title: The value of a carotid duplex surveillance program for stroke prevention.
abstract: BACKGROUND
  Although duplex ultrasonography (DU) can readily identify progression of carotid stenosis, controversy regarding the natural history of asymptomatic carotid stenosis as well as the need and appropriate interval for carotid DU surveillance still exists. Furthermore, consensus has not yet been made in the surgical literature regarding the usefulness, cost-effectiveness, or timing of DU surveillance after carotid endarterectomy (CEA). The purpose of this study was to determine how often DU surveillance for asymptomatic carotid disease or postintervention stenosis resulted in any change in the patient's clinical management, how many strokes were prevented by DU surveillance, and the cost of such a DU surveillance program per stroke prevented.
  
  
  METHODS
  We reviewed a 9-year vascular surgical database to identify all patients enrolled in a carotid DU surveillance program for asymptomatic carotid stenosis or following CEA between January 1, 2000, and December 31, 2008. The number of duplex scans and CEAs performed in those patients through March 2010 was also determined. The results of the Asymptomatic Carotid Atherosclerosis Study were then used to estimate the number of strokes prevented by CEA in the study population. Reimbursement data were assessed to calculate the average cost of each DU and the cost of the DU surveillance program for each stroke prevented.
  
  
  RESULTS
  During the study period, there were 11,531 carotid duplex scans performed on 3,003 patients (mean: 3.84 scans per patient) who had been enrolled in the DU surveillance program. CEA for asymptomatic carotid stenosis was performed on 225 (7.5%) patients. The DU surveillance program prevented approximately 13 strokes (871 carotid duplex scans per stroke prevented). The mean cost of each duplex scan was $332 ± 170. The total cost of the DU surveillance program was approximately $3,830,000 or $290,000 per stroke prevented.
  
  
  CONCLUSIONS
  Although a carotid DU surveillance program generates substantial revenue for a vascular surgery practice, it is costly and inefficient. A reappraisal of the "value" of carotid DU surveillance in stroke prevention is warranted. Consideration should be given to eliminating routine surveillance of postendarterectomy carotids in the absence of contralateral disease and limiting the number of DU surveillance studies for asymptomatic carotid disease.
authors.affiliation: Greenville Hospital System-University Medical Center, University of South Carolina School of Medicine- Greenville Campus, Greenville, SC 29605, USA. dcull@GHS.org
authors.forename: David L
authors.initials: DL
authors.lastname: Cull
authors.forename: Terry
authors.initials: T
authors.lastname: Cole
authors.forename: Blair
authors.initials: B
authors.lastname: Miller
authors.forename: Brent
authors.initials: B
authors.lastname: Johnson
authors.forename: Dustin
authors.initials: D
authors.lastname: Rawlinson
authors.forename: Eric
authors.initials: E
authors.lastname: Walker
authors.forename: Spence M
authors.initials: SM
authors.lastname: Taylor
mesh_terms: D058070:Asymptomatic Diseases; D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000191:economics / Q000628:therapy*; D003362:Cost-Benefit Analysis; D019992:Databases as Topic; D016894:Endarterectomy, Carotid; D017048:Health Care Costs; D006801:Humans; D007349:Insurance, Health, Reimbursement; D008403:Mass Screening / Q000191:economics / Q000379:methods*; D018803:Models, Economic; D009657:North Carolina; D011182:Postoperative Care; D011237:Predictive Value of Tests; D011314:Preventive Health Services / Q000191:economics; D011379:Prognosis; D015397:Program Evaluation; D020521:Stroke / Q000191:economics / Q000209:etiology / Q000628:therapy*; D013997:Time Factors; D018616:Ultrasonography, Doppler, Duplex / Q000191:economics