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Hospital and surgeon determinants of carotid endarterectomy outcomes
Thomas E Feasby1, Hude Quan, William A Ghali
1Department of Clinical Neurosciences, University of Calgary Health Region, Alberta, Canada. feasby@ucalgary.com
Insights
Higher hospital and surgeon case volumes for carotid endarterectomy (CEA) are linked to better patient outcomes. Low-volume surgeons in low-volume hospitals face significantly higher risks of adverse events after CEA.
Area of Science:
- Vascular Surgery
- Health Services Research
- Surgical Outcomes
Background:
- Prior studies suggest links between surgeon/hospital volume and carotid endarterectomy (CEA) outcomes.
- Previous research has not simultaneously evaluated multiple surgeon and hospital factors.
Purpose of the Study:
- To assess associations between hospital volume, teaching status, clinical trial participation, and surgeon specialty/volume with CEA outcomes.
- To identify key determinants of adverse events following CEA.
Main Methods:
- Analysis of a large Canadian administrative hospital discharge database (1994-1997).
- Logistic regression used to correlate adverse outcomes (in-hospital stroke/death) with surgeon and hospital characteristics.
Main Results:
- Inverse relationship found between hospital/surgeon case volumes and adverse outcomes.
- Previous clinical trial participation correlated with better outcomes; general surgeons had worse outcomes.
- Low-volume surgeons in low-volume hospitals had a 3.5x higher risk of adverse outcomes compared to high-volume counterparts.
Conclusions:
- Hospital and surgeon characteristics significantly influence CEA outcomes.
- Low hospital and surgeon case volumes are critical negative predictors.
- Regionalization of CEA and exclusion of low-volume surgeons are recommended.
Background:
Prior studies have found associations between surgeon and hospital case volumes and outcomes after carotid endarterectomy (CEA), but they have not simultaneously assessed the importance of a number of surgeon and hospital characteristics.
Objective:
To simultaneously assess associations between hospital case volume, teaching status, clinical trial participation, and surgeon specialty and case volume and the outcome after CEA.
Design:
Analysis of a large administrative data-base using logistic regression to correlate adverse outcomes after CEA with surgeon and hospital characteristics.
Setting And Patients:
A Canadian administrative hospital discharge database of all patients undergoing CEA in fiscal years 1994 through 1997.
Main Outcome Measures:
In-hospital stroke and/or death.
Results:
We found an inverse relationship between both hospital and surgeon case volumes and adverse outcomes. Teaching status had no association with outcome, but previous clinical trial participation predicted a better outcome. General surgeons fared worse than other specialists. Low-volume surgeons in low-volume hospitals had a relative risk of 3.5 for adverse outcomes compared with high-volume surgeons in high-volume hospitals.
Conclusions:
Several physician and hospital characteristics are determinants of outcome after CEA, but the negative effects of low hospital and surgeon case volumes, in particular, suggest that regionalization should be considered for CEA and that surgeons with low case volumes should not be performing CEA.
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