title: Targets to prevent prolonged length of stay after endovascular aortic repair.
abstract: OBJECTIVE
  Endovascular aneurysm repair (EVAR) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly, even within institutions. The present study reviewed the morbidity, mortality, and the financial effect of increased LOS to establish modifiable factors associated with prolonged hospital LOS, with the goal of improving quality.
  
  
  METHODS
  The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary, elective EVAR at a single institution between January 1, 2011, and May 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤2 days and >2 days.
  
  
  RESULTS
  Complete 30-day variable and cost data were available for 138 patients with an average follow-up of 12 months; of these, 46 (33%) had a LOS >2 days. Variables determined to be statistically significant predictors of prolonged LOS included aneurysm diameter (P = .03), American Society of Anesthesiologists Physical Status Classification score (P < .001), thromboembolectomy (P = .01), and increased postoperative cardiac (P < .001) and renal (P = .01) complications. Specifically, modifiable risk factors that contributed to increased LOS included performance of a concomitant procedure (P < .001), increased volume of iodinated contrast (P = .05), increased volume of intraoperative crystalloid (P = .05), placement in an intensive care unit (P < .001), return to the operating room (P < .001), and the use of vasoactive medications (P < .001). Hospital charges ($102,000 ± $41,000 vs $180,000 ± $73,000; P = .01) and costs ($27,000 ± $10,000 vs $45,000 ± $19,000 P = .01) were significantly higher in patients with prolonged LOS; however, there was no difference in physician charges ($8000 ± $5700 vs $12,000 ± $12,000; P = .09). Increased LOS after EVAR was associated with an increase in mortality at 1 month (0% vs 4% P = .05) and 12 months (3% vs 13% P = .03).
  
  
  CONCLUSIONS
  This study highlights several modifiable risk factors leading to increased LOS after EVAR, including performance of concomitant procedures, admission to the intensive care unit, and postoperative renal and cardiac complications. Further, increased LOS was associated with increased charges, costs, morbidity, and mortality after EVAR. This study highlights specific areas of focus for decreasing LOS after EVAR and, in turn, improving quality in vascular surgery.
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: J Hunter
authors.initials: JH
authors.lastname: Mehaffey
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: Damien J
authors.initials: DJ
authors.lastname: LaPar
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: Margret C
authors.initials: MC
authors.lastname: Tracci
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Cherry
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, Va.
authors.forename: John A
authors.initials: JA
authors.lastname: Kern
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, Va. Electronic address: gru6n@virginia.edu.
authors.forename: Gilbert R
authors.initials: GR
authors.lastname: Upchurch
mesh_terms: D000328:Adult; D017544:Aortic Aneurysm, Abdominal / Q000191:economics / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000191:economics; D057867:Endoleak / Q000453:epidemiology; D057510:Endovascular Procedures / Q000191:economics; D005260:Female; D017722:Hospital Charges; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data*; D008297:Male; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000191:economics; D012189:Retrospective Studies; D012307:Risk Factors