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SAN FRANCISCO – The 30-day unplanned readmission rate following carotid endarterectomy was 6.5% in a single-center study.
In addition, four variables were significantly associated with unplanned readmission: in-hospital postoperative congestive heart failure (CHF) exacerbation; in-hospital postoperative stroke; in-hospital postoperative hematoma; and prior coronary artery bypass graft (CABG).
"Whether these complications are completely avoidable is unknown, but we do identify a group of patients who would probably benefit from more comprehensive discharge planning and careful postdischarge care," Dr. Karen J. Ho said at the Society for Vascular Surgery annual meeting earlier this year.
According to a study of Medicare claims data from 2003 to 2004, 20% of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days (N. Eng. J. Med. 2009;360:1418-28). The 30-day rehospitalization rate after vascular surgery was 24%, "the highest of all surgical specialties examined in the study," said Dr. Ho of the surgery department at Brigham and Women’s Hospital, Boston, who was not involved with the published study. "Medicare has started to decrease reimbursements for hospitals with excess readmissions after acute MI, heart failure, and pneumonia. Hip and knee replacements and chronic obstructive pulmonary disease will be added in 2014, and we anticipate that additional surgical procedures will be added thereafter," she said.
In an effort to determine the rate of 30-day unplanned readmission after carotid endarterectomy (CEA), Dr. Ho and her associates conducted a retrospective study of a prospectively collected vascular surgery database at Brigham and Women’s Hospital. The cohort included 896 consecutive CEAs performed between 2002 and 2011. Combined CABG/CEA procedures were excluded.
The primary endpoint was unplanned readmission within 30 days, defined as "any unanticipated, nonelective hospital readmission," she said. The secondary endpoint was 1-year survival.
The mean age of the patients was 70 years, 60% were male, and 95% were white. More than half (65%) had asymptomatic evidence of carotid artery disease.
Dr. Ho reported that the median postoperative length of stay was 1 day and that 9.9% of patients had at least one in-hospital complication. The most frequent in-hospital complication was bleeding/hematoma (4.1%), followed by arrhythmia (2.1%), dysphagia (1.7%), stroke (1.3%), and myocardial infarction (1.2%). Only 3% of patients required a reoperation, while most (94%) were discharged to home. The 30-day stroke rate was 1.7%, while the 30-day death rate was 0.6%.
The overall 30-day readmission rate was 8.6%, while the unplanned 30-day readmission rate was 6.5%. "Most of the overall readmissions (80%) occurred in the first 10 days, and the median time to unplanned readmission was 4 days," Dr. Ho said.
The most common reason for an unplanned readmission was a cardiac complication, followed by headache, bleeding/hematoma, stroke/transient ischemic attack/intracerebral hemorrhage, or other medical emergency. More than one-quarter of patients (27.5%) had more than one reason for an unplanned readmission, while 87.9% of patients had a CEA-related unplanned readmission.
When the researchers performed a univariate analysis followed by analysis with a multivariable Cox model for unplanned readmission, four variables were independently associated with unplanned readmission: in-hospital postoperative CHF exacerbation (hazard ratio, 15.1), in-hospital postoperative stroke (HR, 5.0), in-hospital postoperative hematoma (HR, 3.1), and prior CABG (HR, 2.0).
They also observed a significant difference in survival at 1 year between patients who had an unplanned readmission and those who did not (91% vs. 96%, respectively; P less than .01.) "It’s unclear whether these deaths in the unplanned readmission group were preventable or if they were related to carotid disease or to a procedure-related complication," Dr. Ho said. "Our guess is that the increased overall burden of comorbid disease in these patients, rather than the readmission itself, predicted decreased survival."
Limitations of the study included its retrospective design and the fact that it was conducted at a single center, she said, "but we do know that our unplanned readmission rate is comparable to estimates from recent Medicare data."
Dr. Ho said she had no relevant financial disclosures.
