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1 1 2 3 1 Trends in Elective and Ruptured Abdominal Aortic Aneurysm Repair by Practice Setting 4 2 in Ontario, Canada from 2003 to 2016: a population-based cross-sectional study 5 3 6 1 1 1 7 4 Konrad Salata , MD; Mohamad A. Hussain , MD, PhD; Charles de Mestral , MD, PhD; Elisa 1 1,2 1 3,4 8 5 Greco , MD, MEd; Badr A. Aljabri, MD ; Sandra Sabongui ; Muhammad Mamdani , 9 6 PharmD, MPH, MA; Thomas L. Forbes5, MD; Deepak L. Bhatt, MD, MPH6,7; Subodh Verma8, 10 7 MD, PhD; Mohammed Al-Omran1,2, MD, MSc. 11 8 12 9 1Division of Vascular Surgery, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, and 13 10 University of Toronto, Toronto, ON, Canada; 2Department of Surgery, King Saud University, 14 3 15 11 Riyadh, Kingdom of Saudi Arabia; Li Ka Shing Centre for Healthcare Analytics Research and 16 12 Training (CHART), Li Ka Shing Knowledge Institute, St. Michael’s Hospital Toronto, ON, 17 13 Canada; 4Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; 18 14 5Division of Vascular Surgery, Peter Munk Cardiac Centre & University Health Network, and 19 15 University of Toronto, Toronto, ON, Canada; 6Brigham and Women's Hospital Heart and 20 7 8 21 16 Vascular Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of 22 17 Cardiac Surgery, Li Ka Shing ConfidentialKnowledge Institute of St. Michael’s Hospital, and University of 23 18 Toronto, Toronto, ON, Canada. 24 19 25 20 Address for Correspondence: Dr. Mohammed Al-Omran, Division of Vascular Surgery, St. 26 21 Michael’s Hospital, 30 Bond Street, Suite 7-074, Bond Wing, Toronto, Ontario, M5B 1W8, 27 22 Canada. Tel: 001-416-864-6047, E-mail: [email protected]. 28 29 23 30 24 Funding: This work was jointly funded by the Physicians’ Service Incorporated Resident 31 25 Research Grant, the Division of Vascular Surgery at St. Michael’s Hospital, Toronto, Ontario, 32 26 and funds from the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi 33 27 Arabia. Dr. Salata is supported in part by the Canadian Institutes of Health Research Canada 34 28 Graduate Scholarship Master’s salary support award, and the Goerc and Toronto Academic 35 29 Vascular Specialists Surgeon Scientist Training Program Scholarship. 36 37 30 38 31 Disclosures: Dr. Deepak L. Bhatt discloses the following relationships - Advisory Board: 39 32 Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board 40 33 of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair: 41 34 American Heart Association Quality Oversight Committee; Data Monitoring Committees: 42 35 Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo 43 44 36 Clinic, Mount Sinai School of Medicine, Population Health Research Institute; Honoraria: 45 37 American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; 46 38 Vice-Chair, ACC Accreditation Committee), Belvoir Publications (Editor in Chief, Harvard 47 39 Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard 48 40 Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in 49 41 Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest 50 42 Editor; Associate Editor), Population Health Research Institute (clinical trial steering 51 52 43 committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), 53 44 Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering 54 45 committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering 55 46 Committee (Chair), VA CART Research and Publications Committee (Chair); Research 56 57 58 59 60 For Peer Review Only Page 3 of 31
2 1 2 3 1 Funding: Abbott, Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, 4 2 Forest Laboratories, Ironwood, Ischemix, Lilly, Medtronic, Pfizer, Regeneron, Roche, Sanofi 5 6 3 Aventis, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A 7 4 Companion to Braunwald’s Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, 8 5 St. Jude Medical (now Abbott); Trustee: American College of Cardiology; Unfunded Research: 9 6 FlowCo, Merck, PLx Pharma, Takeda. The remaining authors of this manuscript declare no 10 7 competing interests. 11 8 12 9 13 14 10 15 11 16 12 17 13 18 14 19 15 20 21 16 22 17 Confidential 23 18 24 19 25 20 26 21 27 22 28 29 23 30 24 31 25 32 26 33 27 34 28 35 29 36 37 30 38 31 39 32 40 33 41 34 42 35 43 44 36 45 37 46 38 47 39 48 40 49 41 50 42 51 52 43 53 44 54 45 55 46 56 57 58 59 60 For Peer Review Only Page 4 of 31
