From the Society for Vascular Surgery

Comparison of 30-day readmission rates and risk factors

between carotid artery stenting and endarterectomy
Hanaa Dakour Aridi, MD, Satinderjit Locham, MD, Besma Nejim, MBChB, MPH, and
Mahmoud B. Malas, MD, MHS, FACS, Baltimore, Md

ABSTRACT
Objective: The aim of this study was to analyze the rates, reasons, and risk factors of 30-day readmission, both planned
and unplanned, after carotid revascularization as well as to evaluate major outcomes associated with those readmissions.
Methods: Using the Premier Healthcare database, we retrospectively identified patients undergoing carotid endarter-
ectomy (CEA) and carotid artery stenting (CAS) between 2009 and 2015. The primary outcome was 30-day all-cause
readmission. Secondary outcomes included mortality and overall cost associated with readmissions. Univariate and
multivariate analyses were used and further validated using coarsened exact matching on baseline differences between
CEA and CAS patients.
Results: A total of 95,687 patients underwent carotid revascularization, 13.5% of whom underwent CAS. Crude 30-day
readmission rates were 6.5% after CEA vs 6.1% after CAS (P ¼ .10). Stroke, bleeding, pneumonia, and respiratory failure
were the most common reasons for readmission after both CEA and CAS (6.7% vs 8.3%, 6.9% vs 5.3%, 3.4% vs 2.4%, and
4.4% vs 3.9%; all P > .05). Myocardial infarction and wound complications were more likely to be an indication for
readmission after CEA (4.1% vs 2.5% and 4.1% vs 1.5%, respectively; P < .05). On the other hand, readmissions due to
vascular or stent-related complications were more likely after CAS compared with CEA (5.8% vs 3.8%; P ¼ .003). On
multivariate analysis, CEA was found to be associated with 41% higher odds of readmission than CAS (adjusted odds ratio,
1.41; 95% confidence interval, 1.29-1.54; P < .001). Age, female gender, emergency/urgent procedures, concomitant cardiac
procedures, rural hospitals, and Midwest region were significantly associated with 30-day readmission. Other risk factors
included major preoperative comorbidities (diabetes, congestive heart failure, renal disease, chronic obstructive pul-
monary disease, peripheral vascular disease, and history of cancer) as well as the occurrence of postoperative stroke and
renal complications during the index admission and nonhome discharge. Coarsened exact matching between CEA and
CAS patients also yielded higher adjusted rates of readmission after CEA (6.2% vs 4.9%; P < .001). On the other hand,
patients readmitted after CAS had a longer length of hospital stay (5 days vs 4 days; P ¼ .001), increased readmission
mortality (6.2% vs 2.8%; P < .001), and higher rehospitalization costs ($8903 vs $7629; P ¼ .01) compared with those
readmitted after CEA.
Conclusions: Our results show that CAS is associated with lower 30-day readmission rates compared with CEA. However,
CAS readmissions are more complex and are associated with higher mortality and costs. We have also identified patients
who are at high risk of readmissions, which can help focus attention on interventions that can improve the management
of these patients and reduce readmission rates. (J Vasc Surg 2017;-:1-13.)

Carotid revascularization has been shown to effectively
reduce the risk of ischemic stroke in selected patients
with severe carotid artery stenosis.1 Prior studies have
focused on the safety and efficacy of carotid
From the Johns Hopkins Bayview Medical Center.
Author conflict of interest: none.
Presented as a poster at the 2017 Vascular Annual Meeting of the Society for
Vascular Surgery, San Diego, Calif, May 31-June 3, 2017.
Additional material for this article may be found online at www.jvascsurg.org.
Correspondence: Mahmoud B. Malas, MD, MHS, FACS, Johns Hopkins Bayview
Medical Center, 4940 Eastern Ave, Bldg A/5, Ste 547, Baltimore, MD 21224
(e-mail: bmalas1@jhmi.edu).
The editors and reviewers of this article have no relevant financial relationships to
disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
0741-5214
Copyright Ó 2017 by the Society for Vascular Surgery. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jvs.2017.05.097
endarterectomy (CEA) and carotid artery stenting
(CAS).2-8 However, reducing readmission has become an
important measurable quality outcome and an area of
active research because of the increased pressure placed
on hospitals and the planned monetary penalties to be
imposed on centers with higher than expected readmis-
sion rates. This has been established through the Hospital
Readmissions Reduction Program and the Patient
Protection and Affordable Care Act.1,9-15 Between 2009
and 2011, nearly 10% of Medicare patients who underwent
carotid revascularization returned to the hospital within
30 days of discharge.1 CEA has been considered the surgi-
cal procedure with the third highest readmission rate.16
However, a study published in the Journal of the
American College of Cardiology found that CAS was asso-
ciated with higher 30-day readmission rates compared
with CEA.

1
2 Dakour Aridi et al
With the continuous improvement of revascularization
techniques, we sought to evaluate 30-day readmission,
including causes and risk factors, after CEA and CAS us-
ing a large nationwide database. This can offer insight
into clinical decision-making and can guide effective
strategies that can reduce readmission and improve
the quality of care of patients undergoing carotid
revascularization.
METHODS
Data source. A retrospective study using the Premier
Healthcare database (PHD) between 2009 and 2015
was performed and approved by the Institutional Review
Board. The PHD is a large, U.S. hospital-based, service-
level, all-payer database that contains information on
inpatient discharges, primarily from geographically
diverse nonprofit, nongovernmental, community and
teaching hospitals and health systems from rural and
urban areas. The PHD is a dynamic database that is
updated weekly. To date, the PHD maintains cumulative
information from >700 hospitals with >80 million inpa-
tient admissions since 2011 (approximately 20% of
annual inpatient discharges in the United States).17
The PHD offers deidentified, Health Insurance Porta-
bility and Accountability Act-compliant data from stan-
dard hospital discharge billing files. These data include
demographics and disease states; admission and
discharge diagnoses; information on billed services,
including costs and charges at the departmental level;
and patient disposition and discharge health status. For
most data elements, <1% of patient records have missing
information; and for key elements, such as demo-
graphics and diagnostic information, <0.01% have
missing data. Data are subject to an extensive validation
process occurring during implementation and with each
monthly data submission by the hospital to ensure accu-
rate and complete reporting.
Subjects. Patients who underwent carotid revasculari-
zation (CAS or CEA) were identified using admission
and primary procedure-specific codes from the Interna-
tional Classification of Diseases, Ninth Revision, Clinical
Modification for CAS (00.63) and CEA (38.12). Patients
with concomitant contralateral or ipsilateral carotid
revascularization (0.12%), length of stay >30 days (0.35%),
and death during the index hospital stay (0.6%) were
excluded from the analysis. The need for informed con-
sent of the patients was waived because the data are
deidentified data and not considered human subjects
research under federal guidelines.
Outcomes. The primary outcome of interest was 30-
day readmission. Using a unique masked identifier, pa-
tients were tracked across the inpatient settings to assess
consecutive admissions to the index hospital in a chro-
nologic order as well as the cumulative number of days
since the previous admission. Secondary outcomes
Journal of Vascular Surgery
--- 2017
ARTICLE HIGHLIGHTS
d
Type of Research: Retrospective analysis of the pro-
spectively collected Premier Healthcare database
d
Take Home Message: Of 95,687 patients who under-
went carotid revascularizations, carotid artery stent-
ing patients had lower 30-day readmission rates
but more complex readmissions with higher mortal-
ity and costs than carotid endarterectomy patients.
d
Recommendation: This study suggests that read-
missions after carotid artery stenting, although less
frequent, are more complex and have higher mortal-
ity rates and costs than readmissions after carotid
endarterectomy.
included medical and surgical complications during
both the initial hospitalization and the readmission stay.
These were identified using secondary diagnosis and
procedure codes provided in Supplementary Table I
(online only). Device-related complications included
stent occlusion, CEA patch infection, and occlusion of
the carotid artery. Furthermore, in-hospital outcomes in
readmitted patients including mortality, complications,
and total hospitalization costs were analyzed. Costs
are those reported by the hospital. They are not the
charge to a payer or the amount reimbursed to the
hospital. Currency data were presented as medians,
adjusted for inflation for 2015 U.S. dollars using the
Consumer Price Index Inflation Calculator from the U.S.
Department of Labor. Symptomatic status was defined
as presenting with transient cerebral ischemia, carotid
artery stenosis with cerebral infarction, stroke, or tran-
sient limb paralysis as well as retinal vascular occlusion
or retinal ischemia.
Statistical analyses. Student independent t-tests and
Wilcoxon rank sum tests were used to analyze contin-
uous variables, and c2 tests were used to compare cate-
gorical variables. Multiple logistic regression models were
used to study the association between 30-day read-
mission and patients’ demographics, comorbidities,
symptomatic status, and discharge destination as well as
hospital teaching status and provider regions. Variables
included in the final models were chosen on the basis of
clinical relevance or a P value # .20 on initial bivariate
analysis. C statistics and the Hosmer-Lemeshow test
evaluated the models’ predictive ability and goodness of
fit, respectively. Regression models were also checked for
multicollinearity using variance inflation factors for each
covariate (mean variance inflation factor, 1.13; maximum,
1.56). The analysis was validated using coarsened exact
matching (CEM) described by Iacus et al18 to ensure valid
evaluation of patients within each procedure and to
avoid selection bias. Matching was performed on base-
line characteristics that were significantly different
Journal of Vascular Surgery Dakour Aridi et al 3
Volume -, Number -

Table I. Baseline characteristics of patients undergoing Table I. Continued.

