title: Carotid endarterectomy then and now: outcome and cost-effectiveness of modern practice.
abstract: BACKGROUND
  During the past decade, our practice of performing carotid endarterectomy (CEA) has changed dramatically, most notably by an abrupt shift from routine to selective preoperative angiography, reliance on defined care plans with full-time nurse practitioner oversight, and increasing reliance on eversion endarterectomy and cervical block anesthesia. This study was designed to determine whether these shifts in policy have been associated with lower costs without sacrificing clinical outcome.
  
  
  METHODS
  All patients undergoing CEA from July 1993 to December 2000 were identified, and inpatient and outpatient charts were reviewed. Cost data were obtained from the central hospital accounting system and converted to 2001 dollars. Thirty-day outcomes and costs were quantified each year and compared between each of 2 temporally well-defined groups: those undergoing "routine" versus "selective" angiography and those cared for before and after defined patient care protocols were instituted.
  
  
  RESULTS
  A total of 1168 CEAs were analyzed. Thirty-day combined stroke and death rate was 3.1%, and no trends or significant differences over time were seen. From 1993 to 2000 the cost of CEA fell from $9302 to $6216 (P<.0002), and length of stay was reduced 1 full day (P=.005). Institution of "selective" angiography was associated with an immediate cost savings of approximately $2000 per case (P<.0001), and nurse practitioner oversight along with institution of defined clinical protocols with a $530 (P<.05) decline in nonoperating room-related costs.
  
  
  CONCLUSIONS
  Changes in policy from routine to selective angiography, reliance on defined postoperative care pathways, eversion endarterectomy, and cervical block anesthesia have been associated with significant cost savings, with no compromise in clinical outcome at our institution.
authors: Division of Vascular Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box 652, Rochester, NY 14642, USA.
authors: Karl A
authors: KA
authors: Illig
authors: Cynthia K
authors: CK
authors: Shortell
authors: Renyu
authors: R
authors: Zhang
authors: Yaron
authors: Y
authors: Sternbach
authors: Jeffrey M
authors: JM
authors: Rhodes
authors: Mark G
authors: MG
authors: Davies
authors: Kenneth
authors: K
authors: Ouriel
authors: William
authors: W
authors: Tansky
authors: Marcia
authors: M
authors: Johansson
authors: Richard M
authors: RM
authors: Green
mesh_terms: D000758:Anesthesia; D000792:Angiography; D003362:Cost-Benefit Analysis; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000191:economics* / Q000401:mortality / Q000639:trends*; D005260:Female; D017048:Health Care Costs; D006801:Humans; D015994:Incidence; D007902:Length of Stay; D008297:Male; D009722:Nurse Practitioners; D016134:Organizational Policy; D011182:Postoperative Care; D020521:Stroke / Q000453:epidemiology / Q000209:etiology; D016896:Treatment Outcome