Annual Health Care Expenditures in Individuals with Peripheral Arterial Disease

1180

Journal of Vascular Surgery

Abstracts

October 2016 used to assess calibration. This model was then compared with Medicare, Vascular Governance Northwest, and Glasgow Aneurysm Score for predicting mortality in the VQI
sample. The Vuong test was performed to compare model fit. Model discrimination was assessed in equally sized risk group VQI
terciles. Results: Data from 4431 cases from the VSGNE sample with the overall 1.4% mortality rate were used to develop the model. An internally validated VSGNE model showed a high discriminating ability in predicting mortality (C ¼ 0.822) and good model fit (Hosmer-Lemeshow, P ¼ .309) among the VSGNE EAR sample. External validation on 16,989 VQI
cases with an overall 0.9% mortality rate showed robust predictive ability of mortality (C ¼ 0.802). Vuong tests yielded a significant fit difference favoring VSGNE to Medicare (C ¼ 0.780), Vascular Governance Northwest (0.774), and Glasgow Aneurysm Score (0.639). Across the three risk terciles, the VSGNE model predicted observed mortality significantly better than other models did. Conclusions: The simple VSGNE AAA RPM showed high fidelity in predicting EAR mortality among a large external sample of AAA cases performed by a diverse array of physicians nationwide. A risk score based on the simple VSGNE model can reliably stratify patients according to their risk of mortality after EAR better than other established models can. Author Disclosures: M. H. Eslami: None; D. V. Rybin: None; G. Doros: None; J. J. Siracuse: None; J. Kalish: None; A. Farber: None.

A Standardized Ten-Step Approach to the Sizing and Planning of a Fenestrated Endovascular Aortic Aneurysm Repair Andres Schanzer, Jessica Simons, Francesco Aiello, Danielle Doucet, Robert Steppacher, Elias Arous, Louis Messina. University of Massachusetts, Worcester, Mass Objective: Fenestrated endovascular aneurysm repair (EVAR) is now a Food and Drug Administration-approved treatment in the United States for short-neck infrarenal aortic aneurysms and for juxtarenal aortic aneurysms. Fenestrated EVAR repairs necessitate more involved sizing and planning than does standard EVAR. Sizing and planning of fenestrated cases can often appear overly complicated and intimidating and act as a barrier to physicians interested in learning these techniques. This video describes a standardized 10-step approach to the sizing and planning of a fenestrated endovascular aortic aneurysm repair. Methods and Results: This is an 81-year-old man who presented for a commercially available fenestrated endovascular repair of a 5.7-cm abdominal aortic aneurysm with a 4-mm infrarenal neck. Currently, the Cook ZFEN graft (Cook Medical, Bloomington, Ind) is the only Food and Drug Administration-approved device in the United States, so this video focuses on this device. We evaluate all patients being considered for aortic aneurysm repair using three-dimensional reconstruction software. For any patient undergoing EVAR, we use a standardized 10-step approach for successful planning and sizing. The 10 steps described in this video are (1) centerline placement, (2) marker placement, (3)

determination of the proximal edge of the endograft, (4) measurement of required diameters, (5) measurement of required lengths, (6) measurement of target artery clock positions, (7) selection of the proximal fenestrated component, (8) selection of the scallop or fenestration design, (9) selection of the distal bifurcated component, and (10) selection of the iliac limbs. Conclusions: We believe that this standardized approach provides a structured and simplified method for surgeons to become comfortable with the key aspects of planning and sizing of fenestrated EVAR. Author Disclosures: A. Schanzer: Consultant: Company/Organization: Cook Medical; J. Simons: None; F. Aiello: None; D. Doucet: None; R. Steppacher: None; E. Arous: None; L. Messina: None.

Annual Health Care Expenditures in Individuals with Peripheral Arterial Disease Rebecca E. Scully, Ann DeBord Smith, Dean J. Arnaoutakis, Marcus Semel, Louis L. Nguyen. Brigham and Women’s Hospital, Boston, Mass Objective: The clinical impact of peripheral arterial disease (PAD) is well characterized and is associated with significant morbidity and mortality. However, the cost of PAD care, both to patients and to payers, is not well described. We sought to estimate PAD care costs in the United States, with a particular focus on the patient’s out-of-pocket expenditures. Methods: The 2012 Agency for Healthcare Research and Quality Medical Expenditure Panel Survey was analyzed for annual inpatient and outpatient costs associated with a diagnosis of PAD. Study participants as well as their employers, insurers, physicians, and affiliated health care providers were surveyed on fees and costs. Weighted expenditures were estimated using multivariable linear regression. Results: Adjusted for age, gender, and race, individuals with a diagnosis of PAD (weighted N ¼ 642,878) had significantly higher average annual health care-related expenditures compared with the U.S. adult population (age $18 years) as a whole. Mean total annual expenditures per person for patients with PAD were $12,702 (95% confidence interval [CI], $5860-$19,543) compared with only $4433 (95% CI, $4124-$4743; P ¼ .02; Table I) for those without. Increased expenditures were driven primarily by increased medication spending ($3025 [95% CI, $1185-$4864] vs $1045 [95% CI, $889-$1200]; P ¼ .04), with out-of-pocket expenditures being significantly higher for individuals with PAD ($903 [95% CI, $304$1501] vs $191 [95% CI, $166-$215]; P ¼ .02). Office-based costs to private insurers were higher for individuals without PAD; however, hospitalbased outpatient private insurance costs were higher for individuals with PAD (Table II). Conclusions: PAD is associated with higher health care-related expenditures, with greater differences seen in hospital-based outpatient care and medication costs, resulting in significant out-of pocket expenses for patients with PAD. These costs compound the lost wages, care by family members, and opportunity costs faced by these individuals, increasing the patient’s burden beyond the clinical impact of PAD.

