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

Abstract Background and Objective ‘Structural factors’ relating to organisation of hospitals may affect procedural outcomes. This study’s aim was to clarify associations between structural factors and outcomes following carotid endarterectomy (CEA) and stenting (CAS). Methods A systematic review of studies published in English since 2005 was conducted. Structural factors assessed were: 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: mortality; stroke; cardiac complications; length of hospital stay (LOS); and cost. Results There were 11 studies (n=95,100 patients) included in this systematic review. For CEA, reduced mortality (p 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 following 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 whilst reducing CEA costs. Large SICUs (≥7 beds) and dedicated Intensivists were associated with decreased mortality following CEA whilst 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 cost less when performed by Vascular Surgeons (p Conclusions Structural factors affect CEA outcomes, but data on CAS were limited. These findings may inform re-configuration of vascular services, reducing risks and costs associated with carotid interventions.