title: Outcomes following emergent open repair for thoracic aortic dissection are improved at higher volume centers in direct admissions and transfers.
abstract: BACKGROUND
  The purpose of this study is (1) to define the proportion of patients undergoing emergent open repair of thoracic aortic dissection admitted directly through the emergency room versus those transferred from outside hospitals and (2) to determine if a volume-outcomes relationship exists for those patients across admission types.
  
  
  METHODS
  De-identified patient-level data was obtained from the Nationwide Inpatient Sample (2004-2008). Patients undergoing emergent aortic surgery for thoracic aortic dissection (n = 1,507) were identified by ICD-9 codes and stratified by annual center volume into low volume (≤5 cases/year) (n = 963; 63.9 %), intermediate volume (6-10 cases/year) (n = 370; 24.5 %), and high volume (≥11 cases/year) (n = 174; 11.6 %) groups. The analysis was further stratified by admission type: direct admission (DA), transfer admission (TA), and other. The primary outcome was in-hospital mortality. Multivariate logistic regression analysis was performed comparing outcomes between high vs low and high vs intermediate volume centers.
  
  
  RESULTS
  Overall in-hospital mortality was 21.8 % (n = 328/1,507). Absolute percent mortality at high volume centers was significantly lower (12.6 %) than at medium (20.6 %) and low volume (23.9 %) centers. For DA patients, mortality was 10.6, 21.4, and 24.0 % for high, medium, and low volume centers respectively. For TA patients, mortality was 10.2, 12.7, and 23.5 % for high, medium, and low volume centers, respectively. Multivariate analysis suggested that patients in low volume center were more likely to die compared to high volume center (Odds Ratio 2.06, 95 % CI 1.25 - 3.38, p = 0.004). Admission source was not associated with increased mortality.
  
  
  CONCLUSIONS
  Direct admissions comprise the largest proportion of dissections regardless of volume strata, and they comprise the largest proportion in the low and intermediate volume cohorts. Admission to low volume center is an independent risk factor for increased mortality. Patients transferred to high volume centers from low volume centers have similar outcome as direct admits in terms of mortality.
authors.affiliation: Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA.|Case Western Reserve University School of Medicine, Cleveland, OH, USA.
authors.forename: Aurelie E
authors.initials: AE
authors.lastname: Merlo
authors.affiliation: Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA. dhavalchauhan86@gmail.com.|Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA. dhavalchauhan86@gmail.com.|Newark Beth Israel Medical Center, Barnabas Health Heart Centers, 201 Lyons Ave, Suite G5, Newark, NJ, 07112, USA. dhavalchauhan86@gmail.com.
authors.forename: Dhaval
authors.initials: D
authors.lastname: Chauhan
authors.affiliation: Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA.
authors.forename: Chris
authors.initials: C
authors.lastname: Pettit
authors.affiliation: Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA.
authors.forename: Kimberly N
authors.initials: KN
authors.lastname: Hong
authors.affiliation: Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Saunders
authors.affiliation: Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA.
authors.forename: Chunguang
authors.initials: C
authors.lastname: Chen
authors.affiliation: Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA.|Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA.|Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Russo
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology