Factors predicting prolonged length of stay after carotid endarterectomy
S P Roddy1, J M Estes, M O Kwoun
1Division of Vascular Surgery, New England Medical Center, Department of Surgery, Tufts University School of Medicine, Boston, MA, USA.
Insights
Early discharge after carotid endarterectomy is common, but some patients require longer stays. Identifying risk factors like complications and older age can help target interventions for safe, earlier patient discharge.
Area of Science:
- Vascular Surgery
- Health Services Research
Background:
- Critical pathways have significantly reduced postoperative length of stay for carotid endarterectomy patients.
- Same-day discharge is increasingly common, potentially impacting reimbursement and care standards.
- This study aimed to identify risk factors for prolonged postoperative length of stay.
Purpose of the Study:
- To identify predictors of postoperative length of stay exceeding one day in patients undergoing carotid endarterectomy.
- To inform targeted interventions for safe early discharge.
Main Methods:
- Retrospective review of 188 carotid endarterectomy patients (May 1996-April 1999).
- Exclusion of combined procedures and subsequent non-carotid procedures.
- Analysis of atherosclerosis risk factors, surgical details, and complications using multiple regression.
Main Results:
- Mean postoperative length of stay was 1.65 days; 57% discharged on postoperative day 1.
- Significant predictors of prolonged stay included postoperative complications, age > 79, diabetes, female sex, and vasodilator use.
- Stroke-mortality rate was 1.6%.
Conclusions:
- While early discharge is feasible for many carotid endarterectomy patients, specific patient subsets are at higher risk for prolonged stays.
- Preoperative medical and social interventions can be targeted to at-risk patients to facilitate safer early discharge.
- Understanding these risk factors is crucial for managing care standards and reimbursement.
Background:
Over the last several years, implementation of critical pathways in patients undergoing carotid endarterectomy has decreased postoperative length of stay significantly. Discharge the day after surgery has become commonplace in many centers, including our own. Unfortunately, managed care may interpret this refinement as a standard of care and limit reimbursement or even disallow admissions extending beyond 1 day. We therefore examined our carotid registry to identify risk factors associated with postoperative length of stay exceeding 1 day.
Methods:
We retrospectively reviewed all patients undergoing carotid endarterectomy at our academic center from May 1996 through April 1999. Combined procedures and patients undergoing subsequent noncarotid-related procedures on those admissions were excluded. The charts were inspected for atherosclerosis risk factors, including sex and age, specific attending surgeon, side of the surgery, use of intravenous vasoactive drugs, actual preoperative blood pressure, and presence of neurologic symptoms or postoperative complications. Multiple regression analysis was performed on all collected variables. Statistical significance was inferred for P less than.05.
Results:
A total of 188 patients met the study criteria and had complete, retrievable medical records. A mean postoperative length of stay of 1.65 +/- 0.08 days and a mean total length of stay of 2.17 +/- 0.14 days were observed. Fifty-seven percent of patients went home the day after surgery. There was a 1.6% stroke-mortality rate. Significant predictors of a prolonged stay, listed in order of decreasing importance on the basis of their calculated contribution to prolonging the postoperative length of stay, are as follows (P value; beta coefficient): postoperative complications (<.0001; 1.03), age > 79 years (.008; 0.547), diabetes mellitus (.011; 0.407), female sex (.007; 0.398), and intravenous vasodilator requirement (. 035; 0.382). Other atherosclerosis risk factors, prior neurologic symptoms, the postoperative use of vasopressors, and reoperative surgery did not contribute to extended length of stay.
Conclusions:
Discharge on the first postoperative day is feasible in many, but not all, patients undergoing carotid endarterectomy. Our data help define subsets of patients at risk for prolonged postoperative stay. Targeting these subsets for preoperative medical and social interventions may allow safe early discharge more frequently.
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