(PC158) The Impact of Rurality on AAA Mortality Among Women in Current U.S. Practice.

Objectives: Nearly one-in-five Americans reside in a rural setting with limited access to specialty healthcare services. This may be particularly consequential for abdominal aortic aneurysm (AAA) repair, where prior work has documented that women may be a particularly vulnerable population and that patients may have improved outcomes in high-volume centers of excellence. The purpose of this analysis was to define trends in AAA repair 30-day mortality among women, and to determine whether rurality and center volume was associated with survival in this population.

Methods: We studied women who underwent elective open (oAAA) or endovascular (EVAR) AAA repair in the VQI from 2003-2024. We classified centers into urban versus rural categories based on the rural-urban area commuting code. We considered centers as high volume if they performed ≥10 oAAA repairs per year, or ≥20 EVAR per year, respectively, for each analysis based on prior literature. We compared 30-day mortality for women across rurality/volume combinations. We used logistic regression to determine the associations of center volume and rurality with 30-day mortality after AAA repair among women.

Results: We identified 3220 women who underwent elective oAAA repair during the study period, 2357(73.2%) at urban centers and 863(26.8%) at rural centers, and 13,314 who underwent EVAR, 10,654(80%) at urban centers and 2660(20%) at rural centers. There were 32 high-volume rural centers for oAAA repair and 167 for EVAR. Among women who underwent oAAA, the 30-day mortality was 5.93% at rural low-volume centers, 3.04% at rural high-volume centers, 6.56% at urban low-volume centers, and 3.65% at urban high-volume centers (Figure). Compared to urban high-volume centers, the adjusted odds ratio of 30-day mortality following oAAA for women treated at rural low-volume centers was 2.50, (95%CI:1.04-5.99) (Table). Among women who underwent EVAR, the 30-day mortality was 0.76% at rural low-volume centers, 1.13% at rural high-volume centers, 1.56% at urban low-volume centers, and 1.47% at urban high-volume centers. Logistic regression revealed no significant difference in 30-day mortality across settings. Mortality among women was greater than men across all analyses performed in both oAAA and EVAR.

Conclusions: Among women undergoing oAAA, there is significant mortality variation based on center volume and geography, with best outcomes at rural high-volume centers, while for EVAR, mortality is consistent across settings. Notably, women undergoing oAAA at rural low-volume centers experienced 2.5-fold odds of mortality. Based on these findings, it appears that women remain an at-risk group when considering AAA repair, particularly when hospitalized at rural low-volume centers.