Ruptured versus Elective Abdominal Aortic Aneurysm Repair: Outcome and Cost

During a recent 30-month period, we repaired 10 ruptured abdominal aortic aneurysms (RAAA) at our institution. To evaluate the survival, postoperative morbidity, and financial impact of treating RAAA, we compared these patients with 10 randomly selected patients undergoing elective AAA (EAAA). Both groups were comparable for age, gender, and incidence of diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease (COPD), and renal failure. Although we have noted a dramatic increase in survival for RAAA (90%), the morbidity continues to be unacceptably high (60%). Efforts should be made toward better detection of AAA prior to rupture as well as development of strategies to minimize or prevent these major complications. Potential average savings accrued from one patient undergoing EAAA repair rather than RAAA repair ($93,139. 21) can be used to perform screening abdominal ultrasound tests in patients at increased risk of having an AAA.     

Endovascular abdominal aortic aneurysm repair is more profitable than open repair based on contribution margin per day

BACKGROUND: Earlier studies have reported that endovascular abdominal aortic aneurysm (EAAA) repair yields lower total profit margins than open AAA (OAAA) repair. This study compared EAAA versus OAAA based on contribution margin per day, which may better measure profitability of new clinical technologies. Contribution margin equals revenue less variable direct costs (VDCs). VDCs capture incremental resources tied directly to individual patients' activity (eg, invoice price of endograft device, nursing labor). Overhead costs factor into total margin, but not contribution margin. METHODS: The University of Michigan Health System's cost accounting system was used to extract fiscal year 2002-2003 information on revenue, total margin, contribution margin, and duration of stay for Medicare patients with principal diagnosis of AAA (ICD-9 code 441.4). RESULTS: OAAA had revenues of $37,137 per case versus $28,960 for EAAA, similar VDCs per case, and thus higher contribution margin per case ($24,404 for OAAA vs $13,911 for EAAA, P < .001). However, OAAA had significantly longer mean duration of stay per case (10.2 days vs 2.2 days, P < .001). Therefore, mean contribution margin per day was $2948 for OAAA, but $8569 for EAAA ( P < .001). CONCLUSIONS: On the basis of contribution margin per day, EAAA repair dominates OAAA repair. The shorter duration of stay with EAAA allows higher throughput, fuller overhead amortization, better use of scarce inpatient beds, and higher health system profits. Surgeons must understand overhead allocation to devices, especially when new technologies cut duration of stay markedly.     

Minimal incision aortic surgery.

PURPOSE: In this study we evaluated the clinical and economic impact of minimal incision aortic surgery (MIAS) for treatment of patients with abdominal aortic aneurysms (AAAs) and aortoiliac occlusive disease (AIOD). METHOD: Fifty patients with either AAA (34) or AIOD (16), prospectively treated with the MIAS technique, were compared with 50 patients (40 AAA and 10 AIOD) treated in the same time period with long midline incision and extracavitary small bowel retraction. MIAS was also compared with a cohort of 32 patients with AAA treated by means of endoaortic stent-grafts. Outcomes and cost (based on metric mean length of stay) were compared for the open and endoaortic techniques. RESULTS: Patients who experienced no perioperative complications after the MIAS or endovascular repair technique had shorter hospital stays than patients with uncomplicated aortic repairs performed with a traditional long midline abdominal incision (3 days vs 3 days vs. 7.2 days). Hospital stay was also significantly shorter for the less invasive procedures when perioperative complications were included (4.8 days vs. 4.3 days vs 9.3 days). The MIAS and endovascular aortic repair groups had a shorter intensive care unit stay (< or = 1.0 day) and a quicker return to general dietary feeding (2.5 days) than patients treated with standard open repair (1.8 days, 4.7 days). The overall morbidity for the MIAS technique (14%) and endovascular technique (21%) was not significantly different from standard open repair (24%). The mortality rate for the different treatment groups was equivalent (MIAS, 2%; endovascular repair, 3%; standard repair, 2%). The MIAS was more cost-efficient than standard open repair ($12,585 vs $18,445) because of shorter intensive care unit and hospital stay and was more cost-efficient than endoaortic repair ($12,585 vs $32,040) because of reduced, direct intraoperative costs. CONCLUSIONS: MIAS is as safe as standard open or endovascular repair in the treatment of AAA and AIOD. MIAS is more cost-efficient than standard open or endoaortic repair.     

