title: Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm.
abstract: Limited data exist comparing perioperative morbidity and mortality after open and endovascular abdominal aortic aneurysm (AAA) repair (EVAR) among regions of the United States. This study evaluated the regional variation in mortality and perioperative outcomes after repair of AAAs.
  
  
  
  The Vascular Quality Initiative (VQI) was used to identify patients undergoing open AAA repair and EVAR between 2009 and 2014. Ruptured and intact aneurysms were evaluated separately, and the analysis of intact aneurysms was limited to infrarenal AAAs. All 16 regions of the VQI were deidentified, and those with <100 open repairs were combined to eliminate the effect of low-volume regions. Regional variation was evaluated using χ2and Fisher exact tests. Regional rates were compared against current quality benchmarks.
  
  
  
  Perioperative outcomes from 14 regions were compared. After open repair of intact aneurysms, no significant variation was seen in 30-day or in-hospital mortality; however, multiple regions exceeded the Society for Vascular Surgery benchmark for in-hospital mortality after open repair of intact aneurysms of <5% (range, 0%-7%; P = .55). After EVAR, all regions met the Society for Vascular Surgery benchmark of <3% (range, 0%-1%; P = .75). Significant variation in in-hospital mortality existed after open (14%-63%; P = .03) and endovascular (3%-32%; P = .03) repair of ruptured aneurysms across the VQI regional groups. After repair of intact aneurysms, wide variation was seen in prolonged length of stay (>7 days for open repair: 32%-53%, P = .54; >2 days for EVAR: 16-43%, P < .01), transfusion (open: 10%-35%, P < .01; EVAR: 7%-18%, P < .01), use of vasopressors (open: 19%-37%, P < .01; EVAR: 3%-7%, P < .01), and postoperative myocardial infarction (open: 0%-13%, P < .01; EVAR: 0%-3%, P < .01). After open repair, worsening renal function (6%-18%; P = .04) and respiratory complications (6%-20%; P = .20) were variable across regions. The frequency of endoleak at completion of EVAR also had considerable variation (15%-38%; P < .01).
  
  
  
  Despite limited variation, multiple regions do not meet current benchmarks for in-hospital mortality after open AAA repair for intact aneurysms. Significant regional variation exists in perioperative outcomes and length of stay, and mortality is widely variable after repair for rupture. These data identify important areas for quality improvement initiatives and clinical practice guidelines.
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, George Washington University Medical Center, Washington, D.C.
authors.forename: Sara L
authors.initials: SL
authors.lastname: Zettervall
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Soden
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Dominique B
authors.initials: DB
authors.lastname: Buck
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Phillip P
authors.initials: PP
authors.lastname: Goodney
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Eslami
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif.
authors.forename: Jason T
authors.initials: JT
authors.lastname: Lee
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D019985:Benchmarking / Q000639:trends; D001803:Blood Transfusion / Q000639:trends; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality / Q000639:trends*; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality / Q000639:trends*; D054625:Healthcare Disparities / Q000639:trends*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000639:trends; D011183:Postoperative Complications / Q000209:etiology* / Q000401:mortality; D017064:Process Assessment, Health Care / Q000639:trends*; D058996:Quality Improvement / Q000639:trends; D019984:Quality Indicators, Health Care / Q000639:trends; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States