title: Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy.
abstract: BACKGROUND
  Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay.
  
  
  METHODS
  The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day.
  
  
  RESULTS
  Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05).
  
  
  CONCLUSIONS
  Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, VA. Electronic address: jhm9t@virginia.edu.
authors.forename: James H
authors.initials: JH
authors.lastname: Mehaffey
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Damien J
authors.initials: DJ
authors.lastname: LaPar
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Margret C
authors.initials: MC
authors.lastname: Tracci
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Cherry
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
authors.forename: John A
authors.initials: JA
authors.lastname: Kern
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Irving
authors.initials: I
authors.lastname: Kron
authors.affiliation: Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
authors.forename: Gilbert R
authors.initials: GR
authors.lastname: Upchurch
mesh_terms: D000368:Aged; D001071:Appointments and Schedules; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000191:economics / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D017046:Cost Savings; D016208:Databases, Factual; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000191:economics / Q000401:mortality; D005260:Female; D017722:Hospital Charges; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D061646:Operative Time; D011183:Postoperative Complications / Q000191:economics / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D019984:Quality Indicators, Health Care; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014768:Virginia