Hospital costs for endovascular and open repair of abdominal aortic aneurysm

Feasibility and Cost Analysis of Ambulatory Endovascular Aneurysm Repair

PURPOSE

We sought to compare the costs of ambulatory endovascular aneurysm repair (a-EVAR) and inpatient EVAR (i-EVAR) at up to 1-year of follow-up.

MATERIALS AND METHODS

A retrospective cohort study of consecutive patients undergoing elective EVAR between April 2016 and December 2018 at two academic centers. Patients planned for a-EVAR were compared with i-EVAR. Costs at 30 days and 1 year were extracted. These included operating room (OR) use, bed occupancy, laboratory and imaging, emergency department (ED) visits, readmissions, and reinterventions. Baseline characteristics were compared. Multiple regression model was used to identify predictors of increased EVAR costs. Repeated measures analysis of variance (ANOVA) was used to compare cost differences at 30 days and 1 year via an intention-to-treat analysis. Bonferroni post hoc test compared between-group differences. A p value<0.05 was considered statistically significant.

RESULTS

One hundred seventy patients were included. Most underwent percutaneous EVAR (>94%) under spinal anesthesia (>84%). Ambulatory endovascular aneurysm repair was successful in 84% (84/100). Ambulatory endovascular aneurysm repair patients (76±8 years) were younger than i-EVAR (78±9 years). They also had a smaller mean aneurysm diameter (56±6 mm) compared with i-EVAR (59±6 mm). Emergency department visits, readmissions, and reinterventions were similar up to 1 year (all p=NS). Ambulatory endovascular aneurysm repair costs showed a non-statistically significant reduction in total costs at 30 days and 1 year by 27% and 21%, respectively. Patients younger than 85 years and males had a 30-day cost reduction by 34% (p=0.027) and 33% (p=0.035), respectively with a-EVAR.

CONCLUSIONS

Same-day discharge is feasible and successful in selected patients. Patients younger than 85 years and males have a short-term cost benefit with EVAR done in the ambulatory setting without increased complications or reinterventions.

CLINICAL IMPACT

This study shows the overall safety of ambulatory EVAR with proper patient selection. These patient had similar post-intervention complications to inpatients. Same day discharge also resulted in short-term reduction in costs in male patients and patients younger than 85 years.

Understanding value and patient complexity among common inpatient vascular surgery procedures

OBJECTIVE

Vascular surgery patients are highly complex, second only to patients undergoing cardiac procedures. However, unlike cardiac surgery, work relative value units (wRVU) for vascular surgery were undervalued based on an overall patient complexity score. This study assesses the correlation of patient complexity with wRVUs for the most commonly performed inpatient vascular surgery procedures.

METHODS

The 2014 to 2017 National Surgical Quality Improvement Program Participant Use Data Files were queried for inpatient cases performed by vascular surgeons. A previously developed patient complexity score using perioperative domains was calculated based on patient age, American Society of Anesthesiologists class of ≥4, major comorbidities, emergent status, concurrent procedures, additional procedures, hospital length of stay, nonhome discharge, and 30-day major complications, readmissions, and mortality. Procedures were assigned points based on their relative rank and then an overall score was created by summing the total points. An observed to expected ratio (O/E) was calculated using open ruptured abdominal aortic aneurysm repair (rOAAA) as the referent and then applied to an adjusted median wRVU per operative minute.

RESULTS

Among 164,370 cases, patient complexity was greatest for rOAAA (complexity score = 128) and the least for carotid endarterectomy (CEA) (complexity score = 29). Patients undergoing rOAAA repair had the greatest proportion of American Society of Anesthesiologists class of ≥IV (84.8%; 95% confidence interval [CI], 82.6%-86.8%), highest mortality (35.5%; 95% CI, 32.8%-38.3%), and major complication rate (87.1%; 95% CI, 85.1%-89.0%). Patients undergoing CEA had the lowest mortality (0.7%; 95% CI, 0.7%-0.8%), major complication rate (8.2%; 95% 95% CI, 8.0%-8.5%), and shortest length of stay (2.7 days; 95% CI, 2.7-2.7). The median wRVU ranged from 10.0 to 42.1 and only weakly correlated with overall complexity (Spearman's ρ = 0.11; P < .01). The median wRVU per operative minute was greatest for thoracic endovascular aortic repair (0.25) and lowest for both axillary-femoral artery bypass (0.12) and open femoral endarterectomy, thromboembolectomy, or reconstruction (0.12). After adjusting for patient complexity, CEA (O/E = 3.8) and transcarotid artery revascularization (O/E = 2.8) had greater than expected O/E. In contrast, lower extremity bypass (O/E = 0.77), lower extremity embolectomy (O/E = 0.79), and open abdominal aortic repair (O/E = 0.80) had a lower than expected O/E.

