Variation in the choice of elective surgical procedure for abdominal aortic aneurysm in Spain

Abstract

M Jesús Quintana,1,2 Ignasi Gich,1–3 Julián Librero,4,5 Sergi Bellmunt-Montoya,6,7 José R Escudero,3,8,9 Xavier Bonfill1–3,10 On behalf of the AAA Spanish Study Group 1Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain; 2CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain; 3Universitat Autònoma de Barcelona, Barcelona, Spain; 4Navarrabiomed-UPNA -Departamento de Salud, IDISNA, Pamplona, Spain; 5Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Bilbao, Spain; 6Department of Angiology, Vascular and Endovascular Surgery, Vall d’Hebron University Hospital, Barcelona, Spain; 7Vall d’Hebron Research Institute (VHIR), Barcelona, Spain; 8Joint Service of Angiology, Vascular and Endovascular Surgery, Sant Pau-Dos de Maig Hospital, Barcelona, Spain; 9CIBER Cardiovascular Diseases (CIBERCV), Barcelona, Spain; 10Iberoamerican Cochrane Centre, Barcelona, Spain Objective: The two main surgical treatments for abdominal aortic aneurysm (AAA) are open surgical repair (OSR) and endovascular aneurysm repair (EVAR). The aim of this study was to analyze variation among Spanish hospitals in the use of OSR or EVAR for AAA. A secondary aim was to assess changes in preferences for these two procedures over time.Methods: This was a retrospective longitudinal study based on discharge data from public hospitals in Spain during 2002–2012. Patient inclusion criteria were: age >18 years, elective admission, primary diagnosis of unruptured AAA, and surgical treatment with OSR or EVAR. The characteristics of the treating center, patients, and in-hospital mortality were recorded.Results: We included 16,737 patients from 114 hospitals; 6,809 (40.7%) underwent EVAR and 9,928 (59.3%) underwent OSR. The total volume of surgeries increased throughout the period, and the probability that any given procedure was EVAR increased by 20% per year (OR 1.20, P<0.001). The volume and distribution of the two procedures varied highly across the participating hospitals. Overall, in-hospital mortality rate was 3.6% and it decreased during the study period (5.3% in 2002 and 3.2% in 2012), mainly due to a decrease in OSR-related mortality, despite a slight increase in EVAR-related mortality. Hospitals with higher surgical volumes were more likely to use EVAR and have lower in-hospital mortality rates.Conclusion: This study reveals high variability in the surgical treatment of unruptured AAA across Spanish hospitals. The number of interventions has increased in recent years, with EVAR accounting for a growing percentage of these surgical procedures. Overall in-hospital mortality rates decreased significantly during this period, mainly due to lower mortality among patients undergoing OSR. In-hospital mortality rates were lower in higher-volume centers, regardless of the surgical approach used. Further research on variability and appropriateness of surgical management of AAA is required to assess the suitability of concentrating elective AAA repair in more experienced centers to potentially achieve better outcomes. Keywords: abdominal aortic aneurysm, open surgical repair, endovascular aneurysm repair, variability

Keywords

• Abdominal aortic aneurysm
• open surgical repair
• endovascular aneurysm repair
• variability.