Esce Antoinette, Medhekar Ankit, Fleming Fergal, Noyes Katia, Glocker Roan, Ellis Jennifer, Raman Kathleen, Stoner Michael, Doyle Adam
Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; Division of Surgical Research, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
Division of Surgical Research, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
Ann Vasc Surg. 2018 Jan;46:17-29. doi: 10.1016/j.avsg.2017.08.017. Epub 2017 Sep 6.
Conflicting literature exists regarding resource utilization for cardiovascular care when stratified by provider volume. This study investigates the differences in value of abdominal aortic aneurysm (AAA) repair by high- and low-volume providers. The hypothesis of this study is that high-volume providers will provide superior value AAA repairs when compared to low-volume providers.
Using the New York Statewide Planning and Research Cooperative System database and its linked death database, patients undergoing intact open and endovascular aneurysm repair (EVAR) were identified over a 10-year period. Charge data were normalized to year 2016 dollars and the data stratified by repair modality and annual surgeon volume. Univariate technique was used to compare the 2 groups over a 3-year follow-up period.
Nine hundred eleven surgeons performed open AAA repairs and 615 performed EVAR. For both repair modalities, and despite a patient population with more vascular risk factors, the cumulative adjusted charge for all aneurysm-related care was significantly less for high-volume providers than low-volume providers. The calculated 3-year value-patient life years per cumulative charge-was also superior for high-volume providers compared to low-volume providers. This difference in charge and value persisted after propensity score matching for race, sex, insurance status, and common vascular comorbidities including hypertension, dyslipidemia, and a history of smoking.
High-volume surgeons performing repair of aortic aneurysms provide superior value when compared to low-volume providers. The improved value margin is driven by both lower charge and improved survival, despite an increased incidence of cardiovascular comorbidities. This study adds support for the regionalization of care for patients with aortic aneurysm.
关于按医疗服务提供者手术量分层的心血管护理资源利用情况，现有文献存在相互矛盾的观点。本研究调查了高手术量和低手术量医疗服务提供者进行腹主动脉瘤（AAA）修复的价值差异。本研究的假设是，与低手术量医疗服务提供者相比，高手术量医疗服务提供者将提供更具价值的AAA修复。
利用纽约州全州规划与研究合作系统数据库及其关联的死亡数据库，确定了在10年期间接受完整开放性和血管内动脉瘤修复（EVAR）的患者。收费数据按2016年美元进行标准化，并按修复方式和外科医生年度手术量进行分层。采用单变量技术在3年随访期内比较两组。
911名外科医生进行了开放性AAA修复，615名进行了EVAR。对于这两种修复方式，尽管患者群体存在更多血管危险因素，但高手术量医疗服务提供者的所有动脉瘤相关护理的累计调整收费显著低于低手术量医疗服务提供者。与低手术量医疗服务提供者相比，高手术量医疗服务提供者每累计收费计算出的3年价值-患者生命年数也更高。在对种族、性别、保险状况以及包括高血压、血脂异常和吸烟史在内的常见血管合并症进行倾向得分匹配后，收费和价值的这种差异仍然存在。
与低手术量医疗服务提供者相比，进行主动脉瘤修复的高手术量外科医生提供了更高的价值。尽管心血管合并症的发生率有所增加，但价值优势的提高是由更低的收费和更高的生存率共同推动的。本研究为主动脉瘤患者护理的区域化提供了支持。
