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(Stroke. 2003;34:1471.)
© 2003 American Heart Association, Inc.

Original Contributions

Editorial Comment: How Appropriate Is Carotid Endarterectomy?

Capital Health, Walter C. Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Because evidence for the efficacy of many treatments was lacking, methodology to measure appropriateness was developed in the 1980s at RAND to provide a contemporary means of determining if health care interventions were done appropriately; that is, if they were worth doing in specific situations.¹ One of the first such studies examined Medicare patients from that era undergoing carotid endarterectomy and found the startling result that two thirds had surgery for uncertain or inappropriate reasons.² Subsequently, the publication of major randomized controlled trials^3–5 has provided evidence for the efficacy of endarterectomy in many scenarios to guide practitioners, so now one might expect an improved rate of appropriateness. Indeed, this was demonstrated by Halm et al⁶ in this issue of Stroke, where they showed in a population of patients from 6 New York hospitals in 1997–1998 that only 15% of patients were operated on for less than appropriate reasons. Appropriateness can also be used even more directly to improve quality. Recently, Findlay and colleagues⁷ showed that appropriateness, used in repeated audit cycles involving feedback to the operating surgeons, resulted in marked improvement in both appropriateness and outcomes.

The role of comorbid disease in determining both appropriateness and outcome of endarterectomy is another important result of the current study.⁶ Some indications, especially for asymptomatic cases, were deemed inappropriate because of high comorbidities. This view was borne out by the excess stroke and/or death rate (OR 2.8; CI 1.1 to 7.5, P=0.03) found in asymptomatic cases with high comorbidities. This should . . . [Full Text of this Article]