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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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Dakour-Aridi H, Nejim B, Locham S, Alshaikh H, Obeid T, Malas MB. Complication-Specific In-Hospital Costs After Carotid Endarterectomy vs Carotid Artery Stenting. J Endovasc Ther 2018; 25:514-521. [DOI: 10.1177/1526602818781580] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To quantify and compare the incremental cost associated with in-hospital stroke, death, and myocardial infarction (MI) after carotid endarterectomy (CEA) vs carotid artery stenting (CAS). Methods: A retrospective analysis was performed of 100,185 patients (mean age 70.7±9.5 years; 58.3% men) who underwent CEA (n=86,035) or CAS (n=14,150) between 2009 and 2015 and were entered into the Premier Healthcare Database. Multivariate logistic models and generalized linear models were used to analyze binary outcomes and hospitalization costs, respectively. Outcomes are presented as the adjusted odds ratio (aOR) and 95% confidence interval (CI). Results: CAS was associated with 1.6 times higher adjusted odds of stroke [aOR 1.55 (95% CI 1.36 to 1.77), p<0.001] and with 2.6 times higher odds of death [aOR 2.60 (95% CI 2.14 to 3.17), p<0.001] compared with CEA. There was no significant difference in MI risk between the 2 procedures. The adjusted incremental cost of death and MI were similar between the 2 procedures. However, the adjusted incremental cost of stroke was significantly higher in CEA compared with CAS by an estimated $2000. When stratified with respect to symptomatic status, the increased adjusted incremental cost of stroke in CEA was mainly seen in asymptomatic patients ($5284 vs $2932, p<0.01). Conclusion: The incremental cost of in-hospital stroke is relatively higher in CEA compared to CAS. However, CEA remains a more cost-effective carotid intervention due to lower complication rates and baseline costs compared with CAS. Long-term cost-effectiveness studies are needed before definite conclusions are made.
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Affiliation(s)
- Hanaa Dakour-Aridi
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Besma Nejim
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Satinderjit Locham
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Husain Alshaikh
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Tammam Obeid
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
| | - Mahmoud B. Malas
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
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de Vries EE, Baldew VGM, den Ruijter HM, de Borst GJ. Meta-analysis of the costs of carotid artery stenting and carotid endarterectomy. Br J Surg 2017; 104:1284-1292. [PMID: 28783225 DOI: 10.1002/bjs.10649] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/02/2017] [Accepted: 06/19/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) is currently associated with an increased risk of 30-day stroke compared with carotid endarterectomy (CEA), whereas both interventions seem equally durable beyond the periprocedural period. Although the clinical outcomes continue to be scrutinized, there are few data summarizing the costs of both techniques. METHODS A systematic search was conducted in MEDLINE, Embase and Cochrane databases in August 2016 identifying articles comparing the costs or cost-effectiveness of CAS and CEA in patients with carotid artery stenosis. Combined overall effect sizes were calculated using random-effects models. The in-hospital costs were specified to gain insight into the main heads of expenditure associated with both procedures. RESULTS The literature search identified 617 unique articles, of which five RCTs and 12 cohort studies were eligible for analysis. Costs of the index hospital admission were similar for CAS and CEA. Costs of the procedure itself were 51 per cent higher for CAS, mainly driven by the higher costs of devices and supplies, but were balanced by higher postprocedural costs of CEA. Long-term cost analysis revealed no difference in costs or quality of life after 1 year of follow-up. CONCLUSION Hospitalization and long-term costs of CAS and CEA appear similar. Economic considerations should not influence the choice of stenting or surgery in patients with carotid artery stenosis being considered for revascularization.
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Affiliation(s)
- E E de Vries
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - V G M Baldew
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M den Ruijter
- Experimental Cardiology Laboratory, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Fixed and variable cost of carotid endarterectomy and stenting in the United States: A comparative study. J Vasc Surg 2017; 65:1398-1406.e1. [DOI: 10.1016/j.jvs.2016.11.062] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/28/2016] [Indexed: 11/22/2022]
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Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MSV, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:3754-832. [PMID: 25355838 PMCID: PMC5020564 DOI: 10.1161/str.0000000000000046] [Citation(s) in RCA: 993] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.