CONCLUSIONS

Patient complexity varies substantially across vascular procedures and is not captured effectively by wRVUs. Increased operative time for open procedures is not adequately accounted for by wRVUs, which may unfairly penalize surgeons who perform complex open operations.

Hospital resource use and costs among abdominal aortic aneurysm repair patients admitted to the intensive care unit

BACKGROUND

Abdominal aortic aneurysm (AAA) repair is associated with significant morbidity and mortality. As a result, many of these patients are monitored postoperatively in the intensive care unit (ICU). However, little is known about resource utilization and costs associated with ICU admission in this population. We sought to evaluate predictors of total costs among patients admitted to the ICU after repair of nonruptured or ruptured AAA.

METHODS

We retrospectively analyzed prospectively collected data (2011-2016) of ICU patients admitted after AAA repair. The primary outcome was total hospital costs. We used elastic net regression to identify pre-ICU admission predictors of hospitalization costs separately for nonruptured and ruptured AAA patients.

RESULTS

We included 552 patients in the analysis. Of these, 440 (79.7%) were admitted after repair of nonruptured AAA, and 112 (20.3%) were admitted after repair of ruptured AAA. The mean age of patients with nonruptured AAA was 74 (standard deviation, 9) years, and the mean age of patients with ruptured AAA was 70 (standard deviation, 8) years. Median total hospital cost (in Canadian dollars) was $21,555 (interquartile range, $17,798-$27,294) for patients with nonruptured AAA and $33,709 (interquartile range, $23,173-$53,913) for patients with ruptured AAA. Among both nonruptured and ruptured AAA patients, increasing age, illness severity, use of endovascular repair, history of chronic obstructive pulmonary disease, and excessive blood loss (≥4000 mL) were associated with increased costs, whereas having an anesthesiologist with vascular subspecialty training was associated with lower costs.

CONCLUSIONS

Patient-, procedure-, and clinician-specific variables are associated with costs in patients admitted to the ICU after repair of AAA. These factors may be considered future targets in initiatives to improve cost-effectiveness in this population.

Predictors of in-hospital adverse events after endovascular aortic aneurysm repair

BACKGROUND

Endovascular aneurysm repair (EVAR) offered outstanding survival benefit but at the expense of cost, periodic radiographic monitoring, and higher reinterventions rates. Perioperative complications, although rare, can occur after EVAR, contributing to longer hospitalization, higher cost, and significant comorbidity and mortality. Therefore, the aim of this study was to identify the predictors of in-hospital events (IHEs) after elective EVAR.

METHODS

The Vascular Quality Initiative database was explored from 2003 to 2017. Patients who had converted to open repair were excluded. IHEs were defined as any in-hospital myocardial infarction, dysrhythmia, congestive heart failure (CHF), stroke, pneumonia, respiratory failure, renal failure, lower extremity ischemia, bowel ischemia, or reoperation. Stepwise backward selection based on the Akaike information criterion statistic was implemented to select the predictors of IHE from the multivariable logistic regression models. Bootstrapping was performed with 1000 replications to internally validate the model and to obtain bias-corrected estimates. Receiver operating characteristic curves (area under the curve [AUC]) and Hosmer-Lemeshow tests were used to assess the discrimination and calibration of the models.