Table I. Mean annual health services expenditures among U.S. adults with and without peripheral arterial disease (PAD) All U.S. adults (weighted N ¼ 236,471,038)

History of PAD (weighted N ¼ 642,878) Adjusted costs, total

Cost (%)

95% CI

P

Cost (%)

95% CI

$1335 (30.1)

$1177-$1494

.10

$
70 to $3043

$354 (8.0)

$299-$410

.15

$764-$2406

$975 (22.0)

$904-$1045

.14

$53-$748

$183 (4.1)

$167-$ 198

.22

Inpatient

$4666 (36.7)

$691-$8641

Outpatient

$1486 (11.7)

Office based

$1585 (12.5)

Emergency department

$400 (3.1)

Medications

$3025 (23.8)

$1185-$4864

$1045 (23.6)

$889-$1200

.04

Total

$12,702

$5860-$19,543

$4433

$4124-$4743

.02

CI, Confidence interval.

Journal of Vascular Surgery

Abstracts

1181

Volume 64, Number 4 Table II. Mean annual health services expenditures by payer History of PAD Adjusted costs, by payer

All U.S. adults

Cost (USD)

95% CI

Medicare

$1473

Medicaid

$306

Private Out-of-pocket

P

Cost (USD)

95% CI


$1208 to $4155

$411

$354-$469

.78


$64 to $676

$174

$118-$230

.70

$1333

$105-$2561

$577

$450-$703

.22

$427


$355 to $1208

$47

$29-$64

.96 .06

Inpatient

Outpatient, hospital based Medicare

$331

$43-$618

$54

$44-$64

Medicaid

$280


$28 to $588

$201

$159-$243

.84

Private

$183

$133-$233

$53

$35-$73

<.001

Out-of-pocket

$54


$2 to $107

$24

$19-$30

.26

Medicare

$654

$88-$1221

$215

$187-$243

.13

Medicaid

$221

$0-$442

$99

$59-$140

.30

Private

$206

$61-$351

$422

$387-$457

.002

Out-of-pocket

$120

$18-$222

$124

$114-$133

0.94

Medicare

$53


$60 to $165

$33

$27-$40

.74

Medicaid

$12

$3-$21

$21

$14-$28

.07

Private

$117


$63 to $297

$80

$69-$90

.68

Out-of-pocket

$67


$14 to $147

$20

$17-$24

.25

Outpatient, office based

Emergency department

Medications Medicare

$883


$85 to $233

$303

$233-$372

.24

Medicaid

$395


$219 to $1010

$94

$71-$119

.34

Private

$656


$162 to $1473

$322

$266-$379

.43

Out-of-pocket

$903

$304-$1501

$191

$166-$215

.02

CI, Confidence interval; PAD, peripheral arterial disease; USD, U.S. dollars. U.S. adults, age $18 years; expenditures in USD; adjusted for age, race, gender.

Author Disclosures: R. E. Scully: None; A. DeBord Smith: None; D. J. Arnaoutakis: None; M. Semel: None; L. L. Nguyen: None.

of complex aortic aneurysms (definition: requiring $1 fenestration or branch). Data were collected prospectively through an Institutional Review Board-approved registry and physician-sponsored investiga-

Outcomes of Fenestrated and Branched Endovascular Repair of Complex Abdominal and Thoracoabdominal Aortic Aneurysms Andres Schanzer,1 Jessica P. Simons,1 Aiello Francesco,1 Danielle Doucet,1 Robert Steppacher,1 Jonathan Durgin,1 William P. Robinson III,2 Julie Flahive,1 Elias Arous,1 Louis L. Messina1. 1University of Massachusetts, Worcester, Mass; 2University of Virginia, Charlottesville, Va Background: Endovascular aneurysm repair accounts for >80% of infrarenal repairs. However, adoption of fenestrated and branched endovascular repair for complex aortic aneurysms has been limited, despite high morbidity and mortality associated with open repair. There are few published reports of outcomes after fenestrated and branched endovascular repair of complex aortic aneurysms. Therefore, we examined a single center’s consecutive experience of fenestrated and branched endovascular repair of complex aortic aneurysms. Methods: This is a single-center, prospective, observational cohort study evaluating 30-day and 1-year outcomes in all consecutive patients who underwent fenestrated or branched endovascular repair

Fig 1. Survival (%).