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Paraskevas KI, Moore WS, Veith FJ. Commentary: carotid artery stenting: still not as cost-effective as carotid endarterectomy, but the contest continues. J Endovasc Ther 2014; 21:303-5. [PMID: 24754291 DOI: 10.1583/13-4549c.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Kosmas I Paraskevas
- 1 Department of Vascular Surgery, Larissa University Hospital, Larissa, Greece
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Kim JH, Choi JB, Park HK, Kim KH, Kuh JH. Cost-Effectiveness of Carotid Endarterectomy versus Carotid Artery Stenting for Treatment of Carotid Artery Stenosis. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:20-5. [PMID: 24570861 PMCID: PMC3928258 DOI: 10.5090/kjtcs.2014.47.1.20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 08/29/2013] [Accepted: 09/03/2013] [Indexed: 12/02/2022]
Abstract
BACKGROUND Symptomatic or asymptomatic patients with significant carotid artery stenosis (range, 70% to 99%) generally undergo either carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) to prevent stroke. In this study, we evaluated the cost effectiveness of these two treatment modalities. METHODS A total of 47 patients (mean age, 67.1±9.1 years; male, 87.2%) undergoing either CEA (n=28) or CAS (n=19) for the treatment of significant carotid artery stenosis were enrolled in this study. Hospitalization costs were subdivided into three parts, namely pre-procedure, procedure and resource, and post-procedure costs. RESULTS Total hospitalization costs were similar in both groups of CEA and CAS (6,377 thousand won [TW] vs. 6,703 TW, p=0.255); however, the total cost minus the pre-procedure cost was higher in the CAS group than in the CEA group (4,948 TW vs. 5,941 TW, p<0.0001). The pre-procedure cost of the CEA group was higher than that of the CAS group (1,429 TW vs. 762 TW, p<0.0001). However, the procedure and resource cost was higher in the CAS group because the resource cost was approximately three times higher in the CAS group than in the CEA group. The post-procedure cost was higher in the CEA group because hospital stays were approximately two times longer. CONCLUSION The total hospitalization cost was not different between the CEA and the CAS groups. The pre-procedure cost was high in the CEA group, but the cost from procedure onset to discharge, including the resource cost, was significantly lower in this group.
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Affiliation(s)
- Jong Hun Kim
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Korea
- Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Korea
| | - Jong Bum Choi
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Korea
- Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Korea
| | - Hyun Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Korea
| | - Kyung Hwa Kim
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Korea
- Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Korea
| | - Ja Hong Kuh
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Korea
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Vilain KR, Magnuson EA, Li H, Clark WM, Begg RJ, Sam AD, Sternbergh WC, Weaver FA, Gray WA, Voeks JH, Brott TG, Cohen DJ. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 2012; 43:2408-16. [PMID: 22821614 DOI: 10.1161/strokeaha.112.661355] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated similar rates of the primary composite end point between carotid artery stenting (CAS) and carotid endarterectomy (CEA), although the risk of stroke was higher with CAS, and the risk of myocardial infarction was higher with CEA. Given the large number of patients who are candidates for these procedures, an understanding of their relative cost and cost-effectiveness may have important implications for health care policy and treatment guidelines. METHODS We performed a formal economic evaluation alongside the CREST trial. Costs were estimated from all trial participants over the first year of follow-up using a combination of resource use data and hospital billing data. Patient-level health use scores were obtained using data from the SF-36. We then used a Markov disease-simulation model calibrated to the CREST results to project 10-year costs and quality-adjusted life expectancy for the 2 treatment groups. RESULTS Although initial procedural costs were $1025/patient higher with CAS, postprocedure costs and physician costs were lower such that total costs for the index hospitalization were similar for the CAS and CEA groups ($15 055 versus $14 816; mean difference, $239/patient; 95% CI for difference, -$297 to $775). Neither follow-up costs after discharge nor total 1-year costs differed significantly. For the CREST population, model-based projections over a 10-year time horizon demonstrated that CAS would result in a mean incremental cost of $524/patient and a reduction in quality-adjusted life expectancy of 0.008 years compared with CEA. Probabilistic sensitivity analysis demonstrated that CEA was economically attractive at an incremental cost-effectiveness threshold of $50 000/quality-adjusted life-year gained in 54% of samples, whereas CAS was economically attractive in 46%. CONCLUSIONS Despite slightly lower in-trial costs and lower rates of stroke with CEA compared with CAS, projected 10-year outcomes from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00004732.
