Cost-efficient carotid surgery: a comprehensive evaluation

In Patients with Heart Failure Undergoing Carotid Endarterectomy, Locoregional Anesthesia is Not Associated with Decreased Mortality, Stroke, or Myocardial Infarction Compared to General Anesthesia

BACKGROUND

While existing literature reports no benefit of locoregional anesthesia (LRA) over general anesthesia (GA) in patients undergoing carotid endarterectomy (CEA), the effect of LRA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this population.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2022 and the procedural targeted ACS-NSQIP database for CEA between 2011-2022, all patients receiving CEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ2 or Fischer's exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. Mortality, stroke, myocardial infarction (MI), and major adverse cardiac events (MACE) were compared between patients receiving GA and LRA using univariate analysis.

RESULTS

A total of 3,040 patients (2,733 undergoing GA, 307 undergoing LRA) with a diagnosis of CHF undergoing CEA were identified. No difference in mortality (GA 3.1% vs. LRA 4.6%, P = 0.162), MI (GA 3.0% vs. LRA 2.3%, P = 0.478), stroke (2.4% vs. 2.6%, P = 0.805) or MACE (GA 7.4% vs. LRA 8.1%, P = 0.654) was observed. LRA patients had a significantly lower hospital stay compared to GA patients (1 day [interquartile range (IQR) 1-3] vs. 2 days [IQR 1-4], P < 0.001). Shunt was more commonly used in patients receiving GA (32.9% vs. 12.5%, P < 0.001) compared to LRA.

CONCLUSIONS

While utilizing LRA compared to GA during CEA in patients with CHF is associated with a shorter hospital stay and less intraoperative shunting, the choice of anesthesia did not impact the outcomes of mortality, MI or stroke. Further research is needed to determine the effect of LRA on the outcomes of CEA among patients with different stages of heart failure.

Reducing costs while maintaining quality in endovascular neurosurgical procedures

Object

As medical costs continue to rise during a time of increasing medical resource utilization, both hospitals and physicians must attempt to limit superfluous health care expenses. Neurointerventional treatment has been shown to be costly, but it is often the best treatment available for certain neuropathologies. The authors studied the effects of 3 policy changes designed to limit the costs of performing neurointerventional procedures at the University of Michigan.

Methods

The authors retrospectively analyzed the costs of performing neurointerventional procedures during the 6-month periods before and after the implementation of 3 cost-saving policies: 1) the use of an alternative, more economical contrast agent, 2) standardization of coil prices through negotiation with industry representatives to receive economies of scale, and 3) institution of a feedback method to show practitioners the costs of unused products per patient procedure. The costs during the 6-month time intervals before and after implementation were also compared with costs during the most recent 6-month time period.

Results

The policy requiring use of a more economical contrast agent led to a decrease in the cost of contrast usage of $42.79 per procedure for the first 6 months after implementation, and $137.09 per procedure for the most current 6-month period, resulting in an estimated total savings of $62,924.31 for the most recent 6-month period. The standardized coil pricing system led to savings of $159.21 per coil after the policy change, and $188.07 per coil in the most recent 6-month period. This yielded total estimated savings of $76,732.56 during the most recent 6-month period. The feedback system for unused items decreased the cost of wasted products by approximately $44.36 per procedure in the 6 months directly after the policy change and by $48.20 per procedure in the most recent 6-month period, leading to total estimated savings of $22,123.80 during the most recent 6-month period. According to extrapolation over a 1-year period, the 3 policy changes decreased costs by an estimated $323,561.34.

Conclusions

Simple cost-saving policies can lead to substantial reductions in costs of neurointerventional procedures while maintaining high levels of quality and growth of services.

Costs of stroke using patient-level data: a critical review of the literature

BACKGROUND AND PURPOSE

With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria.

METHODS

A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups.

RESULTS

A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs.

CONCLUSIONS

This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.

