%73,2%0,5% The rate of programmed admissions has increased in the analyzed period. 16 Peripheral Vascular Disease FMUP

17. Type of admission of hospitalizations ending in fatality Figure 8 - Type of admission of hospitalizations ending in fatality of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008. For hospitalizations ending in fatality, 91.8% had a non-programmed admission. 17 Peripheral Vascular Disease FMUP

18. Type of admission of hospitalizations ending in fatality Figure 9 - Evolution of fatalities according to type of admission of patients diagnosed with PVD as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008 Over time, this association (between death and non scheduled admissions) seems to become clearer. 18 Peripheral Vascular Disease FMUP Number of admissions ending in fatality

19. Type of admission of hospitalizations not ending in fatality Figure 10 - Type of admission of hospitalizations ending in survival of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008. For hospitalizations in which the patients survived, 70.7% had a non- programmed admission. 19 Peripheral Vascular Disease FMUP

20. Hospital mortality per type of admission Table 2 – Hospital mortality and type of admission of patients diagnosed with PVD as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008. (p<0.001) Hospital mortality AliveDead Type of admission Scheduled 96,5%3,5% Not scheduled 85,3%14,7% Recovery programs of waiting lists 93,5%6,5% Total 88,3%11,7% There was a higher percentage of survival with scheduled admissions (96.5%) than with not-scheduled (85.3%). There was 11.7% of hospital mortality. 20 Peripheral Vascular Disease FMUP

21. Conclusions 1.There is an association between non-programmed admission and the outcome death. So, we may say that patient follow-up is a critical component of health care quality; 2.Some statistical background was given to the idea that hot temperatures are a relief factor for PVD, although this conclusion needs deeper research; 3.Endarterectomy is associated with higher mortality than bypass surgery, and that both these procedures are associated with higher mortality than angioplasty, although we cannot point out a cause for these associations. 1.There is an association between non-programmed admission and the outcome death. So, we may say that patient follow-up is a critical component of health care quality; 2.Some statistical background was given to the idea that hot temperatures are a relief factor for PVD, although this conclusion needs deeper research; 3.Endarterectomy is associated with higher mortality than bypass surgery, and that both these procedures are associated with higher mortality than angioplasty, although we cannot point out a cause for these associations. 21 Peripheral Vascular Disease FMUP

22. Limitations The admnistrative records are not all done with the same criteria in the different hospital centres; Not all hospital centres record secondary diagnosis of their patients ; We are dealing with admissions and not with PVD patients; We are not able to detect readmissions of the same PVD patient in the period of analysis. So, the hospital mortality rate we calculated may not reflect the PVD overall mortality; Analysis is limited by the seasonal irregularities. The admnistrative records are not all done with the same criteria in the different hospital centres; Not all hospital centres record secondary diagnosis of their patients ; We are dealing with admissions and not with PVD patients; We are not able to detect readmissions of the same PVD patient in the period of analysis. So, the hospital mortality rate we calculated may not reflect the PVD overall mortality; Analysis is limited by the seasonal irregularities. 22 Peripheral Vascular Disease FMUP

23. Bergan, J.J., et al., Unexpected, late cardiovascular effects of surgery for peripheral artery disease. Veterans Affairs Cooperative Study 199. Arch Surg, 1992. 127(9): p. 1119-23; discussion 1123-4. Bosiers, M., et al., Endovascular therapy as the primary approach for limb salvage in patients with critical limb ischemia: experience with 443 infrapopliteal procedures. Vascular, 2006. 14(2): p. 63- 9. Houston, J.G., et al., Long-term results after placement of aortic bifurcation self-expanding stents: 10 year mortality, stent restenosis, and distal disease progression. Cardiovasc Intervent Radiol, 2007. 30(1): p. 42-7. Inoue, Y., et al., Cuffed anastomosis for above-knee femoropopliteal bypass with a stretch expanded polytetrafluoroethylene graft. Surg Today, 2008. 38(8): p. 679-84. Pulli, R., et al., Midterm results from a multicenter registry on the treatment of infrainguinal critical limb ischemia using a heparin-bonded ePTFE graft. J Vasc Surg, 2010. 51(5): p. 1167-1177 e1. Landry, G.J., et al., Long-term outcome of revised lower-extremity bypass grafts. J Vasc Surg, 2002. 35(1): p. 56-62; discussion 62-3. Chung, J., et al., Wound healing and functional outcomes after infrainguinal bypass with reversed saphenous vein for critical limb ischemia. J Vasc Surg, 2006. 43(6): p. 1183-90. Feinglass, J., et al., Perioperative outcomes and amputation-free survival after lower extremity bypass surgery in California hospitals, 1996-1999, with follow-up through 2004. J Vasc Surg, 2009. 50(4): p. 776-783 e1. Matsi, P.J. and H.I. Manninen, Complications of lower-limb percutaneous transluminal angioplasty: a prospective analysis of 410 procedures on 295 consecutive patients. Cardiovasc Intervent Radiol, 1998. 21(5): p. 361-6. Bergan, J.J., et al., Unexpected, late cardiovascular effects of surgery for peripheral artery disease. Veterans Affairs Cooperative Study 199. Arch Surg, 1992. 127(9): p. 1119-23; discussion 1123-4. Bosiers, M., et al., Endovascular therapy as the primary approach for limb salvage in patients with critical limb ischemia: experience with 443 infrapopliteal procedures. Vascular, 2006. 14(2): p. 63- 9. Houston, J.G., et al., Long-term results after placement of aortic bifurcation self-expanding stents: 10 year mortality, stent restenosis, and distal disease progression. Cardiovasc Intervent Radiol, 2007. 30(1): p. 42-7. Inoue, Y., et al., Cuffed anastomosis for above-knee femoropopliteal bypass with a stretch expanded polytetrafluoroethylene graft. Surg Today, 2008. 38(8): p. 679-84. Pulli, R., et al., Midterm results from a multicenter registry on the treatment of infrainguinal critical limb ischemia using a heparin-bonded ePTFE graft. J Vasc Surg, 2010. 51(5): p. 1167-1177 e1. Landry, G.J., et al., Long-term outcome of revised lower-extremity bypass grafts. J Vasc Surg, 2002. 35(1): p. 56-62; discussion 62-3. Chung, J., et al., Wound healing and functional outcomes after infrainguinal bypass with reversed saphenous vein for critical limb ischemia. J Vasc Surg, 2006. 43(6): p. 1183-90. Feinglass, J., et al., Perioperative outcomes and amputation-free survival after lower extremity bypass surgery in California hospitals, 1996-1999, with follow-up through 2004. J Vasc Surg, 2009. 50(4): p. 776-783 e1. Matsi, P.J. and H.I. Manninen, Complications of lower-limb percutaneous transluminal angioplasty: a prospective analysis of 410 procedures on 295 consecutive patients. Cardiovasc Intervent Radiol, 1998. 21(5): p. 361-6. References 23 Peripheral Vascular Disease FMUP

24. 24 Acknowledgments Prof. Doutor Altamiro da Costa Pereira Prof. Doutor Alberto Freitas Prof. Doutor Sérgio Sampaio Dr. Fernando Lopes Prof. Doutor Altamiro da Costa Pereira Prof. Doutor Alberto Freitas Prof. Doutor Sérgio Sampaio Dr. Fernando Lopes