Abdominal aortic aneurysm surgery in a district general hospital: a 15-years experience

The incidence of patients presenting with both ruptured abdominal aortic aneurysm (RAAA) and elective abdominal aortic aneurysm (EAAA) increases with age. The aim of our study was to find out the incidence of RAAA, age and sex groups of patients at risk, and 30-day all-cause perioperative mortality associated with RAAA as well as EAAA repair in a busy district general hospital over a 15-year time period. All patients operated for AAA during 1989-2003, both elective and ruptured, were included in the study. Patients who died in the community from RAAA were also included. The data were collected from the hospital information system, theater logbooks, intensive therapy unit records, postmortem register, and patients' medical notes. We divided the data for RAAA into two groups of 7.5 years each to see if there was any improvement over time in 30-day postoperative mortality. There were 816 cases of AAA, which included 468 RAAAs (57%) and 348 EAAAs (43%). Out of 468 RAAAs, 243 patients had emergency repair, of whom 213 were males. There were 201 patients who had RAAA postmortem (43%). Median age (range) was 73 (54-94) years in males and 77 (52-99) years in females, with a male-to-female ratio of 7:1. The peak incidence of RAAA was over 60 years of age in males and 70 years in females. Incidence of RAAA was 7.3/100,000/year in males and 5/100,000/year in females. For RAAA, 30-day perioperative mortality was 43% (105/243) while overall mortality was 70% (330/468), which includes deaths in the community. There was no improvement in 30-day mortality over time after comparing data for the first 7.5 years (50/115, 43.5%) with those for the second set of 7.5 years (55/128, 43%). There were 348 patients who had EAAA repair over the same period, comprising 282 males, with a male:female ratio of 4.3:1. The 30-day mortality in the elective group was 7.75%. Incidence and mortality of RAAA remain high. A high proportion of patients with AAA remain undiagnosed and die in the community. More lives may be saved if a screening program is started for AAA.     

The cost-effectiveness of early surgery versus watchful waiting in the management of small abdominal aortic aneurysms

Purpose: The purpose of this study was to compare the relative cost-effectiveness of two clinical strategies for managing 4 to 5 cm diameter abdominal aortic aneurysms (AAAs): early surgery (repair 4 cm AAA when diagnosed) versus watchful waiting (monitor AAA with ultrasound size measurements every 6 months and repair if the diameter reaches 5 cm).Methods: We used a Markov decision tree to compute the expected survival in quality-adjusted life years (QALYs) for each strategy, based on literature-derived estimates for the probabilities of different outcomes in this model. We determined hospital costs for patients undergoing elective and emergency AAA repair at our center. With standard methods of cost accounting, we then calculated the additional cost per year of life saved by early surgery compared with watchful waiting (cost-effectiveness ratio, dollars/QALY).Results: Mean hospital costs for elective and emergency AAA repair were $24,020 and $43,208, respectively (1992 dollars). For our base-case analysis (60-year-old men with 4 cm diameter AAAs, with 5% elective operative mortality rate and 3.3% annual rupture rate), early surgery improved survival by 0.34 QALYs compared with watchful waiting, at an incremental cost of $17,404/QALY. Increased elective surgical mortality rate, decreased AAA rupture risk, and increased patient age all reduced the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery.Conclusions: The cost effectiveness of early surgery for 4 cm diameter AAAs in carefully selected patients compares favorably with that of other commonly accepted preventive interventions such as hypertension screening and treatment. With an upper limit of $40,000/QALY as an "acceptable" cost-effectiveness ratio, early surgery appears to be justified for patients 70 years old or younger, if the AAA rupture risk is 3%/year or more and the elective operative mortality rate is 5% or less. Although not a substitute for clinical judgment, this cost-effectiveness analysis delineates the essential tradeoffs and uncertainties in treating patients with small AAAs. (J VASC SURG 1994;19:980–91.)     

