AAA Repair: Sociodemographic Disparities in Management and Outcomes

Abstract

Objective: To evaluate sociodemographic influences on utilization and outcomes of endovascular abdominal aortic repair (EVAR) for the treatment of abdominal aortic aneurysm (AAA).

Methods: Secondary data analysis of the State Inpatient Databases for New Jersey.

Results: Between 2001 and 2006, a total of 6227 adult subjects (mean [SD] age, 73.3 [8.3] years; 77.6% male) underwent AAA repair (3167 EVAR and 3060 open surgery [OS]). Patients receiving EVAR were older than those undergoing OS (mean [SD] age, 74.2 [8.0] vs 72.4 [8.6] years) (P < .001). Men were 1.60 (95% confidence interval [CI], 1.39-1.77) times more likely to receive EVAR than women. White subjects had the same odds of undergoing EVAR as black subjects, and white subjects had 1.60 (95% CI, 1.29-2.06) times higher odds of receiving EVAR than Hispanics. Subjects with Medicare coverage were 3.90 (96% CI, 2.28-6.59) times more likely to receive EVAR than uninsured subjects. Logistic regression analysis demonstrated that older age, male sex, and Medicare coverage were significantly associated with increased utilization of EVAR and that uninsured subjects and Hispanics are less likely to receive EVAR. Octogenarians and black subjects (odds ratios: 3.69 CI: 2.31-5.91, and 2.59 CI: 1.47-4.54 respectively) had significantly greater likelihood of death after elective AAA repair.

Conclusions: For AAA repair, significant sociodemographic disparities exist in the use of endovascular technology and in mortality. The risk of death after elective AAA repair was significantly greater for black subjects. Further analysis is warranted to delineate inequalities of vascular care for AAA and to assist in formulating policy to address these disparities.

Keywords

outcomes AAA health disparities racial ethnic

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References

EVAR Trial Participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005;365(9478):2179-2186.

Leurs LJ , Buth J. , Harris PL , Blankensteijn JD Impact of study design on outcome after endovascular abdominal aortic aneurysm repair: a comparison between the randomized controlled DREAM-trial and the observational EUROSTAR-registry. Eur J Vasc Endovasc Surg . 2007;33(2):172-176.

Rutherford RB Randomized EVAR trials and advent of level I evidence: a paradigm shift in management of large abdominal aortic aneurysms ? Semin Vasc Surg. 2006;19(2):69-74.

Wilt TJ , Lederle FA , Macdonald R. , Jonk YC , Rector TS , Kane RL Comparison of endovascular and open surgical repairs for abdominal aortic aneurysm. Evid Rep Technol Assess (Full Rep). 2006;(144):1-113.

Zarins CK , Heikkinen MA , Lee ES , Alsac JM , Arko FR Short- and long-term outcome following endovascular aneurysm repair: how does it compare to open surgery? J Cardiovasc Surg (Torino) . 2004;45(4):321-333.

Bhalotra S. , Ruwe MB , Strickler GK , Ryan AM , Hurley CL Disparities in utilization of coronary artery disease treatment by gender, race, and ethnicity: opportunities for prevention. J Natl Black Nurses Assoc. 2007; 18(1):36-49.

Casale SN , Auster CJ , Wolf F. , Pei Y. , Devereux RB Ethnicity and socioeconomic status influence use of primary angioplasty in patients presenting with acute myocardial infarction. Am Heart J. 2007;154(5):989-993.

Du XL , Sun CC , Milam MR , Bodurka DC , Fang S. Ethnic differences in socioeconomic status, diagnosis, treatment, and survival among older women with epithelial ovarian cancer [published online ahead of print September 24, 2007]. Int J Gynecol Cancer . 2007. doi:10.1111/j.1525-1438.2007.01081.x.

Dunlop DD , Manheim LM , Song J. , et al. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. Med Care. 2008;46(2):200-208.

10.

Ibrahim SA Racial and ethnic disparities in hip and knee joint replacement: a review of research in the Veterans Affairs Health Care System. J Am Acad Orthop Surg. 2007;15(suppl 1):S87-S94.

11.

