The comparative effectiveness of surgeons over interventionalists in endovascular repairs of abdominal aortic aneurysm

Abstract

Objective: Comparative effectiveness research has mostly been focused on comparison of treatment techniques. The goal of the present study was to extend the research to physician specialty.

Background: Both surgeons and interventionalists (cardiologists and radiologists) are involved in endovascular repairs (EVAR) of aortic aneurysms, with different residency education, operative experience, preoperative assessment and patient selection, and postoperative continuity of care.

Methods: Retrospective analysis was performed using the Nationwide Inpatient Sample from 1998 to 2009. Patients undergoing EVAR for abdominal aortic aneurysm were identified with International Classification of Diseases, Ninth Revision, procedure code 39.71. Using physician identifiers available in the database, surgeons were identified by case experience in the same calendar year with elective open AAA repairs, arteriovenous fistula repairs, or carotid endarderectomy. Multivariate analysis adjusted for physician volume, AAA ruptured status, patient demographic and comorbidities, and hospital characteristics.

Results: A total of 28,094 EVARs were analyzed. Unadjusted mortality rates, length of stay, and total hospital charges were significantly higher for patients treated by interventionalists than those by surgeons (all Ps < 0.001). This difference persisted on multivariate analysis, where interventionalists were associated with increased likelihood of mortality (odds ratio = 1.39; 95% confidence interval, 1.04-1.89), longer length of stay (1.32 days; 95% confidence interval, 1.03-1.62), and higher total hospital charges ($19,312; 95% confidence interval, 16,471-22,153).

Conclusions: Physician specialty is associated with patient outcomes. Surgeons are associated with improved outcomes, with lower mortality, shorter length of stay, and lower charges for EVAR cases, when compared with interventionalists. This finding has significant implications for future comparative effectiveness research and potential policy changes in patient referrals or physician admitting privileges.