Contemporary predictors of extended postoperative hospital length of stay after carotid endarterectomy.

INTRODUCTION

Hospital length of stay (LOS) contributes to costs. Carotid endarterectomy (CEA) is performed frequently by vascular surgeons, making contemporary CEA LOS rates and predictors vital knowledge for quality evaluation and cost containment initiatives.

METHODS

Using a prospective single-institution database, we retrospectively identified consecutive patients undergoing CEA from 2001 to 2011. Demographic and perioperative factors were prospectively collected. The primary end point was extended postoperative LOS (ELOS), defined as postoperative LOS ≥2 days. Factors associated with ELOS were analyzed in a multivariable logistic regression model. Rates of 1-year readmission and death were compared with the Kaplan-Meier method (log-rank test).

RESULTS

Eight hundred forty patients underwent 897 CEAs with 39% of procedures among females and 35% for symptomatic disease. One hundred two (11.4%) patients were inpatients prior to the day of CEA ("preadmitted"); their preoperative days by definition are not included in ELOS. Median postoperative LOS was 1 day (interquartile range, 1-2). Four hundred fourteen patients (46.2%) had ELOS. Preadmission was associated with ELOS (72% vs 41%; P < .01) and ELOS patients were less likely to be discharged home (11.9% vs 1.5%; P < .01). There was no association between ELOS and unplanned 30-day postdischarge readmission (6.0% vs 7.0%; P = .59). On multivariable analysis, preoperative factors significantly associated with ELOS included preadmission (adjusted odds ratio [OR], 3.3; 95% confidence interval [CI], 1.9-5.7; P < .001), history of congestive heart failure (OR, 2.1; 95% CI, 1.1-4.2; P = .03), female gender (OR, 1.9; 95% CI, 1.4-2.6; P < .001), and history of chronic obstructive pulmonary disease (OR, 1.7; 95% CI, 1.0-2.9; P = .04). Operative factors included electroencephalography change (OR, 1.9; 95% CI, 1.2-3.2; P = .01), operating room start time after 12:00 pm (OR, 1.7; 95% CI, 1.2-2.4; P < .01), and total operating room time (OR, 1.5 per hour; 95% CI, 1.2-2.9; P < .01). Postoperative factors included transfer to intensive care unit (OR, 5.4; 95% CI, 3.1-9.4; P < .01), number of in-hospital postoperative complications (OR, 3.7; 95% CI, 2.2-6.5; P < .01), and Foley catheter placement (OR, 2.1; 95% CI, 1.3-3.4; P < .01). Over 1 year, ELOS was associated with increased hospital readmission (93.6% vs 84.7%; log-rank test, P < .01) and decreased survival (95.1% vs 98.3%; log-rank test, P < .01).

CONCLUSIONS

Nearly half of CEA patients were discharged on or after postoperative day 2. Interventions on modifiable risk factors, such as early Foley catheter placement to prevent urinary retention and morning CEA scheduling, may decrease LOS. ELOS may identify a subset of patients at increased risk for long-term readmission and mortality.