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Duraiswamy S, Cheng TW, Garofalo D, Levin SR, Farber A, King EG, Siracuse JJ. Qualitative Analysis of Length of Stay and Readmission after Carotid Endarterectomy. Ann Vasc Surg 2023; 90:1-6. [PMID: 36442710 DOI: 10.1016/j.avsg.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/23/2022] [Accepted: 10/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Length of stay (LOS) and readmissions are common measures to evaluate quality of health care. The objective of this study was to evaluate factors related to hospital LOS and readmission within 90 days following carotid endarterectomy (CEA) in patients who have not had a stroke. METHODS Using a single institution database, patients who underwent CEA for carotid stenosis between 2014 and 2019 were identified. Asymptomatic carotid stenosis (no history of any stroke or transient ischemic attack (TIA) within 6 months prior to CEA), and patients who had a TIA without stroke were included. Demographic and perioperative factors were collected. Primary outcomes analyzed were increased LOS (>1 day) and readmission within 90 days after surgery. RESULTS There were 125 patients identified who underwent CEA for 133 carotid stenosis, and 8 patients had bilateral CEA; of which 36.8% were asymptomatic carotid stenosis with the remaining being operated on for TIA without any stroke. The mean age was 68 years old and 36.1% of cases were female. The median postoperative LOS was 2 days. Increased LOS occurred in 81 cases (60.9%). Increased LOS, compared to no increased LOS, occurred more often in patients with diabetes (48.1% vs. 30.8%, P = 0.047), in those with operations starting after 12:00 pm (45.7% vs. 21.2%, P = 0.004) and those with any minor complications such as neck swelling, neck pain, and urinary retention (30.9% vs. 15.4%, P = 0.044). Readmission within 90 days after CEA occurred in 24 (18%) of cases. Readmission within 90 days, compared to no readmission within 90 days, occurred more often in patients with a history of coronary artery disease (58.3% vs. 27.5%, P = 0.004), congestive heart failure (37.5% vs. 11%, P = 0.001), and atrial fibrillation (29.2% vs. 8.3%, P = 0.004). CONCLUSIONS More than half of patients undergoing CEA for carotid stenosis were discharged after postoperative day 1. Interventions on modifiable clinical risk factors, such as morning CEA scheduling and management of comorbidities, may decrease LOS and 90-day readmission rates.
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Affiliation(s)
- Swetha Duraiswamy
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Denise Garofalo
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA.
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Nazari P, Golnari P, Ansari SA, Cantrell DR, Potts MB, Jahromi BS. Unplanned readmission after carotid stenting versus endarterectomy: analysis of the United States Nationwide Readmissions Database. J Neurointerv Surg 2023; 15:242-247. [PMID: 35169035 PMCID: PMC9985736 DOI: 10.1136/neurintsurg-2021-018523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospital readmissions are costly and reflect negatively on care delivered. OBJECTIVE To have a better understanding of unplanned readmissions after carotid revascularization, which might help to prevent them. METHODS The Nationwide Readmissions Database was used to determine rates and reasons for unplanned readmission following carotid endarterectomy (CEA) and carotid artery stenting (CAS). Trends were assessed by annual percent change, modified Poisson regression was used to estimate risk ratios (RR) for readmission, and propensity scores were used to match cohorts. RESULTS Analysis yielded 522 040 asymptomatic and 55 485 symptomatic admissions for carotid revascularization between 2010 and 2015. Higher 30-day readmission rates were noted after CAS versus CEA in both symptomatic (9.1% vs 7.7%, p<0.001) and asymptomatic (6.8% vs 5.7%, p<0.001) patients. Readmission rates trended lower over time, significantly so for 90-day readmissions in symptomatic patients undergoing CEA. The most common cause for 30-day readmission was stroke in both symptomatic (5.5%) and asymptomatic (3.9%) patients. Factors associated with a higher risk of readmission included age over 80; male gender; Medicaid health insurance; and increases in severity of illness, mortality risk, and comorbidity indices. Analysis of matched cohorts showed that CAS had higher readmission than CEA (RR=1.14 (95% CI 1.06 to 1.22); p<0.001) only in asymptomatic patients. Adverse events during initial admission which predicted 30-day readmission included acute renal failure and acute respiratory failure in asymptomatic patients; hematoma and cardiac events were additional predictive adverse events in symptomatic patients. CONCLUSIONS Readmission is not uncommon after carotid revascularization, occurs more often after CAS, and is predicted by baseline factors and by preventable adverse events at initial admission.
