title: Variations in rates of appropriate and inappropriate carotid endarterectomy for stroke prevention in 4 Canadian provinces.
abstract: BACKGROUND
  Carotid endarterectomy (CE), when performed on appropriate patients, reduces the incidence of stroke, yet there are marked variations in rates of this procedure. We sought to determine reasons for the variation in CE rates in 4 Canadian provinces.
  
  
  METHODS
  We identified all CEs performed in 4 Canadian provinces between January 2000 and December 2001, inclusive. From chart review and expert assessment, we determined the proportion of these procedures that were appropriate, inappropriate or of uncertain appropriateness, using the RAND/UCLA Appropriateness Method. We sought to determine the variation in rates by province and whether the variation was due to differences in type of hospital, surgical specialty or surgical volume.
  
  
  RESULTS
  Overall, 1656 (52.3%) of the 3167 CEs studied were performed for appropriate indications. The proportions of appropriate procedures were 78.2% (176/225) in Saskatchewan, 58.7% (481/819) in Alberta, 49.1% (350/713) in Manitoba and 46.0% (649/1410) in British Columbia (p < 0.001 across provinces). Rates of appropriate procedures per 100 000 population ranged from 44.3 in Manitoba to 16.2 in Saskatchewan (p < 0.001 across provinces). CEs were more likely to be appropriate when performed by a neurosurgeon compared with all other surgeons (74.4% v. 49.4% were appropriate; p < 0.001), when performed by surgeons doing fewer than 31 procedures over 2 years compared with surgeons doing more than 31 (70.1% v. 49.5% were appropriate; p < 0.001) and when performed in hospitals doing fewer than 135 procedures per year compared with hospitals doing more than 135 (63.4% v. 49.1% were appropriate; p < 0.001). Overall, 10.3% of procedures were done for inappropriate reasons.
  
  
  CONCLUSIONS
  Our findings suggest some overuse (for inappropriate or uncertain indications) but also some underuse (low population rates in some regions). High rates of CE are associated with lower rates of appropriateness for both surgeons and hospitals. That 1 in 10 CEs is done inappropriately suggests the need for preoperative assessment of appropriateness.
authors.affiliation: Department of Clinical Neurosciences, University of Calgary Foothills Hospital, Alta.
authors.forename: James
authors.initials: J
authors.lastname: Kennedy
authors.forename: Hude
authors.initials: H
authors.lastname: Quan
authors.forename: William A
authors.initials: WA
authors.lastname: Ghali
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Feasby
mesh_terms: D000328:Adult; D000368:Aged; D000416:Alberta; D001955:British Columbia; D016009:Chi-Square Distribution; D016894:Endarterectomy, Carotid / Q000706:statistics & numerical data*; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008350:Manitoba; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012525:Saskatchewan; D014600:Utilization Review