3 1 2 3 1 ABSTRACT 4 5 6 2 Background: Recent years have seen centralization of vascular surgery services in Ontario. We 7 8 3 sought to examine the trends in overall and approach specific elective (eAAA) and ruptured 9 10 4 abdominal aortic aneurysm (rAAA) repair by hospital type (teaching vs. community). 11 12 5 Methods: We conducted a population-based time-series analysis of eAAA and rAAA repairs in 13 14 15 6 Ontario, Canada from 2003 to 2016. Quarterly rates of repairs per 100,000 Ontarians > 40 years 16 17 7 old were calculated. We fit exponential smoothing models to the approach and hospital type 18 19 8 stratified data to examine repair trends. 20 21 22 9 Results: We identified 19,219Confidential eAAA and 2,722 rAAA repairs from 2003 to 2016. The rates of 23 24 10 eAAA repair and elective open surgical repair (OSR) in teaching and community hospitals 25 26 11 decreased by 1.15% (p=0.0077), 67% (p<0.0001), 23% (p<0.0001), and 60% (p=0.0002), 27 28 29 12 respectively. The rate of elective endovascular repair (EVAR) increased 667% in teaching 30 31 13 hospitals, (p<0.0001). Elective EVAR began in community centres after 2010 and increased to 32 33 14 0.98/100,000 (p<0.0001), resulting in a rebound in overall eAAA repair rates in the community. 34 35 15 Overall rAAA repairs and ruptured OSR decreased by 84% (p=0.0007) and 88% (p=0.0017) at 36 37 38 16 community centres. Ruptured EVAR at community centres increased from no procedures prior 39 40 17 to 2006, to 0.03/100,000 in 2016 (p=0.0048). 41 42 18 Interpretation: Endovascular aortic repair has seen substantial uptake in teaching and 43 44 45 19 community hospitals in Ontario. Furthermore, community hospital uptake of EVAR has begun 46 47 20 decentralization of AAA repair. Increased experience and training in EVAR, and reduced 48 49 21 specialized care requirements will likely lead to continued decentralization. 50 51 52 22 53 54 23 55 56 57 58 59 60 For Peer Review Only Page 5 of 31
4 1 2 3 1 INTRODUCTION 4 5 6 2 It is well known that open surgical repair (OSR) of abdominal aortic aneurysm (AAA) is 7 8 3 associated with 30-day mortality as high as 7%(1). However, studies have shown that outcomes 9 10 4 can be improved when OSR is conducted at experienced centres. Landon et al. demonstrated a 11 12 5 greater than 3% peri-operative mortality reduction at centres conducting more than 50 OSRs per 13 14 15 6 annum when compared to those that conducted fewer than 10 OSRs(1). Elsewhere, larger 16 17 7 hospital size, academic hospital type and greater annual surgeon volume have been associated 18 19 8 with significantly lower 30-day complication and re-operation rates (2, 3). Consequently, many 20 21 22 9 jurisdictions have moved towardConfidential centralization of AAA care to improve patient outcomes. 23 24 10 The advent of endovascular aortic repair (EVAR), a minimally invasive alternative to 25 26 11 OSR for AAA repair, may have removed the need for centralization. Studies comparing EVAR 27 28 29 12 to OSR for AAA repair have demonstrated superior short term mortality and morbidity for 30 31 13 EVAR, as well as shorter procedure times, transfusion requirements, ventilation times, and 32 33 14 intensive care unit (ICU) and hospital lengths of stay(4-7). In contrast, early work has also 34 35 15 shown the importance of individual volume requirements for EVAR competence and significant 36 37 38 16 shortening of the EVAR learning curve for surgeons learning at experienced centres(8, 9). These 39 40 17 factors would suggest that despite better outcomes and fewer requirements for specialized care, 41 42 18 AAA repair should remain centralized at large academic hospitals. The approach specific trends 43 44 45 19 in elective (eAAA) and ruptured abdominal aortic aneurysm (rAAA) repair by practice setting 46 47 20 are not well-studied, and the results of efforts to centralize AAA care in the endovascular era are 48 49 21 not known. The purpose of the present study is to determine the trends in OSR and EVAR of 50 51 52 22 eAAA and rAAA stratified by practice setting in Ontario, Canada from 2003 to 2016. 53 54 23 55 56 57 58 59 60 For Peer Review Only Page 6 of 31
5 1 2 3 1 METHODS 4 5 6 2 Study Design and Setting 7 8 3 We conducted a population-based, cross-sectional, time-series analysis of open surgical 9 10 4 (OSR) and endovascular repair (EVAR) of elective (eAAA) and ruptured (rAAA) abdominal 11 12 5 aortic aneurysms in Ontario. 13 14 15 6 Data Sources 16 17 7 Data for this study were obtained from the Institute for Clinical and Evaluative Sciences 18 19 8 (ICES), a prescribed entity governed under the Personal Health Information Protection Act 20 21 22 9 (PHIPA). ICES stores and managesConfidential data derived from multiple primary data sources that contain 23 24 10 information on usage of ambulatory, emergency and inpatient healthcare system interactions 25 26 11 requiring the use of an Ontario health card. These data are anonymized and linked together using 27 28 29 12 an ICES key number (IKN). The specific datasets used for this study include the Canadian 30 31 13 Institute for Health Information Discharge Abstract Database (CIHI-DAD) and Same Day 32 33 14 Surgery Database (CIHI-SDS), the National Ambulatory Care Reporting System (NACRS) 34 35 15 database, the Ontario Health Insurance Plan (OHIP) database, and the Institution Information 36 37 38 16 System (INST) Database. See Appendix 1 for a description of each database. 39 40 17 Patient Cohort 41 42 18 Our study cohort consisted of all Ontarians > 40 years of age that underwent eAAA and 43 44 45 19 rAAA repair in Ontario, Canada, from April 1, 2003 to March 31, 2016. We identified elective 46 47 20 and ruptured OSR and EVAR (eOSR, eEVAR, rOSR, rEVAR) patients using a combination of 48 49 21 the Canadian 10th Revision of the International Statistical Classification of Diseases and Related 50 51 52 22 Health Problems (ICD-10-CA), Canadian Classification of Health Intervention (CCI), and 53 54 23 Ontario Health Insurance Plan (OHIP) diagnostic, procedure, and billing claims codes according 55 56 57 58 59 60 For Peer Review Only Page 7 of 31