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Affiliation(s)
- Pouya Nazari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Pedram Golnari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sameer A Ansari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Donald R Cantrell
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Kayhan Kocak FO, Sahin S, Taşkıran E, Simsek H, Daylan A, Arman P, Dikmeer A, Kılıc F, Balci C, Tosun Tasar P, Doventas A, Yavuz BB, Akcicek SF. Frequency and Risk Factors of Re-hospitalization in Geriatric Inpatient Wards: A Multicenter Retrospective Analysis. Exp Aging Res 2023; 49:70-82. [PMID: 35175909 DOI: 10.1080/0361073x.2022.2041323] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE We aimed to evaluate frequency and risk factors of re-hospitalization which are not stated in comorbidity indexes in geriatric wards. METHODS A total of 585 patients who were admitted to tertiary care geriatric inpatient clinics at least once between 1 September 2017 and 1 September 2018 and who survived to discharge during initial hospitalization were included in this cross-sectional retrospective multicenter study. RESULTS Overall, 507(86.7%) patients were hospitalized once for treatment during the study period, while re-hospitalization occurred in 78(13.3%) patients. Rates of previous surgery (10.3 vs. 3.0%, p = .006), urinary incontinence (UI) (50.0 vs. 36.3%, p = .021), controlled hypertension (64.1 vs. 46.4%, p = .024), malnutrition (55.1 vs. 29.6%, p = .014) were significantly higher in re-hospitalized patients. Re-hospitalized patients were younger (mean ± SD 76.4 ± 8.3 vs. 79.6 ± 7.9 years, p = .002) than once-hospitalized patients. Multivariate logistic regression analysis revealed the younger patient age (OR, 0.942, 95% CI 0.910 to 0.976, p = .001), higher Modified Charlson Comorbidity Index (MCCI) score (OR, 1.368, 95% CI 1.170 to 1.600, p < .001) to significantly predict the increased risk of re-hospitalization. CONCLUSIONS Our findings showed that previous history of surgery and geriatric syndromes such as UI, malnutrition were determined to significantly predict the increased risk of re-hospitalization. We suggest that these risk factors be added to prognostic tools designed for elderly patients.
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Affiliation(s)
- Fatma Ozge Kayhan Kocak
- Department of Internal Medicine, Division of Geriatrics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Sevnaz Sahin
- Department of Internal Medicine, Division of Geriatrics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Emin Taşkıran
- Department of Internal Medicine, Division of Geriatrics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Hatice Simsek
- Department of Public Health, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Ayse Daylan
- Department of Internal Medicine, Division of Geriatrics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Pinar Arman
- Department of Internal Medicine, Division of Geriatrics, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Ayse Dikmeer
- Department of Internal Medicine, Division of Geriatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Furkan Kılıc
- Department of Internal Medicine, Division of Geriatrics, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Cafer Balci
- Department of Internal Medicine, Division of Geriatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Pınar Tosun Tasar
- Department of Internal Medicine, Division of Geriatrics, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Alper Doventas
- Department of Internal Medicine, Division of Geriatrics, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Burcu Balam Yavuz
- Department of Internal Medicine, Division of Geriatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Selahattin Fehmi Akcicek
- Department of Internal Medicine, Division of Geriatrics, Ege University Faculty of Medicine, Izmir, Turkey
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Brown CS, Osborne NH, Hider A, Kemp MT, Albright J, Scheidel C, Henke PK. Assessment of Determinants of Value in Carotid Endarterectomy. Ann Vasc Surg 2022; 88:9-17. [PMID: 36058455 DOI: 10.1016/j.avsg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/12/2022] [Accepted: 08/12/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Over 150,000 carotid endarterectomies (CEA) are performed annually worldwide, accounting for $900 million in the US alone. How cost/spending and quality are related is not well understood but remains an essential component in maximizing value. We sought to identify determinants of variability in hospital 90-day episode value for CEA. METHODS Medicare and private-payer admissions for CEA from January 2nd, 2014 to August 28th, 2020 were linked to retrospective clinical registry data for hospitals in Michigan performing vascular surgery. Hospital-specific risk-adjusted 30-day composite complications (defined as reoperation, new neurologic deficit, myocardial infarction, additional procedure including CEA or carotid artery stenting, readmission, or mortality) and 30-day risk-adjusted, price standardized total episode payments were used to categorize hospitals into low or high value by defining the intersection between complications and spending. RESULTS A total of 6595 patients across 39 hospitals were identified across both datasets. Patients at low-value hospitals had a higher rate of 30-day composite complications (17.9% vs 10.1%, p<0.001) driven by a significantly higher rate of reoperation (3.0% vs 1.4%, p=0.016), readmission (10.7% vs 6.2%, p=0.012), new neurologic deficit (4.6% vs 2.3%, p=0.017), and mortality (1.6% vs 0.6%, p<0.049). Mean total episode payments were $19,635 at low-value hospitals compared to $15,709 at high-value hospitals driven by index hospitalization ($10,800 vs $9587, p= 0.002), professional ($3421 vs $2827, p < 0.001), readmission ($3011 vs $1826, p < 0.001) and post-acute care payments ($2335 vs $1486, p < 0.001). Findings were similar when only including patients who did not suffer a complication. CONCLUSIONS There is tremendous variation in both quality and payments across hospitals included for CEA. Importantly, costs were higher at low-value hospitals independent of post-operative complication. There appears to be little to no relationship between total episode spending and surgical quality, suggesting that improvements in value may be possible by decreasing total episode cost without affecting surgical outcomes.
