Endovascular Aneurysm Repair (EVAR)

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1 Endovascular Aneurysm Repair (EVAR) Meeting February 8, 2011 Hay Group Health Care Consulting February 24, Hay Group Limited. All rights reserved

2 Attendees: Dr. Sam Fratesi (SAH) Dr. Rod Willoughby (HRSRH) Dr. Santosh Pudappakkam (HRSRH) Dr. John Fenton (HRSRH) Ms. Monique Rocheleau (NE LHIN) Dr. Isser Dubinsky (Hay Group) 1.0 Introductions The attendees on the videoconference introduced themselves. 2.0 Purpose The meeting had been convened for two purposes. The first was to discuss an application which had been made by the Sault Area Hospital to expand its current vascular surgery program to include an EVAR program. A process to ensure timely access to specialized surgical services out of hours had also been commenced by the NE LHIN, and a second purpose of the meeting was to introduce the fact that this process had commenced, bearing in mind that the outcome of the process, with specific reference to vascular surgery, would be affected by decisions regarding the distribution of EVAR services. 3.0 Current State A previous surgical services review had revealed that the vast majority of patients who live in the NE LHIN and require vascular surgery receive care in the Northeast LHIN hospitals, specifically in Sudbury and Sault Ste. Marie. That report also predicted an increasing demand for endovascular aneurysm repair in the future, and commented specifically on the good relationship between surgeons and radiologists, specifically those with an interest in interventional radiology, who are seen as key to a successful EVAR program. The final report of that review process suggested the vascular surgery service should be consolidated at Sudbury or, if the Sault Area Hospital was successful in recruiting a sufficiently large cadre of vascular surgeons, creating a "combined program" with the Hopital Regional de Sudbury Regional Hospital (HRSRH). The report did, however, mention that the HRSRH should be the sole referral center for vascular surgical procedures outside the Algoma region, and that those requiring shunts for renal dialysis should have this procedure performed in Sudbury, or, if living in the Algoma region, the Sault Area Hospital. Page 1

3 3.1 Current Volumes In reviewing the most recently available data (09/10) for EVAR, it was found that a total of 36 endovascular procedures were performed on patients living in the NE LHIN. All were done in Sudbury, and an additional seven patients were treated outside the LHIN, with two receiving care in the Southwest LHIN and five in Toronto, for a total of 43 cases in that fiscal year. The surgical group in Sudbury believe that the volume of cases to be done in the current (10/11) fiscal year will approximate 45 to 50. A total of 252 aneurysm repairs (open and endovascular) were performed in the NE LHIN, of which 215 were done at HRSRH, 28 at the Sault Area Hospital, and nine at the North Bay General Hospital. The above figures lead to the observation that, at the current time, the percentage of abdominal aortic aneurysms treated using interventional techniques is approximately 15 to 20% of the total volume of cases. It was the opinion of those participating that this is perhaps a slightly lower than a target figure of 25 to 30% of all cases, although it was mentioned that in the United States up to 60% of patients are operated on using endovascular techniques. The total volume of vascular surgery procedures conducted in the 09/10 year was 1213 cases at HRSRH, and 562 in the Sault Area Hospital. Of the 562 cases treated at the Sault, 367 patients had a venous system procedure, 101 a thoraco-abdominal procedure, 62 a renal bypass procedure, and 28 an aneurysm repair. While the previously completed surgical services review had suggested, based on a volume of 312 cases per full-time equivalent vascular surgeon, the Sault Area Hospital would need the services of 1.8 vascular surgeons, it is clear that the projected volume of endovascular aneurysm repairs would be small. Given that only 28 aneurysm repairs were conducted, at a maximum 30% or nine to 10 procedures per year would be appropriate candidates for EVAR. 4.0 Literature Review Dr. Dubinsky had conducted a review of the literature, and highlighted some of the findings from the Journal of Endovascular Therapy (2010) commenting on volume outcome relationships in vascular surgery, the Journal of the American College of Cardiology Competence in Vascular Procedures document written in 2004, and a vascular surgery document written by the Ontario Health Technology Advisory Committee (OHTAC). Among the conclusions of these studies were that the quality of care appears to improve in hospitals that complete 43 open abdominal aneurysms or more per year on an elective basis (significantly more than the current volume in the Sault). In reviewing the OHTAC document, as well as training documents, it would appear that in order to become a competent operator for EVAR one needs to do approximately 50 cases, and to maintain competence, 15 to 20 cases per operator per year. Thus, for a two surgeon program to be successful, it is suggested that a minimum of 15 to 20 cases be completed in the first or the program, 20 to 25 in the second year and 25 to 30 in the third year. Page 2