6 1 2 3 1 to our validated algorithm (Appendix 2). Practice setting for each AAA repair was identified 4 5 6 2 using the teaching hospital designation from within the INST database (Appendix 3). 7 8 3 Statistical Analysis 9 10 4 The study period was divided into 52 quarterly intervals from April 1, 2003 to March 31, 11 12 5 2016. We then generated counts of overall and approach specific eAAA and rAAA repairs for 13 14 15 6 each quarterly interval, and calculated quarterly repair rates stratified by practice setting 16 17 7 (teaching vs. community hospital), using the Ontario population > 40 years old according to the 18 19 8 2015 Canadian census and projections, as the denominator. As the primary teaching hospitals 20 21 22 9 within Ontario are located in fourConfidential of fourteen administrative health regions known as Local 23 24 10 Health Integration Networks (LHINs) (2. South West, 4. Hamilton-Niagara-Haldimand-Brant, 7. 25 26 11 Toronto Central, and 11. Champlain) we also calculated mean LHIN specific repair rates over 27 28 29 12 the study period using the Ontario population > 40, to permit visual representation of the relative 30 31 13 distribution of AAA repairs between teaching and community hospitals using choropleth maps. 32 33 14 To examine the trends of eAAA, rAAA, eOSR, eEVAR, rOSR, and rEVAR repair we fit 34 35 15 additive and multiplicative Winter’s exponential smoothing models (ESM) to the stratified 36 37 38 16 overall and approach specific repair rate data(10, 11). Exponential smoothing model 39 40 17 appropriateness was assessed using autocorrelation, and partial and inverse autocorrelation plots, 41 42 18 as well as the Box-Ljung statistic. Model fit was evaluated using Akaike’s Information Criterion 43 44 2 45 19 (AIC), and the adjusted R values. Statistical significance was set at a two-sided p-value of 0.05. 46 47 20 All statistical analyses were conducted in SAS Enterprise Guide version 7.14 (SAS Institute, 48 49 21 Cary, NC). 50 51 52 22 53 54 23 55 56 57 58 59 60 For Peer Review Only Page 8 of 31
7 1 2 3 1 RESULTS 4 5 6 2 We identified 19,219 eAAA and 2,722 rAAA repairs from Ontario administrative data. 7 8 3 Of the eAAA patients, 11,985 (62%) underwent eOSR and 7,234 (38%) underwent eEVAR. The 9 10 4 rAAA subgroup included, 2,458 (90%) rOSR and 264 (10%) rEVAR repairs. The mean 11 12 5 (standard deviation) age was 72.74 (8.07) years old in the eAAA subgroup, and 73.51 (8.93) the 13 14 15 6 rAAA subgroup. Most patients within each subgroup were males [15,813 (81%) in the eAAA 16 17 7 subgroup, and 2,178 (80%) in the rAAA subgroup]. 18 19 8 Approximately two-thirds of all eAAA repairs during the study period were conducted at 20 21 22 9 teaching hospitals (12,693/19,219),Confidential while 57% of rAAA repairs were conducted at teaching 23 24 10 hospitals (1,562/2,722). Elective and ruptured OSRs were almost equally split between teaching 25 26 11 and community hospitals, with 56% (6,724/11,985) of eOSRs and 54% (1,336/2,458) of rOSRs 27 28 29 12 conducted at teaching hospitals. However, 83% (5,969/7,234) of eEVARs and 86% (226/264) of 30 31 13 rEVAR were conducted at teaching hospitals. Ontario choropleth maps of mean overall and 32 33 14 approach specific eAAA (Figure 1) and rAAA (Figure 2) repair rates by Ontario LHIN 34 35 15 demonstrated similar findings. Mean eAAA (Figure 1A) and eEVAR (Figure 1C) repair rates 36 37 38 16 from 2003 to 2016 were highest in the regions with teaching hospitals (South West, Hamilton- 39 40 17 Niagara-Haldimand-Brant, Toronto Central, and Champlain), while eOSR (Figure 1B) rates were 41 42 18 more uniform across the province. While rAAA (Figure 2A) repair rates were more uniform 43 44 45 19 across the province than eAAA rates, they were still higher in the teaching LHINs, as were rOSR 46 47 20 (Figure 2B) rates. However, rEVARs (Figure 2C) were almost exclusively conducted in the 48 49 21 teaching LHINs. 50 51 52 22 Examination of the practice setting data over time revealed an initial increase in eAAA 53 54 23 repairs at teaching centres, followed by a decrease beginning around 2010 and resulting in a 55 56 57 58 59 60 For Peer Review Only Page 9 of 31
