From the Vascular Research Unit (J.W.N., L.T.S., B.B.), Division of
Neurosurgery (L.T.S., D.R.), Division of Vascular Surgery (R.M.), and
Department of Internal Medicine (P.O.), Sunnybrook Health Science Center,
University of Toronto, Toronto, Ontario, Canada.
Correspondence to J.W. Norris, MD, Stroke Research Unit E-428, Sunnybrook Health Science Center, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5.
Methods—We evaluated 757 consecutive patients, of whom 600 had
CEA procedures in 3 teaching hospitals, and 190 procedures in 2
community hospitals in metropolitan Toronto. We estimated costs
using a specially designed computer program, Transitional System
Incorporated, including surgical complications, in patients admitted
between January 1994 and December 1996.
Results—There was a significant decrease in length of stay in
both groups of hospitals, mainly due to preoperative outpatient
evaluation but also due to lower complication rates, which probably
reflect an increase in asymptomatic surgery in both
hospital groups. Costs fell from approximately $8000 per procedure to
$5000 in asymptomatic patients and from approximately
$10 000 to $7000 in symptomatic patients (Can $).
Conclusions—Major changes in the management of patients
undergoing CEA have resulted in a significant decrease in both length
of hospital stay and utilization of postoperative intensive care. At
the same time, complication rates have significantly fallen, although
our mortality and morbidity figures remain slightly higher than those
from published multicenter trials. Future changes in surgical practice
in Canada, including noninvasive carotid imaging, should produce even
lower costs within the next few years.
Nowhere is this more evident than in the most widely practiced
operation in cerebrovascular surgery, carotid
endarterectomy (CEA). Strategies used in recent
years to improve cost effectiveness include drastic changes in
preoperative, operative, and postoperative management, such as omitting
routine postoperative intensive care and replacing standard angiography
with noninvasive, often less-expensive imaging.2
However, in the scramble to save costs lies the implicit hazard of
impairment of quality of care, about which there has been much recent
debate.3
We have been aware of continuing changes in the practice of CEA in
recent years in major Toronto metropolitan hospitals since our
first report4 and wanted to compare the
difference between clinical practice in our centers and the guidelines
developed by clinical trials in
symptomatic5 and
asymptomatic6 patients. We now have
access to more accurate evaluation of hospital costs by a computerized
system available only in recent years, and with the collaboration of
vascular surgeons and neurosurgeons in 5 Toronto hospitals we
have attempted to evaluate the impact of the changing practice of CEA
on costs and quality of care.
The complications of carotid surgery were divided into major and minor
categories. Major complications included death and stroke with
sustained deficit over 24 hours. Minor complications encompassed
transient ischemic attack, seizure, cranial nerve injury, neck
hematoma, pulmonary edema, pneumonia, respiratory arrest with
successful resuscitation, congestive heart failure, myocardial
ischemia, hypertension, hypotension, and urinary tract
infection.
Direct hospital charges comprised various categories, including
operating room and personnel expenses, nursing, and immediate
postoperative intensive care, as well as expenses related to
diagnostic testing, pharmacy, and physician charges.
Symptomatic and asymptomatic patients were
evaluated separately to ascertain the difference in length of stay,
complication rate, and CEA costs.
Computer analysis of costs was performed in cooperation with
the administration of the Sunnybrook Health Science Center using
Transitional System, Inc, software.8 The
statistical analysis also included the
There were several major differences in surgical practice between
teaching and community hospitals. Regional anesthesia was
the preferred method in community hospitals whereas general
anesthesia was used in 99% of the cases in teaching
hospitals. Although the length of hospital stay was significantly
greater (P<0.009) in the community hospitals in 1994, it
was almost identical in both types of hospital by 1997. There were
significantly more operations on asymptomatic patients in
the community hospitals (P<0.006), but the rate of serious
complications in the 2 hospital groups was similar. In the teaching
hospitals the major stroke and death rate was 3.0%, whereas in
community hospitals it was 2.0% (Table 2
There was a significant reduction (P<0.0001) in
utilization, and hence costs, of postoperative intensive care units
between 1994 and 1996. Data on costs and use of acute care facilities
were available in only 1 hospital. In 1994 we evaluated 69 patients; 50
(72%) had postoperative intensive care, which consumed 23.9±11.65
hours, with a mean cost of $2549±1911. In 1996 we evaluated 73
patients; 59 (80%) had intensive care but stayed only 16.6±4.8 hours,
costing $1191±1398.
Seventy five percent (595) of the total study cohort were
symptomatic (range, 63% to 80% among the hospitals) and
25% (195) were asymptomatic (range, 16% to 37%). Mean
length of hospital stay was 5.7±2.8 days in the
symptomatic group and 4.1±4.9 days in the
asymptomatic group (P<0.01), reflecting the
higher complication rate in symptomatic patients (Table 3
Vascular surgeons performed 491 procedures (62%) compared with 299
(38%) by neurosurgeons, with a lower complication rate for major
stroke and death (2.4% versus 3.6%) (nonsignificant), but they
operated on significantly more asymptomatic patients (32%
versus 13%; P<0.0001).
It is unlikely that improvement of surgical techniques over the period
of study is a major factor. Second, the forced reduction of length of
stay could result in an apparent, rather than real, reduction of
complications, which would occur after hospital discharge and escape
recognition. However, we do not think this is the explanation, because
we have posthospitalization follow-up on most patients, and few
complications occurred. Third, the reduced overall costs of carotid
surgery during the duration of the study could represent a
dilution of high-risk symptomatic patients by low-risk
asymptomatic patients, but our data (Table 1
Another factor is that most preoperative evaluations (carotid
angiography in particular )are now performed as outpatient procedures,
and this artificially reduces costs of hospitalization by transferring
inpatient costs to outpatient costs, without any real cost savings.
Although doubts have been cast on the accuracy of noninvasive imaging
for preoperative assessment,9 these procedures
are gaining credence and have almost replaced standard angiography in
some centers.10 However, it is not the usual
practice in Canada to use noninvasive substitutes such as carotid
duplex with MR angiography. These two procedures cost $107 and $1000
(Can $), respectively, so their combined substitution for standard
angiography (at $1000) would be unlikely to have a major impact on
costs, except by possibly reducing complications.
We believe the major factor in cost reduction is the decreased use of
acute postoperative intensive care facilities on a routine basis. Our
data support this practice, but patient numbers are still relatively
small, and prevention of one death from airway obstruction would not
have a major impact on cost but would be of inestimable clinical
importance. Considerable effort has been expended in recent years to
reduce the costs of CEA, especially in the United States, where
hospital practice is so often dictated by diagnosis related groups.
Cost-cutting procedures include outpatient vascular imaging, more
frequent use of regional
anesthesia,11 12 13 and, most
importantly, reduction of use of intensive care facilities
postoperatively. Harbaugh and Harbaugh14
evaluated early discharge after CEA. They routinely monitored patients
postoperatively for 2 hours, after which they were transferred to an
"intermediate" care unit. No invasive monitoring was used after the
patient left the recovery room. The mortality and morbidity data were
unchanged from those obtained previously, when these patients were
routinely monitored in postoperative intensive care.
In the study by Back et al10 carotid surgery was
performed by a designated clinical pathway, where cerebral angiography
was avoided, intensive postoperative care was minimized and regional
anesthesia was preferred. There was no significant
difference in stroke and death when the "pathway" patients were
compared with those receiving standard care, but there was a highly
significant decrease in costs. Unfortunately, none of these issues are
completely resolved, since there are no randomized studies and the
numbers of patients are invariably too small for adequate statistical
analysis.
Both teaching and community hospitals showed a striking decrease in the
length of hospital stay 1994 to 1996 (Table 2
Our data indicate that the death and stroke rates of carotid
endarterectomy in a large North American
metropolitan center are slightly higher than those in published
studies. In the North American Symptomatic Carotid
Endarterectomy Trial (NASCET), at 30 days the death
and major stroke rate was 2.1% versus 3.5% in this study, whereas the
rate of all strokes and death was 5.8% in
NASCET5 versus 6.4% in this study. In the
Asymptomatic Carotid Atherosclerosis Study
(ACAS),6 the stroke and death rate was 2.3%, but
this included angiographic complications of 1.2%. Our data show 2.6%
stroke and death without angiography, a total of 3.8% (adding the ACAS
angiographic complication rate) (Table 3
Our figure is almost identical to that from a recent multicenter
review18 (from 12 academic medical centers in the
United States) of 463 patients undergoing CEA for
asymptomatic carotid stenosis, in which
postoperative stroke and death occurred in 13 (2.8%). Also, both this
and our study estimated the complication rate only during the period of
hospitalization and not at 30 days as in NASCET and ACAS, so that the
comparable stroke and death rate in our study may be even higher if
this longer period of observation were used. However, our previous
experience4 did not identify strokes later than
12 days after operation, so the discrepancy is probably minor.
