title: Hospital-Level Factors Associated With Mortality After Endovascular and Open Abdominal Aortic Aneurysm Repair.
abstract: OBJECTIVE
  Endovascular technology has become ubiquitous in the modern care of abdominal aortic aneurysm (AAA), yet broad estimates of its efficacy among variable hospital and regional settings is not known.
  
  
  OBJECTIVE
  To perform a preliminary analysis of hospital effects on mortality following open AAA repair (OAR) and endovascular AAA repair (EVAR).
  
  
  METHODS
  A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was conducted on all patients undergoing OAR or EVAR from July 1, 2010, to November 30, 2012, using Current Procedural Terminology codes.
  
  
  METHODS
  Weight-adjusted 30-day observed to expected mortality ratios were compared based on hospital type (academic vs community) and size (100-299 beds vs 300-500 beds vs >500 beds).
  
  
  RESULTS
  Data on 11,250 patients (2466 underwent OAR and 8784 underwent EVAR) were analyzed. Endovascular AAA repair was performed more frequently than OAR at both academic (78.8%) and community (68.2%) hospitals. Overall 30-day mortality was 14.0% for OAR and 4.3% for EVAR (P < .001). Hospital size was significantly associated with mortality for OAR (observed to expected mortality ratio: >500 beds, 0.88 vs 300-500 beds, 1.11 vs 100-299 beds, 1.59; P = .01) but not for EVAR (P = .27). In contrast, hospital type was significantly associated with mortality for EVAR (observed to expected mortality ratio: academic, 0.60 vs community, 2.60; P < .001) but not OAR (P = .46). Multivariable analysis of hospital-level factors suggested that, for all outcomes, academic hospital type was the single most significant predictor of reduced mortality following AAA repair (observed to expected mortality ratio: academic, 0.91 vs community, 2.00; P = .05).
  
  
  CONCLUSIONS
  Based on this preliminary report, outcomes for both OAR and EVAR appear to depend greatly on hospital-level effects. The relative safety of EVAR vs OAR may depend on appropriate patient selection and adequate access to multidisciplinary care in order to minimize failure to rescue rates and improve survival.
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Elizabeth C
authors.initials: EC
authors.lastname: Wick
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Joseph K
authors.initials: JK
authors.lastname: Canner
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Isibor
authors.initials: I
authors.lastname: Arhuidese
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Umair
authors.initials: U
authors.lastname: Qazi
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Tammam
authors.initials: T
authors.lastname: Obeid
authors.affiliation: Office of the Dean, School of Medicine, University of California Davis Health System, Sacramento.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Freischlag
authors.affiliation: Division of Vascular and Endovascular Therapy, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D057510:Endovascular Procedures / Q000401:mortality; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000401:mortality*