One: All Major Arterial Interventions Should Now be Performed in High Volume Centres – Abdominal Aortic Aneurysms

Aortic Aneurysm


Part One: All Major Arterial Interventions Should Now be Performed in High Volume Centres – Abdominal Aortic Aneurysms


Thompson M, Holt P, Loftus I (St George’s Hosp NHS Trust, London, UK) Eur J Vasc Endovasc Surg 42:411–418, 2011§



B.W. Starnes, MD



Evidence Ranking


• D



Expert Rating


• 1



Abstract



Background


Vascular professionals are still debating whether complex surgical interventions such as abdominal aortic aneurysm (AAA) treatment should be performed predominantly at centers with a greater caseload and experience or can be done safely at local, low-volume provider hospitals. Evidence supporting the premise that fewer patients die immediately after elective aneurysm repair if the procedure is done in a unit with a high case volume and record of safety was reviewed.



Evidence for Volume-Outcome Relationship


A meta-analysis of studies covering 421,299 elective aneurysm repairs reported a weighted odds ratio of 0.66 in favor of higher volume centers. Meta-analyses can be subject to publication bias, heterogeneity, and data source criticisms, however. A review of national administrative data found that the mortality in low-caseload units was 8.5% whereas that at high-caseload units was 5.9%. Many small-volume centers had a mortality for elective AAA surgery exceeding 20%. Safety plots assess the individual hospital performance. Of 410 hospitals, 30 at the low end of the volume spectrum had an elective AAA surgery mortality significantly higher than the national average.



Objections to Centralization


All patients should have access to high-quality services with a proven record of safety, making it somewhat irrelevant what difference in mortality is sufficient to support centralization. Between 2003 and 2008, data on ruptured AAA from the United Kingdom indicated an absolute mortality between hospitals in the lowest and highest volume quintiles of 24%. Focusing on case mix and patients deemed ineligible for surgery showed disparate practices for emergency patients between the highest and lowest quintile units. No surgical intervention is offered to over 50% of emergency patients in the lowest quintile units but only 20% in the highest volume centers. Data indicating low-volume units have an elective AAA mortality of 0% may not actually have good results but simply too few cases.


Endovascular approaches have altered elective aneurysm surgery. However, hospital volume is significantly related to elective aneurysm mortality for open repair, endovascular repair, and combined approaches. Higher volume hospitals are more likely to adopt endovascular therapy. Those that do both endovascular and open repair have better than average results from the open repairs.


Patients must consider added travel time as well as clinical issues. About 92% of persons have indicated a willingness to travel at least 1 hour beyond their nearest hospital to access services with lower perioperative mortality, lower nonfatal complication rate, high annual caseload of AAA repairs, and routine availability of endovascular repairs.


The institutional experience is the most important contributor to delivering good quality care. Ceasing to perform aneurysm surgery in a center does not imply the surgeons are performing poorly, since the surgery is just one aspect of treatment. Outcomes may be defined by facilities, protocols, and familiarity with the challenging management of complex interventions.

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Apr 1, 2017 | Posted by in CARDIOLOGY | Comments Off on One: All Major Arterial Interventions Should Now be Performed in High Volume Centres – Abdominal Aortic Aneurysms

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