RESULTS

A total of 28,240 patients with full information about IHEs were included. Any IHE took place in 2365 (8.4%) patients. Patients who had an IHE were slightly older (mean age ± standard deviation, 75.6 ± 8.1 years vs 73.3 ± 8.5 years; P < .001]. A higher proportion of women had an IHE (25.6% vs 17.9%; P < .001). Comorbid conditions were more prevalent in patients who developed an IHE (chronic kidney disease, 49.1% vs 33.2%; coronary artery disease, 34.3% vs 29.0%; moderate to severe CHF, 3.9% vs 1.4%; chronic obstructive pulmonary disease, 42.5% vs 31.9%; hypertension, 87.0% vs 83.1%; and diabetes, 18.0% vs 16.1%; all P ≤ .015). An IHE was associated with high in-hospital (5.6% vs 0.03%) and 30-day mortality (6.3% vs 0.3%; both P < .001) and worse 3-year survival beyond the perioperative period (81.1% [79.3%-82.9%] vs 91.1% [90.7%-91.5%]; P < .001). Two models were constructed, one from preoperative factors and the second from preoperative and intraoperative factors. The selected predictors of IHEs were female sex, moderate or severe CHF, chronic kidney disease, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and aneurysm diameter. Intraoperative factors were contrast material volume, operative time, and packed red blood cell transfusion. Nomograms were constructed from the final models. AUC significantly improved after adding intraoperative factors (AUC [95% confidence interval], 0.71 [0.70-0.73] vs 0.65 [0.64-0.66]; P < .001].

CONCLUSIONS

In-hospital adverse events can complicate the perioperative course of EVAR and increase the risk of operative and long-term mortality. Predicting IHEs and identifying their risk factors can potentially mitigate their development in patients at high risk. Predicting IHE risk can have tremendous prognostic value and help disposition planning. This study introduces an internally validated tool to enable vascular surgeons to identify patients' chance of having an IHE.

Early extubation is associated with reduced length of stay and improved outcomes after elective aortic surgery in the Vascular Quality Initiative

OBJECTIVE

Timing of extubation after open aortic procedures varies across hospitals. This study was designed to examine extubation timing and determine its effect on length of stay (LOS) and respiratory complications after elective open aortic surgery.

METHODS

We studied extubation timing for 7171 patients undergoing elective open abdominal aortic aneurysm repair (2687 [37.5%]) or suprainguinal bypass for aortoiliac occlusive disease (4484 [62.5%]) from October 2010 to April 2015 in hospitals participating in the Vascular Quality Initiative (VQI). Our primary outcome was prolonged LOS (>7 days), and the secondary outcome was respiratory complications (pneumonia or reintubation). The association between extubation timing and outcomes was assessed using multivariable logistic regression mixed-effects models that adjusted for confounding factors at the patient and procedure level. A variable importance analysis was conducted using a chi-pie framework to identify factors contributing to the variability of extubation timing.

RESULTS

The 7171 patients undergoing abdominal aortic surgery were a mean age of 65.4 (standard deviation, 10.2) years, and 63% were male. Extubation occurred (1) in the operating room (76.3%), (2) <12 hours (10.9%), (3) 12 to 24 hours (7.2%), or (4) >24 hours (5.6%) after surgery. Hospitals in the top quartile for case volume had the highest percentage of patients extubated in the operating room (82.8%). Patients least likely to be extubated in the operating room were older, more likely to have chronic obstructive pulmonary disease, require vasopressors, have higher estimated blood loss (EBL), and longer procedure times. After adjustment for patient, procedure, and institutional factors, delayed extubation was associated with prolonged LOS (<12 hours: odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.7; 12-24 hours: OR, 2.1; 95% CI, 1.7-2.7; >24 hours: OR, 5.3; 95% CI, 4.0-6.9), and pulmonary complications (<12 hours: OR, 1.9; 95% CI, 1.4-2.6; 12-24 hours: OR, 2.6; 95% CI, 1.8-3.6; >24 hours: OR, 9.6; 95% CI, 7.1-13.0) compared with those extubated in the operating room. Subset analysis of patients extubated in the operating room or <12 hours showed that extubation out of the operating room was associated with prolonged LOS (OR, 1.4; 95% CI, 1.2-1.7) and pulmonary complications (OR, 1.8; 95% CI, 1.3-2.5). The variable importance analysis demonstrated that EBL (26%) and procedure time (24%) accounted for half of the variation in extubation timing.

CONCLUSIONS

Extubation in the operating room is associated with shorter LOS and morbidity after open aortic surgery. EBL, procedure time, and center variation account for variability in extubation timing. These data advocate for standardized perioperative respiratory care to reduce variation, improve outcomes, and reduce LOS.

