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Original Investigation | Pacific Coast Surgical Association, Innovation in Safety: Safety in Innovation

Comparative Safety of Endovascular Aortic Aneurysm Repair Over Open Repair Using Patient Safety Indicators During Adoption

John Rose, MD, MPH1,2; Christopher Evans, BS1; Andrew Barleben, MD, MPH1; Dennis Bandyk, MD1; S. Eric Wilson, MD3; David C. Chang, PhD, MBA, MPH1; John Lane, MD1
[+] Author Affiliations
1Department of Surgery, University of California, San Diego
2Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
3Department of Surgery, School of Medicine, University of California, Irvine
JAMA Surg. 2014;149(9):926-932. doi:10.1001/jamasurg.2014.1018.
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Importance  In 2003, the Agency for Healthcare Research and Quality established Patient Safety Indicators (PSIs) to monitor preventable adverse events during hospitalizations.

Objective  To evaluate the comparative safety of endovascular aneurysm repair (EVAR) vs open aneurysm repair (OAR) of abdominal aortic aneurysm by measuring PSIs associated with each procedure over time.

Design, Setting, and Participants  Cases of abdominal aortic aneurysm repair were extracted from the Nationwide Inpatient Sample (2003-2010). Patient Safety Indicators were calculated using Agency for Healthcare Research and Quality software (Win QI, version 4.4). Unadjusted analysis included year, age, sex, race/ethnicity, comorbidities, rupture status, hospital teaching status, and emergency status. Multivariable analysis was stratified by year for any PSI in EVAR vs OAR. Postoperative mortality was analyzed to control for the overall safety.

Main Outcomes and Measures  Patient Safety Indicators and mortality.

Results  In total, 43 385 EVARs and 27 561 OARs were documented, with 1289 (3.0%) and 3094 (11.2%) associated PSIs, respectively. Compared with those receiving OAR, patients receiving EVAR were more likely to be male, older, and of white race/ethnicity; have a lower Charlson Comorbidity Index; and seek care at teaching hospitals (P < .001 for all). Patients were less likely to have a PSI after EVAR than after OAR. Overall, multivariable analysis showed that EVAR was associated with a 42.1% decrease in the risk-adjusted odds of any PSI compared with OAR (odds ratio, 0.58; 95% CI, 0.51-0.65). Stratified by year, the risk-adjusted odds of any PSI after EVAR were comparatively less likely than after OAR every year except for 2007, and the odds of death were comparatively less every year. The annual percentage of PSIs among all aortic repairs decreased from 7.4% in 2003 to 4.4% in 2010, while the proportion of total repairs that were EVARs increased from 41.1% in 2003 to 75.3% in 2010.

Conclusions and Relevance  Patient Safety Indicators can be used to monitor the comparative safety of emerging surgical technologies. Herein, EVAR was safer than OAR. The adoption of minimally invasive technology can improve safety among surgical admissions.

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Figure 1.
Total Abdominal Aortic Aneurysm Repairs Between 2003 and 2010

Endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR) components are shown.

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Figure 2.
Risk-Adjusted Odds of Any Patient Safety Indicator (PSI) or Mortality

The first row shows endovascular aneurysm repair (EVAR) over time with 2003 as the reference. The second row shows open aneurysm repair (OAR) over time with 2003 as the reference. The third row shows EVAR compared with OAR stratified for each year.

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