carotid endarterectomy (CEA) and carotid artery stenting
CEA CAS P value
(CAS)
Charlson Comorbidity Index
CEA CAS P value
I 30,834 (37.2) 4474 (34.8) <.001
No. of patients 82,817 (86.5) 12,870 (13.5)
II 26,717 (32.3) 3757 (29.2)
Age, years, 71.9 (8.3) 71.7 (8.5) .06
mean (SD) III 13,024 (15.7) 2148 (16.7)

Gender <.001 IV 6714 (8.1) 1277 (9.9)

Female 34,562 (41.7) 5009 (38.9) V 3260 (3.9) 650 (5.1)

Male 48,246 (58.3) 7861 (61.1) VI 2268 (2.7) 564 (4.4)

Race <.001 CHF, Congestive heart failure; COPD, chronic obstructive pulmonary
disease; MI, myocardial infarction; SD, standard deviation.
White 68,408 (82.6) 10,367 (80.6) Values are reported as number (%) unless otherwise indicated.
Black 3450 (4.2) 604 (4.7)
Others 10,959 (13.2) 1899 (14.7)
Insurance type <.001 between CEA and CAS patients, including age, gender,
Medicare 64,679 (78.5) 9893 (77.6) race, insurance type, admission type (elective, emer-
gency, and urgent), concomitant cardiac procedures,
Medicaid 2359 (2.9) 509 (4.0)
teaching status, region (rural vs urban), provider area,
Private insurance 13,406 (16.3) 2031 (15.9)
symptomatic status, medical comorbidities (old
Other 1978 (2.4) 315 (2.5)
myocardial infarction [MI], congestive heart failure [CHF],
Admission type <.001
renal disease, connective tissue disease, paraplegia/
Elective 66,504 (80.3) 8707 (67.7) hemiplegia, peripheral vascular disease, and cancer), and
Emergency 5870 (7.1) 1773 (13.8) comorbidity index. Some of the advantages of CEM over
Urgent 10,008 (12.1) 2317 (18.0) standard matching approaches, such as propensity score
Others 435 (0.5) 73 (0.6) matching, are that it requires fewer postestimation as-
Concomitant cardiac 18,948 (22.9) 3548 (27.6) <.001 sumptions about how to define a match, automatically
procedures balances treatment and control populations, and has
Teaching hospitals 34,966 (42.5) 7675 (59.8) <.001 superior computational properties for large data sets.
Region <.001 Analysis was performed using Stata version 14.1 (Stata-
Rural 11,128 (13.5) 892 (7.0) Corp, College Station, Tex). Significance tests were two
Urban 71,189 (86.5) 11,948 (93.1) sided with a .05 significance level.
Provider area <.001 RESULTS
Midwest 15,202 (18.5) 2631 (20.5) A total of 95,687 patients underwent carotid revascular-
North-East 10,511 (12.8) 2173 (16.9) ization between 2009 and 2015: 82,817 CEA (86.5%) and
South 44,878 (54.5) 6478 (50.5) 12,870 (13.5%) CAS. Of those, 6118 (6.4%) were readmitted
West 11,726 (14.2) 1558 (12.1) within 30 days of discharge (CEA, 6.5%; CAS, 6.1%; P ¼ .10).
Comorbidities Comparison of baseline characteristics between the two
Symptomatic 10,591 (12.9) 2334 (18.5) <.001 groups is shown in Table I. Occurrence of more than one
Diabetes 28,658 (34.6) 4427 (34.4) .65 readmission was more common after CAS than after
Old MI 10,573 (12.8) 1723 (13.4) .05
CEA (31% vs 25%; P < .001). Compared with patients
not readmitted within 30 days, those readmitted were
CHF 7047 (8.5) 1701 (13.2) <.001
older (73 6 8.6 years vs 71.8 6 8.3 years; P < .001), were
Renal disease 9488 (11.5) 1727 (13.4) <.001
more often women (43.4% vs 41.2%; P < .001) and African
COPD 20,134 (24.3) 3120 (24.2) .87
Americans (5.6% vs 4.1%; P < .001), and were mostly
Connective tissue 1770 (2.1) 186 (1.5) <.001 covered by Medicare (81.7% vs 78.1%; P < .001; Table II).
disease
Moreover, they were more likely to be readmitted after
Peptic ulcer disease 531 (0.6) 72 (0.6) .28
emergency or urgent index procedures (36.2% vs 19.9%;
Paraplegia/hemiplegia 1593 (1.9) 755 (5.9) <.001 P < .001) or with concomitant cardiac procedures
Liver disease 694 (0.8) 104 (0.8) .73 (34.2% vs 22.8%; P < .001).
Peripheral vascular 20,790 (25.1) 4067 (31.6) <.001 Readmitted patients were more likely to be symptom-
disease atic on initial presentation (21.4% vs 13.1%; P < .001) and
Cancer 1471 (1.8) 315 (2.5) <.001 had a higher prevalence of comorbid conditions, such as
(Continued) diabetes (40.9% vs 34.2%), history of MI (15.5% vs 12.7%),
4 Dakour Aridi et al Journal of Vascular Surgery
--- 2017

Table II. Comparison of baseline characteristics and Table II. Continued.

in-hospital complications between patients readmitted
Not
and those not readmitted within 30 days of carotid
readmitted Readmitted P value
revascularization
Peripheral arterial 23,045 (25.7) 1812 (29.6) <.001
Not
disease
readmitted Readmitted P value
Cancer 1594 (1.8) 192 (3.1) <.001
No. of patients 89,569 (94.6) 6118 (6.4)
Charlson Comorbidity
Procedure Index
CEA 77,479 (86.5) 5338 (87.3) .10 I 33,736 (37.6) 1572 (25.7) <.001
CAS 12,090 (13.5) 780 (12.7) II 28,803 (32.2) 1671 (27.3)
Age, years, mean (SD) 71.8 (8.3) 73.0 (8.6) <.001 III 13,996 (15.6) 1176 (19.2)
Gender IV 7234 (8.1) 757 (12.4)
Male 52,642 (58.8) 3465 (56.6) <.001 V 3422 (3.8) 488 (8.0)
Female 36,918 (41.2) 2653 (43.4) VI 2378 (2.7) 454 (7.4)
Race In-hospital complications
White 73,823 (82.4) 4952 (80.9) <.001 Hemorrhage or 6563 (7.3) 699 (11.4) <.001
Black 3712 (4.1) 342 (5.6) bleeding
Others 12,034 (13.4) 824 (13.5) Vascular or stent 135 (0.15) 31 (0.5) <.001
complication
Insurance type
Cardiac (MI, CHF, 5178 (5.8) 615 (10.1) <.001
Medicare 69,598 (78.1) 4974 (81.7) <.001
arrhythmia)
Medicaid 2666 (3.0) 202 (3.3)
Respiratory (pneumonia 1382 (1.5) 287 (4.7) <.001
Private insurance 14,672 (16.5) 765 (12.6) or respiratory failure)
Other 2147 (2.4) 146 (2.4) Renal (AKI, UTI, others) 2304 (2.6) 424 (6.9) <.001
Admission type Stroke 1077 (1.2) 326 (5.3) <.001
Elective 71,345 (79.7) 3866 (63.2) <.001 Infectious (wound, 160 (0.2) 44 (0.7) <.001
Emergency 7046 (7.9) 597 (9.8) sepsis, others)
Urgent 10,709 (12.0) 1616 (26.4) Ileus 99 (0.1) 29 (0.5) <.001
Others 469 (0.5) 39 (0.6) Venous thromboembolic 66 (0.07) 14 (0.2) <.001
Concomitant cardiac 20,402 (22.8) 2094 (34.2) <.001 (DVT, PE)
procedures Length of stay, days, 1 (1-3) 3 (1-8) <.001
Teaching hospitals 39,931 (44.8) 2710 (44.5) .66 median (IQR)

