title: Aortic anatomic severity grade correlates with resource utilization.
abstract: BACKGROUND
  Potential cost effectiveness of endovascular aneurysm repair (EVAR) compared with open aortic repair (OAR) is offset by the use of intraoperative adjuncts (components) or late reinterventions. Anatomic severity grade (ASG) can be used preoperatively to assess abdominal aortic aneurysms, and provide a quantitative measure of anatomic complexity. The hypothesis of this study is that ASG is directly related to the use of intraoperative adjuncts and cost of aortic repair.
  
  
  METHODS
  Patients who undergo elective OAR and EVAR for abdominal aortic aneurysms were identified over a consecutive 3-year period. ASG scores were calculated manually using three-dimensional reconstruction software by two blinded reviewers. Statistical analysis of cost data was performed using a log transformation. Regression analyses, with a continuous or dichotomous outcome, used a generalized estimating equations approach with the sandwich estimator, being robust with respect to deviations from model assumptions.
  
  
  RESULTS
  One hundred forty patients were identified for analysis, n = 33 OAR and n = 107 EVAR. The mean total cost (± standard deviation) for OAR was per thousand (k) $38.3 ± 49.3, length of stay (LOS) 13.5 ± 14.2 days, ASG score 18.13 ± 3.78; for EVAR, mean total cost was k $24.7 ± 13.0 (P = .016), LOS 3.0 ± 4.4 days (P = .012), ASG score 15.9 ± 4.13 (P = .010). In patients who underwent EVAR, 25.2% required intraoperative adjuncts, and analysis of this group revealed a mean total cost of k $31.5 ± 15.9, ASG score 18.48 ± 3.72, and LOS 3.9 ± 4.5, which were significantly greater compared with cases without adjunctive procedures. An ASG score of ≥15 correlated with an increased propensity for requirement of intraoperative adjuncts; odds ratio, 5.75 (95% confidence interval, 1.82-18.19). ASG >15 was also associated with chronic kidney disease, end stage renal disease, hypertension, female sex, increased cost, and use of adjunctive procedures.
  
  
  CONCLUSIONS
  Complex aneurysm anatomy correlates with increased total cost and need for adjunctive procedures during EVAR. Preoperative assessment with ASG scores can delineate patients at greater risk for increased resource use. Patient comorbid factors are associated with anatomic complexity defined according to ASG. A critical examination of the relationship between anatomic complexity and finances is required within the context of aggressive endovascular treatment strategies and shifts toward value-based reimbursement.
authors.affiliation: Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
authors.forename: Khurram
authors.initials: K
authors.lastname: Rasheed
authors.affiliation: Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
authors.forename: John P
authors.initials: JP
authors.lastname: Cullen
authors.affiliation: University of Rochester Medical School, University of Rochester Medical Center, Rochester, NY.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Seaman
authors.affiliation: Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY.
authors.forename: Susan
authors.initials: S
authors.lastname: Messing
authors.affiliation: Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Ellis
authors.affiliation: Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
authors.forename: Roan J
authors.initials: RJ
authors.lastname: Glocker
authors.affiliation: Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Doyle
authors.affiliation: Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY. Electronic address: michael_stoner@urmc.rochester.edu.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Stoner
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000191:economics / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000191:economics / Q000706:statistics & numerical data*; D016009:Chi-Square Distribution; D003362:Cost-Benefit Analysis; D017558:Elective Surgical Procedures; D057510:Endovascular Procedures / Q000009:adverse effects / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D017048:Health Care Costs; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000191:economics; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000191:economics / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome