P162. Impact of Transfer and Travel Distance on Operative Outcomes of Acute Ascending Aortic Dissection Repair: A Geospatial Analysis
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
Baylor College of Medicine
Houston, TX
United States - Contact Me
Travis J. Miles, MD is a general surgery resident in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine, where he serves as the NIH T32 Research Fellow in Cardiovascular Surgery. His research focuses on vasoplegic shock and acute kidney injury following cardiac surgery. His clinical interests include adult cardiac surgery, aortic surgery, and surgical critical care.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
Objective: Aortic dissection is a surgical emergency mandating expedient surgical repair. However, many dissections are repaired at low volume centers, possibly due to concerns of delay in care associated with transfer to experienced aortic centers. We hypothesized that interfacility transfer and distance travelled by the patient would not adversely impact outcomes after repair of acute type A aortic dissection (ATAAD).
Methods: The Texas State Inpatient Database was queried for patients who underwent emergent surgical repair for ATAAD from 2018-2021. Distance travelled to hospital was determined by extracting latitude and longitude from patient home and hospital zip codes. Patients and outcomes were stratified by transfer status and hospital ATAAD repair volume. High volume hospitals were defined as those in the top surgical volume quartile. Adjusted logistic regression models were used to assess the independent effect of distance on in-hospital mortality and major morbidity (stroke, renal failure, reoperation, prolonged ventilation, and DSWI).
Results: A total of 1036 patients underwent ATAAD repair at 69 hospitals, of which 56.0% (n=580) underwent transfer prior to surgery. Top quartile ATAAD volume centers performed a median 7 [IQR:5.1-14.1] repairs/year, with the five highest volume centers performing 27 [16-38] dissections/year. Transferred patients traveled greater distances (median [IQR] 26.0 [12.1-78.6]) miles) compared to non-transferred patients (10.8 [4.7-26.7] miles, p<0.001) and were more frequently (92%[537/580] vs. 72.8%[332/456] operated on at high-volume hospitals (p<0.001). Transferred patients had similar mortality (16.6%[96/580] vs. 19.5%[89/456], p=0.25) and major morbidity (41.7%[242/580] vs. 39.5%[180/456], p=0.39) compared to non-transferred patients. When comparing the outcomes of the five highest volume centers to all other centers, there was a signal towards lower observed mortality in the highest volume centers (15.7%[86/546] vs. 20.2%[99/490], p=0.07). After multivariate risk adjustment, distance travelled (OR [95% CI]: 0.998 [0.996-1.0004]) and transfer status (OR 0.783 [0.551-1.112]) did not increase operative mortality, whereas undergoing surgery at high-volume centers demonstrated a protective effect (OR 0.409 [0.283-0.591]). Prior cardiac surgery (OR 2.46 [1.43-4.20] and pre-operative hemodynamic instability (OR 2.10 [1.31-3.36]) represented the greatest risk factors for operative mortality.
Conclusion: Interfacility transfer and distance travelled do not adversely impact outcomes for ATAAD repair. Travel distance alone should not preclude transfer of stable patients with ATAAD to experienced aortic centers. Regionalization of aortic dissection management is safe and has the potential to improve outcomes.
Authors
Travis Miles (1), Robert Seniors (2), Vicente Orozco (3), Todd Rosengart (3), Marc Moon (3), Joseph Coselli (3), Subhasis Chatterjee (3), Ravi Ghanta (3)
Institutions
(1) Baylor College of Medicine, Houston, TX, (2) University of Texas Health Science Center, Houston, TX, (3) Baylor College of Medicine / Texas Heart Institute, Houston, TX
Methods: The Texas State Inpatient Database was queried for patients who underwent emergent surgical repair for ATAAD from 2018-2021. Distance travelled to hospital was determined by extracting latitude and longitude from patient home and hospital zip codes. Patients and outcomes were stratified by transfer status and hospital ATAAD repair volume. High volume hospitals were defined as those in the top surgical volume quartile. Adjusted logistic regression models were used to assess the independent effect of distance on in-hospital mortality and major morbidity (stroke, renal failure, reoperation, prolonged ventilation, and DSWI).
Results: A total of 1036 patients underwent ATAAD repair at 69 hospitals, of which 56.0% (n=580) underwent transfer prior to surgery. Top quartile ATAAD volume centers performed a median 7 [IQR:5.1-14.1] repairs/year, with the five highest volume centers performing 27 [16-38] dissections/year. Transferred patients traveled greater distances (median [IQR] 26.0 [12.1-78.6]) miles) compared to non-transferred patients (10.8 [4.7-26.7] miles, p<0.001) and were more frequently (92%[537/580] vs. 72.8%[332/456] operated on at high-volume hospitals (p<0.001). Transferred patients had similar mortality (16.6%[96/580] vs. 19.5%[89/456], p=0.25) and major morbidity (41.7%[242/580] vs. 39.5%[180/456], p=0.39) compared to non-transferred patients. When comparing the outcomes of the five highest volume centers to all other centers, there was a signal towards lower observed mortality in the highest volume centers (15.7%[86/546] vs. 20.2%[99/490], p=0.07). After multivariate risk adjustment, distance travelled (OR [95% CI]: 0.998 [0.996-1.0004]) and transfer status (OR 0.783 [0.551-1.112]) did not increase operative mortality, whereas undergoing surgery at high-volume centers demonstrated a protective effect (OR 0.409 [0.283-0.591]). Prior cardiac surgery (OR 2.46 [1.43-4.20] and pre-operative hemodynamic instability (OR 2.10 [1.31-3.36]) represented the greatest risk factors for operative mortality.
Conclusion: Interfacility transfer and distance travelled do not adversely impact outcomes for ATAAD repair. Travel distance alone should not preclude transfer of stable patients with ATAAD to experienced aortic centers. Regionalization of aortic dissection management is safe and has the potential to improve outcomes.
Authors
Travis Miles (1), Robert Seniors (2), Vicente Orozco (3), Todd Rosengart (3), Marc Moon (3), Joseph Coselli (3), Subhasis Chatterjee (3), Ravi Ghanta (3)
Institutions
(1) Baylor College of Medicine, Houston, TX, (2) University of Texas Health Science Center, Houston, TX, (3) Baylor College of Medicine / Texas Heart Institute, Houston, TX
Presentation Duration
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