Society For Clinical Vascular Surgery

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Superior 5-Year Value of Aortofemoral Bypass with High-Volume Providers
Peng Zhao, MD, Mark D. Balceniuk, MD, Joshua T. Geiger, BS, Antoinette Esce, BA, BS, Fergal J. Fleming, MBBCh, Jennifer L. Ellis, MD, Roan J. Glocker, MD, MPH, Kathleen G. Raman, MD, MPH, Michael C. Stoner, MD, Adam J. Doyle, MD
University of Rochester, Rochester, NY

OBJECTIVE:
Volume-outcome relationships in surgery have been well established. Recent studies have shown that high-volume surgeons provide higher value open abdominal aneurysm and mesenteric vasculature repair. The hypothesis of this study is that high-volume surgeons provide superior value performing Aortofemoral Bypass (AFB) when compared to low-volume surgeons.
METHODS:
The New York Statewide Planning and Research Cooperative System was utilized. We evaluated patient undergoing AFB from 2000 to 2010 without a diagnosis of abdominal aortic aneurysm. The data were grouped into quartiles based on the surgeonsí yearly volume of completed procedures. Charge data were normalized to 2018 dollars and used to calculate a 5-year value. Value is defined as patient life years per cumulative charges associated with the revascularization. Rates of complication during index hospitalization, 30-day survival, and 5-year survival were also analyzed. X2 and Kruskal-Wallis tests were performed to compare the variance between the surgeonsí volume quartiles for categorical and continuous variables, respectively.
RESULTS:
773 surgeons performed 6,734 AFB in 167 hospitals over the 11-year period. The groups were similar in age and race, and had similar Charlson Comorbidity Indices (Table). The cumulative adjusted charge for AFB was significantly less for high-volume surgeons than low-volume surgeons. The calculated 5-year value was 1.54 year/K charge for the highest quartile surgeons, followed by 1.31, 1.09 and 0.93 year/K charge for the 3rd, 2nd and 1st quartile surgeons, respectively (p=<0.001). In addition, length of stay, rates of complications during index hospitalization, 30-day survival, 5-year survival and major adverse limb events all favors high-volume surgeons.
CONCLUSIONS:
These data are the first to demonstrate that high-volume surgeons performing aortofemoral bypass provide superior value, reduced complications, and improved long term survival, when compared to low-volume surgeons. These data provide further evidence that open abdominal vascular surgery should be centralized to high-volume surgeons.

Comparison of charge, value and outcomes stratified by surgeon volume
AortofemoralBypass(n=6,734)
1st Quartile Surgeon Volume (n=2203)2nd Quartile Surgeon Volume (n=1470)3rd Quartile Surgeon Volume (n=1529)4th Quartile Surgeon Volume (n=1532)P value
5-year value (year/K)0.9261.0891.3121.536<0.001
Charge (K)9.7477.7366.3475.073<0.001
Charlson Comorbidity Index2.1331.9992.0542.0980.193
Complication during index hospitalization (%)37.9941.8436.0424.22<0.001
Length of stay (days)13.9811.8110.508.99<0.001
30-day survival (%)93.7895.9895.2396.54<0.001
5-year survival (%)69.1774.6972.1371.74<0.001

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