title: Socioeconomic and geographic disparities in access to endovascular abdominal aortic aneurysm repair.
abstract: BACKGROUND
  Within Southwestern Ontario, abdominal aortic aneurysm (AAA) surgery has been centralized to a single university-affiliated medical center. The referral area serves 1.9 million people and includes community hospitals with limited vascular surgery capabilities. We reviewed the role of patients' travel distance, geographic location, and socioeconomic status (SES) to determine if centralization of endovascular programs results in disparity in access to endovascular surgery. We hypothesized that patients would travel a longer distance to specifically seek elective endovascular surgery while having open and emergent surgery closer to home.
  
  
  METHODS
  All patients who underwent AAA repair (July 2005-June 2010) at London Health Science Centre were identified from the vascular surgery database. Method of repair, clinical presentation, and in-hospital mortality were recorded. Travel distance from each patient's home to our hospital and rural versus urban status was determined for each patient. SES was determined by using a previously validated, locally developed deprivation index.
  
  
  RESULTS
  During this 5-year period, 1,243 patients were included in our analysis; 46.8% (n=581) underwent endovascular repair (EVAR) and 53.2% (n=662) underwent open repair. For elective cases, the in-hospital mortality rate was 2.0% (n=11) for EVAR and 3.6% (n=20) for open repair (P=0.1). There was no difference in clinical presentation between SES groups, but open repair was more frequently used in patients of lower SES compared to higher SES (odds ratio=1.32; 95% confidence interval: 1.02-1.72). Travel distance and rural/urban status were not associated with increased odds of EVAR. When ruptured aneurysms were excluded, elective patients of lower SES continued to have a higher rate of open surgery.
  
  
  CONCLUSIONS
  Despite the centralization of endovascular programs in Canada, patients do not appear to be traveling a longer distance for EVAR while having open repairs closer to home as we expected. We did note that higher SES was associated with increased odds of EVAR, which may suggest a health care access bias for EVAR for patients of higher SES. Larger, population-based studies at the provincial or national level could confirm these initial findings.
authors.affiliation: Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Jason
authors.initials: J
authors.lastname: Faulds
authors.forename: Nathaniel J
authors.initials: NJ
authors.lastname: Bell
authors.forename: David M
authors.initials: DM
authors.lastname: Harrington
authors.forename: Teresa V
authors.initials: TV
authors.lastname: Novick
authors.forename: Jeremy R
authors.initials: JR
authors.lastname: Harris
authors.forename: Guy
authors.initials: G
authors.lastname: DeRose
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Forbes
mesh_terms: D000046:Academic Medical Centers; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D002497:Centralized Hospital Services; D017558:Elective Surgical Procedures; D004630:Emergencies; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D017052:Hospital Mortality; D006801:Humans; D016017:Odds Ratio; D009864:Ontario; D010342:Patient Acceptance of Health Care; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D012017:Referral and Consultation; D012111:Residence Characteristics; D012189:Retrospective Studies; D012307:Risk Factors; D012959:Socioeconomic Factors; D014186:Transportation; D016896:Treatment Outcome