Rural Hospitals Face a Higher Burden of Ruptured Abdominal Aortic Aneurysm and Are More Likely to Transfer Patients for Emergent Repair
ABSTRACT The influence of rural hospital location on abdominal aortic aneurysm (AAA) outcomes is unknown. We undertook a study to determine the difference in the risk of ruptured AAA presentation and outcomes after ruptured AAA between rural and urban areas.
Patients in the Nationwide Inpatient Sample from 2001 to 2007, with intact AAA repair or ruptured AAA, were included. Patients transferred from another hospital, with unrecorded hospital ZIP code, or age less than 50 years were excluded. Health system variables were obtained from the Area Resource File. Vascular surgeon census was determined from the Society for Vascular Surgery online registry. Multivariable logistic regression was used to analyze outcomes in patients with AAA, adjusting for patient, hospital, and health system variables.
Rural hospital location was associated with higher risk of ruptured AAA presentation (odds ratio [OR] 2.46, 95% CI 1.90 to 3.19) and transfer to another hospital without ruptured AAA repair (9.3% vs 1.4%, p < 0.001). The adjusted risk of death was similar for patients with ruptured AAA admitted to rural and urban hospitals (OR 0.96, 95% CI 0.73 to 1.27). Hospital elective AAA repair volume less than 15 was a risk factor for death after ruptured AAA.
Rural hospitals face a disproportionate burden of ruptured AAA and are more likely to transfer patients with ruptured AAA without performing repair, compared with urban hospitals. Solutions to rural disparity in ruptured AAA outcomes should focus on improving rural patients' access to vascular surgeons for elective and emergent AAA repair.
- [Show abstract] [Hide abstract]
ABSTRACT: Ruptured abdominal aortic aneurysm (rAAA) is a critically time-sensitive condition with outcomes dependent on rapid diagnosis and definitive treatment. Emergency department (ED) death reflects the hemodynamic stability of the patient upon arrival and the ability to mobilize resources before hemodynamic stability is lost. The goals of this study were to determine the incidence and predictors of ED death for patients presenting to EDs with rAAAs. Data for patients presenting with International Classification of Disease, 9th Revision, Clinical Modification codes for rAAA from 2006 to 2008 were extracted from discharge data using the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. The NEDS is the largest stratified weighted sample of US hospital-based ED visits with links to inpatient files. We compared those transferred to those admitted and treated. Sample weights were applied to produce nationally representative estimates. Patient and hospital factors associated with transfer were identified using multivariate logistic regression. These factors were then analyzed for a relationship with ED deaths. A total of 18,363 patients were evaluated for rAAAs. Of these, 7% (1201) died in the ED, 6% (1160) were admitted and died without a procedure, 42% (7731) were admitted and died after repair, and 41% (7479) were admitted, treated, and survived. Transfers accounted for 4% (793) of all ED visits for rAAAs. ED death was more likely for patients seen in nonmetropolitan hospitals (12.7%) vs metropolitan nonteaching (7.0%) or metropolitan teaching hospitals (4.5%; P < .0001). Compared with other regions, the West had a higher ED mortality rate (9.6% vs 5.1%-6.9%; P = .0038). On multivariate analysis, ED death was associated with hospital groups exhibiting both high and low transfer rates. ED death remains a significant cause for mortality for rAAAs and varies by hospital type, rural/urban location, and geographic region. Both delays in ED arrival and delays in providing definitive care may contribute to increased ED death rates, suggesting that improved regional systems of care may improve survival after rAAA.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2012; 56(3):651-5. DOI:10.1016/j.jvs.2012.02.025 · 2.98 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Background Rural and regional populations suffer higher rates of preventable disease and all-cause mortality than urban areas, with rural areas of the USA experiencing double the rate of ruptured abdominal aortic aneurysms (AAAs). We investigated the incidence and outcomes of ruptured AAAs in an Australian rural and regional setting, and compared these with those of an urban population. Methods We undertook a retrospective analysis of all patients suffering AAA rupture in New South Wales (NSW) from 2009/2010 to 2010/2011. Variables included rates of rupture, mortality and intensive care admission. Urban and rural-regional areas were stratified according to NSW Health Local Health Districts, and comparisons between the two groups were performed. ResultsRuptured AAAs had an incidence of 4.1/100000, with males twice as likely to suffer AAA rupture (P = 0.009), but females 88% more likely to die from rupture (P = 0.001). There was no significant difference between AAA rupture rates (5.0 versus 3.4 per 100000; P = 0.054) nor case-fatality rates (41.22% versus 40.94%; P = 0.087) in rural-regional and urban populations. Patients in urban areas had a longer hospital stay (5 days versus 1 day, P = 0.001), were more likely to be admitted to intensive care unit (29.4% versus 19.9%, P = 0.001) and were less likely to be transferred to another hospital (19% versus 32%, P = 0.001). ConclusionsAAA ruptures remain a significant public health burden. Rural and regional areas suffer disproportionately, which may be improved by implementation of AAA screening and funding for rural and regional hospitals to sustain adequate surgical and intensive care facilities.ANZ Journal of Surgery 01/2013; 83(11). DOI:10.1111/ans.12080 · 1.12 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Our aim was to determine national trends in treatment of ruptured abdominal aortic aneurysm (RAAA), with specific emphasis on open surgical repair (OSR) and endovascular aneurysm repair (EVAR) and its impact on mortality and complications. Data from the Nationwide Inpatient Sample (NIS) from 2005 to 2009 were queried to identify patients older than 59 years with RAAA. Three groups were studied: nonoperative (NO), EVAR, and OSR. Chi-square analysis was used to determine the relationship between treatment type and patient demographics, clinical characteristics, and hospital type. The impact of EVAR compared with OSR on mortality and overall complications was examined using logistic regression analysis. We identified 21,206 patients with RAAA from 2005 to 2009, of which 16,558 (78.1%) underwent operative repair and 21.8% received no operative treatment. In the operative group, 12,761 (77.1%) underwent OSR and 3,796 (22.9%) underwent EVAR. Endovascular aneurysm repair was more common in teaching hospitals (29.1% vs 15.2%, p < .0001) and in urban versus rural settings. Nonoperative approach was twice as common in rural versus urban hospitals. Reduced mortality was seen in patients transferred from another institutions (31.2% vs 39.4%, p = 0.014). Logistic regression analysis demonstrated a benefit of EVAR on both complication rate (OR = 0.492; CI, 0.380-0.636) and mortality (OR=0.535; CI, 0.395-0.724). Endovascular aneurysm repair use is increasing for RAAA and is more common in urban teaching hospitals while NO therapy is more common in rural hospitals. Endovascular aneurysm repair is associated with reduced mortality and complications across all age groups. Efforts to reduce mortality from RAAA should concentrate on reducing NO and OSR in patients who are suitable for EVAR.Journal of the American College of Surgeons 04/2013; 216(4):745-54. DOI:10.1016/j.jamcollsurg.2012.12.028 · 4.45 Impact Factor