Ruptured abdominal aortic aneurysm in a well-defined geographic area

OBJECTIVE: Despite an increasing number of elective operations on abdominal aortic aneurysms (AAAs), the age- and sex-standardized mortality rate of ruptured AAA (RAAA) continues to increase. In the Pirkanmaa region, population 440,000, all aortic surgery is performed at Tampere University Hospital (TAUH). Procedures have been collected into the vascular registry. The purpose of this study was (1) to establish the incidence, modes of treatment, and mortality of RAAA in a defined geographic area; (2) to evaluate the prerupture history to determine if there are any ways to prevent rupture; and to make a forecast about the increase of RAAAs in the next decades. METHODS: Population and outcome data in the Pirkanmaa region and information on all patients who died of RAAA during 1990-1997 were provided by Statistics Finland. All operated RAAAs that underwent procedures during 1990 to 1999 were identified from the local vascular registry. To make a forecast for the next decades, an incidence of RAAA was calculated separately for each age group in 5-year intervals. RESULTS: From 1990 to 1997, 221 patients presented with RAAA. The mean incidence was 6.3/100,000 inhabitants. The incidence in the population over 65 years was 35.5/100,000. The total RAAA mortality was 76.9%. A total of 139 patients reached TAUH and 111 underwent emergency surgery. The overall hospital mortality in TAUH was 63.3%. The calculated annual number of RAAA will increase 49.6% in the next 2 decades, and the overall incidence will increase from 6.3 to 8.9/100,000 inhabitants. According to the vascular registry, 166 patients were operated on for RAAA during 1990 to 1999 in TAUH. The 30-day mortality was 50.6%. A minority of the patients (n = 18, 10.8%) had a previously documented AAA. The median diameter at the time of rupture was 7 cm. Seven (5.0%) men and six (24.0%) women had a diameter of less than 5.5 cm. CONCLUSION: The incidence of RAAA in the Pirkanmaa region in 1990s was the Finnish average. In the next two decades, the number of individuals with RAAA will increase significantly. One quarter of women had a diameter of AAA at the time of rupture that was under the current threshold indicator for elective operation.     

Factors affecting the results of surgery for chronic critical leg ischemia—a nationwide survey

Purpose: To assess the factors affecting immediate outcome of surgery for chronic critical leg ischemia, especially the influence of surgeon's caseload and hospital volume. Methods: The data of Finnvasc registry were retrospectively analyzed. A total of 11,747 surgical vascular reconstructions included 1,761 operations for chronic critical leg ischemia during 1991 to 1994. Results: The 30-day postoperative leg amputation rate was 7.5% and the mortality rate 4.7%. Diabetes, previous vascular surgery or amputation, preoperative ulcer or gangrene, a surgeon's annual caseload fewer than 10 operations, and hospital volume fewer than 20 operations for chronic critical leg ischemia adversely affected amputation rates. The presence of coronary artery disease and renal dysfunction increased postoperative mortality rates. Both amputation rates and postoperative mortality rates were affected by the type of procedure. Conclusions: A surgeon's caseload and hospital volume affect amputation rate, but not mortality rate, in patients operated for chronic critical leg ischemia. (J Vasc Surg 1998;27:940-7.)     

The role of vascular registries in improving the management of abdominal aortic aneurysm.

Treatment of abdominal aortic aneurysm (AAA) is one of the vascular surgical index procedures and an important part of the total workload. Whichever way treated, it typically has high mortality and morbidity. Furthermore, endovascular repair is still a relatively new treatment method and under evolution. Therefore continuous quality control with subsequent outcome analysis, benchmarking, intervention and reassessment are mandatory to achieve high level aneurysm care. Vascular registries are tools for this audit. The aim of this review is to focus on the problems and solutions related to attempts to improve the management of abdominal aortic aneurysm with emphasis on the experience gathered in Finland. This includes great variations in dynamics over time in Southern Finland. To control the influence of patient selection and case-mix, total hospital mortality is emphasized as the most appropriate outcome measure of the level of treatment of ruptured abdominal aortic aneurysm (RAAA). Total aneurysm mortality (including total hospital mortality of RAAA and other AAA surgery) is introduced as an outcome measure of vascular service.     

