Surgeon specialty and patient outcomes in carotid endarterectomy

Abstract

OBJECTIVE The goal of this study was to compare outcomes of carotid endarterectomy performed by neurological, general, and vascular surgeons. METHODS The authors identified 80,475 patients who underwent carotid endarterectomy between 2006 and 2015 in the National Surgical Quality Improvement Program, a prospectively collected, national clinical database with established reproducibility and validity. Nine hundred forty-three patients were operated on by a neurosurgeon; 75,649 by a vascular surgeon; and 3734 by a general surgeon. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by the surgeon’s primary specialty. Using propensity scores, comprising pre- and intraoperative characteristics as well as procedure and diagnostic codes, the authors matched 203 neurosurgery (NS) patients to 203 vascular surgery (VS) patients and 203 NS patients to 203 general surgery (GS) patients. No pre- or intraoperative factors were significantly different between specialties in the matched sample. Regular logistic regression and conditional logistic regression were used to predict postoperative complications in the full sample and in the matched sample. RESULTS In the complete population sample, NS patients, when compared to patients of general and vascular surgeons, were less likely to be admitted from home and more likely to have carotid artery occlusion or stenosis with cerebral infarction, to be a current smoker, to have had recent chemo- or radiotherapy, to have surgery under general anesthesia, to undergo multiple procedures, and to have longer surgery times. In unadjusted analyses, NS patients were more likely to experience major complications (NS vs VS: odds ratio 1.3, 95% CI 1.1–1.6; NS vs GS: odds ratio 1.3, 95% CI 1.0–1.7); minor complications (NS vs VS: odds ratio 2.9, 95% CI 2.0–4.1; NS vs GS: odds ratio 2.7, 95% CI 1.7–4.2); intra- or postoperative transfusions (NS vs VS: odds ratio 1.6, 95% CI 1.4–1.9; NS vs GS: odds ratio 1.9, 95% CI 1.6–2.3); prolonged hospitalization (NS vs VS: odds ratio 3.0, 95% CI 2.6–3.5; NS vs GS: odds ratio 2.6, 95% CI 2.2–3.0); and discharge to skilled care facilities (NS vs VS: odds ratio 2.8, 95% CI 2.3–3.4; NS vs GS: odds ratio 3.1, 95% CI 2.4–4.1). In adjusted, propensity-matched analyses, however, patients’ outcome with carotid endarterectomy performed by NS was comparable with those completed by GS and VS. CONCLUSIONS Patients who undergo carotid endarterectomy performed by a neurosurgeon tend to have a greater preoperative disease burden than do those treated by a general or vascular surgeon, which contributes significantly to more morbid postoperative courses. In patients matched carefully on the basis of health status at the time of surgery and intraoperative variables that affect results, patients’ outcomes after carotid endarterectomy do not appear to depend on the attending surgeon’s primary specialty.