Vascular surgery, ICU and HDU: a 14-year observational study

INTRODUCTION

Over the course of the past decade, numerous changes have occurred in the management of patients undergoing vascular surgical operations. The introduction of high dependency units (HDUs) has meant that many patients previously requiring observation in intensive care units (ICUs) are now managed in this new environment. In addition, many vascular patients may now be suitable for management on a vascular ward immediately following their surgery. This study reports the chronological changes in resource utilisation of patients undergoing major vascular surgery in a district general hospital over a 14-year period.

PATIENTS AND METHODS

Details of all patients admitted to either the ICU or HDU under the care of a single vascular surgeon during the period 1991-2004 were extracted from a prospectively maintained anaesthetic department database. Details of the age and gender of the patients were obtained together with source of admission, place of discharge and need for re-admission. Operative details for each patient were extracted from a prospectively maintained vascular surgery database including type of procedure undertaken and degree of urgency.

RESULTS

During the 14-year period under study, there was a dramatic decrease in the use of ICU facilities for the management of vascular patients from 100% in 1991 to 36% in 2004. There was a corresponding increase in the use of HDU for major vascular cases during the same period from 0% to 66%. However, despite a significant increase in the total number of major vascular operations performed, from 67 in 1991 to 185 in 2004 as a result of sub-specialisation, overall use of all high-care facilities fell as the number of patients returned directly to the vascular ward increased from 34% in 1991 to 64% in 2004. The efficacy of the choice of management venue was confirmed by the observation that only 7.7% of those managed on ICU had been initially managed at a lower level of care. In addition, only 1.8% of patients managed on HDU had been admitted after initially being managed on the vascular ward.

CONCLUSIONS

Sub-specialisation over the past decade has meant a significantly increased major vascular work-load. Since the introduction of the HDU, there has been a significant fall in the use of ICU facilities for routine cases. These changes in resource utilisation have significant implications in terms of budget allocation. It would appear that finances, in relation to vascular surgery, should be concentrated on expanding HDU facilities and ensuring vascular surgery expertise amongst ward nursing staff.

[Early transfer from intensive care does not influence clinical results of carotid endarterectomy]

The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.

Dollars and sense: the economics and outcomes of patients undergoing carotid endarterectomy at Royal Adelaide Hospital

This study examined the costs and outcomes of patients undergoing carotid endarterectomy who returned directly to the vascular unit after surgery rather than to the intensive care unit (ICU)/high dependency unit (HDU). The ICU/HDU is for critically ill patients. HDU is the step-down area from the ICU. The nurse-to-patient ratio for these patients is 1:2 and senior medical staff are available 24 hours a day. To prepare staff for the change in practice, an intense educational program was provided and protocols for patient management were developed and implemented. Outcomes were then monitored for the group of patients who returned directly to the vascular unit. Case notes audits, informal patient interviews, daily monitoring of patient outcomes, and an analysis of costing data from Australian Diagnostic Related Groups demonstrated that 50% of patients required transfer to the ICU/HDU after surgery for respiratory, hemodynamic, or neurologic management. The remaining 50% of patients returned directly to the vascular unit with no major complications and had better outcomes with less intensive nursing care overall. The length of hospital stay and the management costs were reduced significantly.

Cost of identifying patients for carotid endarterectomy

BACKGROUND AND PURPOSE

The cost of carotid endarterectomy (CEA) usually considers only the cost of the preoperative investigations and the procedure for the individual patient but ignores the cost incurred in selecting a patient from a referred "pool" of potential candidates or the "total direct program cost." The aim of this study was to estimate the total direct program cost (workup and procedure) of CEA in a large major teaching hospital in Edinburgh, Scotland using a retrospective study design.

METHODS

Participants were patients with transient ischemic attacks and mild strokes referred to the neurovascular clinics for assessment, investigation, and possible CEA. The "workup" was defined as the clinical consultation, carotid duplex, 1 follow-up visit, and a catheter angiogram where indicated. We used data routinely collected from the neurovascular clinics during a 1-year period to estimate the workup cost of patients who might be suitable for CEA. The CEA procedure cost was estimated prospectively in a concurrent study. Estimated costs were applied to the proportions assessed at the different levels of investigation to determine the total direct program cost of CEA.

