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Higher Institutional Volume Reduces Mortality in Reoperative Proximal Thoracic Aortic Surgery

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Higher Institutional Volume Reduces Mortality in Reoperative Proximal Thoracic Aortic Surgery Published online: 2020-11-05 THIEME Original Research Article 59 Higher Institutional Volume Reduces Mortality in Reoperative Proximal Thoracic Aortic Surgery Nicholas J. Shea, MD, MS1 Alex M. D’Angelo, MD1 Antonio R. Polanco, MD1 Philip Allen, BS1 Joseph E. Sanchez, BS1 Paul Kurlansky, MD1 Virendra I. Patel, MD, MPH1 Hiroo Takayama, MD, PhD1 1 Department of Surgery, New York-Presbyterian Hospital, Columbia Address for correspondence Hiroo Takayama, MD, PhD, 177 Ft University Aortic Surgery Center, Columbia University Irving Medical Washington Avenue, MHB 7GN 435, New York, NY 10032 Center,NewYork,NewYork (e-mail: [email protected]). AORTA 2020;8:59–65. Abstract Objective This study aims to determine the impact of institutional volume on mortality in reoperative proximal thoracic aortic surgery patients using national outcomes data. Methods The Nationwide Inpatient Sample was queried from 1998 to 2011 for patients with diagnoses of thoracic aneurysm and/or dissection who underwent open mediastinal repair. A total of 103,860 patients were identified. A total of 1,430 patients had prior cardiac surgery. Patients were further stratified into groups by institutional aortic volume: low (<12 cases/year), medium (12–39 cases/year), and high (40þ cases/year) volume. Multivariable risk-adjusted analysis accounting for emergent status and aortic dissection among other factors was performed to determine the impact of institutional volume on mortality. Results Overall mortality was 12% in the reoperative population. When the redo cohort was divided into tertiles, high-volume group had a 5% operative mortality compared with 9 and 15% for the medium- and low-volume groups, respectively. Multivariable analysis revealed that patients operated on at low- (odds ratio [OR] ¼ 5.0, Keywords 95% confidence interval [CI]: 2.6–9.6, p < 0.001) and medium-volume centers ► reoperation (OR ¼ 2.1, 95% CI: 1.1–4.2, p ¼ 0.03) had higher odds of mortality when compared ► aortic surgery with patients operated on at high-volume centers. ► aortic aneurysm Conclusions High-volume aortic centers can significantly reduce mortality for reo- ► aortic dissection perative aortic surgery, compared with lower volume institutions. 2,3 Introduction tions, or infectious complications. Several institutions have reported their outcomes in this reoperative proximal In the current era, first time proximal aortic surgical oper- aortic surgical population, with some referral centers report- ations (e.g., root, ascending, and arch procedures) are being ing operative mortality as low as 4%, while others report – performed with low operative mortality, with some institu- mortality as high as 19%.4 15 Anecdotally, higher volume tions reporting mortality less than 5%.1 While these excellent centers experience lower mortality, although the relation- outcomes in first time patients are encouraging, an increas- ship between surgical volume and mortality in this complex ing number of reoperative aortic procedures are being surgical population remains largely unexamined. performed. Patients with prior open aortic and cardiac In this study, we hypothesize that outcomes in the reo- operations are aging and requiring surgery for aortic disease perative proximal aortic surgical population vary with insti- including progressive aneurysmal degeneration, new dissec- tutional volume. To test this hypothesis, we used national received DOI https://doi.org/ Copyright © 2020 by Thieme Medical May 28, 2019 10.1055/s-0040-1713860. Publishers, Inc., 333 Seventh Avenue, accepted ISSN 2325-4637. New York, NY 10001, USA. May 18, 2020 Tel: +1(212) 760-0888. 60 Reducing Death after Redo Aortic Surgery Shea et al. outcomes data to evaluate the impact of institutional annual Volume reoperative proximal thoracic aortic surgical (i.e., root, as- A unique hospital identifier is provided by the NIS to cending, or arch procedure) volume on operative mortality identify the institution from which a patient was dis- among patients in the United States with prior cardiac or charged. Using this unique identifier, all patients included aortic surgery via sternotomy. in our cohort had the institution performing their operation identified. The total annual volume of proximal thoracic Materials and Methods aortic surgeries performed at each individual institution was determined over the course of the study period using Data Source the same inclusion criteria outlined above. After annual This study is a retrospective cohort analysis of patients who volume was determined for the relevant institutions, they underwent reoperative proximal thoracic aortic surgery in were stratified into tertiles by annual volume. High-volume the United States in the years 1998 to 2011 selected from centers (HVCs) were defined as those centers performing the Healthcare Cost and Utilization Project National