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Affiliation(s)
- Craig S Brown
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI.
| | - Nicholas H Osborne
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Ahmad Hider
- Medical School, University of Michigan, Ann Arbor, MI
| | - Michael T Kemp
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Jeremy Albright
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Caleb Scheidel
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Peter K Henke
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
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Goicoechea S, Walsh M, Soult M, Halandras PM, Bechara C, Aulivola B, Crisostomo P. Female Gender Increases Risk of Stroke and Readmission after CEA and CAS. J Vasc Surg 2021; 75:1935-1944. [PMID: 34740804 DOI: 10.1016/j.jvs.2021.10.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/21/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Carotid endarterectomy (CEA) has historically demonstrated a higher rate of perioperative adverse events for female patients. However, recent evidence suggests similar outcomes for CEA between genders. In contrast, fewer studies have examined gender in carotid artery stenting (CAS). Using contemporary data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we aim to determine if gender impacts differences in postoperative complications in patients who undergo CEA or CAS. METHODS The ACS NSQIP database was queried from 2005-2017 using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes for retrospective review. Patients with carotid intervention (CEA or CAS) were stratified into asymptomatic vs symptomatic cohorts to determine the effect of gender on 30-day postoperative outcomes. Symptomatic patients were defined as those with perioperative transient cerebral ischemic attack or stenosis of carotid artery with cerebral infarction. Descriptive statistics were calculated. Risk-adjusted odds of 30-day postoperative outcomes were calculated using multivariate regression analysis with fixed effects for age, race, and comorbidities. RESULTS There were 106,568 patients with CEA or CAS (104,412 CEA and 2,156 CAS). Average age was 70.9 years old and female patients accounted for 39.9% of the population. For asymptomatic patients that underwent CEA or CAS, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.005), readmission (10%, p=0.004), bleeding complication (32%, p=0.001), and UTI (54%, p=0.001) as well as less infection (26%, p=0.001). In the symptomatic cohort, female gender was associated with significantly higher rates of CVA/stroke (32%, p=0.034), bleeding complication (203%, p=0.001), and UTI (70%, p=0.011), while female gender was associated with a lower rate of pneumonia (39%, p=0.039). Subset analysis found that, compared to male patients, female patients <75yo have an increased rate of CVA/stroke (21%, p=0.001) and readmission (15%, p<0.001), while female patients ≥75yo did not. In asymptomatic and symptomatic patients that underwent CEA, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.006 and 31%, p=0.044, respectively), but this finding was present not in patients undergoing CAS. CONCLUSION In patients undergoing carotid intervention, female gender was associated with significantly increased rates of postoperative CVA/stroke in the asymptomatic and symptomatic cohorts as well as readmission in the asymptomatic cohort. Female gender was associated with higher rates of CVA/stroke following CEA, but not CAS. We recommend that randomized control trials ensure adequate representation of female patients to better understand gender-based disparities in carotid intervention.
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Affiliation(s)
- Steven Goicoechea
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Martin Walsh
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Michael Soult
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Pegge M Halandras
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Carlos Bechara
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Bernadette Aulivola
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Paul Crisostomo
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL.