Pierce RO Jr. Ethnic and racial disparities in diagnosis, treatment, and follow-up care. J Am Acad Orthop Surg. 2007;15(suppl 1):S8-S12.

12.

Sosa JA , Mehta PJ , Wang TS , Yeo HL , Roman SA Racial disparities in clinical and economic outcomes from thyroidectomy. Ann Surg. 2007;246(6):1083-1091.

13.

Wilson RT , Adams-Cameron M. , Burhansstipanov L. , et al. Disparities in breast cancer treatment among American Indian, Hispanic and non-Hispanic white women enrolled in Medicare. J Health Care Poor Underserved. 2007; 18(3):648-664.

14.

Agency for Healthcare Research and Quality Web site. Overview of the State Inpatient Databases (SID) : Healthcare Cost and Utilization Project (HCUP). http://hcup-us.ahrq.gov/sidoverview.jsp. Accessed March 15, 2008.

15.

Elixhauser A. , Steiner C. , Harris DR , Coffey RM Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27.

16.

Bonds DE , Zaccaro DJ , Karter AJ , Selby JV , Saad M. , Goff DC Jr. Ethnic and racial differences in diabetes care: the Insulin Resistance Atherosclerosis Study. Diabetes Care. 2003;26(4):1040-1046.

17.

Ofili E. Ethnic disparities in cardiovascular health. Ethn Dis. 2001;11(4):838-840.

18.

Kulig K. , Bingham CO III , Steele LL. Racial, ethnic, and geographic disparities in rates of knee arthroplasty . N Engl J Med. 2004;350(3):305-306.

19.

Stanley A. , DeLia D. , Cantor JC Racial disparity and technology diffusion: the case of cardioverter defibrillator implants, 1996-2001. J Natl Med Assoc. 2007 ;99(3): 201-207.

20.

Escarce JJ , Epstein KR , Colby DC , Schwartz JS Racial differences in the elderly's use of medical procedures and diagnostic tests. Am J Public Health. 1993;83(7):948-954.

21.

Ko DT , Krumholz HM , Wang Y. , et al. Regional differences in process of care and outcomes for older acute myocardial infarction patients in the United States and Ontario, Canada . Circulation. 2007;115(2):196-203.

22.

Rutherford RB Commentary: endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomized controlled trial. Perspect Vasc Surg Endovasc Ther. 2006;18(1):74-76.

23.

Prinssen M. , Buskens E. , Blankensteijn JD The Dutch Randomised Endovascular Aneurysm Management (DREAM) trial: background, design and methods. J Cardiovasc Surg (Torino). 2002;43(3):379-384.

24.

Vogel TR , Nackman GB , Crowley JG , et al. Factors impacting functional health and resource utilization following abdominal aortic aneurysm repair by open and endovascular techniques . Ann Vasc Surg. 2005;19(5): 641-647.

25.

Prinssen M. , Buskens E. , Blankensteijn JD Quality of life endovascular and open AAA repair: results of a randomised trial. Eur J Vasc Endovasc Surg. 2004;27(2):121-127.

26.

Morrissey NJ , Giacovelli J. , Egorova N. , et al. Disparities in the treatment and outcomes of vascular disease in Hispanic patients. J Vasc Surg. 2007;46(5):971-978.

27.

Gomez SL , O'Malley CD , Stroup A. , Shema SJ , Satariano WA Longitudinal, population-based study of racial/ethnic differences in colorectal cancer survival: impact of neighborhood socioeconomic status, treatment and comorbidity. BMC Cancer. 2007;7:e193.

28.

Krumholz HM , Wang Y. , Mattera JA , et al. An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with an acute myocardial infarction. Circulation. 2006; 113(13):1683-1692.

29.

Bach PB , Guadagnoli E. , Schrag D. , Schussler N. , Warren JL Patient demographic and socioeconomic characteristics in the SEER-Medicare database applications and limitations. Med Care. 2002;40(8)(suppl):IV-19-IV-25.

30.

Warren JL , Klabunde CN , Schrag D. , Bach PB , Riley GF Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care. 2002;40(8)(suppl):IV-3-IV-18.