Age stratified, perioperative, and one-year mortality after abdominal aortic aneurysm repair: A statewide experience

ObjectiveThe purpose of this study was to determine the in-hospital, 30-day, and 365-day mortality for the open repair of abdominal aortic aneurysms (AAAs), when stratified by age, in the general population. Age stratification could provide clinicians with information more applicable to an individual patient than overall mortality figures.MethodsIn a retrospective analysis, data were obtained from the California Office of Statewide Health Planning and Development (OSHPD) for the years 1995 to 1999. Out-of-hospital mortality was determined via linkage to the state death registry. All patients undergoing AAA repair as coded by International Classification of Diseases, 9th Revision (ICD-9) procedure code 38.44 and diagnosis codes 441.4 (intact) and 441.3/441.5 (ruptured) in California were identified. Patients <50 years of age were excluded. We determined in-hospital, 30-day, and 365-day mortality, and stratified our findings by patient age. Multivariate logistic regression was used to determine predictors of mortality in the intact and ruptured AAA cohorts.ResultsWe identified 12,406 patients (9,778 intact, 2,628 ruptured). Mean patient age was 72.4 ± 7.2 years (intact) and 73.9 ± 8.2 (ruptured). Men comprised 80.9% of patients, and 90.8% of patients were white. Overall, intact AAA patient mortality was 3.8% in-hospital, 4% at 30 days, and 8.5% at 365 days. There was a steep increase in mortality with increasing age, such that 365-day mortality increased from 2.9% for patients 51 to 60 years old to 15% for patients 81 to 90 years old. Mortality from day 31 to 365 was greater than both in-hospital and 30-day mortality for all but the youngest intact AAA patients. Perioperative (in-hospital and 30-day) mortality for ruptured cases was 45%, and mortality at 1 year was 54%.ConclusionsThere is continued mortality after the open repair of AAAs during postoperative days 31 to 365 that, for many patients, is greater than the perioperative death rate. This mortality increases dramatically with age for both intact and ruptured AAA repair

Disparities in the Utilization of High-Volume Hospitals for Complex Surgery

Context Referral to high-volume hospitals has been recommended for operations with a demonstrated volume-outcome relationship. The characteristics of patients who receive care at low-volume hospitals may be different from those of patients who receive care at high-volume hospitals. These differences may limit their ability to access or receive care at a high-volume hospital. Objective To identify patient characteristics associated with the use of high-volume hospitals, using California’s Office of Statewide Health Planning and Development patient discharge database. Design, Setting, and Participants Retrospective study of Californians receiving the following inpatient operations from 2000 through 2004: elective abdominal aortic aneurysm repair, coronary artery bypass grafting, carotid endarterectomy, esophageal cancer resection, hip fracture repair, lung cancer resection, cardiac valve replacement, coronary angioplasty, pancreatic cancer resection, and total knee replacement. Main Outcome Measures Patient race/ethnicity and insurance status in highvolume (highest 20% of patients by mean annual volume) and in low-volume (lowest 20%) hospitals. Results A total of 719 608 patients received 1 of the 10 operations. Overall, nonwhites, Medicaid patients, and uninsured patients were less likely to receive care at high volume hospitals and more likely to receive care at low-volume hospitals when controlling for other patient-level characteristics. Blacks were significantly (P.05) less likely than whites to receive care at high-volume hospitals for 6 of the 10 operations (relative risk [RR] range, 0.40-0.72), while Asians and Hispanics were significantly less likely to receive care at high-volume hospitals for 5 (RR range, 0.60-0.91) and 9 (RR range, 0.46-0.88), respectively. Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for 7 of the operations (RR range, 0.22-0.66), while uninsured patients were less likely to be treated at high volume hospitals for 9 (RR range, 0.20-0.81). Conclusions There are substantial disparities in the characteristics of patients receiving care at high-volume hospitals. The interest in selective referral to high volume hospitals should include explicit efforts to identify the patient and system factors required to reduce current inequities regarding their use