Aortic Aneurysm

Part Two: The Case Against Centralisation of Abdominal Aortic Aneurysm Surgery in Higher Volume Centers

Forbes TL (London Health Sciences Ctr and The Univ of Western Ontario, Ontario, Canada) Eur J Vasc Endovasc Surg 42:414–417, 2011^§

Abstract

Background

The centerpiece for arguments favoring the centralization of abdominal aortic aneurysm (AAA) surgery is the volume-outcome relationship. The intricacies, challenges, and possible negative effects with centralization were reviewed.

Volume-Outcome Relationship

Recent systematic reviews question the existence or at least the strength of the volume-outcome relationship based on methodological challenges. Some studies focus on the surgeon’s experience whereas others consider hospital case volumes in determining the volume component. In addition, definitions of what constitutes a high or low volume are inconsistent. An alternative method is to consider quality of care indices, since a higher case volume may not necessarily cause better patient outcomes. A California study found a 51% reduction in mortality in hospitals with a policy of perioperative beta-blocker use but no difference between hospitals based on case volume threshold. Achieving quality of care indices improves patient outcomes more successfully than performing a certain number of repairs. Positive volume-outcome relationships may reflect certain best practices and quality of care standards accompanying experience.

Other Considerations

If aneurysm repair is centralized, regional centers must be equipped to meet the increased demands for emergency surgery in terms of human resources and infrastructure. Centralization will be unsuccessful without these measures.

Ruptured aneurysms present a time-sensitive, life-threatening problem requiring immediate attention. Three North American studies found that although transferring patients to the regional center delayed definitive surgical repair, it did not adversely affect patients’ chances of survival. However, these studies only considered patients who survived transfer, a preselection that excludes unstable patients who died before or during transfer. No attempt was made to determine if such patients would have survived if offered repair at the local hospital. Centralization may therefore produce low operative and survival rates in patients not transferred to regional vascular units. Also, the actual aneurysm repair is just one component of treatment, with expert anesthesia and intensive care unit experiences also needed to ensure survival.

Patients may see local care as offering benefits not available with a regional center. These benefits include convenience, proximity to personal support systems, and continuity of care with familiar physicians. Forty-five percent of American patients indicated they would prefer local surgery for pancreatic cancer even if mortality was double that at a regional center. The specific patient population being considered must also be assessed. North American patients must travel farther distances to obtain tertiary and quaternary surgical care compared with European patients.

The impact of centralization on the provision of general vascular care must also be considered. Hospitals that no longer offer AAA repairs may also lose most vascular surgery coverage because vascular surgeons will shift practices to the centers where AAA surgery is done. Financial and budgetary benefits are additional concerns.

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