Hospital Volume and Social Determinants of Health Do Not Impact Outcomes in Fenestrated Visceral Segment Endovascular Aortic Repair for Patients Treated at VQI Centers.

Ruojia Debbie Li, Rylie O'Meara, Priya Rao, Ian Kang, Michael C Soult, Carlos F Bechara, Matthew Blecha
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If lower volume centers achieve equivalent outcomes to higher volume centers, then limiting access to a small number of centers may not be justified.MethodsVascular Quality Initiative (VQI) was utilized as the data source. Four adverse outcomes categories were investigated : (1) Lack of follow up data in the VQI database at 1 year postoperatively; (2) Thirty day operative mortality; (3) Composite perioperative adverse event outcome; and (4) Twelve month mortality. Social determinants of health exposure variables included rural status, non-metropolitan living area, highest and lowest decile and quintile area deprivation index, insurance status, and non-home living status. Designated categories were created for patients operated on in centers within the top 25% of case volume, centers in the bottom 25% of case volume, and in centers with less than 10 total fenestrated endograft cases. Univariable analyses were performed with Chi-squared testing for categorical variables and <i>t</i> test for comparison of means. Multivariable binary logistic regression was performed to identify risks for the composite adverse perioperative event.ResultsThere was no statistically significant association with the composite adverse perioperative event category, 30-day mortality or 12-month mortality for any of the social determinants of health or center volume categories. Patients who live in rural areas (<i>P</i> = .029) and patients with Military/VA insurance (<i>P</i> < .001) were significantly more likely to be lost to follow up at their index VQI center at 1 year. When accounting for all standard co-morbidities, none of the following variables had any significant association with the composite adverse perioperative event on multivariable analysis: absolute center volume as an ordinal variable (<i>P</i> = .985); procedure at a bottom 25<sup>th</sup> percentile volume center (<i>P</i> = .214); procedure at a center with less than 10 total fenestrated cases in the database (<i>P</i> = .521); rural home status (<i>P</i> = .622); remote from metropolitan home status (<i>P</i> = .619); highest 10% ADI (<i>P</i> = .903); highest 20% ADI (<i>P</i> = .219); Lowest 10% of ADI (<i>P</i> = .397). The variables that had a statistically significant multivariable association with the composite adverse event were 3 or 4 visceral vessels stented vs 2 vessels (<i>P</i> < .001), baseline renal insufficiency (<i>P</i> < .001), female sex (<i>P</i> < .001), ESRD on dialysis (<i>P</i> = .002), and history of coronary revasculizaiton (<i>P</i> = .047). There was noted to be a statistically significant (<i>P</i> < .01) increase in 30 day mortality, composite adverse perioperative event, and 12 month mortality in moving from 2 to 3 to 4 fenestrated stented vessels. However, amongst patients who were treated with 3 and 4 vessel fenestrated stenting, patients treated at bottom 25<sup>th</sup> percentile centers and centers with less than 10 total cases did not experience a higher rate of composite adverse perioperative event, 30 day mortality, or 12 month mortality relative to top 25% volume centers indicating safety of these procedures in lower volume centers.ConclusionsSocial determinants of health and center volume do not impact outcomes in fenestrated visceral segment aortic endograft procedures performed at centers participating in the Vascular Quality Initiative. There is progressive morbidity and mortality in moving from 2 to 3 to 4 visceral stents and fenestrations, however lower volume centers within VQI achieve equivalent outcomes to high volume centers in performing 3 and 4 vessel visceral fenestrated stent cases. Female sex, ESRD, prior coronary revascularization, and baseline renal insufficiency portend an increased risk for perioperative morbidity for fenestrated visceral segment aortic endografting.</p>","PeriodicalId":94265,"journal":{"name":"Vascular and endovascular surgery","volume":" ","pages":"15385744251330017"},"PeriodicalIF":0.0000,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Vascular and endovascular surgery","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1177/15385744251330017","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
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Abstract

