Evaluation of regional variations in length of stay after elective, uncomplicated carotid endarterectomy in North America.

ABSTRACT

OBJECTIVE: The objective of this study was to evaluate factors affecting regional variation in length of stay (LOS) after elective, uncomplicated carotid endarterectomy (CEA). METHODS: Data were obtained from the Vascular Quality Initiative database and included patients with complete data who received elective CEA without complications between 2012 and 2017 across 18 regions in North America and 294 centers. The main outcome measure was LOS >1 day after surgery (LOS >1 postoperative day [POD]). Using least absolute shrinkage and selection operator regression, multivariable modeling, and mixed-effects general linear modeling, we evaluated whether regional variations in LOS were independent of demographic, clinical, or center-related factors and to what extent these factors accounted for postoperative variation in LOS. RESULTS: A total of 36,004 patients were included. Mean postprocedure LOS was 1.6 ± 6.6 days. Overall, 24% of patients had an LOS >1 POD. After adjustment for important demographic, clinical, and center-related factors, the region in which a patient was treated independently and significantly affected LOS after elective, uncomplicated CEA. Region and center of treatment accounted for 18% of LOS variation. Demographic, clinical, and surgical factors accounted for another 32% of variation in LOS. Of these factors, postoperative discharge to a facility other than home (odds ratio [OR], 6.3; confidence interval [CI], 5.2-7.6), use of intravenous (IV) vasoactive agents (OR, 3.2; CI, 3-3.4), intraoperative drain placement (OR, 1.4; CI, 1.3-1.55), and female sex (OR, 1.4; CI, 1.3-1.5) were associated with longer LOS. Factors associated with LOS ≤1 POD included preoperative aspirin (OR, 0.88; CI, 0.8-0.96) and statin use (OR, 0.9; CI, 0.83-0.98), high surgeon volume (highest quartile OR, 0.68; CI, 0.5-0.87), and completion evaluation after CEA (eg, Doppler, ultrasound; OR, 0.87; CI, 0.8-0.95). We also found that use of IV vasoactive medications varied significantly across regions, independent of demographic and clinical factors. CONCLUSIONS: Significant regional variation in LOS exists after elective, uncomplicated CEA even after controlling for a wide range of important factors, indicating that there remain unmeasured causes of longer LOS in some regions. Even so, modification of certain clinical practices may reduce overall LOS. Regional differences in use of IV vasoactive medications not driven by clinical factors warrant further analysis, given the strong association with longer LOS.