Hospital Volume Association With Abdominal Aortic Aneurysm Repair Mortality
2019; Lippincott Williams & Wilkins; Volume: 140; Issue: 15 Linguagem: Inglês
10.1161/circulationaha.119.042504
ISSN1524-4539
AutoresSalvatore T. Scali, Adam W. Beck, Art Sedrakyan, Jialin Mao, Maarit Venermo, Rumi Faizer, Marc L. Schermerhorn, Barry Beiles, Zoltán Szeberin, Nikolaj Eldrup, Ian Thomson, Kevin Cassar, Martin Altreuther, Christian‐Alexander Behrendt, Sebastian Debus, Jonathan R. Boyle, Amundeep S. Johal, Martin Björck, Jack L. Cronenwett, Kevin Mani,
Tópico(s)Abdominal vascular conditions and treatments
ResumoHomeCirculationVol. 140, No. 15Hospital Volume Association With Abdominal Aortic Aneurysm Repair Mortality Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBHospital Volume Association With Abdominal Aortic Aneurysm Repair MortalityAnalysis of the International Consortium of Vascular Registries Salvatore T. Scali, MD, Adam W. Beck, MD, Art Sedrakyan, MD, PhD, Jialin Mao, MD, MS, Maarit Venermo, MD, PhD, Rumi Faizer, MD, Marc Schermerhorn, MD, Barry Beiles, MB BCh, FRACS, Zoltán Szeberin, MD, PhD, Nikolaj Eldrup, MD, PhD, Ian Thomson, MBChB, FRACS, Kevin Cassar, MD, FRCS(Ed), Martin Altreuther, MD, Christian-Alexander Behrendt, MD, Sebastian Debus, MD, PhD, Jonathan R. Boyle, MBChB, MD, FRCS, Amundeep Johal, PhD, Martin Bjorck, MD, PhD, Jack Cronenwett, MD and Kevin Mani, MD, PhD Salvatore T. ScaliSalvatore T. Scali Salvatore T. Scali, MD, FACS, RPVI, Division of Vascular Surgery and Endovascular Therapy, PO Box 100128, Suite NG-45, Health Science Center, 1600 SW Archer Rd, Gainesville, FL 32610. Email E-mail Address: [email protected] Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville (S.T.S.). , Adam W. BeckAdam W. Beck Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham (A.B.). , Art SedrakyanArt Sedrakyan Healthcare Policy and Research, Weill Cornell Medical College, New York, NY (A.S., J.M.). , Jialin MaoJialin Mao Healthcare Policy and Research, Weill Cornell Medical College, New York, NY (A.S., J.M.). , Maarit VenermoMaarit Venermo Department of Vascular Surgery, Helsinki University Hospital, Finland (M.V.). , Rumi FaizerRumi Faizer Division of Vascular Surgery, University of Minnesota, Minneapolis (R.F.). , Marc SchermerhornMarc Schermerhorn Division of Vascular Surgery and Endovascular Therapy, Beth Israel Deaconess Medical Center, Boston, MA (M.S.). , Barry BeilesBarry Beiles Australasian Vascular Audit, Australasian Society for Vascular Surgery, Melbourne, Australia (B.B.). , Zoltán SzeberinZoltán Szeberin Department of Vascular Surgery, Semmelweis University, Budapest, Hungary (Z.S.). , Nikolaj EldrupNikolaj Eldrup Department of Cardio-Thoracic and vascular Surgery, Aarhus University Hospital Skejby, Denmark (N.E.). , Ian ThomsonIan Thomson Department of Surgery, University of Otago, Dunedin, New Zealand (I.T.). , Kevin CassarKevin Cassar Department of Surgery, Faculty of Medicine and Surgery, University of Malta (K.C.). , Martin AltreutherMartin Altreuther Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway (M.A.). , Christian-Alexander BehrendtChristian-Alexander Behrendt Department of Vascular Medicine, Working Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (C.-A.B., S.D.). , Sebastian DebusSebastian Debus Department of Vascular Medicine, Working Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (C.-A.B., S.D.). , Jonathan R. BoyleJonathan R. Boyle Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, United Kingdom (J.R.B.). , Amundeep JohalAmundeep Johal Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom (A.J.). , Martin BjorckMartin Bjorck Department of Surgical Sciences, Uppsala University, Sweden (M.B., K.M.). , Jack CronenwettJack Cronenwett Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (J.C.). and Kevin ManiKevin Mani Department of Surgical Sciences, Uppsala University, Sweden (M.B., K.M.). Originally published7 Oct 2019https://doi.org/10.1161/CIRCULATIONAHA.119.042504Circulation. 