Endovascular versus “Fast-Track” Abdominal Aortic Aneurysm Repair

Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 ±0.13 vs 6.1 ±0.17 cm, p=0.008), and had more patients designated American Society of Anesthesia class 4 (p<0.0001). Both groups were predominantly male. Otherwise there were no statistically significant differences in risk factors. Patients who underwent fast-track repair tended to have a longer operation (216 ±7.4 vs 158 ±6.8 minutes, p<0.0001), with a greater volume of blood (1.8 ±0.29 vs 0.32 ±0.24 units, p=0.0005), colloid (565 ±89 vs 32 ±22 cc, p<0.0001), and crystalloid transfusions (4,625 ±252 vs 2,627 ±170 cc, p<0.0001). There were no statistically significant differences in the number of intraoperative or postoperative complications between the 2 groups. EVAR patients resumed a regular diet earlier (0.21 ±0.08 vs 1.8 ±0.11 days, p<0.0001). Intensive care unit stay was shorter for EVAR (0.50 ±0.10 vs 0.87 ±0.10 days, p=0.01), but floor (2.1 ±0.23 vs 2.6 ±0.21 days, p=0.17), and total hospital lengths of stay (2.8 ±0.32 vs 3.4 ±0.18 days, p=0.07) were similar between the 2 groups. Total hospital cost was lower in the fast-track ($10,205 ±$736 vs $20,640 ±$1,206, p<0.0001) leading to greater overall hospital earnings ($6,141 ±$1,280 vs $107 ±$1,940, p=0.01). Fast-track AAA repair is a viable alternative for the treatment of abdominal aortic aneurysms. Compared to endovascular repair, the fast-track method had increased transfusions of blood and intravenous fluids and increased operating room times, but equivalent lengths of floor and total hospital stay and increased total hospital earnings.

Comparison of costs of endovascular repair versus open surgical repair for abdominal aortic aneurysm in Korea

This study was designed to compare the hospital-related costs of elective abdominal aortic aneurysm (AAA) treatment and cost structure between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) in Korean health care system. One hundred five primary elective AAA repairs (79 OSRs and 26 EVARs) performed in the Seoul National University Hospital from 2005 to 2009 were included. Patient characteristics were similar between two groups except for older age (P = 0.004) and more frequent history of malignancy (P = 0.031) in EVAR group. Thirty-day mortality rate was similar between two groups and there was no AAA-related mortality in both groups for 5 yr after repair. The total in-hospital costs for the index admission were significantly higher in EVAR patients (mean, KRW19,857,119) than OSR patients (mean KRW12,395,507) (P < 0.001). The reimbursement was also significantly higher in EVAR patients than OSR patients (mean, KRW14,071,081 vs KRW6,238,895, P < 0.001) while patients payments was comparable between two groups. EVAR patients showed higher follow-up cost up to 2 yr due to more frequent imaging studies and reinterventions for type II endoleaks (15.4%). In the perspective of cost-effectiveness, this study suggests that the determination of which method to be used in AAA treatment be more finely trimmed and be individualized.

AAA stent-grafts: past problems and future prospects

Endovascular aneurysm repair (EVAR) has quickly gained popularity for infrarenal abdominal aortic aneurysm repair during the last two decades. The improvement of available EVAR devices is critical for the advancement of patient care in vascular surgery. Problems are still associated with the grafts, many of which can necessitate the conversion of the patient to open repair, or even result in rupture of the aneurysm. This review attempts to address these problems, by highlighting why they occur and what the failings of the currently available stent grafts are, respectively. In addition, the review gives critical appraisal as to the novel methods required for dealing with these problems and identifies the new generation of stent grafts that are being or need to be designed and constructed in order to overcome the issues that are associated with the existing first- and second-generation devices.

Effects of study design and trends for EVAR versus OSR

Purpose:

To investigate if study design factors such as randomization, multi-center versus single center evidence, institutional surgical volume, and patient selection affect the outcomes for endovascular repair (EVAR) versus open surgical repair (OSR). Finally, we investigate trends over time in EVAR versus OSR outcomes.

