Longitudinal Spending on Endovascular and Open Abdominal Aortic Aneurysm Repair

Abstract

Background: Endovascular repair (EVR) has replaced open surgery as the procedure of choice for patients requiring elective abdominal aortic aneurysm (AAA) repair. Long-term outcomes of the 2 approaches are similar, making the relative cost of caring for these patients over time an important consideration. Methods and Results: We linked Medicare claims to Vascular Quality Initiative registry data for patients undergoing elective EVR or open AAA repair from 2004 to 2015. The primary outcome was Medicare’s cumulative disease-related spending, adjusted to 2015 dollars. Disease-related spending included the index operation and associated hospitalization, surveillance imaging, reinterventions (AAA-related and abdominal wall procedures), and all-cause admissions within 90 days. We compared the incidence of disease-related events and cumulative spending at 90 days and annually through 7 years of follow-up. The analytic cohort comprised 6804 EVR patients (median follow-up: 1.85 years; interquartile range: 0.82–3.22 years) and 1889 open repair patients (median follow-up: 2.62 years; interquartile range: 1.13–4.80 years). Spending on index surgery was significantly lower for EVR (median [interquartile range]: $25 924 [$22 280–$32 556] EVR versus $31 442 [$24 669–$40 419] open; P <0.001), driven by a lower rate of in-hospital complications (6.6% EVR versus 38.0% open; P <0.001). EVR patients underwent more surveillance imaging (1.8 studies per person-year EVR versus 0.7 studies per person-year open; P <0.001) and AAA-related reinterventions (4.0 per 100 person-years EVR versus 2.1 per 100 person-years open; P =0.041). Open repair patients had higher rates of 90-day readmission (12.9% EVR versus 17.8% open; P <0.001) and abdominal wall procedures (0.6 per 100 person-years EVR versus 1.5 per 100 person-years open; P <0.001). Overall, EVR patients incurred more disease-related spending in follow-up ($7355 EVR versus $2706 open through 5 years). There was no cumulative difference in disease-related spending between surgical groups by 5 years of follow-up (−$33 EVR [95% CI: −$1543 to $1476]). Conclusions: We observed no cumulative difference in disease-related spending on EVR and open repair patients 5 years after surgery. Generalized recommendations about which approach to offer elective AAA patients should not be based on relative cost.

Treatment of abdominal aortic aneurysms in Korea: a nationwide study

“…The present study found that the cost of the initial procedure was much lower than in previous studies [ 14 15 ], with the overall in-hospital costs for the initial procedure being similar in the EVAR and OSR groups. This was likely due to the provisions of the Korean insurance system, in which the cost of an open surgical procedure is unreasonably lower than that of endovascular treatment based on procedure time.…”

“…Clinical situations requiring reinterventions in patients who underwent OSR were likely more serious or complex despite the lower reintervention rate. By contrast, previous studies showed no significant differences in disease-related expenditures between patients who underwent EVAR and OSR [ 14 17 ].…”

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

“…5-9 In addition, significant variability in costs across organizations and countries, and changing efficiencies in techniques, makes it difficult to make recommendations on preferred interventional approaches based primarily on relative costs. 6,10,11…”

“…In patients with AAA, studies comparing EVAR to open surgical repair generally show lower initial costs for EVAR based on shorter hospital stays; however, ongoing expenses for EVAR surveillance and reinterventions may minimize long-term cost advantages after 2 to 5 years. 5-9 In addition, significant variability in costs across organizations and countries, and changing efficiencies in techniques, makes it difficult to make recommendations on preferred interventional approaches based primarily on relative costs. 6,10,11…”