Cost of Identifying Patients for Carotid Endarterectomy

Abstract

Background and Purpose-The cost of carotid endarterectomy (CEA) usually considers only the cost of the preoperative investigations and the procedure for the individual patient but ignores the cost incurred in selecting a patient from a referred "pool" of potential candidates or the "total direct program cost." The aim of this study was to estimate the total direct program cost (workup and procedure) of CEA in a large major teaching hospital in Edinburgh, Scotland using a retrospective study design. Methods-Participants were patients with transient ischemic attacks and mild strokes referred to the neurovascular clinics for assessment, investigation, and possible CEA. The "workup" was defined as the clinical consultation, carotid duplex, 1 follow-up visit, and a catheter angiogram where indicated. We used data routinely collected from the neurovascular clinics during a 1-year period to estimate the workup cost of patients who might be suitable for CEA. The CEA procedure cost was estimated prospectively in a concurrent study. Estimated costs were applied to the proportions assessed at the different levels of investigation to determine the total direct program cost of CEA. Results-A total of 790 new patients with symptoms suggestive of transient ischemic attacks and mild strokes were identified. Four hundred one (51%) patients were referred for carotid duplex. Duplex identified 78 (10%) with carotid stenosis of Ն70%. Of the total of 790 patients, 26 (3.3%) had catheter angiogram and 18 (2.3%) had CEA. The total direct program cost to investigate this cohort was about £207 000, with 68% (£140 000) of the cost incurred before any surgery was performed. Conclusion-The cost of identifying suitable patients for carotid surgery is quite high, with more than 30% of the cost attributed to the initial consultation at the neurovascular clinics. The cost of preventing 1 stroke by CEA is in the region of £100 000 at 1997/1998 prices if all the costs incurred in the workup of a cohort for potential CEA are included.

Estenose de carótida extracraniana

“…Vale lembrar da importância de uma abordagem criteriosa dos pacientes com suspeita de doença de carótida, já que para prevenir um acidente vascular cerebral, gastam-se 100.000 libras esterlinas 10 .…”

Costs of Secondary Prevention of Stroke by Carotid Endarterectomy

“…Decision on referral for DUS is one of many elements within a consultation for stroke/TIA in hospital and at the general practitioner, and it is not represented as a cost element on its own in the DRG tariff. Other researchers used price of one consultation in a neurovascular unit plus the price of a follow-up consultation as an estimate of this cost element [4]. We chose the stroke unit’s/general practitioner’s reimbursement for one out-patient consultation according to the DRG tariff as our best estimate of this cost element.…”

“…However, when including the costs of identifying patients eligible for CEA and numbers needed to treat (NNT) in order to prevent a stroke, CEA turns out to be a relatively costly way of secondary prevention. In studies from Denmark [3] and the United Kingdom [4], estimated costs to the national health services of these countries of preventing 1 recurrent stroke were EUR 192,000 and 113,910, respectively.…”

“…Available estimations of costs are based on patients sampled in 1991/1993 [3] and 1996/1997 [4]. Recent analyses of pooled data from randomized trials published in 2004 show that the NNT in order to prevent a stroke can be substantially reduced if CEA is done early after stroke, i.e.…”

“…within 2 weeks of the last ischemic event [5]. Hence, numbers needed to screen relative to the numbers of strokes being prevented by CEA may now be lower, and as a consequence costs per prevented stroke may also be lower than previously estimated [3,4]. …”