The effect of patient transfer on outcomes after rupture of an abdominal aortic aneurysm

OBJECTIVE: Centralization of vascular surgery services has resulted in patients being transferred longer distances for treatment of life-threatening conditions. The purpose of this study was to determine whether patient transfer adversely affects the survival of people with a ruptured abdominal aortic aneurysm (RAAA). METHODS: We performed a retrospective review of all patients undergoing attempted repair of an RAAA at our centre, over a recent 3.5-year period (August 2000-December 2003). Patients were divided into those presenting directly to our centre and those transferred from another hospital. The main outcome variable was in-hospital or 30-day mortality, with secondary variables including time to surgical treatment, mortality in the first 24 hours and length of hospitalization. RESULTS: Eighty-one patients (73% men) underwent attempted open repair of an RAAA at our centre during this period. Twenty-four patients (29.6%) presented directly to our hospital, while 57 (70.4%) were transferred from another institution. The overall mortality rate was 53%. Although transferred patients took twice as long as direct patients to get to the operating room (6.3 v. 3.2 h, p=0.03), there was no difference in mortality between the 2 groups (50% v. 54%, p=ns). However, deaths of transferred patients were more likely to occur in the first 24 postoperative hours, compared with direct patients (40% v. 33%, p<0.05). Neither mean intensive care unit stay (5.8 and 8.1 d) nor total hospitalization (20.9 and 18.8 d) differed between the 2 groups. CONCLUSIONS: Although the transfer of patients with RAAA results in a treatment delay, it does not adversely affect the already high mortality rates associated with this condition. These results may be attributed to a preselection of patients who are able to tolerate such a delay.     

In-hospital operative mortality of ruptured abdominal aortic aneurysm: a population-based analysis of 5593 patients in The Netherlands over a 10-year period.

OBJECTIVE: To determine the operative mortality of ruptured abdominal aortic aneurysm (RAAA) in The Netherlands. DESIGN: Retrospective population-based study of nation-wide in-hospital mortality of RAAA repair. METHODS: Data were obtained from a national registry for medical diagnosis and procedures. In-hospital mortality of RAAA repair, defined as death during hospital admission irrespective of the cause of death, was determined in the period 1991-2000. Variables of potential influence on in-hospital mortality, including age, gender, date of surgery and hospital type (0-399 beds, > or =400 beds or university hospitals) were studied in a multivariate analysis. RESULTS: The overall in-hospital mortality of RAAA repair in 5593 patients in the 10-year period was 41% (95% confidence interval: 40-42%). In the multivariate analysis, age and hospital type were the most important independent predictors for in-hospital mortality. Gender, year and season of surgery could not be identified as significant risk factors. CONCLUSIONS: Over a recent decade, in-hospital mortality of RAAA repair remained unchanged at 41%. Age and hospital class were the most important independent risk factors.     

Community and hospital outcome from ruptured abdominal aortic aneurysm within the catchment area of a regional vascular surgical service.

OBJECTIVE: The objective of this study was to examine patterns of referral, management, and outcome of patients with ruptured abdominal aortic aneurysm (RAAA) within the catchment area of this regional vascular unit (RVU). METHODS: Referral, management, and outcome data regarding 972 consecutive patients admitted to the hospital or certified deceased in the community because of RAAA between January 1, 1989, and December 31, 1995, were retrieved from prospectively gathered computerized national and local databases. RESULTS: Of 381 (39.2%) patients admitted to this unit, 316 (82.9%) underwent surgery, and of those, 188 (59.5%) survived. There was no significant difference in overall mortality between patients who were admitted directly to this unit (152 of 310, 49%) and those who were transferred from elsewhere (41 of 71, 58%). Surgical patients traveled significantly farther to the RVU than nonsurgical patients (P <.001), but there was no significant difference in traveling distance between surgical patients who survived and those who did not. Of 372 (38%) patients who were admitted to other units and not transferred, 24 (6.4%) underwent surgery and 14 (3.8%) survived. Of 972 patients, the overall community mortality from RAAA was 770 (79%). CONCLUSION: Transferring patients from outlying units did not appear to prejudice operative outcome in this RVU. However, less than half of all RAAA patients were transferred, and only a small minority of those not transferred underwent surgery. Although the overall community mortality from RAAA was similar to that reported in earlier studies from other regions and countries where centralization has not occurred, centralization of vascular surgical services may be associated with an inappropriately low operation and survival rate for those patients who are not transferred to the regional center. The effect of centralization on the community outcome of emergent vascular surgical conditions requires further investigation.     

