Objective: The safety and efficacy of conventional abdominal aortic aneurysm (AAA) repair are undergoing increased examination in parallel with the development of less invasive repair methods. Because most published studies of elective AAA repair report operations performed in tertiary referral institutions and thus may not reflect the outcome in the surgical community at large, the current population-based study was undertaken to document the results obtained across a broad spectrum of clinical practice in a defined geographic area and to examine the factors that influence the outcomes.
Methods: The Maryland Health Services Cost Review Commission database was used to identify all the elective AAA repairs that were performed in all the nonfederal acute care hospitals in the state from 1990 to 1995.
Results: Elective AAA repair was performed on 2335 patients (mean age, 70.4 years) in 46 of the 52 (88%) nonfederal acute care hospitals in the state, including seven high-volume (>100 cases), nine moderate-volume (50 to 99 cases), and 30 low-volume (<50 cases) institutions. The in-hospital mortality rate was 3.5% and increased significantly with advancing age: less than 65 years, 2.2%; 65 to 69 years, 2.5%; 70 to 79 years, 3.5%; and more than 80 years, 7.3% (P =.002). Mortality rates were higher for women (4.5% vs 3.2%; P =.17), for blacks (6.7% vs 3.2%; P =.046), and for patients with renal failure (11.8% vs 3. 4%; P =.11) but not for patients with hypertension, diabetes, heart disease, and pulmonary disease. The operative mortality rate was inversely correlated with hospital volume (4.3% in low-volume hospitals, 4.2% in moderate-volume hospitals, and 2.5% in high-volume hospitals; P =.08), although no differences were noted in the mean ages or comorbidity levels of patients who underwent operations in these three hospital populations. The operative mortality rate was inversely correlated with the experience of the individual surgeon: one case, 9.9%; two to nine cases, 4.9%; 10 to 49 cases, 2.8%; 50 to 99 cases, 2.9%; and more than 100 cases, 3.8% (P =.01). Multivariate analysis results identified patient age (P =. 002), low hospital volume (P =.039), and very low surgeon volume (P =.01) as independent predictors of operative mortality. The mean length of stay and mean hospital charges were 10.6 days and $17,589 and decreased with increasing surgeon volume: one case, 22.7 days/$32,800; two to nine cases, 10.6 days/$18,509; 10 to 49 cases, 10.0 days/$16,611; 50 to 99 cases, 10.9 days/$17,843; and more than 100 cases, 9.6 days/$16,682 (P <.0001/P <.0001).
Conclusion: Elective AAA repair is a safe procedure in contemporary practice in Maryland. Operative risk is increased among the elderly and when operations are performed by surgeons with very low volumes or in low-volume hospitals. Hospital lengths of stay were shorter and charges were lower when elective AAA repair was performed by surgeons with higher volumes.