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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 with the goal of improving quality.
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 and pre-operative beta-blocker therapy being protective. Intraoperative indication for 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. Specifically, 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), post-operative 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 morbidity and mortality following CEA. This study highlights several modifiable risk factors leading to increased LOS. Further, these specific areas of focus should be targets for improving quality in vascular surgery.