Cost management strategies for carotid endarterectomy

Integration and added value of the modern noninvasive vascular laboratory in vascular diseases management

BACKGROUND AND PURPOSE

Today's vascular laboratory technology offers broad applications throughout vascular medicine. We explore the diagnostic work-up and management of selected peripheral vascular diseases by benchmarking the institutional mix of invasive and noninvasive technology utilization and associated cost burdens.

METHODS

Specialized diagnostic studies for prevention of stroke and pulmonary embolism, and diagnosis and management of femoral pseudoaneurysm were reviewed for our 355-physician clinic and hospital practice. The proportions and costs for invasive and noninvasive diagnostic procedures were tabulated for carotid stenosis, deep venous thrombosis (DVT), and iatrogenic femoral pseudoaneurysm. Current technology utilization mix cost burdens were compared to projected cost burdens for hypothetical equivalent medical value (i.e., the same total test volume) in the theoretical absence of noninvasive laboratory services.

RESULTS

The technology utilization mix was dominated by noninvasive duplex ultrasonography for all 3 vascular disease workups. The technology utilization mix benchmarks were 92% noninvasive for carotid stenosis, 98% noninvasive for DVT, and 100% noninvasive for pseudoaneurysm. Under hypothetical constant test volume normalized to utilization level for the 2-year period, the maximal range in cost burdens between current reliance on noninvasive diagnoses versus projected 100% reliance on invasive procedures for the 3 vascular applications is approximately $6 million.

CONCLUSION

Benchmark indices reveal near total adoption of noninvasive technology for vascular diagnostic workups at our center. The benefits to institutions of benchmarking their technology utilization mix and costs are discussed in relation to identifying potential for cost-containment from modifying technology utilization practices.

Costs and benefits of carotid endarterectomy and associated preoperative arterial imaging: a systematic review of health economic literature

BACKGROUND AND PURPOSE

Carotid endarterectomy (CEA) reduces the risk of stroke in patients with severe stenosis of the internal carotid artery. However, the cost implications of this procedure have not yet been satisfactorily addressed. The objective of this systematic review was to critically appraise the studies addressing the economic implications of CEA and the associated preoperative arterial imaging.

METHODS

A systematic search strategy was developed to identify research articles related to the economic evaluation of CEA and the associated preoperative imaging. MEDLINE, EMBASE, and BIOSIS were electronically searched, and reference lists from identified studies were searched manually. Methods used to critically appraise these studies followed proposed guidelines for an economic evaluation that addresses 10 distinct aspects under 3 separate headings.

RESULTS

Studies identified were either partial economic or full economic evaluations, with the majority coming from the United States. The methodological quality seems to have improved over time. The studies that assessed cost-effectiveness of CEA were all modeling studies; although the same baseline parameters were used, divergent conclusions were reached. Variation in the cost estimates of CEA ($9500 to $11 500) in the same health care system was also observed in the studies reporting only on the cost of carotid surgery. For a symptomatic patient, the benefit of CEA ranged from 0.35 quality adjusted life years (QALYs) (4.2 months) at a cost of $4100 per QALY to 0.93 QALYs (11.2 months) at a cost of $434 per QALY. For an asymptomatic patient, the cost-effectiveness of CEA varied from 0.15 QALYs (1.8 months) at a cost of $52 700 per QALY to 0.25 QALYs (3 months) at a cost of $8004 per QALY.

CONCLUSIONS

Divergent conclusions of the cost-effectiveness of CEA were reported from studies that addressed the same questions and using similar parameters in their models. The cost estimates of the procedure and the different time periods used in the studies might explain these inconsistencies. Modeling studies in hypothetical cohorts might also be to blame. The cost-effectiveness of CEA will only definitively be assessed when real patient data are used.

Carotid artery stent placement for atherosclerotic disease: rationale, technique, and current status

Carotid arterial endarterectomy is considered to be the standard for the treatment of atherosclerotic carotid arterial occlusive disease. This has been validated with results of several randomized controlled trials in which its effectiveness has been demonstrated over that of the best nonsurgical therapy. In the past several years, however, carotid angioplasty with stent placement has emerged as a potential alternative to carotid endarterectomy. This article represents a critical examination of the rationale for carotid revascularization; the history of endovascular techniques for the treatment of carotid atherosclerosis, beginning with balloon angioplasty and evolving to the use of stents; and the evidence supporting the effectiveness of the endovascular approach. A brief description of the current technical aspects of carotid artery stent placement is presented. The future status of the endovascular approach will be determined with randomized trials in which carotid artery stent placement is directly compared with endarterectomy, as well as by the potential for further innovation and improvement in endovascular devices, technique, and safety.