Surgeon Volume as an Indicator of Outcomes After Carotid Endarterectomy

BACKGROUND: High-volume hospitals have been shown to have superior outcomes after carotid endarterectomy (CEA), but the contribution of surgeon volume and specialty practice to CEA outcomes in a national sample is unknown. STUDY DESIGN: Using the National Inpatient Sample for 1996 and 1997, 35,821 patients who underwent CEA (ICD-9-CM code 3812) and had data for unique surgeon identification were studied. Surgeons were categorized in terms of annual CEA volume as low-volume surgeons ( or = 30). Data from cardiac, general, neurologic, and vascular surgical practices were analyzed. In-hospital mortality, postoperative stroke, and prolonged length of stay (> 4 days) were the primary outcomes variables. Unadjusted and case-mix adjusted analyses were performed. RESULTS: The overall in-hospital mortality was 0.61%. CEA was performed annually by high-volume surgeons in 52% of patients, by medium-volume surgeons in 30% of patients, and by low-volume surgeons in 18% of patients. Observed mortality by surgeon volume was 0.44% for high-volume surgeons, 0.63% for medium-volume surgeons, and 1.1% for low-volume surgeons (p 65 years (OR = 2.0; 95% CI 1.3 to 3.1, p = 0.001), low-volume surgeon (OR = 1.9; 95% CI 1.4 to 2.5, p < 0.001), and COPD (OR = 1.8; 95% CI 1.3 to 2.5, p = 0.001). Low hospital CEA volume (< 100) was not a significant risk factor in the multivariate analysis. CONCLUSIONS: More than 50% of the CEAs in the United States are performed by high-volume surgeons with superior outcomes. Health policy efforts should focus on reducing the number of low-volume surgeons, regardless of surgeon specialty or total hospital CEA volume.