Conference Coverage

SVS: AAA reimbursement needs to take anatomic complexity into account

Key clinical point: Get the hang of calculating Anatomic Severity Grade scores on your triple A cases; it might one day increase your reimbursements.

Major finding: EVAR cases below an ASG score of 15 cost a mean of $22,020 and had a length of stay of 2.93 days. Above 15, the cost was $26,574 and mean LOS was 3.07 days.

Data source: Review of 33 open and 107 endovascular repairs at the University of Rochester in New York.

Disclosures: The investigators have no disclosures.




CHICAGO – Anatomic complexity should be factored into reimbursements for abdominal aortic aneurysm repairs, University of Rochester (N.Y.) investigators concluded after they compared costs to complexity in 33 open and 107 endovascular repairs during 2007-2010.

They found that complex aneurysms – especially ones with Anatomic Severity Grade (ASG) scores above 15 – need more adjunctive procedures and cost more to repair, although at the moment, payers don’t usually take complexity directly into account.

It’s the first study to show a direct relationship between anatomic complexity and hospital cost. “Preoperative assessment with ASG scores can delineate patients at greater risk for increased resource utilization. A critical examination of the relationship between anatomic complexity and finances is required within the context of aggressive endovascular treatment strategies and shifts towards value-based reimbursement. Anatomy is related to cost. [Complexity] should be considered as a factor when calculating limited bundle reimbursements,” said investigator Dr. Khurram Rasheed, a vascular surgery resident in Rochester.

Developed by the Society for Vascular Surgery, the ASG is an assessment of the aortic neck, aneurysm body, iliac arteries, and pelvic perfusion for 16 parameters, including angles, calcifications, and tortuosity. Each parameter is scored from 0-3. Higher scores mean greater complexity, with 48 being the highest possible score (J. Vasc. Surg. 2002;35:1061-6).

An ASG of 15 proved to be a handy marker for when complexity starts to affect the bottom line. A score of 15 or higher correlated with increased costs and increased propensity for requiring intraoperative adjuncts such as renal artery stenting (odds ratio, 5.75; 95% confidence interval, 1.82-18.19). It also correlated with chronic kidney disease and end-stage renal disease, meaning that sicker patients were likely to have worse anatomy and cost more to repair, Dr. Rasheed reported at the meeting hosted by the Society for Special Surgery.

All the cases in the study were elective, and the majority of the patients were elderly white men.

The mean total-cost of endovascular aortic repair (EVAR) was $24,701, mean length of stay (LOS) of 3.0 days, and mean ASG score of 15.9. Cases below an ASG score of 15 cost a mean of $22,020 and had a mean LOS of 2.93 days. Above 15, the mean cost was $26,574 and mean LOS was 3.07 days.

About a quarter of EVAR patients required intraoperative adjuncts, most above an ASG score of 15; their cases cost a mean of $31,509, with a mean ASG score of 18.48 and LOS of 3.85 days.

For open repair, the mean total cost was $38,310, LOS of 13.5 days, and ASG score of 18.1. When five patients with unusually long hospital stays were excluded, open repair cost less than EVAR, which is consistent with previous reports. Just two open-repair patients (6%) needed adjunct procedures.

Open-repair cases with an ASG score below 15 cost a mean of $24,508 and had a mean LOS of 10 days. Cases with a higher score cost a mean of $41,071 and stayed in the hospital an average of 14.2 days. Despite trends, the ASG score differences in cost and LOS for open-repair cases did not reach statistical significance; type II error was probably to blame, Dr. Rasheed said.

The investigators have no disclosures.

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