International Variations in Abdominal Aortic Aneurysm Care

Study Questions:

What is the variation in contemporary management of abdominal aortic aneurysm (AAA) with relation to the recommended treatment guidelines from the Society for Vascular Surgery and the European Society for Vascular Surgery?


Registry data for both open and endovascular repair of AAA between 2010 and 2013 were collected from 11 countries. Variations in patient selection and treatment modalities were compared across countries and centers within countries using generalized linear mixed models.


Among 51,153 patients, 86% were treated for nonruptured AAA, whereas 14% were treated for ruptured AAA. Women consisted of 18% of the entire cohort (range 12%-21%). Nonruptured AAAs were repaired at smaller than guideline-recommended diameters (<5.5 cm for men, <5 cm for women) in 31% of men (range 6%-41%, p < 0.001) and 12% of women (range 0%-16%, p < 0.001). Overall, national utilization of endovascular repair for nonruptured AAA varied from 28%-79% (p < 0.01), and for ruptured AAA, varied from 5%-52% (p < 0.01). In countries with a fee-for-service reimbursement system (Australia, Germany, Switzerland, and United States), the proportion of small AAA (33%) and octogenarians undergoing nonruptured AAA repair (25%) was higher as compared to countries with a population-based reimbursement model (small AAA repair 16%, octogenarians 18%, p < 0.01 for both). Center-level variation within countries (correlation coefficient 0.60, p < 0.01) in AAA management was similarly significant as variation between countries (correlation coefficient 0.92, p < 0.01).


The authors concluded that despite homogenous society guidelines for AAA repair, significant variation exists, most notably in the size of nonruptured AAA repair and utilization of endovascular repair.


By bringing together 11 international registries of AAA management, the authors provide important insights into variations in practice patterns both between and within individual countries. It should not be surprising that countries with a fee-for-service reimbursement design are associated with higher use of non–guideline-based AAA repair (especially smaller AAA diameters). While 100% guideline compliance is never the intended goal, quality assurance efforts are needed to continuously monitor practice patterns and provide real-time feedback to clinicians about treatment choices and clinical outcomes. Expanding these efforts internationally is an intriguing opportunity.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine

Keywords: Aortic Aneurysm, Abdominal, Aortic Rupture, Cardiac Surgical Procedures, Endovascular Procedures, Fee-for-Service Plans, Geriatrics, Primary Prevention, Quality Assurance, Health Care, Vascular Diseases

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