Elective Revascularization for Chronic Mesenteric Ischemia Results in Lower Healthcare Costs and Lower Mortality Compared to Emergent Revascularization
Huong Truong, MD, PhD, Viktor Dombrovskiy, MD, PhD, Saum Rahimi, MD, Khanjan H. Nagarsheth, MD, MBA, RPVI.
Rutgers University - Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Objective(s): In order to identify trends in techniques and outcomes of mesenteric revascularization for chronic mesenteric ischemia (CMI) over time, we performed a database review.
Methods: Using the ICD-9 diagnosis code 557.1 and appropriate procedure codes in the Nationwide Inpatient Sample 2007-2014 we selected patients with CMI who underwent revascularization. Outcomes between those with elective (EL) and non-elective (NEL) hospitalization were compared using Chi-square test, Cochran-Armitage trend test, multivariable logistic regression analysis and Wilcoxon rank sum test.
Results: During the study time we estimated nationally 12,021 hospitalizations with CMI and revascularization: 4,161 EL and 7,860 NEL. Postoperative mortality in NEL (5.7%) was almost twice that in EL (3.0%; P<0.0001). In both groups mortality after open surgery (EL: 5.0%; NEL: 16.8%) was higher than after endovascular repair (EL: 1.5%; NEL: 3.6%); P<0.0001. From 2007 to 2014 hospital mortality steadily significantly decreased in both EL (from 6.6% to 2.3%; P<0.0001) and NEL (from 8.4% to 5.3%; P=0.004) but still was considerably greater in those with NEL admissions. Non-elective hospitalizations were significantly longer (median 7 days, IQR [interquartile range] 4-12 vs 5 days, IQR 1-8; P<0.0001) and more expensive (median $21,923, IQR 15,173-34,853 vs $17, 577, IQR 12,057-26,612; P<0.0001) than EL admissions. When examining the need for bowel resection after revascularization, NEL patients were more likely than EL patients (OR[odds ratio]=3.1; 95%CI [confidence interval] 2.24-4.19). In the multivariable logistic regression analysis with adjustment for patient age, gender, and race, comorbidities, type of admission and procedure, NEL were still 4.4 times as likely as EL (95%CI 3.17-6.15) to have bowel resection. Likelihood of bowel resection was also greater after open surgery compared to endovascular repair (OR=2.9; 95%CI 2.24-3.72), in males (OR=1.4; 95%CI 1.07-1.76) and in African Americans compared to whites (OR=1.7; 95%CI 1.09-2.65).
Conclusions: Non-elective revascularization of chronic mesenteric ischemia has a higher mortality, longer length of stay and associated healthcare costs as well as higher rate of bowel resection. Over time, though there has been a reduction in mortality for both non-elective and elective revascularizations. The rate of mortality has decreased more dramatically for elective revascularization. These findings may point to benefit from elective revascularization for CMI but longitudinal studies are needed to see if this benefit extends beyond the index hospitalization.
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