The Weekend Effect in Carotid Endarterectomy
Thomas FX O'Donnell, MD1, Marc L. Schermerhorn, MD1, Patric Liang, MD1, Chun Li, MD1, Nicholas J. Swerdlow, MD1, Grace J. Wang, MD2, Kristina A. Giles, MD3, Mark C. Wyers, MD1
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2University of Pennsylvania, Philadelphia, PA, USA, 3University of Florida, Gainesville, FL
OBJECTIVES: Patients undergoing surgery on the weekend may experience worse outcomes, but this “weekend effect” has not been studied in carotid endarterectomy (CEA).
METHODS: We identified patients undergoing isolated CEA in the VQI between 2003-2018. Our primary outcome was in-hospital stroke or perioperative death (stroke/death). For asymptomatic patients, we also compared rates of the Centers for Medicare and Medicaid Services quality metric “prolonged length of stay” (>2 days or failed discharge home). We calculated propensity scores and employed multilevel, inverse probability weighted logistic regression clustering at the hospital level.
RESULTS: There were 86,123 repairs during the study period, 53% asymptomatic lesions and 47% symptomatic. Only 0.7% of asymptomatic patients underwent CEA on the weekend, compared to 3.1% of symptomatic patients. Patients undergoing weekend repairs were more often white, with lower rates of most comorbidities. In asymptomatic patients, weekend operations were associated significantly higher odds of stroke/death (OR 2.3 [1.1-4.8], P = 0.02), and prolonged length of stay (OR 3.6 [2.7 - 4.7], P < 0.001). In symptomatic patients, weekend operations were associated with significantly higher adjusted odds of stroke/death (OR 1.7 [1.2-2.4], P = 0.007), and longer postoperative length of stay (3.3 days vs 2.0 days, P = 0.002). However, the difference in stroke/death was driven by patients presenting with stroke (OR 2.2 [1.5-2.3], P < 0.001), rather than those presenting with transient ischemic attack (TIA: OR 1.2 [0.6-2.1], P = 0.56.
CONCLUSIONS: We found evidence of a significant weekend effect in CEA, as weekend operations in asymptomatic patients and symptomatic patients who presented with stroke were associated with higher rates of stroke/death and prolonged length of stay. However, there was no evidence of such an effect in patients with TIA. These data suggest that weekend CEA should be avoided except in the case of expedited revascularization following TIA. 
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