Prediction of survival after 48-h of intensive care following open surgical repair of ruptured abdominal aortic aneurysm.

OBJECTIVE: To identify predictive factors for 30-day mortality after 48 h of maximal treatment in intensive care unit (ICU) after repair for ruptured abdominal aortic aneurysm (RAAA). DESIGN: Retrospective study in the ICU of the university central hospital. MATERIALS AND METHODS: Between 1999 and 2003, a total of 197 patients were admitted to emergency unit due to RAAA, and 185 of them underwent open surgical repair. A total of 138 patients survived at least 48-h and were included in a study to identify factors predictive of 30-day mortality by logistic regression analysis. RESULTS: Thirty-day mortality of all RAAA patients was 46% (87/197) whereas the 30-day mortality for those alive at 48 h was 22% (31/138). Forward stepwise multivariate logistic regression analysis revealed that only organ dysfunction by SOFA score (sequential organ failure assessment) at 48-h, preoperative Glasgow Aneurysm Score, and supra-renal clamping in operation were independent predictors of death. CONCLUSIONS: Degree of organ dysfunction by SOFA score was the best predictor of 30-day mortality in RAAA patients alive at 48-h after open surgical repair.     

Community mortality after ruptured abdominal aortic aneurysm is unrelated to the distance from the surgical centre

BACKGROUND: Ruptured abdominal aortic aneurysm (RAAA) carries a high community mortality. Raigmore Hospital, Inverness serves Highland Region, an area the size of Wales with a population of 204,000. The aim of this retrospective review was to determine the community mortality and hospital mortality rates from RAAA in Highland Region and to assess whether distance travelled had any significant impact on survival. METHODS: Data were retrieved from hospital records, the Registrar General for Scotland and the Information and Statistics Division of the National Health Service in Scotland about patients diagnosed with RAAA between 1992 and 1999. RESULTS: Of 198 patients with RAAA, 131 (66 per cent) were transferred to Raigmore Hospital while the other 67 (34 per cent) died in a community hospital or at home. Of those reaching Raigmore 109 (83 per cent) had surgery, of whom 65 (60 per cent) survived. The overall community mortality rate was 67 per cent while the hospital mortality rate was 50 per cent. The hospital and community mortality rates for patients living within 50 miles of Raigmore Hospital were 60 and 67 per cent respectively, compared with 26 and 68 per cent for those living more than 50 miles away. CONCLUSION: Distance from Raigmore Hospital had no significant impact on community mortality from RAAA.     

Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality

OBJECTIVE: The purpose of this study is to evaluate contemporary results of ruptured aortoiliac aneurysms (RAAA) and identify the role of surgeons' annual aortic volume and other prognostic indicators for early outcome. METHODS: A retrospective review identified 213 consecutive patients who presented with an atherosclerotic RAAA without thoracic extension over 6.5 years ending in June 2007. Excluded were 31 ruptures treated by endovascular repair (EVAR) or following previous EVAR, also excluded were two chronic asymptomatic hemodynamically stable ruptures. Ten patients were not treated due to either patient's refusal or prohibitive surgical risk. Demographic, preoperative, intraoperative, and postoperative variables were collected. Log rank test and Cox proportional hazard model analyses were utilized to identify factors contributing to mortality and morbidity in these patients. Survival rates were estimated by Kaplan-Meier method. RESULTS: One hundred thirty-one males and 39 females with a mean age of 74.5 +/- 8.1 years underwent consecutive RAAA repairs. The operative mortality rate was 38.2% (65/170), including 29 intraoperative deaths. Using multivariate analysis, surgeon's average annual AAA volume (<20/y), advanced age, and postoperative intestinal ischemia were independent predictors of perioperative deaths. Shock on presentation, preoperative cardiopulmonary resuscitation or free rupture were not. High-volume surgeons (>20 average annual AAA cases/y) had a higher 30-day survival rates (78.4% vs 57.9%, P = .024). Octogenarians had a lower 30-day survival rate of 49.0% vs 70.5% (P = .012). Patients who developed postoperative intestinal ischemia had a lower 30-day survival rate compared with patients without (48.1% vs 15.3%, P = .002). Increased intraoperative fluid and blood product usage was associated with bowel ischemia (P < .05). CONCLUSIONS: RAAA remains a highly lethal problem. The improved early outcomes of surgeons with high-volume AAA have strong implications for training, emergency staffing needs and alternative treatment strategies.     

Use of resources and postoperative outcome.

OBJECTIVE: To characterise those surgical patients who consume one half of all hospital patient days, and to compare their outcome with that of low consumers. DESIGN: A retrospective cohort study. SETTING: Tertiary referral centre, Finland. PATIENTS: 13025 surgical patients who were admitted to a university hospital in Kuopio, Finland, during 1997. INTERVENTIONS: The length of stay below which half of all patient days fell was chosen as a cut-off value to divide patients into low and high consumers. MAIN OUTCOME MEASURES: Hospital and 12-month mortality and standardised mortality ratios (SMR: observed deaths/expected deaths based on the corresponding general population). RESULTS: The 2239 patients (17%) whose length of stay exceeded 9 days (high consumers) took up one half of all patient days. The pattern of resource use varied between operative specialities. At 12 months the SMRs showed excess mortality among high consumers (5.0, 95% confidence interval 4.4 to 5.7) compared with low consumers (2.1, 95% CI 1.9 to 2.3). CONCLUSIONS: Relating the length of stay to the proportion of resources consumed may provide a feasible tool for the recognition of different patterns of use of resources. SMRs may be more relevant measures of outcome than hospital mortality when assessing the efficacy of operative treatment.     

Is there a minimum caseload that achieves acceptable operative mortality in abdominal aortic aneurysm operations?

BACKGROUND: Studies have shown correlation between operative workload and mortality for major operations. Is there a threshold for case volume that predicts an acceptable mortality for abdominal aortic aneurysm surgery? METHODS: Hospital Episode Statistics (HES) Data for England between 1997-2002 was analysed using ICD-10 codes I71.x and OPCS-4 codes L16.x-L26.x. Mortality was identified by the method of discharge. RESULTS: 31,078 operations on abdominal aortic aneurysms were studied in 223 NHS Trusts. 6,007 in-hospital deaths were identified in both elective and emergency cases (overall mortality rates 7.7% and 40%, respectively). Trusts with large elective workloads had reduced mortality for both elective and emergency operations. Using parabolic regression and logarithmic transformation, 14 elective operations per Trust per year was identified as a cut-off point above which the decrease in mortality rate with increasing case volume was relatively small. A similar effect was not seen with increasing emergency workload alone. CONCLUSION: HES data analysis suggests increasing elective workload correlates with lower in-hospital mortality for elective and emergency operations on abdominal aortic aneurysm. Data suggests a range of hospital caseload that correlate with an acceptable elective and emergency mortality rate.     

Ruptured abdominal aortic aneurysm--outcome in a community teaching hospital intensive care unit.

Ruptured abdominal aortic aneurysm (RAAA) is a surgical emergency associated with a high mortality often requiring postoperative intensive care. Our objectives were to assess the outcome of RAAA management in a nontertiary community hospital intensive care unit (ICU) and to compare this with historical data from tertiary hospitals. We also sought to identify variables related to outcome and evaluate the potential of an organ failure score to identify patients at increased risk of death. The study was a retrospective chart review of patients with RAAA over 11 years (1986-1996 inclusive) at Manly District Hospital, a 210 bed community teaching hospital with eight intensive care beds. Forty patients were identified in the study period as having been admitted to ICU after RAAA surgery. There was an overall hospital mortality rate of 47.5% and intensive care mortality rate of 42.5% for successfully operated RAAA. Five variables were significantly different between survivors and non-survivors. These were age, total amount of blood products required, duration of operation, development of hypotension (systolic blood pressure < 90 mmHg) in ICU postoperatively, and APACHE II score at Day 1 ICU. A trend was also found between mortality rate and the number of failed systems after 48 hours intensive care stay. Mortality for a patient with zero failed systems was 38%, one failed system 42%, two 58% and three 67%. Based on these results, management of RAAA in a non-tertiary setting appears appropriate with postoperative care occurring in an ICU where there is adequate equipment and medical and nursing staff experienced in the care of complex critical illness.     

Impact of delay on survival in patients with ruptured abdominal aortic aneurysm

Rupture of the abdominal aortic aneurysm (RAAA) is a common surgical emergency. Surgical treatment of this condition carries a high morbidity and mortality rate. For successful outcome, an early diagnosis and prompt treatment are essential. However, recently, some centers have reported better results in patients whose surgery had been delayed because of interhospital transfer. Delay in treatment sometimes occurs as patients are transferred from one institution to another where specialized vascular care is available. This retrospective study sought to determine the effect of delay in treatment on the mortality of patients with RAAA repair.The time from arrival at the emergency room to surgery and operative time were obtained from the case notes of 45 consecutive patients with RAAA. Patients' physiology scores on admission were calculated using V-POSSUM for the RAAA model.Thirty-five patients were diagnosed with RAAA in the emergency room and were transferred to surgery. These patients were divided into two groups: patients who had surgery within 1 hour (n = 23) and those in whom surgery was delayed for up to 4 hours (n = 12).There was no significant difference in physiology score between the two groups (p = .12). The time to surgery and operative time with death as the outcome were plotted on a logistic regression model that showed that the delay in surgical treatment increases the mortality rate following RAAA repair (p = .041). Furthermore, a long operative time was associated with a higher surgical mortality rate (p = .029).Delay to surgery and a long operation increase the mortality rate following RAAA repair. However, delay to surgery alone did not influence the mortality rate.     

The influence of gender on outcome after ruptured abdominal aortic aneurysm

BACKGROUND: The influence of gender on the management of coronary artery disease is well documented, but few reports exist regarding the influence of gender on the management of peripheral arterial disease. OBJECTIVE: The purpose of this study was to examine the influence of gender on selection for and short-term and long-term outcomes of repair of ruptured abdominal aortic aneurysm (RAAA) in a regional vascular surgery unit. METHODS: Analysis of the prospectively gathered Lothian Surgical Audit database identified 692 patients (542 male and 150 female) admitted with RAAA between January 1, 1983, and December 31, 1995. Case notes were reviewed for patients who were admitted but not operated on. Operative mortality was defined as death within the same hospital admission. Long-term survival data were obtained from the General Register Office (GRO1 records) through record linkage by the Information and Statistics Division of the National Health Service of Scotland. RESULTS: A total of 542 men (78%; median age, 72 years; age range, 46-93 years) and 150 women (22%; median age, 74 years; age range, 55-93 years) were admitted with RAAA (P =.12; Mann-Whitney U test). There was no significant difference in perioperative mortality between men and women. Although women who were not operated on (median age, 81 years; age range, 68-93 years) were significantly (P =.005) older than men who were not operated on (median age, 77 years; age range, 54-93 years), for any given age group, women appeared less likely than men to be offered surgical repair. Long-term survival after successful repair was comparable for the genders. CONCLUSIONS: Gender has no influence on either short-term or long-term outcome for patients undergoing operative repair of RAAA. However, women are less likely to be selected for operation than their male counterparts.     

