Skip to main content
Search
Search
    Quick Search anywhere
    Quick search in Citations
Advanced Search
Skip main navigation
Previous article
Next article
Thematic focus: Vascular claims – Original communication

Regional variation in endovascular treatment rate and in-hospital mortality of abdominal aortic aneurysms in Germany

Secondary data analysis of nationwide hospital DRG data from 2012 to 2014

Published Online:November 29, 2019https://doi.org/10.1024/0301-1526/a000830

Abstract

Summary:Background: Abdominal aortic aneurysms (AAA) can be treated by either open surgery (OAR) or endovascular aortic repair (EVAR). The aim of this study was to analyze regional variations in application of (EVAR) and in-hospital mortality after intact AAA (iAAA) repair. Methods: Using data provided by the German Federal Statistical Office, a nationwide analysis for 2012 to 2014 was conducted. Patients with a diagnosis of iAAA (I71.4) and corresponding procedure codes for OAR (5-384.5/7) or EVAR (5-38a.1) were included. Odds ratios (ORs) for use of EVAR (proportion of EVAR among total EVAR + OAR cases) and mortality were calculated for all regions in Germany. ORs for EVAR use were adjusted for age, sex, and risk (Elixhauser score). ORs for mortality were additionally adjusted for type of procedure (OAR/EVAR). Results: Finally, 31,757 procedures for iAAA were included. Median age of all patients was 73 years (interquartile range 67–78 years) and 87.1 % were male. The mean proportion of EVAR procedures was 72.6 %; however, the application of EVAR for repair of iAAA varied widely depending on region. The lowest unadjusted regional rate of EVAR use was 48.8 %, while the highest was 92.5 %. After adjustment, the lowest regional OR for EVAR use (compared to the nationwide mean) was 0.23 (95 % confidence interval [0.15–0.36]), the highest 5.93 [1.79–19.65]. Overall in-hospital mortality was 2.9 % (OAR 6.2 %; EVAR 1.7 %). The adjusted regional OR for mortality ranged from 0.31 [0.07–1.42] to 4.98 [2.08–11.93]. Conclusions: This study reveals variations in use of EVAR and in-hospital mortality for iAAA treatment in Germany. This may imply that selection of treatment might not only be influenced by patient characteristics, but also by regional location. These results need to be taken into account when discussing centralization of AAA treatment in Germany.

References

  • 1 Eckstein HH, Bockler D, Flessenkamper I, Schmitz-Rixen T, Debus S, Lang W. Ultrasonographic screening for the detection of abdominal aortic aneurysms. Dtsch Arztebl Int. 2009;106(41):657–63. First citation in articleMedline, Google Scholar

  • 2 Debus ES, Heidemann F, Gross-Fengels W, Mahlmann A, Muhl E, Pfister K, et al. Short version of the S3 guideline on screening, diagnosis, therapy and follow-up of abdominal aortic aneurysms. Gefässchirurgie. 2018. First citation in articleGoogle Scholar

  • 3 Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, European Society for Vascular Surgery (ESVS), et al. Clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg.. 2019. First citation in articleGoogle Scholar

  • 4 Beck AW, Sedrakyan A, Mao J, Venermo M, Faizer R, Debus S, et al. Variations in abdominal aortic aneurysm care: a report from the International Consortium of Vascular Registries. Circulation. 2016;134(24):1948–58. First citation in articleCrossref Medline, Google Scholar

  • 5 Trenner M, Haller B, Söllner H, Storck M, Umscheid T, Niedermeier HP, et al. 12 Jahre „Qualitätssicherung BAA” der DGG- Teil 1: Trends in Therapie und Outcome des nicht rupturierten abdominellen Aortenaneurysmas in Deutschland zwischen 1999 und 2010. Gefässchirurgie. 2013;18(3):206–13. First citation in articleCrossref, Google Scholar

  • 6 Trenner M, Kuehnl A, Reutersberg B, Salvermoser M, Eckstein HH. Nationwide analysis of risk factors for in-hospital mortality in patients undergoing abdominal aortic aneurysm repair. Br J Surg. 2018;105(4):379–87. First citation in articleCrossref Medline, Google Scholar

  • 7 Droesler SE. Regionale Unterschiede in der Operationshäufigkeit – Bewertung der Daten und Handlungsbedarf. Im Auftrag der Bundesärztekammer. 2015; Available from https://www.bundesaerztekammer.de/fileadmin/user_upload/downloads/pdf-Ordner/Versorgungsforschung/2015-05-29_GutachtenRegVariationen.pdf. First citation in articleGoogle Scholar

  • 8 Anderson HV. Regional variation: only moderately interesting: a word of caution. Circ Cardiovasc Qual Outcomes. 2010;3(1):6–7. First citation in articleCrossref Medline, Google Scholar

  • 9 Kuehnl A, Salvermoser M, Erk A, Trenner M, Schmid V, Eckstein HH. Spatial analysis of hospital incidence and in hospital mortality of abdominal aortic aneurysms in Germany: Secondary data analysis of Nationwide Hospital Episode (DRG) Data. Eur J Vasc Endovasc Surg. 2018;55(6):852–9. First citation in articleCrossref Medline, Google Scholar

