Assessment of Determinants of Value in Carotid Endarterectomy

Abstract

More than 150,000 carotid endarterectomies (CEAs) are performed in the United States, accounting for $2 to $3 billion, annually. How cost and spending and quality are related is not well understood but remains an essential component in maximizing value. We sought to identify the determinants of variability in hospital 90-day episode value for CEA. Medicare and private-payer admissions for CEA from January 2, 2014 to August 28, 2020 were linked to retrospective clinical registry data for 39 hospitals in Michigan. Hospital-specific, risk-adjusted 30-day composite complications (defined as reoperation, new neurologic deficit, myocardial infarction, additional procedures [including CEA or carotid artery stenting], readmission, and mortality) and 30-day risk-adjusted, price-standardized total episode payments were used to categorize hospitals into low or high value by defining the intersection between complications and spending. A total of 6595 patients across 39 hospitals were identified within both datasets (Fig 1). Patients at low-value hospitals had a higher rate of 30-day composite complications (17.9% vs 10.1%; P < .001), driven by a significantly higher rate of reoperations (3.0% vs 1.4%; P = .016), readmissions (10.7% vs 6.2%; P = .012), new neurologic deficits (4.6% vs 2.3%; P = .017), and mortality (1.6% vs 0.6%; P < .049). The mean total episode payment was $19,635 at low-value hospitals compared with $15,709 at high-value hospitals. The differences resulted from index hospitalization ($10,800 vs $9587; P = .002) professional ($3421 vs $2827; P < .001), readmission ($3011 vs $1826; P < .001), and post–acute care payments ($2335 vs $1486; P < .001; Fig 2). Tremendous variation exists in both quality and payments across hospitals performing CEA. We found little to no relationship between total episode spending and surgical quality, suggesting that improvements in value might be possible by decreasing total episode costs without affecting the surgical outcomes.Fig 2Bar graph showing costs stratified by payment types overall and for patients without complications.View Large Image Figure ViewerDownload Hi-res image Download (PPT)