Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, Rush Medical College, Rush University Medical Center, Chicago, IL.
Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH.
J Vasc Surg. 2022 Dec;76(6):1548-1554.e1. doi: 10.1016/j.jvs.2022.05.020. Epub 2022 Jun 22.
The interfacility transfer (IT) of patients with a ruptured abdominal aortic aneurysm (rAAA) occurs not infrequently to allow for a higher level of care. In the present study, we evaluated, using a contemporary administrative database, the effects of IT on mortality after rAAA repair.
The Healthcare Cost and Utilization Project Database for New York (2016) and New Jersey, Maryland, and Florida (2016-2017) was queried using the International Classification of Diseases, 10th edition, to identify patients who had undergone open or endovascular repair of AAAs. The hospitals were categorized into quartiles (Qs) per overall volume. The mortality rates for IT vs nontransferred (NT) rAAA patients stratified by treatment modality (open aneurysm repair of an rAAA [rOAR] vs endovascular aneurysm repair of an rAAA [rEVAR]) were compared. A Cox proportional hazard model was used to estimate the hazard ratios (HRs) for mortality.
A total of 1476 patients had presented with a rAAA, of whom 673 (45.7%) were not treated. Of the remaining 803 patients, 226 (28.1%) were transferred, of whom 50 (22.1%) had died without repair after IT. The remaining 753 patients (IT, n = 176; NT, n = 576) had undergone rEVAR (n = 492) or rOAR (n = 261). The baseline characteristics were similar between the IT and NT patients, except for a greater proportion of black patients (P = .03), lower income families (P = .049), and rOAR (45.5% vs 31.4%; P = .001) for the IT patients. The overall mortality rates were similar between the NT (30.2%) and IT (27.3%) groups (P = .46). The subgroup analysis revealed that the operative mortality rates after rEVAR were similar between the NT and IT patients, without significant differences among the hospital quartiles. After rOAR, however, the operative mortality rates were lower for the IT patients, largely owing to improved outcomes in the Q4 hospitals (Q4 vs Q1-Q3, P = .001). Cox regression analysis demonstrated that age (HR, 1.03; 95% confidence interval, 1.00-1.06; P = .02) and treatment at a low-volume hospital (Q1-Q3; HR, 1.89; 95% confidence interval, 1.02-3.51; P = .04) were predictors of mortality. The total charges were similar (IT, $286,727; vs NT, $265,717; P = .38).
The results from the present study have shown that <30% of rAAA patients deemed a candidate for repair will be transferred. We found that IT did not affect the mortality rates after rEVAR, irrespective of the hospital volume. For rOAR candidates, however, regionalization of care with prompt transfer to a high-volume center could improve the survival benefits without increased healthcare costs.
患者腹主动脉瘤破裂（rAAA）的医院间转移（IT）并不少见，这是为了提供更高水平的治疗。在本研究中，我们使用当代行政数据库评估了 IT 对 rAAA 修复后死亡率的影响。
利用纽约（2016 年）和新泽西州、马里兰州、佛罗里达州（2016-2017 年）的医疗保健成本和利用项目数据库，使用国际疾病分类第 10 版，确定接受开放或血管内修复治疗的 AAA 患者。根据总体容量将医院分为四分位数（Qs）。比较了 IT 与非转移（NT）rAAA 患者的死亡率（rOAR 治疗 rAAA 患者与 rEVAR 治疗 rAAA 患者）。使用 Cox 比例风险模型估计死亡率的风险比（HRs）。
共有 1476 例患者出现 rAAA，其中 673 例（45.7%）未接受治疗。在其余 803 例患者中，226 例（28.1%）进行了转移，其中 50 例（22.1%）在 IT 后未经修复死亡。其余 753 例患者（IT，n=176；NT，n=576）接受了 rEVAR（n=492）或 rOAR（n=261）治疗。IT 和 NT 患者的基线特征相似，除了黑人患者的比例较大（P=0.03）、低收入家庭比例较高（P=0.049）和 rOAR 患者比例较高（45.5% vs 31.4%；P=0.001）。NT（30.2%）和 IT（27.3%）组的总死亡率相似（P=0.46）。亚组分析显示，NT 和 IT 患者 rEVAR 后的手术死亡率相似，各医院四分位数之间无显著差异。然而，在 rOAR 后，IT 患者的手术死亡率较低，这主要是由于 Q4 医院的预后改善（Q4 与 Q1-Q3，P=0.001）。Cox 回归分析表明，年龄（HR，1.03；95%置信区间，1.00-1.06；P=0.02）和在低容量医院治疗（Q1-Q3；HR，1.89；95%置信区间，1.02-3.51；P=0.04）是死亡率的预测因素。总费用相似（IT，$286727；vs NT，$265717；P=0.38）。
本研究结果表明，<30%的 rAAA 患者被认为是修复的候选者。我们发现，rEVAR 后 IT 并不影响死亡率，与医院容量无关。然而，对于 rOAR 候选者，通过及时转移到高容量中心进行区域化治疗可以提高生存率，而不会增加医疗成本。