ObjectiveThe purpose of this study is to investigate the impact of social determinants of health on access to high volume centers and clinical outcomes in fenestrated abdominal aortic endografting. Further, the effect of center volume in fenestrated endografting on outcomes will be sought as this is ill defined. The data herein have the potential to affect referral patterns and locations of complex fenestrated aortic aneurysm care. If lower volume centers achieve equivalent outcomes to higher volume centers, then limiting access to a small number of centers may not be justified.MethodsVascular Quality Initiative (VQI) was utilized as the data source. Four adverse outcomes categories were investigated : (1) Lack of follow up data in the VQI database at 1 year postoperatively; (2) Thirty day operative mortality; (3) Composite perioperative adverse event outcome; and (4) Twelve month mortality. Social determinants of health exposure variables included rural status, non-metropolitan living area, highest and lowest decile and quintile area deprivation index, insurance status, and non-home living status. Designated categories were created for patients operated on in centers within the top 25% of case volume, centers in the bottom 25% of case volume, and in centers with less than 10 total fenestrated endograft cases. Univariable analyses were performed with Chi-squared testing for categorical variables and t test for comparison of means. Multivariable binary logistic regression was performed to identify risks for the composite adverse perioperative event.ResultsThere was no statistically significant association with the composite adverse perioperative event category, 30-day mortality or 12-month mortality for any of the social determinants of health or center volume categories. Patients who live in rural areas (P = .029) and patients with Military/VA insurance (P < .001) were significantly more likely to be lost to follow up at their index VQI center at 1 year. When accounting for all standard co-morbidities, none of the following variables had any significant association with the composite adverse perioperative event on multivariable analysis: absolute center volume as an ordinal variable (P = .985); procedure at a bottom 25th percentile volume center (P = .214); procedure at a center with less than 10 total fenestrated cases in the database (P = .521); rural home status (P = .622); remote from metropolitan home status (P = .619); highest 10% ADI (P = .903); highest 20% ADI (P = .219); Lowest 10% of ADI (P = .397). The variables that had a statistically significant multivariable association with the composite adverse event were 3 or 4 visceral vessels stented vs 2 vessels (P < .001), baseline renal insufficiency (P < .001), female sex (P < .001), ESRD on dialysis (P = .002), and history of coronary revasculizaiton (P = .047). There was noted to be a statistically significant (P < .01) increase in 30 day mortality, composite adverse perioperative event, and 12 month mortality in moving from 2 to 3 to 4 fenestrated stented vessels. However, amongst patients who were treated with 3 and 4 vessel fenestrated stenting, patients treated at bottom 25th percentile centers and centers with less than 10 total cases did not experience a higher rate of composite adverse perioperative event, 30 day mortality, or 12 month mortality relative to top 25% volume centers indicating safety of these procedures in lower volume centers.ConclusionsSocial determinants of health and center volume do not impact outcomes in fenestrated visceral segment aortic endograft procedures performed at centers participating in the Vascular Quality Initiative. There is progressive morbidity and mortality in moving from 2 to 3 to 4 visceral stents and fenestrations, however lower volume centers within VQI achieve equivalent outcomes to high volume centers in performing 3 and 4 vessel visceral fenestrated stent cases. Female sex, ESRD, prior coronary revascularization, and baseline renal insufficiency portend an increased risk for perioperative morbidity for fenestrated visceral segment aortic endografting.

医院容量和健康的社会决定因素不影响在VQI中心治疗的患者开窗内脏段血管内主动脉修复的结果。
目的探讨社会健康因素对开窗腹主动脉植入术进入大容量手术中心和临床结果的影响。此外,中心体积对开窗内移植术结果的影响将被寻求,因为这是不明确的。本文的数据有可能影响复杂开窗主动脉瘤护理的转诊模式和位置。如果低容量中心与高容量中心取得相同的结果,那么限制进入少数中心可能是不合理的。方法采用血管质量倡议(VQI)作为数据来源。调查了四类不良结局:(1)术后1年VQI数据库中缺乏随访数据;(2) 30天手术死亡率;(3)围手术期不良事件综合结局;(4) 12个月死亡率。健康暴露变量的社会决定因素包括农村状况、非大都市居住区域、最高和最低十分位数和五分位数地区剥夺指数、保险状况和非家庭生活状况。在病例量前25%的中心,病例量后25%的中心,以及总开窗内移植病例少于10例的中心,对患者进行了指定的分类。单变量分析分类变量采用卡方检验,均数比较采用t检验。采用多变量二元logistic回归来确定复合不良围手术期事件的风险。结果与围手术期综合不良事件类别、30天死亡率或12个月死亡率的任何社会健康决定因素或中心容量类别均无统计学意义的关联。居住在农村地区的患者(P = 0.029)和有军人/退伍军人保险的患者(P < 0.001)在1年后更有可能在其指数VQI中心丢失随访。当考虑到所有标准合并症时,在多变量分析中,以下变量与围手术期综合不良事件均无显著关联:绝对中心容积为顺序变量(P = .985);第25百分位容积中心底部手术(P = .214);数据库中开窗病例总数少于10例的中心的手术(P = .521);农村家庭状况(P = .622);远离大都市家庭状态(P = .619);最高10% ADI (P = .903);最高20% ADI (P = 0.219);最低10%的ADI (P = .397)。与复合不良事件有统计学意义的多变量相关的变量是3或4根血管支架vs 2根血管(P < 0.001)、基线肾功能不全(P < 0.001)、女性(P < 0.001)、透析后ESRD (P = 0.002)和冠状动脉血运重建史(P = 0.047)。有统计学意义(P < 0.01)的30天死亡率,围手术期综合不良事件,以及从2到3到4个开窗支架血管的12个月死亡率增加。然而,在接受3支和4支开窗支架治疗的患者中,在最低25百分位中心和总病例少于10例的中心接受治疗的患者,与最高25%容量中心相比,没有更高的围手术期综合不良事件发生率、30天死亡率或12个月死亡率,这表明在低容量中心进行这些手术的安全性。健康和中心容量的社会决定因素不影响在参与血管质量倡议的中心进行的开窗内脏段主动脉瓣内移植物手术的结果。从2支到3支,再到4支内脏支架和开窗,发病率和死亡率逐渐增加,然而,在VQI内的低容量中心,在实施3支和4支内脏开窗支架的病例中,与高容量中心取得了相同的结果。女性、ESRD、既往冠状动脉血运重建术和基线肾功能不全预示着开窗内脏段主动脉瓣植入术围手术期发病率的增加。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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