Region Discharge destination

Rural 11,218 (12.6) 802 (13.2) .18 Home 77,265 (86.6) 3720 (61.2) <.001

Urban 77,855 (87.4) 5282 (86.8) Home under home 6792 (7.6) 687 (11.3)
health care
Provider area
General hospital 462 (0.52) 52 (0.9)
Midwest 16,569 (18.6) 1264 (20.8) <.001
Skilled nursing facility 3041 (3.4) 585 (9.6)
North-East 11,860 (13.3) 824 (13.5)
Other rehabilitation or 1672 (1.9) 1036 (17.0)
South 48,167 (54.1) 3189 (52.4) hospice
West 12,477 (14.0) 807 (13.3)
AKI, Acute kidney injury; CAS, carotid artery stenting; CEA, carotid
Comorbidities endarterectomy; CHF, congestive heart failure; COPD, chronic
obstructive pulmonary disease; DVT, deep venous thrombosis; IQR,
Symptomatic 11,632 (13.1) 1293 (21.4) <.001
interquartile range; MI, myocardial infarction; PE, pulmonary embo-
Diabetes 30,585 (34.2) 2500 (40.9) <.001 lism; SD, standard deviation; UTI, urinary tract infection.
Values are reported as number (%) unless otherwise indicated.
Old MI 11,346 (12.7) 950 (15.5) <.001
CHF 7703 (8.6) 1045 (17.1) <.001
Renal disease 9991 (11.2) 1224 (20.0) <.001 CHF (17.1% vs 8.6%), chronic obstructive pulmonary
COPD 21,453 (24.0) 1801 (29.4) <.001 disease (COPD; 29.4% vs 24.0%), and peripheral vascular
Connective tissue 1805 (2.0) 151 (2.5) .02 disease (29.6% vs 25.7%), compared with patients who
disease were not readmitted within 30 days (all P < .001). Read-
Peptic ulcer disease 550 (0.6) 53 (0.9) .02 mitted patients experienced more stroke (5.3% vs 1.2%),
Paraplegia/hemiplegia 1903 (2.1) 445 (7.3) <.001 hemorrhage/bleeding (11.4% vs 7.3%), cardiac complica-
Liver disease 735 (0.8) 63 (1.0) .08 tions (including acute MIs, CHF, and arrhythmias; 10.1%
(Continued) vs 5.8%), and more respiratory (4.7% vs 1.5%) and renal
Journal of Vascular Surgery
Volume -, Number -
35
30
25
Percentage
20
15
10
Fig. Most common readmission indications after carotid endarterectomy (CEA) and carotid artery stenting
(CAS). GI, Gastrointestinal.
(6.9% vs 2.6%) complications during the index admission
compared with patients not readmitted (all P < .001). Me-
dian index length of stay was significantly higher in read-
mitted patients (median [interquartile range], 3 [1-8] vs 1
[1-3] days; P < .001). A significant portion of readmitted pa-
tients were not discharged home initially, with 10.5%
transferred to a general hospital or a skilled nursing facility
and 11.3% discharged home under a home health service
organization.
Causes of readmission. A total of 7153 readmissions
occurred, mostly 1 week after discharge from the hospi-
tal. Other than nonspecific complaints such as fatigue,
fever, headache, syncope, and admission for physical
therapy, most common indications of these readmis-
sions (n ¼ 7153) were related to cardiac, neurologic, infec-
tious, and respiratory complications (Fig). Stroke was one
of the most common reasons for readmission after both
CAS and CEA (8.3% vs 6.7%; P ¼ .07), followed by hem-
orrhage/shock/bleeding (5.3% vs 6.9%; P ¼ .06), pneu-
monia (2.4 vs 3.4%; P ¼ .12), and respiratory failure (3.9% vs
4.4%; P ¼ .5). MI and wound complications were more
Dakour Aridi et al 5
CEA CAS
likely to be an indication for readmission after CEA
compared with CAS (4.1% vs 2.5% [P ¼ .02] and 4.1% vs
1.5% [P < .001], respectively; Table III). On the other hand,
readmissions due to vascular or stent-related complica-
tions were more likely after CAS than after CEA (5.8% vs
3.8%; P ¼ .003).
Predictors of 30-day readmission. After multivariate
adjustment, CEA was found to be associated with 41%
higher odds of readmission compared with CAS
(adjusted odds ratio [aOR], 1.41; 95% confidence interval
[CI], 1.29-1.54). Advanced age (aOR, 1.01; 95% CI,
1.00-1.01), female gender (aOR, 1.09; 95% CI, 1.03-1.16),
emergency and urgent procedures (aOR, 1.43 [95% CI,
1.32-1.55] and 1.14 [95% CI, 1.03-1.26], respectively), and
concomitant cardiac procedures (aOR, 1.18; 95% CI,
1.11-1.26) were significantly associated with higher odds of
readmission (P < .05). Other risk factors included hospi-
tals’ location (rural and Midwest areas had higher odds of
readmission); major comorbidities, such as diabetes,
CHF, renal disease, COPD, peripheral arterial disease, and
a history of cancer; and nonhome discharge. The model
6 Dakour Aridi et al
was able to predict only 8.8% of variability in 30-day
readmission (R2 ¼ 8.8%; C statistic ¼ 69.5%). Further
including in-hospital complications did not significantly
improve predictability (R2 ¼ 8.9%; C statistic ¼ 69.6%).
Among in-hospital complications, stroke increased the
odds of 30-day readmission by 40% (aOR, 1.40; 95% CI,
1.20-1.64; P < .001) and renal adverse events by 14% (aOR,
1.14; 95% CI, 1.01-1.30; P ¼ .04; Table IV).
Subgroup analysis: CEM. Exact one-to-one matching
was performed on the basis of baseline characteristics
that were shown to be significantly different between
CEA and CAS patients, including age, gender, race, in-
surance coverage, admission type, presence of concom-
itant cardiac procedures, region (urban vs rural), provider
area, hospital teaching status, and medical comorbidities
that make up the Charlson Comorbidity Index (history of
MI, CHF, connective tissue disease, paraplegia/hemiple-
gia, peripheral arterial disease, and renal disease). This
yielded two comparison groups each with 8966 patients
(Supplementary Table II, online only). Comparison of the
two groups showed higher adjusted 30-day readmission
rates after CEA compared with CAS (6.2% vs 4.9%; P <
.001). Secondary outcomes that are significantly different
between CEA and CAS were in-hospital stroke (1.8% vs
1.2%; P < .01), arrhythmia (4.9% vs 6.7%; P < .001), hem-
orrhage/bleeding (8.6% vs 7.4%; P < .01), acute kidney
injury (1.8% vs 1.5%; P ¼ .05), and discharge disposition
(Table V). We further controlled for in-hospital post-
operative complications, and readmission was still 35%
higher after CEA compared with CAS (aOR, 1.35; 95% CI,
1.18-1.54; P < .001).
Outcomes of readmitted patients. Patients readmitted
after CAS had a longer length of hospital stay (5 days vs
4 days; P ¼ .001) and significantly higher readmission
mortality (6.2% vs 2.8%; P < .001) compared with those
readmitted after CEA. Adjusted readmission mortality
was two times higher in patients readmitted after CAS
vs CEA (aOR, 2.0; 95% CI, 1.5-2.8; P < .001). Throughout
the readmission, patients were also subject to various
adverse events complicating the course of their rehospi-
talization after CEA and CAS. These included bleeding
(4.8% after CEA vs 3.1% after CAS; P ¼ .02), cardiac (6.7%
vs 6.1%; P ¼ .53), respiratory (3.5% vs 5.0%; P ¼ .03), and
renal (5.3% vs 6.7%; P ¼ .10) complications. The median
total, fixed, and variable costs of readmission were higher
if the readmission occurred after CAS compared with
CEA ($8903, $4313, and $4390 vs $7629, $3762, and
$3651, respectively). Adjusted rehospitalization costs after
CAS were higher by around U.S. $700 compared with
those after CEA (Table VI).
DISCUSSION
Carotid revascularization is a high-volume procedure
with significant readmission rates. The likelihood that
the Centers for Medicare and Medicaid Services will
Journal of Vascular Surgery
--- 2017
penalize readmissions after vascular procedures in the
future is high; thus, reducing unplanned readmissions
has become of prominent importance to improve qual-
ity of care and to reduce significant expenses both to
the health care system and to the patient.19
The overall 30-day readmission rate in our study was
around 6.4%, which is comparable to that reported using
other large population databases.20-22 Al-Damluji et al1
reported a much higher unadjusted 30-day readmission
rate (9.6%). For CEA, overall reported readmission rates
are around 6.5%15,20,22,23 but can be as high as 9.4%.24
On the other hand, reported readmission rates after
CAS range between 9.7%22 and 11.11%,25 which is higher
compared with our study (6.1%).
Our study shows an association between CEA and
increased all-cause readmission rates after risk adjust-
ment (aOR, 1.41; 95% CI, 1.29-1.54; P < .001) as well as after
exact matching (6.2% vs 4.9%; P < .001). This is in contrast
to two previous studies that demonstrated higher
adjusted risk of readmission after CAS compared with
CEA.1,25 Galinanes et al25 used the Centers for Medicare
and Medicaid Services Medicare Provider Analysis and
Review file between 2005 and 2009 and showed
increased odds of readmission in patients undergoing
CAS compared with those undergoing CEA within
30 days (aOR, 1.21; 95% CI, 1.15-1.26; P < .0001), 60 days
(aOR, 1.34; 95% CI, 1.29-1.39; P < .0001), and 90 days after
discharge (aOR, 1.36; 95% CI, 1.31-1.40), with coronary ar-
tery disease being the most common reason for read-
mission. In addition, Al-Damluji et al1 showed 13%
higher adjusted risk of readmission after CAS (aOR, 1.13,
95% CI, 1.08-1.18; P < .001) using Medicare beneficiaries
from 2009 to 2011 with the same relationship holding
true in a propensity-matched cohort (OR, 1.18; 95% CI,
1.07-1.23) regardless of symptomatic status, age, sex, and
race. An important finding by the authors was that the
variation in proportional use of CAS was not associated
with differences in hospital risk-standardized readmis-
sion rates. Thus, hospitals with more frequent CAS use
will not necessarily be disadvantaged when hospitals
with higher than expected readmissions are penalized.
However, an editorial comment on that study cautioned
that the poorer performance of CAS might be due to se-
lection bias, which could not be adjusted for, and that
the small difference in readmission rates between the
two procedures might not be meaningful as it could
be a potential artifact of the study’s large sample size.26
The lower readmission rates after CAS in our study
might be explained by several factors, such as the use
of different databases and different time frames as well
as the continuous decline in 30-day major adverse events
after CAS due to the refinement in CAS techniques,
development of better stents and protection devices,
better selection of patients for each procedure, and
increased expertise of operators over time. Unlike the
cited studies that examined Medicare data between
Journal of Vascular Surgery Dakour Aridi et al 7
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Table III. Most common indications for 30-day readmission after carotid endarterectomy (CEA) and carotid artery stenting
(CAS)
CEA CAS P value Total
No. of readmissions 6205 (86.7) 948 (13.3) 7153
More than one readmission 1552 (25.0) 293 (30.9) <.001 1845 (25.8)
Time to readmission, days (IQR) 6 (1-16) 7 (1-17) .89 6 (1-16)
Hemorrhage/shock/bleeding 428 (6.9) 50 (5.3) .06 478 (6.7)
Vascular or stent complication 235 (3.8) 55 (5.8) .003 290 (4.1)
Cardiac
MI 255 (4.1) 24 (2.5) .02 279 (3.9)
Heart failure 212 (3.4) 33 (3.5) .92 245 (3.4)
Chest pain 221 (3.6) 34 (3.6) .97 255 (3.6)
Arrhythmia 240 (3.9) 35 (3.7) .79 275 (3.8)
Other cardiac 16 (0.3) 1 (0.1) .37 17 (0.2)
Respiratory
Pneumonia 211 (3.4) 23 (2.4) .12 234 (3.3)
Respiratory failure 272 (4.4) 37 (3.9) .50 309 (4.3)
Other 433 (7.0) 56 (5.9) .22 489 (6.8)
Renal or urologic
Acute kidney injury 151 (2.4) 21 (2.2) .68 172 (2.4)
Others 180 (2.9) 21 (2.2) .23 201 (2.8)
Neurologic
Stroke 417 (6.7) 79 (8.3) .07 496 (6.9)
Paraplegia 5 (0.1) 0 .38 5 (0.1)
Other neurologic 485 (7.8) 92 (9.7) .05 577 (8.1)
Infectious
Wound complication 254 (4.1) 14 (1.5) <.001 268 (3.7)
Sepsis 184 (3.0) 36 (3.8) .17 220 (3.1)
UTI/pyelonephritis 31 (0.5) 5 (0.5) .91 36 (0.5)
Other infection 173 (2.8) 12 (1.3) .01 185 (2.6)
Gastrointestinal
Bowel obstruction 16 (0.3) 3 (0.3) .73 19 (0.3)
Bowel ischemia 5 (0.1) 0 1.0 5 (0.1)
Venous thromboembolic
Deep venous thrombosis 13 (0.2) 3 (0.3) .46 16 (0.2)
Pulmonary embolism 44 (0.7) 5 (0.5) .67 49 (0.7)
Other venous 5 (0.1) 0 1.0 5 (0.1)
Reoperation
Carotid revascularization 17 (0.3) 3 (0.3) .74 20 (0.3)
Other vascular reoperation 74 (1.2) 16 (1.7) .20 90 (1.3)
Other abdominal 183 (3.0) 33 (3.5) .37 216 (3.0)
Cancer 58 (0.9) 5 (0.5) .21 63 (0.9)
Nonspecific/others
Headache 78 (1.3) 9 (1.0) .42 87 (1.2)
Nausea/vomiting/dysphagia 128 (2.1) 12 (1.3) .10 140 (2.0)
Syncope/collapse 183 (3.0) 23 (2.4) .37 206 (2.9)
Fever 79 (1.3) 11 (1.2) .77 90 (1.3)
Fatigue 120 (1.9) 14 (1.5) .33 134 (1.9)
Physical therapy 1065 (17.2) 199 (21.0) .004 1264 (17.7)
Unknown 1360 (21.9) 213 (22.5) .70 1573 (22.0)
IQR, Interquartile range; MI, myocardial infarction; UTI, urinary tract infection.
Values are reported as number (%) unless otherwise indicated.
8 Dakour Aridi et al Journal of Vascular Surgery
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Table IV. Bivariate and multivariate logistic regression models of the predictors of 30-day readmission after carotid
revascularization
Unadjusted OR (95% CI) P value Adjusted OR (95% CI) P value
Procedure
CAS 1.0 (reference) 1.0 (reference)
CEA 1.07 (0.99-1.15) .097 1.41 (1.29-1.54) <.001
Age 1.02 (1.01-1.02) <.001 1.01 (1.00-1.01) <.001
Gender
Male 1.0 (reference) 1.0 (reference)
Female 1.09 (1.04-1.15) <.01 1.09 (1.03-1.16) <.01
Race
White 1.0 (reference) 1.0 (reference)
Black 1.37 (1.22-1.54) <.001 1.09 (0.97-1.24) .16
Others 1.02 (0.95-1.10) .60 0.98 (0.90-1.06) .60
Insurance type
Medicare 1.0 (reference) 1.0 (reference)
Medicaid 1.06 (0.92-1.23) .43 1.06 (0.90-1.24) .51
Private insurance 0.73 (0.67-0.79) <.001 0.94 (0.85-1.02) .15
Other 0.95 (0.80-1.13) .57 1.08 (0.90-1.31) .40
Admission type
Elective 1.0 (reference) 1.0 (reference)
Emergency 2.78 (2.62-2.96) <.001 1.43 (1.32-1.55) <.001
Urgent 1.56 (1.43-1.71) <.001 1.14 (1.03-1.26) .01
Others 1.53 (1.11-2.13) .01 1.26 (0.88-1.79) .20
Concomitant cardiac procedures 1.76 (1.67-1.86) <.001 1.18 (1.11-1.26) <.001
Teaching hospitals 0.99 (0.94-1.04) .66 d d
Region
Rural 1.0 (reference) 1.0 (reference)
Urban 0.95 (0.88-1.02) .18 0.88 (0.81-0.96) <.01
Provider area
Midwest 1.0 (reference) 1.0 (reference)
North-East 0.91 (0.83-0.99) .04 0.83 (0.76-0.92) <.001
South 0.87 (0.81-0.93) <.001 0.92 (0.85-0.98) .02
West 0.85 (0.77-0.93) <.001 0.94 (0.85-1.03) .20
Comorbidities
Symptomatic 1.81 (1.70-1.93) <.001 1.06 (0.98-1.14) .17
Diabetes 1.33 (1.26-1.40) <.001 1.15 (1.09-1.22) <.001
Old MI 1.27 (1.18-1.36) <.001 1.06 (0.98-1.14) .16
CHF 2.19 (2.04-2.35) <.001 1.47 (1.36-1.60) <.001
Renal disease 1.99 (1.86-2.13) <.001 1.39 (1.29-1.50) <.001
COPD 1.32 (1.25-1.40) <.001 1.17 (1.10-1.25) <.001
Connective tissue disease 1.23 (1.04-1.46) .02 1.10 (0.92-1.31) .31
Peptic ulcer disease 1.41 (1.07-1.88) .02 1.07 (0.79-1.45) .66
Paraplegia/hemiplegia 3.61 (3.25-4.02) <.001 1.02 (0.89-1.17) .75
Liver disease 1.26 (0.97-1.63) .08 1.06 (0.80-1.40) .69
Peripheral arterial disease 1.21 (1.15-1.29) <.001 1.11 (1.04-1.18) <.01
Cancer 1.79 (1.54-2.08) <.001 1.52 (1.29-1.79) <.001
Discharge destination
Home 1.0 (reference) 1.0 (reference)
Home under home health care 2.10 (1.93-2.29) <.001 1.59 (1.45-1.74) <.001
(Continued on next page)
Journal of Vascular Surgery Dakour Aridi et al 9
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Table IV. Continued.

