p. tripodi, g. mestres and v. riambau vascular surgery ... · as surgeons performed higher annual...
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P. Tripodi, G. Mestres and V. Riambau
Vascular Surgery Division
Cardiovascular Institute, Hospital Clínic of Barcelona
On Behalf of Catalan Vascular Group-Catalan Health Service
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NONE
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1.Background and Context
2.Objectives
3.Patients and Methods
4.Results
5.Summary
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1.Background and Context
2.Objectives
3.Patients and Methods
4.Results
5.Summary
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As surgeons performed higher annual volumes of elective open AAA repairs, significantly
lower mortality rates were demonstrated. Surgeons wishing to perform elective AAA
repairs should achieve a minimum case volume of 13 repairs per annum.
J Vasc Surg 2007
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Higher annual operation volumes are associated with significantly lower
mortality in both elective and ruptured AAA repair. This suggests that
AAA surgery should be performed only at higher-volume centres.
Elective Ruptured
15 rAAAs per annum45 eAAAs per annum
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• AAA repair should only be performed in hospitals
performing at least 50 elective cases per annum,
whether by open repair or EVAR. Level 2c,
Recommendation B.
EJVES 2011
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EJVES 2019
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• Is a political decision
• Is a health organization
model
• Does it represent a real
health value?
• Is it the right model to go
and expand?
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AAA repair should only be performed in hospitals
performing at least 30 elective cases per
annum, whether by open repair or EVAR
Centralization was completed on July 2015
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7 543 825 inhabitants and a density of 234 inhabitants/km²
22 Hospitals withVS. capabilities
Low complexity
10 Hub for Level IIIHigh Complexity: AAA, Carotids , endo DTAA
5 Hub for Level IV
Very High Complexity:
Ao dissection, Open DTAA, ATAA, Cardiac S.
requirements
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1.Background and Context
2.Objectives
3.Patients and Methods
4.Results
5.Summary
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• To analyze the impact of centralization
– in-hospital mortality
– length of stay (LoS) in elective and urgent repair of AAA
• Secondary endpoints include
– In-hospital Mortality and LoS in high volume centers
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1.Background and Context
2.Objectives
3.Patients and Methods
4.Results
5.Summary
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Dec 2017Jan 2008
Jul 20152nd Doc 09/215
7.5 year period
P1: Pre-centralization
2.5 year period
P2: Post-centralization
Jul 20141st Doc 09/2014
Feb 2013Starting meeting
Jun 2015implemented
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1.Background and Context
2.Objectives
3.Patients and Methods
4.Results
5.Summary
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*http://catsalut.gencat.cat/ca/proveidors-professionals/registres-catalegs/registres/cmbd/
Hospital Discharge
Minimum Basic Data Set (HDMBD)*
2008-2017
ICD9-CM
441.4 (iAAA) 441.3 (rAAA)
38.44, 39.25 (OR) 39.71 (EVAR)
4298 registries
-62 (Cleaning unclear records)
42363802 iAAA and 434 rAAA
P1
3046P2
1190
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Co-morbidities All (N=4236) Before Centralization
(N=3046)
After Centralization
(N=1190)
P
Value
N (% ) N (% ) N (% )
Age (mean ± SD years) 72.95±8.27 72.71±8.27 73.45±8.58 .010
Sex (male) 4077 (96.2%) 2939 (96.5%) 1138 (95.6%) .187
Smoking history 1677 (39.6%) 1204 (39.5%) 473 (39.7%) .895
Alcoholism or other drugs addiction 145 (3.4%) 93 (3.1%) 52 (4.4%) .034
Hypertension 2396 (56.6%) 1725 (56.6%) 672 (56.5%) .924
Dyslipemia 2046 (48.3%) 1382 (45.4%) 665 (55.9%) <.001
Diabetes Mellitus 726 (17.1%) 502 (16.5%) 224 (18.8%) .069
Coronary disease 903 (21.3%) 647 (21.2%) 256 (21.5%) .846
Chronic renal failure 524 (12.4%) 338 (11.1%) 186 (15.6%) <.001
Hemodialysis 115 (2.7%) 84 (2.8%) 31 (2.6%) .783
Chronic pulmonary disease 1017 (24.0%) 739 (24.3%) 278 (23.4%) .538
Carotid stenosis 136 (3.2%) 94 (3.1%) 42 (3.5%) .462
Other aneurysms 463 (10.9%) 304 (10.0%) 159 (13.4%) .002
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Type of AAA Before centralization After centralization P
All AAA (N=4236) 274 (9.0%) 68 (5.7%) <.001
iAAA (N=3802) 113 (4.1%) 20 (1.9%) .001
rAAA (N=434) 161 (52.8%) 48 (37.2%) .003
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Treatment Type of AAA Before centralization After centralizatio p
EVAR 75 (4.1%) 37 (4.1%) .968
iAAA 33 (1.9%) 12 (1.5%) .412
rAAA 42 (38.9%) 25 (28.7%) .138
OR 199 (16.3%) 31 (11.0%) .026
iAAA 80 (7.8%) 8 (3.3%) .014
rAAA 119 (60.4%) 23 (54.8%) .499
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Before centralization (SD) After centralization(SD) P
EVAR 8.14 (10.70) 6.89 (10.68) .004
iAAA 7.45 (8.60) 5.84 (7.65) < .001
rAAA 19.06 (25.28) 16.83 (23.15) .526
OR 14.08 (17.76) 13.69 (24.60) .759
iAAA 13.05 (13.28) 12.78 (20.24) .799
rAAA 19.43 (31.71) 18.86 (41.52) .920
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Mortality Length of stay
Before
centralization
After
centralization
P Before centralization
(SD)
After centralization
(SD)
P
All AAA
(N=3933)
241 (8.7%) 67 (5.7%) < .001 10.41 (13.91) 8.53 (15.51) < .001
iAAA
(N=3523)
93 (3.8%) 20 (1.9%) .004 9.42 (10.87) 7.42 (12.12) < .001
rAAA
(N=410)
148 (52.3%) 47 (37.0%) .004 19.13 (27.77) 17.72 (30.4) .643
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1.Background and Context
2.Objectives
3.Patients and Methods
4.Results
5.Summary
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• Centralization significantly improves in-hospital mortality after repair of iAAA and rAAA
• Centralization has a significant impact on in-hospital mortality after elective OR
• For elective cases, LoS significantly improves after centralization, especially for
elective EVAR cases
• For high-volume centers, Mortality and LoS significantly improve after centralization
• These results support the hypothesis that AAA procedures have better outcomes after
centralization in high-volume centers.
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P. Tripodi, G. Mestres and V. Riambau
Vascular Surgery Division
Cardiovascular Institute, Hospital Clínic of Barcelona
On Behalf of Catalan Vascular Group-Catalan Health Service