Factors that determine the length of stay after carotid endarterectomy represent opportunities to avoid financial losses

Glaser, Julia; Kuwayama, David P.; Stone, David H.; Schanzer, Andres; Eldrup-Jørgensen, Jens; Powell, Richard J.; Stanley, Andrew; Nolan, Brian

doi:10.1016/j.jvs.2014.03.292

Cited by 28 publications

(25 citation statements)

References 20 publications

(21 reference statements)

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“…As demonstrated by Glaser et al the hospital is losing money if patients require more than one-day hospitalization after elective operations. [4] It is interesting to note that there was a wide variation in charges identified in this study with wide standard deviations. This illustrates the ongoing problem with identifying and reducing medical expense in our country, all patients received the same operation, but cost differed greatly.…”

Section: Discussionmentioning

confidence: 72%

Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy

Mehaffey

LaPar

Tracci

et al. 2017

Annals of Vascular Surgery

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Objective(s) Carotid Endarterectomy (CEA) is a commonly performed vascular operation. Yet, post-operative length of stay (LOS) varies greatly even within institutions. In the present study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed in order to establish modifiable factors associated with prolonged hospital stay. Methods The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between 6/1/2011 and 11/28/2014. Pre-operative patient characteristics, intra-operative details, post-operative factors, long-term outcomes and cost data were reviewed using an Institutional Review Board (IRB) approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤ 1 day and >1 day. Results Complete 30-day variable and cost data was available for 219 patients with an average follow-up of 12 months. 79 (36%) patients had a LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included pre-operative creatinine (p=0.02) and severe congestive heart failure (p=0.05) with self-pay status (p=0.02) and pre-operative beta-blocker therapy (p=0.04) being protective. Shunt placement (p=0.04), arterial re-exploration and post-operative cardiac (p=0.001) or neurological (p=0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (p=0.04), drain placement (p=0.05), prolonged operative time (101 minutes vs 125 minutes p=0.01), return to the OR (p=0.01), and post-operative hypertension (p=0.02) or hypotension (p=0.04). Of note, there was no difference in LOS associated with technique (conventional vs eversion), patch use (p=0.49), protamine administration (p=0.60), EEG monitoring (p=0.45), measurement of stump pressure (p=0.63), doppler (p=0.36) or duplex (p=0.92). Both hospital charges (p=0.0001) and costs (p=0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (p=.10). Increased LOS after CEA was associated with an increase in 12-month mortality (p=0.05). Conclusions Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Further, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.

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Section: Discussionmentioning

confidence: 72%

Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy

Mehaffey

LaPar

Tracci

et al. 2017

Annals of Vascular Surgery

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“…TCAR may lead to cost-saving benefits with earlier discharges because hospitals can incur a financial loss for patients who stay >1 postoperative day after carotid revascularization. 22 Last, TCAR is more often performed under local or regional anesthesia compared with CEA, thereby minimizing the theoretical cardiovascular and cognitive risks associated with general anesthesia. As TCAR techniques continue to improve, it is possible that more cases will be performed under local or regional anesthesia rather than under general anesthesia.…”

Section: Discussionmentioning

confidence: 99%

In-hospital outcomes of transcarotid artery revascularization and carotid endarterectomy in the Society for Vascular Surgery Vascular Quality Initiative