Unadjusted OR (95% CI) P value Adjusted OR (95% CI) P value
General hospital 2.34 (1.75-3.12) <.001 1.41 (1.03-1.93) .03
Skilled nursing facility 4.00 (3.64-4.39) <.001 2.60 (2.3-2.89) <.001
Other rehabilitation or hospice 12.9 (11.8-14.0) <.001 9.2 (8.26-10.2) <.001
In-hospital complications
Hemorrhage/shock/bleeding 1.63 (1.50-1.77) <.001 1.06 (0.97-1.17) .20
Vascular or stent 3.37 (2.28-4.99) <.001 1.33 (0.84-2.09) .22
Cardiac 1.82 (1.67-1.99) <.001 1.03 (0.92-1.14) .59
Respiratory 3.14 (2.76-3.58) <.001 1.12 (0.97-1.31) .13
Renal (AKI, UTI, others) 2.82 (2.53-3.14) <.001 1.14 (1.01-1.30) .04
Stroke 4.62 (4.07-5.25) <.001 1.4 (1.20-1.64) <.001
Infectious 4.05 (2.90-5.66) <.001 1.18 (0.80-1.74) .39
Ileus 4.30 (2.84-6.52) <.001 1.32 (0.81-2.13) .27
Venous thromboembolic 3.11 (1.75-5.54) <.001 0.81 (0.39-1.71) .59
AKI, Acute kidney injury; CAS, carotid artery stenting; CEA, carotid endarterectomy; CHF, congestive heart failure; CI, confidence interval; COPD, chronic
obstructive pulmonary disease; MI, myocardial infarction; OR, odds ratio; UTI, urinary tract infection.

2005 and 2009 and between 2009 and 2011, our results
represent more recent real-world outcomes and include
private insurance data in addition to Medicare data.
The most common indications of readmission in our
cohort were stroke, cardiac, infectious, and respiratory
complications, which are more likely to develop in CEA
patients after hospital discharge compared with the im-
mediate complications of CAS.20,27,28 In the Carotid
Revascularization Endarterectomy versus Stenting Trial
(CREST), the majority of CAS strokes occurred on day 0 af-
ter the procedure, whereas CEA strokes were distributed
evenly over 30 days postoperatively. This could explain
increased readmission after CEA due to stroke despite
lower overall stroke rates compared with CAS.27 A recent
study by our group using the American College of Sur-
geons National Surgical Quality Improvement Program
database and another by Greenleaf et al using the Penn-
sylvania Health Care Cost Containment Council database
showed that the risk of 30-day readmission was not pro-
cedure related but rather determined by symptomatic
status and comorbidities.22,24 In our analyses, readmis-
sion remained significantly higher after CEA than after
CAS even after adjusting for patients’ comorbidities and
symptomatic status. These findings add to the benefits
and cost-effectiveness of the less invasive CAS in high-
risk patients who are not candidates for surgery. Howev-
er, the lower readmission rates of CAS are opposed by
the high mortality associated with these readmissions.
As evident in Table VI, patients readmitted after CAS
have a longer hospital stay compared with patients read-
mitted after CEA (5 days vs 4 days; P ¼ .001), higher crude
mortality (6.2% vs 2.8%; P < .001), and increased respira-
tory complications (5.0 vs 3.5%; P ¼ .03), reflecting a more
difficult rehospitalization course in the high-risk CAS
patients compared with CEA patients. This leads to
significantly higher adjusted readmission costs for CAS
patients by around $700 (Table VI).
Identifying preventable causes of readmission after ca-
rotid revascularization is a complex task, especially given
that vascular surgery patients are usually older and have
multiple comorbidities compared with patients in other
surgical specialties. Readmission in this population of pa-
tients is thus highly related to their medical illnesses and
comorbidities rather than to the index procedure. On the
other hand, many readmissions in vascular surgery are
planned.25,29 A significant portion of patients in our study
were readmitted for nonspecific or nonrelated causes,
such as cancer/chemotherapy, abdominal surgeries,
and nonspecific complaints, such as fatigue, fever, head-
ache, syncope, and physical therapy (Table III).
The key to reducing preventable readmissions is better
perioperative planning and comorbidity management in
high-risk patients. Older patients and those with major
preoperative comorbidities (diabetes, renal disease,
COPD, peripheral arterial disease, and cancer) are re-
ported to have increased risk of adverse events leading
to higher hospital readmissions. These may require a
more intense preoperative maximization of the patient
and close postoperative follow-up.25,30 Another promi-
nent risk factor associated with increased readmission
was nonhome discharge, mainly to skilled nursing facil-
ities, rehabilitation centers, and hospice care. Among pa-
tients who were readmitted from those facilities, 16.8%
had prior CAS compared with 11.2% who were readmit-
ted from home (P < .001). Moreover, they had significant
comorbidities, such as paraplegia/hemiplegia (21.6% vs
1.3%), CHF (21.4% vs 13.6%), renal disease (23.3% vs
17.0%), diabetes (43.8% vs 39.1%), and dementia (2.4%
vs 0.9%), and more frequent complications during their
index admission, including stroke (16.0% vs 0.8%) and
10 Dakour Aridi et al Journal of Vascular Surgery
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Table V. Perioperative outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS) patients before and
after coarsened exact matching (CEM)
Before CEM, No. (%) After CEM, No. (%)
CEA (n ¼ 82,817) CAS (n ¼ 12,870) P value CEA (n ¼ 8966) CAS (n ¼ 8966) P value
Readmission
30 days 5338 (6.5) 780 (6.1) .1 560 (6.2) 438 (4.9) <.001
90 days 8512 (10.3) 1286 (10.0) .32 881 (9.8) 749 (8.3) <.01
In-hospital complications 300 (0.4) 72 (0.6)
Stroke 1082 (1.3) 321 (2.5) <.001 111 (1.2) 161 (1.8) <.01
Cardiac
MI 553 (0.7) 99 (0.8) .19 49 (0.5) 42 (0.5) .46
Heart failure 344 (0.4) 60 (0.5) .41 24 (0.27) 22 (0.24) .77
Arrhythmia 4202 (5.1) 907 (7.1) <.001 439 (4.9) 598 (6.7) <.001
Any cardiac 4794 (5.8) 999 (7.8) <.001 489 (5.4) 637 (7.1) <.001
Hemorrhage/shock/bleeding 6113 (7.4) 1149 (8.9) <.001 666 (7.4) 772 (8.6) <.01
Vascular or stent complication 79 (0.1) 87 (0.7) <.001 6 (0.07) 46 (0.5) <.001
Respiratory
Pneumonia 500 (0.6) 112 (0.9) <.001 49 (0.5) 37 (0.4) .20
Respiratory failure 1015 (1.2) 204 (1.6) .001 113 (1.3) 88 (1.0) .08
Any respiratory 1386 (1.7) 283 (2.2) <.001 148 (1.7) 110 (1.2) .02
Renal or urologic
Acute kidney injury 1817 (2.2) 314 (2.4) .08 164 (1.8) 130 (1.5) .05
Urinary tract infection 560 (0.7) 173 (1.3) <.001 43 (0.5) 73 (0.8) .01
Any renal 2264 (2.7) 464 (3.6) <.001 203 (2.3) 192 (2.1) .58
Infectious 167 (0.2) 37 (0.3) .05 17 (0.2) 15 (0.2) .72
Ileus 112 (0.1) 16 (0.1) .75 10 (0.1) 7 (90.08) .47
Venous thromboembolic event 58 (0.07) 22 (0.2) <.001 7 (0.08) 5 (0.06) .56
Discharge destination <.001 <.001
Home 70,447 (85.1) 10,538 (81.9) 7746 (86.4) 7948 (88.7)
Home under home health care 6655 (8.0) 824 (6.4) 677 (7.6) 433 (4.8)
General hospital 402 (0.5) 112 (0.9) 38 (0.4) 51 (0.6)
Skilled nursing facility 3046 (3.7) 580 (4.5) 288 (3.2) 244 (2.7)
Others or unknown 1964 (2.4) 744 (5.8) 216 (2.4) 282 (3.2)
MI, Myocardial infarction.

acute renal failure (10.7% vs 2.7%). This subpopulation of
patients might benefit from more discharge planning
and improved transitional care and, in certain cases,
deferring carotid intervention, especially for asymptom-
atic high-risk patients. Similarly, patients who experience
stroke and renal complications during their index admis-
sion have 40% and 14% increased odds of 30-day read-
mission (aOR, 1.4 [95% CI, 1.20-1.64] and 1.14 [95% CI,
1.01-1.30], respectively) and should be followed up closely.
Because concomitant cardiac procedures were also
associated with an increase in the odds of 30-day read-
mission (aOR, 1.18; 95% CI, 1.11-1.26; P < .001), staging of
those procedures, especially in high-risk patients, could
prove effective in reducing readmission (Table IV).
Despite the granularity of our clinical data, the model
was able to predict only around 9% of the variability in
30-day readmission (R2 ¼ 8.8; C statistic ¼ 69.5). Even
after including in-hospital complications, the predictabil-
ity did not significantly improve (R2 ¼ 8.9; C statistic ¼
69.6). This is not uncommon because the creation of
models predicting preventable readmissions using inpa-
tient hospital data and information present at discharge
has been shown to be challenging in medical as well as
in surgical patients, with C statistics similar to that re-
ported in our study.19,31-34 Moreover, readmissions in pa-
tients undergoing vascular surgery are mainly driven by
postoperative complications that are identified after
discharge.34,35 Al-Damluji et al1 found that almost one-
third of readmission diagnoses were potentially due to
procedural complications. Similarly, Lawson et al35 also
identified postoperative complications occurring after
discharge as the single most predictive factor in surgical
readmissions and a high-yield area for improvement of
patient care.
Journal of Vascular Surgery Dakour Aridi et al 11
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Table VI. In-hospital outcomes in readmitted patients

Readmission after CEA Readmission after CAS Adjusted OR
(n ¼ 6205) (n ¼ 948) P value (CAS vs CEA) 95% CI P value
Mortality, No. (%) 172 (2.8) 58 (6.2) <.001 2.03 1.45-2.84 <.001
Complications, No. (%)
Hemorrhage/shock/bleeding 296 (4.8) 29 (3.1) .02 0.58 0.39-0.87 .01
Vascular or graft complication 15 (0.2) 2 (0.2) 1 0.82 0.18-3.62 .79
Cardiac 418 (6.7) 58 (6.1) .53 0.83 0.62-1.12 .22
Respiratory 219 (3.5) 47 (5.0) .03 1.31 0.94-1.82 .11
Renal or urologic 330 (5.3) 63 (6.7) .1 1.19 0.89-1.58 .24
Neurologic 54 (0.9) 14 (1.5) .1 1.55 0.85-2.84 .16
Infectious 62 (1.0) 15 (1.6) .11 1.58 0.88-2.81 .12
Gastrointestinal 42 (0.7) 7 (0.7) .83 1.1 0.449-2.48 .82
Venous thromboembolic 20 (0.3) 6 (0.6) .15 1.96 0.77-4.95 .16
Cost (U.S. $), median (IQR)
Total cost 7629 (4428-14,457) 8903 (4471-16,052) .01 735 182-1288 .01
Fixed cost 3762 (2138-6852) 4313 (2176-7645) .02 368 95-640 .01
Variable cost 3651 (2010-6844) 4390 (2211-7871) <.001 581 287-875 <.001
CAS, Carotid artery stenting; CEA, carotid endarterectomy; CI, confidence interval; IQR, interquartile range; OR, odds ratio.