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Yang K, Tan J, Deng Y, Shi W, Yu B. Endovascular Debulking of Human Carotid Plaques by Using an Excimer Laser Combined With Balloon Angioplasty: An ex vivo Study. Front Cardiovasc Med 2021; 8:700497. [PMID: 34616779 PMCID: PMC8488149 DOI: 10.3389/fcvm.2021.700497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: We aimed to evaluate the safety and effectiveness of applying an excimer laser in debulking human carotid atherosclerotic plaques by investigating the distal debris, plaque luminal gain, and micromorphology of the plaque surface. Methods: Eighteen plaque samples obtained from carotid endarterectomy (CEA) were randomly allocated to the excimer laser ablation (45 mJ/mm2, 25 Hz) alone group (group 1), balloon angioplasty (8 atm) alone group (group 2), and excimer laser ablation combined with balloon angioplasty group (group 3). Hematoxylin–eosin staining and Movat's pentachrome staining were performed on the collected particles to quantify the size and composition of the debris. The superficial micromorphological structure of the plaque lumen surface after device treatments was observed using a scanning electron microscope. Micro-CT, tissue sections, and pathological stainings were applied to the treated plaques. The plaque lumen and artery lumen were three-dimensionally reconstructed using clinical computed tomography angiography and the micro-CT images. Lumen enlargement was set as the main measurement of effectiveness. Results: Group 3 produced the highest luminal gain (5.40 ± 4.51 mm2), while the other two groups had gains of 4.05 ± 3.20 and 3.77 ± 2.55 mm2. Both devices caused disruptions to the plaque lumen surface. Laser ablation exposed the fibers under the endothelium and balloon angioplasty cracked the surface. The mean amounts were 3,611 ± 1,475.4 for group 1, 2,828 ± 1,266.7 for group 2, and 4,400 ± 2,567.9 for group 3. More than 90% of the distal debris was smaller than 10 μm. Group 2 produced the most debris with Feret (maximum caliper diameter) ≥ 40 μm; group 1 had the least. There was little difference in the contents of collagen and reticular fiber in the debris in each group, but a big difference was observed in the contents of fibrin and mucin. Conclusion: Excimer laser ablation could significantly increase the luminal gain of carotid plaque with high stenosis. Excimer laser combined with balloon angioplasty achieved the highest lumen enlargement. Our result also suggests that the embolic protection strategy needs to be renewed for the application of a plaque debulking device in the future.
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Affiliation(s)
- Kai Yang
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China.,Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Jinyun Tan
- Department of Vascular Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Ying Deng
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China.,Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Weihao Shi
- Department of Vascular Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Bo Yu
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China.,Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China.,Department of Vascular Surgery, Huashan Hospital, Fudan University, Shanghai, China
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7
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Sastry RA, Pertsch NJ, Sagaityte E, Poggi JA, Toms SA, Weil RJ. Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis. Neurosurgery 2021; 89:653-663. [PMID: 34320217 DOI: 10.1093/neuros/nyab250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 06/17/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially. OBJECTIVE To evaluate rates of adverse outcomes after CAS and CEA in a large national database. METHODS We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n = 81 361) or CEA (n = 2830), from 2011 to 2018, in the American College of Surgeons' National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n = 2821) cohorts through logistic regression. RESULTS In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients. CONCLUSION In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Nathan J Pertsch
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Emilija Sagaityte
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jonathan A Poggi
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
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8
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Braet DJ, Smith JB, Bath J, Kruse RL, Vogel TR. Risk factors associated with 30-day hospital readmission after carotid endarterectomy. Vascular 2021; 29:61-68. [PMID: 32628069 PMCID: PMC7782206 DOI: 10.1177/1708538120937955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The current study evaluated all-cause 30-day readmissions after carotid endarterectomy. METHODS Patients undergoing carotid endarterectomy were selected from the Cerner Health Facts® database using ICD-9-CM procedure codes from their index admission. Readmission within 30 days of discharge was determined. Chi-square analysis determined characteristics of the index admission (demographics, diagnoses, postoperative medications, and laboratory results) associated with readmission. Multivariate logistic regression models were used to identify characteristics independently associated with readmission. RESULTS In total, 5257 patients undergoing elective carotid endarterectomy were identified. Readmission within 30 days was 3.1%. After multivariable adjustment, readmission was associated with end-stage renal disease (OR: 3.21, 95% CI: 1.01-10.2), hemorrhage or hematoma (OR: 2.34, 95% CI: 1.15-4.77), procedural complications (OR: 3.07, 95% CI: 1.24-7.57), use of bronchodilators (OR: 1.48, 95% CI: 1.03-2.11), increased Charlson index scores (OR: 1.22, 95% CI: 1.08-1.38), and electrolyte abnormalities (hyponatremia < 135 mEq/L (OR: 1.69, 95% CI: 1.07-2.67) and hypokalemia less than 3.7 mEq/L (OR: 2.26, 95% CI: 1.03-4.98)). CONCLUSIONS Factors associated with readmission following carotid endarterectomy included younger age, increased comorbidity burden, end-stage renal disease, electrolyte disorders, the use of bronchodilators, and complications including bleeding (hemorrhage or hematoma). Of note, in this real-world study, only 40% of the patients received protamine, despite evidence-based literature demonstrating the reduced risk of bleeding complications. As healthcare moves towards quality of care-driven reimbursement, physician modifiable targets such as protamine utilization to reduce bleeding are greatly needed to reduce readmission, and failure to reduce preventable physician-driven complications after carotid interventions may be associated with decreased reimbursement.
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Affiliation(s)
- Drew J. Braet
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| | - Jamie B. Smith
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Missouri
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| | - Robin L. Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Missouri
| | - Todd R. Vogel
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri
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Abstract
BACKGROUND Stroke is the third leading cause of death and the most common cause of long-term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications. This is an update of a Cochrane Review, originally published in 1999, and most recently updated in 2017. OBJECTIVES To determine the balance of benefit versus risk of endarterectomy plus best medical management compared with best medical management alone, in people with a recent symptomatic carotid stenosis (i.e. transient ischaemic attack (TIA) or non-disabling stroke). SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) portal to October 2019. We also reviewed the reference lists of all relevant studies and abstract books from research proceedings. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing carotid artery surgery plus best medical treatment with best medical treatment alone. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risk of bias, and extracted the data. We assessed the results and the quality of the evidence of the primary and secondary outcomes by the GRADE method, which classifies the quality of evidence as high, moderate, low, or very low. MAIN RESULTS We included three trials involving 6343 participants. The trials differed in the methods of measuring carotid stenosis and in the definition of stroke. Using the primary electronic data files, we pooled and analysed individual patient data on 6092 participants (35,000 patient-years of follow-up), after reassessing the carotid angiograms and outcomes from all three trials, and redefining outcome events where necessary, to achieve comparability. Surgery increased the five-year risk of any stroke or operative death in participants with less than 30% stenosis (risk ratio (RR) 1.25, 95% confidence interval (CI) 0.99 to 1.56; 2 studies, 1746 participants; high-quality evidence). Surgery decreased the five-year risk of any stroke or operative death in participants with 30% to 49% stenosis (RR 0.97, 95% CI 0.79 to 1.19; 2 studies, 1429 participants; high-quality evidence), was of benefit in participants with 50% to 69% stenosis (RR 0.77, 95% CI 0.63 to 0.94; 3 studies, 1549 participants; moderate-quality evidence), and was highly beneficial in participants with 70% to 99% stenosis without near-occlusion (RR 0.53, 95% CI 0.42 to 0.67; 3 studies, 1095 participants; moderate-quality evidence). However, surgery decreased the five-year risk of any stroke or operative death in participants with near-occlusions (RR 0.95, 95% CI 0.59 to 1.53; 2 studies, 271 participants; moderate-quality evidence). AUTHORS' CONCLUSIONS Carotid endarterectomy reduced the risk of recurrent stroke for people with significant stenosis. Endarterectomy might be of some benefit for participants with 50% to 69% symptomatic stenosis (moderate-quality evidence) and highly beneficial for those with 70% to 99% stenosis (moderate-quality evidence).
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Affiliation(s)
- Amaraporn Rerkasem
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Saritphat Orrapin
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum thani, Thailand
| | - Dominic Pj Howard
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kittipan Rerkasem
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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10
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Bondi S, Yang D, Croll L, Torres J. Patient Characteristics Associated With Readmission to 3 Neurology Services at an Urban Academic Center. Neurohospitalist 2020; 11:25-32. [PMID: 33868553 DOI: 10.1177/1941874420953320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose Hospital 30-day readmissions in patients with primary neurological problems are not well characterized. We sought to determine patient characteristics associated with readmission across 3 different inpatient neurology services at New York University Langone Hospital. Methods We retrospectively reviewed all 30-day readmissions from the General Neurology, Epilepsy, and Stroke services at NYULH Brooklyn and Manhattan campuses from 2016-2017 and compared them to a random sample of non-readmitted neurology patients. We used univariate analyses to compare demographics, clinical characteristics, disease specific metrics, and discharge factors of non-readmitted and readmitted groups and binomial logistic regression to examine specific variables with adjustment for confounders. Results We included 284 patients with 30-day readmissions and 306 control patients without readmissions matched by discharge location and service. After adjusting for confounders, we found that the following factors were associated with increased readmission risk: a recent hospital encounter increased risk for all services, increased number of medications at discharge, intensive care unit stay, higher length of stay, and prior history of seizure for the General Neurology Service, increased number of medications at discharge for the Epilepsy Service, and active malignancy and higher discharge modified Rankin Scale score for the Stroke Service. Conclusion This study identifies potential risk factors for readmission in patients across multiple neurology services. Further research is needed to establish whether these risk factors hold across multiple institutions.
