Mortality From Ruptured Abdominal Aortic Aneurysms: Clinical Lessons From a Comparison of Outcomes in England and the USA
What are the outcomes of patients with ruptured abdominal aortic aneurysm (rAAA) in England and the USA, with comparison of in-hospital mortality, the proportion of patients managed by noncorrective treatment, and the availability of endovascular surgery?
The investigators compared data from the Hospital Episode Statistics for England and the Nationwide Inpatient Sample for the USA for patients admitted to the hospital with rAAA from 2005 to 2010. Primary outcomes were in-hospital mortality, mortality after intervention, and decision to follow noncorrective treatment. In-hospital mortality and the rate of noncorrective treatment were analyzed by binary logistic regression for each health care system, after adjustment for age, sex, year, and Charlson comorbidity index.
The study included 11,799 patients with rAAA in England and 23,838 patients with rAAA in the USA. In-hospital mortality was lower in the USA than in England (53.05%; 95% confidence interval [CI], 51.26-54.85 vs. 65.90%; p < 0.0001). Intervention (open or endovascular repair) was offered to a greater proportion of cases in the USA than in England (19,174 [80.43%] vs. 6,897 [58.45%]; p < 0.0001) and endovascular repair was more common in the USA than in England (4,003 [20.88%] vs. 589 [8.54%]; p < 0.0001). Postintervention mortality was similar in both countries (41.77% for England and 41.65% for USA). These observations persisted in age-matched and sex-matched comparisons. In both countries, reduced mortality was associated with increased use of endovascular repair, increased hospital caseload (volume) for rAAA, high hospital bed capacity, hospitals with teaching status, and admission on a weekday.
The authors concluded that in-hospital survival from rAAA, intervention rates, and uptake of endovascular repair are lower in England than in the USA.
This study reports that the in-hospital mortality of patients with rAAA was significantly lower in the USA than in England. This difference was mainly because US hospitals offered aneurysm repair to a significantly greater proportion of patients. Although operative mortality was similar between countries, patients in the USA were more than twice as likely to be offered endovascular repair and were more often managed in a teaching hospital than were patients in England. The data suggest that outcomes might be improved by reductions in rates of noncorrective treatment and increases in provision of endovascular technology for rAAA. Patients with rAAA should ideally be directed to teaching hospitals with a high aortic workload, endovascular capabilities, and proficiency in weekend working and capabilities. At the same time, every effort should be made to diagnose and treat AAAs prior to rupture.
Clinical Topics: Vascular Medicine
Keywords: Endovascular Procedures, Hospital Mortality, Hospital Bed Capacity, Inpatients, Aortic Aneurysm, Abdominal, England, Hospitals, Teaching
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