INCREASED TRAVEL TIME TO THE TERTIARY CENTRE IS ASSOCIATED WITH DECREASED LONG-TERM SURVIVAL FOLLOWING ASCENDING AORTIC OPERATIONS

Abstract

<h3>BACKGROUND</h3> The association between travel time from the tertiary care centre and outcomes after aortic surgery is unknown. Our objective was to determine the effect of estimated travel time from tertiary care centre on outcomes in ascending aortic repair in Nova Scotia. <h3>METHODS AND RESULTS</h3> A retrospective analysis of all elective and emergent ascending thoracic aortic operations, performed either in isolation or in combination with other cardiac surgery procedures, from 2005 and 2015 was carried out. Clinical characteristics as well as in-hospital outcomes were recorded. Patient's residential geographical coordinates were used to calculate estimated driving time using geographic information system software (ArcMAP, ESRI). Socioeconomic deprivation quintiles were derived from the 2006 Census based on the patient's residential postal code. Long-term survival was identified through Vital Statistics database. Multivariable logistic regression was performed to determine the independent effect of estimated travel time ≥1 hour on in-hospital outcomes. Cox-proportional hazard modeling and Kaplan-Meier survival estimates were created to determine the independent effect of estimated travel time on long-term survival. A total of 476 patients underwent ascending thoracic aortic surgery from 2005 to 2015. Mean age was 59.1 (±13.3) years and 107 (22.5%) were female. Compared to patients at < 1 hour from the tertiary care centre, patients who lived ≥1 hour did not experience higher rates of in-hospital mortality (OR 1.51, 95% CI 0.45-5.00), composite in-hospital complications (OR 1.09, 95% CI 0.62-1.91), discharge disposition to another institution or nursing home (OR 1.33, 95% CI 0.56-3.14), or prolonged hospital length of stay (OR 1.15, 95% CI 0.68-1.93). Kaplan-Meier survival estimates (Figure) and adjusted Cox proportional hazard modeling revealed that patients who lived ≥1 hour from the tertiary centre had increased long-term mortality (HR 2.19, 95% CI 1.13-4.28, p=0.02). In a sensitivity analysis of only elective ascending aortic aneurysm repair patients (n=380), there was a persistent finding of increased mortality in patients who lived ≥1 hour from the tertiary centre (HR 2.56, 95% CI 1.14-5.75, p=0.02). Statistical analysis was performed using Stata, version 14 (College Station, TX). <h3>CONCLUSION</h3> Compared to patients who live in close proximity to the tertiary centre, patients at increased travel time experience equivalent in-hospital outcomes but decreased long-term survival following ascending aortic operations. Resource expansion to improve follow-up monitoring of patients who live remotely is needed.