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A Population Analysis of Aortic Aneurysm Repair—Better Than Randomized Clinical Trials?

A Population Analysis of Aortic Aneurysm Repair—Better Than Randomized Clinical Trials? It is hard to beat randomized clinical trials (RCTs) when comparing 2 treatment options. But how do results from RCTs reflect practice in the community? In this issue of JAMA Surgery, Chang et al1 analyze morbidity and long-term mortality rates in all patients in California who underwent aortic aneurysm repair between 2001 and 2009. The study includes approximately 23 000 patients. The authors identified practice patterns and outcomes in the nonresearch setting, considering both community and teaching hospitals alike, and examined changes in outcomes over time. These are all obvious advantages of this population-based study. The authors found that postoperative rupture and reintervention rates were consistently higher in patients who underwent endovascular repair compared with open repair. Short-term 30-day mortality rates were similar to rates reported by RCTs. Longer-term mortality rates within the first 2 years were higher in patients with open surgery; mortality rates at 4 and 5 years were higher with endovascular repairs. These findings are consistent with the RCTs on open vs endovascular repairs and consistent with previously published registry-based studies that found no improvement in survival with endovascular repair.2,3 By examining longitudinal outcomes in a population (the most populous state, no less), the study by Chang et al1 serves as a good example of how to advance health services research, especially in surgery. The goal now is to do more. We are at the point where health services research can use information technology to confirm or challenge RCTs. Through the development of more sophisticated databases, ideally through electronic medical records that can support patient care while simultaneously aggregating and analyzing data, we can move beyond research focused on a snapshot of information to dynamic, real-time, population-based feedback. Integrated health information systems should be able to identify hot spots of poor surgical outcomes, such as through device failures, and provide an ongoing comparison of outcomes between treatment options. They could be used to examine resource allocation to improve efficiency of medical care. And they could allow for more immediate interventions. The study by Chang et al1 offers a glimpse into the future of population-based health services research methods. With the dawn of electronic medical records and big data, we should be able to develop surgical outcomes research that can compete with and complement the randomized trial. This study is a good start. Back to top Article Information Corresponding Author: James W. Holcroft, MD, Department of Surgery, University of California Davis Medical Center, 2221 Stockton Blvd, 2nd Floor, Sacramento, CA 95817 (jwholcroft@ucdavis.edu). Published Online: September 2, 2015. doi:10.1001/jamasurg.2015.2651. Conflict of Interest Disclosures: None reported. References 1. Chang DC, Parina RP, Wilson SE. Survival after endovascular vs open aortic aneurysm repairs [published online September 2, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.2644.Google Scholar 2. Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307(15):1621-1628.PubMedGoogle ScholarCrossref 3. Lederle FA, Freischlag JA, Kyriakides TC, et al; OVER Veterans Affairs Cooperative Study Group. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med. 2012;367(21):1988-1997.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

A Population Analysis of Aortic Aneurysm Repair—Better Than Randomized Clinical Trials?

JAMA Surgery , Volume 150 (12) – Dec 1, 2015

A Population Analysis of Aortic Aneurysm Repair—Better Than Randomized Clinical Trials?

Abstract

It is hard to beat randomized clinical trials (RCTs) when comparing 2 treatment options. But how do results from RCTs reflect practice in the community? In this issue of JAMA Surgery, Chang et al1 analyze morbidity and long-term mortality rates in all patients in California who underwent aortic aneurysm repair between 2001 and 2009. The study includes approximately 23 000 patients. The authors identified practice patterns and outcomes in the nonresearch setting, considering both...
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Publisher
American Medical Association
Copyright
Copyright © 2015 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2015.2651
Publisher site
See Article on Publisher Site

Abstract

It is hard to beat randomized clinical trials (RCTs) when comparing 2 treatment options. But how do results from RCTs reflect practice in the community? In this issue of JAMA Surgery, Chang et al1 analyze morbidity and long-term mortality rates in all patients in California who underwent aortic aneurysm repair between 2001 and 2009. The study includes approximately 23 000 patients. The authors identified practice patterns and outcomes in the nonresearch setting, considering both community and teaching hospitals alike, and examined changes in outcomes over time. These are all obvious advantages of this population-based study. The authors found that postoperative rupture and reintervention rates were consistently higher in patients who underwent endovascular repair compared with open repair. Short-term 30-day mortality rates were similar to rates reported by RCTs. Longer-term mortality rates within the first 2 years were higher in patients with open surgery; mortality rates at 4 and 5 years were higher with endovascular repairs. These findings are consistent with the RCTs on open vs endovascular repairs and consistent with previously published registry-based studies that found no improvement in survival with endovascular repair.2,3 By examining longitudinal outcomes in a population (the most populous state, no less), the study by Chang et al1 serves as a good example of how to advance health services research, especially in surgery. The goal now is to do more. We are at the point where health services research can use information technology to confirm or challenge RCTs. Through the development of more sophisticated databases, ideally through electronic medical records that can support patient care while simultaneously aggregating and analyzing data, we can move beyond research focused on a snapshot of information to dynamic, real-time, population-based feedback. Integrated health information systems should be able to identify hot spots of poor surgical outcomes, such as through device failures, and provide an ongoing comparison of outcomes between treatment options. They could be used to examine resource allocation to improve efficiency of medical care. And they could allow for more immediate interventions. The study by Chang et al1 offers a glimpse into the future of population-based health services research methods. With the dawn of electronic medical records and big data, we should be able to develop surgical outcomes research that can compete with and complement the randomized trial. This study is a good start. Back to top Article Information Corresponding Author: James W. Holcroft, MD, Department of Surgery, University of California Davis Medical Center, 2221 Stockton Blvd, 2nd Floor, Sacramento, CA 95817 (jwholcroft@ucdavis.edu). Published Online: September 2, 2015. doi:10.1001/jamasurg.2015.2651. Conflict of Interest Disclosures: None reported. References 1. Chang DC, Parina RP, Wilson SE. Survival after endovascular vs open aortic aneurysm repairs [published online September 2, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.2644.Google Scholar 2. Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307(15):1621-1628.PubMedGoogle ScholarCrossref 3. Lederle FA, Freischlag JA, Kyriakides TC, et al; OVER Veterans Affairs Cooperative Study Group. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med. 2012;367(21):1988-1997.PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: Dec 1, 2015

Keywords: aortic aneurysm,survival analysis,postoperative complications,randomized controlled trial,vascular surgical procedures,electronic medical records,aortic surgery,evar trial

References