Over the past several years, the role of carotid endarterectomy (CEA) for asymptomatic carotid stenosis has, again, come under the microscope; with many proponents still advocating CEA as the treatment of choice for asymptomatic patients with greater than or equal to 60% stenosis, while some propose greater than or equal to 70-80% stenosis in good surgical risk patients. Meanwhile, others oppose this philosophy because of the advances in modern medical therapy for patients with atherosclerosis, in general, with emphasis on risk modification. The findings of this article are quite disturbing, since the authors concluded that the 30-day unplanned re-admission rate after CEA was 6.5%; this is especially surprising to me, coming from this institution.
| Dr. AbuRahma |
The authors also concluded that unplanned re-admission rate was influenced by congestive heart failure, in-hospital postoperative stroke, in-hospital postoperative hematoma, and prior coronary artery bypass grafting. This emphasizes the importance of selection, selection, selection for asymptomatic carotid artery stenosis, if the outcome is to be acceptable to those who still advocate carotid endarterectomy for asymptomatic carotid disease.
Perhaps this procedure should not be encouraged for patients with congestive heart failure or those with severe coronary artery disease, unstable angina. Today, Level I evidence still supports carotid endarterectomy for patients with severe carotid artery stenosis, provided the patient is a good surgical risk, with relatively good longevity; with perioperative stroke and/or death rates of less than 3%. Several modern clinical series have concluded that CEA can be done in these patients with a stroke and/or death rate of less than 1-2%, which was produced most recently in the CREST trial. For those clinicians who cannot keep these numbers down, perhaps this procedure should not be done for asymptomatic carotid disease. What’s also surprising to me, is the in-hospital postoperative hematomas, which I presume necessitated the re-admission and, perhaps, reoperation. This should highlight the fact that, perhaps, we need to look further as to whether or not these patients should be on a combined regimen of aspirin and Plavix, preoperatively and postoperatively, as prescribed by many clinicians.
There is no Level I evidence to support that the combination of aspirin and Plavix, postoperatvely, for these patients would yield a better outcome than simple aspirin daily. It is difficult to determine from this study whether a significant portion of their patients were on dual antiplatelet therapy.
It is also interesting to notice that the authors found that almost 10% of patients had at least one in-hospital complication; some of which were major complications, e.g. stroke, MI, and dysphagia. Including bleeding/hematoma in these complications, which may not have necessitated surgery, may have inflated this number. A similar observation can be made regarding postoperative arrhythmias, particularly if they did not necessitate extra therapy. However, the fact of the matter is that it should be emphasized that the selection of patients for carotid endarterectomy in asymptomatic patients is extremely critical if this procedure is to be continued or blessed.
Dr. Ali F. AbuRahma is Professor of Surgery and Chief, Vascular & Endovascular Surgery, and Director, Vascular Surgery Fellowship and Residency Programs, and Medical Director, Vascular Laboratory, Co-Director, Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston. He is a also an associate medical editor of Vascular Specialist.
Over the past several years, the role of carotid endarterectomy (CEA) for asymptomatic carotid stenosis has, again, come under the microscope; with many proponents still advocating CEA as the treatment of choice for asymptomatic patients with greater than or equal to 60% stenosis, while some propose greater than or equal to 70-80% stenosis in good surgical risk patients. Meanwhile, others oppose this philosophy because of the advances in modern medical therapy for patients with atherosclerosis, in general, with emphasis on risk modification. The findings of this article are quite disturbing, since the authors concluded that the 30-day unplanned re-admission rate after CEA was 6.5%; this is especially surprising to me, coming from this institution.
| Dr. AbuRahma |
The authors also concluded that unplanned re-admission rate was influenced by congestive heart failure, in-hospital postoperative stroke, in-hospital postoperative hematoma, and prior coronary artery bypass grafting. This emphasizes the importance of selection, selection, selection for asymptomatic carotid artery stenosis, if the outcome is to be acceptable to those who still advocate carotid endarterectomy for asymptomatic carotid disease.
Perhaps this procedure should not be encouraged for patients with congestive heart failure or those with severe coronary artery disease, unstable angina. Today, Level I evidence still supports carotid endarterectomy for patients with severe carotid artery stenosis, provided the patient is a good surgical risk, with relatively good longevity; with perioperative stroke and/or death rates of less than 3%. Several modern clinical series have concluded that CEA can be done in these patients with a stroke and/or death rate of less than 1-2%, which was produced most recently in the CREST trial. For those clinicians who cannot keep these numbers down, perhaps this procedure should not be done for asymptomatic carotid disease. What’s also surprising to me, is the in-hospital postoperative hematomas, which I presume necessitated the re-admission and, perhaps, reoperation. This should highlight the fact that, perhaps, we need to look further as to whether or not these patients should be on a combined regimen of aspirin and Plavix, preoperatively and postoperatively, as prescribed by many clinicians.
