Stanford type A aortic dissection repair outcomes—including mortality, perioperative complications, length of stay, and costs—were similar at safety-net and non–safety-net hospitals in the US, based on a retrospective analysis of nearly 26,000 cases, suggesting that capable safety-net centers "may serve as valuable regional providers…."
Published in the journal Surgery by Peyman Benharash, MD, of the University of California, Los Angeles, and colleagues, the study analyzed National Inpatient Sample data from 2017 to 2022 for adult patients diagnosed with type A aortic dissection and evaluated the impact of safety-net status (defined as institutions in the top quartile of the proportion of Medicaid/uninsured) on clinical and financial outcomes following surgical repair.
Care Delivery in a Time-Sensitive Emergency
Although infrequent, per the researchers, type A aortic dissection carries an in-hospital mortality rate of greater than 50% without surgical intervention. They further noted that mortality increases by 1% to 2% for every hour of delay following symptom onset, emphasizing the importance of timely identification and intervention.
The researchers noted that previous studies have shown repairs at high-volume teaching hospitals—found to be associated with greater surgical expertise and improved management of perioperative complications—are linked to improved outcomes, yet most patients are still treated at the initial admitting facility due to concerns about potential mortality during interhospital transfer.
In the current analysis, a total of 27% (n = 7,055 of 25,936) of the population was managed at a safety-net hospital. Excluding patients who did not undergo aortic surgical intervention, the proportion transferred from acute care hospitals to safety-net hospitals increased from 28% to 48%; according to the researchers, "This notable rise suggests a growing capacity among select safety-net hospitals to serve as regional centers specialized in aortic interventions such as type A aortic dissection repair."
Comparable Mortality and Resource Use
Bivariate comparison revealed similar risks of mortality (13% vs 16%) and perioperative complications between patients who were vs were not treated at safety-net hospitals. Following adequate risk adjustment, safety-net hospitals were not found to alter the odds of in-hospital mortality.
The median length of stay was 10 days at both safety-net and non–safety-net hospitals. Median hospitalization costs of $81,400 and $78,800, respectively, were reported.
Higher center volume for type A aortic dissection appeared to be associated with reduced odds of death, independent of safety-net status, reflecting the previously established role of procedural experience. "Given this apparent influence of surgeon-level expertise, increasing procedural volume at capable safety-net hospitals may further optimize results," the researchers commented.
Reconsidering the Role of Safety-Net Hospitals
The researchers wrote that safety-net hospitals are underfunded and therefore resource-constrained, driving concerns about compromised infrastructural capabilities and patient outcomes. However, as noted, the current findings add to evidence suggesting that select safety-net institutions can perform type A aortic dissection repairs without increasing postoperative risk.
Of note, in this study, over 93% of safety-net hospitals performing aortic dissection repair were teaching hospitals, and annual procedural volumes had the same median of three repairs per year in safety-net and non–safety-net centers.
With their findings taken together, the researchers concluded, "Safety-net hospitals can function as regional entry points for patients transferred from acute care facilities, enabling continuity of care and potentially reducing secondary transfers."
What This Means for Surgeons
For physicians involved in emergency cardiovascular care, the study highlights several system-level considerations:
• Safety-net hospitals managed more than one-quarter of patients undergoing type A aortic dissection repairs.
• Nearly half of operative cases transferred from acute care hospitals were treated at safety-net hospitals.
• Mortality, perioperative complications, length of stay, and costs were found to be similar across hospital types.
• Outcomes at safety-net hospitals may depend more on surgeon- and team-specific expertise than institutional resources alone.
As health systems continue to refine pathways for time-sensitive surgical conditions, the researchers concluded that "future studies are warranted to further investigate the impact of safety-net status on long-term outcomes, as well as rates of readmission and reoperation."
Peyman Benharash, MD, of the University of California, Los Angeles, is the corresponding author of the article in Surgery.
Disclosure: For full disclosures of the study authors, visit sciencedirect.com.
Source: Surgery