4 Finally, a New England Journal of Medicine article (January 2008) attempting to identify the longterm cost benefit of EVAR as opposed to open repairs, made note of the fact that there appears to be no demonstrable long-term benefit of one procedure versus the other. 5.0 Evaluative Framework In determining the advisability of establishing an EVAR program at the Sault Area Hospital a pro/con analysis was conducted. It was agreed by the participants that EVAR procedures can be conducted at a lower cost than open procedures, and that the cost benefit is appreciable. It was also agreed that it would be necessary for a sufficient volume of cases to be conducted to allow not only the operating surgeon, but his or her colleagues in diagnostic imaging and other hospital staff, such as nursing and critical care staff, to maintain their competence. It was also felt that it would, for all intents and purposes, be impossible for any site to recruit a solo vascular surgeon owing to the quality of life issues implicit in providing coverage, and that it would be almost equally impossible to recruit two surgeons and expect them to take call every other night. The surgeons in Sudbury were acknowledged for their willingness to cover the needs of patients living in the Sault Ste. Marie area, and committed to continuing to provide services to that cohort of patients. The loss of the vascular surgery capacity of the Sault was seen as having potentially negative effects on the population of that area. It would mean a considerable increase in travel time to receive care, diminish ICU volumes (and thus interfere with the ability to create a closed ICU and recruit full-time intensivists) diminish the workload of the interventional radiologists, and potentially interfere with the hospital s well established dialysis program. The hospital has also recently undergone a financial review, and been found to be in a precarious financial position, and has, in fact, received specific advice not to add any more programs or services at this time. The current vascular surgeon is committed to remaining in practice for a period of five to 10 years, and will, no matter the outcome of this process, commit to continuing as a resource to the community for open aortic and other vascular procedures, including establishing shunts for dialysis patients. It was agreed that it would be difficult, even with a significant increase in volume, for a solo vascular surgeon to maintain his or her competence in EVAR (i.e. perform 15 to 20 procedures per year) in the Sault given that the anticipated volume of cases, based on current data, would indicate that the total volume of cases would be nine to 10 per year. Thus, if, indeed, the community were to attempt to recruit two surgeons, each surgeon would be able to perform, at a maximum, five to six cases, Page 3

5 Furthermore, trainees in vascular surgery are increasingly reliant on interventional procedures as an alternative to surgical procedures. As a consequence, more and more graduates of vascular surgery programs are drifting to centers that can offer them the opportunity to perform a full gamut of interventional procedures, none of which, with the exception of EVAR, are available even in Sudbury, and will certainly not be available in the Sault. 6.0 Alternatives A number of alternatives for vascular surgery in the Sault were considered. As outlined above, it was felt, at this time, given the combination of the volume of cases available (and, importantly, necessary to maintain competence), the cost of infrastructure, particularly seen in light of the Sault Area Hospital's current financial position, and the willingness of the group in Sudbury to continue to provide EVAR service for residents of the Sault, that an EVAR program should not be established in the Sault Area Hospital at this time. An outreach program, with Sudbury surgeons providing service in Sault Ste. Marie was discussed. However, the experience of the Sudbury surgeons when a similar model was adopted in Timmins was unsatisfactory. Based on the volume of activity, it would be cost-inefficient to have Sudbury surgeons travel to the Sault. It was also acknowledged, given that a maximum of 12 vascular surgeons emerge from training programs in a year, and oftentimes the number is lower (6 to 8), it would be virtually impossible to anticipate recruiting one, let alone two, vascular surgeons to Sault Ste. Marie. Thus, in the interim, the consensus opinion emerged that at this time EVAR should be single sited in Sudbury, but that all other vascular surgery procedures would continue to be performed in Sault Ste. Marie. Given that surgical technology evolves rapidly, that costs tend to decrease over time, and that future research may indicate incremental benefits to endovascular procedures, or result in an increasing menu of indications for endovascular procedures, this decision should be revisited in two to three years. In the interim, the Sault Area Hospital will continue to provide open aneurysm repairs, as well as the current array of vascular surgery procedures. Page 4

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