Evaluation of regional variations in length of stay after elective, uncomplicated carotid endarterectomy in North America

ObjectiveThe objective of this study was to evaluate factors affecting regional variation in length of stay (LOS) after elective, uncomplicated carotid endarterectomy (CEA).MethodsData were obtained from the Vascular Quality Initiative database and included patients with complete data who received elective CEA without complications between 2012 and 2017 across 18 regions in North America and 294 centers. The main outcome measure was LOS >1 day after surgery (LOS >1 postoperative day [POD]). Using least absolute shrinkage and selection operator regression, multivariable modeling, and mixed-effects general linear modeling, we evaluated whether regional variations in LOS were independent of demographic, clinical, or center-related factors and to what extent these factors accounted for postoperative variation in LOS.ResultsA total of 36,004 patients were included. Mean postprocedure LOS was 1.6 ± 6.6 days. Overall, 24% of patients had an LOS >1 POD. After adjustment for important demographic, clinical, and center-related factors, the region in which a patient was treated independently and significantly affected LOS after elective, uncomplicated CEA. Region and center of treatment accounted for 18% of LOS variation. Demographic, clinical, and surgical factors accounted for another 32% of variation in LOS. Of these factors, postoperative discharge to a facility other than home (odds ratio [OR], 6.3; confidence interval [CI], 5.2-7.6), use of intravenous (IV) vasoactive agents (OR, 3.2; CI, 3-3.4), intraoperative drain placement (OR, 1.4; CI, 1.3-1.55), and female sex (OR, 1.4; CI, 1.3-1.5) were associated with longer LOS. Factors associated with LOS ≤1 POD included preoperative aspirin (OR, 0.88; CI, 0.8-0.96) and statin use (OR, 0.9; CI, 0.83-0.98), high surgeon volume (highest quartile: OR, 0.68; CI, 0.5-0.87), and completion evaluation after CEA (eg, Doppler, ultrasound; OR, 0.87; CI, 0.8-0.95). We also found that use of IV vasoactive medications varied significantly across regions, independent of demographic and clinical factors.ConclusionsSignificant regional variation in LOS exists after elective, uncomplicated CEA even after controlling for a wide range of important factors, indicating that there remain unmeasured causes of longer LOS in some regions. Even so, modification of certain clinical practices may reduce overall LOS. Regional differences in use of IV vasoactive medications not driven by clinical factors warrant further analysis, given the strong association with longer LOS

Statin Intensity or Achieved LDL? Practice-based Evidence for the Evaluation of New Cholesterol Treatment Guidelines

<div><p>Background</p><p>The recently updated American College of Cardiology/American Heart Association cholesterol treatment guidelines outline a paradigm shift in the approach to cardiovascular risk reduction. One major change included a recommendation that practitioners prescribe fixed dose statin regimens rather than focus on specific LDL targets. The goal of this study was to determine whether achieved LDL or statin intensity was more strongly associated with major adverse cardiac events (MACE) using practice-based data from electronic health records (EHR).</p><p>Methods</p><p>We analyzed the EHR data of more than 40,000 adult patients on statin therapy between 1995 and 2013. Demographic and clinical variables were extracted from coded data and unstructured clinical text. To account for treatment selection bias we performed propensity score stratification as well as 1:1 propensity score matched analyses. Conditional Cox proportional hazards modeling was used to identify variables associated with MACE.</p><p>Results</p><p>We identified 7,373 adults with complete data whose cholesterol appeared to be actively managed. In a stratified propensity score analysis of the entire cohort over 3.3 years of follow-up, achieved LDL was a significant predictor of MACE outcome (Hazard Ratio 1.1; 95% confidence interval, 1.05–1.2; P < 0.0004), while statin intensity was not. In a 1:1 propensity score matched analysis performed to more aggressively control for covariate balance between treatment groups, achieved LDL remained significantly associated with MACE (HR 1.3; 95% CI, 1.03–1.7; P = 0.03) while treatment intensity again was not a significant predictor.</p><p>Conclusions</p><p>Using EHR data we found that on-treatment achieved LDL level was a significant predictor of MACE. Statin intensity alone was not associated with outcomes. These findings imply that despite recent guidelines, achieved LDL levels are clinically important and LDL titration strategies warrant further investigation in clinical trials.</p></div

Demographic and clinical characteristics of matched patient cohort (N = 2,056).

<p>Demographic and clinical characteristics of matched patient cohort (N = 2,056).</p

Word cloud of top 75 words enriched in patients having a major adverse cardiac event during follow-up compared to those who did not (N = 7,373).

<p>Word cloud of top 75 words enriched in patients having a major adverse cardiac event during follow-up compared to those who did not (N = 7,373).</p

Inclusion/Exclusion criteria.

<p>LDL, low-density lipoprotein.</p

Statin therapy dosage and intensity (from ACC/AHA Guidelines)^a.

<p>Statin therapy dosage and intensity (from ACC/AHA Guidelines)<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0154952#t001fn001" target="_blank">^a</a>.</p

Stratified Cox proportional hazards model^a of MACE outcomes in matched cohort (N = 2,056).

<p>Stratified Cox proportional hazards model<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0154952#t004fn001" target="_blank">^a</a> of MACE outcomes in matched cohort (N = 2,056).</p

Demographic and Clinical Data for 7,373 patients.

<p>Demographic and Clinical Data for 7,373 patients.</p

Hazard ratios for cholesterol levels and intensity of statin therapy in matched cohort (N = 2,056).

<p>LDL, low-density lipoprotein; HDL, high-density lipoprotein.</p

Propensity score distribution <i>before</i> matching.

<p>Propensity score distribution <i>before</i> matching.</p