Methods:

Search strategies for comparative studies were performed individually for: OVID’s MEDLINE, EMBASE, CINAHL, HAPI, and Evidence Based Medicine (EBM) Reviews (including Cochrane DSR, ACP Journal Club, DARE and CCTR), limited to 1990 and November 2006.

Results:

Identified literature: 84 comparative studies pertaining to 57,645 patients. These include 4 randomized controlled trials (RCTs), plus 2 RCTs with long-term follow-up. The other 78 comparative studies were nonrandomized with 75 reporting perioperative outcomes, of which 16 were multi-center, and 59 single-center studies. Of the single-center studies 31 were low-volume and 28 were high-volume centers. In addition, 5 studies had all patients anatomically eligible for EVAR, and 8 studies included high-risk patients only. Finally, 25 long term observational studies reported outcomes up to 3 years.

Outcomes:

Lower perioperative mortality and rates of complications for EVAR versus OSR varied across study designs and patient populations. EVAR adverse outcomes have decreased in recent times.

Conclusion:

EVAR highlights the problem of performing meta-analysis when the experience evolves over time.

Endovascular Abdominal Aortic Aneurysm Repair: A Community Hospital's Experience

Endovascular abdominal aortic aneurysm repair (EVAR) has become the first-line approach for the treatment of abdominal aortic aneurysms. Outcomes outside of tertiary care settings remain unknown. The purpose of this study is to report the midterm outcomes of EVAR in a community hospital. A retrospective review of 75 elective, consecutive EVARs performed at a single nonacademic community hospital was performed. There were no conversions to open repair during or after endovascular repair. The mean follow-up was 18 months. There were no postoperative ruptures or aneurysm-related deaths. At 24 months, freedom from aneurysm-related death was 100%, freedom from secondary interventions was 91%, and freedom from endoleak was 69%. EVAR in the community setting is a safe and durable procedure, even in a medically high-risk population. Comparable outcomes can be achieved to tertiary care centers, in carefully selected patients with favorable anatomy.

Cost and effectiveness comparison of endovascular aneurysm repair versus open surgical repair of abdominal aortic aneurysm: a single-center experience

The study objective was to compare the cost and effectiveness of two surgical techniques: open repair and endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). We assessed 58 surgical operations of AAA repair conducted in 54 men and 4 women (aged 49-94 years) during 2003 and 2004. Open surgical repair was performed in 21 patients, and EVAR was performed in 37 patients. The evaluation of the effectiveness of both methods was based on the following factors: mortality within 30 days, surgery duration, total hospitalization time, and intensive care unit stay duration. The segmental costs of grafts, anesthesia, and extra materials were included in the calculations for the comparison of the costs of the two methods. A 30-day mortality of 5.17% and 0% was demonstrated for open surgical repair and EVAR, respectively. In regard to the operation's mean duration, this was calculated to 279.52 minutes for open repair and 193.57 minutes for EVAR. The mean duration of the in-hospital stay was 11.3 and 4.09 days for open repair and EVAR, respectively. Accordingly, the mean duration of intensive care unit stay was 2.81 and 0.23 days, respectively. The cost evaluation revealed a mean cost of 5374.3euro ($7,643.49) and 20,592.52euro ($29,287.50) for open repair and EVAR, respectively. Open repair is a "tested method" of its own time. EVAR seems to have the advantage on aspects of effectiveness, yet its major hallmark is its significant cost, as indicated in the relevant part of the current study.

Adoption of an innovation to repair aortic aneurysms at a Canadian hospital: a qualitative case study and evaluation

Background

Priority setting in health care is a challenge because demand for services exceeds available resources. The increasing demand for less invasive surgical procedures by patients, health care institutions and industry, places added pressure on surgeons to acquire the appropriate skills to adopt innovative procedures. Such innovations are often initiated and introduced by surgeons in the hospital setting. Decision-making processes for the adoption of surgical innovations in hospitals have not been well studied and a standard process for their introduction does not exist. The purpose of this study is to describe and evaluate the decision-making process for the adoption of a new technology for repair of abdominal aortic aneurysms (endovascular aneurysm repair [EVAR]) in an academic health sciences centre to better understand how decisions are made for the introduction of surgical innovations at the hospital level.