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Affiliation(s)
- Steven Bondi
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Dixon Yang
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Leah Croll
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Jose Torres
- Department of Neurology, New York University Langone Health, New York, NY, USA
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11
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Edla S, Atti V, Kumar V, Tripathi B, Neupane S, Nalluri N, Abela G, Rosman H, Mehta RH. Comparison of nationwide trends in 30-day readmission rates after carotid artery stenting and carotid endarterectomy. J Vasc Surg 2020; 71:1222-1232.e9. [DOI: 10.1016/j.jvs.2019.06.190] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/02/2019] [Indexed: 11/28/2022]
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12
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Lima FV, Kolte D, Kennedy KF, Wang LJ, Abbott JD, Soukas PA, Aronow HD. Thirty-Day Readmissions After Carotid Artery Stenting Versus Endarterectomy: Analysis of the 2013-2014 Nationwide Readmissions Database. Circ Cardiovasc Interv 2020; 13:e008508. [PMID: 32212834 DOI: 10.1161/circinterventions.119.008508] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Contemporary, nationally representative 30-day readmissions data after carotid artery stenting (CAS) and carotid endarterectomy (CEA) are lacking. METHODS Patients undergoing CAS or CEA were identified from the 2013 to 2014 Nationwide Readmissions Databases. Propensity matching was used to balance baseline clinical characteristics. Thirty-day nonelective readmission rates, length of stay, and causes of readmission were compared. RESULTS Overall, 85 337 (national estimate of 194 332) patients were identified before propensity score matching, 11 490 (13.4%) of whom underwent CAS and 73 847 (86.6%) of whom underwent CEA. Crude 30-day readmission rates were higher for patients treated with CAS than CEA (8.3% versus 6.8%; P<0.001), but these differences were negated in the propensity-matched cohort (n=22 214; 8.4% versus 7.9%, P=0.20), and readmission length of stay was longer for CEA than CAS (2 versus 1 day, respectively; P=0.002). The most common reasons for readmission were neurological and cardiac events; readmission reasons varied by revascularization modality. Readmission due to a stroke or transient ischemic attack was more common among patients treated with CAS than CEA (1.2% versus 0.9%; P=0.042), while readmission for procedural or medical complications occurred more often following CEA than CAS (1.1% versus 0.5%; P<0.001); readmission rates for cardiac causes were similar between groups. CONCLUSIONS Less than 8% of patients are readmitted within 30 days of a carotid revascularization procedure. After adjusting for baseline differences, readmission rates are similar for CAS and CEA although readmission length of stay is longer after the latter. Readmission for neurological causes was more common following CAS while readmission for procedural or medical complications occurred more often following CEA. Higher annual institutional CEA volumes were associated with lower risk for 30-day readmission; in contrast, institutional CAS volumes were not related to readmission risk. These data provide important insights into the short-term, outcomes of patients following carotid artery revascularization.
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Affiliation(s)
- Fabio V Lima
- Division of Cardiology, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (F.V.L., J.D.A., P.A.S., H.D.A.)
| | - Dhaval Kolte
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.K.)
| | - Kevin F Kennedy
- Statistical Consultant, Mid America Heart and Vascular Institute, St. Luke's Hospital, Kansas City (K.F.K.)
| | - Lily J Wang
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI (L.J.W.)
| | - J Dawn Abbott
- Division of Cardiology, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (F.V.L., J.D.A., P.A.S., H.D.A.)
| | - Peter A Soukas
- Division of Cardiology, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (F.V.L., J.D.A., P.A.S., H.D.A.)
| | - Herbert D Aronow
- Division of Cardiology, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (F.V.L., J.D.A., P.A.S., H.D.A.)
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13
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Cole TS, Mezher AW, Catapano JS, Godzik J, Baranoski JF, Nakaji P, Albuquerque FC, Lawton MT, Little AS, Ducruet AF. Nationwide Trends in Carotid Endarterectomy and Carotid Artery Stenting in the Post-CREST Era. Stroke 2020; 51:579-587. [DOI: 10.1161/strokeaha.119.027388] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) demonstrated equivalent composite outcomes between carotid endarterectomy (CEA) and carotid artery stenting (CAS) for treating carotid stenosis. We investigated nationwide trends in these procedures and associated periprocedural stroke, myocardial infarction, death, cost, and readmission rates since CREST outcomes were published.
Methods—
We queried the Nationwide Readmissions Database to identify patients undergoing CEA and CAS for asymptomatic and symptomatic carotid stenosis from 2010 to 2015. Patients were matched based on demographics, comorbidities, and severity of illness.