Health-related quality of life in survivors of open ruptured abdominal aortic aneurysm repair: a matched, controlled cohort study

OBJECTIVE: The objective of this study was to document the health-related quality of life (HRQOL) for patients who survived operative repair of a ruptured abdominal aortic aneurysm (RAAA) and to compare this with a matched group of patients who survived elective operative repair of an abdominal aortic aneurysm (EAAA). METHODS: A matched, controlled cohort study of HRQOL was used to compare patients surviving RAAA with an EAAA control group. The study was conducted at two university-affiliated vascular tertiary care referral centers. Survivors of RAAA and EAAA during an 8.5-year period were identified and followed up. The RAAA and EAAA control patients were matched for age, serum creatinine concentration, gender, and duration of follow-up since surgery. HRQOL was measured with the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Scores for the EAAA and RAAA cohorts were also compared with age-corrected SF-36 population scores. RESULTS: Of 267 patients operated for RAAA during the study period, 130 (49%) survived to hospital discharge. Death after discharge was documented in 35 patients, leaving a potential study population of 95 RAAA survivors. Thirteen were lost to follow-up, seven refused to participate, and four patients were not able to participate. The SF-36 was completed by 71 RAAA patients (75% of surviving RAAA patients). The 71 RAAA survivors and 189 EAAA control patients were similar for seven of eight domains of the SF-36: Physical Function, Role-Physical, Bodily Pain, General Health, Vitality, Mental Health, and Role-Emotional. There was also no difference in the Physical Health Summary and Mental Health Summary scores. The social function component of the SF-36 demonstrated a statistically significant decline in the EAAA group. Both the EAAA and RAAA SF-36 individual and summary scores compared favorably with population norms that were adjusted only for age. CONCLUSION: Long-term survivors of RAAA enjoy a HRQOL that does not differ significantly from EAAA survivors. Scores for both groups compare favorably with population scores adjusted only for age.     

The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004

INTRODUCTION: The elective repair of abdominal aortic aneurysms (AAA) may decrease a patient's risk of rupture and confers a significantly lower in-hospital mortality rate than emergency repair. Previous works have shown that AAA rupture rates are higher in women compared to men, and that women have higher associated in-hospital mortality rates. This study was performed to evaluate, currently, to what extent patient gender influences presentation and treatment of AAA and the associated outcomes in the United States. METHODS: The Nationwide Inpatient Sample was used, with pertinent ICD-9 codes, to identify all patient-discharges that occurred with the primary diagnosis of intact (iAAA) or ruptured/dissecting (rAAA) abdominal aortic aneurysms between the years 2001 and 2004. Univariate and multiple logistic regression analyses of variables were performed. RESULTS: An estimated 220,403 AAA patient-discharges were identified during the study period. 37,016 (17%) patients presented with rAAA. A higher percentage of women with AAA presented with rupture compared to men (21% vs 16%; odds ratio [OR] 1.40, 95% confidence interval [CI], 1.27-1.54). This rupture rate did not significantly change from 2001 to 2004 (P = .85 for trend). For iAAA, women had higher odds of in-hospital mortality than men (OR 1.60; 95% CI, 1.24-2.07). Compared to men, in-hospital mortality rates for women with iAAA were higher for both endovascular (2.1% vs 0.83%, P < .0001) and open repairs (6.1% vs 4.0%, P < .0001). For iAAA, fewer women underwent endovascular repair (32.4% vs 46.7%, P < .0001; O.R. 0.59, 95% CI, 0.52-0.67). For patients who presented with rAAA, women were less likely to undergo surgical intervention compared to men (59% vs 70%, P < .0001). For those that underwent repair, women had higher in-hospital mortality rates than men (43% vs 36%, P < .0001; OR 1.49, 95% CI, 1.16-1.91). CONCLUSION: A higher percentage of women currently present with aneurysm rupture. They have higher in-hospital mortality rates for both iAAA and rAAA. This gender difference in the outcomes following repair of abdominal aortic aneurysm has persisted over time, the cause of which is not explained by these or previous data, a fact that warrants further investigation.     