RESULTS

A total of 790 new patients with symptoms suggestive of transient ischemic attacks and mild strokes were identified. Four hundred one (51%) patients were referred for carotid duplex. Duplex identified 78 (10%) with carotid stenosis of > or =70%. Of the total of 790 patients, 26 (3.3%) had catheter angiogram and 18 (2.3%) had CEA. The total direct program cost to investigate this cohort was about 207 000 pounds sterling, with 68% (140 000 pounds sterling) of the cost incurred before any surgery was performed.

CONCLUSION

The cost of identifying suitable patients for carotid surgery is quite high, with more than 30% of the cost attributed to the initial consultation at the neurovascular clinics. The cost of preventing 1 stroke by CEA is in the region of 100 000 pounds sterling at 1997/1998 prices if all the costs incurred in the workup of a cohort for potential CEA are included.

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.

Short stay carotid surgery for veterans: an emerging standard

We have taken the short stay approach to carotid artery surgery to our VA setting over the past 5 to 6 years. Retrospectively, we reviewed the efficacy and safety of that approach in 201 consecutive carotid operations over the recent 4-year period (January 1, 1996-December 31, 1999). In 1996 we had already begun the transition to an algorithm to (1) utilize carotid color flow Doppler duplex exams for diagnosis, (2) same-day admission (SDA), (3) intensive care unit (ICU) only when deemed medically necessary, and (4) next-day discharge. Results of this approach have been a decrease in the utilization of diagnostic arteriograms and utilization of the ICU from 100% previous to the onset of this approach to 17 and 22%, respectively. SDA increased from 24 to 89%. Mean LOS decreased from 5.13+/-0.9 to 1.97+/-0.4 days. The percentage of patients completing the algorithm went from 15 to 72%. Stroke and/or death varied from 0 to 3.7% each year and was only 2.4% over the 4-year period. In conclusion, this approach to short stay carotid surgery in the veteran population has proven both efficacious and safe with results similar to those in university and community practices.

Cost Containment in Vascular Surgery

In the last decade, the delivery of health care and the role of the physician have undergone radical change. With the ad vent of managed care and the tightening of restrictions by Medicare and insurance companies, physicians have been required to review, re-engineer, and revitalize their role. Increasing financial pressures at the hospital level have caused administrators to cut costs at all levels. It is imper ative that physicians take an active role in cost containment so that the quality of care is not sacrificed. Cost containment in vascular surgery is an urgent priority in health care. Copyright © 2000 by W.B. Saunders Company.

Carotid endarterectomy: the financial impact of practice changes

PURPOSE

New techniques in the management of extracranial carotid occlusive disease have focused attention on the outcome and economics of carotid endarterectomy (CEA). Changing practice patterns for CEA must be assessed to allow accurate comparisons. The purpose of this study was to evaluate the effect of practice modifications related to CEA on patient outcome and cost data.

METHODS

Data on patients undergoing CEAs at a single institution from fiscal year 1992 to 1998 were prospectively collected and entered into a computerized database. Records were reviewed for patient demographics and outcome with regard to stroke and death. Selected years that corresponded to transitions in perioperative management were audited for complete hospital financial information from.

RESULTS

We performed 960 CEAs during the study period, with a combined stroke and death rate of 1.1%. Inflation-adjusted hospital costs per patient in 1998 dollars for the years 1992, 1996, and 1998 were $5494, $4476, and $3350, respectively. In 1998, costs for patients who required arteriography were $1825 greater than those operated on during duplex scan examination alone in 1998. Statistically significant differences occurred in the year-to-year comparisons in the use of arteriography, intensive care unit monitoring, same day admissions, and length of stay. There were no statistically significant differences in the stroke and death rate between years.

CONCLUSION

Practice changes related to CEA have resulted in significant savings without detriment in patient outcome. Comparisons between CEA and endovascular techniques will need to be evaluated within this context. Given these advances in perioperative management, it will be difficult to justify carotid stenting on the basis of current economic considerations.