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Affiliation(s)
- Katherine R Vilain
- Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA
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Carotid endarterectomy is more cost-effective than carotid artery stenting. J Vasc Surg 2012; 55:1623-8. [DOI: 10.1016/j.jvs.2011.12.045] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 12/19/2011] [Accepted: 12/19/2011] [Indexed: 11/18/2022]
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Paraskevas KI, Moore WS, Veith FJ. Cost implications of more widespread carotid artery stenting consistent with the American College of Cardiology/American Heart Association Guideline. J Vasc Surg 2012; 55:585-7. [DOI: 10.1016/j.jvs.2011.10.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 10/04/2011] [Accepted: 10/13/2011] [Indexed: 11/16/2022]
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Eslami MH, McPhee JT, Simons JP, Schanzer A, Messina LM. National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007. J Vasc Surg 2011; 53:307-15. [DOI: 10.1016/j.jvs.2010.08.080] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 08/26/2010] [Accepted: 08/26/2010] [Indexed: 10/18/2022]
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Maud A, Vázquez G, Nyman JA, Lakshminarayan K, Anderson DC, Qureshi AI. Cost-effectiveness analysis of protected carotid artery stent placement versus endarterectomy in high-risk patients. J Endovasc Ther 2010; 17:224-9. [PMID: 20426644 DOI: 10.1583/09-2938.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the cost-effectiveness of carotid angioplasty with stent placement (CAS) under emboli protection versus carotid endarterectomy (CEA) in patients with severe carotid stenosis considered to be at high surgical risk for CEA. METHODS The probabilities of various outcomes were adopted from the SAPPHIRE trial results. The quality-adjusted life year (QALYs) associated with each treatment modality were estimated by using the frequencies of various quality-adjusted outcomes (QALY weights of ipsilateral stroke, myocardial infarction, and death). Total cost associated with each intervention was computed using the frequency of stroke, myocardial infarction, and death in each group. Costs are expressed in 2006 US$. Incremental cost-effectiveness ratios (ICERs) were estimated for a 1-year postprocedure period. RESULTS The mean (range) estimated net costs at 1 year for patients treated with CAS and CEA were $12,782 ($12,205-$13,563) and $8,916 ($8,267-$9,766), respectively. Overall QALYs for the CAS and CEA groups were 0.753 and 0.701 [within a range of 0.0 (meaning death) to 0.815 (meaning no adverse events)]. The mean cost per QALY gained for CAS was $16,223 ($15,315-$17,474) and the mean cost per QALY gained for CEA was $12,745 ($11,372-$14,605). The estimated median ICER for CAS versus CEA treatment was $67,891 (-$129,372 to $379,661). CONCLUSION The proven non-inferiority of CAS versus CEA in high-surgical-risk patients with severe carotid stenosis might provide a marginal benefit that is offset by the higher cost associated with this procedure.
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Affiliation(s)
- Alberto Maud
- Zeenat Qureshi Stroke Research Center, Department of Neurology, and , University of Minnesota, Minneapolis, MN 55455 USA.
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Paraskevas KI, Mikhailidis DP, Veith FJ. Are Symptomatic Patients Appropriate Candidates For Carotid Artery Stenting? No (at Least Not At Present). Vascular 2010; 18:185-8. [DOI: 10.2310/6670.2010.00027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Most symptomatic patients should not be candidates for carotid artery stenting (CAS); at least not at present. In these patients, CAS is associated with higher stroke, as well as recurrent stenosis rates compared with carotid endarterectomy (CEA). Furthermore, CAS is considerably more expensive than CEA. These facts raise the question, why perform CAS in symptomatic patients when you have CEA, which is associated with lower stroke and recurrent stenosis rates, and is also a more cost-effective option. This article supports the theory that currently most symptomatic patients are not appropriate candidates for CAS.