There is no Level I evidence to support that the combination of aspirin and Plavix, postoperatvely, for these patients would yield a better outcome than simple aspirin daily. It is difficult to determine from this study whether a significant portion of their patients were on dual antiplatelet therapy.
It is also interesting to notice that the authors found that almost 10% of patients had at least one in-hospital complication; some of which were major complications, e.g. stroke, MI, and dysphagia. Including bleeding/hematoma in these complications, which may not have necessitated surgery, may have inflated this number. A similar observation can be made regarding postoperative arrhythmias, particularly if they did not necessitate extra therapy. However, the fact of the matter is that it should be emphasized that the selection of patients for carotid endarterectomy in asymptomatic patients is extremely critical if this procedure is to be continued or blessed.
Dr. Ali F. AbuRahma is Professor of Surgery and Chief, Vascular & Endovascular Surgery, and Director, Vascular Surgery Fellowship and Residency Programs, and Medical Director, Vascular Laboratory, Co-Director, Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston. He is a also an associate medical editor of Vascular Specialist.
Over the past several years, the role of carotid endarterectomy (CEA) for asymptomatic carotid stenosis has, again, come under the microscope; with many proponents still advocating CEA as the treatment of choice for asymptomatic patients with greater than or equal to 60% stenosis, while some propose greater than or equal to 70-80% stenosis in good surgical risk patients. Meanwhile, others oppose this philosophy because of the advances in modern medical therapy for patients with atherosclerosis, in general, with emphasis on risk modification. The findings of this article are quite disturbing, since the authors concluded that the 30-day unplanned re-admission rate after CEA was 6.5%; this is especially surprising to me, coming from this institution.
| Dr. AbuRahma |
The authors also concluded that unplanned re-admission rate was influenced by congestive heart failure, in-hospital postoperative stroke, in-hospital postoperative hematoma, and prior coronary artery bypass grafting. This emphasizes the importance of selection, selection, selection for asymptomatic carotid artery stenosis, if the outcome is to be acceptable to those who still advocate carotid endarterectomy for asymptomatic carotid disease.
Perhaps this procedure should not be encouraged for patients with congestive heart failure or those with severe coronary artery disease, unstable angina. Today, Level I evidence still supports carotid endarterectomy for patients with severe carotid artery stenosis, provided the patient is a good surgical risk, with relatively good longevity; with perioperative stroke and/or death rates of less than 3%. Several modern clinical series have concluded that CEA can be done in these patients with a stroke and/or death rate of less than 1-2%, which was produced most recently in the CREST trial. For those clinicians who cannot keep these numbers down, perhaps this procedure should not be done for asymptomatic carotid disease. What’s also surprising to me, is the in-hospital postoperative hematomas, which I presume necessitated the re-admission and, perhaps, reoperation. This should highlight the fact that, perhaps, we need to look further as to whether or not these patients should be on a combined regimen of aspirin and Plavix, preoperatively and postoperatively, as prescribed by many clinicians.
There is no Level I evidence to support that the combination of aspirin and Plavix, postoperatvely, for these patients would yield a better outcome than simple aspirin daily. It is difficult to determine from this study whether a significant portion of their patients were on dual antiplatelet therapy.
It is also interesting to notice that the authors found that almost 10% of patients had at least one in-hospital complication; some of which were major complications, e.g. stroke, MI, and dysphagia. Including bleeding/hematoma in these complications, which may not have necessitated surgery, may have inflated this number. A similar observation can be made regarding postoperative arrhythmias, particularly if they did not necessitate extra therapy. However, the fact of the matter is that it should be emphasized that the selection of patients for carotid endarterectomy in asymptomatic patients is extremely critical if this procedure is to be continued or blessed.
