ABDOMINAL AORTIC-ANEURYSM REPAIR IN VETERANS AFFAIRS MEDICAL-CENTERS

Purpose: This study was performed to define outcomes after abdominal a ortic aneurysm (AAA) repair in Veterans Affairs (VA) medical centers d uring fiscal years 1991 through 1993. Methods: With VA patient treatme nt file data, patients were selected from diagnosis-related groups 110 and 111 and were then classified in a patient management category. In the categories of repair of nonruptured and ruptured AAA, mortality a nd postoperative complication rates were defined for patients who unde rwent AAA repair in VA medical centers during the 3-year study period. Results: Hospital mortality rates were 4.86% (166 of 3419) after repa ir of nonruptured AAA and 47.0% (126 of 268) after repair of ruptured AAA (p < 0.001). Of 292 deaths after AAA repair, 126 (43.2%) followed repair of ruptured AAA, even though ruptured AAA comprised only 7.3% o f total AAA surgical volume. AAA repairs were performed at 116 VA medi cal centers, with 31.8 +/- 23.1 (range, 1 to 140) procedures performed at each center. Although many lower-volume centers had excellent resu lts, centers that performed greater than or equal to 32 AAA repairs te nded to have lower in-hospital mortality rates after repair of nonrupt ured AAA than those that performed less than or equal to 31 procedures (4.2% +/- 3.5% compared with 6.7% +/- 7.8%;p < 0.05). Poisson regress ion analysis revealed an inverse relationship between the volume of AA A repairs and individual hospital mortality (p = 0.001) and a direct r elationship between illness severity and hospital mortality (p = 0.008 ). The proportion of ruptured AAAs treated in a hospital was also dire ctly related to individual hospital mortality rates (p < 0.005). Posto perative complications were associated with an increased hospital mort ality rate (11.7% with complication compared with 6.5% without; p < 0. 001) and length of stay (23.6 +/- 17.1 days compared with 18.0 +/- 12. 4 days; p < 0.0001). In a logistic regression model, increased mortali ty rates after AAA repair were associated with hospital type (adjusted odds ratio [OR] = 0.6), increasing age (OR 1.1), patient management c ategory severity score (OR = 2.2), hemorrhage (OR = 2.3), myocardial i nfarction (OR = 2.6), disseminated intravascular coagulation (OR = 4.7 ), AAA rupture (OR 6.0), postoperative shock (OR 10.7), cardiopulmonar y arrest (OR = 15.4), central nervous system complications (OR 16.0) a nd urologic complications (OR 2.4). Conclusions: Mortality rates after AAA repair in VA hospitals were comparable with those previously repo rted in other large series. Outcomes for veterans with AAA may improve by referring patients eligible for elective repair to VA medical cent ers with a greater operative volume or to lower-volume centers that ha ve had excellent results.