Carotid artery stenting: Impact of practitioner specialty and volume on outcomes and resource utilization

Abstract

A variety of endovascular specialists perform carotid artery stenting (CAS), but little data exist on outcomes and resource utilization among these specialists. We analyzed differences in outcomes after CAS was performed by radiologists (RAD), cardiologists (CRD), and vascular surgeons (VAS). Secondary data analysis of the 2005-2006 State Inpatient Databases for New Jersey were analyzed. Patients with elective admission to the hospital who had CAS procedure <or=2 days after admission were identified. CAS outcomes were analyzed with respect to practitioner specialty and volume, associated complications, and hospital resource utilization. We identified 625 CAS cases. CRD performed 378 (60.5%), VAS, 199 (31.8%); and RAD, 48 (7.7%). The overall stroke rate was 2.72% and by specialty was CRD, 3.17%; VAS, 2.01%, and RAD, 2.08% (P = .6880). The overall cardiac complication rate was 2.40% (CRD, 2.12%; VAS, 3.02%; RAD, 2.08%; P = .7899). Renal and pulmonary complications were low (0.64% and 0.32%, respectively). Mean hospital length of stay (LOS) in days was significantly shorter for VAS (1.64 +/- 1.40) compared with RAD (2.83 +/- 5.15; P = .0167) and had the same trend compared with CRD (2.14 +/- 3.37; P = .0649). Intensive care unit (ICU) LOS was shorter for VAS (0.52 +/- 0.97) and CRD (0.30 +/- 0.71) than for RAD (2.12 +/- 4.48; P < .0001). The mean total hospital cost was significantly greater for RAD ($20,987 +/- $26,603) and CRD ($18,182 +/- $16,364) than for VAS ($10,000 +/- $4947; P = .0011 and P < .0001, respectively). ICU cost for RAD ($5963 +/- $14,551) was also more than for VAS ($864 +/- $1514; P < .0001) and CRD ($473 +/- $1561; P < .0001). Medical supply costs were significantly greater for CRD ($8772 +/- $9546) than for VAS ($3354 +/- $2261; P < .0001) and RAD ($4964 +/- $2595; P = .0142). Total hospital cost, LOS, and medical supplies were significantly lower for high-volume practitioners vs low-volume practitioners (P < .0001). Stroke rates after CAS did not vary significantly among practitioner specialties. Hospital resource utilization did vary significantly: Vascular surgeons had the lowest utilization of hospital resources for performing CAS. High practitioner volume was associated with lower hospital resource utilization. Elucidation of factors creating resource utilization disparities among endovascular practitioners may lead to improved patient outcomes and permit significant future cost savings for carotid interventions.