Cost-effectiveness of conventional and endovascular repair of abdominal aortic aneurysms: results of a randomized trial

BACKGROUND: Two randomized trials have shown similar mid-term outcomes for survival and quality of life after endovascular and conventional open repair of abdominal aortic aneurysms (AAA). With reduced hospital and intensive care stay, endovascular repair has been hypothesized to be more efficient than open repair. The Dutch Randomized Endovascular Aneurysm Management (DREAM) trial was undertaken to assess the balance of costs and effects of endovascular vs open aneurysm repair. METHODS: We conducted a multicenter, randomized trial comparing endovascular repair with open repair in 351 patients with an AAA and studied costs, cost-effectiveness, and clinical outcome 1 year after surgery. In addition to clinical outcome, costs and quality of life were recorded up to 1 year in 170 patients in the endovascular repair group and in 170 in the open repair group. Incremental cost-effectiveness ratios were estimated for cost per life-year, event-free life-year, and quality adjusted life-year (QALY) gained. Uncertainty regarding these outcomes was assessed using bootstrapping. RESULTS: Patients in the endovascular repair group experienced 0.72 QALY vs 0.73 in the open repair group (absolute difference, 0.01; 95% confidence interval [CI], -0.038 to 0.058). Endovascular repair was associated with additional euro 4293 direct costs (euro 18,179 vs euro 13.886; 95% CI, euro 2,770 to euro 5,830). Most of the bootstrap estimates indicated that endovascular repair resulted in slightly longer overall and event-free survival associated with respective incremental cost-effectiveness ratios of euro76,100 and euro 171,500 per year gained. Open repair appeared the dominant strategy in costs per QALY. CONCLUSION: Presently, routine use of endovascular repair in patients also eligible for open repair does not result in a QALY gain at 1 year postoperatively, provides only a marginal overall survival benefit, and is associated with a substantial, if not prohibitive, increase in costs.     

Effectiveness and cost of screening for abdominal aortic aneurysm: results of a population screening program

OBJECTIVES: We undertook this study to calculate the cost per life-year gained in the first round of a screening program for abdominal aortic aneurysm (AAA) and to estimate the costs in a subsequent round. METHODS: This was an intervention study, with follow-up for ruptured aneurysms. Men older than 50 years were screened for asymptomatic AAA. Outcome measures included cost per life-year saved and number of men needed to be screened to save one life. RESULTS: The incidence of ruptured AAA was 2.6 per 10,000 person- years in the screening group and 7.1 per 10,000 person-years in the control group. Screening is estimated to have prevented 10.8 ruptured AAA and 8 deaths per year, gaining 51 life-years per year for the study population, and to have reduced the incidence of ruptured AAA by 64% (95% CI, 42%-77%). Each life-year gained during the first screening round cost $1107. To save one life, 1000 men need to be screened and 5 elective operations performed. We predict that a second round of screening can be cost neutral. CONCLUSIONS: The cost-effectiveness of screening for AAA compares favorably with screening programs for other disorders in adults.     

