Glaser Julia, Kuwayama David, Stone David, Schanzer Andres, Eldrup-Jorgensen Jens, Powell Richard, Stanley Andrew, Nolan Brian
Department of Surgery, Section of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
J Vasc Surg. 2014 Oct;60(4):966-72.e1. doi: 10.1016/j.jvs.2014.03.292. Epub 2014 May 24.
A postoperative length of stay (LOS) >1 day after elective surgery incurs financial losses for hospitals, given fixed diagnosis-related group-based reimbursement. We sought to identify factors leading to a prolonged LOS (>1 postoperative day) after carotid endarterectomy (CEA).
Patients undergoing CEA in 23 centers of the Vascular Study Group of New England between 2003 and 2011 (n = 8860) were analyzed. Only elective, primary CEAs were analyzed, leaving a study cohort of 7108 procedures. Hierarchical multivariable logistic regression analysis was performed to identify predictors of a postoperative LOS >1 day. A Knaus-Wagner chi-pie analysis was performed to determine the relative contributions of each significant covariate to a postoperative LOS >1 day.
A postoperative LOS >1 day occurred in 17.5% of the sample (n = 1244). The average LOS was 1.4 days (range, 1-91 days; median, 1). There was significant variation in rates of postoperative LOS >1 day across centers (range, 5%-100%; P < .001). Factors independently associated with a postoperative LOS >1 day and their percentage contribution to the prediction model included the need for postoperative intravenous medications for hypertension or hypotension (26%), any major adverse event (MAE) postoperatively (21%), low-volume (<15 CEAs per year) surgeons (28%), increasing age (7%), female gender (4%), positive result on a preoperative stress test (3%), preoperative major stroke ≤30 days (2%), medication-dependent diabetes (1%), severe chronic obstructive pulmonary disease (1%), history of congestive heart failure (1%), and CEA performed on Friday (2%).
Certain patient characteristics predispose to a postoperative LOS >1 day after elective CEA. However, patient characteristics play only a modest (17%) role in determining LOS. The need for postoperative blood pressure control and MAEs are the biggest drivers of postoperative LOS >1 day, but system factors, such as low operative volume, contribute substantially to postoperative LOS >1 day, independent of MAEs. These findings can be used to guide quality improvement efforts designed to reduce LOS after elective CEA.
鉴于基于诊断相关分组的固定报销方式，择期手术后住院时间（LOS）超过1天会给医院带来经济损失。我们试图确定导致颈动脉内膜切除术（CEA）后住院时间延长（术后超过1天）的因素。
对2003年至2011年期间在新英格兰血管研究组23个中心接受CEA手术的患者（n = 8860）进行分析。仅分析择期、初次CEA手术，最终研究队列包括7108例手术。进行分层多变量逻辑回归分析以确定术后住院时间超过1天的预测因素。进行Knaus-Wagner卡方分析以确定每个显著协变量对术后住院时间超过1天的相对贡献。
样本中17.5%（n = 1244）的患者术后住院时间超过1天。平均住院时间为1.4天（范围1 - 91天；中位数为1天）。各中心术后住院时间超过1天的发生率存在显著差异（范围5% - 100%；P <.001）。与术后住院时间超过1天独立相关的因素及其在预测模型中的贡献百分比包括术后因高血压或低血压需要静脉用药（26%）、术后发生任何重大不良事件（MAE）（21%）、手术量少（每年<15例CEA手术）的外科医生（28%）、年龄增加（7%）、女性（4%）、术前应激试验结果阳性（3%）、术前3０天内发生重大卒中（2%）、药物依赖型糖尿病（1%）、严重慢性阻塞性肺疾病（1%）、充血性心力衰竭病史（1%）以及在周五进行CEA手术（2%）。
某些患者特征易导致择期CEA术后住院时间超过1天。然而，患者特征在确定住院时间方面仅起适度作用（17%）。术后血压控制的需求和重大不良事件是术后住院时间超过1天的最大驱动因素，但诸如手术量少等系统因素在术后住院时间超过1天方面也有很大贡献，且独立于重大不良事件。这些发现可用于指导旨在减少择期CEA术后住院时间的质量改进工作。
