Hospital-Level Factors Associated With Mortality After Endovascular and Open Abdominal Aortic Aneurysm Repair.

IMPORTANCE Endovascular technology has become ubiquitous in the modern care of abdominal aortic aneurysm (AAA), yet broad estimates of its efficacy among variable hospital and regional settings is not known. OBJECTIVE To perform a preliminary analysis of hospital effects on mortality following open AAA repair (OAR) and endovascular AAA repair (EVAR). DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was conducted on all patients undergoing OAR or EVAR from July 1, 2010, to November 30, 2012, using Current Procedural Terminology codes. MAIN OUTCOMES AND MEASURES Weight-adjusted 30-day observed to expected mortality ratios were compared based on hospital type (academic vs community) and size (100-299 beds vs 300-500 beds vs >500 beds). RESULTS Data on 11,250 patients (2466 underwent OAR and 8784 underwent EVAR) were analyzed. Endovascular AAA repair was performed more frequently than OAR at both academic (78.8%) and community (68.2%) hospitals. Overall 30-day mortality was 14.0% for OAR and 4.3% for EVAR (P < .001). Hospital size was significantly associated with mortality for OAR (observed to expected mortality ratio: >500 beds, 0.88 vs 300-500 beds, 1.11 vs 100-299 beds, 1.59; P = .01) but not for EVAR (P = .27). In contrast, hospital type was significantly associated with mortality for EVAR (observed to expected mortality ratio: academic, 0.60 vs community, 2.60; P < .001) but not OAR (P = .46). Multivariable analysis of hospital-level factors suggested that, for all outcomes, academic hospital type was the single most significant predictor of reduced mortality following AAA repair (observed to expected mortality ratio: academic, 0.91 vs community, 2.00; P = .05). CONCLUSIONS AND RELEVANCE Based on this preliminary report, outcomes for both OAR and EVAR appear to depend greatly on hospital-level effects. The relative safety of EVAR vs OAR may depend on appropriate patient selection and adequate access to multidisciplinary care in order to minimize failure to rescue rates and improve survival.

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