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Two questions of public health significance are: 1) Whether surgery for
small AAA's is cost-effective; and 2) Whether hospital mortality rates
could be reduced by selective referral of patients to high-volume vascular
services in larger hospitals. Recent publications in major journals have
addressed these issues, and they will be the subject of this month's
POM's.
1. Dudleyu RA, and others. Selective referral to high-volume hospitals:
estimating potentially avoidable deaths. JAMA 2000; 283: 1159-66
Brief summary: Many studies have shown that high-volume hospitals (HVH)
and a lower mortality rate than low-volume hospitals (LVH) for numerous
complex and specialized surgical procedures. However, there have been
few attempts by health plans or government programs to channel their
insureds to HVH's. The authors began by searching medline for the key
words hospital, outcome, mortality, volume, risk and quality. Then they
calculated odds ratios (OR) for different procedures in HVH vs LVH. AAA
was among the procedures where there was a better outcome in HVH.
They calculated that several hundred lives would be saved each year in
the state of California if the high risk procedures, like AAA, were done in
HVH.
Comment by mdt: I believe that their conclusion is correct, but the authors
point out that "the impact of loss of continuity of care for some patients
and the reduction in the availability of specialists for patients remaining
at LVHs could not be assessed." And *that* is why something so
rational has not been done. With insurance companies making medical
decisions based on "bottom line", in retrospect, I think we would have
been better off with some form of "socialized" medicine. If you don't
agree, please don't flame me; I don't have time to reply to flames.
2. Schermerhorn ML, and others, including Jack Cronenwett. Cost-
effectiveness of surgery for small AAA's on the basis of data from the
UK small aneurysm trial. J Vasc Surg 2000: 31; 217-26.
Brief summary: Although the UK investigators concluded that there was
no survival benefit for early operations for small AAA (4-5.5cm); the
Dartmouth group has re-analyzed their data by "decision" analysis,
which has greater statistical power to detect small but potentially
meaningful gains. Please refer to the original paper for details about
the "Markov model" and the findings. The bottom line was that
operation for small AAA's has a measurable improvement in cost per
quality-adjusted life years saved, particularly in the younger patients
(<72 y/o) with the larger AAA's (>4.5).
Comment by mdt: Very fine work, as we have come to expect from
the Dartmouth group. The authors do point out that since the gains
are relatively small, "clinical decision making should be strongly
guided by patient preferences."