Rural and urban areas equally likely to receive endovascular aneurysm repair care

A new study published in the September issue of Journal of Vascular Surgery® reveals that rural and urban patients have equivalent access to endovascular aneurysm repair (EVAR) care from vascular surgeons, increased referral to high-volume hospitals and improved outcomes after repair.

Co-author Matthew W. Mell, MD, serves as director of vascular surgery clinics and vascular laboratory, as well as assistant professor of vascular surgery at Stanford University in Stanford, Calif. He reported that 2,616 selected patients (identified from a standard 5 percent random sample of all Medicare beneficiaries) underwent intact AAA repair in 2005 to 2006. Data on patient demographics, comorbidities, type of repair and specialty of operating surgeon were collected. Hospitals were stratified into quintiles by yearly AAA volume and primary outcomes included 30-day mortality and re- hospitalization.

Patients had repair for intact AAA (40 percent open, 60 percent EVAR). "Those from rural and urban areas were equally likely to receive EVAR (rural 60 percent vs. urban 61 percent) and be treated by a vascular surgeon (rural 48 percent vs. urban 50 percent)," noted Dr. Mell. Most rural patients (86 percent) received care in urban centers. Primary outcomes occurred in 11.6 percent of rural patients (1.3 percent had 30-day mortality; 10.3 percent were re-hospitalization) vs. 16.0 percent of urban patients (3 percent 30-day mortality, 13 percent re-hospitalization).

In multivariate analyses, rural residence was independently associated with treatment at high-volume centers with an odds ratio (OR) of 1.64 and 95 percent confidence interval (CI), 1.34-2.01, and decreased death or re-hospitalization (OR of 0.69 and 95 percent CI, 0.49-0.97).

"Our study is the first to describe the national experience for treatment of intact AAA's in the endovascular era for patients living in rural areas, said Dr. Mell. "Lack of local expertise and the need to refer elsewhere for AAA treatment may have allowed rural patients paradoxically improved access to high-volume centers compared with urban patients. This access may, in part, account for the rural patients' improved outcomes, as the potential benefit of AAA treatment at high-volume centers is well-documented. However, study researchers added that some rural patients also may have been cared for at high-quality low-volume centers or by highly skilled specialists and outcomes of rural patients represent access to high quality care regardless of volume.

Another potential concern is that urban patients had worse outcomes than rural patients, even after adjusting for race and Medicaid, according to researchers. Urban patients had a higher proportion of minorities and those on Medicaid, which may have impacted outcomes. Some research shows that minorities are less likely to receive complex surgical care in high-volume hospitals for AAA's because they are not referred to such centers.

"Our study supports the need for better criteria that defines centers of excellent aortic care to extend the benefits of regionalization to all patients, which would allow improved outcomes for across the board," said Dr. Mell. However, he added that many barriers prevent regionalization for complex surgical care.

"Barriers can include patients who have a preference for local care and will trade increased mortality for decreased travel distances," noted Dr. Mell. He added that primary care physicians often value the local specialist's medical skills, quality communication between the specialist, patient and referring physician, and that the hope that the specialist will return the patient to the primary physician. Less important to local physicians are hospital affiliation, office location and patient convenience.

Willingness to refer rural patients to urban settings also may reflect a severe shortage of qualified resources at rural hospitals including recruitment of surgeons, said Dr. Mell, and the cost of a viable endovascular program (specially trained personnel, radiologic imaging and adequate inventory) may prohibit rural hospitals from attracting appropriately trained physicians, even though surgeons have a vital role in the financial viability of these institutions.

Some urban communities do not have high-quality hospitals and patients would prefer to remain in their own urban area rather than travel to another urban center for care. Referrals for these patients often are based on matching hospital affiliation or insurance coverage between the referring physician and specialist, without knowledge or ability of the primary physician to choose a specialist based on expertise and outcomes.