Low-volume Surgeons Performing Open Abdominal Aortic Surgery Have Similar Outcomes Independent Of Hospital Volume
Ambar Mehta, MD, MPH1, Priya Patel, M.D.1, Thomas O'Donnell, M.D.2, Karan Garg, M.D.3, William Clouse4, Jeffrey Siracuse5, Marc Schermerhorn, M.D.2, Hiroo Takayama, M.D.1, Virendra Patel1.
1Columbia University Medical Center, New York, NY, USA, 2Beth Israel Deaconess Department of Vascular Surgery, Boston, MA, USA, 3NYU Langone Vascular & Endovascular Surgery, New York, NY, USA, 4UVA Department of Vascular Surgery, Charlottesville, VA, USA, 5Boston University Department of Vascular Surgery, Boston, MA, USA.
OBJECTIVES: As the number of open abdominal aortic surgeries has decreased in the past few decades, the volume-outcomes relationship for these operations has become more pronounced, both at the surgeon and hospital level. The aim of this study was to evaluate whether lower volume surgeons have better outcomes when operating at higher volume hospitals for open aortic surgeries.
METHODS: We queried all patients undergoing open repairs of abdominal aortic aneurysms or aorto-iliac/femoral occlusive disease in the 2012 to 2019 Vascular Quality Initiative registry. Using the Leapfrog Volume Expert Panel guideline, we included patients by low-volume surgeons (<7 cases/year) and dichotomized hospitals into low-volume (<10 cases/year) and high-volume (≥10 cases/year). Outcomes included 30-day perioperative mortality, complications, and failure-to-rescue (death after a major postoperative complication). We used multivariable logistic regressions to evaluate the outcomes among elective or urgent repairs after adjusting for patient demographics and operative factors. RESULTS: We identified 11,469 patients who underwent open aortic surgeries (52% abdominal aortic aneurysms, 48% aorto-iliac/femoral occlusive disease) by 1218 low-volume surgeons across 249 hospitals. One-third (33%) of all cases were performed at low-volume hospitals and the remaining two-third (67%) occurred at high-volume hospitals. Overall outcomes were 3.8% for 30-day perioperative death, 35% for complications, and 9.9% for failure-to-rescue. After adjustment, there was no significant difference in outcomes between low-volume surgeons operating at low-volume hospitals versus low-volume surgeons operating at high-volume hospitals: death (aOR 1.17 [95%-CI 0.91-1.51]), complications (aOR 1.01 [0.88-1.15]), failure-to-rescue (aOR 1.10 [0.84-1.43]). Similarly, low-volume surgeons who operated at hospitals that had at least one high-volume surgeon did not have different outcomes relative to their counterparts: death (aOR 1.15 [95%-CI 0.86-1.53]), complications (aOR 1.00 [0.84-1.18]), failure-to-rescue (aOR 1.07 [0.78-1.48]). High-volume surgeons (≥7 cases/year) had lower adjusted rates of all three outcomes relative to low-volume surgeons.
CONCLUSIONS: For open abdominal aortic surgeries, low-volume surgeons had higher rates of perioperative mortality, complications, or failure-to-rescue, independent of operating at a high-volume hospital or a hospital with at least one high-volume surgeon. Several factors may explain this, including patient selection, intraoperative factors, and the underlying impact of surgeon volume on outcomes.
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