Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume

John A Cowan, Justin B Dimick, B Gregory Thompson, James C Stanley, Gilbert R Upchurch
Journal of the American College of Surgeons 2002, 195 (6): 814-21

BACKGROUND: High-volume hospitals have been shown to have superior outcomes after carotid endarterectomy (CEA), but the contribution of surgeon volume and specialty practice to CEA outcomes in a national sample is unknown.

STUDY DESIGN: Using the National Inpatient Sample for 1996 and 1997, 35,821 patients who underwent CEA (ICD-9-CM code 3812) and had data for unique surgeon identification were studied. Surgeons were categorized in terms of annual CEA volume as low-volume surgeons (< 10 procedures), medium-volume surgeons (10 to 29), and high-volume surgeons (> or = 30). Data from cardiac, general, neurologic, and vascular surgical practices were analyzed. In-hospital mortality, postoperative stroke, and prolonged length of stay (> 4 days) were the primary outcomes variables. Unadjusted and case-mix adjusted analyses were performed.

RESULTS: The overall in-hospital mortality was 0.61%. CEA was performed annually by high-volume surgeons in 52% of patients, by medium-volume surgeons in 30% of patients, and by low-volume surgeons in 18% of patients. Observed mortality by surgeon volume was 0.44% for high-volume surgeons, 0.63% for medium-volume surgeons, and 1.1% for low-volume surgeons (p < 0.001). The postoperative stroke rate was 1.14% for high-volume surgeons, 1.63% for medium-volume surgeons, and 2.03% for low-volume surgeons (p < 0.001). Surgeon specialty had no statistically significant effect on mortality or postoperative stroke. In the logistic regression model, increased risk of mortality was associated with emergent admission (odds ratio [OR] = 2.1; 95% confidence interval [CI] 1.6 to 2.8, p < 0.001), patient age > 65 years (OR = 2.0; 95% CI 1.3 to 3.1, p = 0.001), low-volume surgeon (OR = 1.9; 95% CI 1.4 to 2.5, p < 0.001), and COPD (OR = 1.8; 95% CI 1.3 to 2.5, p = 0.001). Low hospital CEA volume (< 100) was not a significant risk factor in the multivariate analysis.

CONCLUSIONS: More than 50% of the CEAs in the United States are performed by high-volume surgeons with superior outcomes. Health policy efforts should focus on reducing the number of low-volume surgeons, regardless of surgeon specialty or total hospital CEA volume.

Full Text Links

Find Full Text Links for this Article


You are not logged in. Sign Up or Log In to join the discussion.

Trending Papers

Remove bar
Read by QxMD icon Read

Save your favorite articles in one place with a free QxMD account.


Search Tips

Use Boolean operators: AND/OR

diabetic AND foot
diabetes OR diabetic

Exclude a word using the 'minus' sign

Virchow -triad

Use Parentheses

water AND (cup OR glass)

Add an asterisk (*) at end of a word to include word stems

Neuro* will search for Neurology, Neuroscientist, Neurological, and so on

Use quotes to search for an exact phrase

"primary prevention of cancer"
(heart or cardiac or cardio*) AND arrest -"American Heart Association"