High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization

Poorthuis, Michiel; Brand, Eelco C.; Halliday, Alison; Bulbulia, Richard; Bots, Michiel L.; Borst, Gert J. de

doi:10.1097/sla.0000000000002880

Cited by 45 publications

(25 citation statements)

References 64 publications

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“…A recent systematic review showed that high volume hospitals have a lower risk of postoperative complications after CEA. 14 More research is needed to investigate whether centralisation can lead to fewer post-operative complications.…”

Section: Discussionmentioning

confidence: 99%

A Composite Measure for Quality of Care in Patients with Symptomatic Carotid Stenosis Using Textbook Outcome

Kuhrij¹,

Karthaus²,

Akker³

et al. 2020

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDSThe peri-operative outcome of carotid endarterectomy is still mostly reported as a composite end point of combined ipsilateral stroke and death rate, both at individual patient level and at hospital level. This paper shows that textbook outcome, a composite measure achieved for an individual patient when all undesirable outcomes are absent, could be added to individual outcome measures to better evaluate hospital performance, especially in surgical interventions with low baseline risk such as carotid interventions.Objective: Composite measures may better objectify hospital performance than individual outcome measures (IOM). Textbook outcome (TO) is an outcome measure achieved for an individual patient when all undesirable outcomes are absent. The aim of this study was to assess TO as an additional outcome measure to evaluate quality of care in symptomatic patients treated by carotid endarterectomy (CEA). Methods: All symptomatic patients treated by CEA in 2018, registered in the Dutch Audit for Carotid Interventions, were included. TO was defined as a composite of the absence of 30 day mortality, neurological events (any stroke or transient ischaemic attack [TIA]), cranial nerve deficit, haemorrhage, 30 day readmission, prolonged length of stay (LOS; > 5 days) and any other surgical complication. Multivariable logistic regression was used to identify covariables associated with achieving TO, which were used for casemix adjustment for hospital comparison. For each hospital, an observed vs. expected number of events ratio (O/E ratio) was calculated and plotted in a funnel plot with 95% control limits. Results: In total, 70.7% of patients had a desired outcome within 30 days after CEA and therefore achieved TO. Prolonged LOS was the most common parameter (85%) and mortality the least common (1.1%) for not achieving TO. Covariates associated with achieving TO were younger age, the absence of pulmonary comorbidity, higher haemoglobin levels, and TIA as index event. In the case mix adjusted funnel plot, the O/E ratios between hospitals ranged between 0.63 and 1.27, with two hospitals revealing a statistically significantly lower rate of TO (with O/E ratios of 0.63 and 0.66). Conclusion:In the Netherlands, most patients treated by CEA achieve TO. Variation between hospitals in achieving TO might imply differences in performance. TO may be used as an additive to the pre-existing IOM, especially in surgical care with low baseline risk such as CEA.

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Section: Discussionmentioning

confidence: 99%

A Composite Measure for Quality of Care in Patients with Symptomatic Carotid Stenosis Using Textbook Outcome

Kuhrij¹,

Karthaus²,

Akker³

et al. 2020

European Journal of Vascular and Endovascular Surgery

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“…Furthermore, a recent meta-analysis showed that high volume hospitals have a decreased risk of procedural death and stroke. 15 Therefore, fear of delay to CEA should not stand in the way of referring patients to high volume hospitals. To reduce delay, the present authors advise the multidisciplinary teams involved in treatment of symptomatic patients with high degree carotid stenosis considered an indication of revascularisation, to review their protocol regarding carotid revascularisation.…”

Section: Discussionmentioning

confidence: 99%

Factors Associated with Hospital Dependent Delay to Carotid Endarterectomy in the Dutch Audit for Carotid Interventions

Kuhrij

Meershoek

Karthaus

et al. 2019

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDS This paper identifies factors that are associated with hospital dependent delay to carotid endarterectomy (CEA) using data from a nationwide mandatory clinical audit in the Netherlands. By establishing these factors, other hospitals can learn which patients are at risk of a longer waiting time for CEA and can evaluate their own protocol accordingly. Objectives: As the risk of a recurrent neurological event in patients with symptomatic carotid stenosis requiring carotid endarterectomy (CEA) is highest in the early phase after the first neurological event, guidelines recommend operating on these patients as soon as possible or at least within 14 days of their initial event. However, in real world practice this is often not met. The aim of this study is to identify factors that cause hospital dependent delay to CEA. Methods: All consecutive patients with symptomatic carotid stenosis undergoing CEA registered in the mandatory Dutch Audit for Carotid Interventions from January 2014 up to and including December 2017 were included in the current analysis. Univariable followed by multivariable logistic regression was used to identify independent factors associated with hospital dependent waiting time, defined as time from the first consultation at any hospital to CEA of more than 14 days. Results: A total of 8620 patients were included. The median time to CEA was 11 days (IQR 8e14). Seventy-eight per cent of patients underwent CEA within 14 days of first hospital consultation. Factors associated with a hospital dependent waiting time longer than 14 days were age (OR 0.99 per year, 95% CI 0.98e0.99), any previous CEA (OR 1.67, 95% CI 1.32e2.09), ocular symptoms as index event (OR 1.31, 95% CI 1.15e1.50), and indirect referral (OR 1.53, 95% CI 1.34e1.73). Hospital surgical volume was not identified as a factor for delay, except for the delay of indirectly referred patients where high volume hospitals reported the shortest delay. Conclusion: This cohort derived from a validated nationwide prospective audit identified younger age, previous CEA, ocular symptoms, and indirect referral as hospital dependent factors for delay. High volume hospitals had a similar hospital dependent waiting time to middle and low volume hospitals. However, high volume hospitals had more indirect referrals, implying that their logistics are more efficiently organised.

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“…Hospital care and specific specialised treatments are increasingly centralised, resulting in high operator and centre volume which have been associated with a decreased risk of procedural death and stroke after CEA and CAS. 26 We predict that centralization with standardized protocols for perioperative care among the country may lead to lower periprocedural complication rates.…”

Section: Discussionmentioning

confidence: 99%

Variation in perioperative cerebral and hemodynamic monitoring during carotid endarterectomy

Fassaert

Toorop

Petri

et al. 2021

Annals of Vascular Surgery

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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization

Abstract: This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.

Cited by 45 publications

References 64 publications

A Composite Measure for Quality of Care in Patients with Symptomatic Carotid Stenosis Using Textbook Outcome

A Composite Measure for Quality of Care in Patients with Symptomatic Carotid Stenosis Using Textbook Outcome

Factors Associated with Hospital Dependent Delay to Carotid Endarterectomy in the Dutch Audit for Carotid Interventions

Variation in perioperative cerebral and hemodynamic monitoring during carotid endarterectomy

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