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A Novel Scoring System to Assess Pre-Operative Documentation Quality of Lifestyle Limitation in Claudicants with Surgical Intervention
Richard Shi, Nicholas Bulatao, Rupak Mukherjee, Adam Tanious
Medical University of South Carolina, Charleston, SC

Background: There remains no consistent, objective measure used clinically to define lifestyle limitation in the diagnosis of claudication. It remains unclear how vascular interventionalists determine pre-operative lifestyle limitation. This study evaluates a novel scoring system to assess the quality of documentation of lifestyle limitation and OMT/SET in claudicants undergoing surgical intervention and its impact on perioperative outcomes.
Methods: 7 key metrics taken from validated patient reported outcome measures (Vascular Quality of Life Questionnaire, Walking Impairment Questionnaire) were utilized to assess of documentation quality: walking distance, walking ability, symptom location, symptom character, activities of daily living (ADL), OMT, and SET. After applying appropriate weights, a 9-point system was created, where <4 was deemed inappropriate documentation and >4 was appropriate. With this scoring system, pre- and post-operative progress notes for claudicants with intervention by vascular surgeons (VS) or non-vascular interventionalists (NV; interventional radiology/cardiology) from 2013 - 2023 were analyzed. Our primary outcome was symptom improvement between appropriate and inappropriate documentation groups. This was determined from changes in walking distances/ability and ADLs in pre- and post-operative documentation. Statistical analysis included χ2 tests, t test, and logistic regression modeling. Variables were included in a multivariable model if the univariate effect on symptom improvement was associated at p < .05 or was clinically significant.
Results: 105 claudicants were identified: 48 (53.3%) with appropriate pre-operative documentation while 57 (46.7%) had inappropriate documentation. Amongst disciplines, VS had a 67.6% appropriate documentation rate, compared to 29.4% for NVs (p = .006) (Fig. 1a). For post-operative documentation, 42.9% were appropriate and 57.1% were inappropriate with higher rates amongst VS compared to NV (50.7% vs 26.5%, p = .023) (Fig. 1b). When assessing compliance rates per key metric, documentation rates of walking distance, activities on daily living and supervised exercise therapy were higher amongst VS. Patients with appropriate documentation had greater SET participation (28.1% vs 8.3%, p = .01). Post-operatively, there were greater improvements in ABI (.24 vs .13, p = .032) and claudication symptoms (94.5% vs 81.3%, p = .036) at one-year for patients with appropriate documentation. There was no difference in amputation and reintervention rates between the two groups. On multivariable logistic regression, appropriate documentation was significantly associated with symptom improvement (OR = 5.05 (1.15, 22.13), p = .032) (Table 1).
Conclusions: While VS have the highest rates of appropriate documentation, significant improvements across all specialties are necessary. Appropriate pre-operative documentation of lifestyle limitation is imperative as it leads to clearer surgical indications and is associated with a greater likelihood of resolving claudication symptoms.


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