Elsevier

The Lancet

Volume 383, Issue 9921, 15–21 March 2014, Pages 963-969
The Lancet

Articles
Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA

https://doi.org/10.1016/S0140-6736(14)60109-4Get rights and content

Summary

Background

The outcome of patients with ruptured abdominal aortic aneurysm (rAAA) varies by country. Study of practice differences might allow the formulation of pathways to improve care.

Methods

We compared data from the Hospital Episode Statistics for England and the Nationwide Inpatient Sample for the USA for patients admitted to hospital with rAAA from 2005 to 2010. Primary outcomes were in-hospital mortality, mortality after intervention, and decision to follow non-corrective treatment. In-hospital mortality and the rate of non-corrective treatment were analysed by binary logistic regression for each health-care system, after adjustment for age, sex, year, and Charlson comorbidity index.

Findings

The study included 11 799 patients with rAAA in England and 23 838 patients with rAAA in the USA. In-hospital mortality was lower in the USA than in England (53·05% [95% CI 51·26–54·85] vs 65·90%; p<0·0001). Intervention (open or endovascular repair) was offered to a greater proportion of cases in the USA than in England (19 174 [80·43%] vs 6897 [58·45%]; p<0·0001) and endovascular repair was more common in the USA than in England (4003 [20·88%] vs 589 [8·54%]; p<0·0001). Postintervention mortality was similar in both countries (41·77% for England and 41·65% for USA). These observations persisted in age-matched and sex-matched comparisons. In both countries, reduced mortality was associated with increased use of endovascular repair, increased hospital caseload (volume) for rAAA, high hospital bed capacity, hospitals with teaching status, and admission on a weekday.

Interpretation

In-hospital survival from rAAA, intervention rates, and uptake of endovascular repair are lower in England than in the USA. In England and the USA, the lowest mortality for rAAA was seen in teaching hospitals with larger bed capacities and doing a greater proportion of cases with endovascular repair. These common factors suggest strategies for improving outcomes for patients with rAAA.

Funding

None.

Introduction

The rupture of an abdominal aortic aneurysm (rAAA) is frequently fatal and accounts for the death of at least 45 individuals per 100 000 population.1 Surgical intervention is associated with high mortality, and the evidence to suggest improvement in outcome with time is inconsistent.2, 3, 4, 5 In both the USA and England, evidence suggests interhospital variation in the mortality of patients admitted to hospital with rAAA. The outcome of patients with rAAA also varies between countries, with different outcomes published for health-care systems in the USA, the UK, western Europe, and Australia.6, 7, 8

Modifiable technical, organisational, or hospital-related factors play an important part in patient care, and merit further study to optimise service delivery and improve patient outcomes. A detailed study to compare international outcomes for rAAA would place data from an individual health-care system in a broad context, and might allow the identification of factors that affect survival or the formulation of pathways to improve care.

We present the outcomes of patients with rAAA in England and the USA, with comparison of in-hospital mortality, the proportion of patients managed by non-corrective treatment, and the availability of endovascular surgery.

Section snippets

Study design

Demographic and in-hospital outcome data were extracted from Hospital Episode Statistics (HES) and the Nationwide Inpatient Sample (NIS) for all patients diagnosed with rAAA between Jan 1, 2005, and Dec 31, 2010. The HES are the administrative dataset for the English National Health Service (NHS) and contain information about every admission of a patient to hospital. The NIS from the Healthcare Cost and Utilisation Project, Agency for Healthcare Research and Quality, is an anonymised,

Results

11 799 patients in England and 23 838 patients in the USA were admitted to hospital with a rAAA during the study period. In England, the mean age was 78·2 years (SD 8·0) and 8694 patients (73·7%) were men. In the USA, the mean age was 76·6 years (SD 9·6) and 17 020 (71·4%) of patients were men. The appendix shows the full demographic details of patient characteristics.

In-hospital mortality was lower in the USA than in England (table 1). Intervention (rEVAR or open surgery) was offered to a

Discussion

The main finding of this study was that the in-hospital mortality of patients with rAAA was significantly lower in the USA than in England. This difference was mainly because US hospitals were less likely to manage rAAA by non-corrective treatment and offered aneurysm repair to a significantly greater proportion of patients. Although operative mortality was similar between countries, patients in the USA were more than twice as likely to be offered rEVAR and were more often managed in a teaching

References (51)

  • DT Hardman et al.

    Ruptured abdominal aortic aneurysms: who should be offered surgery?

    J Vasc Surg

    (1996)
  • CD Karkos et al.

    A meta-analysis and metaregression analysis of factors influencing mortality after endovascular repair of ruptured abdominal aortic aneurysms

    Eur J Vasc Endovasc Surg

    (2011)
  • GA Antoniou et al.

    Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair

    J Vasc Surg

    (2013)
  • RJ Hinchliffe et al.

    A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm – results of a pilot study and lessons learned for future studies

    Eur J Vasc Endovasc Surg

    (2006)
  • LL Hoornweg et al.

    The Amsterdam Acute Aneurysm Trial: suitability and application rate for endovascular repair of ruptured abdominal aortic aneurysms

    Eur J Vasc Endovasc Surg

    (2007)
  • A Anjum et al.

    Explaining the decrease in mortality from abdominal aortic aneurysm rupture

    Br J Surg

    (2012)
  • MJ Bown et al.

    A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair

    Br J Surg

    (2002)
  • A Wanhainen et al.

    Outcome after abdominal aortic aneurysm repair in Sweden 1994–2005

    Br J Surg

    (2008)
  • K Mani et al.

    Changes in the management of infrarenal abdominal aortic aneurysm disease in Sweden

    Br J Surg

    (2013)
  • PJ Holt et al.

    Propensity scored analysis of outcomes after ruptured abdominal aortic aneurysm

    Br J Surg

    (2010)
  • C Gibbons

    Second Vascular Surgery Database Report. European Society for Vascular Surgery, 2008

  • PJ Holt et al.

    Provider volume and long-term outcome after elective abdominal aortic aneurysm repair

    Br J Surg

    (2012)
  • PJ Holt et al.

    Epidemiological study of the relationship between volume and outcome after abdominal aortic aneurysm surgery in the UK from 2000 to 2005

    Br J Surg

    (2007)
  • PJ Holt et al.

    Effect of endovascular aneurysm repair on the volume-outcome relationship in aneurysm repair

    Circ Cardiovasc Qual Outcomes

    (2009)
  • JN Armitage et al.

    Identifying co-morbidity in surgical patients using administrative data with the Royal College of Surgeons Charlson Score

    Br J Surg

    (2010)
  • Cited by (235)

    View all citing articles on Scopus
    View full text