Significant reductions in length of stay after carotid endarterectomy can be safely accomplished without modifying either anesthetic technique or postoperative ICU monitoring

BACKGROUND AND PURPOSE

We sought to determine whether postoperative length of stay (LOS) and resource utilization could be safely reduced without changing our uniform protocol of performing carotid endarterectomy (CEA) under general anesthesia with postoperative intensive care unit monitoring.

METHODS

We retrospectively reviewed the hospital records of 421 consecutive CEA operations performed during a 3-year period of transition in discharge policy to determine LOS, complications, and resource utilization. We divided operated patients into 3 cohorts: cohort I patients were operated on before a stay reduction policy was instituted (1995, n=171); cohort II patients were operated on after the institution of a single-day-stay policy for selected patients (January to August 1996, n=95); and cohort III patients were operated on after the institution of a universal single-day-stay policy (September 1996 to December 1997, n=155).

RESULTS

While significant in-hospital complications leading to increased LOS remained essentially unchanged over time (cohort I: 4.0%; II: 6.3%; III: 3.9%; P=NS), the mean postoperative LOS decreased from 2.6+/-0.3 days in cohort I to 1.6+/-0.1 days in cohort III (P<0.0001). The median postoperative LOS also decreased from 2 days to 1 day from cohort I to III, with 70% of patients discharged after 1 day in cohort III compared with only 32% for cohort I (P<0.0001). In addition, the total number of laboratory studies ordered decreased from 8.0+/-0.8 per patient in cohort I to 6.4+/-0.5 in cohort III (P<0.01).

CONCLUSIONS

A uniform policy of discharge home from the intensive care unit on postoperative day 1 following CEA under general anesthesia can reduce LOS and decrease resource utilization without compromising care.

Cerebral tomographic findings in patients undergoing carotid endarterectomy for asymptomatic carotid stenosis: short-term and long-term implications

PURPOSE

Preoperative cerebral imaging has been considered not to be cost-effective in carotid endarterectomy (CEA) for asymptomatic carotid stenosis. Yet, silent brain infarction (SBI) has been associated with the embolization potential of a severe carotid stenosis. Thus the presence of SBI may represent an additional indication for CEA in asymptomatic patients. We examined the predictive value of preoperatively detected silent cerebral lesions on early and late outcomes in patients undergoing CEA for asymptomatic carotid stenosis.

METHODS

Preoperative cerebral tomographic (CT) scans performed on 301 asymptomatic patients undergoing 346 CEAs from 1986 to 1995 were reviewed by a single neuroradiologist blinded to patients' records. Mean follow-up was 67. 3 months (range, 24-130 months). The degree of internal carotid lumen reduction was measured bilaterally in all patients (602 carotid arteries); carotid stenosis of 60% or more was found in 399 carotid arteries.

RESULTS

Of the 103 (34%) CT scans positive for cerebral lesions, 58% were lacunar. No significant association was observed between the side of the cerebral lesion on CT scan and the severity of the corresponding carotid stenosis; 38 silent lesions were detected in the 203 hemispheres ipsilateral to carotid stenoses that were less than 60% versus 95 SBIs in the 399 hemispheres ipsilateral to carotid stenoses that were 60% or more (19% vs 24%; P =.2). There were no significant differences in the perioperative stroke/death rate in patients with or without cerebral CT lesions (2% vs 1%; odds ratio, 1.94; P =.6). Mortality rate during follow-up was 22% in patients with preoperative SBI and 15% in patients without SBI (P =.1). However, actuarial survival at 10 years was shorter (P =.02) in patients with SBI. Late stroke occurred in 11% of patients with preoperative SBI and in 3% of patients without preoperative SBI (P =.006). Cox regression analysis showed that both preoperative lacunar and nonlacunar infarctions were independent predictors of late stroke (hazard ratio, 3.6; P =.04; and hazard ratio, 7.1; P =.001; respectively).

