Readmissions after carotid artery revascularization in the Medicare population
Mohammed Salim Al-Damluji1, Kumar Dharmarajan2, Weiwei Zhang3
1Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
Insights
Nearly 10% of Medicare patients were readmitted within 30 days of carotid revascularization. Carotid artery stenting (CAS) showed higher readmission risk than carotid endarterectomy (CEA), but hospital readmission rates did not vary by CAS use.
Area of Science:
- Vascular Surgery
- Health Services Research
- Stroke Prevention
Background:
- Carotid revascularization effectively reduces ischemic stroke in selected patients.
- Focus has been on efficacy and safety, with less attention to readmission outcomes.
Purpose of the Study:
- Assess 30-day readmission frequency, timing, and diagnoses after carotid revascularization.
- Compare readmission rates between carotid endarterectomy (CEA) and carotid artery stenting (CAS).
- Examine hospital variation in risk-standardized readmission rates (RSRR) and its association with procedural choice.
Main Methods:
- Analysis of Medicare fee-for-service claims data (2009-2011) for CEA and CAS procedures.
- Calculation of crude 30-day all-cause readmissions and comparison using Kaplan-Meier curves and logistic regression.
- Estimation of hospital RSRRs via hierarchical generalized logistic regression, stratified by proportional CAS use.
Main Results:
- 180,059 revascularizations analyzed; 81.5% CEA, 18.5% CAS.
- Overall 30-day readmission rate was 9.6%.
- CAS was associated with higher readmission risk than CEA; hospital RSRR showed modest variation (median 9.5%) and was not linked to CAS procedural preference.
Conclusions:
- Approximately 10% of Medicare patients face 30-day readmission post-carotid revascularization.
- Carotid artery stenting (CAS) carries a higher risk of readmission compared to carotid endarterectomy (CEA).
- Hospital readmission rates are not significantly influenced by the proportion of CAS procedures performed.
Background:
In appropriately selected patients with severe carotid stenosis, carotid revascularization reduces ischemic stroke. Prior clinical research has focused on the efficacy and safety of carotid revascularization, but few investigators have considered readmission as a clinically important outcome.
Objectives:
The aims of this study were to examine frequency, timing, and diagnoses of 30-day readmission following carotid revascularization; to assess differences in 30-day readmission between patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS); to describe hospital variation in risk-standardized readmission rates (RSRR); and to examine whether hospital variation in the choice of procedure (CEA vs. CAS) is associated with differences in RSRRs.
Methods:
We used Medicare fee-for-service administrative claims data to identify acute care hospitalizations for CEA and CAS from 2009 to 2011. We calculated crude 30-day all-cause hospital readmissions following carotid revascularization. To assess differences in readmission after CAS compared with CEA, we used Kaplan-Meier survival curves and fitted mixed-effects logistic regression. We estimated hospital RSRRs using hierarchical generalized logistic regression. We stratified hospitals into 5 groups by their proportional CAS use and compared hospital group median RSRRs.
Results:
Of 180,059 revascularizations from 2,287 hospitals, CEA and CAS were performed in 81.5% and 18.5% of cases, respectively. The unadjusted 30-day readmission rate following carotid revascularization was 9.6%. Readmission risk after CAS was greater than that after CEA. There was modest hospital-level variation in 30-day RSRRs (median: 9.5%; range 7.5% to 12.5%). Variation in proportional use of CAS was not associated with differences in hospital RSRR (range of median RSRR across hospital groups 9.49% to 9.55%; p = 0.771).
Conclusions:
Almost 10% of Medicare patients undergoing carotid revascularization were readmitted within 30 days of discharge. Compared with CEA, CAS was associated with a greater readmission risk. However, hospitals' RSRR did not differ by their proportional CAS use.
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