Variation in Hospital Door-to-Intervention Time for Ruptured AAAs and Its Association with Outcomes

Abstract

A ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition that carries a high mortality rate. Recent guidelines have recommended a goal "door-to-intervention" time of ≤90minutes despite a paucity of evidence to support this goal. The aim of this study was to analyze recent trends in door-to-intervention time for rAAAs and determine the effect of the 90-minute door-to-intervention benchmark on postoperative complications. A retrospective analysis of all patients who underwent open aortic repair (OAR) or endovascular aneurysm repair (EVAR) of a rAAA in the Vascular Quality Initiative database (2003-2018) was performed. Variation in door-to-intervention time was analyzed at the patient and hospital level. Patients were dichotomized into ≤90 or >90minute door-to-intervention time cohorts. Hierarchical modeling controlling for the hospital random effect and multivariate logistic models was used to analyze the association on 30-day mortality and major in-hospital complications. A total of 3,630 operative cases for rAAA were identified (1696 OAR and 1934 EVAR). For the OAR cohort, 1035 patients (61%) had a door-to-intervention time of ≤90minutes. However, at the hospital level, a minority of hospitals (49%) reliably achieved the OAR goal door-to-intervention time. For OARs, there was no difference in 30-day risk-adjusted major complications or mortality between the ≤90- and>90-minute cohorts. For EVAR, 1014 patients (53.8%) had a door-to-intervention time of ≤90minutes and a minority of hospitals (40%) upheld the recommended ≤90minute door-to-intervention threshold. In the EVAR group, patients with a ≤90minute door-to-intervention time had higher rates of postoperative myocardial infarction (12.0% vs. 8.5%; P<0.05) but no difference in 30-day risk-adjusted mortality. A low percentage of rAAAs are being treated within the recommended door-to-intervention time. Despite this deficiency, the ≤90-minute benchmark has minimal impact on postoperative morbidity and mortality. Based on these findings, alternative quality metrics should be identified to improve the clinical care of patients with rAAA.