Carotid endarterectomy is probably the most studied
surgical procedure ever. Economic restrictions on health budgets and
accumulating data from continuing surgical trials have had a major
impact on the practice of this procedure. The present study
suggests that cost-cutting measures in recent years have not adversely
affected outcome, but data are still needed to identify those rare
complications with major human costs which necessitate special acute
care postoperatively.
Received May 8, 1998;
revision received July 22, 1998;
accepted July 22, 1998.
2.
Gibbs BF, Guzzetta VJ, Furmanski D. Cost-effective
carotid endarterectomy in community practice.
Ann Vasc Surg. 1995;9:423–427.[Medline]
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3.
Rowland LP. The quality of neurological care.
Arch Neurol. 1997;54:1327–1328.
4.
Toronto Cerebrovascular Study Group. Risks of
carotid endarterectomy. Stroke. 1986;17:848–852.
5.
North American Symptomatic Carotid
Endarterectomy Trial Collaborators. Beneficial
effect of carotid endarterectomy in
symptomatic patients with high-grade carotid
stenosis. N Engl J Med. 1991;325:445–453.[Abstract]
6.
Executive Committee for the Asymptomatic
Carotid Atherosclerosis Study.
Endarterectomy for asymptomatic carotid
artery stenosis. JAMA. 1995;273:1421–1428.
7.
Bamford JM, Sandercock PA, Warlow CP, Slattery J.
Interobserver agreement for the assessment of handicap in stroke
patients. Stroke. 1989;20:828. Letter.[Medline]
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8.
Transitional Systems, Inc. Information Solutions
to Manage the Quality and Economics of Health Care. Atlanta, Ga:
Transition Systems Inc; 1993.
9.
Eliasziw M, Rankin RN, Fox AJ, Haynes RB, Barnett HJM.
Accuracy and prognostic consequences of ultrasonography in identifying
severe carotid stenosis: North American Symptomatic
Carotid Endarterectomy Trial (NASCET) Group.
Stroke. 1995;26:1747–1752.
10.
Back MR, Harward TR, Huber TS, Carlton LM, Flynn TC,
Seeger JM. Improving the cost-effectiveness of carotid
endarterectomy. J Vasc Surg. 1997;26:456–464.[Medline]
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Allen BT, Anderson CB, Rubin BG, Thompson RW, Flye MW,
Young-Beyer P, Frisella P, Sicard GA. The influence of anesthetic
technique on perioperative complications after carotid
endarterectomy. J Vasc Surg. 1994;19:834–843.[Medline]
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Morasch MD, Hodgett D, Burke K, Baker WH. Selective use
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endarterectomy. Ann Vasc Surg. 1995;9:229–234.[Medline]
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Collier PE. Carotid endarterectomy:
a safe and cost-efficient approach. J Vasc Surg. 1992;16:926–933.[Medline]
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14.
Harbaugh KS, Harbaugh RE. Early discharge after carotid
endarterectomy. Neurosurgery.
1995;37(No. 2):219–225.
15.
Rothwell PM, Slattery J, Warlow CP. A systematic
comparison of the risks of stroke and death due to carotid
endarterectomy for symptomatic and
asymptomatic patients. Stroke. 1996;27:266–269.
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Wong JH, Max Findlay J, Suarez-Almazor ME. Regional
performance of carotid endarterectomy:
appropriateness, outcomes, and risk factors for complications.
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Perry JR, Szalai JP, Norris JW. Consensus against both
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© 1998 American Heart Association, Inc.
Original Contributions
Changing Practice and Costs of Carotid Endarterectomy in Toronto, Canada
Abstract
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Background and Purpose—During
our annual audits of carotid endarterectomy (CEA)
in Toronto metropolitan hospitals, we have been aware of major
changes in the practice of this operation in recent years. To evaluate
the effect of changing practice on costs of carotid
endarterectomy, we have therefore compared the
effects of changes in length of stay, complication rates, and other
variables on cost during the last 3 years for which we have
complete data.
Key Words: costs and cost analysis • carotid endarterectomy
Introduction
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Despite endlessly shrinking healthcare budgets, costs
continue to spiral, consuming a generous 14% of the gross domestic
product in the United States and 8% in Canada. Rationing of
healthcare services is politically and ethically
unacceptable1 but the only alternative is to
reduce costs of the individual patient. This has resulted in shorter,
more cost-effective surgical procedures that minimize or even abolish
the enormous daily expenses of hospital admission.
