Longer patient travel distance is associated with increased non-index readmission after complex aortic surgery.
Longer patient travel distance is associated with increased non-index readmission after complex aortic surgery.
复制标题
较长的患者移动距离与复杂主动脉手术后非指数再入院的增加有关。
DOI：
10.1016/j.jvs.2023.02.005
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发表时间：
2023
影响因子：
4.3
通讯作者：
Srivastava,SunitaD
中科院分区：
文献类型：
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作者：
Feldman,ZachM;Zheng,Xinyan;Mao,Jialin;Sumpio,BrandonJ;Mohebali,Jahan;Chang,DavidC;Goodney,PhilipP;Conrad,MarkF;Srivastava,SunitaD
目的最近不断发展的复杂主动脉手术实践模式导致美国的护理中心越来越少，因此患者可能不得不前往更远的地方进行复杂的主动脉护理。旅行距离与非血管手术后的不良结局相关，特别是非指数再入院。本研究旨在评估患者出行距离对复杂主动脉手术后围手术期结果和再入院的影响。方法对血管质量倡议和血管植入监测和介入结果网络数据库中接受复杂主动脉腔内修复术（EVAR）的所有患者进行回顾性评价，包括髂内或内脏血管受累、复杂胸腔血管内修复术 主动脉修复 (TEVAR) 包括 0 至 2 区近端范围或分支装置，以及复杂的开放性腹主动脉瘤 (AAA) 修复，包括肾上或更高的钳位部位。出行距离按农村/城市通勤区（RUCA）人口密度类别进行分层。 Wilcoxon 和 χ2 检验用于评估旅行距离五分位数与基线特征、死亡率和再入院之间的关系。将旅行距离和其他因素纳入多变量 Cox 生存模型和避免再入院的 Fine-Gray 竞争风险模型中。 结果 2011 年至 2018 年，血管质量倡议和血管植入监测和介入结果网络数据库中的 8782 例患者接受了复杂的主动脉手术，其中包括 4822 例复杂 EVAR、2672 例复杂 TEVAR 和 1288 例复杂开放手术AAA级维修。中位出行距离为 22.8 英里（四分位距 [IQR]，8.6-54.8 英里）。所有距离五分位数的中位年龄均为 75 岁，但旅行距离较长的患者更有可能患有较大直径的 AAA（五分位数 5 [Q5] 的中位数为 59 毫米，而 Q1 的中位数为 19.9%；P< .001）、白人（Q5 的 93.8% 与 Q1 的 83.8%；P< .001）。 Q1 为 55 毫米；P< .001)，以及 既往接受过主动脉手术（第 5 季度为 20.8%，第 1 季度为 5.9%；P< .001）。总体而言，距离较远的地区，30 天再入院率更高（第 5 季度为 18.1%，第 1 季度为 14.8%；P= .003），非指数再入院率较高（第 5 季度为 11.2%，第 1 季度为 2.7%；P< .001），相反，指数再入院率较低（第 5 季度为 6.9%，第 1 季度为 12.0%；P< .001）。多变量调整的 Fine-Gray 模型证实，距离越远，非指数再入院的风险越大，Q5 风险比为 3.02（95% 置信区间，2.12-4.30；P< .001）。多变量调整的 Cox 模型表明，旅行距离与长期生存率之间没有关联，但发现非指标再入院与长期死亡率增加相关（风险比，1.46；95% 置信区间，1.20-1.78；P= .0001）。 结论 因复杂主动脉手术而走得更远的患者表现出更高的非指标再入院率，这反过来又与长期死亡风险增加相关。主动脉卓越中心应考虑针对这些患者进行更全面的随访和护理协调，以改善预后。
ObjectiveRecently evolving practice patterns in complex aortic surgery have led to regionalization of care within fewer centers in the United States, and thus patients may have to travel farther for complex aortic care. Travel distance has been associated with inferior outcomes after non-vascular surgery, particularly non-index readmission. This study aims to assess the impact of patient travel distance on perioperative outcomes and readmissions after complex aortic surgery.MethodsA retrospective review was conducted of all patients in the Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network databases undergoing complex endovascular aortic repair (EVAR) including internal iliac or visceral vessel involvement, complex thoracic endovascular aortic repair (TEVAR) including zone 0 to 2 proximal extent or branched devices, and complex open abdominal aortic aneurysm (AAA) repair including suprarenal or higher clamp sites. Travel distance was stratified by rural/urban commuting area (RUCA) population-density category. Wilcoxon and χ2tests were used to assess relationships between travel distance quintiles and baseline characteristics, mortality, and readmission. Travel distance and other factors were included in multivariable Cox models for survival and Fine-Gray competing risk models for freedom from readmission.ResultsBetween 2011 and 2018, 8782 patients underwent complex aortic surgery in the Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network databases, including 4822 complex EVARs, 2672 complex TEVARs, and 1288 complex open AAA repairs. Median travel distance was 22.8 miles (interquartile range [IQR], 8.6-54.8 miles). Median age was 75 years for all distance quintiles, but patients traveling longer distances were more likely female (26.8% in quintile 5 [Q5] vs 19.9% in Q1;P< .001), white (93.8% of Q5 vs 83.8% of Q1;P< .001), to have larger-diameter AAAs (median 59 mm for Q5 vs 55 mm for Q1;P< .001), and to have had prior aortic surgery (20.8% for Q5 vs 5.9% for Q1;P< .001). Overall 30-day readmission was more common at farther distances (18.1% for Q5 vs 14.8% for Q1;P= .003), with higher non-index readmission (11.2% for Q5 vs 2.7% for Q1;P< .001) and conversely lower index readmission (6.9% for Q5 vs 12.0% for Q1;P< .001). Multivariable-adjusted Fine-Gray models confirmed greater hazard of non-index readmission with farther distance, with a Q5 hazard ratio of 3.02 (95% confidence interval, 2.12-4.30;P< .001). Multivariable-adjusted Cox models demonstrated no association between travel distance and long-term survival but found that non-index readmission was associated with increased long-term mortality (hazard ratio, 1.46; 95% confidence interval, 1.20-1.78;P= .0001).ConclusionsPatients traveling farther for complex aortic surgery demonstrate higher non-index readmission, which, in turn, is associated with increased long-term mortality risk. Aortic centers of excellence should consider targeting these patients for more comprehensive follow-up and care coordination to improve outcomes.