Surgery or not—the health care system and reimbursement model decide

Abdominal aortic aneurysm is a potentially fatal disease which is treated with surgery or minimally invasive repair. Through a unique international collaboration, researchers have assessed how this disease is treated in eleven countries over three continents. Surprising variations in treatment patterns across and within countries was found, indicating opportunities for harmonization of best practices.

This international analysis demonstrated that in countries with a private health care system and fee-for-service reimbursement model (USA, Australia, Germany and Switzerland) doctors are more prone to perform prophylactic surgery in patients early on at smaller aneurysm diameters, which is not recommended by society guidelines. Doctors in these countries are also generally more prone to offer surgical repair in elderly patients above the age of 80, and to perform repair with minimally invasive technique (so called endovascular aneurysm repair, EVAR).

Conversely, in countries with socialized health-care and population-based reimbursement for surgery (Denmark, Finland, Hungary, Iceland, New Zealand, Norway and Sweden), doctors more often follow the current evidence-based guidelines for surgery, and wait with repair until the aneurysm reaches the recommended threshold size of 5.5 cm for men and 5.0 cm for women. In some countries, access to minimally invasive surgery is constrained by local regulations and financial disincentives.

"The impressive variations in surgical practice between countries and centers is surprising. This is in light of the fact that the best practice in surgical treatment of abdominal aortic aneurysms has been studied in several randomized trials, and there are coherent international guidelines for how and when to treat patients," says Dr Adam Beck, Associate Professor of Vascular Surgery at University of Alabama at Birmingham, and the corresponding author of the study.

"The report indicates that health care system and reimbursement have as much impact on treatment patterns and indication for surgery as scientific studies and guidelines, with both positive and negative incentives affecting practice," continues Dr Kevin Mani, Associate Professor of Vascular Surgery at Uppsala University, Sweden.

The study comprises >50,000 patients treated during the years 2010-2013 in eleven countries. The study was performed by the International Consortium of Vascular Registries, which is a collaboration of national and regional vascular registries in Europe, Australia and the USA. The study, performed by principal investigators at University of Alabama at Birmingham, USA, and Uppsala University, Sweden, is published in Circulation.