News Daily News

Compliance With Follow-up Imaging Poor After EVAR

By L.A. McKeown

Approximately half of patients who undergo endovascular abdominal aortic aneurysm repair (EVAR) are lost to imaging follow-up within 5 years of the procedure despite guidelines that recommend annual lifelong imaging, according to a study published online November 1, 2014, ahead of print in the Journal of Vascular Surgery. 

Methods
Andres Schanzer, MD, of UMass Memorial Medical Center (Worcester, MA), and colleagues examined data from 19,962 continuously enrolled Medicare beneficiaries ages 65 years and older who underwent EVAR between 2001 and 2008. Information was collected on all abdominal imaging studies likely to have been performed for ongoing EVAR follow-up through the end of 2010.
Most patients were male (82%) and white (94%), with an average age of 76.3 years. EVAR was performed electively in 84%, urgently or emergently for intact aneurysm in 13%, and emergently for ruptured aneurysm in 2%.


Steady Loss to Follow-up Seen

A dramatic increase was seen in the number of hospitalizations for EVAR during the study period (from 1,400 in 2001 to 3,529 in 2008), accounting for a more than 2.5-fold increase in the annual rate of EVAR procedures (P for trend < .001).

The percentage of patients lost to annual imaging follow-up increased steadily from 22% at 1 year after EVAR to 38% at 3 years and 50% by 5 years, according to Kaplan-Meier estimates. On multivariable analysis, advanced age and aneurysm rupture on presentation were the factors most strongly associated with loss to follow-up (table 1). 

Table 1. Independent Predictors of Loss to Imaging Follow-up

Other independent predictors included:

 

  • Prior history of congestive heart failure 
  • Chronic renal insufficiency 
  • Chronic obstructive pulmonary disease 
  • Cancer 
  • Cerebrovascular disease 
  • Diabetes 
  • Residence in the Southern and Western regions of the United States  

 

Furthermore, the percentage of patients with documented annual imaging follow-up decreased with increasing years since EVAR. Among patients alive at 2 years, for example, 94.8% received 1 or more annual imaging studies after undergoing EVAR. But by 8 years, only 36.6% of those still alive received at least 1 imaging study between years 6 and 8.

Efforts Needed to Improve Coordination, Reward Follow-up  

“These rates are surprisingly low, given the clear evidence supporting the importance of annual imaging follow-up for identifying correctable problems after EVAR that can lead to aneurysm sac enlargement, rupture, and death,” Dr. Schanzer and colleagues write.   

One possible explanation, they say, is that patients categorized as “lost” to annual imaging follow-up were not lost per se, “but may have stopped receiving follow-up by choice, or they may have been told by their physician that they no longer needed further follow-up.”   

Yet another possibility, the authors note, is that in patients with multiple comorbidities “the patient and treating physicians may lose focus on surveillance of an [abdominal aortic aneurysm] after EVAR because of the demands of caring for their high burden of competing medical risks.”

Ultimately, the findings suggest the need for quality improvement efforts to “enhance care coordination across providers of care and to reward appropriate imaging follow-up among patients at high risk for loss to follow-up,” Dr. Schanzer and colleagues say. Some novel ideas for doing this, they add, may include physician-patient contracts, improved preoperative education materials, and financial incentives for patients and their clinicians.

 

Source: 
Schanzer A, Messina LM, Ghosh K, et al. Follow-up compliance after endovascular abdominal aortic aneurysm repair in Medicare beneficiaries. J Vasc Surg. 2014;Epub ahead of print. 

Disclosure:

  • Dr. Schanzer reports consulting fees from Bolton Medical and Cook Medical. 

Related Stories:

Comments

Aortic