Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy

Abstract

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.

Benefit of selective shunt use during carotid endarterectomy under regional anesthesia

“…2 Recommendations do not advocate the use of routine shunting as evidence supports shunting only for severe persistent ischemia. 6,33 Literature reports conflicting results with evidence of beneficial, 15 detrimental, 8,11 or no effect 34,35 of selective shunting. In patients with a higher risk of intraoperative cerebral hypoperfusion, 34,36 shunting did not display a clear benefit.…”

Impact of rural versus urban geographic location on length of stay after carotid endarterectomy

“…14 Finally, patient level predictors that have been investigated include pre-existing medical comorbidities, standard demographic information (age, race, gender, and insurance status), indication for surgery, reoperation status, and urgency of surgery. 2–4,13,15…”

“…Extended length of stay (ELOS) after carotid endarterectomy (CEA), defined as LOS > 1 day, is associated with an increased risk of hospital-acquired infections, cost, resource utilization, and decreased patient satisfaction. 1 As a result, a LOS ≤ 1 day has been cited as a quality metric to reduce cost as well as hospital-acquired morbidity 2,3 and has been recognized by the Vascular Quality Initiative (VQI) as an important quality measure for CEA. In addition, the recognition of LOS ≤ 1 day as a quality measure may have implications for future quality-based reimbursement models by third-party payers.…”

Perioperative outcomes after reoperative carotid endarterectomy are worse than expected

“…18 Furthermore, a prolonged procedure duration may lead to an increase in postoperative hospital length of stay (P < .001), which further increases the patient's risk of morbidity and mortality as well as hospital charges and costs. 18,19 It is difficult to discern whether time is an independent risk factor or whether this is reflective of a more difficult operation.…”