Dr. Ali F. AbuRahma is Professor of Surgery and Chief, Vascular & Endovascular Surgery, and Director, Vascular Surgery Fellowship and Residency Programs, and Medical Director, Vascular Laboratory, Co-Director, Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston. He is a also an associate medical editor of Vascular Specialist.
SAN FRANCISCO – The 30-day unplanned readmission rate following carotid endarterectomy was 6.5% in a single-center study.
In addition, four variables were significantly associated with unplanned readmission: in-hospital postoperative congestive heart failure (CHF) exacerbation; in-hospital postoperative stroke; in-hospital postoperative hematoma; and prior coronary artery bypass graft (CABG).
"Whether these complications are completely avoidable is unknown, but we do identify a group of patients who would probably benefit from more comprehensive discharge planning and careful postdischarge care," Dr. Karen J. Ho said at the Society for Vascular Surgery annual meeting earlier this year.
According to a study of Medicare claims data from 2003 to 2004, 20% of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days (N. Eng. J. Med. 2009;360:1418-28). The 30-day rehospitalization rate after vascular surgery was 24%, "the highest of all surgical specialties examined in the study," said Dr. Ho of the surgery department at Brigham and Women’s Hospital, Boston, who was not involved with the published study. "Medicare has started to decrease reimbursements for hospitals with excess readmissions after acute MI, heart failure, and pneumonia. Hip and knee replacements and chronic obstructive pulmonary disease will be added in 2014, and we anticipate that additional surgical procedures will be added thereafter," she said.
In an effort to determine the rate of 30-day unplanned readmission after carotid endarterectomy (CEA), Dr. Ho and her associates conducted a retrospective study of a prospectively collected vascular surgery database at Brigham and Women’s Hospital. The cohort included 896 consecutive CEAs performed between 2002 and 2011. Combined CABG/CEA procedures were excluded.
The primary endpoint was unplanned readmission within 30 days, defined as "any unanticipated, nonelective hospital readmission," she said. The secondary endpoint was 1-year survival.
The mean age of the patients was 70 years, 60% were male, and 95% were white. More than half (65%) had asymptomatic evidence of carotid artery disease.
Dr. Ho reported that the median postoperative length of stay was 1 day and that 9.9% of patients had at least one in-hospital complication. The most frequent in-hospital complication was bleeding/hematoma (4.1%), followed by arrhythmia (2.1%), dysphagia (1.7%), stroke (1.3%), and myocardial infarction (1.2%). Only 3% of patients required a reoperation, while most (94%) were discharged to home. The 30-day stroke rate was 1.7%, while the 30-day death rate was 0.6%.
The overall 30-day readmission rate was 8.6%, while the unplanned 30-day readmission rate was 6.5%. "Most of the overall readmissions (80%) occurred in the first 10 days, and the median time to unplanned readmission was 4 days," Dr. Ho said.
The most common reason for an unplanned readmission was a cardiac complication, followed by headache, bleeding/hematoma, stroke/transient ischemic attack/intracerebral hemorrhage, or other medical emergency. More than one-quarter of patients (27.5%) had more than one reason for an unplanned readmission, while 87.9% of patients had a CEA-related unplanned readmission.
When the researchers performed a univariate analysis followed by analysis with a multivariable Cox model for unplanned readmission, four variables were independently associated with unplanned readmission: in-hospital postoperative CHF exacerbation (hazard ratio, 15.1), in-hospital postoperative stroke (HR, 5.0), in-hospital postoperative hematoma (HR, 3.1), and prior CABG (HR, 2.0).
They also observed a significant difference in survival at 1 year between patients who had an unplanned readmission and those who did not (91% vs. 96%, respectively; P less than .01.) "It’s unclear whether these deaths in the unplanned readmission group were preventable or if they were related to carotid disease or to a procedure-related complication," Dr. Ho said. "Our guess is that the increased overall burden of comorbid disease in these patients, rather than the readmission itself, predicted decreased survival."
Limitations of the study included its retrospective design and the fact that it was conducted at a single center, she said, "but we do know that our unplanned readmission rate is comparable to estimates from recent Medicare data."
Dr. Ho said she had no relevant financial disclosures.
SAN FRANCISCO – The 30-day unplanned readmission rate following carotid endarterectomy was 6.5% in a single-center study.
