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The Potential Impact of "Take the Volume Pledge" on Outcomes After Carotid Artery Stenting
Christian Lopez Ramos1, Michael G Brandel1, Robert C Rennert1
1Department of Neurosurgery, University of California, San Diego, La Jolla, California.
Insights
High-volume surgeons performing carotid artery stenting (CAS) significantly improve patient outcomes, reducing complications and hospital stays. High-volume hospitals, however, did not show similar improvements in all measured outcomes.
Area of Science:
- Vascular Surgery
- Health Services Research
- Quality Improvement
Background:
- The "Volume Pledge" policy recommends centralizing carotid artery stenting (CAS) to high-volume hospitals (≥10 procedures/year) and surgeons (≥5 procedures/year).
- Assessing the impact of this policy on patient outcomes is crucial for improving care quality.
Purpose of the Study:
- To compare perioperative outcomes for CAS between hospitals and surgeons who meet or do not meet the Volume Pledge thresholds.
- To evaluate the effectiveness of volume standards in improving patient safety and care quality in CAS procedures.
Main Methods:
- Analysis of the Nationwide Inpatient Sample (NIS) database for CAS admissions from 2005 to 2011.
- Categorization of hospitals and surgeons into low-volume and high-volume (HV) groups based on Volume Pledge criteria.
- Application of multivariable hierarchical regression models to assess the association between provider volume and perioperative outcomes.
Main Results:
- Between 2005-2011, 22,215 CAS admissions were analyzed. Most procedures (86.4%) were performed at HV hospitals.
- No significant difference in poor outcomes (mortality, major complications) was observed between HV and low-volume hospitals.
- HV hospitals were associated with fewer other complications, nonroutine discharges, and shorter hospitalizations.
- From 2005-2009, 9,454 CAS admissions with physician identifiers were analyzed; 79.2% were by HV surgeons.
- HV surgeons, unlike HV hospitals, were significantly associated with decreased odds of poor outcomes (OR 0.76), complications (OR 0.56), nonroutine discharge (OR 0.70), and prolonged hospitalization (OR 0.52).
Conclusions:
- While most CAS procedures are performed by providers meeting Volume Pledge standards, only high-volume surgeons demonstrated improved patient outcomes.
- The findings suggest that surgeon volume is a more critical factor than hospital volume in achieving superior outcomes for carotid artery stenting.
- Policy recommendations should emphasize surgeon-specific volume targets to enhance patient safety and care quality in CAS.
Background:
The "Volume Pledge" aims to centralize carotid artery stenting (CAS) to hospitals and surgeons performing ≥10 and ≥5 procedures annually, respectively.
Objective:
To compare outcomes after CAS between hospitals and surgeons meeting or not meeting the Volume Pledge thresholds.
Methods:
We queried the Nationwide Inpatient Sample for CAS admissions. Hospitals and surgeons were categorized as low volume and high volume (HV) based on the Volume Pledge. Multivariable hierarchical regression models were used to examine the impact of hospital volume (2005-2011) and surgeon volume (2005-2009) on perioperative outcomes.
Results:
Between 2005 and 2011, 22 215 patients were identified. Most patients underwent CAS by HV hospitals (86.4%). No differences in poor outcome (composite endpoint of in-hospital mortality, postoperative neurological or cardiac complications) were observed by hospital volume but HV hospitals did decrease the likelihood of other complications, nonroutine discharge, and prolonged hospitalization. From 2005 to 2009, 9454 CAS admissions were associated with physician identifiers. Most patients received CAS by HV surgeons (79.2%). On multivariable analysis, hospital volume was not associated with improved outcomes but HV surgeons decreased odds of poor outcome (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.97; P = .028), complications (OR 0.56, 95% CI 0.46-0.71, P < .001), nonroutine discharge (OR 0.70, 95% CI 0.57-0.87; P = .001), and prolonged hospitalization (OR 0.52, 95% 0.44-0.61, P < .001).
Conclusion:
Most patients receive CAS by hospitals and providers meeting the Volume Pledge threshold for CAS. Surgeons but not hospitals who met the policy's volume standards were associated with superior outcomes across all measured outcomes.