CONCLUSION

In our experience, preoperative SBI did not occur more frequently in the hemisphere ipsilateral to asymptomatic severe carotid stenosis. Although our study lacks a medically treated control group, our data show that SBI is predictive of poor neurologic outcome in asymptomatic patients undergoing CEA. We conclude that CT before CEA, selectively applied, provides information on long-term neurologic prognosis and that a less aggressive attitude towards CEA in asymptomatic patients with SBI may be justified.

Cost savings associated with the nonroutine use of carotid angiography

BACKGROUND

To evaluate the economic impact of performing carotid endarterectomy based only on a diagnosis of duplex scanning, we evaluated a cohort of patients treated at our institution during 1 calendar year.

METHODS

Ninety-seven patients were evaluated and divided into two groups: those with and without arteriogram prior to their operation. Duplex scan and arteriogram results were reviewed to determine their effect on the operative plan. Hospital charges and physician fees were assessed for each patient admission. Operative results, complications, and total charges were compared between the two groups.

RESULTS

There was one operative stroke in each group for a stroke rate of 2%. Angiographic complications included one stroke and one femoral artery thrombosis. Two arteriograms led to a change in the operative plan. The hospital charges for patients without an arteriogram was $10,292 verses $13,906 for patients with an arteriogram (P < 0.01). Physician charges for patients without an arteriogram were $3,882, with angiograms and $6,297. The total charges related to the endarterectomy were $14,174 and $20,203, respectively. Arteriograms accounted for an increase of 43% in total charges.

CONCLUSION

Nonroutine use of angiography does not increase operative risk or postoperative length of stay, and preoperative angiography increases total charges by 43% ($6,029) per patient.

Do clinical pathways for major vascular surgery improve outcomes and reduce cost?

PURPOSE

This study was performed to determine whether the implementation of clinical pathways for patients who undergo major vascular procedures in a community hospital would shorten the length of stay and reduce charges when compared with Medicare standards.

METHODS

Length of stay, hospital costs, and morbidity, mortality, and readmission rates for the four most common vascular diagnosis-related group (DRG) categories at our institution were compared with Medicare standards. The four categories were DRG 005 (extracranial vascular procedures), DRG 110 (aortic and renal procedures), DRG 478 (leg bypass with comorbidity), and DRG 479 (leg bypass without comorbidity). Between May 1, 1994, and June 30, 1996, 112 patients underwent carotid endarterectomy, 42 patients underwent aortic or renal procedures, and 130 patients underwent lower extremity bypass procedures (68% with comorbidity). Only Medicare patients were included because exact cost/reimbursement data were available. No admissions were excluded.

RESULTS

The average length of stay was 1.2 days for DRG 005, 6.9 days for DRG 110, and 3.2 and 2.1 days for DRGs 478 and 479, respectively. The average cost savings when compared with the Medicare reimbursement was $4338 for DRG 005, $7161 for DRG 110, $4108 for DRG 478, and $2313 for DRG 479. Readmission was necessary for 9% of peripheral bypass patients. Ten percent of patients in DRG 005 and 86% of patients in DRG 110 needed intensive care, whereas only 2% of patients who underwent complicated bypass procedures did. Ninety percent of carotid endarterectomy patients and 23% of leg bypass patients were discharged on the first postoperative day. There were two postoperative strokes (2%) after carotid surgery. Thirty-three percent of aortic/renal patients had complications that led to care outside the clinical pathway. Twenty-five percent of leg bypass patients required home care to treat open foot wounds. Total inpatient cost savings were $1,256,000 when compared with Medicare reimbursement.

CONCLUSIONS

Clinical pathways significantly improve the length of stay and decrease inpatient charges for major vascular surgical procedures while maintaining high standards of care. Factors that favorably affected the length of stay and hospital charges were outpatient arteriography, same-day admission, early ambulation, physical therapy, home care, use of the intensive care unit on a selective basis, and early discharge. Factors that adversely affected these outcomes were emergency admission, inpatient arteriography, thrombolytic therapy, complications, and the need for dialysis or anticoagulation.