Readmission significantly constitutes a large burden to
patients and health care systems.36-38 Prior studies have
suggested several interventions that focus on minimizing
risk factors and addressing known and preventable rea-
sons for readmission, such as wound infections, to
improve health care quality and resource use.26 Such in-
terventions include improving outpatient management
and transitional care,39,40 closer primary care follow-up
after discharge,41 and avoidance of premature discharge
in high-risk patients to limit early and short readmissions.
The majority of readmissions in our study occurred
within the first week of discharge (median, 6
[interquartile range, 1-16] days), with some patients hav-
ing more than one readmission within 30 days. This
was also reported in other published studies.1,42 However,
the success of isolated interventions has been ques-
tioned, especially that most have been studied in a retro-
spective manner.43 Thus, prospective studies on overall
cost-effectiveness of patient-centered bundled interven-
tions are warranted.19 Until then, it is reasonable to recon-
sider penalizing hospitals with high risk-standardized
rates of readmissions.
Limitations. This retrospective analysis offers an over-
view of readmission after carotid revascularization using
a large nationwide database, which can provide a plat-
form for further investigations and targets for interven-
tion. The multivariate analysis is further validated using
CEM to ensure the validity and help reduce selection
bias. However, risk adjustment and exact matching
cannot control for all confounding variables or eliminate
inherent selection bias of patients undergoing CAS vs
those undergoing CEA. Furthermore, patients in both
groups that could not be matched were discarded or
pruned from the matched cohort. Thus, the matched
cohort is likely not representative of the whole popula-
tion of patients but rather provides risk-adjusted esti-
mates of treatment effects. Another important limitation
is that readmissions to a different hospital, other than the
index hospital, are not tracked in the database, which
might underestimate readmission rates. We cannot
provide exact estimates on the number of readmissions
to hospitals other than the index hospital, but this should
not compromise the validity of our findings because our
readmissions are limited to 30 days after discharge, in
which most patients are readmitted usually to the index
hospital where their vascular surgeon is available, espe-
cially if the readmissions are procedure related. In addi-
tion, administrative claims data may not be suitable for
identifying staged or planned revascularization proced-
ures. Planned or staged readmissions are significant in
discussing peripheral revascularization procedures rather
than carotid revascularizations.
CONCLUSIONS
In this study, overall 30-day readmission after carotid
revascularization was 6.5%. After risk adjustment, CAS
had lower readmission rates than CEA. However, the mor-
tality and overall costs of readmissions were higher after
CAS. Reducing readmissions requires identifying high-
risk patients and managing their comorbidities and risk
factors. Further prospective studies are needed to eval-
uate the cost-effectiveness of strategies aiming to reduce
readmission rates after carotid revascularization.
The authors thank Nasr Ghajar, MS, for his contribution
in reviewing the literature.
12 Dakour Aridi et al
AUTHOR CONTRIBUTIONS
Conception and design: HDA, BN, MM
Analysis and interpretation: HDA, SA, BN, MM
Data collection: HDA
Writing the article: HDA, MM
Critical revision of the article: HDA, SA, BN
Final approval of the article: HDA, SA, BN, MM
Statistical analysis: HDA, BN
Obtained funding: Not applicable
Overall responsibility: MM
REFERENCES
1. Al-Damluji MS, Dharmarajan K, Zhang W, Geary LL, Stilp E,
Dardik A, et al. Readmissions after carotid artery revascu-
larization in the Medicare population. J Am Coll Cardiol
2015;65:1398-408.
2. Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG. The
carotid revascularization endarterectomy versus stenting
trial (CREST). Stroke 2010;41(Suppl 1):S34.
3. Mozes G, Sullivan TM, Torres-Russotto DR, Bower TC,
Hoskin TL, Sampaio SM, et al. Carotid endarterectomy in
SAPPHIRE-eligible high-risk patients: implications for
selecting patients for carotid angioplasty and stenting.
J Vasc Surg 2004;39:958-65.
4. Mahoney EM, Greenberg D, Lavelle TA, Natarajan A,
Berezin R, Ishak KJ, et al. Costs and cost-effectiveness of
carotid stenting versus endarterectomy for patients at
increased surgical risk: results from the SAPPHIRE trial.
Catheter Cardiovasc Intervent 2011;77:463-72.
5. Vilain KR, Magnuson EA, Li H, Clark WM, Begg RJ, Sam AD,
et al. Costs and cost-effectiveness of carotid stenting versus
endarterectomy for patients at standard surgical risk. Stroke
2012;43:2408-16.
6. Brott TG, Howard G, Roubin GS, Meschia JF, Mackey A,
Brooks W, et al. Long-term results of stenting versus endar-
terectomy for carotid-artery stenosis. N Engl J Med 2016;374:
1021-31.
7. Featherstone RL, Dobson J, Ederle J, Doig D, Bonati LH,
Morris S, et al. Carotid artery stenting compared with end-
arterectomy in patients with symptomatic carotid stenosis
(International Carotid Stenting Study): a randomised
controlled trial with cost-effectiveness analysis. Health
Technol Assess 2016;20:1-94.
8. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT,
Mishkel GJ, et al. Protected carotid-artery stenting versus
endarterectomy in high-risk patients. N Engl J Med 2004;351:
1493-501.
9. Brooke BS, De Martino RR, Girotti M, Dimick JB, Goodney PP.
Developing strategies for predicting and preventing read-
missions in vascular surgery. J Vasc Surg 2012;56:556-62.
10. Centers for Medicare & Medicaid Services. Readmissions
reduction program. Available at: https://www.cms.gov/
medicare/medicare-fee-for-service-payment/acuteinpatientpps/
readmissions-reduction-program.html. Accessed September 15,
2016.
11. Pizer SD. Should hospital readmissions be reduced through
payment penalties? Med Care 2013;51:20-2.
12. Joynt KE, Jha AK. Characteristics of hospitals receiving
penalties under the Hospital Readmissions Reduction Pro-
gram. JAMA 2013;309:342-3.
13. Shaw FE, Asomugha CN, Conway PH, Rein AS. The Patient
Protection and Affordable Care Act: opportunities for pre-
vention and public health. Lancet 2014;384:75-82.
Journal of Vascular Surgery
--- 2017
14. Vaduganathan M, Bonow RO, Gheorghiade M. Thirty-day
readmissions: the clock is ticking. JAMA 2013;309:345-6.
15. Ho KJ, Madenci AL, Semel ME, McPhee JT, Nguyen LL,
Ozaki CK, et al. Predictors and consequences of unplanned
hospital readmission within 30 days of carotid endarterec-
tomy. J Vasc Surg 2014;60:77-84.
16. Lawson EH, Hall BL, Louie R, Zingmond DS, Ko CY. Read-
mission following surgical procedures: implications for
quality improvement and cost savings. J Am Coll Surg
2011;213:S106.
17. Premier Healthcare database whitepaper. Available at:
http://www.premierinc.com/transforming-healthcare/health
care-performance-improvement/premier-research-services/.
Accessed April 2017.
18. Iacus SM, King G, Porro G. Matching for casual inference
without balance checking: coarsened exact matching.
Available at: http://gking.harvard.edu/_les/abs/cem-abs.shtml.
Accessed December 15, 2016.
19. Eun JC, Nehler MR, Black JH, Glebova NO. Measures to
reduce unplanned readmissions after vascular surgery.
Semin Vasc Surg 2015;28:103-11.
20. Rambachan A, Smith TR, Saha S, Eskandari MK, Bendok BR,
Kim JY. Reasons for readmission after carotid endarterec-
tomy. World Neurosurg 2014;82:e776.
21. Kennedy BS, Fortmann SP, Stafford RS. Elective and isolated
carotid endarterectomy: health disparities in utilization and
outcomes, but not readmission. J Natl Med Assoc 2007;99:480.
22. Nejim B, Obeid T, Arhuidese I, Hicks C, Wang S, Canner J,
et al. Predictors of perioperative outcomes after carotid
revascularization. J Surg Res 2016;204:267-73.
23. Gupta PK, Fernandes-Taylor S, Ramanan B, Engelbert TL,
Kent KC. Unplanned readmissions after vascular surgery.
J Vasc Surg 2014;59:473-82.
24. Greenleaf EK, Han DC, Hollenbeak CS. Carotid endarterec-
tomy versus carotid artery stenting: no difference in 30-day
postprocedure readmission rates. Ann Vasc Surg 2015;29:
1408-15.
25. Galinanes EL, Dombroviskiy VY, Hupp CS, Kruse RL, Vogel TR.
Evaluation of readmission rates for carotid endarterectomy
versus carotid artery stenting in the US Medicare population.
Vasc Endovascular Surg 2014;48:217-23.
26. Katzen BT. Readmissions after carotid artery revasculariza-
tion in the Medicare population. J Am Coll Cardiol 2015;65:
1409-10.
27. Brott TG, Hobson RW, Howard G, Roubin GS, Clark WM,
Brooks W, et al. Stenting versus endarterectomy for treat-
ment of carotid-artery stenosis. N Engl J Med 2010;363:11-23.
28. Fry DE, Pine M, Locke D, Reband A, Torres Z, Pine G. Medicare
inpatient and 90-day post discharge adverse outcomes in
carotid artery surgery. Surgery 2015;158:1056-64.
29. Jackson BM, Nathan DP, Doctor L, Wang GJ, Woo EY,
Fairman RM. Low rehospitalization rate for vascular surgery
patients. J Vasc Surg 2011;54:767-72.
30. Kind AJ, Bartels C, Mell MW, Mullahy J, Smith M. For-profit
hospital status and rehospitalizations at different hospitals:
an analysis of Medicare data. Ann Intern Med 2010;153:718-27.
31. Morris MS, Graham LA, Richman JS, Hollis RH, Jones CE,
Wahl T, et al. Postoperative 30-day readmission: time to
focus on what happens outside the hospital. Ann Surg
2016;264:621-31.
32. Donz J, Aujesky D, Williams D, Schnipper JL. Potentially
avoidable 30-day hospital readmissions in medical patients:
derivation and validation of a prediction model. JAMA Intern
Med 2013;173:632-8.
33. Kansagara D, Englander H, Salanitro A, Kagen D, Theobald C,
Freeman M, et al. Risk prediction models for hospital read-
mission: a systematic review. JAMA 2011;306:1688-98.
Journal of Vascular Surgery
Volume -, Number -
34. Glebova NO, Bronsert M, Hammermeister KE, Nehler MR,
Gibula DR, Malas MB, et al. Drivers of readmissions in
vascular surgery patients. J Vasc Surg 2016;64:194.e3.
35. Lawson EH, Hall BL, Louie R, Ettner SL, Zingmond DS,
Han L, et al. Association between occurrence of a post-
operative complication and readmission: implications for
quality improvement and cost savings. Ann Surg 2013;258:
10-8.
36. Hockenberry JM, Burgess JF Jr, Glasgow J, Vaughan-
Sarrazin M, Kaboli PJ. Cost of readmission: can the Veterans
Health Administration (VHA) experience inform national
payment policy? Med Care 2013;51:13-9.
37. Jencks SF, Williams MV, Coleman EA. Rehospitalizations
among patients in the Medicare fee-for-service program.
N Engl J Med 2009;360:1418-28.
38. Orszag PR, Emanuel EJ. Health care reform and cost control.
N Engl J Med 2010;363:601-3.
39. Brooke BS, Kraiss LW, Stone DH, Nolan B, De Martino RR,
Reiber GE, et al. Improving outcomes for diabetic patients
undergoing revascularization for critical limb ischemia: does
the quality of outpatient diabetic care matter? Ann Vasc
Surg 2014;28:1719-28.
Dakour Aridi et al 13
40. Rümenapf G, Geiger S, Schneider B, Amendt K, Wilhelm N,
Morbach S, et al. Readmissions of patients with diabetes
mellitus and foot ulcers after infra-popliteal bypass
surgerydattacking the problem by an integrated case
management model. Vasa 2013;42:56-67.
41. Brooke BS, Stone DH, Cronenwett JL, Nolan B,
DeMartino RR, MacKenzie TA, et al. Early primary care pro-
vider follow-up and readmission after high-risk surgery.
JAMA Surg 2014;149:821-8.
42. Dawes AJ, Sacks GD, Russell MM, Lin AY, Maggard-
Gibbons M, Winograd D, et al. Preventable readmissions to
surgical services: lessons learned and targets for improve-
ment. J Am Coll Surg 2014;219:382-9.
43. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. In-
terventions to reduce 30-day rehospitalization: a systematic
review. Ann Intern Med 2011;155:520-8.
Submitted Mar 6, 2017; accepted May 5, 2017.
Additional material for this article may be found online
at www.jvascsurg.org.
13.e1 Dakour Aridi et al Journal of Vascular Surgery
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Supplementary Table I (online only). International Classification of Diseases, Ninth Revision diagnosis and procedure
codes used to identify readmission diagnoses and certain major adverse events
Diagnoses
Hemorrhage, shock, or bleeding
285.1 Acute posthemorrhagic anemia
99.04 Transfusion of packed cells
458.29 Other iatrogenic hypotension
998 Other complications of procedures not elsewhere classified
998.1 Hemorrhage or hematoma complicating a procedure not elsewhere classified
99.06 Transfusion of coagulation factors
99.07 Transfusion of other serum
998.01 Postoperative shock, cardiogenic
998.11 Hemorrhage complicating a procedure
998.12 Hematoma complicating a procedure
39.41 Control of hemorrhage following vascular surgery
39.98 Control of hemorrhage, not otherwise specified
41.50 Total splenectomy
Vascular or graft related
996.1 Mechanical complication of other vascular device, implant, and graft
996.6 Infection and inflammatory reaction due to internal prosthetic device implant and graft
996.62 Infection and inflammatory reaction due to other vascular device, implant, and graft
996.74 Other complications due to other vascular device, implant, and graft
38.00 Incision of vessels, unspecified
38.06 Incision of vessels, abdominal arteries
38.08 Incision of vessels, lower limb arteries
38.80 Other surgical occlusion of vessels, unspecified
38.86 Other surgical occlusion of vessels, abdominal arteries
39.49 Other revision of vascular procedure
39.5 Other repair of vessels
39.56 Repair of blood vessel with tissue patch graft
39.57 Repair of blood vessel with synthetic patch graft
39.58 Repair of blood vessel with unspecified type of patch graft
39.59 Other repair of vessel
Respiratory
Pneumonia
465.9 Acute upper respiratory infections of unspecified site
466 Acute bronchitis and bronchiolitis
481 Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia)
482 Other bacterial pneumonia
482.1 Pneumonia due to Pseudomonas
482.2 Pneumonia due to Haemophilus influenzae (H. influenzae)
482.3 Pneumonia due to streptococcus
482.31 Pneumonia due to streptococcus, group A
482.32 Pneumonia due to streptococcus, group B
482.39 Pneumonia due to other streptococcus
482.4 Pneumonia due to staphylococcus
482.41 Methicillin-susceptible pneumonia due to Staphylococcus aureus
482.49 Other staphylococcus pneumonia
482.81 Pneumonia due to anaerobes
482.82 Pneumonia due to Escherichia coli (E. coli)
482.83 Pneumonia due to other gram-negative bacteria
(Continued on next page)
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Supplementary Table I (online only). Continued.

