title: Factors that determine the length of stay after carotid endarterectomy represent opportunities to avoid financial losses.
abstract: BACKGROUND
  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).
  
  
  METHODS
  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.
  
  
  RESULTS
  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%).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Section of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Julia
authors.initials: J
authors.lastname: Glaser
authors.affiliation: Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors.forename: David
authors.initials: D
authors.lastname: Kuwayama
authors.affiliation: Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors.forename: David
authors.initials: D
authors.lastname: Stone
authors.affiliation: Department of Surgery, Section of Vascular Surgery, University of Massachusetts Medical Center, Worcester, Mass.
authors.forename: Andres
authors.initials: A
authors.lastname: Schanzer
authors.affiliation: Department of Surgery, Section of Vascular Surgery, Maine Medical Center, Portland, Me.
authors.forename: Jens
authors.initials: J
authors.lastname: Eldrup-Jorgensen
authors.affiliation: Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors.forename: Richard
authors.initials: R
authors.lastname: Powell
authors.affiliation: Department of Surgery, Section of Vascular Surgery, Fletcher-Allen Medical Center, Burlington, Vt.
authors.forename: Andrew
authors.initials: A
authors.lastname: Stanley
authors.affiliation: Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH. Electronic address: brian.w.nolan@hitchcock.org.
authors.forename: Brian
authors.initials: B
authors.lastname: Nolan
mesh_terms: D000368:Aged; D002340:Carotid Artery Diseases / Q000191:economics / Q000601:surgery*; D003953:Diagnosis-Related Groups / Q000191:economics; D004469:Economics, Hospital / Q000639:trends*; D017558:Elective Surgical Procedures; D016894:Endarterectomy, Carotid; D005260:Female; D005500:Follow-Up Studies; D017721:Hospital Costs / Q000639:trends*; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D009511:New England; D011183:Postoperative Complications / Q000191:economics*; D011184:Postoperative Period; D012189:Retrospective Studies