Options Presented During Clinic Visits For Patients With Abdominal Aortic Aneurysm Nearing Threshold For Repair
Eric J. Goodney1, Philip P. Goodney, MD2, Shipra Arya, MD3, Jason M. Johanning, MD4, Panos Kougias, MD5, Peter Henke, MD6, Gale Tang, MD7, Leila Mureebe, MD8, David H. Stone, MD1, Edith Tzeng, MD9, Eugene Lee, MD, PhD10, Benjamin S. Brooke, MD, PhD11, Hasan Dosluoglu, MD12, Mark Eid, MD1, Jonathan Barnes, MD1, Peter Nelson, MD13, Emily Spangler, MD14, Vivienne Halpern, MD15, Olamide Alabi, MD16, Joseph Raffetto, MD17, Wei Zhou, MD18, Naiem Nassiri, MD19, Daniel Inhat, MD20, Jessica O'Connell, MD21, Salvatore Scali, MD22.
1White River Junction VA Medical Center, White River Junction, VT, USA, 2Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 3Palo Alto VA Medical Center, Palo Alto, CA, USA, 4Nebraska VA Medical Center, Lincoln, NE, USA, 5Houston VA Medical Center, Houston, TX, USA, 6Ann Arbor VA Medical Center, Ann Arbor, MI, USA, 7Seattle VA Medical Center, Seattle, WA, USA, 8Durham VA Medical Center, Durham, NC, USA, 9Pittsburgh VA Medical Center, Pittsburgh, PA, USA, 10Sacramento VA Medical Center, Sacramento, CA, USA, 11Salt Lake City VA Medical Center, Salt Lake City, UT, USA, 12Buffalo VA Medical Center, Buffalo, NY, USA, 13Tulsa VA Medical Center, Tulsa, OK, USA, 14Birmingham VA Medical Center, Birmingham, AL, USA, 15Phoenix VA Medical Center, Phoenix, AZ, USA, 16Athens VA Medical Center, Athens, GA, USA, 17West Roxbury VA Medical Center, West Roxbury, MA, USA, 18Tuscon VA Medical Center, Tuscon, AZ, USA, 19West Haven VA Medical Center, West Haven, CT, USA, 20Minneapolis VA Medical Center, Minneapolis, MN, USA, 21LA VA Medical Center, Los Angeles, CA, USA, 22Gainesville VA Medical Center, Gainesville, FL, USA.
Objective: Patients with abdominal aortic aneurysm can be treated with open or endovascular repair. However, it is unclear how these options are presented to patients during clinic interactions with vascular surgeons. Our objective was to describe the choices presented to patients when they are seen in a VA vascular surgery clinic for an abdominal aortic aneurysm (AAA) which measures at least 5.0 cm in diameter and is a candidate for open or endovascular repair. Methods: Using a standardized algorithm, we qualitatively assessed the clinic notes of 40 US Veterans enrolled at three VA hospitals participating in the Preferences for Open Versus Endovascular Repair of AAA (PROVE-AAA) Study, a 20 site randomized trial of a decision aid to help Veterans choose between open AAA repair and EVAR. We studied (1) the type of clinic visit (consult or ongoing surveillance) (2) the initial options for repair shared by the surgeon with the patient (no repair/surveillance, open AAA repair, and EVAR), and whether factors were recorded in the note by the surgeon or patient in making their treatment choice. Results: When patients presented for their discussion, the visit type was a new consult for 40% of patients, while 60% of patients reported to clinic for ongoing surveillance. Three out of four patient notes (75%) described a discussion of “options” for treatment for the patient's AAA. These options included a review of options for open and endovascular repair in 53% (Figure), EVAR alone in 20%, and open repair alone in 5%. Nearly six out of ten Veterans agreed with a recommendation for EVAR, and 20% of patients were advised to continue surveillance. Conclusion: More than half of patients with an AAA at least 5.0 cm in size recieve physician advice which includes a review of both open surgical repair options and endovascular options for AAA. One in five patients received a recommendation for EVAR alone, and one in five are recommended to continue surveillance. Even among Veterans hospitals which perform a majority of their AAA repairs with EVAR, recommendations for aneurysm treatment type received at VA medical centers are balanced between open and endovascular repair. 
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