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Home > Vascular Annual Meeting > giacovelli_surgeon_volume

Surgeon Volume Outcome Relationship for Endovascular Aortic Aneurysm Repair

Jeannine K. Giacovelli^1,2, Natalia Egorova², Giampaolo Greco², Roman Nowygrod¹, Nicholas J. Morrissey¹, Rajeev Dayl¹, Annetine Gelijns², Alan Moskowitz², James McKinsey¹, K. Craig Kent.^1
1Division of Vascular Surgery, New York Presbyterian Hospital, Columbia College of Physicians and Surgeons, Weill Medical College of Cornell University, New York, N.Y.;²International Center for Health Outcomes and Innovation Research, Columbia University Health Sciences, New York, N.Y.

OBJECTIVES: A reverse correlation between surgeon volume and outcome for open vascular procedures has been demonstrated, however, the volume outcome relationships for endovascular interventions have not been explored. In this analysis we investigate whether surgeon volume influences mortality after endovascular aortic aneurysm repair (EVAR).

METHODS: The Medicare database was analyzed (1995-2004) for patients undergoing elective EVAR or open repair (OR). We examined the relationship between 30 day peri-operative mortality and annual surgeon volume (distributed by quintiles). Patients were also stratified by pre-operative risk using Charlson scores to evaluate whether severity of illness affects the volume outcome relationships. Patients with Charlson score ≥3 were considered high risk.

RESULTS: For surgeons performing <3 EVARs per year the mortality was 2.87%, whereas mortality diminished significantly to 1.58% for surgeons performing 3-4 EVARs per year. Surprisingly, a further increase in yearly EVAR volume was not associated with a further diminution in mortality (e.g. 1.72% for ≥17 EVARs per year, see Table). This volume outcome relationship was preserved in high risk EVAR patients, (e.g. 3.7% for 1-2 EVARs per year to 1.4% for 3-4 EVARs per year to 2.3% for ≥17 EVARs per year). In contrast, for OR there was continuous improvement in mortality with increasing surgeon volume. The greatest change in mortality (6.06% to 4.42%) occurred at a threshold of 4 open repairs per year, and further improvement in mortality was achieved with each quintile (e.g. 2.89% for surgeons ≥17 ORs per year). The same volume outcome relationship was noted with OR in high risk patients, (e.g., 6.7% for 1-3 ORs per year to 5.0% for ≥4 ORs per year to 3.7% for ≥17 ORs per year).

CONCLUSIONS: Relatively low yearly surgeon volumes (≥3 per year) are associated with excellent outcomes for EVAR. In contrast for OR, there is a continuous decrease in mortality with increasing surgeon volume. These relationships between surgeon volume and outcome are preserved even in high risk patients.

AUTHOR DISCLOSURES: J.K. Giacovelli, None; N. Egorova, None; G. Greco, None; R. Nowygrod, None; N.J. Morrissey, None; R. Dayl, None; A. Gelijns, None; A. Moskowitz, None; J. McKinsey, None; K. Kent, None.