Cost of routine screening for carotid and lower extremity occlusive disease in patients with abdominal aortic aneurysms

OBJECTIVE: The burden of clinically relevant noncoronary atherosclerotic occlusive disease in patients with abdominal aortic aneurysms (AAAs) is poorly defined. Furthermore, the cost-effectiveness of routine versus selective preoperative noninvasive examination of the carotid and lower extremity arterial beds has not been established in patients who undergo elective AAA repair. METHODS: Diagnostic vascular laboratory study results were reviewed in 206 patients who underwent evaluation before AAA repair from 1994 to 1998. The patients underwent routine preoperative carotid duplex scan examinations and lower extremity Doppler scan arterial studies with ankle-brachial index (ABI) determinations. The medical records were reviewed for the identification of clinical evidence consistent with cerebrovascular or lower extremity arterial occlusive disease. The costs of routine screening and selective screening were determined with Medicare reimbursement schedules. RESULTS: The prevalence rate of advanced (80% to 100%) carotid artery stenosis (CAS) was 3.4%, and 18% of the patients had CAS between 60% and 100%. Advanced peripheral vascular occlusive disease (PVOD; ABI, <0.3) was found in 3% of the patients, and 12% of the patients had an ABI of less than 0.6. Most patients with advanced CAS (71%) or advanced PVOD (83%) had clinical indications of their disease. The absence of clinical evidence of disease had a negative predictive value of 99% for both advanced CAS and PVOD. The cost of routine screening for all patients for advanced CAS was $5445 per case. Routine screening for severe PVOD costs were $3732 per case discovered. In contrast, the costs for selective screening for advanced CAS or PVOD in patients with appropriate history or symptoms were $1258 and $785 per case found, respectively. CONCLUSION: Routine noninvasive diagnostic testing for the identification of asymptomatic CAS and PVOD in patients with AAA may not be justified. Preoperative screening is more clearly indicated for patients with AAAs who have clinical evidence suggestive of CAS or PVOD.     

Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion--Case reports

While the mortality rate for elective abdominal aortic aneurysm (AAA) repair has declined over the last several decades, the rate for ruptured abdominal aortic aneurysm (RAAA) has unfortunately remained disturbingly high. Undiagnosed aneurysms may present with little warning until abdominal pain, syncope, and hypotension signify rupture. Fifty percent of patients with ruptured aneurysms die before reaching a medical facility, and their survival is highly dependent on hemodynamic stability at presentation. The degree of rupture containment and comorbid status of the patient determine hemodynamic stability. Endovascular stent grafting has significantly improved perioperative morbidity and mortality rates for elective AAA repair, and some of the same endovascular techniques can be used to obtain proximal control in patients presenting with RAAA. We describe 3 consecutive cases of RAAA where proximal control was obtained using a percutaneously placed, transfemoral aortic occlusion balloon before induction of anesthesia.     

The cost-effectiveness of a "quick-screen" program for abdominal aortic aneurysms

BACKGROUND: The incidence of abdominal aortic aneurysm (AAA) is increasing, and the prognosis of ruptured AAA remains dismal. Early diagnosis and intervention are crucial. We designed this study to determine whether selected population screening with a brief "quick-screen" ultrasound could be cost-effective. METHODS: A series of 25 patients with risk factors for AAA were evaluated in a blinded fashion by a quick-screen ultrasound and a full conventional study. Times and accuracy for the 2 approaches were compared. An analysis of the cost-effectiveness of screening for AAA was then performed using a Markov model. We determined the long-term survival in quality-adjusted life years and lifetime costs for a hypothetical cohort of 70-year-old males undergoing either AAA screening or not. Our measure of outcome was the cost-effectiveness ratio (CER). RESULTS: The average time for a quick screen was one-sixth that of a conventional study (4 vs 24 minutes). The accuracy of the quick screen was 100%. In our base-case analysis, screening for AAA was cost-effective with a CER of $11,215. Society usually is willing to pay for interventions with CER of less than $60,000 (eg, CER for coronary artery bypass grafting, $9500; breast cancer screening, $16,000). In sensitivity analysis, reducing the cost of screening from $259 (approximate Medicare reimbursement) to $40 (the quick screen) improved the CER to $6850. Moreover, screening populations with increased prevalence of AAA (eg, male with family history [18%]) further improved the CER. CONCLUSIONS: Our analysis demonstrates that ultrasound screening for AAA should be offered to all males above the age of 60. Widespread screening for AAA should be adopted and reimbursed by Medicare and other insurers.     

