A Patient-Centered Textbook Outcome Measure Effectively Discriminates Contemporary Elective Open Abdominal Aortic Aneurysm Repair Quality

Abstract

IntroductionThere is persistent controversy surrounding the merit of surgical volume benchmarks being used solely as a sufficient proxy for assessing the quality of open abdominal aortic aneurysm (AAA) repair. Importantly, operative volume quotas may fail to reflect a more nuanced and comprehensive depiction of surgical outcomes most relevant to patients. Accordingly, we herein propose a patient-centered “textbook outcome” (TO) for AAA repair that is analogous to other large magnitude extirpative operations performed in other surgical specialties, and test its feasibility to discriminate hospital performance using Society for Vascular Surgery (SVS) volume guidelines. MethodsAll elective open infrarenal AAA repairs (OAR) in the SVS-Vascular Quality Initiative were examined (2009-2022). The primary end-point was a TO, defined as a composite of no in-hospital complication or re-intervention/re-operation, length of stay ≤ 10-days, home discharge and 1-year survival. The discriminatory ability of the TO measure was assessed by comparing centers that did or did not meet the SVS annual OAR volume threshold recommendation (high-volume ≥ 10 OARs/year; low-volume <10 OARs/year). Logistic regression and multivariable models adjusted for patient and procedure-related differences. ResultsA total of 9,657 OARs across 198 centers were analyzed (mean age-69.5±8.4, female-26%, non-white-12%). A TO was identified in 44% (N = 4,293) of the overall cohort. The incidence of individual TO components included: no in-hospital complication (61%), no in-hospital re-intervention/re-operation (92%), LOS ≤ 10-days (78%), home discharge (76%), and 1-year survival (91%). Median annual center volume was 6 [IQR 3, 10] and a majority of centers did not meet the SVS volume suggested threshold (<10 OARs/year: N = 148 [74%]). However, most patients (N = 6,265 of 9,657 [65%]) underwent OAR in high-volume hospitals. When comparing high and low-volume centers, a TO was more likely to occur in high-volume institutions: ≥10 OARs/year, 46% vs. <10 OARs/year, 42%; P=.0006. The association of a protective effect for higher center volume remained after risk adjustment: OR 1.1, 95%CI 1.05-1.26; P=.003. ConclusionsTextbook outcomes for elective OAR reflect a more nuanced and comprehensive patient centered proxy to measure care delivery consistent with other surgical specialties. Surprisingly, a TO was achieved in < 50% of elective AAA cases nationally. Though the likelihood of a TO appears to correlate with SVS center volume recommendations, it more importantly reflects elements which may be prioritized by patients and thus offers insights into further improving real-world AAA care.