2019;140:1285–1287Abdominal aortic aneurysm (AAA) management has undergone significant changes because of broad dissemination of endovascular repair (EVAR),1 with significant variation in AAA care between countries.2 An inverse relationship between hospital volume and postoperative open surgical repair (OSR) mortality for intact AAA (iAAA) has been reported based on administrative data3; however, center volume association may vary between countries because of differences in patient selection, geography, and healthcare systems. The hypothesis of this analysis was that a volume-outcome relationship would be present in a large contemporary, multinational dataset that included both iAAA and ruptured AAA (rAAA) repair.Data on primary AAA procedures from 2010 to 2016 were prospectively collected in vascular surgical registries from 11 countries (Australia, Denmark, Germany, Hungary, Finland, Malta, New Zealand, Norway, Sweden, the United Kingdom, and the United States) and submitted to the Medical Device Epidemiology Network for analysis. Details regarding registries, including coverage and validity, have been published previously.1,2 This study was approved by Weill Cornell Medicine Institutional Review Board (No. 1511016772). No informed consent was needed because all patient data were obtained from existing registry effort.Hospital annual volumes for EVAR and OSR were calculated separately, averaged across years, and volume quartiles were created among 4 groups (intact/ruptured EVAR, intact/ruptured OSR). Generalized linear mixed models were adjusted for age, sex, comorbidities (diabetes mellitus, cardiac history, and renal dysfunction [creatinine ≥1.7 mg/dL]), procedure year, aneurysm size, and registry and hospital random effects.A total of 178 860 patients were analyzed. EVAR was used in 68.0% of iAAA and 27.9% of rAAA repairs. Overall mean age was 73.2 years; 15.3% of patients were women. Comorbidity frequency included cardiac disease (41.6%), diabetes mellitus (16.2%), and renal dysfunction (5.0%). Crude in-hospital mortality was 1.0% for iAAA with EVAR, 4.7% for iAAA with OSR, 23.1% for rAAA with EVAR, and 37.1% for rAAA with OSR.Median case volumes varied between countries (range for EVAR from a low of 7 cases in Germany to 76 in Denmark; range for OSR: Germany 4, Denmark 86). Proportions treated with EVAR increased significantly from 2010 to 2013 (iAAA, 64.7%; rAAA, 23.7%) to 2014 to 2016 (iAAA, 72.4%; rAAA, 34.0%; P<0.001). Concurrently, mean OSR number per center decreased (from 36.4 to 29.8 cases/year; P<0.0001), whereas the mean EVAR volume increased from 43.2 to 45.4 cases/year (P<0.0001).In both crude and risk-adjusted analysis, no volume effect on in-hospital or 30-day mortality was identified after EVAR for either iAAA or rAAA; however, there was a significant volume-outcome relationship after OSR for both (Figure). A significant reduction in mortality was identified when we compared the highest to lowest volume quartiles for OSR of iAAA (quartile 4, 3.6% versus quartile 1, 6.0%; odds ratio, 0.62 [95% CI, 0.40–0.98]; P=0.04), as well as for OSR of rAAA (quartile 4, 30.2% versus quartile 1, 44.2%; odds ratio, 0.41 [95% CI, 0.29–0.58]; P 90% national or regional coverage of AAA repairs, which reduces the risk for systematic selection bias. Additionally, data regarding perioperative or 30-day mortality, which was the primary outcome of the current analysis, are highly valid.In conclusion, this international analysis underscores the importance of case volume and its effect on mortality after OSR for iAAA and rAAA. The decrease in OSR volumes resulting from increasing EVAR utilization will continue to reduce the number of centers with sufficient volumes to support contemporary training and credentialing thresholds. These findings have important consequences on hospital accreditation and care regionalization to improve overall AAA repair mortality outcomes internationally.AcknowledgmentsAll listed authors have provided data and assisted in the analysis, as well as the interpretation of results from the study. All authors have had the opportunity to review the submitted manuscript and agree to be responsible for its content.Sources of FundingThe project and efforts were funded in part by the US Food and Drug Administration through grant 1U01FD005478 (principal investigator: Dr Sedrakyan). Views expressed in the publication do not necessarily reflect the official policies of the Department of Health and Human Services, nor does any mention of trade names, commercial practices, or organization imply endorsement by the US government.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circEthics approval for the collection and analysis of vascular registry data was obtained on the basis of national regulations for each registry for this international collaborative project.Salvatore T. Scali, MD, FACS, RPVI, Division of Vascular Surgery and Endovascular Therapy, PO Box 100128, Suite NG-45, Health Science Center, 1600 SW Archer Rd, Gainesville, FL 32610. 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