A cost-effectiveness analysis of standard versus endovascular abdominal aortic aneurysm repair.

OBJECTIVE: To compare endovascular and standard open repair of abdominal aortic aneurysms in terms of initial in-hospital costs and the costs of secondary interventions and surveillance. DESIGN: A retrospective study. SETTING: A university-affiliated tertiary care medical centre. PATIENTS: Seven patients who underwent elective endovascular (EV) repair of an abdominal aortic aneurysm in 1998 and 31 patients anatomically suitable for endovascular repair who underwent standard (STAN) elective repair. Follow-up ranged from 2 to 14 months. INTERVENTIONS: Elective repair of an abdominal aortic aneurysm with use of the standard technique or endovascular technology. OUTCOME MEASURES: Costs common to both groups were not determined. Costs were determined for total hospital stay, preoperative or postoperative embolization, grafts, additional endovascular equipment, and follow-up computed tomography. RESULTS: Groups were similar with respect to demographic data and aneurysm size (EV = 6.23 cm v. STAN = 6.05 cm). All patients were in American Society of Anesthesiologists class III or IV. Vanguar bifurcated grafts and extensions were used in the EV group. The total cost for both groups in Canadian dollars included: cost of stay (EV, 5.6 d, $2092.63 v. STAN, 10.7 d, $4449.19; p = 0.009); cost of embolization (EV, n = 3; $900/procedure); cost of follow-up CT (EV, 5.4 per patient; $450/CT); cost of grafts (EV = $8571.43, STAN = $374); additional radiologic equipment costs (EV = $1475). The mean total cost differed significantly between the 2 groups (EV = $14,967.63 v. STAN = $4823.19; p = 0.004). The additional cost associated with a reduction in hospital stay was calculated by determining the incremental cost-effectiveness ratio (ICER, difference in mean costs/difference in mean length of stay = $1604.51). CONCLUSIONS: Endovascular repair continues to be more expensive than standard open repair determined according to procedural and follow-up costs. The technology is still in the developmental stage, but as it evolves and follow-up protocols are streamlined, it is hoped that there will be an eventual reduction in the costs associated with the endovascular procedure.     

Cost of endovascular versus open surgical repair of abdominal aortic aneurysms

BACKGROUND: Endovascular repair of abdominal aortic aneurysms (AAA) is a new minimally invasive method of aneurysm exclusion that has been adopted with increasing enthusiasm, and with acceptable clinical results. It is important, however, to assess new health-care technologies in terms of their economic as well as their clinical impact. The aim of the present study was to compare the total treatment costs for endovascular (EVR) and open surgical repair (OSR) for AAA. METHODS: A retrospective review of patient hospital and outpatient records for 62 patients undergoing either EVR (n = 31) or OSR (n = 31) was carried out between June 1996 and October 1999. Resource utilization was determined by a combination of patient clinical and financial accounting data. Costs were determined for preoperative assessment, inpatient hospital stay, cost of readmissions and follow up, and predicted lifetime follow-up costs. RESULTS: The two groups were well matched, with no significant difference with respect to age, gender, maximum aneurysm diameter or comorbid factors. Endovascular treatment resulted in a shorter intensive care unit (ICU) and hospital stay (mean: 0.07 vs 2.9 days, P < 0.001; mean: 6.0 vs 13.4 days, P < 0.001; respectively) and fewer postoperative complications (P = 0.003). The cost of hospitalization was less for EVR ($7614 vs $15092, P < 0.001), but this was offset by the more costly vascular prosthesis ($10284 vs $686). Costs were higher for the EVR group for preoperative assessment ($2328 vs $1540, P < 0.001) and follow up ($1284 vs $70, P < 0.001). Lifelong follow up could be expected to cost an additional $4120 per patient after EVR. Total lifetime treatment costs including costs associated with readmission for procedure-related complications were higher for EVR ($26909 vs $17650). CONCLUSION: Treatment costs for endovascular repair are higher than conventional surgical repair due to the cost of the vascular prosthesis and the greater requirement for radiological imaging studies.     

