title: Mortality variability after endovascular versus open abdominal aortic aneurysm repair in a large tertiary vascular center using a Medicare-derived risk prediction model.
abstract: OBJECTIVE
  Previous reports have documented better outcomes after open abdominal aortic aneurysm (AAA) repair in tertiary centers compared with lower-volume hospitals, but outcome variability for endovascular AAA repair (EVAR) vs open AAA repairs in a large tertiary center using a Medicare-derived mortality risk prediction model has not been previously reported. In the current study, we compared the observed vs predicted mortality after EVAR and open AAA repair in a single large tertiary vascular center.
  
  
  METHODS
  We retrospectively analyzed all patients who underwent repair of a nonruptured infrarenal AAA in our center from 2003 to 2012. Univariable and multivariable logistic regression were used to evaluate 30-day mortality. Patients were stratified into low-risk, medium-risk, and high-risk groups, and mortality was predicted for each patient based on demographics and comorbidities according to the Medicare risk prediction model.
  
  
  RESULTS
  We analyzed 297 patients (EVAR, 72%; open AAA repair, 28%; symptomatic, 25%). Most of our patients were of high and moderate risk (48% and 28%, respectively). The observed 30-day mortality was 1.9% after EVAR vs 2.4% after open repair (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.14-4.29; P = .67). There was no difference in mortality with EVAR vs open repair after adjusting for predefined patient characteristics (OR, 0.92; 95% CI, 0.16-7.43; P = .93); only preoperative renal disease was predictive of 30-day mortality after AAA repair in our cohort (OR, 8.39; 95% CI, 1.41-67.0). The observed mortality within our study was significantly lower than the Medicare-derived expected mortality for each treatment group within patients stratified as high risk or medium risk (P ≤ .0002 for all).
  
  
  CONCLUSIONS
  Despite treating patients with high preoperative risk status, we report a 10-fold decrease in operative mortality for EVAR and open AAA repair in a tertiary vascular center compared with national Medicare-derived predictions. High-risk patients should be considered for aneurysm management in dedicated aortic centers, regardless of approach.
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Isibor
authors.initials: I
authors.lastname: Arhuidese
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Luda
authors.initials: L
authors.lastname: Asanova
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Umair
authors.initials: U
authors.lastname: Qazi
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Perler
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Freischlag
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality*