医疗保险患者中行开放手术、血管内和分支开窗血管内主动脉瘤修复术的国家趋势。
National trends in open surgical, endovascular, and branched-fenestrated endovascular aortic aneurysm repair in Medicare patients.
机构信息
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; VA Outcomes Group, White River Junction, Vt; Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH.
出版信息
J Vasc Surg. 2018 Jun;67(6):1690-1697.e1. doi: 10.1016/j.jvs.2017.09.046. Epub 2017 Dec 28.
BACKGROUND
Open repair effectively prevents rupture for patients with abdominal aortic aneurysm (AAA) and is commonly studied as a metric reflecting hospital and surgeon expertise in cardiovascular care. However, given recent advances in endovascular aneurysm repair (EVAR), such as branched-fenestrated EVAR, it is unknown how commonly open surgical repair is still used in everyday practice.
METHODS
We analyzed trends in open AAA repair, EVAR, and branched-fenestrated EVAR for AAA in Medicare beneficiaries from 2003 to 2013. We used Medicare Part B claims to ascertain counts of these repair types annually during the study period. We assessed regional and national trends in characteristics of the patients and procedure volume.
RESULTS
Between 2003 and 2013, the total number of AAA repairs performed in fee-for-service Medicare patients declined by 26% from 31,582 to 23,421 (P < .001), after a peak number of 32,540 was performed in 2005 (28% decline since 2005). The number of open AAA repairs steadily declined by a total of 76%, from 20,533 in 2003 to 4916 in 2013 (P < .001). Whereas the number of EVARs increased from 11,049 in 2003 to 19,247 in 2011 (P < .001), it has since declined a total of 15% to only 16,362 repairs in 2013 (P < .001). After its introduction in 2011, the number of branched-fenestrated EVAR cases continuously rose from 335 procedures in 2011 to 2143 procedures in 2013 (P < .001). By 2013, virtually all hospital referral regions in the United States had rates of open AAA repair that would have been in the lowest quintile of volume in 2003.
CONCLUSIONS
The number of open AAA repairs fell by nearly 80% during the last decade, whereas traditional EVAR declined slightly and branched-fenestrated EVAR rapidly disseminated into national practice. These results suggest that open AAA repair is now performed too infrequently to be used as a metric in the assessment of hospital and surgeon quality in cardiovascular care. Furthermore, surgical training paradigms will need to reflect the changing dynamics necessary to ensure that surgeons and interventionists can safely perform these high-risk surgical procedures.
背景
开放修复有效地防止了腹主动脉瘤（AAA）的破裂，并且通常被研究为反映医院和外科医生在心血管护理方面专业知识的指标。然而，鉴于血管内动脉瘤修复（EVAR）的最新进展，例如分支型 EVAR，目前尚不清楚在日常实践中仍广泛使用哪种开放性手术修复。
方法
我们分析了 2003 年至 2013 年 Medicare 受益人的开放性 AAA 修复、EVAR 和分支型 EVAR 治疗 AAA 的趋势。我们使用 Medicare 第 B 部分的索赔来确定研究期间每年这些修复类型的数量。我们评估了患者特征和手术量的区域和国家趋势。
结果
在 2003 年至 2013 年期间，在按服务付费的 Medicare 患者中进行的 AAA 修复总数下降了 26%，从 31582 例降至 23421 例（P<.001），2005 年达到了 32540 例的峰值（自 2005 年以来下降了 28%）。开放性 AAA 修复的数量稳步下降了 76%，从 2003 年的 20533 例降至 2013 年的 4916 例（P<.001）。尽管 EVAR 的数量从 2003 年的 11049 例增加到 2011 年的 19247 例（P<.001），但此后已总共下降了 15%，2013 年仅为 16362 例（P<.001）。分支型 EVAR 病例自 2011 年推出以来，数量从 2011 年的 335 例持续增加到 2013 年的 2143 例（P<.001）。到 2013 年，美国几乎所有的医院转诊区的开放性 AAA 修复率都将处于 2003 年最低五分位数。
结论
在过去十年中，开放性 AAA 修复的数量下降了近 80%，而传统的 EVAR 略有下降，分支型 EVAR 迅速传播到全国实践中。这些结果表明，开放性 AAA 修复现在的实施频率太低，无法用作评估心血管护理中医院和外科医生质量的指标。此外，手术培训模式将需要反映出必要的动态变化，以确保外科医生和介入医生能够安全地进行这些高风险的手术。
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