The Relationship between Hospital Case Volume and Outcome from Carotid Endartectomy in England from 2000 to 2005

Objectives

To assess the outcome of carotid endarterectomy in England with respect to the hospital case-volume.

Methods

Data were from English Hospital Episode Statistics (2000–2005). Admissions were classified as elective or emergency. Risk-adjusted data were analysed through modelling of death rate, complication rate and length of admission with regard to the year of procedure and annual hospital volume of surgery. Hospitals with elevated death rates were identified and the evidence quantified that they had outlying mortality rates.

Results

There were 280 081 diagnoses of extra-cranial atherosclerotic arterial disease in which 18 248 CEA were performed. The mean mortality rates were 1.04% for elective and 3.16% for emergency CEA.

A volume-related improvement in mortality (p=0.047) was seen for elective CEA. Length of stay decreased as annual volume increased for elective and emergency CEA (p<0.001).

20% of the operations were performed in 67.1% of the hospitals, each of which performed fewer than 10 CEA per annum. A number of hospitals had elevated death rates.

Conclusions

Volume-related improvements in outcome were demonstrated for elective CEA. Minimum volume-criteria of 35 CEA per annum should be established in England. Hospitals performing low annual volumes of surgery should consider arrangements to network services.

Keywords: Carotid endarterectomy, Mortality, Volume, Outcome, Stroke, Centralization