Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative

Abstract

Background The objective of this study was to examine the variation in practice patterns and associated outcomes for carotid endarterectomy (CEA) within the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe), a regional quality group of the Vascular Quality Initiative. Methods All cases entered in the CEA registry by the So Cal VOICe were included in the study. Results From September 2010 through September 2015, 1,110 CEA cases were entered by 9 centers in the So Cal VOICe. Six hundred seventy-seven patients (61%) were male with mean age of 73 years. Nine hundred eighty-eight (89%) were hypertensive, 655 (59%) were prior or current smokers, 389 (35%) were diabetics, and 233 (21%) had coronary artery disease. Eight hundred twenty-one (74%) patients were asymptomatic (no history of ipsilateral neurologic event). The percentage of asymptomatic patients varied across the 9 centers from 57% to 91%. Preoperatively, 344 (31%) underwent cardiac stress test, center variation 13–75%, 500 (45%) underwent only duplex, center variation 11–72%. Intraoperatively, 600 (54%) underwent routine shunting, whereas 67 (6%) were shunted for an indication, and 444 (40%) were not shunted. Wound drainage was used in 422 (38%) cases, center variation 2–98%. Completion imaging by duplex and/or angiogram was performed in 766 (69%) cases, center variation 0–100%. Postoperatively, 11 (1%) patients had a new ipsilateral postoperative neurologic event, center variation 0–1.3%, 6 (0.5%) had a postoperative myocardial infarction, center variation 0–1.3%, and 8 (0.7%) required return to operating room for bleeding, center variation 0–1.3%. Conclusions Despite wide variation in practice patterns surrounding CEA in the So Cal VOICe, postoperative complications were uniformly low. Further work will focus on identifying practices that can be modified to improve cost-effectiveness while maintaining excellent outcomes.

Risk factors associated with 30-day hospital readmission after carotid endarterectomy

“…Furthermore, protamine utilization has an extremely wide variation in practice patterns across hospitals, with some centers using none after CEA despite significant data demonstrating that protamine utilization is effective to lower bleeding complications. 22–24 Given strong supporting data for using protamine to reduce bleeding after CEA, this could represent a target area for hospital-based quality improvement in terms of reducing readmission following CEA. Taking this a step further, there may be financial penalties for hospital systems that demonstrate hospital readmissions related to postoperative bleeding complications after CEA without protamine reversal.…”

Examining variation in Medicare payments and drivers of cost for carotid endarterectomy

“…4 Secondly, in our dataset we are unable to examine preoperative payment variation, however this was recently examined by Chan et al, where they found a wide variation in practice pattern and resource utilization in Southern California Vascular Outcomes Improvement Collaborative including increased preoperative cardiac stress testing and completion imaging suggesting our results are underestimating the total variation. 27 Additionally, our cohort examines only the Medicare population and does not include patients with Medicaid or private insurance, however in a recent study by Obeid et al, they found that 75.7% of asymptomatic and 73.9% of symptomatic patients were covered under Medicare. 28 This suggests that this dataset is likely to capture the majority of CEAs performed in the United States.…”