8 1 2 3 1 1.15% overall reduction over the study period (from 3.62/100,000 in the second quarter of 2003 4 5 6 2 to 3.58/100,000 in the second quarter of 2016, p=0.0077). In contrast the rate of eAAA repairs in 7 8 3 community centres demonstrated an initial decrease, followed by a rebound beginning around 9 10 4 2010. Overall, the rate decreased by 23% (from 2.61 to 2.00/100,000, p<0.0001) (Figure 3). In 11 12 5 teaching centres, as the rate of eOSR declined (from 3.30 to 1.09, 67% decrease, p<0.0001), the 13 14 15 6 rate of eEVAR increased (from 0.34 to 2.49/100,000, 667% increase, <0.0001). In contrast, 16 17 7 community centres showed a 60% decline in the rate of eOSR (from 2.61 to 1.03/100,000, 18 19 8 p=0.0002), which was supplemented by eEVAR starting after 2010 and increasing to 20 21 22 9 0.98/100,000 in the second quarterConfidential of 2016 (p<0.0001). 23 24 10 The overall and approach specific rates of rAAA repair at teaching centres showed 25 26 11 similar trends, but these were not statistically significant (Figure 4). The rate of rAAA repair 27 28 29 12 decreased by 71% (from 0.90 to 0.25/100,000, p=0.3236), the rate of rOSR decreased by 80% 30 31 13 (from 0.90 to 0.18/100,000, p=0.97), and the rate of rEVAR increased from 0 to 0.07/100,000 32 33 14 (p=0.13). Non-teaching centres saw similar, but statistically significant decreases in overall 34 35 15 rAAA repairs (from 0.72 to 0.11/100,000, 84% decrease, p=0.0007) and rOSR (from 0.72 to 36 37 38 16 0.08/100,000, 88% decrease, p=0.0017), and a concomitant statistically significant increase in 39 40 17 rEVARs, from no procedures until late 2006, to 0.03/100,000 rEVARs in 2016 (p=0.0048). 41 42 18 INTERPRETATION 43 44 45 19 Our population-based time series analysis of overall and approach specific eAAA and 46 47 20 rAAA repair rates in Ontario from 2003 to 2016 grouped by practice setting, demonstrated 48 49 21 significant uptake of EVAR in both teaching and, a couple of years later, in community hospital 50 51 52 22 settings. Furthermore, although rates of EVAR were higher in teaching centres in both eAAA 53 54 55 56 57 58 59 60 For Peer Review Only Page 10 of 31
9 1 2 3 1 and rAAA contexts, commencement of EVAR in community hospitals after 2010 has 4 5 6 2 demonstrated the beginnings of decentralization of AAA care in Ontario. 7 8 3 Studies investigating the organization of aneurysm surgery services in the EVAR era are 9 10 4 sparse. In the only Canadian study to examine the effect of EVAR on the organization of 11 12 5 aneurysm surgery, Forbes et al. demonstrated an increase in infrarenal eAAA case volume from 13 14 15 6 1997-2003, at a tertiary teaching centre in Southwestern Ontario(12). This increase was 16 17 7 attributed to increases in referral rates from increasingly distant geographic regions, and was 18 19 8 accompanied by an increase in the proportion of these patients that received EVAR. Using 20 21 22 9 Ontario-wide data, we confirmedConfidential the continuation of centralization of AAA surgery to teaching 23 24 10 centres until approximately 2010, when EVAR was introduced in community settings and 25 26 11 overall eAAA repair rates began to recover. The well-known, substantially lower peri-operative 27 28 29 12 mortality risk associated with EVAR could have facilitated the commencement of 30 31 13 decentralization to the community(4, 6). However, the studies from which these results are 32 33 14 derived were conducted in experienced, high-volume centres, which may not reflect the 34 35 15 effectiveness of EVAR in all practice settings. Indeed, research has demonstrated volume- 36 37 38 16 outcome relationships for both OSR and EVAR. A recent population-based study by Zettervall 39 40 17 et al. demonstrated lower EVAR perioperative mortality at hospitals within the highest volume 41 42 18 quintiles (> 30 cases per annum)(13). Such studies have led the Society for Vascular Surgery to 43 44 45 19 recommend minimum annual volumes of 10 cases for proficiency with OSR and EVAR(14). In 46 47 20 Ontario, funding of EVAR programs is conditional on more conservative volumes (30 cases per 48 49 21 year). Increased experience, training and the minimal specialized peri-operative care 50 51 52 22 requirements have allowed these volumes to be achieved in community settings. Furthermore, 53 54 23 patient preference may also have facilitated the development of these volumes. In a survey of 67 55 56 57 58 59 60 For Peer Review Only Page 11 of 31
