Surgeon specialty and patient outcomes in carotid endarterectomy

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OBJECTIVE

The goal of this study was to compare outcomes of carotid endarterectomy performed by neurological, general, and vascular surgeons.

METHODS

The authors identified 80,475 patients who underwent carotid endarterectomy between 2006 and 2015 in the National Surgical Quality Improvement Program, a prospectively collected, national clinical database with established reproducibility and validity. Nine hundred forty-three patients were operated on by a neurosurgeon; 75,649 by a vascular surgeon; and 3734 by a general surgeon. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by the surgeon’s primary specialty. Using propensity scores, comprising pre- and intraoperative characteristics as well as procedure and diagnostic codes, the authors matched 203 neurosurgery (NS) patients to 203 vascular surgery (VS) patients and 203 NS patients to 203 general surgery (GS) patients. No pre- or intraoperative factors were significantly different between specialties in the matched sample. Regular logistic regression and conditional logistic regression were used to predict postoperative complications in the full sample and in the matched sample.

RESULTS

In the complete population sample, NS patients, when compared to patients of general and vascular surgeons, were less likely to be admitted from home and more likely to have carotid artery occlusion or stenosis with cerebral infarction, to be a current smoker, to have had recent chemo- or radiotherapy, to have surgery under general anesthesia, to undergo multiple procedures, and to have longer surgery times. In unadjusted analyses, NS patients were more likely to experience major complications (NS vs VS: odds ratio 1.3, 95% CI 1.1–1.6; NS vs GS: odds ratio 1.3, 95% CI 1.0–1.7); minor complications (NS vs VS: odds ratio 2.9, 95% CI 2.0–4.1; NS vs GS: odds ratio 2.7, 95% CI 1.7–4.2); intra- or postoperative transfusions (NS vs VS: odds ratio 1.6, 95% CI 1.4–1.9; NS vs GS: odds ratio 1.9, 95% CI 1.6–2.3); prolonged hospitalization (NS vs VS: odds ratio 3.0, 95% CI 2.6–3.5; NS vs GS: odds ratio 2.6, 95% CI 2.2–3.0); and discharge to skilled care facilities (NS vs VS: odds ratio 2.8, 95% CI 2.3–3.4; NS vs GS: odds ratio 3.1, 95% CI 2.4–4.1). In adjusted, propensity-matched analyses, however, patients’ outcome with carotid endarterectomy performed by NS was comparable with those completed by GS and VS.

CONCLUSIONS

Patients who undergo carotid endarterectomy performed by a neurosurgeon tend to have a greater preoperative disease burden than do those treated by a general or vascular surgeon, which contributes significantly to more morbid postoperative courses. In patients matched carefully on the basis of health status at the time of surgery and intraoperative variables that affect results, patients’ outcomes after carotid endarterectomy do not appear to depend on the attending surgeon’s primary specialty.

ABBREVIATIONS BMI = body mass index; CPR = cardiopulmonary resuscitation; CPT = Current Procedural Terminology; CVA = cerebrovascular accident; DVT = deep venous thrombosis; GS = general surgery; ICD-9 = International Classification of Diseases, Ninth Revision; INR = international normalized ratio; LOS = length of hospital stay; MI = myocardial infarction; NS = neurosurgery; NSQIP = National Surgical Quality Improvement Program; OR = operating room; TIA = transient ischemic attack; VS = vascular surgery.

Article Information

Correspondence Andreea Seicean: University of Illinois at Chicago, IL. andreea.seicean@gmail.com.

INCLUDE WHEN CITING Published online August 10, 2018; DOI: 10.3171/2018.2.JNS173014.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Patient selection criteria: flow diagram demonstrating entry and exclusion criteria and breakdown of patients in the analyses.

References

  • 1

    AbuRahma AFStone PASrivastava MHass SMMousa AYDean LS: The effect of surgeon’s specialty and volume on the perioperative outcome of carotid endarterectomy. J Vasc Surg 58:6666722013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Ahmed SElsheikh MStratton IMPage RCAdams CBWass JA: Outcome of transphenoidal surgery for acromegaly and its relationship to surgical experience. Clin Endocrinol (Oxf) 50:5615671999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Allen WC: The relationship between residency programs and fellowships in the educational setting. Clin Orthop Relat Res (257):57601990

    • Search Google Scholar
    • Export Citation
  • 4

    American College of Surgeons: Data collection, analysis, and reporting. FACS.org. (https://www.facs.org/quality-programs/acs-nsqip/program-specifics/data) [Accessed April 6 2018]

    • Export Citation
  • 5

    Angus DCvan der Poll T: Severe sepsis and septic shock. N Engl J Med 369:20632013

