1. Matthew S. Slater, MD, Brian S. Diggs, PhD Frederick A. Tibayan, MD Steven G Guyton, MD, MPH Howard K. Song, MD, PhD The Department of Surgery, and the Division of Cardiothoracic Surgery, Oregon Health and Sciences University, Portland, Oregon The Effect of Age on Cost and Outcomes Following Thoracic Aortic Dissection

2. Aortic dissection is a highly lethal disease The majority of aortic dissections, especially those in the thoracic aorta, occur in the elderly Treatment can be medical, surgical, or endovascular The effect of age on mortality, LOS and cost is poorly defined and important in the formulation treatment and resource allocation decisions The National Inpatient Sample (NIS) Federally supported 1 in 5 hospitalized patients Administrative data In-hospital survival ICD-9 disease and procedure codes

3. The Effect of Age on Cost and Outcomes Following Thoracic Aortic Dissection This study is a retrospective analysis of aortic dissection utilizing the NIS Mortality LOS Cost Discharge disposition Analysis focussed on thoracic dissection NIS Dissections 26,896 Thoracic 12,916 Surgery (“A”) 3,893 30% No Surgery (“B”) 9,023 70% Thoraco- abdominal 4,178 Abdominal 7,59 “Other” 2,743

4. Mortality Under 70 v. Over 70

5. Utilization of the National Inpatient Sample (NIS) to Evaluate Aortic Disease PRO: Large number of patients, cross section of the entire country CON: Definitions and categories of disease not ideal

6. Thoracic Dissections: Mortality by Age Patient DistributionMortality Linear increase in mortality with age, particularly with surgical intervention No clear “age threshold” SurgeryNo SurgerySurgeryNo Surgery

7. Thoracic Dissections: Outcomes LOSCost No significant change in cost with ageNo significant change in LOS with age Surgery No Surgery

8. Thoracic Dissections: Distribution of DC to Home Percent Patients Discharged to Home by Age and surgery / No Surgery SurgeryNo Surgery

9. Cost* per patient, per survivor, and per routine (to home) discharge Surgery and No surgery combined *Cost per survivor is total cost for entire cohort divided by number of survivors

10. Cost per patient, per survivor, and per routine (to home) discharge Surgery and No surgery separated

11. Limitations Definitions of DissectionLimited data fields NIS – “Thoracic” Thoracic + Surgery=Ascending Thoracic – surgery= Descending A and B Ascending and Decending I-IV Length of follow-up Quality of life evaluation Pre-operative risk factors lacking, multivariate risk analysis limited

12. Conclusions: Thoracic Dissection MortalityCost and LOS There is no discreet age above which mortality increases dramatically, rather the effect is linear. Age “cutoffs” for limiting care for elderly patient with thoracic dissections are arbitrary. Cost and length of stay remain constant despite increasing age for both surgery and medical patients. Therefore, neither cost nor LOS are relevant reasons to limit care in the elderly. Although a lower percentage of elderly patient are discharged home, this has not been a traditional variable to determine care allocation