10 1 2 3 1 Ontarians with AAA, Landau et al. demonstrated that 56% of patients would prefer surgery at a 4 5 6 2 centre within 1-hour drive of their place of residence assuming no difference in a baseline 2% 7 8 3 perioperative mortality risk(15). 9 10 4 Limitations 11 12 5 Due to the use of population-level data, our study results should be interpreted 13 14 15 6 considering the limitations associated with population-level research. First, we used 16 17 7 administrative codes for the identification of our patient cohorts. While we validated our coding 18 19 8 algorithms, our chart re-abstraction methodology only allowed use to calculate the positive 20 21 22 9 predictive values of our codes.Confidential Thus, despite confirming high positive predictive values for our 23 24 10 codes, our study may under-represent the number of OSR and EVAR repairs of eAAA and 25 26 11 rAAA conducted during the study period as we were not able to calculate the sensitivity of these 27 28 29 12 codes. Second, our work was conducted using Ontario administrative data. Consequently, our 30 31 13 findings may have limited generalizability secondary to demographic and geographic factors and 32 33 14 the presence of a single-payer publicly funded healthcare system. The latter may limit 34 35 15 generalizability to jurisdictions with other healthcare system payment models. 36 37 38 16 Conclusions 39 40 17 Our population-based time series analysis demonstrated significant EVAR uptake in both 41 42 18 teaching and community hospitals, in Ontario from 2003 to 2016. The development of EVAR 43 44 45 19 programs at community hospitals has begun a resurgence of AAA repair in community settings. 46 47 20 Equivalent peri-operative outcomes in the community compared to teaching hospitals, increased 48 49 21 experience with and training in EVAR, and no need for specialized intensive care unit team 50 51 52 22 requirements for AAA repair have likely contributed to this decentralization. It is likely that this 53 54 55 56 57 58 59 60 For Peer Review Only Page 12 of 31
11 1 2 3 1 shift will propagate specialization of teaching centres toward complex fenestrated and branched 4 5 6 2 EVAR. However, the trends in the latter types of repairs remain to be investigated. 7 8 3 Acknowledgements: This study was supported by the Institute for Clinical Evaluative Sciences 9 10 4 (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term 11 12 5 Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the 13 14 15 6 authors and are independent from the funding sources. No endorsement by ICES or the Ontario 16 17 7 MOHLTC is intended or should be inferred. 18 19 8 Parts of this material is based on data and/or information compiled and provided by CIHI. 20 21 22 9 However, the analyses, conclusions,Confidential opinions and statements expressed in the material are those 23 24 10 of the author(s), and not necessarily those of CIHI. 25 26 11 The authors of this manuscript would also like to thank Cindy Fong from ICES for 27 28 29 12 provision of administrative support, and Alice Chong and Atul Sivaswamy for help with dataset 30 31 13 definition and creation. 32 33 14 34 35 15 36 37 38 16 39 40 17 41 42 18 43 44 45 19 46 47 20 48 49 21 50 51 52 22 53 54 23 55 56 57 58 59 60 For Peer Review Only Page 13 of 31
12 1 2 3 1 REFERENCES 4 5 6 2 1. Landon BE, O'Malley AJ, Giles K, Cotterill P, Schermerhorn ML. Volume-outcome 7 8 3 relationships and abdominal aortic aneurysm repair. Circulation. 2010;122(13):1290-7. 9 10 4 2. Dubois L, Allen B, Bray-Jenkyn K, Power AH, DeRose G, Forbes TL, et al. Higher 11 12 5 surgeon annual volume, but not years of experience, is associated with reduced rates of 13 14 15 6 postoperative complications and reoperations after open abdominal aortic aneurysm repair. J 16 17 7 Vasc Surg. 2017. 18 19 8 3. Hicks CW, Wick EC, Canner JK, Black JH, 3rd, Arhuidese I, Qazi U, et al. Hospital- 20 21 22 9 Level Factors Associated WithConfidential Mortality After Endovascular and Open Abdominal Aortic 23 24 10 Aneurysm Repair. JAMA Surg. 2015;150(7):632-6. 25 26 11 4. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG, participants Et. 27 28 29 12 Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic 30 31 13 aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet. 32 33 14 2004;364(9437):843-8. 34 35 15 5. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et al. A 36 37 38 16 randomized trial comparing conventional and endovascular repair of abdominal aortic 39 40 17 aneurysms. N Engl J Med. 2004;351(16):1607-18. 41 42 18 6. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Jr., Matsumura JS, Kohler TR, et 43 44 45 19 al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a 46 47 20 randomized trial. JAMA. 2009;302(14):1535-42. 48 49 21 7. Becquemin JP, Pillet JC, Lescalie F, Sapoval M, Goueffic Y, Lermusiaux P, et al. A 50 51 52 22 randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal 53 54 23 aortic aneurysms in low- to moderate-risk patients. J Vasc Surg. 2011;53(5):1167-73 e1. 55 56 57 58 59 60 For Peer Review Only Page 14 of 31