Results—
In total, 378 354 CEA and 57 273 CAS patients were treated during this 6-year period. CEA volume decreased by an average of 2669 procedures annually (
P
=0.001) with stable CAS volume (
P
=0.225). After matching, CEA patients had a higher rate of periprocedural stroke than CAS patients, driven by increased stroke risk in symptomatic CEA patients (8.1% versus 5.6%; odds ratio, 1.47 [CI, 1.29–1.68];
P
<0.001) but a lower rate of overall inpatient mortality (0.8% versus 1.4%; odds ratio, 0.57 [CI, 0.48–0.68];
P
<0.001). CEA patients were less likely to be readmitted within 30 days (7.2% versus 8.0%; odds ratio, 0.90 [CI, 0.84–0.96];
P
=0.018) and 90 days (12.3% versus 14.1%; odds ratio, 0.86 [CI, 0.81–0.90];
P
<0.001), and mean hospital costs were lower for CEA compared with CAS ($14 433 versus $19 172;
P
<0.001).
Conclusions—
The procedural treatment of carotid stenosis has changed dramatically in the post-CREST era. When matched for characteristics and illness severity, patients undergoing CEA had a higher rate of perioperative stroke than patients undergoing CAS, primarily among symptomatic patients. These findings are in contrast to the findings of CREST, which showed nearly twice the risk of stroke in CAS patients compared with CEA patients. CEA was associated with lower procedure cost and readmission rate.
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Affiliation(s)
- Tyler S. Cole
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Andrew W. Mezher
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Joshua S. Catapano
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Jakub Godzik
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Jacob F. Baranoski
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Peter Nakaji
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Felipe C. Albuquerque
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Michael T. Lawton
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Andrew S. Little
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Andrew F. Ducruet
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
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Jones CD, Boxer RS. Home care after elective vascular surgery: still more questions than answers. BMJ Qual Saf 2019; 29:968-970. [PMID: 31796575 DOI: 10.1136/bmjqs-2019-009754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
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15
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Rasheed AS, White RS, Tangel V, Storch BM, Pryor KO. Carotid Revascularization Procedures and Perioperative Outcomes: A Multistate Analysis, 2007-2014. J Cardiothorac Vasc Anesth 2019; 33:1963-1972. [DOI: 10.1053/j.jvca.2019.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Indexed: 11/11/2022]
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16
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Abstract
Stroke is one of the leading causes of death in the world and carotid artery stenosis is a major cause of ischaemic strokes. Symptomatic patients are often treated with either carotid endarterectomy (CEA) or carotid artery stenting (CAS). Asymptomatic patients can be treated with best medical therapy, CEA or CAS. While guidelines exist for the management of carotid artery stenosis, the results of recent studies are controversial regarding the safety of CAS compared with CEA. This review aims to outline the current guidelines while reviewing up-to- date studies and analyses. Future studies and emerging technologies are outlined in an attempt to provide an evaluation of the current data and management of this complex problem.
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Affiliation(s)
- Edward Y Woo
- Medstar Washington Hopsital Center, Washington DC, US
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17
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Usefulness of the Clavien-Dindo Classification to Rate Complications after Carotid Endarterectomy and Its Implications in Patient Prognosis. Ann Vasc Surg 2019; 55:232-238. [DOI: 10.1016/j.avsg.2018.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/16/2018] [Accepted: 06/28/2018] [Indexed: 11/17/2022]
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18
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Transradial supra-aortic arteries interventions: a good option for elderly patients. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2018; 15:634-638. [PMID: 30416512 PMCID: PMC6221847 DOI: 10.11909/j.issn.1671-5411.2018.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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19
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Dakour-Aridi H, Nejim B, Locham S, Alshaikh H, Obeid T, Malas MB. Complication-Specific In-Hospital Costs After Carotid Endarterectomy vs Carotid Artery Stenting. J Endovasc Ther 2018; 25:514-521. [DOI: 10.1177/1526602818781580] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To quantify and compare the incremental cost associated with in-hospital stroke, death, and myocardial infarction (MI) after carotid endarterectomy (CEA) vs carotid artery stenting (CAS). Methods: A retrospective analysis was performed of 100,185 patients (mean age 70.7±9.5 years; 58.3% men) who underwent CEA (n=86,035) or CAS (n=14,150) between 2009 and 2015 and were entered into the Premier Healthcare Database. Multivariate logistic models and generalized linear models were used to analyze binary outcomes and hospitalization costs, respectively. Outcomes are presented as the adjusted odds ratio (aOR) and 95% confidence interval (CI). Results: CAS was associated with 1.6 times higher adjusted odds of stroke [aOR 1.55 (95% CI 1.36 to 1.77), p<0.001] and with 2.6 times higher odds of death [aOR 2.60 (95% CI 2.14 to 3.17), p<0.001] compared with CEA. There was no significant difference in MI risk between the 2 procedures. The adjusted incremental cost of death and MI were similar between the 2 procedures. However, the adjusted incremental cost of stroke was significantly higher in CEA compared with CAS by an estimated $2000. When stratified with respect to symptomatic status, the increased adjusted incremental cost of stroke in CEA was mainly seen in asymptomatic patients ($5284 vs $2932, p<0.01). Conclusion: The incremental cost of in-hospital stroke is relatively higher in CEA compared to CAS. However, CEA remains a more cost-effective carotid intervention due to lower complication rates and baseline costs compared with CAS. Long-term cost-effectiveness studies are needed before definite conclusions are made.