In addition, four variables were significantly associated with unplanned readmission: in-hospital postoperative congestive heart failure (CHF) exacerbation; in-hospital postoperative stroke; in-hospital postoperative hematoma; and prior coronary artery bypass graft (CABG).
"Whether these complications are completely avoidable is unknown, but we do identify a group of patients who would probably benefit from more comprehensive discharge planning and careful postdischarge care," Dr. Karen J. Ho said at the Society for Vascular Surgery annual meeting earlier this year.
According to a study of Medicare claims data from 2003 to 2004, 20% of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days (N. Eng. J. Med. 2009;360:1418-28). The 30-day rehospitalization rate after vascular surgery was 24%, "the highest of all surgical specialties examined in the study," said Dr. Ho of the surgery department at Brigham and Women’s Hospital, Boston, who was not involved with the published study. "Medicare has started to decrease reimbursements for hospitals with excess readmissions after acute MI, heart failure, and pneumonia. Hip and knee replacements and chronic obstructive pulmonary disease will be added in 2014, and we anticipate that additional surgical procedures will be added thereafter," she said.
In an effort to determine the rate of 30-day unplanned readmission after carotid endarterectomy (CEA), Dr. Ho and her associates conducted a retrospective study of a prospectively collected vascular surgery database at Brigham and Women’s Hospital. The cohort included 896 consecutive CEAs performed between 2002 and 2011. Combined CABG/CEA procedures were excluded.
The primary endpoint was unplanned readmission within 30 days, defined as "any unanticipated, nonelective hospital readmission," she said. The secondary endpoint was 1-year survival.
The mean age of the patients was 70 years, 60% were male, and 95% were white. More than half (65%) had asymptomatic evidence of carotid artery disease.
Dr. Ho reported that the median postoperative length of stay was 1 day and that 9.9% of patients had at least one in-hospital complication. The most frequent in-hospital complication was bleeding/hematoma (4.1%), followed by arrhythmia (2.1%), dysphagia (1.7%), stroke (1.3%), and myocardial infarction (1.2%). Only 3% of patients required a reoperation, while most (94%) were discharged to home. The 30-day stroke rate was 1.7%, while the 30-day death rate was 0.6%.
The overall 30-day readmission rate was 8.6%, while the unplanned 30-day readmission rate was 6.5%. "Most of the overall readmissions (80%) occurred in the first 10 days, and the median time to unplanned readmission was 4 days," Dr. Ho said.
The most common reason for an unplanned readmission was a cardiac complication, followed by headache, bleeding/hematoma, stroke/transient ischemic attack/intracerebral hemorrhage, or other medical emergency. More than one-quarter of patients (27.5%) had more than one reason for an unplanned readmission, while 87.9% of patients had a CEA-related unplanned readmission.
When the researchers performed a univariate analysis followed by analysis with a multivariable Cox model for unplanned readmission, four variables were independently associated with unplanned readmission: in-hospital postoperative CHF exacerbation (hazard ratio, 15.1), in-hospital postoperative stroke (HR, 5.0), in-hospital postoperative hematoma (HR, 3.1), and prior CABG (HR, 2.0).
They also observed a significant difference in survival at 1 year between patients who had an unplanned readmission and those who did not (91% vs. 96%, respectively; P less than .01.) "It’s unclear whether these deaths in the unplanned readmission group were preventable or if they were related to carotid disease or to a procedure-related complication," Dr. Ho said. "Our guess is that the increased overall burden of comorbid disease in these patients, rather than the readmission itself, predicted decreased survival."
Limitations of the study included its retrospective design and the fact that it was conducted at a single center, she said, "but we do know that our unplanned readmission rate is comparable to estimates from recent Medicare data."
Dr. Ho said she had no relevant financial disclosures.
Major finding: Four variables were independently associated with unplanned readmission: in-hospital postoperative CHF exacerbation (hazard ratio, 15.1), in-hospital postoperative stroke (HR, 5.0), in-hospital postoperative hematoma (HR, 3.1), and prior CABG (HR, 2.0).
Data source: A study of 896 consecutive CEAs performed between 2002 and 2011 at Brigham and Women’s Hospital, Boston.
Disclosures: Dr. Ho said she had no relevant financial disclosures.
