Improving the appropriateness of carotid endarterectomy: results of a prospective city-wide study.
OBJECTIVE
In light of previously reported concerns regarding carotid endarterectomy (CEA) use in our city, our goal was to determine the influence of a prospective audit and educational campaign on the performance of CEA with respect to surgical appropriateness and complication frequency.


METHODS
Results of our previous audit of 291 CEAs, along with CEA practice guidelines and notification of prospective surveillance, were supplied to surgeons performing CEA in our city. After this, 184 consecutive patients undergoing CEA from September 1996 to August 1997 were followed prospectively. On the basis of blinded standardized remeasurements of angiographic carotid stenoses, CEA was classified as appropriate for patients with symptomatic carotid stenoses >/=70%, uncertain for those with symptomatic stenoses <70% or asymptomatic stenoses >/=60%, and inappropriate for patients with asymptomatic carotid stenoses <60% or preoperative neurological or medical instability.


RESULTS
Forty percent of patients were asymptomatic. Compared with our prior audit, the rate of appropriate CEAs improved from 33% previously to 49% of cases in the present study (P=0.0005), uncertain indications did not change significantly (49% versus 47%; P=0.61), and inappropriate indications dropped from 18% to 4% (P=0. 00002). Perioperative stroke or death occurred in 6.4% of symptomatic patients but developed in only 2.7% of asymptomatic patients, which was improved from the 5.1% rate previously found.


CONCLUSIONS
In our city, the use of a surgical audit identified areas of concern regarding CEA, and subsequent education and ongoing surveillance significantly improved the use and performance of this procedure.
Wong
J H
JH
University of Alberta, Edmonton, Alber. Department of Surgery, MacKenzie Health Sciences Centre, University of Alberta, Edmonton, Canada.
Lubkey
T B
TB
Suarez-Almazor
M E
ME
Findlay
J M
JM
D016893:Carotid Stenosis / Q000601:surgery*; D004502:Education, Medical, Continuing / Q000592:standards; D016894:Endarterectomy, Carotid / Q000706:statistics & numerical data*; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006786:Hospitals, Urban / Q000706:statistics & numerical data*; D006801:Humans; D008485:Medical Audit; D011183:Postoperative Complications / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011446:Prospective Studies; D016896:Treatment Outcome