Schermerhorn

Liang

Dakour-Aridi

et al. 2020

Journal of Vascular Surgery

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135

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Objective: Transcarotid artery revascularization (TCAR) with flow reversal offers a less invasive option for carotid revascularization in high-risk patients and has the lowest reported overall stroke rate for any prospective trial of carotid artery stenting. However, outcome comparisons between TCAR and carotid endarterectomy (CEA) are needed to confirm the safety of TCAR outside of highly selected patients and providers.Methods: We compared in-hospital outcomes of patients undergoing TCAR and CEA from January 2016 to March 2018 using the Society for Vascular Surgery Vascular Quality Initiative TCAR Surveillance Project registry and the Society for Vascular Surgery Vascular Quality Initiative CEA database, respectively. The primary outcome was a composite of in-hospital stroke and death.Results: A total of 1182 patients underwent TCAR compared with 10,797 patients who underwent CEA. Patients undergoing TCAR were older (median age, 74 vs 71 years; P < .001) and more likely to be symptomatic (32% vs 27%; P < .001); they also had more medical comorbidities, including coronary artery disease (55% vs 28%; P < .001), chronic heart failure (20% vs 11%; P < .001), chronic obstructive pulmonary disease (29% vs 23%; P < .001), and chronic kidney disease (39% vs 34%; P ¼ .001). On unadjusted analysis, TCAR had similar rates of in-hospital stroke/death (1.6% vs 1.4%; P ¼ .33) and stroke/death/myocardial infarction (MI; 2.5% vs 1.9%; P ¼ .16) compared with CEA. There was no difference in rates of stroke (1.4% vs 1.2%; P ¼ .68), in-hospital death (0.3% vs 0.3%; P ¼ .88), 30-day death (0.9% vs 0.4%; P ¼ .06), or MI (1.1% vs 0.6%; P ¼ .11). However, on average, TCAR procedures were 33 minutes shorter than CEA (78 6 33 minutes vs 111 6 43 minutes; P < .001). Patients undergoing TCAR were also less likely to incur cranial nerve injuries (0.6% vs 1.8%; P < .001) and less likely to have a postoperative length of stay >1 day (27% vs 30%; P ¼ .046). On adjusted analysis, there was no difference in terms of stroke/death (odds ratio, 1.3; 95% confidence interval, 0.8-2.2; P ¼ .28), stroke/death/MI (odds ratio, 1.4; 95% confidence interval, 0.9-2.1, P ¼ .18), or the individual outcomes.Conclusions: Despite a substantially higher medical risk in patients undergoing TCAR, in-hospital stroke/death rates were similar between TCAR and CEA. Further comparative studies with larger samples sizes and longer follow-up will be needed to establish the role of TCAR in extracranial carotid disease management. (J Vasc Surg 2020;71:87-95.)

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“…12 After the Virginia’s Vascular Study Group Regional meeting in 2014, our institution was noted to have a higher than expected observed-to-expected ratio for LOS in patients undergoing EVAR. This is attributed to our institution being the major referral center in our region with a high case complexity compared with surrounding centers.…”

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confidence: 90%

Targets to prevent prolonged length of stay after endovascular aortic repair

Mehaffey

LaPar

Tracci

et al. 2015

Journal of Vascular Surgery

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Objective Endovascular aneurysm repair (EVAR) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly, even within institutions. The present study reviewed the morbidity, mortality, and the financial effect of increased LOS to establish modifiable factors associated with prolonged hospital LOS, with the goal of improving quality. Methods The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients under-going primary, elective EVAR at a single institution between January 1, 2011, and May 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤2 days and >2 days. Results Complete 30-day variable and cost data were available for 138 patients with an average follow-up of 12 months; of these, 46 (33%) had a LOS >2 days. Variables determined to be statistically significant predictors of prolonged LOS included aneurysm diameter (P = .03), American Society of Anesthesiologists Physical Status Classification score (P < .001), thromboembolectomy (P = .01), and increased postoperative cardiac (P < .001) and renal (P = .01) complications. Specifically, modifiable risk factors that contributed to increased LOS included performance of a concomitant procedure (P < .001), increased volume of iodinated contrast (P = .05), increased volume of intraoperative crystalloid (P = .05), placement in an intensive care unit (P < .001), return to the operating room (P < .001), and the use of vasoactive medications (P < .001). Hospital charges ($102,000 ± $41,000 vs $180,000 ± $73,000; P = .01) and costs ($27,000 ± $10,000 vs $45,000 ± $19,000 P = .01) were significantly higher in patients with prolonged LOS; however, there was no difference in physician charges ($8000 ± $5700 vs $12,000 ± $12,000; P = .09). Increased LOS after EVAR was associated with an increase in mortality at 1 month (0% vs 4% P = .05) and 12 months (3% vs 13% P = .03). Conclusions This study highlights several modifiable risk factors leading to increased LOS after EVAR, including performance of concomitant procedures, admission to the intensive care unit, and postoperative renal and cardiac complications. Further, increased LOS was associated with increased charges, costs, morbidity, and mortality after EVAR. This study highlights specific areas of focus for decreasing LOS after EVAR and, in turn, improving quality in vascular surgery.

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Factors that determine the length of stay after carotid endarterectomy represent opportunities to avoid financial losses

Cited by 28 publications

References 20 publications

Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy

Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy

In-hospital outcomes of transcarotid artery revascularization and carotid endarterectomy in the Society for Vascular Surgery Vascular Quality Initiative

Targets to prevent prolonged length of stay after endovascular aortic repair

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