Outcomes and Cost Comparison of Percutaneous Endovascular Aortic Repair versus Endovascular Aortic Repair With Open Femoral Exposure.

BACKGROUND: The objective of this study was to assess cost differences between patients who underwent percutaneous endovascular aortic repair (PEVAR) and open surgical femoral exposure in elective endovascular aortic repair (EVAR) of abdominal aortic aneurysms. MATERIALS AND METHODS: An IRB-approved single center retrospective analysis of patients who underwent elective EVAR for abdominal aortic aneurysms from 2009 to 2016 was performed. One hundred patients were selected with 50 patients who underwent PEVAR and 50 patients who underwent open surgical femoral exposure. Patient demographics, procedural variables, and hospital outcomes were collected and compared. Primary outcomes assessed used in cost calculations included operating time (OR time), hospital length of stay (LOS), and intensive care unit stay (ICU LOS). Extrapolated cost differences were based on known, published cost multipliers for the primary outcomes observed. RESULTS: Patients undergoing PEVAR had significant reduction in mean OR time (113.9 min versus 144.9 min, P < 0.001), mean ICU LOS (19.7 h versus 28.9 h, P = 0.094), and overall LOS (28.3 h versus 33.1 h, P = 0.020). There was no statistically significant difference in access related complications, although there was a trend toward less complication rates with PEVAR (0% versus 5%, P = 0.056). Calculated cost of procedures based on mean ICU LOS, hospital LOS, and OR time, showed significant reduction in mean hospital costs with PEVAR ($16,628.5 versus $21,705.8, P < 0.001). Multiple linear regression analysis demonstrated an overall 23% cost reduction with PEVAR. CONCLUSIONS: Prior reports comparing PEVAR versus EVAR with open femoral exposures have shown improvement in overall patient time to ambulation and other hospital metrics such as LOS with PEVAR. There is, however, a paucity of overall cost comparison data regarding PEVAR. In this study, adoption of PEVAR was seen to significantly reduce OR times (19%) and overall hospital LOS (50%). The outcomes observed ultimately translated into significant reduction in hospital costs.

Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic Practice.

BACKGROUND: Insurance coverage of vascular surgery patients may differ from patients with less chronic surgical pathologies. The goal of this study is to identify trends in insurance status of vascular surgery patients over the last 10 years at a busy academic center. METHODS: All consecutive patient visits for a vascular procedure from 2006 to 2016 were retrospectively reviewed from a prospectively collected institutional database. Data points included insurance status, procedures performed, and date of admission. The insurance status was categorized as Medicare, Medicaid, and uninsured. Samples were divided between 2006-2009 and 2011-2016 for comparison. Unpaired t-test, chi-squared test, and regression analysis were used to determine significant trends over the study period. RESULTS: From 2006 to 2016, 6,007 vascular surgery procedures were performed. Procedure volume increased significantly from 1,309 to 4,698 between the 2 timeframes (P < 0.05), whereas the percentage of Medicaid and Medicare patients trended upward but did not achieve significance. There was a significant decrease in the percentage of uninsured patients between the cohorts (5.65% vs. 2.96%, P < 0.05). In 2012, 10.14% of patients were uninsured compared with 2.56% in 2016 (P < 0.05). CONCLUSIONS: Insurance status affects access to care and subsequent outcomes. In our busy academic center, insurance coverage for vascular surgery has significantly increased over the past decade. The number of Medicaid and Medicare patients has slowly increased, but a significant and continuing decline in uninsured patients was observed. Implementation of the Affordable Care Act during this time period may have played a role in providing coverage for patient needing vascular surgery.

Epidemiology of Peripheral Arterial Disease and Critical Limb Ischemia.

With a rise in the aging popluation, the prevalence of peripheral arterial disease (PAD) is markedly increasing. The overall disease prevalence of PAD is in the range of 3%-10%, which increases to 15%-20% in persons older than 70 years of age. Given this upward trend in disease prevalence, the economic and societal burden of PAD would be considerable. The subgroup of patients who develop critical limb ischemia (CLI) represents the most challenging population to manage medically, surgically, and endovascularly. Patients with symptomatic PAD and CLI have an increased risk for death and cardiovascular events, especially in those with CLI who carry with them a substantial risk of limb loss. Advances in medical, surgical, and endovascular techniques have shown excellent outcomes in the treatment of these patients, however the optimal management paradigm has not been elucidated. This article reviews the classification and epidemiology, risk factors, natural history, and health care costs associated with PAD and CLI.

