title: Carotid artery stenting: Impact of practitioner specialty and volume on outcomes and resource utilization.
abstract: OBJECTIVE
  A variety of endovascular specialists perform carotid artery stenting (CAS), but little data exist on outcomes and resource utilization among these specialists. We analyzed differences in outcomes after CAS was performed by radiologists (RAD), cardiologists (CRD), and vascular surgeons (VAS).
  
  
  METHODS
  Secondary data analysis of the 2005-2006 State Inpatient Databases for New Jersey were analyzed. Patients with elective admission to the hospital who had CAS procedure <or=2 days after admission were identified. CAS outcomes were analyzed with respect to practitioner specialty and volume, associated complications, and hospital resource utilization.
  
  
  RESULTS
  We identified 625 CAS cases. CRD performed 378 (60.5%), VAS, 199 (31.8%); and RAD, 48 (7.7%). The overall stroke rate was 2.72% and by specialty was CRD, 3.17%; VAS, 2.01%, and RAD, 2.08% (P = .6880). The overall cardiac complication rate was 2.40% (CRD, 2.12%; VAS, 3.02%; RAD, 2.08%; P = .7899). Renal and pulmonary complications were low (0.64% and 0.32%, respectively). Mean hospital length of stay (LOS) in days was significantly shorter for VAS (1.64 +/- 1.40) compared with RAD (2.83 +/- 5.15; P = .0167) and had the same trend compared with CRD (2.14 +/- 3.37; P = .0649). Intensive care unit (ICU) LOS was shorter for VAS (0.52 +/- 0.97) and CRD (0.30 +/- 0.71) than for RAD (2.12 +/- 4.48; P < .0001). The mean total hospital cost was significantly greater for RAD ($20,987 +/- $26,603) and CRD ($18,182 +/- $16,364) than for VAS ($10,000 +/- $4947; P = .0011 and P < .0001, respectively). ICU cost for RAD ($5963 +/- $14,551) was also more than for VAS ($864 +/- $1514; P < .0001) and CRD ($473 +/- $1561; P < .0001). Medical supply costs were significantly greater for CRD ($8772 +/- $9546) than for VAS ($3354 +/- $2261; P < .0001) and RAD ($4964 +/- $2595; P = .0142). Total hospital cost, LOS, and medical supplies were significantly lower for high-volume practitioners vs low-volume practitioners (P < .0001).
  
  
  CONCLUSIONS
  Stroke rates after CAS did not vary significantly among practitioner specialties. Hospital resource utilization did vary significantly: Vascular surgeons had the lowest utilization of hospital resources for performing CAS. High practitioner volume was associated with lower hospital resource utilization. Elucidation of factors creating resource utilization disparities among endovascular practitioners may lead to improved patient outcomes and permit significant future cost savings for carotid interventions.
authors.affiliation: Division of Vascular Surgery, The Surgical Outcomes Research Group, University of Medicine and Dentistry, New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ 08903-0019, USA. vogelto@umdnj.edu
authors.forename: Todd R
authors.initials: TR
authors.lastname: Vogel
authors.forename: Viktor Y
authors.initials: VY
authors.lastname: Dombrovskiy
authors.forename: Paul B
authors.initials: PB
authors.lastname: Haser
authors.forename: Alan M
authors.initials: AM
authors.lastname: Graham
mesh_terms: D017130:Angioplasty / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation; D002309:Cardiology; D002340:Carotid Artery Diseases / Q000191:economics / Q000601:surgery*; D002983:Clinical Competence; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003422:Critical Care; D019992:Databases as Topic; D004470:Economics, Medical; D006280:Health Workforce; D006331:Heart Diseases / Q000209:etiology; D017721:Hospital Costs; D006801:Humans; D007674:Kidney Diseases / Q000209:etiology; D007902:Length of Stay; D009515:New Jersey; D010043:Outcome and Process Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000191:economics; D015642:Radiology, Interventional; D013038:Specialization; D015607:Stents / Q000191:economics; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures