Division of Cardiac, Thoracic, and Vascular Surgery, NewYork-Presbyterian Columbia University Medical Center, New York, NY.
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
J Vasc Surg. 2021 Sep;74(3):851-860. doi: 10.1016/j.jvs.2021.02.047. Epub 2021 Mar 26.
A nationwide variation in mortality stratified by hospital volume exists after open repair of complex abdominal aortic aneurysms (AAAs). In the present study, we assessed whether the rates of postoperative complications or failure-to-rescue (defined as death after a major postoperative complication) would better explain the lower mortality rates among higher volume hospitals.
Using the 2004 to 2018 Vascular Quality Initiative database, we identified all patients who had undergone open repair of elective or symptomatic AAAs, in which the proximal clamp sites were at least above one renal artery. We divided the patients into hospital quintiles according to the annual hospital volume and compared the risk-adjusted outcomes. Multivariable logistic regression, adjusted for patient characteristics, operative factors, and hospital volume, was used to evaluate three outcomes: 30-day mortality, overall complications, and failure-to-rescue.
We identified 3566 patients who had undergone open repair of elective or symptomatic complex AAAs (median age, 71 years; 29% women; 4.1% black; 48% Medicare insurance). The unadjusted rates of 30-day postoperative mortality, overall complications, and failure-to-rescue were 5.0%, 44%, and 10%, respectively. Common complications included renal dysfunction (25%), cardiac dysrhythmia (14%), and pneumonia (14%), with the specific failure-to-rescue rate ranging from 12% to 22%. On adjusted analysis, the risk-adjusted mortality rate was 2.5 times greater for the lower volume hospitals relative to the higher volume hospitals (7.4% vs 3.0%; P < .01). Although the risk-adjusted complication rates were similar between these hospital groups (30% vs 27%; P = .06), the failure-to-rescue rate was 2.3 times greater for the lower volume hospitals relative to the higher volume hospitals (6.3% vs 2.7%; P = .02).
Higher volume hospitals had lower mortality rates after open repair of complex AAAs because they were better at the "rescue" of patients after the occurrence of postoperative complications. Both an understanding of the clinical mechanisms underlying this association and the regionalization of open repair might improve patient outcomes.
在开放性复杂腹主动脉瘤（AAA）修复后，按医院容量分层存在死亡率的全国性差异。在本研究中，我们评估了术后并发症发生率或救援失败（定义为重大术后并发症后死亡）是否可以更好地解释高容量医院较低的死亡率。
使用 2004 年至 2018 年血管质量倡议数据库，我们确定了所有接受择期或有症状 AAA 开放性修复的患者，近端夹闭部位至少在一个肾动脉以上。我们根据医院每年的容量将患者分为五组，并比较了风险调整后的结果。多变量逻辑回归，根据患者特征、手术因素和医院容量进行调整，用于评估三个结果：30 天死亡率、总并发症和救援失败。
我们确定了 3566 名接受择期或有症状复杂 AAA 开放性修复的患者（中位年龄 71 岁；29%为女性；4.1%为黑人；48%为医疗保险）。未经调整的 30 天术后死亡率、总并发症和救援失败率分别为 5.0%、44%和 10%。常见并发症包括肾功能障碍（25%）、心律失常（14%）和肺炎（14%），具体救援失败率在 12%至 22%之间。在调整分析中，低容量医院的风险调整死亡率是高容量医院的 2.5 倍（7.4%比 3.0%；P<.01）。尽管这些医院组之间的风险调整并发症率相似（30%比 27%；P=0.06），但低容量医院的救援失败率是高容量医院的 2.3 倍（6.3%比 2.7%；P=0.02）。
高容量医院在开放性复杂 AAA 修复后死亡率较低，因为他们在术后并发症发生后更擅长“救援”患者。对这种关联的临床机制的理解以及开放性修复的区域化可能会改善患者的预后。
