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Experience Predicts Outcomes for Endo-AAA Repair
BY MARK S. LESNEY
Significant reductions in perioperative complications and mortality occurred with increased surgeon experience in endovascular abdominal aortic aneurysm repair, based upon a large study of data obtained from the Medicare database, according to Natalia N. Egorova, Ph.D.
"The data show significant reduction in perioperative complications and mortality with increased surgeon experience in EVAR," she said in an interview.
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'THE DATA SHOW SIGNIFICANT REDUCTION IN PERIOPERATIVE COMPLICATIONS AND MORTALITY WITH INCREASED SURGEON EXPERIENCE IN EVAR.' |
"The procedure code for EVAR was introduced in 2000 and use of this treatment has markedly increased.
"Despite rapid adoption of this technique, there is little research about the relationship between physician experience in EVAR and patient outcomes," said Dr. Egorova.
She and her colleagues identified patients with the ICD-9 procedure code 38.44 for EVAR and specific operating physician codes from the Medicare Database from the years 2000-2004.
The cumulative physician experience with EVAR over this period was used, and patient demographics, comorbidities, perioperative complications, and 30-day mortality were assessed using multivariate logistic regression, the student t-test, and chi-square analysis.
In all, 39,815 EVARs were performed by 4,339 physicians in 2000-2004, according to the Medicare database. Low-experience physicians were defined as those having performed fewer than 10 total EVARs. High-experience physicians were defined as those who had performed more than 50 EVAR procedures. Patients were uniformly distributed without significant differences in age, gender, race, or ethnicity between low- and high-experience surgeons.
"EVARs performed by low-experienced surgeons had a significantly higher 30-day mortality (2.1%), compared with surgeons with a cumulative experience of greater than 10 EVARS (1.4%-1.6%)," she said.
Multivariate analysis showed that low experience was an independent predictor of mortality when controlling for morbidity. Bleeding, respiratory and cardiac complications, and urgent conversion to open repair were also significantly higher for the low-experience surgeon (P less than .05). There was some improvement in trends seen over the period considered, as the percentage of procedures performed by physicians with low experience decreased as more procedures were performed.
In fact, the number of procedures performed by low-experience surgeons decreased from 64% in 2001 to 30% in 2003. During this same period, EVARs performed by high-experience physicians increased from 3% to 23%. But this did not change the fact that there was a definite learning curve seen with these procedures.
"Since about one-third of patients are being treated by low-experience surgeons with [higher] procedure-related complications and mortality, guidelines for surgical accreditation need to be set. Our data indicate that this minimum experience level is greater than 10 procedures," the Dr. Egorova and her colleagues concluded.
When asked to comment on this paper, Dr. Keith D. Calligaro, chief, section of vascular surgery, Pennsylvania Hospital, and clinical professor of surgery, University of Pennsylvania School of Medicine, Philadelphia, stated:
"I doubt many vascular surgeons would find the results of the study by Egorova and her colleagues surprising, namely that increasing experience with inserting EVARs leads to better outcomes. Cardiothoracic surgeons wishing to perform TEVARs should heed the results of this study before proceeding with endovascular repair of thoracic aneurysms.
"Cardiologists wishing to perform EVAR via percutaneous access routes should realize that these aortic procedures have their own technical and management problems that are unfamiliar to specialists who deal with coronary catheterizations. The dilemma is establishing reasonable criteria for any interventionalist to perform these complicated endovascular cases.
"As the immediate past chairman for the Clinical Practice Council of the Society for Vascular Surgery, I was charged with updating guidelines for hospital credentialing for vascular surgeons. The biggest challenge was establishing minimum criteria for granting privileges for open vascular and endovascular cases, and the most controversial criterion was the minimum number of EVARs.
"Although the other coauthors and I have not yet reached a conclusion and we are awaiting recommendations of the vascular RRC, the conclusion reached by the authors in this article, namely 10 cases, may be reasonable.
"More than 90% of vascular fellowship training programs meet this criterion for their trainees. However, the struggle has to do with how high to set the bar. Establishing a minimum of 20-25 EVAR cases met with a great deal of support on the writing committee. Final recommendations will be forthcoming, but the previously established minimum of 5 EVAR cases has clearly gone the way of the dinosaur, which this article emphatically shows," Dr. Calligaro concluded.
Also commenting on this article, Dr. George Andros, Los Angeles Vascular Specialists of Encino, Calif., and medical editor of Vascular Specialist, stated: "While we are mindful that a reasonable number of endo-AAAs need to be done during training, we also ought to bear in mind that your teachers won't be at your shoulder when you are called upon to perform this procedure for the first time alone, nor will they be there if you need to convert to an open procedure."
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© 2010 VascularWeb. All rights reserved. Use of the VascularWeb site constitutes acceptance of all of the policies, rules and regulations for the site.