Targets to prevent prolonged length of stay after endovascular aortic repair

Abstract

Objective Endovascular aneurysm repair (EVAR) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly, even within institutions. The present study reviewed the morbidity, mortality, and the financial effect of increased LOS to establish modifiable factors associated with prolonged hospital LOS, with the goal of improving quality. Methods The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients under-going primary, elective EVAR at a single institution between January 1, 2011, and May 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤2 days and >2 days. Results Complete 30-day variable and cost data were available for 138 patients with an average follow-up of 12 months; of these, 46 (33%) had a LOS >2 days. Variables determined to be statistically significant predictors of prolonged LOS included aneurysm diameter (P = .03), American Society of Anesthesiologists Physical Status Classification score (P < .001), thromboembolectomy (P = .01), and increased postoperative cardiac (P < .001) and renal (P = .01) complications. Specifically, modifiable risk factors that contributed to increased LOS included performance of a concomitant procedure (P < .001), increased volume of iodinated contrast (P = .05), increased volume of intraoperative crystalloid (P = .05), placement in an intensive care unit (P < .001), return to the operating room (P < .001), and the use of vasoactive medications (P < .001). Hospital charges ($102,000 ± $41,000 vs $180,000 ± $73,000; P = .01) and costs ($27,000 ± $10,000 vs $45,000 ± $19,000 P = .01) were significantly higher in patients with prolonged LOS; however, there was no difference in physician charges ($8000 ± $5700 vs $12,000 ± $12,000; P = .09). Increased LOS after EVAR was associated with an increase in mortality at 1 month (0% vs 4% P = .05) and 12 months (3% vs 13% P = .03). Conclusions This study highlights several modifiable risk factors leading to increased LOS after EVAR, including performance of concomitant procedures, admission to the intensive care unit, and postoperative renal and cardiac complications. Further, increased LOS was associated with increased charges, costs, morbidity, and mortality after EVAR. This study highlights specific areas of focus for decreasing LOS after EVAR and, in turn, improving quality in vascular surgery.

The Impact of Body Mass Index on Perioperative and Postoperative Outcomes for Endovascular Abdominal Aneurysm Repair

“…For these reasons, reducing length of stay is often used as a quality metric to lower costs and reduce hospital-acquired morbidity. 23 The major limitation of our study is its power. A large percentage of patients had to be excluded from the study, either because their height and weight were not recorded at the time of surgery or because they did not have follow-up for at least 1-year following surgery.…”

Leveraging vascular quality initiative data to improve hospital length of stay for patients undergoing endovascular aneurysm repair

“…We found no Canadian data. Mehaffey and colleagues 8 identified modifiable risk factors at different points on the patient's continuum of care; in other words, different pre-, peri-and postoperative factors played a role. They identified preoperative factors, including ASA class and congestive heart failure, as the most relevant.…”

Development of novel patient selection criteria for a short stay endovascular aneurysm repair pathway: Improving patient selection for short stay endovascular aneurysm repair

“…Subsequently, with this information and a knowledge of the co-morbidities that have previously been shown to effect outcomes following EVAR, 20–22 two investigators developed a set of low and high risk criteria. The low risk criteria were essentially designed to ensure that it would be safe for a relatively fit and healthy individual to undergo SS-EVAR.…”

“…Vascular 28(1) heterogeneously identified as being associated with pathway non-completion included advanced age, 15 ASA class !4, 15 home oxygen therapy, presence of heart failure, 17 smaller external iliac artery diameter and larger aneurysm size. 15 Subsequently, with this information and a knowledge of the co-morbidities that have previously been shown to effect outcomes following EVAR, [20][21][22] two investigators developed a set of low and high risk criteria. The low risk criteria were essentially designed to ensure that it would be safe for a relatively fit and healthy individual to undergo SS-EVAR.…”