Critical pathways can improve results with carotid endarterectomy

Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed 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 June 1, 2011 and November 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 ≤1 day and >1 day.

RESULTS

Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative 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 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram 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 = 0.10). 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. Furthermore, 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.

Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research

AIM AND OBJECTIVE

To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP).

METHOD

Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge SM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications.

RESULTS

The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested.

CONCLUSION

Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes.