Factors impacting functional health and resource utilization following abdominal aortic aneurysm repair by open and endovascular techniques.

We assessed the impact on patient outcomes of comorbidities and type of aneurysm repair, open vs. endovascular aortic repair (EVAR). Functional health status was measured prospectively using the Short Form 36 (SF-36) Health Survey. Length of stay (LOS) and need for postdischarge resources (nursing and rehabilitation) were compared between groups. We reviewed the records of 218 patients (126 open, 92 EVAR) who underwent intervention between 1998 and 2003. The SF-36 was completed preoperatively and at intervals ranging from 2 weeks to 1 year after intervention. To identify factors impacting outcome, univariate and multivariate analyses were performed. Overall mortality was 1.9%: 3.2% for open repair and 0% for EVAR (p = 0.13). Physical and mental health were higher during the 3 months following EVAR compared with open repair: physical function (PF) (65.2 +/- 4.1 vs. 54.0 +/- 4.1), vitality (VT) (55.5 +/- 2.5 vs. 44.9 +/- 3.4), and emotional role (ER) (74.9 +/- 5.0 vs. 51.4 +/- 6.7) (analysis of variance p < 0.05). Women following EVAR had decreased physical summary scores (PSS) (34.8 +/- 2.5 vs. 40.4 +/- 1.1, p < 0.05) compared with men postprocedure despite no difference preoperatively. Congestive heart failure (CHF) was an independent factor that negatively impacted PF, body pain (BP), and PSS. EVAR was associated with improved VT and ER. Differences among open repair and EVAR diminished over time. LOS (in days) was greater for open vs. EVAR (9.2 +/- 0.78 vs. 2.0 +/- 0.17) and in women following both open (11.8 +/- 1.5 vs. 8.0 +/- 0.9) and EVAR (3.2 +/- 0.9 vs. 1.8 +/- 0.1) procedures (p < 0.05). Factors that adversely affected LOS were open repair, age, renal insufficiency, pulmonary disease, CHF, and female gender. Following EVAR, patients were less likely to require home care or transfer to a rehabilitation facility than after open repair (14.1 vs. 36.0%, p < 0.05). Women were significantly more likely to require postdischarge care after open repair (48.7 vs. 30.1%) and EVAR (41.7 vs. 10.0%) (p < 0.05). Logistic regression identified female gender, open repair, advanced age, and pulmonary disease as independent predictors of need for postdischarge care. Those patients undergoing abdominal aortic aneurysm (AAA) repair by open technique (compared to EVAR) had significantly impaired functional health with regard to PF, VT, and ER in the first 3 months after surgery. CHF and hypertension also significantly impaired individual functional health scores. Of significance was that female gender was associated with increased LOS and increased utilization of postdischarge nursing and rehabilitation resources following both open and endovascular surgery for AAA.

Resource utilization and outcomes: effect of transfer on patients with ruptured abdominal aortic aneurysms.

We evaluated the transfer of patients with the diagnosis of a ruptured AAA (rAAA) from community centers to a tertiary care center. Our purpose was to identify factors associated with mortality and outcomes following the open repair of rAAA and to evaluate the differences between transferred and nontransferred patients. All patients who underwent repair of rAAA at our institution between 1995 and 2002 were retrospectively reviewed. Univariate and multivariate analysis was performed to identify patient specific factors on presentation and intraoperatively. Fifty-two patients underwent repair of rAAA, 20 patients were transferred to our institution. The overall mortality rate was 67%. The mortality rates for nontransferred and transferred groups were 69% and 65%, respectively. The incidence of mortality within 24 hr of surgery was significantly higher in the patients who were not transferred, 10 vs. 41% (p < 0.05). Patient-specific factors assessed for impact on survival by logistic regression included decreased body temperature on arrival to our institution (p = 0.02) and free rupture (p = 0.05). Of intraoperative factors tested, low systolic blood pressure was significantly associated with mortality (p = 0.05). No difference in total length of stay was noted. Transfer patients' length of stay in the intensive care unit was significantly greater than that of nontransferred patients (18.8 +/- vs. 7.3 +/- days, p < 0.05). The difference in ICU cost was dollar 36,000 among groups. We found the acceptance of transfer patients from community centers with rAAA did not adversely affect patient survival. Transferred patients had an over twofold increases in ICU days used. The identification of hypothermia was the single independent factor associated with poor survival and may be a marker for transfer selection. Given reduced reimbursements and increased utilization, tertiary care centers will need to consider the economic ramifications of accepting transfer patients with rAAA.