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Affiliation(s)
- Kosmas I. Paraskevas
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Department of Vascular Surgery, The Cleveland Clinic and New York University Medical Center, New York, NY
| | - Dimitri P. Mikhailidis
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Department of Vascular Surgery, The Cleveland Clinic and New York University Medical Center, New York, NY
| | - Frank J. Veith
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Department of Vascular Surgery, The Cleveland Clinic and New York University Medical Center, New York, NY
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Chatterjee A, Payette MJ, Demas CP, Finlayson SRG. Opportunity cost: a systematic application to surgery. Surgery 2009; 146:18-22. [PMID: 19541006 DOI: 10.1016/j.surg.2009.03.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2008] [Accepted: 03/27/2009] [Indexed: 01/21/2023]
Abstract
BACKGROUND Opportunity cost is the potential gain or loss when a person chooses to perform an activity over its next best alternative. With respect to surgery, opportunity cost can occur if a less efficient technology uses more operating time than its next best alternative. This additional operating time could be used in a productive way that, when economically valued, adds a "cost" to the less efficient technology. Although fundamental to the economist's view of costs and widely used in economic assessments, opportunity cost analysis is infrequently used in economic evaluation of surgical technology. Previous cost comparison studies in the surgical literature have not addressed opportunity cost when estimating the efficiency of competing technologies. With increasing healthcare costs and new technologic advancements in surgery, a surgeon's ability to understand opportunity cost and apply it when choosing between two comparable technologies is essential. Our objective is to present a system to estimate the opportunity cost for given surgical specialties and present a model to demonstrate its principle. METHODS To demonstrate the principle of opportunity cost, our model used a hypothetical scenario comparing two clinically equivalent technologies that differed in that the use of one device (Device A) extended operating time in a hypothetical procedure by 30 minutes compared to its competitor device (Device B). How this extra operating time could potentially be used was then valued using the opportunity cost calculated by our study design. Our study design included 5 surgical procedures from 5 surgical specialties that were elective, profitable, high-volume (performed more than 100 times per year), and had a duration of less than 240 minutes. The data were taken from a university hospital setting in 2007 and included procedure volume, profit margin, and duration. The outcome measure was opportunity cost, which was estimated by dividing the selected procedure's profit margin by its duration. RESULTS Surgical specialty results are presented in the accompanying Tables. Otolaryngology has the highest opportunity cost at $38/min. This cost was calculated by using myringotomy as the procedure that was elective, short in duration, performed in high volume, and provided the highest profit margin. By applying our model, the otolaryngology surgeon using the less efficient Device A to perform a hypothetical procedure would incur an opportunity cost of $1,140 ($38/min x 30 min). This is because he could have performed additional myringotomy procedures in the time saved had he instead used the more efficient Device B in his hypothetical cases. General surgery has the lowest opportunity cost at $9/min; laparoscopic inguinal hernia repair was the procedure used for its calculation. Under the same model, the general surgeon using Device A would incur an opportunity cost of $270 ($9/min x 30 min). This is because the general surgeon could have performed additional laparoscopic femoral/hernia repairs had she used the more efficient Device B in her hypothetical cases. CONCLUSION In acknowledging opportunity cost, a surgeon can more accurately compare the efficiency of competing surgical devices. This comparison is carried out by estimating and applying a dollar amount to the potential utility of time created by the use of the less efficient device.
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Affiliation(s)
- Abhishek Chatterjee
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA.
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Vogel TR, Dombrovskiy VY, Haser PB, Scheirer JC, Graham AM. Outcomes of carotid artery stenting and endarterectomy in the United States. J Vasc Surg 2009; 49:325-30; discussion 330. [DOI: 10.1016/j.jvs.2008.08.112] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 08/18/2008] [Accepted: 08/30/2008] [Indexed: 11/30/2022]
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O'Byrne WT, Weavind L, Selby J. The science and economics of improving clinical communication. Anesthesiol Clin 2009; 26:729-44, vii. [PMID: 19041626 DOI: 10.1016/j.anclin.2008.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article presents a complex clinical scenario based on actual communication breakdowns that led to a sentinel event. Basic communication theory that underlies clinical interactions and the tenets of health care economic evaluation are reviewed. The process of the handoff as it relates to clinical interactions is discussed and the weaknesses in communication arising from handoff failures in the operative and critical care environments are examined. The discussion follows by looking at the influences of current medical culture, emerging technology, and changing care environments and their impact on communication behaviors and resultant effect on patient outcomes. A detailed cost analysis of the charges incurred for both standard and escalated care required for the case is followed by a discussion of the economic basis for improving clinical communication and patient safety using the SBAR tool.
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Affiliation(s)
- William T O'Byrne
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, 1211 21st Avenue, South Suite 526, Nashville, TN 37212-1120, USA.
