A Patient-Centered Textbook Outcome Measure Effectively Discriminates Contemporary Elective Open Abdominal Aortic Aneurysm Repair Quality
Amy E. Felsted1, Adam W. Beck2, Adam Banks2, Dan Neal3, Jesse A. Columbo1, David H. Stone1, Salvatore T. Scali3
1Dartmouth-Hitchcock Medical Center, Lebanon, NH;2University of Alabama-Birmingham, Birmingham, AL;3University of Florida- Gainesville, Gainesville, FL
INTRODUCTION: There is persistent controversy surrounding the merit of surgical volume benchmarks alone as a sufficient proxy for assessing the quality of open abdominal aortic aneurysm(AAA) repair. Moreover, operative volume quotas may fail to reflect a more nuanced and comprehensive depiction of surgical outcomes most relevant to patients. Accordingly, we herein propose a novel patient-centered “textbook outcome”(TO) for AAA repair, and test its feasibility to discriminate surgical outcomes using SVS volume guidelines.
METHODS: All elective open infrarenal AAA repairs(OAR) in the SVS-VQI were examined(2009-2022). The primary end-point was a TO, defined as a composite end-point including no in-hospital complication or re-intervention/re-operation, length of stay ≤10 days, home discharge and 1-year survival. The discriminatory ability of the TO measure was assessed by comparing centers that did or did not meet the SVS annual OAR volume threshold(high-volume≥10 OARs/year; low-volume<10 OARs/year). Logistic regression and multivariable models adjusted for patient and procedure-related differences.
RESULTS: A total of 10,959 OARs across 199 centers were analyzed(mean age-69±8, female-26%, non-white-13%). A TO was identified in 45%(N=4,293) of the overall cohort. Incidence of individual TO components included: no in-hospital complication(66%), no in-hospital re-intervention/re-operation(92%), LOS≤10 days(78%), home discharge(79%), and 1-year survival(91%). Median annual center volume was 6[IQR 3,10] and a majority of centers did not meet the SVS volume standard(<10 OARs/year: N=148[74%]). However, most patients(N=7,116 of 10,959[65%]) underwent OAR in high-volume hospitals(N=7,116 of 10,959[65%]). When comparing high and low-volume centers, a TO was more likely to occur in high-volume institutions: ≥10 OARs/year, 46% vs. <10 OARs/year, 42%; P=.0006(Figure). The association of a protective effect for higher center volume remained in risk-adjusted analysis: OR 1.1, 95%CI 1.05-1.26;P=.003.
CONCLUSIONS: Textbook outcomes for elective OAR reflect a more nuanced and comprehensive patient centered proxy to measure care delivery consistent with other surgical specialties. Surprisingly, a TO was achieved in <50% of elective AAA cases nationally. While TO correlated with SVS center volume, it reflects elements which may be prioritized by patients and offers insights into improving real-world AAA care.
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