13 1 2 3 1 8. Forbes TL, DeRose G, Kribs SW, Harris KA. Cumulative sum failure analysis of the 4 5 6 2 learning curve with endovascular abdominal aortic aneurysm repair. J Vasc Surg. 7 8 3 2004;39(1):102-8. 9 10 4 9. Forbes TL, DeRose G, Lawlor DK, Harris KA. The association between a surgeon's 11 12 5 learning curve with endovascular aortic aneurysm repair and previous institutional experience. 13 14 15 6 Vasc Endovascular Surg. 2007;41(1):14-8. 16 17 7 10. Gardner ES. Exponential smoothing: The state of the art—Part II. International Journal of 18 19 8 Forecasting. 2006;22(4):637-66. 20 21 22 9 11. Gardner ES. ExponentialConfidential smoothing: the state of the art. Journal of Forecasting. 23 24 10 1985(4):1-28. 25 26 11 12. Forbes TL, Lawlor DK, Derose G, Harris KA. Examination of the trend in Canada 27 28 29 12 toward geographic centralization of aneurysm surgery during the endovascular era. Ann Vasc 30 31 13 Surg. 2006;20(1):63-8. 32 33 14 13. Zettervall SL, Schermerhorn ML, Soden PA, McCallum JC, Shean KE, Deery SE, et al. 34 35 15 The effect of surgeon and hospital volume on mortality after open and endovascular repair of 36 37 38 16 abdominal aortic aneurysms. J Vasc Surg. 2017;65(3):626-34. 39 40 17 14. Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA, Mansour MA, et al. The 41 42 18 Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic 43 44 45 19 aneurysm. J Vasc Surg. 2018;67(1):2-77 e2. 46 47 20 15. Landau JH, Novick TV, Dubois L, Power AH, Harris JR, Derose G, et al. Determination 48 49 21 of patient preference for location of elective abdominal aortic aneurysm surgery. Vasc 50 51 52 22 Endovascular Surg. 2013;47(4):288-93. 53 54 23 55 56 57 58 59 60 For Peer Review Only Page 15 of 31
14 1 2 3 1 FIGURES 4 5 6 2 Figure 1A: Mean eAAA repair rates by Ontario LHIN from 2003 to 2016 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Confidential 23 24 25 26 27 28 29 30 31 32 33 34 35 36 3 37 38 4 1=Erie St. Clair; 2=South West; 3=Waterloo Wellington; 4=Hamilton Niagara Haldimand Brant; 39 40 41 5 5=Central West; 6=Mississauga Halton; 7=Toronto Central; 8=Central; 9=Central East; 42 43 6 10=South East; 11=Champlain; 12=North Simcoe Muskoka; 13=North West; 14=North East. 44 45 7 46 47 8 48 49 50 9 51 52 10 53 54 11 55 56 57 58 59 60 For Peer Review Only Page 16 of 31
15 1 2 3 1 Figure 1B: Mean eOSR repair rates by Ontario LHIN from 2003 to 2016 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Confidential 23 24 25 26 27 28 29 30 31 32 33 34 2 35 36 3 1=Erie St. Clair; 2=South West; 3=Waterloo Wellington; 4=Hamilton Niagara Haldimand Brant; 37 38 4 5=Central West; 6=Mississauga Halton; 7=Toronto Central; 8=Central; 9=Central East; 39 40 41 5 10=South East; 11=Champlain; 12=North Simcoe Muskoka; 13=North West; 14=North East. 42 43 6 44 45 7 46 47 8 48 49 50 9 51 52 10 53 54 11 55 56 57 58 59 60 For Peer Review Only Page 17 of 31
16 1 2 3 1 Figure 1C: Mean eEVAR repair rates by Ontario LHIN from 2003 to 2016 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Confidential 23 24 25 26 27 28 29 30 31 32 33 34 2 35 36 3 1=Erie St. Clair; 2=South West; 3=Waterloo Wellington; 4=Hamilton Niagara Haldimand Brant; 37 38 4 5=Central West; 6=Mississauga Halton; 7=Toronto Central; 8=Central; 9=Central East; 39 40 41 5 10=South East; 11=Champlain; 12=North Simcoe Muskoka; 13=North West; 14=North East. 42 43 6 44 45 7 46 47 8 48 49 50 9 51 52 10 53 54 11 55 56 57 58 59 60 For Peer Review Only Page 18 of 31
17 1 2 3 1 Figure 2A: Mean rAAA repair rates by Ontario LHIN from 2003 to 2016 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Confidential 23 24 25 26 27 28 29 30 31 32 33 34 2 35 36 3 1=Erie St. Clair; 2=South West; 3=Waterloo Wellington; 4=Hamilton Niagara Haldimand Brant; 37 38 4 5=Central West; 6=Mississauga Halton; 7=Toronto Central; 8=Central; 9=Central East; 39 40 41 5 10=South East; 11=Champlain; 12=North Simcoe Muskoka; 13=North West; 14=North East. 42 43 6 44 45 7 46 47 8 48 49 50 9 51 52 10 53 54 11 55 56 57 58 59 60 For Peer Review Only Page 19 of 31
18 1 2 3 1 Figure 2B: Mean rOSR repair rates by Ontario LHIN from 2003 to 2016 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Confidential 23 24 25 26 27 28 29 30 31 32 33 34 2 35 36 3 1=Erie St. Clair; 2=South West; 3=Waterloo Wellington; 4=Hamilton Niagara Haldimand Brant; 37 38 4 5=Central West; 6=Mississauga Halton; 7=Toronto Central; 8=Central; 9=Central East; 39 40 41 5 10=South East; 11=Champlain; 12=North Simcoe Muskoka; 13=North West; 14=North East. 42 43 6 44 45 7 46 47 8 48 49 50 9 51 52 10 53 54 11 55 56 57 58 59 60 For Peer Review Only Page 20 of 31
19 1 2 3 1 Figure 2C: Mean rEVAR repair rates by Ontario LHIN from 2003 to 2016 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Confidential 23 24 25 26 27 28 29 30 31 32 33 34 2 35 36 3 1=Erie St. Clair; 2=South West; 3=Waterloo Wellington; 4=Hamilton Niagara Haldimand Brant; 37 38 4 5=Central West; 6=Mississauga Halton; 7=Toronto Central; 8=Central; 9=Central East; 39 40 41 5 10=South East; 11=Champlain; 12=North Simcoe Muskoka; 13=North West; 14=North East. 42 43 6 44 45 7 46 47 8 48 49 50 9 51 52 10 53 54 11 55 56 57 58 59 60 For Peer Review Only Page 21 of 31
