title: Improving the cost-effectiveness of carotid endarterectomy.
abstract: OBJECTIVE
  Carotid endarterectomy (CEA) has been shown to significantly reduce the risk of stroke caused by carotid artery stenosis. Limiting the costs of CEA without increasing the risks will improve the cost-effectiveness of this procedure.
  
  
  METHODS
  Results were prospectively collected from 63 consecutive CEAs performed in 60 patients who were entered into a clinical pathway for CEA that included avoidance of cerebral arteriography, preferential use of regional anesthesia, selective use of the intensive care unit (ICU), and early hospital discharge. The mortality rate, complications, hospital costs, and net income in these patients were then compared with results from 45 CEAs performed in 42 consecutive patients immediately before beginning the CEA pathway. Age, comorbid risk factors, incidence of symptoms, and degree of carotid artery stenosis were similar in both patient groups.
  
  
  RESULTS
  The rates of mortality and complications associated with CEA were low (mortality rate, 0%; stroke, 0.9%; transient ischemic attack, 2.8%) and did not vary between the two groups. Implementation of the CEA pathway resulted in significant (p < 0.001) reductions in the use of arteriography (74% to 13%), general anesthesia (100% to 24%), ICU use (98% to 30%), and mean hospital length of stay (5.8 days to 2.0 days). These changes resulted in a 41% reduction in mean total hospital cost ($9652 to $5699) and a 124% increase in mean net hospital income ($1804 to $4039) per CEA (p < 0.01). For the 39 patients (62%) who achieved all elements of the CEA pathway, the mean hospital length of stay was 1.3 days, the mean hospital cost was $4175, and the mean hospital income was $4327.
  
  
  CONCLUSIONS
  Costs associated with CEA can be reduced substantially without increased risk. This makes CEA an extremely cost-effective treatment of carotid disease against which new therapeutic approaches must be measured.
authors.affiliation: Section of Vascular Surgery, University of Florida College of Medicine, Gainesville 32610-0286, USA.
authors.forename: M R
authors.initials: MR
authors.lastname: Back
authors.forename: T R
authors.initials: TR
authors.lastname: Harward
authors.forename: T S
authors.initials: TS
authors.lastname: Huber
authors.forename: L M
authors.initials: LM
authors.lastname: Carlton
authors.forename: T C
authors.initials: TC
authors.lastname: Flynn
authors.forename: J M
authors.initials: JM
authors.lastname: Seeger
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000601:surgery; D016009:Chi-Square Distribution; D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data*; D019091:Critical Pathways / Q000191:economics*; D017558:Elective Surgical Procedures / Q000191:economics; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000191:economics* / Q000401:mortality / Q000706:statistics & numerical data; D005431:Florida / Q000453:epidemiology; D017721:Hospital Costs / Q000706:statistics & numerical data; D006785:Hospitals, University / Q000191:economics; D006801:Humans; D010043:Outcome and Process Assessment, Health Care / Q000191:economics / Q000706:statistics & numerical data; D011182:Postoperative Care / Q000191:economics; D011446:Prospective Studies; D018709:Statistics, Nonparametric