International Consortium of Vascular Registries Reports on Variation in AAA Treatment
December 16, 2016—A report from the International Consortium of Vascular Registries (ICVR), a collaboration of 11 vascular surgical quality registries, on variations in abdominal aortic aneurysm (AAA) care was published by Adam W. Beck, MD, et al in Circulation (2016;134:1948–1958).
As noted in Circulation, this study was designed to evaluate international variation in the contemporary management of AAA with relation to recommended treatment guidelines from the Society for Vascular Surgery and the European Society for Vascular Surgery.
For the report, registry data for open and endovascular AAA repair (EVAR) during 2010 to 2013 were collected from 11 countries. Variations in patient selection and treatment were compared across countries and across centers within countries.
The investigators detailed that among 51,153 patients, 86% were treated for intact AAA and 14% for ruptured AAA. Women constituted 18% of the entire cohort (range, 12% in Switzerland–21% in the United States; P < .01). Intact AAAs were repaired at diameters smaller than recommended by guidelines in 31% of men (< 5.5 cm; range, 6% in Iceland–41% in Germany; P < .01) and 12% of women with intact AAA (< 5 cm; range, 0% in Iceland–16% in the United States; P < .01).
Other findings included that the use of EVAR for intact AAA varied from 28% in Hungary to 79% in the United States and for ruptured AAA from 5% in Denmark to 52% in the United States.
The investigators found that in addition to the between-country variations, significant variations were present between centers in each country in terms of EVAR use and rate of small AAA repair. Countries that more frequently treated small AAAs tended to use EVAR more frequently (trend: correlation coefficient, 0.51; P = .14).
Octogenarians made up 23% of all patients, ranging from 12% in Hungary to 29% in Australia (P < .01). In countries with a fee-for-service reimbursement system (Australia, Germany, Switzerland, and the United States), the proportions of small AAA (33%) and octogenarians undergoing intact AAA repair (25%) were higher compared to countries with a population-based reimbursement model (small AAA repair, 16%; octogenarians, 18%; P < .01). In general, center-level variation within countries in the management of AAA was as important as variation between countries.
Despite homogeneous guidelines from professional societies, significant variation exists in the management of AAA, most notably for intact AAA diameter at repair, use of EVAR, and the treatment of elderly patients, noted the investigators. They concluded that ICVR provides an opportunity to study treatment variation across countries and to encourage optimal practice by sharing these results.