20 1 2 3 1 Figure 3: Actual overall and approach specific eAAA repair rates by practice setting in Ontario 4 5 6 2 from 2003 to 2016 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Confidential 23 24 25 26 27 28 29 30 31 32 33 34 35 36 3 37 38 4 eAAA=elective abdominal aortic aneurysm; eEVAR=elective endovascular aortic repair; 39 40 41 5 eOSR=elective open surgical repair. 42 43 6 44 45 7 46 47 48 8 49 50 9 51 52 10 53 54 55 56 57 58 59 60 For Peer Review Only Page 22 of 31
21 1 2 3 1 Figure 4: Actual overall and approach specific rAAA repair rates by practice setting in Ontario 4 5 6 2 from 2003 to 2016 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Confidential 23 24 25 26 27 28 29 30 31 32 33 34 35 36 3 37 38 4 rAAA=ruptured abdominal aortic aneurysm; rEVAR=ruptured endovascular aortic repair; 39 40 41 5 rOSR=ruptured open surgical repair. 42 43 6 44 45 7 46 47 48 8 49 50 9 51 52 10 53 54 11 55 56 57 58 59 60 For Peer Review Only Page 23 of 31
22 1 2 3 1 APPENDICES 4 5 6 2 Appendix 1: Summary of ICES databases used for time-series analysis 7 8 Database Years Coding system Data Elements 9 Available 10 CIHI-DAD April 1988 – < April 2002: ICD-9/CCP Patient-level information 11 March 2017 > April 2002: ICD-10-CA/CCI including patient age, gender, 12 13 location of residence, hospital 14 of admission, up to 25 different 15 diagnoses and procedures 16 (distinguished by most- 17 responsible, pre-admission, and 18 comorbid), treating physician, 19 length of stay, disposition, and 20 21 resource consumption. 22 CIHI-SDS April 1991 –
23 1 2 3 1 System Database; NACRS=National Ambulatory Care Reporting System database; OHIP=Ontario Health Insurance 4 2 Plan (OHIP) database 5 3 6 4 7 8 5 9 6 10 7 11 8 12 9 13 10 14 11 15 16 12 17 13 18 14 19 15 20 16 21 17 Confidential 22 18 23 24 19 25 20 26 21 27 22 28 23 29 24 30 25 31 32 26 33 27 34 28 35 29 36 30 37 31 38 39 32 40 33 41 34 42 35 43 36 44 37 45 38 46 47 39 48 40 49 41 50 42 51 43 52 44 53 45 54 55 56 57 58 59 60 For Peer Review Only Page 25 of 31
24 1 2 3 1 Appendix 2: Validated administrative data coding algorithm for identification of OSR and 4 5 6 2 EVAR in eAAA and rAAA patients 7 8 Indication and Code Combination Positive Predictive Value 9 repair % (95% CI) 10 11 12 13 14 15 I71.4 AND 1.KA.80.LA-XX-N OR 1.KA.76.MZ- 16 eOSR 95 (88,98) 17 XX-N OR 1.KA.76.NB-XX-N OR R802 18 19 20 21 22 eEVAR I71.4 ANDConfidential 1.KA.80.GQ-NR-N OR R875 96 (90,99) 23 24 25 26 27 I71.3 AND 1.KA.80.LA-XX-N OR 1.KA.76.MZ- rOSR 87 (79,93) 28 XX-N OR 1.KA.76.NB-XX-N OR R802 29 30 31 I71.3 AND E627 AND 1.KA.80.GQ-NR-N OR 32 R875 33 rEVAR 91 (59,100) 34 35 36 37 3 CI=Confidence Interval; eAAA=Elective Abdominal Aortic Aneurysm; eEVAR=Elective Endovascular Aortic 38 4 Repair; eOSR=Elective Open Surgical Repair; EVAR=Endovascular Aortic Repair; OSR=Open Surgical Repair; 39 5 rAAA=Ruptured Abdominal Aortic Aneurysm; rEVAR= Ruptured Endovascular Aortic Repair; rOSR=Ruptured 40 6 Open Surgical Repair 41 7 42 43 8 44 45 9 46 47 48 10 49 50 11 51 52 12 53 54 55 13 56 57 58 59 60 For Peer Review Only Page 26 of 31
25 1 2 3 1 Appendix 3: Ontario hospitals designated as teaching hospitals 4 5 6 Institution Name Location LHIN # LHIN Name 7 Bridgepoint Hospital Toronto 7 Toronto Central 8 Centre For Addiction and Mental Toronto 7 Toronto Central 9 Health, Detox 10 11 Centre For Addiction and Mental Toronto 7 Toronto Central 12 Health 13 Centre For Addiction and Mental Toronto 7 Toronto Central 14 Health, Arf 15 Centre For Addiction and Mental Toronto 7 Toronto Central 16 Health, Clarke 17 18 Centre For Addiction and Mental Toronto 7 Toronto Central 19 Health, Donwood 20 Centre For Addiction and Mental Toronto 7 Toronto Central 21 Health, Queen 22 Children's Hospital of Eastern ConfidentialOntario Ottawa 11 Champlain 23 24 Hamilton Detoxification Centre Hamilton 4 Niagara Hamilton 25 Haldimand Brant 26 Hamilton Health Sciences Corporation, Hamilton 4 Niagara Hamilton 27 Chedoke Haldimand Brant 28 Hamilton Health Sciences Corporation, Hamilton 4 Niagara Hamilton 29 General Haldimand Brant 30 31 Hamilton Health Sciences Corporation, Hamilton 4 Niagara Hamilton 32 Juravinski Haldimand Brant 33 Hamilton Health Sciences Corporation, Hamilton 4 Niagara Hamilton 34 McMaster Haldimand Brant 35 Hamilton Health Sciences Corporation, Hamilton 4 Niagara Hamilton 36 St. Peter's Haldimand Brant 37 38 Hamilton Health Sciences Corporation, Hamilton 4 Niagara Hamilton 39 West End Urgent Care Haldimand Brant 40 Hamilton Health Sciences Corporation, Hamilton 4 Niagara Hamilton 41 Gen, Regional Rehab Haldimand Brant 42 Hamilton Health Sciences Corporation, Grimsby 4 Niagara Hamilton 43 West Lincoln Haldimand Brant 44 45 Hamilton Regional Cancer Centre Hamilton 4 Niagara Hamilton 46 Haldimand Brant 47 Health Sciences North, General Sudbury 13 North East 48 Health Sciences North, Laurentian Sudbury 13 North East 49 50 Health Sciences North, Memorial Sudbury 13 North East 51 Hopital Montfort Ottawa 11 Champlain 52 Hopital Regional De Sudbury, Sudbury 13 North East 53 Laurentian 54 Hospital For Sick Children Toronto 7 Toronto Central 55 56 Hotel Dieu Detoxification Kingston 10 South East 57 58 59 60 For Peer Review Only Page 27 of 31
