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From Georgia Medical Care Foundation (H.R.K., W.D.F., C.C.S., B.T., D.M.)
and Rollins School of Public Health, Emory University (W.D.F.), Atlanta, Ga.
Background and Purpose—We sought to
examine the appropriateness and the surgical outcomes of carotid
endarterectomy (CE) in unselected community
hospitals to identify opportunities for improvement.
Methods—We performed a retrospective review of all CEs performed
on Medicare beneficiaries in Georgia in 1993 (n=1945). Conclusions
regarding appropriateness were based on current guidelines as
interpreted by a physician reviewer and were supported by the aggregate
results of structured, blinded overreading by clinicians with relevant
expertise. Adverse outcomes were confirmed and rated as to severity by
a physician. Outcomes were correlated with demography, vascular
anatomic findings, comorbidity, surgical techniques, and hospital
characteristics.
Results—The majority of the patients (51%) were
asymptomatic at presentation. CEs were
performed appropriately in 96.1% of the cases in accordance with
current guidelines. There was no significant difference in the rate of
appropriateness between the symptomatic (96%) and the
asymptomatic patients (96.4%). Survival without stroke or
myocardial infarction (MI) was 94.3%. The 30-day mortality was 1.9%;
moderate to severe strokes occurred in 1.8%, stroke-related death in
0.7%, MI in 1.1%, and MI-related death in 0.5%. Those hospitals
performing <10 CEs in the observed year had a statistically
significant higher morbidity and mortality as well as an increase in
less severe complications such as hematomas, wound dehiscence, wound
infection, and pneumonia than did hospitals with higher volume of CEs..
Older patients and women had statistically significantly higher
morbidity and mortality. Patients with a Charlson Severity Index score
of
Conclusions—The great majority of CEs performed in Georgia on
Medicare patients were appropriate, according to current guidelines.
Slightly more than half of the patients were asymptomatic
as defined in the Asymptomatic Carotid
Atherosclerosis Study. In hospitals performing <CEs in
the index year, we noted higher morbidity and mortality, as well as an
increase in less severe complications. This relationship between the
volume of surgery and outcome was confirmed in the analysis of
the 30-day mortality for all Medicare cases (n=10 569) performed in
Georgia from 1991 to 1995. This was the most important opportunity for
improvement identified in this study. In view of the increased use of
CE, it is important to continue to monitor the patterns of practice for
this procedure to improve outcomes.
© 1998 American Heart Association, Inc.
Original Contributions
Carotid Endarterectomy Among Medicare Beneficiaries
A Statewide Evaluation of Appropriateness and Outcome
1 had a risk for adverse outcomes 3.4 times higher than patients
with a score of 0 after adjustment for age and sex.
Key Words: appropriateness review • carotid artery disease • community hospitals • endarterectomy • outcome • physicians' practice patterns • retrospective chart review • utilization review
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