Factors that determine the length of stay after carotid endarterectomy represent opportunities to avoid financial losses
Department of Surgery, Division of Vascular and Endovascular Surgery
Medical Subject Headings
Aged; Carotid Artery Diseases; Diagnosis-Related Groups; Economics, Hospital; Elective Surgical Procedures; *Endarterectomy, Carotid; Female; Follow-Up Studies; Hospital Costs; Hospitals; Humans; Length of Stay; Male; New England; Postoperative Complications; Postoperative Period; Retrospective Studies
Cardiovascular Diseases | Health and Medical Administration | Surgery
BACKGROUND: A postoperative length of stay (LOS) > 1 day after elective surgery incurs financial losses for hospitals, given fixed diagnosis-related group-based reimbursement. We sought to identify factors leading to a prolonged LOS ( > 1 postoperative day) after carotid endarterectomy (CEA).
METHODS: Patients undergoing CEA in 23 centers of the Vascular Study Group of New England between 2003 and 2011 (n = 8860) were analyzed. Only elective, primary CEAs were analyzed, leaving a study cohort of 7108 procedures. Hierarchical multivariable logistic regression analysis was performed to identify predictors of a postoperative LOS > 1 day. A Knaus-Wagner chi-pie analysis was performed to determine the relative contributions of each significant covariate to a postoperative LOS > 1 day.
RESULTS: A postoperative LOS > 1 day occurred in 17.5% of the sample (n = 1244). The average LOS was 1.4 days (range, 1-91 days; median, 1). There was significant variation in rates of postoperative LOS > 1 day across centers (range, 5%-100%; P < .001). Factors independently associated with a postoperative LOS > 1 day and their percentage contribution to the prediction model included the need for postoperative intravenous medications for hypertension or hypotension (26%), any major adverse event (MAE) postoperatively (21%), low-volume ( < 15 CEAs per year) surgeons (28%), increasing age (7%), female gender (4%), positive result on a preoperative stress test (3%), preoperative major stroke < / = 30 days (2%), medication-dependent diabetes (1%), severe chronic obstructive pulmonary disease (1%), history of congestive heart failure (1%), and CEA performed on Friday (2%).
CONCLUSIONS: Certain patient characteristics predispose to a postoperative LOS > 1 day after elective CEA. However, patient characteristics play only a modest (17%) role in determining LOS. The need for postoperative blood pressure control and MAEs are the biggest drivers of postoperative LOS > 1 day, but system factors, such as low operative volume, contribute substantially to postoperative LOS > 1 day, independent of MAEs. These findings can be used to guide quality improvement efforts designed to reduce LOS after elective CEA.
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Citation: J Vasc Surg. 2014 Oct;60(4):966-72.e1. doi: 10.1016/j.jvs.2014.03.292. Epub 2014 May 24. Link to article on publisher's site
Glaser, Julia; Kuwayama, David; Stone, David; Schanzer, Andres; Eldrup-Jorgensen, Jens; Powell, Richard; Stanley, Andrew; and Nolan, Brian, "Factors that determine the length of stay after carotid endarterectomy represent opportunities to avoid financial losses" (2014). Surgery Publications and Presentations. 144.