A new study published in the September print issue of the Journal of Vascular Surgery reveals that rural and urban patients have equivalent access to endovascular aneurysm repair (EVAR) care from vascular surgeons, increased referral to high-volume hospitals and improved outcomes after repair.
Matthew W Mell (director of vascular surgery clinics and vascular laboratory, and assistant professor of vascular surgery at Stanford University in Stanford, USA) and colleagues reported that 2,616 selected patients (identified from a standard 5% random sample of all Medicare beneficiaries) underwent intact abdominal aortic aneurysm repair in 2005 to 2006.
Data on patient demographics, comorbidities, type of repair and specialty of operating surgeon were collected. Hospitals were stratified into quintiles by yearly abdominal aortic aneurysm volume and primary outcomes included 30-day mortality and re-hospitalisation.
Patients had repair for intact abdominal aortic aneurysm (40% open, 60% EVAR). “Those from rural and urban areas were equally likely to receive EVAR (rural 60% vs. urban 61%) and be treated by a vascular surgeon (rural 48% vs. urban 50%),” noted Mell. Most rural patients (86%) received care in urban centres. Primary outcomes occurred in 11.6% of rural patients (1.3% 30-day mortality; 10.3% re-hospitalisation) vs. 16% of urban patients (3% 30-day mortality, 13% re-hospitalisation).
In multivariate analyses, rural residence was independently associated with treatment at high-volume centres with an odds ratio (OR) of 1.64 and 95% confidence interval (CI), 1.34–2.01, and decreased death or re-hospitalisation (OR of 0.69 and 95% CI, 0.49–0.97).
“Our study is the first to describe the national experience for treatment of intact abdominal aortic aneurysms in the endovascular era for patients living in rural areas, said Mell. “Lack of local expertise and the need to refer elsewhere for aneurysm treatment may have allowed rural patients paradoxically improved access to high-volume centres compared with urban patients. This access may, in part, account for the rural patients’ improved outcomes, as the potential benefit of aneurysm treatment at high-volume centres is well-documented. However, study researchers added that some rural patients also may have been cared for at high-quality low-volume centres or by highly skilled specialists and outcomes of rural patients represent access to high quality care regardless of volume.
Another potential concern is that urban patients had worse outcomes than rural patients, even after adjusting for race and Medicaid, according to researchers. Urban patients had a higher proportion of minorities and those on Medicaid, which may have impacted outcomes. Some research shows that minorities are less likely to receive complex surgical care in high-volume hospitals for abdominal aortic aneurysms because they are not referred to such centres.
“Our study supports the need for better criteria that defines centres of excellent aortic care to extend the benefits of regionalisation to all patients, which would allow improved outcomes for across the board,” said Mell. However, he added that many barriers prevent regionalisation for complex surgical care.
“Barriers can include patients who have a preference for local care and will trade increased mortality for decreased travel distances,” noted Mell. He added that primary care physicians often value the local specialist’s medical skills, quality communication between the specialist, patient and referring physician, and that the hope that the specialist will return the patient to the primary physician. Less important to local physicians are hospital affiliation, office location and patient convenience.
Willingness to refer rural patients to urban settings also may reflect a severe shortage of qualified resources at rural hospitals including recruitment of surgeons, said Mell, and the cost of a viable endovascular programme (specially trained personnel, radiologic imaging and adequate inventory) may prohibit rural hospitals from attracting appropriately trained physicians, even though surgeons have a vital role in the financial viability of these institutions.
Some urban communities do not have high-quality hospitals and patients would prefer to remain in their own urban area rather than travel to another urban centre for care. Referrals for these patients often are based on matching hospital affiliation or insurance coverage between the referring physician and specialist, without knowledge or ability of the primary physician to choose a specialist based on expertise and outcomes.