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McPhee JT, Schanzer A, Messina LM, Eslami MH. Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg 2008; 48:1442-50, 1450.e1. [PMID: 18829236 DOI: 10.1016/j.jvs.2008.07.017] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 07/10/2008] [Accepted: 07/10/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) remains the procedure of choice for treatment of patients with severe carotid artery stenosis. The role of carotid artery stenting (CAS) in this patient group is still being defined. Prior single and multicenter studies have demonstrated economic savings associated with CEA compared with CAS. The purpose of this study was to compare surgical outcomes and resource utilization associated with these two procedures at the national level in 2005, the first year in which a specific ICD-9 procedure code for CAS was available. METHODS All patient discharges for carotid revascularization for the year 2005 were identified in the Nationwide Inpatient Sample based on ICD9-CM procedure codes for CEA (38.12) and CAS (00.63). The primary outcome measures of interest were in-hospital mortality and postoperative stroke; secondary outcome measures included total hospital charges and length of stay (LOS). All statistical analyses were performed using SAS version 9.1 (Cary, NC), and data are weighted according to the Nationwide Inpatient Sample (NIS) design to draw national estimates. Univariate analyses of categorical variables were performed using Rao-Scott chi(2), and continuous variables were analyzed by survey weighted analysis of variance (ANOVA). Multivariate logistic regression was performed to evaluate independent predictors of postoperative stroke and mortality. RESULTS During 2005, an estimated 135,701 patients underwent either CEA or CAS nationally. Overall, 91% of patients underwent CEA. The mean age overall was 71 years. Postoperative stroke rates were increased for CAS compared with CEA (1.8% vs 1.1%, P < .05), odds ratio (OR) 1.7; (95% confidence interval [CI] 1.2-2.3). Overall, mortality rates were higher for CAS compared with CEA (1.1% vs 0.57%, P < .05) this difference was substantially increased in regard to patients with symptomatic disease (4.6% vs 1.4%, P < .05). By logistic regression, CAS trended toward increased mortality, OR 1.5; (95% CI .96-2.5). Overall, the median total hospital charges for patients that underwent CAS were significantly greater than those that underwent CEA ($30,396 vs $17,658 P < .05). CONCLUSIONS Based on a large representative sample during the year 2005, CEA was performed with significantly lower in-hospital mortality, postoperative stroke rates, and lower median total hospital charges than CAS in US hospitals. As the role for CAS becomes defined for the management of patients with carotid artery stenosis, clinical as well as economic outcomes must be continually evaluated.
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Affiliation(s)
- James T McPhee
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA
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Carotid Stenting versus Carotid Endarterectomy: Evidence Basis and Cost Implications. Eur J Vasc Endovasc Surg 2008; 36:258-64; discussion 265-6. [DOI: 10.1016/j.ejvs.2008.05.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Accepted: 05/17/2008] [Indexed: 11/21/2022]
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Siewiorek GM, Eskandari MK, Finol EA. The Angioguard embolic protection device. Expert Rev Med Devices 2008; 5:287-96. [PMID: 18452377 DOI: 10.1586/17434440.5.3.287] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endovascular management of cardiovascular disease is quickly becoming a more popular treatment. The effectiveness in using embolic protection devices (EPDs), such as the Angioguard XP filter, during carotid artery stenting (CAS) is a topic of ongoing controversy and scrutiny. Early clinical results indicate that EPDs can reduce complications associated with CAS. However, the incidence of stroke and postprocedural embolic events are statistically similar when comparing CAS with the gold standard in carotid stenosis repair, carotid endarterectomy (CEA). The focus of this manuscript is the critical evaluation of Angioguard XP with respect to numerous in vitro and ex vivo experiments, and clinical trials that have been conducted by the authors and other researchers to investigate the efficacy of EPDs with the objective of suggesting engineering design considerations for future generations of these devices. Angioguard XP has had mixed performance outcomes in in vitro testing reported in the literature. In our laboratory, this device had undesirable measures of performance in bench-top testing protocols using in vitro flow models. Technical considerations relevant to design of EPDs, such as ideal pore size, effective wall apposition in tortuous geometry and maximization of capture efficiency have not been addressed adequately in the literature. It is likely that in the future both CAS and CEA will coexist as potential forms of treatment in the clinical management of cerebrovascular disease.
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Affiliation(s)
- Gail M Siewiorek
- Biomedical Engineering Department, Carnegie Mellon University, 1210 Hamburg Hall, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA.
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How I Interpreted the Randomised Trials of Carotid Angioplasty/stenting versus Endarterectomy. Eur J Vasc Endovasc Surg 2008; 36:34-40. [DOI: 10.1016/j.ejvs.2008.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Accepted: 04/02/2008] [Indexed: 11/18/2022]
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