title: A new metric for centralization of ruptured abdominal aortic aneurysm repair in large territories.
abstract: OBJECTIVE
  This study proposes the DEDE (Door-from-Emergency to Door-to-EVAR [endovascular aneurysm repair]) time as a new metric for ruptured abdominal aortic aneurysm (RAAA) delay time to surgery, permitting coherent centralization in large territories. It demonstrates how the DEDE time can be applied, using data from the province of Quebec, and looks at its potential effect on 30-day mortality.
  
  
  METHODS
  We used the Quebec Integrated Chronic Disease Surveillance System (QICDSS), the linkage of five health administrative databases, to build a retrospective cohort of RAAA patients repaired operatively between April 1, 2006, and March 31, 2013. A validated algorithm was used to identify open surgical repair (OSR) and EVAR patients. Hospitals performing these operations were further characterized according to their location, volume of RAAA, types of surgeries (OSR vs EVAR), and surgeon's volume. Logistic and log-binomial regression analyses identified the risk of 30-day mortality with age, sex, hospital volume, and surgical groups as variables. Using the DEDE 90 metric and the attributable fraction, we projected how centralization and increasing the number of EVAR would affect the 30-day mortality.
  
  
  RESULTS
  Among patients aged ≥65 years, 895 RAAAs were identified. OSR was performed in 839 patients (93.7%) and EVAR in 56 (6.3%). The overall 30-day mortality was 34.4%, and more specifically, was 35.5% for OSR compared with 17.9% for EVAR (P = .0046). RAAAs were treated in 39 hospitals, including 16 centers averaging less than one RAAA repair per year. Low-volume (39.4%) vs high-volume centers (32.5%) had similar 30-day mortality (P = .2198). In the multivariate analysis, the relative risk for OSR was 1.95 (P = .0211) and was not significant for hospital volume. Applying the DEDE 90 metric and increasing access to EVAR to 50% of patients, the overall 30-day mortality would be 26.8%.
  
  
  CONCLUSIONS
  DEDE 90 is a new metric for a coherent centralization model, particularly in large territories, where transport time is crucial. Increasing access to EVAR performed in high-volume centers, with consideration to transport time, could improve the 30-day mortality after a RAAA repair.
authors.affiliation: Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Division of Vascular and Endovascular Surgery, CISSSO, Gatineau, Quebec, Canada. Electronic address: patrice_nault@ssss.gouv.qc.ca.
authors.forename: Patrice
authors.initials: P
authors.lastname: Nault
authors.affiliation: Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
authors.forename: Camille
authors.initials: C
authors.lastname: Brisson-Tessier
authors.affiliation: Institut national de santé publique du Québec (INSPQ), Quebec City, Quebec, Canada.
authors.forename: Denis
authors.initials: D
authors.lastname: Hamel
authors.affiliation: Cardiovascular Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada.
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Lambert
authors.affiliation: Institut national de santé publique du Québec (INSPQ), Quebec City, Quebec, Canada; Faculty of Pharmacy, Laval University, Quebec City, Quebec, Canada.
authors.forename: Claudia
authors.initials: C
authors.lastname: Blais
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000401:mortality / Q000601:surgery*; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D015999:Multivariate Analysis; D011792:Quebec; D012189:Retrospective Studies; D013997:Time Factors; D061665:Time-to-Treatment / Q000706:statistics & numerical data*