Methods

A qualitative case study of the decision to adopt EVAR was conducted using a modified thematic analysis of documents and semi-structured interviews. Accountability for Reasonableness was used as a conceptual framework for fairness in priority setting processes in health care organizations.

Results

There were two key decisions regarding EVAR: the decision to adopt the new technology in the hospital and the decision to stop hospital funding. The decision to adopt EVAR was based on perceived improved patient outcomes, safety, and the surgeons' desire to innovate. This decision involved very few stakeholders. The decision to stop funding of EVAR involved all key players and was based on criteria apparent to all those involved, including cost, evidence and hospital priorities. Limited internal communications were made prior to adopting the technology. There was no formal means to appeal the decisions made.

Conclusion

The analysis yielded recommendations for improving future decisions about the adoption of surgical innovations. ese empirical findings will be used with other case studies to help develop guidelines to help decision-makers adopt surgical innovations in Canadian hospitals.

Long-term postplacement cost after endovascular aneurysm repair

BACKGROUND

Previous studies have demonstrated that the initial hospital cost associated with endovascular aneurysm repair (EVAR) is approximately $20,000. However, the cost of long-term surveillance and secondary procedures is poorly characterized.

METHODS

Between December 1998 and June 2006, 259 patients underwent EVAR for infrarenal aneurysms at a single institution. Follow-up costs were calculated using a relative value unit based hospital cost accounting system, which incorporates departmental direct and indirect costs. Institutional overhead costs were included using a conversion factor. Costs for professional services were determined by a cost-to-charge ratio, and outpatient visits were calculated with a time-based formula. Year 2006 costs were applied to prior years. To minimize costs associated with the early learning curve, the initial 50 EVAR patients between December 1995 and 1998 were excluded. Patients with <1 year follow-up were also excluded. Data are expressed as mean +/- standard error.

RESULTS

The mean follow-up after EVAR for 136 patients was 34.7 +/- 1.8 months. The cumulative 5-year postplacement cost per patient was $11,351. The 27 patients (19.9%) who required secondary procedures had a 5-year cumulative cost of $31,696 compared with $3668 for 109 patients without secondary procedures (8.6-fold increase, P < .05). The 5-year cost for patients with endoleak was $26,739 compared with $5706 for those without endoleak (4.7-fold increase, P < .05). Overall, major cost components were 57.4% for secondary procedures and 32.5% for radiologic studies.

CONCLUSIONS

During a 5-year period, the postplacement cost of EVAR increases the global cost by 44%. The subgroups of patients with endoleaks and those requiring secondary procedures generate a disproportionate share of postplacement costs. Efforts at minimizing cost should emphasize technical and device modifications aimed at reducing endoleaks and the need for secondary procedures.

Cost-effectiveness of abdominal aortic aneurysm repair: A systematic review

Objectives: A systematic review of the cost-effectiveness of abdominal aortic aneurysm (AAA) repair was conducted. Although open surgery has been considered the gold standard for prevention of AAA rupture, emerging less-invasive endovascular treatments have led to increased interest in evaluating the cost and cost-effectiveness of treatment options.

Methods: A systematic review of studies published in MEDLINE between 1999 and 2005 reporting the cost and/or cost-effectiveness of endovascular and/or open surgical repair of nonruptured AAAs was conducted. Case series studies with less than fifty patients per treatment were excluded.

Results: Of twenty eligible articles, three were randomized controlled trials, twelve case series, four Markov models, and one systematic review. Regardless of time frame, all studies found that endovascular repair costs more than open surgery. Although the high cost of the endovascular prosthesis was partially offset by reduced intensive care, hospital length of stay, operating time, blood transfusions, and perioperative complications, hospital costs were still greater for endovascular than open surgical repair. For patients medically fit for open surgery, mid-term costs were greater for endovascular repair with no difference in overall survival or quality of life. For patients medically unfit for open surgery, endovascular repair costs more than no intervention with no difference in survival.

Conclusions: Although conclusions regarding the cost-effectiveness of AAA treatment options are time dependent and vary by institutional perspective, from a societal perspective, endovascular repair is not currently cost-effective for patients with large AAA regardless of medical fitness.