Inpa- 40þ thoracic aortic operations/year (lower limit of upper tient Sample (HCUP-NIS), sponsored by the Agency for tertile), medium-volume centers (MVC) were defined as Healthcare Research and Quality. HCUP-NIS is a 20% strati- those performing 12 to 39 thoracic aortic operations/year, fied probability sample including approximately 8 million and low-volume centers (LVC) as those performing <12 acute hospital stays annually from more than 1,000 hospi- thoracic aortic operations/year (upper limit of lower ter- tals in 42 states. It is the largest all-payer inpatient care tile). Further details of redo aortic case volume based on observational cohort in the United States, representing each volume tertile can be found in ►Table 1. A comparison approximately 90% of all hospital discharges. Each record of clinical characteristics and demographics is detailed in the database represents an inpatient stay and includes in ►Tables 2 and 3. patient demographics, principal diagnoses, comorbidities and complications, and procedures coded according to the Study Endpoints and Statistical Analysis International Classification of Diseases, Ninth Revision, The primary endpoint of this study was in-hospital mortal- Clinical Modification (ICD-9-CM). Weights based on sam- ity. A comparison of in-hospital clinical outcomes is de- pling probabilities for each stratum are used in the analysis tailed in ►Table 4. Univariate analysis was performed using to ensure that the hospitals studied are representative of Pearson’s Chi-square test for categorical variables and anal- all U.S. hospitals. This study was granted exemption from ysis of variance for continuous variables. Multivariable institutional review board approval at our institution be- analysis was performed using a binary logistic regression cause HCUP-NIS is a public database with no personal model to determine the impact of annual aortic volume on identifying information. in-hospital mortality. Stepwise construction was not per- formed so as not to overfit the data. All baseline character- Patient Selection istics were included in the multivariable model. Annual The NIS database was queried from 1998 to 2011, and all aortic volume was placed into the model as a categorical patients with a history of prior heart surgery (ICD-9-CM code variable corresponding to the tertile of the institution at V15.1) and a procedure code for thoracic aortic replacement which a patient had surgery. HVCs were used as a reference (ICD-9-CM codes 38.34, 38.35, 38.45) were identified. group. In-hospital mortality was chosen as the dependent Patients were only included in the final analysis if they variable in this model. Results of the multivariable analyses had diagnosis codes for thoracic aortic aneurysm (ICD-9- are represented as odds ratios (OR) with 95% confidence CM codes 441.1 or 441.2) or dissection (ICD-9-CM code intervals (CIs). A multivariable subanalysis was performed 441.01). In an attempt to remove patients undergoing sur- on patients who presented for elective surgery using a gery for descending thoracic aortic aneurysms, patients were similar analysis. Both multivariable analyses are detailed excluded if they did not have a diagnosis code for cardiopul- in ►Table 5. The number of redo proximal thoracic aortic monary bypass (ICD-9-CM 39.61), cardioplegia (ICD-9-CM operations over the study period by year is detailed 39.63), hypothermia (ICD-9-CM 39.62), or concomitant valve in ►Fig. 1. All analyses were performed with SPSS for or coronary bypass procedures. A total of 1,430 patients were Macintosh, Version 24 (IBM Corporation, Armonk, NY). All identified meeting our inclusion criteria and represent the tests were two-sided, with statistical significance set at a cohort for this study. value of p < 0.05. Table 1 Redo aortic case volume details based on institutional volume tertile groupings Variable Overall HVC MVC LVC Mean (SD) 57.8 (38.4) 83.8 (30.4) 26.6 (7.7) 8.2 (3.1) Range 0.36–155.9 45.4–155.9 12–39.7 0.36–11.8 Median [IQR] 50.6 [26.8, 77.3] 75.3 [64.5, 92.1] 26.8 [20.2, 33.8] 9.4 [5.5, 11] Total number of centers 98 21 39 38 Abbreviations: HVC, high-volume center; IQR, interquartile range; LVC, low-volume center; MVC, medium-volume center; SD, standard deviation. AORTA Vol. 8 No. 3/2020 Reducing Death after Redo Aortic Surgery Shea et al. 61 Table 2 Patient characteristics comparison between volume tertile groupings Variable HVC (n ¼ 534) MVC (n ¼ 503) LVC (n ¼ 392) p-Value %(no.) %(no.) %(no.) Age (mean) in y 55.6 56.9 46.1 <0.001 Female gender 17.6 (94) 27.4 (138) 29.8 (117) <0.001 Chronic kidney disease 1.9 (10) 6.2 (31) 1 (4) <0.001 Chronic obstructive pulmonary disease 14.6 (78) 8.9 (45) 6.4 (25) <0.001 Diabetes 9.3 (50) 15.5 (78) 14.3 (56) 0.008 Cerebrovascular disease 1.7 (9) 4.8 (24) 1.3 (5) 0.001 Peripheral vascular disease 0.9 (5) 7.5 (38) 1.3 (5) <0.001 Hypertension 60.7 (325) 49 (247) 49.9 (196) <0.001 Operation performed at teaching institution 89.2 (477) 86.3 (435) 76.0 (294) <0.001 Abbreviations: HVC, high-volume center; LVC, low-volume center; MVC, medium-volume center.
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