482.84 Pneumonia due to Legionnaires’ disease
482.89 Pneumonia due to other specified bacteria
482.9 Bacterial pneumonia, unspecified
485 Bronchopneumonia, organism unspecified
486 Pneumonia, organism unspecified
Respiratory failure
518.81 Acute respiratory failure
518.84 Acute and chronic respiratory failure
799.1 Respiratory arrest
93.9 Insertion of airway and other continuous invasive mechanical ventilation
96.71 Continuous invasive mechanical ventilation for less than 96 consecutive hours
96.72 Continuous invasive mechanical ventilation for 96 consecutive hours or more
Other respiratory
491.21 Obstructive chronic bronchitis with (acute) exacerbation
507 Pneumonitis due to solids and liquids
511.8 Other specified forms of pleural effusion except tuberculous
511.9 Unspecified pleural effusion
512.1 Iatrogenic pneumothorax
518 Other diseases of lung
518.4 Acute edema of lung, unspecified
786.3 Hemoptysis
997.3 Respiratory complications not elsewhere classified
31.1 Temporary tracheostomy
31.21 Mediastinal tracheostomy
31.29 Other permanent tracheostomy
34.04 Insertion of intercostal catheter for drainage
96.04 Insertion of endotracheal tube
786.09 Other respiratory abnormalities
Cardiac
Myocardial infarction
410 Acute myocardial infarction
411 Other acute and subacute forms of ischemic heart disease
411.1 Intermediate coronary syndrome
411.81 Acute coronary occlusion without myocardial infarction
411.89 Other acute and subacute forms of ischemic heart disease, other
412 Old myocardial infarction
Heart failure
428.21 Acute systolic heart failure
428.23 Acute on chronic systolic heart failure
428.31 Acute diastolic heart failure
428.33 Acute on chronic diastolic heart failure
428.41 Acute combined systolic and diastolic heart failure
428.43 Acute on chronic combined systolic and diastolic heart failure
785.51 Cardiogenic shock
Arrhythmia
00.51 Implantation of cardiac resynchronization defibrillator, total system
427 Cardiac dysrhythmias
Others
997.1 Cardiac complications, not elsewhere classified
(Continued on next page)
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Supplementary Table I (online only). Continued.

Renal or urologic
Acute kidney injury
584.5 Acute kidney failure with lesion of tubular necrosis
584.6 Acute kidney failure with lesion of renal cortical necrosis
584.7 Acute kidney failure with lesion of renal medullary (papillary) necrosis
584.8 Acute kidney failure with other specified pathological lesion in kidney
584.9 Acute kidney failure, unspecified
Others
996.73 Other complications due to renal dialysis device, implant, and graft
59.8 Ureteral catheterization
585 Chronic kidney disease (CKD)
591 Hydronephrosis
592 Calculus of kidney and ureter
599 Other disorders of urethra and urinary tract
788.2 Retention of urine
788.29 Other specified retention of urine
997.5 Urinary complications, not elsewhere classified
593.81 Vascular disorders of kidney
Neurologic
Paraplegia/monoplegia
344.1 Paraplegia
344.3 Monoplegia of lower limb
Spinal cord ischemia
336.1 Vascular myelopathies, applies to acute infarction of spinal cord
Stroke
434.11 Cerebral embolism with cerebral infarction
434.91 Cerebral artery occlusion, unspecified with cerebral infarction
437.1 Other generalized ischemic cerebrovascular disease
997.02 Iatrogenic cerebrovascular infarction or hemorrhage
Others
293.9 Unspecified transient mental disorder in conditions classified elsewhere
01.31 Incision of cerebral meninges
430 Subarachnoid hemorrhage
431 Intracerebral hemorrhage
436 Acute, but ill-defined, cerebrovascular disease
780.09 Other alteration of consciousness
780.39 Other convulsions
997 Complications affecting specified body system not elsewhere classified
997.01 Central nervous system complication
997.09 Other nervous system complications
351 Facial nerve disorders
351.0 Bell’s palsy
351.8 Other facial nerve disorders
351.9 Facial nerve disorders, unspecified
352.3 Disorders of pneumogastric (10th) nerve
352.5 Disorders of hypoglossal (12th) nerve
780.97 Altered mental status
Infections
Clostridium difficile
8.45 Intestinal infection due to Clostridium difficile
(Continued on next page)
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Supplementary Table I (online only). Continued.

