Carotid Endarterectomy in Academic Versus Community Hospitals: The National Surgical Quality Improvement Program Data

Abstract

Carotid endarterectomy (CEA) is among the most commonly performed vascular operations in both academic and community hospital settings. The excellent results of the large prospective studies (North American Symptomatic Carotid Endarterectomy Trial, Asymptomatic Carotid Atherosclerosis Study) have been criticized because of a widely held impression that community hospitals could not duplicate the excellent surgical results achieved in high volume university hospitals or clinics. The purpose of this study was to use the National Surgical Quality Improvement Program data to evaluate the outcomes of CEA in academic versus community hospitals. All patients undergoing CEA were identified in the National Surgical Quality Improvement Program database conducted between January 1, 2005 and October 30, 2009. The patients were stratified on the basis of the hospital of care: academic hospital or community hospital. All postoperative outcomes were analyzed. A total of 17,388 CEAs met the inclusion criteria, among which 9,649 cases were performed at an academic institution and 7,739 cases were performed at a community hospital. There were more women in the community hospital cohort (42.5% vs. 40.2%, p = 0.0197). Preoperatively, the community hospital cohort had more patients with dyspnea (22.8% vs. 18.1%, p < 0.0001), chronic obstructive pulmonary disease (COPD) (10.7% vs. 9.7%, p = 0.0322), angina (2.6% vs. 1.9%, p = 0.0021), previous stroke with no deficit (9.0% vs. 7.6%, p = 0.0009), and past transient ischemic attacks (28.3% vs. 25.1%, p < 0.0001). The academic hospital cohort had more patients with recent alcohol use (4.5% vs. 3.8%, p = 0.0245), cardiac surgery (24.0% vs. 22.5%, p = 0.0206), and hemiplegia (4.8% vs. 4.1%, p = 0.0288). Postoperatively, there was no difference in the two groups in 30-day stroke rate (1.2% vs. 1.5%, p = 0.1035), 30-day myocardial infarction rate (0.5% vs. 0.6%, p = 0.2149), or 30-day mortality rate (0.5% vs. 0.6%, p = 0.6335). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (2.2% vs. 2.7%, p = 0.0568). In the asymptomatic patient cohort, there were a total of 9,285 cases, with 5311 cases performed at an academic institution and the remainder at community hospitals. Preoperatively, the community hospitals had more patients with dyspnea (78.3% vs. 82.1%, p < 0.0001). The academic cohort had more patients with acute renal failure (0.3% vs. 0.1%, p = 0.0426). Postoperatively, there was no difference in the two groups in 30-day stroke rate (0.9% vs. 1.1%, p = 0.2899), 30-day myocardial infarction rate (0.4% vs. 0.5%, p = 0.4348), or 30-day mortality rate (0.5% vs. 0.4%, p = 0.6370). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (1.8% vs. 2.0%, p = 0.4394). CEA is widely performed in both academic and community hospital settings. This study demonstrates that the results are equivalent and have equally good 30-day outcomes in both asymptomatic and combined populations.