  • 6

    Austin PC: Propensity-score matching in the cardiovascular surgery literature from 2004 to 2006: a systematic review and suggestions for improvement. J Thorac Cardiovasc Surg 134:112811352007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Austin PC: The use of propensity score methods with survival or time-to-event outcomes: reporting measures of effect similar to those used in randomized experiments. Stat Med 33:124212582014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Bergstralh EJKosanke JL: Computerized Matching of Cases to Controls. Technical Report Number 56. Rochester, MN: Mayo Clinic1995 (http://www.mayo.edu/research/documents/biostat-56pdf/doc-10026923) [Accessed April 6 2018]

    • Export Citation
  • 9

    Brott TGHobson RW IIHoward GRoubin GSClark WMBrooks W: Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 363:11232010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Cowan JA JrDimick JBThompson BGStanley JCUpchurch GR Jr: Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume. J Am Coll Surg 195:8148212002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Diggle PLiang KYZeger SL: Longitudinal Data Analysis. New York: Oxford University Press1994

    • Export Citation
  • 12

    Enomoto LMHill DCDillon PWHan DCHollenbeak CS: Surgical specialty and outcomes for carotid endarterectomy: evidence from the National Surgical Quality Improvement Program. J Surg Res 188:3393482014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Feasby TEKennedy JQuan HGhali WA: Outcomes in carotid endarterectomy performed by vascular surgeons or neurosurgeons. Stroke 33:14582002

  • 14

    Ferguson GGEliasziw MBarr HWClagett GPBarnes RWWallace MC: The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke 30:175117581999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    French BFarjah FFlum DRHeagerty PJ: A general framework for estimating volume-outcome associations from longitudinal data. Stat Med 31:3663822012

  • 16

    Halm EAHannan ELRojas MTuhrim SRiles TSRockman CB: Clinical and operative predictors of outcomes of carotid endarterectomy. J Vasc Surg 42:4204282005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Hannan ELPopp AJFeustel PHalm EBernardini GWaldman J: Association of surgical specialty and processes of care with patient outcomes for carotid endarterectomy. Stroke 32:289028972001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Hollenbeak CSBowman ARHarbaugh RECasale PNHan D: The impact of surgical specialty on outcomes for carotid endarterectomy. J Surg Res 159:5956022010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Hussain MAMamdani MTu JVSaposnik GSalata KBhatt DL: Association between operator specialty and outcomes after carotid artery revascularization. J Vasc Surg 67:478489489.e1–489.e6 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kempczinski RFBrott TGLabutta RJ: The influence of surgical specialty and caseload on the results of carotid endarterectomy. J Vasc Surg 3:9119161986

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Khuri SFHenderson WGDaley JJonasson OJones RSCampbell DA Jr: The patient safety in surgery study: background, study design, and patient populations. J Am Coll Surg 204:108911022007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Lieber BAHenry JKAgarwal NDay JDMorris TW IIIStephens ML: Impact of surgical specialty on outcomes following carotid endarterectomy. Neurosurgery 80:2172252017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Nicoll DMcPhee SPignone MMark L: Pocket Guide to Diagnostic Testsed 6. New York: McGraw-Hill2010

    • Export Citation
  • 24

    O’Neill LLanska DJHartz A: Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy. Neurology 55:7737812000

  • 25

    Ringleb PAAllenberg JBrückmann HEckstein HHFraedrich GHartmann M: 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 368:123912472006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Rosenbaum PR: Coherence in observational studies. Biometrics 50:3683741994

  • 27

    Rosenbaum PRRubin DB: The central role of the propensity score in observational studies for causal effects. Biometrika 70:41551983

  • 28

    Roubin GSNew GIyer SSVitek JJAl-Mubarak NLiu MW: Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis. Circulation 103:5325372001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Ruby STRobinson DLynch JTMark H: Outcome analysis of carotid endarterectomy in Connecticut: the impact of volume and specialty. Ann Vasc Surg 10:22261996

  • 30

    Schmidt CMTurrini OParikh PHouse MGZyromski NJNakeeb A: Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg 145:6346402010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Seicean AAlan NSeicean SNeuhauser DBenzel ECWeil RJ: Surgeon specialty and outcomes after elective spine surgery. Spine (Phila Pa 1976) 39:160516132014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Shah DMDarling RCChang BBPaty PSKreienberg PBRoddy SP: Analysis of factors contributing to improved outcome for carotid endarterectomy. Semin Vasc Surg 17:2572592004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Shiloach MFrencher SK JrSteeger JERowell KSBartzokis KTomeh MG: Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 210:6162010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Witt PDWahlen JCMarsh JLGrames LMPilgram TK: The effect of surgeon experience on velopharyngeal functional outcome following palatoplasty: is there a learning curve? Plast Reconstr Surg 102:137513841998

    • Crossref
    • Search Google Scholar
    • Export Citation

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