Wound complications
998.13 Seroma complicating a procedure
998.3 Disruption of operation wound
998.30 Disruption of wound, unspecified
998.31 Disruption of internal operation (surgical) wound
998.32 Disruption of external operation (surgical) wound
998.5 Postoperative infection not elsewhere classified
998.51 Infected postoperative seroma
998.59 Other postoperative infection
998.83 Non-healing surgical wound
46.94 Revision of anastomosis of large intestine
54.0 Incision of abdominal wall
54.19 Other laparotomy
54.61 Reclosure of postoperative disruption of abdominal wall
54.91 Percutaneous abdominal drainage
86.22 Excisional débridement of wound, infection, or burn
86.27 Débridement of nail, nail bed, or nail fold
86.28 Nonexcisional débridement of wound, infection, or burn
Sepsis
038 Septicemia
995.91 Sepsis
995.92 Severe sepsis
Urinary tract infection
590.80
996.64 Infection and inflammatory reaction due to indwelling urinary catheter
996.65 Infection and inflammatory reaction due to other genitourinary device, implant, and graft
Others
682.8 Cellulitis and abscess of other specified sites
682.9 Cellulitis and abscess of unspecified sites
707.15 Ulcer of other part of foot
86.04 Other incision with drainage of skin and subcutaneous tissue
999.3 Other infection due to medical care not elsewhere classified
682.6 Cellulitis and abscess of leg, except foot
682.7 Cellulitis and abscess of foot, except toes
Gastrointestinal
Bowel ischemia
557.0 Acute vascular insufficiency of intestine
Small bowel obstruction
560.81 Intestinal or peritoneal adhesions with obstruction (postoperative)
560.9 Unspecified intestinal obstruction
Ileus
537.2 Chronic duodenal ileus
560.1 Paralytic ileus
560.31 Gallstone ileus
Thromboembolic
Pulmonary embolism
415.1 Pulmonary embolism and infarction (examples below)
415.11 Iatrogenic pulmonary embolism and infarction
415.12 Septic pulmonary embolism
415.19 Other pulmonary embolism and infarction
(Continued on next page)
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Supplementary Table I (online only). Continued.

Deep venous thrombosis
453.4 Acute venous embolism and thrombosis of deep vessels of lower extremity
Other venous
453.2 Other venous embolism and thrombosis of inferior vena cava
453.3 Other venous embolism and thrombosis of renal vein
453.8 Acute venous embolism and thrombosis of other specified veins
Reoperation
Vascular
0.55 Insertion of drug-eluting peripheral vessel stent(s)
00.60 Insertion of drug-eluting stent(s) of superficial femoral artery
17.56 Atherectomy of other non-coronary vessel(s)
38.18 Endarterectomy, lower limb arteries
39.25 Aorta-iliac-femoral bypass
39.29 Other (peripheral) vascular shunt or bypass
39.49 Other revision of vascular procedure
39.50 Angioplasty of other non-coronary vessel
38.12 Carotid endarterectomy
0.61 Percutaneous angioplasty of extracranial vessel(s)
0.63 Carotid artery stenting
38.44 Resection of vessel with replacement, aorta
39.71 Endovascular implantation of graft in abdominal aorta
Other abdominal surgeries
568 Other disorders of peritoneum
44.61 Suture of laceration of stomach
45.71 Open and other multiple segmental resection of large intestine
45.72 Open and other cecectomy
45.73 Open and other right hemicolectomy
45.74 Open and other resection of transverse colon
45.75 Open and other left hemicolectomy
45.76 Open and other sigmoidectomy
45.79 Other and unspecified partial excision of large intestine
45.8 Total intra-abdominal colectomy
46.71 Suture of laceration of duodenum
46.73 Suture of laceration of small intestine, except duodenum
46.75 Suture of laceration of large intestine
46.79 Other repair of intestine
48.71 Suture of laceration of rectum
50.61 Closure of laceration of liver
51.91 Repair of laceration of gallbladder
53 Repair of hernia
53.1 Other bilateral repair of inguinal hernia
53.2 Unilateral repair of femoral hernia
53.3 Bilateral repair of femoral hernia
53.5 Repair of other hernia of anterior abdominal wall (without graft or prosthesis)
53.6 Repair of other hernia of anterior abdominal wall with graft or prosthesis
54.1 Laparotomy
54.11 Exploratory laparotomy
54.12 Reopening of recent laparotomy site
54.21 Laparoscopy
(Continued on next page)
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Supplementary Table I (online only). Continued.

54.51 Laparoscopic lysis of peritoneal adhesions
54.59 Other lysis of peritoneal adhesions
54.92 Removal of foreign body from peritoneal cavity
55.81 Suture of laceration of kidney
56.75 Transureteroureterostomy
56.82 Suture of laceration of ureter
56.86 Removal of ligature from ureter
56.89 Other repair of ureter
57.81 Suture of laceration of bladder
57.83 Repair of fistula involving bladder and intestine
57.84 Repair of other fistula of bladder
58.41 Encounter for planned postoperative wound closure
69.41 Suture of laceration of uterus
Cancer
155 Malignant neoplasm of liver and intrahepatic bile ducts
V58.1 Encounter for antineoplastic chemotherapy
157 Malignant neoplasm of pancreas
162 Malignant neoplasm of trachea, bronchus, and lung
182 Malignant neoplasm of body of uterus
183 Malignant neoplasm of ovary and other uterine adnexa
185 Malignant neoplasm of prostate
197 Secondary malignant neoplasm of respiratory and digestive systems
173 Other and unspecified malignant neoplasm of skin
99.25 Injection or infusion of cancer chemotherapeutic substance
V58.0 Encounter for radiotherapy
Others nonspecific diagnoses
Headache
784.0 Headache
Syncope/collapse
780.2 Syncope and collapse
Fever
780.6 Fever and other physiologic disturbances of temperature regulation
780.62 Postprocedural fever
Fatigue/weakness
780.79 Other malaise and fatigue
Gastrointestinal
787.0 Nausea and vomiting
787.2 Dysphagia
789.00 Abdominal pain, unspecified site
537.2 Chronic duodenal ileus
Physical therapy
93.39 Other physical therapy
V57.1 Care involving other physical therapy
93.89 Rehabilitation, not elsewhere classified
V57.89 Care involving other specified rehabilitation procedure
57.9 Care involving unspecified rehabilitation procedure
Palliative care
V66.7 Encounter for palliative care
13.e7 Dakour Aridi et al Journal of Vascular Surgery
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Supplementary Table II (online only). Baseline charac- Supplementary Table II (online only). Continued.
teristics of the study groups after coarsened exact
No. (%) No. (%)
matching (CEM)
Charlson Comorbidity Index
After CEM
I 3904 (43.4) 3904 (43.4) 1.0
CEA CAS P value
II 2955 (32.9) 2955 (32.9)
No. of patients 8966 8966
III 1262 (14.0) 1262 (14.0)
Age, years, 72.4 (8.2) 72.4 (8.2) .63
IV 566 (6.3) 566 (6.3)
mean (SD)
V 199 (2.2) 199 (2.2)
No. (%) No. (%)
VI 110 (1.2) 110 (1.2)
Gender
CAS, Carotid artery stenting; CEA, carotid endarterectomy; CHF,
Female 3408 (37.9) 3408 (37.9) 1.0 congestive heart failure; COPD, chronic obstructive pulmonary disease;
MI, myocardial infarction; SD, standard deviation.
Male 5588 (62.1) 5588 (62.1)
Race
White 7814 (86.9) 7814 (86.9) 1.0
Black 230 (2.6) 230 (2.6)
Others 952 (10.6) 952 (10.6)
Insurance type
Medicare 7371 (82.2) 7371 (82.2) 1.0
Medicaid 157 (1.8) 157 (1.8)
Private insurance 1313 (14.7) 1313 (14.7)
Other 122 (1.4) 122 (1.4)
Admission type
Elective 7154 (79.5) 7154 (79.5) 1.0
Emergency 868 (9.7) 868 (9.7)
Urgent 954 (10.6) 954 (10.6)
Others 20 (0.22) 20 (0.22)
Concomitant cardiac 1894 (21.1) 1894 (21.1) 1.0
procedures
Teaching hospitals 5206 (57.9) 5206 (57.9) 1.0
Region
Rural 528 (5.9) 528 (5.9) 1.0
Urban 8457 (94.1) 8457 (94.1)
Provider area
Midwest 1721 (19.2) 1721 (19.2) 1.0
North-East 1365 (15.2) 1365 (15.2)
South 4846 (53.9) 4846 (53.9)
West 1053 (11.7) 1053 (11.7)
Comorbidities
Symptomatic 993 (11.1) 993 (11.1) 1.0
Diabetes 2810 (31.2) 2710 (30.1) .11
Old MI 844 (9.4) 844 (9.4) 1.0
CHF 654 (7.3) 654 (7.3) 1.0
Renal disease 751 (8.4) 751 (8.4) 1.0
COPD 1899 (21.1) 1940 (21.6) .46
Connective tissue 47 (0.5) 47 (0.5) 1.0
disease
Peptic ulcer disease 43 (0.5) 41 (0.5) .83
Paraplegia/hemiplegia 150 (1.7) 150 (1.7) 1.0
Liver disease 60 (0.67) 48 (0.53) .25
Peripheral vascular 2452 (27.3) 2452 (27.3) 1.0
disease
Cancer 96 (1.1) 123 (1.4) .07
(Continued)