Benchmarking Surgeon Performance in Lower Extremity Revascularization Using a Composite Outcome Metric

Peripheral artery disease (PAD) programs rely on consistent surgical outcomes for high-level limb-salvage performance. Despite the known influence of procedural volume, reliable surgeon-level benchmarking methods remain limited. The Limb Evaluation and Amputation Prevention Program (LEAPP) is a multidisciplinary limb salvage initiative at a large tertiary center. This study aimed to analyze surgeon performance and volume-outcome patterns using a composite quality assessment framework.

In this single-center study, 147 PAD patients (Rutherford 0-6) undergoing lower extremity revascularization were followed for 1 year. The primary outcome was adverse event-free survival (freedom from bleeding, thrombotic/stenotic events, or amputation). Surgeon-level performance was assessed using a composite z-score integrating standardized adverse event rates, observed-to-expected ratios, and hazard ratios.

Among the cohort, 70.5% had chronic limb-threatening ischemia, the mean age was 70.2 ± 9.7 years and 68.7% were male. A total of 31 patients (21.1%) experienced an adverse event: major bleeding 1.4%, thrombotic/stenotic events 10.2%, and amputation 8.2%. Kaplan-Meier analysis showed no significant differences across surgeons for composite or event-specific outcomes (log-rank P > 0.05 for all). Median intraoperative blood loss varied numerically (range 15-1,500 mL; P = 0.31), with lower values among higher-volume surgeons. Composite z-scores ranged from -1.47 to +1.57; surgeons with positive scores were higher-volume operators.

Surgeon-level outcomes in our limb-salvage program were consistent, with no significant variation in survival or complication rates across surgeons. Higher-volume surgeons demonstrated numerically lower blood loss and consistently positive composite performance scores, suggesting a directional volume-outcome relationship supporting published literature regarding volume. The composite scoring framework offers a feasible, multidimensional approach for surgeon-level benchmarking and may help maintain consistent outcomes and support quality improvement.