Study Finds Similar Effectiveness and Costs of Elective Open vs. Endovascular Aortic Abdominal Aneurysm Repair in VA

BACKGROUND:
Every year elective procedures to repair abdominal aortic aneurysm (AAA) are performed in 40,000 individuals in the United States. Perioperative deaths occur in about 1,250 of these AAA repairs, which constitute the second most common cause of death among patients undergoing vascular or general surgery procedures after colectomy. VA's Open vs. Endovascular Repair (OVER) trial was one of several multicenter randomized controlled trials that compared the two methods of elective AAA repair – and the only one conducted in North America. In the OVER trial, Veterans (99% male) who had planned elective repair of AAA and were candidates for both procedures were randomized to endovascular (n=444) or open (n=437) repair from October 2002 to April 2008 in 42 VAMCs – and were followed until October 2011. [Follow-ups were scheduled 1 month after surgery, 6 and 12 months after study enrollment, and then yearly.] This study compared the total and AAA-related use of healthcare resources, costs, and cost-effectiveness of the randomized groups to the end of the OVER trial, with 9 years of follow-up. Effectiveness was measured in life-years after randomization and in QALYs (quality-adjusted life years), which incorporated health-related quality of life and medical outcomes into a single measure.

FINDINGS:

• Survival, quality of life, costs, and cost-effectiveness were not significantly different between elective open and endovascular AAA repair after a mean of 5.2 years of follow-up.
• Mortality was significantly lower with endovascular repair at 30 days after surgery – and 2 and 3 years after randomization, but not thereafter.
• Total mean healthcare costs did not differ significantly between the two groups: $142,745 for endovascular compared to $153,533 for open. Lower costs due to shorter hospitalization for initial endovascular repair were offset by increased costs from AAA-related secondary procedures and imaging studies.
• The probability of endovascular repair being both less costly and more effective was 57% when effectiveness was measured in life years, and 55% when measured in QALYs for total costs, and 31% and 34%, respectively, for AAA-related costs.

IMPLICATIONS:

• For patients with AAA who are candidates for both procedures, selection of either one remains reasonable and can be guided by patient and physician preference.

LIMITATIONS:

• Study protocol required some deviations from usual practice, e.g., computed tomography at one year after open repair.

AUTHOR/FUNDING INFORMATION:
This study was funded through VA's Cooperative Studies Program.

Lederle F, Stroupe K, Kyriakides T, et al. Long-Term Cost-Effectiveness in the Veterans Affairs Open vs. Endovascular Repair Study of Aortic Abdominal Aneurysm. JAMA Surgery. September 14, 2016;e-pub ahead of print.