Endovascular aneurysm repair patients who are lost to follow-up have worse outcomes

Abstract

Background Society for Vascular Surgery practice guidelines recommend 1- and 12-month follow-up with computed tomography imaging for the year after endovascular aneurysm repair (EVAR). We describe the incidence, risk factors, and outcomes of EVAR patients who are lost to follow-up (LTF). Methods All patients undergoing elective EVAR in the Vascular Quality Initiative (VQI) data set (January 2003-December 2015) were stratified according to long-term follow-up method (in-person vs phone call vs LTF). Mortality was captured for all patients by linkage with the Social Security Death Index. Univariable statistics, Kaplan-Meier estimated survival curves, and Cox proportional hazard modeling were used to compare groups. Coarsened exact matching analysis was then performed to refine the association between LTF and risk of post-EVAR death. Results During the study period, 11,309 patients underwent elective EVAR (78% in-person follow-up, 11% phone call follow-up, 11% LTF). On univariable analysis, LTF patients had larger baseline aneurysms, higher American Society of Anesthesiologists scores, more comorbidities, and worse baseline functional status compared to patients with in-person or phone call follow-up (P ≤ .05). Procedural factors (contrast material volume, blood transfusions, postoperative vasopressor use) were higher in the LTF group, as was the incidence of postoperative complications (P ≤ .05). Accordingly, LTF patients had longer postoperative lengths of stay and were less frequently discharged to home (P < .001). Five-year survival was lower for LTF vs phone call follow-up vs in-person follow-up (62% vs 68% vs 84%; P < .001). On multivariable analysis correcting for baseline differences between groups, there was a significantly higher risk of death for both the LTF group (hazard ratio, 6.45; 95% confidence interval, 4.89-8.51) and phone call follow-up group (hazard ratio, 3.48; 95% confidence interval, 2.66-4.57) compared with patients who followed up in person (P < .001). After coarsened exact matching on 30 preoperative and perioperative variables, 5-year survival after EVAR for LTF vs phone call follow-up vs in-person follow-up was 84.9% vs 84.8% vs 91.9%, respectively (log-rank, P < .001). Notably, patients with phone call follow-up had a lower prevalence of documented postoperative imaging compared with patients with in-person follow-up (56.1% vs 85.1%; P < .001). Conclusions EVAR patients with more comorbidities and a higher incidence of in-hospital complications tend to be more frequently LTF and ultimately have worse survival outcomes. In-person follow-up is associated with better post-EVAR survival and a higher rate of postoperative imaging. Phone follow-up confers a mortality risk equivalent to lack of follow-up, possibly as a result of inadequate postoperative imaging. Surgeons should stress the importance of office-based postoperative follow-up to all EVAR patients, particularly those with poor baseline health and functional status and more complicated perioperative courses.

Editor's Choice – The Implications of Non-compliance to Endovascular Aneurysm Repair Surveillance: A Systematic Review and Meta-analysis

“…To account for confounding factors, matched cohorts were used where possible. This included the studies by Garg et al and Hicks et al for comparative meta-analyses of mortality,16,19 and the study by Garg et al for comparative meta-analyses of re-intervention rates 19…”

“…For three studies,16,20,21 Kaplane–Meier curves for “non-compliant” groups and “lost to follow-up” were provided separately. It was agreed that, although the “lost to follow-up” group is a more non-compliant group, this particular survival curve would not be analysed for meta-analysis.…”

“…In the study by Hicks et al,16 an assumption was agreed by the authors, whereby patients who had telephone follow-up were considered as non-compliant, whereas patients who attended clinic for follow-up were considered as compliant. This was done in order to resemble the current real world scenario where patients physically attend follow-up sessions.…”

A comparison of reintervention rates after endovascular aneurysm repair between the Vascular Quality Initiative registry, Medicare claims, and chart review

“…This finding is consistent with long-term results from randomized trials, 2 and may account for the inferior outcomes associated with patients who are lost to follow up. 8 Furthermore, this indicates that patients who undergo EVAR must have long-term surveillance, as the rate of reintervention does not appear to plateau. The method described in our report, which leverages registry data and Medicare claims, may be a cost-effective approach for a distributed surveillance network to evaluate EVAR performance over time.…”

Loss to follow-up 1 year after lower extremity peripheral vascular intervention is associated with worse survival

“…4 The follow up of patients after other vascular procedures, such as endovascular aneurysm repair (EVAR), has been published recently, espousing the importance of in-person follow-up and surveillance imaging, to reap the benefits of close surveillance on mortality. 5 The authors go on to stress the importance of office-based outpatient follow-up, particularly in those patient populations that they discovered were more likely to be lost to follow-up. We sought to establish whether loss to follow-up (LTF) at 1 year was associated with worse outcomes in the national Vascular Quality Initiative (VQI).…”