Preventable Complications Driving Rising Costs in Management of Patients with Critical Limb Ischemia.

BACKGROUND: This study aimed to identify factors that drive increasing health-care costs associated with the management of critical limb ischemia in elective inpatients. METHODS: Patients with a primary diagnosis code of critical limb ischemia (CLI) were identified from the 2001-2011 Nationwide Inpatient Sample. Demographics, CLI management, comorbidities, complications (bleeding, surgical site infection [SSI]), length of stay, and median in-hospital costs were reviewed. Statistical analysis was completed using Students' t-test and Mann-Kendall trend analysis. Costs are reported in 2011 US dollars corrected using the consumer price index. RESULTS: From 2001 to 2011, there were a total of 451,823 patients who underwent open elective revascularization as inpatients for CLI. Costs to treat CLI increased by 63% ($12,560 in 2001 to $20,517 in 2011, P < 0.001 in trend analysis). Endovascular interventions were 20% more expensive compared with open surgery ($19,566 vs. $16,337, P < 0.001). Age, gender, and insurance status did not affect the cost of care. From 2001 to 2011, the number of patient comorbidities (7.56-12.40) and percentage of endovascular cases (13.4% to 27.4%) increased, accounting for a 6% annual increase in total cost despite decreased median length of stay (6 to 5 days). Patients who developed SSI had total costs 83% greater than patients without SSIs ($30,949 vs. $16,939; P < 0.001). Patients who developed bleeding complications had total costs 41% greater than nonbleeding patients ($23,779 vs. $16,821, P < 0.001). Overall, there was a 32% reduction in SSI rates but unchanged rates of bleeding complications during this period. CONCLUSIONS: The cost of CLI treatment is increasing and driven by rising endovascular use, SSI, and bleeding in the in-patient population. Further efforts to reduce complications in this patient population may contribute to a reduction in health care-associated costs of treating CLI.

A Cross-Sectional Survey of Interventional Radiologists and Vascular Surgeons Regarding the Cost and Reimbursement of Common Devices and Procedures.

PURPOSE: To evaluate knowledge of interventional radiologists (IRs) and vascular surgeons (VSs) on the cost of common devices and procedures and to determine factors associated with differences in understanding. MATERIALS AND METHODS: An online survey was administered to US faculty IRs and VSs. Demographic information and physicians' opinions on hospital costs were elicited. Respondents were asked to estimate the average price of 15 commonly used devices and to estimate the work relative value units (wRVUs) and average Medicare reimbursements for 10 procedures. Answer estimates were deemed correct if values were ± 25% of the actual costs. Multivariate logistical regression was used to calculate odds ratios and 95% confidence intervals. RESULTS: Of the 4,926 participants contacted, 1,090 (22.1%) completed the questionnaire. Overall, 19.8%, 22.8%, and 31.9% were accurate in price estimations of devices, Medicare reimbursement, and wRVUs for procedures. Physicians who thought themselves adequately educated about wRVUs were more accurate in predicting procedural costs in wRVUs than physicians who responded otherwise (odds ratio = 1.40, 95% confidence interval, 1.29-1.52; P < .0001). Estimation accuracies for procedures showed a positive trend in more experienced physicians (≥ 16 y), private practice physicians, and physicians who practice in rural areas. CONCLUSIONS: This study suggests that IRs and VSs have limited knowledge regarding device costs. Given the current health care environment, more attention should be placed on cost education and awareness so that physicians can provide the most cost-effective care.

Assessment of an innovative antimicrobial surface disinfectant in the operating room environment using adenosine triphosphate bioluminescence assay.

Terminal cleaning in the operating room is a critical step in preventing the transmission of health care-associated pathogens. The persistent disinfectant activity of a novel isopropyl alcohol/organofunctional silane solution (ISO) was evaluated in 4 operating rooms after terminal cleaning. Adenosine triphosphate bioluminescence documented a significant difference (P < .048) in surface bioburden on IOS-treated surfaces versus controls. RODAC plate cultures revealed a significant (P < .001) reduction in microbial contamination on IOS-treated surfaces compared with controls. Further studies are warranted to validate the persistent disinfectant activity of ISO within selective health care settings.