Trooboff Spencer W, Wanken Zachary J, Gladders Barbara, Columbo Jesse A, Lurie Jon D, Goodney Philip P
Section of General Surgery (S.W.T.), Dartmouth-Hitchcock Medical Center, Lebanon, NH.
VA Quality Scholars Program, Veterans Health Association, White River Junction, VT (S.W.T., J.A.C.).
Circ Cardiovasc Qual Outcomes. 2020 May;13(5):e006249. doi: 10.1161/CIRCOUTCOMES.119.006249. Epub 2020 May 7.
Endovascular repair (EVR) has replaced open surgery as the procedure of choice for patients requiring elective abdominal aortic aneurysm (AAA) repair. Long-term outcomes of the 2 approaches are similar, making the relative cost of caring for these patients over time an important consideration.
We linked Medicare claims to Vascular Quality Initiative registry data for patients undergoing elective EVR or open AAA repair from 2004 to 2015. The primary outcome was Medicare's cumulative disease-related spending, adjusted to 2015 dollars. Disease-related spending included the index operation and associated hospitalization, surveillance imaging, reinterventions (AAA-related and abdominal wall procedures), and all-cause admissions within 90 days. We compared the incidence of disease-related events and cumulative spending at 90 days and annually through 7 years of follow-up. The analytic cohort comprised 6804 EVR patients (median follow-up: 1.85 years; interquartile range: 0.82-3.22 years) and 1889 open repair patients (median follow-up: 2.62 years; interquartile range: 1.13-4.80 years). Spending on index surgery was significantly lower for EVR (median [interquartile range]: $25 924 [$22 280-$32 556] EVR versus $31 442 [$24 669-$40 419] open; <0.001), driven by a lower rate of in-hospital complications (6.6% EVR versus 38.0% open; <0.001). EVR patients underwent more surveillance imaging (1.8 studies per person-year EVR versus 0.7 studies per person-year open; <0.001) and AAA-related reinterventions (4.0 per 100 person-years EVR versus 2.1 per 100 person-years open; =0.041). Open repair patients had higher rates of 90-day readmission (12.9% EVR versus 17.8% open; <0.001) and abdominal wall procedures (0.6 per 100 person-years EVR versus 1.5 per 100 person-years open; <0.001). Overall, EVR patients incurred more disease-related spending in follow-up ($7355 EVR versus $2706 open through 5 years). There was no cumulative difference in disease-related spending between surgical groups by 5 years of follow-up (-$33 EVR [95% CI: -$1543 to $1476]).
We observed no cumulative difference in disease-related spending on EVR and open repair patients 5 years after surgery. Generalized recommendations about which approach to offer elective AAA patients should not be based on relative cost.
血管内修复术（EVR）已取代开放手术，成为需要择期腹主动脉瘤（AAA）修复患者的首选治疗方法。两种治疗方法的长期疗效相似，因此随着时间推移，照顾这些患者的相对成本成为一个重要的考虑因素。
我们将医疗保险理赔数据与血管质量倡议登记数据相链接，纳入2004年至2015年接受择期EVR或开放性AAA修复的患者。主要结局是医疗保险的累积疾病相关支出，已根据2015年美元进行调整。疾病相关支出包括首次手术及相关住院治疗、监测成像、再次干预（与AAA相关和腹壁手术）以及90天内的全因住院。我们比较了疾病相关事件的发生率以及90天时和长达7年随访期间每年的累积支出。分析队列包括6804例接受EVR的患者（中位随访时间：1.85年；四分位间距：0.82 - 3.22年）和1889例接受开放修复的患者（中位随访时间：2.62年；四分位间距：1.13 - 4.80年）。EVR的首次手术支出显著更低（中位值[四分位间距]：EVR为25924美元[22280 - 32556美元]，开放手术为31442美元[24669 - 40419美元]；<0.001），这是由于住院并发症发生率较低（EVR为6.6%，开放手术为38.0%；<0.001）。EVR患者接受更多的监测成像检查（EVR每人每年1.8次检查，开放手术每人每年0.7次检查；<0.001）以及与AAA相关的再次干预（EVR每100人年4.0次，开放手术每100人年2.1次；=0.041）。接受开放修复的患者90天再入院率更高（EVR为12.9%，开放手术为17.8%；<0.001），腹壁手术率也更高（EVR每100人年0.6次，开放手术每100人年1.5次；<0.001）。总体而言，EVR患者在随访期间产生的疾病相关支出更多（EVR为7355美元，开放手术至5年时为2706美元）。至随访5年时，手术组之间的疾病相关支出无累积差异（EVR为 - 33美元[95%置信区间： - 1543至1476美元]）。
我们观察到术后5年，EVR和开放修复患者在疾病相关支出方面无累积差异。对于择期AAA患者应采用哪种治疗方法的一般性建议不应基于相对成本。