Aortoenteric Fistula Development following Endovascular Abdominal Aortic Aneurysm Repair: A Case Report

Aortoenteric fistulae (AEF) are now known to occur following endovascular repair of abdominal aortic aneurysms (AAA), presumably because of mechanical forces of dislodged or migrating devices. We present an unusual case of fistula development between the ileum and an AAA presenting as a graft infection following endovascular AAA repair in the absence of direct mechanical strain. Continued pressurization of the aneurysm sac due to endoleak may predispose to this event, especially in large aneurysms. Aggressive surveillance and early interventions are necessary following all endovascular AAA repairs.     

Financial Implications of Ventral Hernia Repair: A Hospital Cost Analysis

Introduction

Complicated ventral hernias are often referred to tertiary care centers. Hospital costs associated with these repairs include direct costs (mesh materials, supplies, and nonsurgeon labor costs) and indirect costs (facility fees, equipment depreciation, and unallocated labor). Operative supplies represent a significant component of direct costs, especially in an era of proprietary synthetic meshes and biologic grafts. We aim to evaluate the cost-effectiveness of complex abdominal wall hernia repair at a tertiary care referral facility.

Methods

Cost data on all consecutive open ventral hernia repairs (CPT codes 49560, 49561, 49565, and 49566) performed between 1 July 2008 and 31 May 2011 were analyzed. Cases were analyzed based upon hospital status (inpatient vs. outpatient) and whether the hernia repair was a primary or secondary procedure. We examined median net revenue, direct costs, contribution margin, indirect costs, and net profit/loss. Among primary hernia repairs, cost data were further analyzed based upon mesh utilization (no mesh, synthetic, or biologic).

Results

Four-hundred and fifteen patients underwent ventral hernia repair (353 inpatients and 62 outpatients); 173 inpatients underwent ventral hernia repair as the primary procedure; 180 inpatients underwent hernia repair as a secondary procedure. Median net revenue ($17,310 vs. 10,360, p?<?0.001) and net losses (3,430 vs. 1,700, p?<?0.025) were significantly greater for those who underwent hernia repair as a secondary procedure. Among inpatients undergoing ventral hernia repair as the primary procedure, 46 were repaired without mesh; 79 were repaired with synthetic mesh and 48 with biologic mesh. Median direct costs for cases performed without mesh were $5,432; median direct costs for those using synthetic and biologic mesh were $7,590 and 16,970, respectively (p?<?.01). Median net losses for repairs without mesh were $500. Median net profit of $60 was observed for synthetic mesh-based repairs. The median contribution margin for cases utilizing biologic mesh was ?$4,560, and the median net financial loss was $8,370. Outpatient ventral hernia repairs, with and without synthetic mesh, resulted in median net losses of $1,560 and 230, respectively.

Conclusions

Ventral hernia repair is associated with overall financial losses. Inpatient synthetic mesh repairs are essentially budget neutral. Outpatient and inpatient repairs without mesh result in net financial losses. Inpatient biologic mesh repairs result in a negative contribution margin and striking net financial losses. Cost-effective strategies for managing ventral hernias in a tertiary care environment need to be developed in light of the financial implications of this patient population.     

