Relationships between 2-Year Survival, Costs, and Outcomes following Carotid Endarterectomy in Asymptomatic Patients in the Vascular Quality Initiative

• Published in: Annals of vascular surgery Vol. 35; pp. 174 - 182
• Main Authors: Wallaert, Jessica B, Newhall, Karina A, Suckow, Bjoern D, Brooke, Benjamin S, Zhang, Min, Farber, Adrienne E, Likosky, Donald, Goodney, Philip P
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01-08-2016
• Subjects: Aged; Aged, 80 and over; Asymptomatic Diseases; Carotid Stenosis - diagnostic imaging; Carotid Stenosis - economics; Carotid Stenosis - mortality; Carotid Stenosis - surgery; Endarterectomy, Carotid - adverse effects; Endarterectomy, Carotid - economics; Endarterectomy, Carotid - mortality; Female; Health Care Costs; Humans; Kaplan-Meier Estimate; Male; Medicare; Proportional Hazards Models; Prospective Studies; Quality Improvement - economics; Quality Indicators, Health Care - economics; Registries; Risk Assessment; Risk Factors; Severity of Illness Index; Surgery; Time Factors; Treatment Outcome; United States
• ISSN: 0890-5096; 1615-5947
• DOI: 10.1016/j.avsg.2016.01.024

Background Carotid endarterectomy (CEA) for asymptomatic patients with limited life expectancy may not be beneficial or cost-effective. The purpose of this study was to examine relationships among survival, outcomes, and costs within 2 years following CEA among asymptomatic patients. Methods Prospectively collected data from 3097 patients undergoing CEA for asymptomatic disease from Vascular Quality Initiative VQI registry were linked to Medicare. Models were used to identify predictors of 2-year mortality following CEA. Patients were classified as low, medium, or high risk of death based on this model. Next, we examined costs related to cerebrovascular care, occurrence of stroke, rehospitalization, and reintervention within 2 years following CEA across risk strata. Results Overall, 2-year mortality was 6.7%. Age, diabetes, smoking, congestive heart failure (CHF), chronic obstructive pulmonary disease, renal insufficiency, absence of statin use, and contralateral internal carotid artery (ICA) stenosis were independently associated with a higher risk of death following CEA. In-hospital costs averaged $7500 among patients defined as low risk for death, and exceeded $10,800 among high risk patients. Although long-term costs related to cerebrovascular disease were 2 times higher in patients deemed high risk for death compared with low risk patents ($17,800 vs. $8800, P  = 0.001), high risk of death was not independently associated with a high probability of high cost. Predictors of high cost at 2 years were severe contralateral ICA stenosis, dialysis dependence, and American Society for Anesthesia Class 4. Both statin use and CHF were protective of high cost. Conclusions Greater than 90% of patients undergoing CEA live long enough to realize the benefits of their procedure. Moreover, the long-term costs are supported by the effectiveness of this procedure at all levels of patient risk.