Relationship between surgical volume and early outcomes of total hip arthroplasty: do results continue to get better?

This retrospective study explored the relationship between the volume of total hip arthroplasties (THA) and postoperative mortality and early complications from a single institution. One thousand hip arthroplasties in 932 patients were identified during a 1-year period, which included 786 primary and 214 revision hip arthroplasties. The postoperative 6-month combined medical and orthopedic complication rate for primary and revision THA was 7.9% and 16.5%, respectively. The 6-month mortality rate for the overall group was 0.5% (5 deaths), for the primary hips was 0.4% (3 deaths), and for the revision hip was 0.9% (2 deaths). The mortality and complication rates of many surgical procedures, including joint arthroplasties, are inversely related to hospital and surgical volume. The reduction in complication rate, however, approaches a plateau and does not improve regardless of an increase in the surgical and hospital volume.     

Survival of ruptured abdominal aortic aneurysms in the west of Ireland: do prognostic indicators of outcome exist?

Ruptured abdominal aortic aneurysm (RAAA) is a demanding vascular surgical problem and the cause of significant morbidity and mortality. The aim of this study was to identify prognostic factors that influence outcome. Over 6 years, 42 ruptured abdominal aortic aneurysms were operated on with a mean diameter of 7.2 cm. RAAA was defined as free intraperitoneal rupture. Data were collected retrospectively from hospital medical records. The male: female ratio was 8:1 and the mean age was 74 years (range 55-89). Fifteen were in hypovolemic shock and 27 patients were clinically stable. The perioperative mortality rate for the 15 shocked patients was 60% (9 patients) and the 1-year cumulative survival rate was 33%. The perioperative mortality rate for the 27 clinically stable patients was 40% (11 patients) and the 1-year cumulative survival rate was 56%. Survival curves were constructed for these groups to compare male versus female, age >/= 70 versus age < 70, shocked versus stable, and preoperative hemoglobin (Hb) 10. No patient with preoperative cardiac arrest survived more than 24 hours. With VassarStats, the confidence interval for age, gender, hemodynamic status, and preoperative Hb were calculated. The standard weighted mean analysis by ANOVA gave a p value of < 0.001. The overall 30-day mortality rate was 47% (20 of 42) and the 1-year mortality rate was 52% (22 of 42). Male patients over 70 years with RAAA in hypovolemic shock with low Hb have a higher 30-day mortality rate and few survive more than 1 year. The study suggests that each of these 4 parameters separately was not a strong prognostic indicator. Collectively, however, they strongly influence the prognosis of patients with RAAA. These findings strengthen the case for selective treatment for RAAA.     

院内发生的腹主动脉瘤破裂诊治

目的 总结5例院内发生的腹主动脉瘤破裂的救治经验.方法 对2006年1月～2009年12月我院5例院内发生的腹主动脉瘤破裂患者的临床资料进行回顾性分析.结果 1例因出血性休克所致急性呼吸循环衰竭死亡;其余4例患者采用开腹手术救治,行肾动脉下腹主动脉阻断,采用自体血液回输,行急诊腹主动脉瘤切除人造血管移植术,4例手术成功,随访6～38个月,无并发症发生.结论 手术治疗腹主动脉瘤破裂是有效治疗方法,对于非腹部疾病引起的住院腹主动脉瘤患者特别是有明确诱因患者,采取术前降低血压并紧急外科手术治疗是降低破裂腹主动脉瘤死亡率的关键.     

A comparison between the short term and long term benefits of screening for abdominal aortic aneurysms from the Huntingdon Aneurysm screening programme.

BACKGROUND: The UK Multicentre Aneurysm Screening Study (MASS) showed a 44% reduction in AAA-related mortality after 4 years and predicted an increased number of deaths prevented in the longer term. We aim to compare the 5 and 13 years benefit from aneurysm screening in the Huntingdon Aneurysm screening programme. METHODS: Incidence and mortality of ruptured AAA (RAAA) after 5 and 13 years of screening in a population based aneurysm screening program. RESULTS: Five years of screening resulted in a reduction in the incidence of RAAA of 49% (95% CI: 3-74%). Nine out of 11 ruptures in the invited group did not survive (mortality 82%; 95% CI: 48-98%) compared to 38 non-survivors from 51 ruptures in the control group (mortality 75%; 95% CI: 60-86%). Five years of screening resulted in an RAAA-related mortality reduction of 45% (95% CI: -15 to 74%). After 13 years of screening the incidence of RAAA was reduced by 73% (95% CI: 58-82%). Twenty-one out of 29 ruptures in the invited group did not survive (mortality 72%; 95% CI: 53-87%) compared to 64 non-survivors from 82 ruptures in the control group (mortality 78%; 95% CI: 68-86%). Thirteen years screening resulted in a reduction of mortality from RAAA of 75% (95% CI: 58-84%). The number needed to screen to prevent one death reduced from 1380 after 5 years to 505 after 13 years. The number of elective AAA operations needed to prevent one death reduced from 6 after 5 years to 4 after 13 years. CONCLUSION: AAA screening becomes increasingly beneficial as screening continues over the longer term. Benefits continue to increase after screening has ceased.     

Long-term survival and health-related quality of life of patients with ruptured abdominal aortic aneurysm.

INTRODUCTION: the outcome of ruptured abdominal aortic aneurysm (RAAA) patients is most frequently measured as operative or in-hospital mortality rate. However, survival alone is not an indicator of quality of the treatment. Assessment of quality of life (QoL) is used increasingly and is a relevant measure of outcome. OBJECTIVE:to assess long-term survival and QoL of patients undergoing repair of RAAA. DESIGN: follow-up study with cross-sectional QoL evaluation. MATERIALS AND METHODS: between 1996 and 2000, 199 of 220 patients with RAAA underwent surgery. Survivors were sent the generic the RAND 36-item Health Survey (RAND-36) self-administered questionnaire. RESULTS: total hospital mortality and operative mortality were 103 of 220 (47%) and 82 of 199 (41%). Of the 117 initial survivors, 21 were deceased at the time of the study. When compared to an age- and sex-adjusted general population, only physical functioning was significantly impaired (p=0.01) in the 82 of 93 (88%) RAAA survivors who responded. CONCLUSIONS: survivors after repair of RAAA had almost the same QoL as the norms of an age- and sex-adjusted general population, justifies an aggressive operative policy in RAAA.     

Potential benefits of the new Leapfrog standards: effect of process and outcomes measures

OBJECTIVE: The Leapfrog Group standards for evidence-based hospital referral underwent significant revision in 2003. In addition to other changes, risk-adjusted mortality and process of care measures now augment or replace volume standards for some procedures. The objective of this study was to estimate the potential benefits of these newly expanded standards. METHODS: Leapfrog's 2003 standards were based on minimum volume standards alone for 2 operations (esophagectomy, pancreatectomy), volume standards and a process measure (perioperative beta blockade) for 1 operation (abdominal aortic aneurysm repair), and volume standards coupled with risk-adjusted mortality rates for 2 operations (coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI]). We used data from the 2000 Nationwide Inpatient Sample to determine eligible surgical populations, volume-outcome associations, and risk-adjusted hospital mortality rates for the 5 operations. A recent meta-analysis was used to estimate the effectiveness of perioperative beta-blocker use. RESULTS: Approximately 23,790 patients died in 2000 in the United States undergoing 1 of the 5 procedures. We estimate that full implementation of the Leapfrog standards would have averted 7818 of these deaths: CABG (4089), PCI (3016), elective abdominal aortic aneurysm repair (356), esophageal resection (180), and pancreatic resection (177). For CABG and PCI, standards based on risk-adjusted mortality rates would save at least 5 times more lives than those based on volume criteria alone. CONCLUSIONS: Widespread implementation of the 2003 Leapfrog standards for evidence-based referral could avert a large number of surgical deaths. For some procedures, standards comprised of process of care or direct outcome measures would be more effective than those based on volume alone.