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Carotid endarterectomy in academic versus community hospitals: the national surgical quality improvement program data
Joy Garg1, David A Frankel, Ralph B Dilley
1Division of Vascular Surgery, Scripps Clinic Torrey Pines, La Jolla, CA, USA.
Insights
Carotid endarterectomy (CEA) outcomes are comparable between academic and community hospitals. This study found no significant differences in 30-day stroke, myocardial infarction, or mortality rates for either asymptomatic or combined patient groups.
Area of Science:
- Vascular Surgery
- Health Services Research
- Quality Improvement
Background:
- Carotid endarterectomy (CEA) is a common vascular procedure.
- Concerns exist regarding the transferability of excellent results from high-volume centers to community settings.
- This study addresses these concerns by comparing CEA outcomes in academic versus community hospitals.
Purpose of the Study:
- To evaluate and compare the postoperative outcomes of carotid endarterectomy (CEA) performed in academic versus community hospitals.
- To determine if the quality of CEA outcomes differs based on the hospital setting.
Main Methods:
- Utilized data from the National Surgical Quality Improvement Program (NSQIP) database.
- Included 17,388 patients undergoing CEA between January 2005 and October 2009.
- Stratified patients by hospital type (academic vs. community) and analyzed 30-day postoperative outcomes.
Main Results:
- No significant differences were observed in 30-day stroke, myocardial infarction, or mortality rates between academic and community hospitals for both combined and asymptomatic patient cohorts.
- Preoperative comorbidities varied between groups, with community hospitals having more patients with dyspnea and COPD, while academic hospitals had more patients with recent alcohol use and hemiplegia.
- Overall combined 30-day adverse event rates were similar across both settings.
Conclusions:
- Carotid endarterectomy (CEA) yields equivalent 30-day outcomes regardless of whether it is performed in an academic or community hospital setting.
- The study demonstrates that high-quality CEA results can be achieved in both types of institutions.
- Findings support the generalizability of CEA best practices across diverse healthcare settings.
Background:
Carotid endarterectomy (CEA) is among the most commonly performed vascular operations in both academic and community hospital settings. The excellent results of the large prospective studies (North American Symptomatic Carotid Endarterectomy Trial, Asymptomatic Carotid Atherosclerosis Study) have been criticized because of a widely held impression that community hospitals could not duplicate the excellent surgical results achieved in high volume university hospitals or clinics. The purpose of this study was to use the National Surgical Quality Improvement Program data to evaluate the outcomes of CEA in academic versus community hospitals.
Methods:
All patients undergoing CEA were identified in the National Surgical Quality Improvement Program database conducted between January 1, 2005 and October 30, 2009. The patients were stratified on the basis of the hospital of care: academic hospital or community hospital. All postoperative outcomes were analyzed.
Results:
A total of 17,388 CEAs met the inclusion criteria, among which 9,649 cases were performed at an academic institution and 7,739 cases were performed at a community hospital. There were more women in the community hospital cohort (42.5% vs. 40.2%, p = 0.0197). Preoperatively, the community hospital cohort had more patients with dyspnea (22.8% vs. 18.1%, p < 0.0001), chronic obstructive pulmonary disease (COPD) (10.7% vs. 9.7%, p = 0.0322), angina (2.6% vs. 1.9%, p = 0.0021), previous stroke with no deficit (9.0% vs. 7.6%, p = 0.0009), and past transient ischemic attacks (28.3% vs. 25.1%, p < 0.0001). The academic hospital cohort had more patients with recent alcohol use (4.5% vs. 3.8%, p = 0.0245), cardiac surgery (24.0% vs. 22.5%, p = 0.0206), and hemiplegia (4.8% vs. 4.1%, p = 0.0288). Postoperatively, there was no difference in the two groups in 30-day stroke rate (1.2% vs. 1.5%, p = 0.1035), 30-day myocardial infarction rate (0.5% vs. 0.6%, p = 0.2149), or 30-day mortality rate (0.5% vs. 0.6%, p = 0.6335). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (2.2% vs. 2.7%, p = 0.0568). In the asymptomatic patient cohort, there were a total of 9,285 cases, with 5311 cases performed at an academic institution and the remainder at community hospitals. Preoperatively, the community hospitals had more patients with dyspnea (78.3% vs. 82.1%, p < 0.0001). The academic cohort had more patients with acute renal failure (0.3% vs. 0.1%, p = 0.0426). Postoperatively, there was no difference in the two groups in 30-day stroke rate (0.9% vs. 1.1%, p = 0.2899), 30-day myocardial infarction rate (0.4% vs. 0.5%, p = 0.4348), or 30-day mortality rate (0.5% vs. 0.4%, p = 0.6370). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (1.8% vs. 2.0%, p = 0.4394).
Conclusion:
CEA is widely performed in both academic and community hospital settings. This study demonstrates that the results are equivalent and have equally good 30-day outcomes in both asymptomatic and combined populations.