Increasing surveillance of EVAR patients to improve long-term outcomes

The problem
Nationally, we’ve seen a 600% increase in the number of endovascular aneurysm repair procedures performed since the procedure was approved; these procedures account for almost half of all abdominal aortic aneurysm repairs today. EVAR is a minimally invasive procedure to repair an aneurysm of the abdominal aorta using a graft placed percutaneously (through the skin). The alternative AAA treatment is invasive, open repair by surgery.

AAA occurs mostly in those ages 60 and older. In the future, our aging population could see a significant increase in the prevalence of AAA, likely leading to more EVAR procedures. The EVAR procedure is not without risk.

National guidelines recommend long-term surveillance after EVAR to monitor for endoleaks (aneurysm sac growth), graft migration or device failure, all of which require definitive treatment. An endoleak is defined as persistent blood flow in the aneurysm sac after EVAR. Such complications have been found in up to 15% of patients more than five years after their procedure. However, these may be identified early through CT imaging or duplex ultrasound leading to prompt treatment to avert more serious outcomes. Monitoring for these procedural complications can prevent late rupture and aneurysm-related death. The recommended surveillance is CTA at six months and 12 months after EVAR.

The opportunity
The BMC2 - Vascular Surgery* collaborative saw an opportunity to address this problem when they discovered a statistically significant, higher proportion of endoleaks in cases where images were documented in patient charts. The reasoning stands that the more documentation is done, the more such cases are caught early, ultimately contributing to more re-operations conducted to repair endoleaks, therefore reducing adverse events. The act of documentation facilitates treatment, which creates a measure of accountability for treatments when committed to the medical record. Therefore, BMC2 established “documentation of one year EVAR surveillance imaging” as a quality improvement incentive goal. Additionally, consortiumwide meeting presentations and discussions on this topic were organized. Feedback was also provided to member hospitals during annual site visits and through quarterly data reports, performance measure feedback.

The outcome
As a result of quality improvement initiatives, BMC2 was able to dramatically improve surveillance imaging documentation in hospitals across the state of Michigan by over 65% since 2017 (see graph).

The impact

Performance and documentation of surveillance imaging allowed the BMC2 participating providers to catch and address problems before they progressed to life-threatening aneurysm ruptures. A significantly higher percent of patients identified as having an endoleak or follow-up procedure, had surveillance imaging performed and documented. Only one rupture occurred in patients who had surveillance imaging, versus six in patients who did not.

Lessons learned
This example demonstrates that preventive care works to prevent re-intervention and death. Additionally, it shows that medical record documentation is a useful proxy for taking action. In short, improving processes through collaborative quality improvement can save lives.

*BMC2-Vascular Surgery is a statewide consortium working to improve the quality of care and outcomes in patients who undergo vascular procedures by collecting and reporting data back to hospitals across Michigan and providing a forum for learning from one another. They collect and report data on:

1. Open abdominal aneurysm repair
2. Endovascular abdominal aneurysm repair, infrarenal, suprarenal, and juxtarenal repairs
3. Open bypass procedures, upper and lower extremity
4. Open thrombectomy procedures, upper and lower extremity
5. Carotid stenting
6. Carotid endarterectomy

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.