The cost-effectiveness of repairing ruptured abdominal aortic aneurysms

BACKGROUND: Although advances in technology have reduced the operative risk of elective abdominal aortic aneurysm (AAA) repair, the surgical repair of ruptured AAAs is associated with a much poorer prognosis and a higher cost. Accordingly, it has been suggested that patients with predictably high rates of morbidity and mortality from ruptured AAA may not benefit from surgical intervention.Methods and Results: A cost-effectiveness analysis was performed with the use of a Markov decision-analytic model to compute long-term survival in quality-adjusted life years and lifetime costs for a hypothetical cohort of patients with ruptured AAAs managed with either a strategy of open surgical repair or no intervention. Probability estimates for the various outcomes were based on a review of the literature. Average costs of (1) the immediate hospitalization ($28,356) and (2) complications resulting from the procedure were based on the average use of resources as reported in the literature and from a hospital's cost accounting system. Our measure of outcome was the incremental cost-effectiveness ratio. For our base-case analysis, the repair of ruptured AAAs was cost-effective with an incremental cost-effectiveness ratio of $10,754. (Society is usually willing to pay for interventions with cost-effectiveness ratios of less than $60,000; for example, the costeffectiveness ratios for coronary artery bypass grafting and dialysis are $9500 and $54,400, respectively.) In sensitivity analyses, the cost-effectiveness of repairing ruptured AAAs was influenced only by alterations in the operative mortality. If the operative mortality exceeded 88%, repair of ruptured AAAs was no longer cost-effective. As an independent variable, increasing age had no substantial impact on the cost-effectiveness, although it is reported to be associated with increased operative mortality. It was necessary that the patient's cost of the initial hospitalization for ruptured AAA exceed $195,000 before repairing ruptured AAAs was no longer cost-effective. CONCLUSIONS: Our analysis suggests that despite the high cost and poor outcomes, the surgical repair of ruptured AAAs is still cost-effective when compared with no intervention. The cost of repairing ruptured AAAs falls within society's acceptable limits and therefore should not be a consideration in the management of patients with AAAs.     

A cost analysis of surgery for ruptured abdominal aortic aneurysm.

OBJECTIVE: This study compares our costs of salvaging patients with ruptured abdominal aortic aneurysms (AAA) with the costs for unruptured AAAs. METHODS: Details of all AAAs presenting over 18 months were obtained. Costs of repair were carefully calculated for each case and were based upon ITU and ward stay and the use of theatre, radiology and pathology services. We compared the costs in unruptured AAAs with both uncomplicated ruptures and ruptures with one or more system failure. RESULTS: The mortality rate for ruptures undergoing repair was 18% and for elective repairs was 1.6%. The median cost for uncomplicated ruptures was 6427 Pounds (range 2012-13,756 Pounds). For 12 complicated ruptures, it was 20,075 Pounds (range 13,864-166,446 Pounds), and for 63 unruptured AAAs, was 4762 Pounds (range 2925-47,499 Pounds). CONCLUSION: Relatively low operative mortality rates for ruptured AAA repair can be achieved but this comes at substantial cost. On average, a ruptured AAA requiring system support costs four times as much as an elective repair.     

Outcome in patients requiring renal replacement therapy after surgery for ruptured and non-ruptured aneurysm of the abdominal aorta.

OBJECTIVES: to study the course of postoperative acute renal failure requiring renal replacement therapy (RRT) in patients with ruptured (RAAA) and non-ruptured (EAAA) aneurysm of the abdominal aorta (AAA) and to investigate the predictive value regarding outcome of parameters collected during the illness. DESIGN: retrospective study in a university hospital. MATERIALS AND METHODS: the records of 42 patients, 21 with RAAA and 21 with EAAA, were reviewed. RESULTS: overall mortality was 69%, 71% for RAAA patients and 66% for EAAA patients. RRT was started 9 (2-28) days - median (range) - postoperatively and continued during 9 (2-50) days. Renal function recovered in nine of the 13 survivors after 18 (2-50) days. Length of ICU stay was 50 (2-132) days for survivors vs. 19 (6-56) days for non-survivors. The systemic inflammatory response syndrome (SIRS) or need for vasoactive support was associated with poor outcome and the ability to wean from vasoactive or ventilatory support with improved outcome. CONCLUSIONS: RAAA and EAAA patients requiring postoperative RRT both had a high mortality. The ICU stay of non-survivors was shorter than that of survivors, who had a 75% chance of regaining renal function. The ability to wean from ventilatory and inotropic support may be of help in the clinical management of patients requiring RRT after AAA surgery.