26 1 2 3 Hotel Dieu Hospital, Kingston Kingston 10 South East 4 5 Kingston General Hospital Kingston 10 South East 6 Kingston Regional Cancer Centre Kingston 10 South East 7 London Health Sciences Centre, South London 2 South West 8 Street 9 10 London Health Sciences Centre, London 2 South West 11 University Hospital 12 London Health Sciences Centre, London 2 South West 13 Victoria Hospital 14 London Health Sciences Centre, London 2 South West 15 Victoria South 16 17 London Regional Cancer Centre London 2 South West 18 Northeastern Ontario Cancer Treat Sudbury 13 North East 19 Centre 20 Ontario Shores Centre For Mental Whitby 9 Central East 21 Health Sciences 22 Confidential 23 Ottawa Hospital, Civic Site Ottawa 11 Champlain 24 Ottawa Hospital, General Site Ottawa 11 Champlain 25 Ottawa Hospital, Riverside Site Ottawa 11 Champlain 26 Ottawa Hospital, The Rehab Centre Ottawa 11 Champlain 27 28 Ottawa Regional Cancer Centre (Civic Ottawa 11 Champlain 29 Division) 30 Ottawa Regional Cancer Centre (Gen Ottawa 11 Champlain 31 Division) 32 Penetanguishene Mental Healthcare Penetanguishene 12 North Simcoe 33 34 Oakridge Division Muskoka 35 Penetanguishene Mental Healthcare Penetanguishene 12 North Simcoe 36 Regional Division Muskoka 37 Providence Care Centre, Mental Health Kingston 10 South East 38 Services 39 Providence Care Centre, St. Mary's of Kingston 10 South East 40 41 the Lake 42 Providence Continuing Care Centre, Kingston 10 South East 43 Kingston Mental Health 44 Royal Ottawa Health Care Group Ottawa 11 Champlain 45 Royal Ottawa Health Care Group, Ottawa 11 Champlain 46 47 Mental Health 48 Royal Ottawa Health Care Group, Ottawa 11 Champlain 49 Psych Site 50 Royal Ottawa Health Care Group, Brockville 10 South East 51 Brockville Mental Health 52 Sinai Health System, Bridgepoint Site Toronto 7 Toronto Central 53 54 Sinai Health System, Mount Sinai Site Toronto 7 Toronto Central 55 St John's Rehabilitation Hospital Toronto 7 Toronto Central 56 57 58 59 60 For Peer Review Only Page 28 of 31
27 1 2 3 St Joseph's Community Health Centre Hamilton 4 Niagara Hamilton 4 Haldimand Brant 5 6 St Joseph's Health Care System, Hamilton 4 Niagara Hamilton 7 Hamilton, Mental Health Haldimand Brant 8 St Joseph's Health Care System, Hamilton 4 Niagara Hamilton 9 Hamilton Haldimand Brant 10 St Joseph's Hospital Detox Centre Hamilton 4 Niagara Hamilton 11 Haldimand Brant 12 13 St Michael's Detoxification Toronto 7 Toronto Central 14 St Michael's Hospital Toronto 7 Toronto Central 15 St. Joseph's Health Care, London London 2 South West 16 17 St. Joseph's Health Care, London, London 2 South West 18 Detox Centre 19 St. Joseph's Health Care, London, London 2 South West 20 London Mental Health 21 St. Joseph's Health Care, London,Confidential London 2 South West 22 Parkwood 23 24 St. Joseph's Health Care, London, St. St Thomas 2 South West 25 Thomas 26 Sunnybrook & Women's College Toronto 7 Toronto Central 27 Health Sciences, Women's 28 Sunnybrook Health Sciences Centre Toronto 7 Toronto Central 29 30 Sunnybrook Health Sciences Centre, Toronto 7 Toronto Central 31 Orthopaedic 32 Sunnybrook Health Sciences Centre, Toronto 7 Toronto Central 33 St. John's 34 Thunder Bay Regional Cancer Centre Thunder Bay 14 North West 35 36 Thunder Bay Regional Health Sciences Thunder Bay 14 North West 37 Thunder Bay Regional Health, Port Thunder Bay 14 North West 38 Arthur 39 Toronto Rehabilitation Institute, Bickle Toronto 7 Toronto Central 40 Centre 41 Toronto Rehabilitation Institute, Toronto 7 Toronto Central 42 43 Hillcrest/Un 44 Toronto Rehabilitation Institute, Toronto 7 Toronto Central 45 Lyndhurst 46 Toronto Sunnybrook Regional Cancer Toronto 7 Toronto Central 47 Centre 48 49 University Health Network Toronto 7 Toronto Central 50 University Health Network, Bickle Toronto 7 Toronto Central 51 Centre 52 University Health Network, General Toronto 7 Toronto Central 53 Site 54 University Health Network, Toronto 7 Toronto Central 55 56 Hillcrest/University 57 58 59 60 For Peer Review Only Page 29 of 31
28 1 2 3 University Health Network, Lyndhurst Toronto 7 Toronto Central 4 Site 5 6 University Health Network, Princess Toronto 7 Toronto Central 7 Marg 8 University Health Network, Western Toronto 7 Toronto Central 9 Site 10 University of Ottawa Heart Institute Ottawa 11 Champlain 11 12 Waypoint Centre For Mental Health Penetanguishene 12 North Simcoe 13 Care, Provincial Muskoka 14 Waypoint Centre For Mental Health Penetanguishene 12 North Simcoe 15 Care, Regional Muskoka 16 West Lincoln Memorial Hospital Grimsby 4 Niagara Hamilton 17 Haldimand Brant 18 19 Whitby Mental Health Centre Whitby 9 Central East 20 Women's College Hospital Toronto 7 Toronto Central 21 Women's Own Detox Centre Toronto 7 Toronto Central 22 Confidential 1 LHIN=Local Health Integration Network 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only