  • 10 Kuehnl A, Salvermoser M, Knipfer E, Zimmermann A, Schmid V, Eckstein HH. Regional frequency variation of revascularization procedures for carotid stenosis in Germany: Secondary data analysis of DRG data from 2012 to 2014. Gefässchirurgie. 2018;23(Suppl 2):56–65. First citation in articleCrossref Medline, Google Scholar

  • 11 Ng TT, Mirocha J, Magner D, Gewertz BL. Variations in the utilization of endovascular aneurysm repair reflect population risk factors and disease prevalence. J Vasc Surg. 2010;51(4):801–9.e1. First citation in articleCrossref Medline, Google Scholar

  • 12 Zettervall SL, Soden PA, Buck DB, Cronenwett JL, Goodney PP, Eslami MH, et al. Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm. J Vasc Surg. 2017;65(5):1305–12. First citation in articleCrossref Medline, Google Scholar

  • 13 Zettervall SL, Buck DB, Soden PA, Cronenwett JL, Goodney PP, Eslami MH, et al. Regional variation exists in patient selection and treatment of abdominal aortic aneurysms. J Vasc Surg. 2016;64(4):921–7.e1. First citation in articleCrossref Medline, Google Scholar

  • 14 Quintana MJ, Gich I, Librero J, Bellmunt-Montoya S, Escudero JR, Bonfill X. Variation in the choice of elective surgical procedure for abdominal aortic aneurysm in Spain. Vasc Health Risk Manag. 2019;15:69–79. First citation in articleCrossref Medline, Google Scholar

  • 15 Kuehnl A, Erk A, Trenner M, Salvermoser M, Schmid V, Eckstein HH. Incidence, Treatment and Mortality in Patients with Abdominal Aortic Aneurysms – a secondary analysis of diagnosis-related groups (DRG) data from 2005–2014. Dtsch Arztebl Int. 2017;114(22–23):391–8. First citation in articleMedline, Google Scholar

  • 16 Nimptsch U, Krautz C, Weber GF, Mansky T, Grutzmann R. Nationwide in-hospital mortality following pancreatic surgery in Germany is higher than anticipated. Ann Surg. 2016;264(6):1082–90. First citation in articleCrossref Medline, Google Scholar

  • 17 Trenner M, Eckstein HH, Kallmayer MA, Reutersberg B, Kühnl A. Secondary analysis of statutorily collected routine data. Gefässchirurgie. 2019;24(3):220–7. First citation in articleCrossref, Google Scholar

  • 18 Trenner M, Kuehnl A, Salvermoser M, Reutersberg B, Geisbuesch S, Schmid V, et al. Editor’s choice: High annual hospital volume is associated with decreased in hospital mortality and complication rates following treatment of abdominal aortic aneurysms: Secondary data analysis of the Nationwide German DRG Statistics from 2005 to 2013. Eur J Vasc Endovasc Surg. 2018;55(2):185–94. First citation in articleCrossref Medline, Google Scholar

  • 19 Swart E, Gothe H, Geyer S, Jaunzeme J, Maier B, Grobe TG, et al. Good Practice of Secondary Data Analysis (GPS): guidelines and recommendations. Gesundheitswesen. 2015;77(2):120–6. First citation in articleMedline, Google Scholar

  • 20 Benchimol EI, Smeeth L, Guttmann A, Harron K, Hemkens LG, Moher D, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. Z Evid Fortbild Qual Gesundhwes. 2016;115–116:33–48. First citation in articleCrossref Medline, Google Scholar

  • 21 Swart E, Bitzer EM, Gothe H, Harling M, Hoffmann F, Horenkamp-Sonntag D, et al. STandardisierte BerichtsROutine für Sekundärdaten Analysen (STROSA) – ein konsentierter Berichtsstandard für Deutschland, Version 2. Gesundheitswesen. 2016;78(S01):145–60. First citation in articleGoogle Scholar

  • 22 R Core Team. A language and environment for statistical computing. R Foundation for Statistical Computing. Vienna, 2018. Available from: https://www.R-project.org/. First citation in articleGoogle Scholar

  • 23 Wickham H. ggplot2: Elegant Graphics for Data Analysis. New York: Springer-Verlag; 2016. First citation in articleCrossref, Google Scholar

  • 24 Moll FL, Powell JT, Fraedrich G, Verzini F, Haulon S, Waltham M, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg. 2011;41(Suppl 1):S1–s58. First citation in articleCrossref Medline, Google Scholar

  • 25 Debus ES, Nüllen H, Torsello G, Lang W, Flessenkämper I, Hupp T, et al. Zur Behandlung des abdominellen Aortenaneurysmas in Deutschland. Gefässchirurgie. 2014;19(5):412–21. First citation in articleCrossref, Google Scholar

  • 26 Trenner M, Haller B, Storck M, Reutersberg B, Kallmayer MA, Eckstein HH. Trends in Patient Safety of Intact Abdominal Aortic Aneurysm Repair: German Registry Data on 36,594 Procedures. Eur J Vasc Endovasc Surg. 2017;53(5):641–7. First citation in articleCrossref Medline, Google Scholar