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Affiliation(s)
- Hanaa Dakour-Aridi
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Besma Nejim
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Satinderjit Locham
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Husain Alshaikh
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Tammam Obeid
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Mahmoud B. Malas
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
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20
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Nejim B, Beaulieu RJ, Alshaikh H, Hamouda M, Canner J, Malas MB. A Unique All-Payer Rate-Setting System Controls the Cost but Not the Racial Disparity in Lower Extremity Revascularization Procedures. Ann Vasc Surg 2018; 52:116-125. [PMID: 29783031 DOI: 10.1016/j.avsg.2018.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/11/2017] [Accepted: 03/10/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with peripheral arterial disease often have high comorbidity burden that may complicate post-interventional course and drive increased health-care expenditures. Racial disparity had been observed in lower extremity revascularization (LER) patterns and outcomes. In 2014, Maryland adopted an all-payer rate-setting system to limit the rising hospitalization costs. This resulted in an aggregate payment system in which hospital compensation takes place as an overall per capita expenditure for hospital services. We sought to examine racial differences and other patient-level factors that might lead to discrepancies in LER hospital costs in the State of Maryland. METHODS We used International Classification of Diseases, Ninth Revision codes to identify patients who underwent infrainguinal open bypass (open) and endovascular repair (endo) in the Maryland Health Services Cost Review Commission database (2009-2015). Multivariable generalized linear model regression analysis was conducted to report cost differences adjusting for patient-specific demographics, comorbidities, and insurance status. Logistic regression analysis was used to assess quality metrics: intensive care unit (ICU) admission, 30-day readmission, protracted length of stay (pLOS) (endo: pLOS >9, open: pLOS > 10 days) and in-hospital mortality. RESULTS Among patients undergoing open, costs were higher for nonwhite patients (African-American [AA]: $6,092 [4,682-7,501], other: $3,324 [437-6,212]; both P ≤ 0.024), diabetics ($2,058 [837-3,279]; P < 0.001), and patients with Medicaid had an increased cost over Medicare patients by $4,325 (1,441-7,209). Critical limb ischemia (CLI) was associated with $5,254 (4,014-6,495) risk-adjusted cost increment. In addition, AA patients demonstrated higher risk-adjusted odds of ICU admission (adjusted odds ratio [aOR] [95% confidence interval {CI}]:1.65 [1.46-1.86]; P < 0.001) and pLOS (aOR [95% CI]: 1.56 [1.37-1.79]; P < 0.001) than their white counterparts. For patients undergoing endo, costs were higher for nonwhite patients (AA: $2,642 [1,574-3,711], other: $4,124 [2,091-6,157]; both P < 0.001). Patients with CLI and heart failure had increased costs after endo. AA patients were more likely to be readmitted or stayed longer after endo (1.16 [1.03-1.29], 1.34 [1.21-1.49]; both P < 0.010, respectively). The overall cost trend was rapidly increasing before all-payer rate policy implementation but it dramatically plateaued after 2014. CONCLUSIONS This study showed that the all-payer rate-setting system has curbed the LER rising costs, but these costs remained disproportionally higher for disadvantaged populations such as AA and Medicaid communities. This underpins the existing racial disparity in LER. AA patients had higher LER costs, most likely driven by extended hospitalization and ICU admission. Efforts could be directed to evaluate the contributing socioeconomic factors, invest in primary prevention of comorbid conditions that had shown to be associated with prohibitive costs, and identify mechanisms to overcome the existing racial disparity in LER within the promising cost-saving payment system at the State of Maryland.
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Affiliation(s)
- Besma Nejim
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Robert J Beaulieu
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Husain Alshaikh
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Mohammed Hamouda
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Joseph Canner
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Mahmoud B Malas
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD.
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21
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Anesthetic type and hospital outcomes after carotid endarterectomy from the Vascular Quality Initiative database. J Vasc Surg 2018; 67:1419-1428. [DOI: 10.1016/j.jvs.2017.09.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/12/2017] [Indexed: 11/21/2022]
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