Subjects and Methods
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
We evaluated all consecutive patients who underwent CEA in 3
Toronto teaching hospitals and 2 community hospitals during the
3-year period from 1994 through 1996. CEA procedures combined with
coronary artery bypass grafts were not included in the
analysis. We used the hospital computer database systems to
retrieve the files of these patients and performed a retrospective
chart review to assess demographic data (age, gender), length of
hospital stay, neurological symptoms before surgery, complications of
CEA, and subsequent medical treatment or surgical interventions during
the hospital stay. We used the Modified Rankin
Scale7 to define stroke severity, scoring >3 as
a severe stroke. 
2 and Student t tests.
Results
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
During the period from January 1994 through December 1996,
757 consecutive patients underwent CEA in 5 Toronto hospitals.
Six hundred procedures were performed in the 3 Toronto teaching
hospitals and 190 in the 2 community hospitals, giving a total of 790
carotid procedures. A total of 514 procedures were performed on men and
276 on women, and the patients' mean age was 68±9 years. More than
half the costs were for the operating room and postoperative intensive
care (Figure
). However, these costs decreased
significantly during the course of the study (Table 1), during which time there was an almost
threefold increase in asymptomatic surgery (32 patients in
1994, 80 in 1996) that was comparable in teaching hospitals and
community hospitals (Table 2). Over the
course of the study, the time of hospital admission to the surgical
procedure shortened significantly, from 1.7±2.5 to 0.8±1.85 days
(P<0.0001), as did the time from surgery to hospital
discharge, from 5.5±2.0 to 2.9±2.1 days (P<0.0001).
View larger version (57K):
[in a new window]
Figure 1. Breakdown of direct hospital expenses for physician,
pharmacy, diagnostic tests, and nursing charges as well as
the operating room (OR), postanesthesia care unit (PACU),
and intensive care unit (ICU).
View this table:
[in a new window]
Table 1. Length of Stay, Hospital Costs, and Incidence of
Stroke and Death in Asymptomatic Versus Symptomatic Carotid
Endarterectomy,
1994–19961
View this table:
[in a new window]
Table 2. Surgical Practice in Teaching Versus Community
Hospitals 
) (a nonsignificant
difference). Patients with no surgical complications were discharged
earlier, at 4.3±3 days (total hospital stay) compared to those with
complications at 7.0±1.1 days (P<0.0001), and the costs
were significantly higher (P<0.0001) in those with surgical
complications ($6769±2815 versus $9758±6955). ). This is also reflected in the
significantly increased costs of surgery in symptomatic
patients ($7366±5290 versus $5330±1652 in asymptomatic
patients).
View this table:
[in a new window]
Table 3. Complication Rates in 195 Asymptomatic Compared With
595 Symptomatic Procedures
Discussion
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Our data clearly indicate that carotid
endarterectomy is becoming less costly, but is it
more cost effective and has the quality of care been compromised? It
seems not, because parallel with decreased costs was a decreased
incidence of complications, thus shortening the length of stay, a major
factor in costs. There are several possible explanations for this
finding. ) indicate that
the same number of symptomatic procedures were performed
each year at decreasing costs. Fourth, selection of less risky patients
over the 3-year period of this study was not a factor, since the age,
sex, and comorbid disease probably did not change significantly from
year to year. ), and by 1996 duration of
hospital stay was almost identical, even though regional
anesthesia was commonly performed in community hospitals
(74% versus 1%). This does not agree with the findings of other
studies11 in which regional
anesthesia was the preferred method and hospital stay was
shorter. The higher proportion of asymptomatic surgery in
community hospitals compared with teaching hospitals was sustained
throughout the study period and was significantly different
(P<0.006). The stroke and death rates did not differ
between the 2 hospital groups despite the tendency toward more
asymptomatic CEA in community hospitals and the lower
documented stroke rates complicating carotid
endarterectomy in asymptomatic
patients.15 Most stroke neurologists would not be
comfortable with the high proportion (37%) of asymptomatic
patients in our community hospitals, though this figure is comparable
with those in other reports.16 17 ). This rather high figure for
asymptomatic CEA affords even less justification for
surgery in this group and supports concerns
raised17 about whether the low stroke and death
rate achieved by ACAS surgeons is applicable to community wide or
multicenter experience.
Acknowledgments
We would like to gratefully acknowledge the helpful
collaboration and advice from our vascular and neurosurgical colleagues
involved in this project at the Toronto Hospital (General
and Western Divisions), Sunnybrook Health Science Center,
Toronto East General and Orthopaedic Hospital Inc, and St
Joseph's Health Center.
References
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
1.
Asch D, Ubel P. Rationing by any other name.
N Engl J Med. 1997;335:1668–1671.
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