Auditing Carotid Endarterectomy: A Regional Experience

Abstract

326Studies and commentaries from the 1980s expressing concern about the efficacy, appropriateness, and complications of carotid endarterectomy (CEA), 1 -8 were followed by a series of multicenter randomized controlled trials comparing CEA to medical treatment alone. Reported throughout the 1990s, these studies validated the use of CEAunder certain circumstances, [9][10][11][12][13][14][15] and led to a rapid and large resurgence in the use of CEA in A B S T R A C T: Background: Proof from randomized controlled trials that carotid endarterectomy (CEA) is efficacious in stroke prevention has resulted in a large resurgence of its use in recent years. We wished to determine if patients in our region were being selected and treated with complication rates consistent with the randomized trials. Methods: We have completed four audits of CEAs performed in our region since 1994, each followed by feed-back of results to the participating surgeons. Operations for > 70% symptomatic stenosis were considered appropriate, those for 50%-69% symptomatic and > 60% asymptomatic stenosis were considered uncertain and all others, including those in medically or neurologically unstable patients, were designated inappropriate. In part 4, the referral source and nature of the patients was also determined. Results: Part 1 (April 1994 -September 1995 found that of 291 CEAs performed 33% were appropriate, 48% were uncertain and 18% were inappropriate, and 40% of patients who underwent CEA were asymptomatic. In part 2 (September 1996 -September 1997) appropriate indications significantly improved to 49% of 184 CEAs (P=0.005), uncertain indications remained nearly the same at 47%, inappropriate indications fell to 4% (P=0.00002), and asymptomatic patients remained at 40%. T h e results of part 3 (October 1997 -October 1998) remained nearly the same as part 2 (249 CEAs, 47% appropriate, 51% uncertain, 2% inappropriate, 45% asymptomatic). Part 4 (October 1999 -October 2000) results were significantly better than part 3, appropriate indications increasing from 47% to 58% of 222 CEAs (P=0.02), and an elimination of inappropriate operations (P=0.03). Stroke and death complications declined over the study period from an overall rate of 5.2% in part 1 to 2.3% in part 4. In part 4 the majority of patients (69%) were referred to surgeons directly from general practitioners, including 58 (73%) of the 80 asymptomatic patients who underwent CEA. Interpretation: Regular auditing and feedback of results and information to surgeons has resulted in significant and continued improvements in the surgical performance of CEAin our region. Since the majority of patients are referred directly to surgeons by general practitioners, it is important that this group of physicians be familiar with current CEA g u i d e l i n e s . RÉSUMÉ: Évaluation de l'endartérectomie carotidienne: une expérience régionale. Introduction: La preuve basée sur des études contrôlées randomisées que l'endartérectomie carotidienne (EAC) est efficace dans la prévention de l'accident vascul...

Variations in rates of appropriate and inappropriate carotid endarterectomy for stroke prevention in 4 Canadian provinces

“…Inappropriate surgery could be curtailed by applying appropriateness ratings before surgery 19 or by consistently educating surgeons with feedback of their own results. 20 In addition to the patient factors used to determine appropriateness, surgical skill is of critical importance, and its assessment requires outcome measurements in all cases. 20 This study allows a deeper understanding of the factors contributing to marked practice variation across western Canada than was previously described with the use of an administrative database.…”

“…20 In addition to the patient factors used to determine appropriateness, surgical skill is of critical importance, and its assessment requires outcome measurements in all cases. 20 This study allows a deeper understanding of the factors contributing to marked practice variation across western Canada than was previously described with the use of an administrative database. 21 CE volume had a clear inverse relation with the rate of appropriate CE, both high-volume surgeons and high-volume hospitals having lower CE appropriateness rates.…”

The inappropriate use of carotid endarterectomy

“…Although this better selection of surgical candidates is admirable, one must also be aware that previous studies have reported that low-volume surgeons in low-volume hospitals have more perioperative complications of stroke and death than do high-volume surgeons in institutions making extensive use of CE. 7,8 Although the current study does not provide details of hospital complication rates, one can expect that these rates will be higher in low-volume centres. It is not sufficient for CE to be done for appropriate reasons only.…”

Temporal trends in safety of carotid endarterectomy in asymptomatic patients

“…Only one study had a small (7%) proportion of patients reviewed by an independent neurologist postprocedure. 34 Inclusion criteria ranged from "no documented history of ipsilateral cerebral ischemia" 33 to "no ipsilateral hemispheric symptoms in the past 6 months" 38 and in 6 cases were not stated. Exclusion criteria were variable.…”