Technology Penetration of Endovascular Aortic Aneurysm Repair in Southern California

Our objective was to investigate the penetration of endovascular abdominal aortic aneurysm repair (EVAR) in the large, diverse health-care market of southern California over 3 years and to study variability in the pattern of distribution of EVAR in southern California counties by analyzing available demographic, geographic, and socioeconomic data from California state health-care databases. Information abstracted from the inpatient hospital discharge data for patients undergoing AAA repair for the years 2001, 2002, and 2003, derived from the Office of Statewide Health Planning and Development, included age, gender, race, hospitals performing EVAR, and payors for the service. Per-capita income (PCI) for the year 1999 and the population size of each county for the respective years were obtained from the U.S. Census Bureau. Data pertaining to members of the Southern California Vascular Surgical Society (SCVSS) serving the southern California region were obtained from the SCVSS membership directory. Data were categorized based on 10 counties in southern California. All the above variables were analyzed using the chi-squared test, with p < 0.05 considered significant. The proportions of EVAR for the years 2001, 2002, and 2003 were 15.4% (n = 409), 20.2% (n = 492), and 25.9% (n = 566), respectively. This is a 67.8% (p < 0.0001) increase in EVAR application in southern California since 2001. However, the proportion of EVAR varied among counties (p < 0.0001), with 457 EVARs performed in Los Angeles County and eight in Imperial County during the study period. EVAR proportion was higher in patients aged > or =65 years (p < 0.0001) and male patients (p < 0.0001). The proportion of EVAR was significantly higher in counties with more than 20 vascular surgeons available (p < 0.0001) and PCI >21,000 US$ (p < 0.0001) and in Medicare, health maintenance organization, preferred provider organization, and private insurance holders (p < 0.0001). There was a trend toward increased EVARs in counties with more than eight hospitals that performed EVAR (p = 0.0545). However, no significant difference in EVAR proportion was observed among subgroups based on race (p = 0.535) and population size (p = 0.84). Although the number and proportion of EVAR increased significantly in southern California over 3 years, the penetration of the procedure varied among counties. County affluence, payor mix, and the number of vascular surgeons/county influenced the variability. These observations suggest that economic barriers may limit access to new biomedical technology. This has implications for health-care public policy directed toward providing equal access to medical care without regard to economic status.

Follow-up costs increase the cost disparity between endovascular and open abdominal aortic aneurysm repair

OBJECTIVE

This study compared the hospital and follow-up costs of patients who have undergone endovascular (EVAR) or open (OR) elective abdominal aortic aneurysm repair.

METHODS

The records of 195 patients (EVAR, n = 55; OR, n = 140) who underwent elective aortic aneurysm repair between 1995 and 2004 were reviewed. Primary costing data were analyzed for 54 EVAR and 135 OR patients. Hospital costs were divided into preoperative, operative, and postoperative costs. Follow-up costs for EVAR patients were recorded, with a median follow-up time of 12 months.

RESULTS

Mean preoperative costs were slightly higher in the EVAR group (AU $961/US $733 vs AU $869/US $663; not significant). Operative costs were significantly higher in the EVAR group (AU $16,124/US $12,297 vs AU $6077/US $4635; P < .001); this was entirely due to the increased cost of the endograft (AU $10,181/US $7,765 for EVAR vs AU $476/US $363 for OR). Postoperative costs were significantly reduced in the EVAR group (AU $4719/US $3599 vs AU $11,491/US $8,764; P < .001). Total hospital costs were significantly greater in the EVAR group (AU $21,804/US $16,631 vs AU $18,437/US $14,063; P < .001). The increase in total hospital costs was due to a significant difference in graft costs, which was not offset by reduced postoperative costs. The average follow-up cost per year after EVAR was AU $1316/US $999. At 1 year of follow-up, EVAR remained significantly more expensive than OR (AU $23,120/US $17,640 vs AU $18,510/US $14,122; P < .001); this cost discrepancy increased with a longer follow-up.

CONCLUSIONS

EVAR results in significantly greater hospital costs compared with OR, despite reduced hospital and intensive care unit stays. The inclusion of follow-up costs further increases the cost disparity between EVAR and OR. Because EVAR requires lifelong surveillance and has a high rate of reintervention, follow-up costs must be included in any cost comparison of EVAR and OR. The economic cost, as well as the efficacy, of new technologies such as EVAR must be addressed before their widespread use is advocated.