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Multilevel revascularizations using a combination of endovascular and open (hybrid) techniques have been reported since the early 1990s,1 and have been enthusiastically embraced by many vascular surgeons, in line with their increasing experience with endovascular interventions. Hybrid procedures allow more complex anatomy to be treated by less invasive procedures in medically higher risk patients. Examples of such multimodal, multilevel vascular reconstructions are common femoral endarterectomy, combined with open iliac artery transluminal angioplasty and stent,2,3 or originating infrainguinal bypasses distal to either an iliac or superficial femoral artery (SFA) percutaneous transluminal angioplasty and stent (PTAS).4 Usually the procedures are performed simultaneously, although individual patient anatomy plays a part in the decision of whether to perform both portions simultaneously or not. For example, if the proximal intervention's patency is dependent on the distal runoff, such as with an iliac stenosis with concomitant severe common femoral disease, both portions, iliac PTA and common femoral endarterectomy, should be performed either simultaneously or soon thereafter to prevent thrombosis of the proximally treated artery.3
Single-institution reports with hybrid surgery have been enthusiastic and show long-term results comparable to traditional, open surgery.2,5-8 Some have addressed how simple changes in clinical practice can lower the costs of new endovascular technology,9 but no studies to date have addressed the costs of hybrid procedures specifically.
We intend to characterize national trends in the utilization of hybrid procedures and also to examine whether staging hybrid procedures, compared with performing them on the same day, translates into higher or lower healthcare costs. We selected staging hybrid procedures as our primary focus because they are potentially modifiable and may have a profound effect on resource utilization. On the other hand, a hybrid procedure may need to be staged due to purely medical reasons. Differentiating between those that could be performed simultaneously and those that could not was an important distinction in our analysis.
Methods
Data source
We used the Nationwide Inpatient Sample (NIS), which is the largest publicly available all-payer inpatient database. It is a 20% stratified random sample of all hospital discharges in the United States and is a part of the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality (AHRQ).10 It...