The Decline of Open AAA Surgery in the Medicare Population and its Implications for Vascular Surgical Training
Danielle C. Sutzko, MD, MS, Elizabeth A. Andraska, BS, Nicholas H. Osborne, MD, MS.
University of Michigan, Ann Arbor, MI, USA.
OBJECTIVES: Abdominal aortic aneurysm repair has evolved rapidly since the development of endovascular aneursym repairs (EVAR). Currently, EVAR is performed for the majority of infrarenal aneurysms. With such a rapid shift toward endovascular repair, it is unclear how many hospitals continue to perform open repair and whether open aneurysm repair (OAR) has in effect been regionalized to high volume centers distributed across the US. We sought to examine the proportion of hospitals continuing to perform open repair and the distribution of high volume centers across the US.
METHODS: All patients undergoing open and endovascular infrarenal AAA repair between 2009 and 2012 were identified in the MedPar database. Hospital volume was calculated for both OAR and EVAR. Descriptive statistics were used to examine both hospital and state level variation in the volume of OAR and EVAR performed.
RESULTS: Among 156,608 patients, 49,951 patients (32%) underwent OAR and 106,657 patients (68%) underwent EVAR between 2009 and 2012, in a total of 2,083 hospitals. Only 100 hospitals did not perform OAR during the study period. Median yearly hospital volume was 3 OARs (IQR 1, 7) and 7 EVARs (IQR 1, 17). Importantly, only 717 (34%) of hospitals performed more than 5 OARs per year, as compared to 1209 hospitals (58%) performed 5 EVARs per year. In comparison, 61 hospitals (2.9%) performed more than 30 OARs per year and 252 hospitals (12%) performed more than 30 EVARs per year. Examining variation across states, only 23 states have a hospital that performs more than 30 OARs per year as compared 45 states with a hospital that performs more than 30 EVARs per year.
CONCLUSIONS: As EVAR has become the dominant repair for infrarenal AAA, there has ben a dramatic decrease in the volume of open repair. OAR is performed in high volumes (more than 30 per year) in less than 3% of hospitals nationwide. Although open volumes remain low, it appears that a minority of hospitals performs the majority of open repairs across the country. As open repair continues to become less common, appropriate volumes to train future vascular surgeons appear to be inadequate.
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