Boom in endovascular AAA repair is appropriate, study suggests

2009 07 02 15 23 32 255 2009 07 03 Levin Fig3 394

A rapid shift to endovascular-based treatment for abdominal aortic aneurysms (AAA) hasn't resulted in inappropriate use of the procedure, according to a study published in this month's Journal of the American College of Radiology.

Clear treatment guidelines regarding when endovascular-based therapy should be performed have helped manage imaging use, according to a study by Dr. David C. Levin and colleagues at the Center for Research on Utilization of Imaging Services at Thomas Jefferson University Hospital in Philadelphia (JACR, July 2009, Vol. 6:7, pp. 506-509).

Levin and colleagues examined the extent to which endovascular aneurysm repair (EVAR) is replacing open surgical repair (OSR), a more invasive, risky, and expensive procedure. The team also examined whether the less invasive EVAR technique led to a corresponding rise in AAA repair procedures.

Levin's team studied Medicare Part B datasets for 2001 through 2006. They found that a total of 31,965 open surgeries for AAA were performed in Medicare beneficiaries in 2001, dropping to 15,665 by 2006, a decrease of 51%. EVAR was performed in 11,028 instances in 2001 and increased to 28,937 cases in 2006, representing growth of 162%.

The utilization rate for OSR per 100,000 beneficiaries dropped from 90 to 42 during the study period, while the rate for EVAR increased from 31 to 77.

2009 07 02 15 23 32 576 2009 07 03 Levin Fig2 394
Procedure volume for OSR (surg repair) of AAAs compared with EVAR in the Medicare fee-for-service population, 2001 to 2006. All images courtesy of the American College of Radiology.

Procedure volume and market share by specialty for EVAR in 2006 were as follows:

  • 22,003 procedures by surgeons (76% share)
  • 3,287 procedures by radiologists (11% share)
  • 1,915 procedures by cardiologists (7% share)
  • 1,732 procedures by other physicians (6% share)
2009 07 02 15 23 32 255 2009 07 03 Levin Fig3 394
EVAR procedures among the different specialty groups in the Medicare fee-for-service population between 2001 and 2006. Note that the trend lines for cardiologists and other physicians are almost superimposed.

EVAR appears not to have increased the overall rate of intervention use for AAA, Levin and colleagues wrote, providing an encouraging example of responsible introduction of new technology.

"In all likelihood, a major factor in the restraint that has been shown has been the existence of a clear guideline when intervention is indicated," they wrote. "Despite the opportunity for self-referral that exists when a patient presents to a surgeon with an AAA, the general agreement that intervention is not warranted until an aneurysm grows to a diameter of 5.5 cm seems to have been adhered to."

The authors contrasted the study results with less favorable use patterns found in the diagnosis of vascular disease by imaging technologies such as MR or CT angiography: Although like EVAR, these technologies are less invasive than conventional ones, their availability has led to considerable increase in the use of catheter angiography by surgeons and cardiologists, they wrote.

"We postulate that the existence of a single, well-established guideline [that AAAs less than 5.5 cm should not be treated] explains the difference," they wrote.

The researchers concluded that guidelines can help control technology use -- and, therefore, healthcare costs -- although they conceded that guidelines are easier to apply in treatment situations than in diagnostic ones.

By Kate Madden Yee staff writer
July 6, 2009

Related Reading

Screening men for abdominal aortic aneurysm saves lives, but is it cost-effective? June 26, 2009

VC/AAA screening combo cost-effective in older adults, March 26, 2009

Study: Endovascular repair can come first for AAA, March 12, 2009

Which modality for AAA? Depends on what you seek, says ISET speaker, February 5, 2008

3-mm CT slices best for endovascular repair of AAA, January 14, 2008

Copyright © 2009

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