Improving Quality of Carotid Interventions: Identifying Hospital-Level Structural Factors that can Improve Outcomes

Kamran Gaba,Dylan Morris,Alison Halliday,Richard Bulbulia,Prem Chana

doi:10.1016/j.avsg.2020.09.066

Kamran Gaba, Dylan Morris + Show 3 more

Open Access

https://doi.org/10.1016/j.avsg.2020.09.066

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Abstract

Background“Structural factors” relating to organization of hospitals may affect procedural outcomes. This study's aim was to clarify associations between structural factors and outcomes after carotid endarterectomy (CEA) and carotid endarterectomy stenting (CAS).MethodsA systematic review of studies published in English since 2005 was conducted. Structural factors assessed were as follows: population size served by the vascular department; number of hospital beds; availability of dedicated vascular beds; established clinical pathways; surgical intensive care unit (SICU) size; and specialty of surgeon/interventionalist. Primary outcomes were as follows: mortality; stroke; cardiac complications; length of hospital stay (LOS); and cost.ResultsThere were 11 studies (n = 95,100 patients) included in this systematic review.For CEA, reduced mortality (P < 0.0001) and stroke rates (P = 0.001) were associated with vascular departments serving >75,000 people. Larger hospitals were associated with lower mortality, stroke rate, and cardiac events, compared with smaller hospitals (less than 130 beds).Provision of vascular beds after CEA was associated with lower mortality (P = 0.0008) and fewer cardiac events (P = 0.03). Adherence to established clinical pathways was associated with reduced stroke and cardiac event rates while reducing CEA costs.Large SICUs (≥7 beds) and dedicated intensivists were associated with decreased mortality after CEA while a large SICU was associated with reduced stroke rate (P = 0.001).Vascular surgeons performing CEA were associated with lower stroke rates and shorter LOS (P = 0.0001) than other specialists. CAS outcomes were not influenced by specialty but costless when performed by vascular surgeons (P < 0.0001).ConclusionsStructural factors affect CEA outcomes, but data on CAS were limited. These findings may inform reconfiguration of vascular services, reducing risks and costs associated with carotid interventions.

Highlights

The structure of a health care system can impact on quality of patient care
We aimed to examine the evidence for an association between structural factors and procedural outcomes (mortality; stroke; combined stroke/ death; myocardial infarction (MI)/cardiac events; length of hospital stay (LOS); and cost) after carotid endarterectomy (CEA) or carotid artery stenting (CAS)
There was no effect on MI/cardiac event rate (2.5% vs. 2.2%; P 1⁄4 0.32).[22]

Summary

Introduction

The structure of a health care system can impact on quality of patient care. Donabedian described how three factors involved in health care delivery interact to influence quality of outcome for a given patient.[1] First, ‘‘structural factors’’ assess the systemic/organizational elements that reflect the setting within which care is delivered.[1] Second, ‘‘process factors’’ assess the quality of care that a patient receives.[1] For example, Hannan et al.[2] demonstrated that use of shunts, patches, eversion, and protamine reduced complication rates after carotid endarterectomy (CEA). ‘‘outcome measures’’ are useful for assessing the results of the intervention.[1] Table I provides examples of these factors with their advantages and disadvantages.[3]

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