Study looks at endovascular abdominal aortic aneurysm repair

Minimally invasive endovascular abdominal aortic aneurysm repair (EVAR) has been praised by many vascular surgeons and patients due to its benefits: shorter operating time, reduced hospital stays, faster recovery and less scarring.

It is performed through two small groin incisions rather than a large, full-length abdominal incision used in open repair. Also, EVAR is often feasible for patients when a traditional operation is prohibitive due to co-existing medical conditions.

However, after EVAR, long-term surveillance (regular visits and diagnostic studies) is necessary. Secondary procedures (which may be a consequence of the original aneurysm or complication of the repair itself) also might be required. According to some reports, global costs for follow-up services over a five-year period after initial EVAR surgery can increase the overall cost of EVAR by nearly 50 percent.

Researchers embarked on a study of EVAR patients from the Ochsner Clinic Foundation in New Orleans, where reimbursement for post-surgical surveillance costs were evaluated over a five-year period on 152 patients that qualified for the study. The mean follow-up after EVAR for this group of patients was approximately 38 months. Medicare provided coverage for 56 percent of patients; capitated insurance was used by 32 percent of patients and 12 percent of patients had commercial insurance. The costs and reimbursement of performing the EVAR itself were excluded from the study in order to concentrate only on the reimbursement associated with follow-up surveillance costs.

"The cumulative five-year postoperative cumulative surveillance costs totaled $12,027 per patient, while reimbursements were $9,792, or a net loss of $2,235," said lead author W. Charles Sternbergh III, MD, section head of vascular and endovascular surgery at the Ochsner Clinic Foundation. He added that although 123 patients without secondary procedures generated a five-year cumulative gain of $1,830 per patient, the average loss was derived from the 29 patients (19.1 percent) with secondary procedures that averaged a five-year cumulative loss of $9,378 per patient. The average reimbursement rate for all payors during this period was 35.9 percent of submitted charges, with the lowest reimbursement rate seen in patients from the Medicare group at 31.6 percent.

Researchers noted that improvements in technical skills, patient selection, endograft device durability and endograft manufacturing (to decrease the incidence of endograft failure, migration or endoleak) will be instrumental in decreasing the rate of secondary procedures and reduce the deficit between reimbursement and cost. Additionally, modifications to the surveillance protocol derived from ongoing review of evidence based medicine may further help to reduce costs of long-term follow-up.

"Current reimbursement for long-term surveillance and secondary procedures after endovascular aneurysm repair does not cover the institutional costs," added Dr. Sternbergh. "This fiscal reality is not sustainable for our hospitals. If left uncorrected, this could ultimately result in a contraction of these resources and negatively impact patient outcomes."

Complete details of this study have been published in the December 2008 issue of the Journal of Vascular Surgery , published by the Society for Vascular Surgery.