title: Superior outcomes for rural patients after abdominal aortic aneurysm repair supports a systematic regional approach to abdominal aortic aneurysm care.
abstract: OBJECTIVE
  The impact of geographic isolation on abdominal aortic aneurysm (AAA) care in the United States is unknown. It has been postulated but not proven that rural patients have less access to endovascular aneurysm repair (EVAR), vascular surgeons, and high-volume treatment centers than their urban counterparts, resulting in inferior AAA care. The purpose of this study was to compare the national experience for treatment of intact AAA for patients living in rural areas or towns with those living in urban areas.
  
  
  METHODS
  Patients who underwent intact AAA repair in 2005 to 2006 were identified from a standard 5% random sample of all Medicare beneficiaries. Data on patient demographics, comorbidities, type of repair, and specialty of operating surgeon were collected. Hospitals were stratified into quintiles by yearly AAA volume. Primary outcomes included 30-day mortality and rehospitalization.
  
  
  RESULTS
  A total of 2616 patients had repair for intact AAA (40% open, 60% EVAR). Patients from rural and urban areas were equally likely to receive EVAR (rural 60% vs urban 61%; P = .99) and be treated by a vascular surgeon (rural 48% vs urban 50%; P = .82). Most rural patients (86%) received care in urban centers. Primary outcomes occurred in 11.6% of rural patients (1.3% 30-day mortality; 10.3% rehospitalization) vs 16.0% of urban patients (3% 30-day mortality, 13% rehospitalization; P = .04). In multivariate analyses, rural residence was independently associated with treatment at high-volume centers (odds ratio, 1.64; 95% confidence interval, 1.34-2.01; P < .0001) and decreased death or rehospitalization (odds ratio, 0.69; 95% confidence interval, 0.49-0.97; P = .03).
  
  
  CONCLUSIONS
  Despite geographic isolation, patients in rural areas needing treatment for intact AAAs have equivalent access to EVAR and vascular surgeons, increased referral to high-volume hospitals, and improved outcomes after repair. This suggests that urban patients may be disadvantaged even with nearby access to high-quality centers. This study supports the need for criteria that define centers of excellence to extend the benefit of regionalization to all patients.
authors.affiliation: Division of Vascular Surgery, Stanford University, Stanford, Calif, USA. mwmell@stanford.edu
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Mell
authors.forename: Christie
authors.initials: C
authors.lastname: Bartels
authors.forename: Amy
authors.initials: A
authors.lastname: Kind
authors.forename: Glen
authors.initials: G
authors.lastname: Leverson
authors.forename: Maureen
authors.initials: M
authors.lastname: Smith
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010359:Patient Readmission; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000601:surgery; D012086:Reoperation; D012111:Residence Characteristics; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D019035:Rural Health Services; D013997:Time Factors; D014187:Transportation of Patients; D016896:Treatment Outcome; D014481:United States; D019037:Urban Health Services; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality