AAA repair racks up a $1 billion/year toll
Reducing peri-op complications lowers costs
Diagnosis of abdominal aortic aneurysms (AAA) has increasingly become common due to increased physician awareness and improved imaging techniques. That’s good, because the unheralded rupture of an AAA often causes death.
More than 40,000 repairs are performed each year in the United States — more than 35 per 100,000 people. At an estimated cost of $25,000 per procedure, that’s $1 billion per year.
AAA repair is safer than it used to be, with average mortality rates now ranging from 4.8% to 6.8%. However, the procedure is still associated with exorbitantly expensive perioperative morbidity and mortality mostly associated with coronary artery disease (CAD).
Researchers recently analyzed inhospital costs associated with repair and examined the impact of perioperative events on cost.1
They looked at 71 patients who underwent AAA repair at the Cleveland Clinic over a one-year period and were at high-risk for perioperative complications. These high-risk patients smoked and had hypertension, CAD, previous infarction, history of congestive heart failure (CHF), and diabetes. Most study participants were referred for elective surgery, but a few required urgent or emergent procedures due to ruptured aneurysms or acute dissections.
Their costs varied. Their median length of stay (LOS) in the surgical intensive care unit (SICU) was two days, and median inhospital stay was nine days, resulting in inhospital costs ranging from $14,000 to $82,000, with a mean of $26,000.
Among the six patients with in-hospital costs of less than $50,000, the median number of SICU days was 14 days and the median hospital LOS was 25.5 days. Among the five with inhospital costs of less than $15,000, the median number of SICU days was one, and the median hospital LOS was six. Among the 18% of patients who incurred adverse clinical outcomes — infarction, CHF, or death — the median inhospital cost was $30,000. In contrast, the median inhospital cost for patients who did not incur an adverse outcome was $19,500, close to $11,000 in lower inhospital costs.
The investigators concluded the most important correlates of inhospital cost were the number of days spent in the SICU and the total hospital LOS. Their analysis demonstrated that perioperative non-cardiac ischemia — lower limb ischemia associated with aortic cross-clamping — and postoperative CHF are major factors that drive up the cost of AAA repair by significantly increasing the number of days spent in the SICU and hospital.
Any intervention that reduces LOS will significantly reduce the total inhospital cost, they report, and they suggest practical steps to reduce perioperative complications and LOS, such as preoperative identification and treatment of patients at risk for perioperative cardiac events.
Studies have shown that more than 80% of complications associated with AAA repair are a result of CAD, and preventing those complications may require coronary revascularization procedures before the repair. Although those interventions also have inherent costs and complications, studies suggest that they are ultimately beneficial to the patient. Same-day admissions and outpatient recovery programs may also decrease overall LOS. The investigators also suggest new less-invasive techniques such as endovascular stenting to repair AAAs.
Reference
1. Benzaquen BS, Eisenberg MJ, Challapalli R, et al. Correlates of in-hospital cost among patients undergoing abdominal aortic aneurysm repair. Am Heart J 1998; 136:696-702.
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