title: Wait times among patients with symptomatic carotid artery stenosis requiring carotid endarterectomy for stroke prevention.
abstract: BACKGROUND
  Current Canadian and international guidelines suggest patients with transient ischemic attack (TIA) or nondisabling stroke and ipsilateral internal carotid artery stenosis of 50% to 99% should be offered carotid endarterectomy (CEA) ≤ 2 weeks of the incident TIA or stroke. The objective of the study was to identify whether these goals are being met and the factors that most influence wait times.
  
  
  METHODS
  Patients who underwent CEA at the Ottawa Hospital for symptomatic carotid artery stenosis from 2008 to 2010 were identified. Time intervals based on the dates of initial symptoms, referral to and visit with a vascular surgeon, the decision to operate, and the date of surgery were recorded for each patient. The influence of various factors on wait times was explored, including age, sex, type of index event, referring physician, distance from the surgical center, degree of stenosis, and surgeon assigned.
  
  
  RESULTS
  Of the 117 patients who underwent CEA, 92 (78.6%) were symptomatic. The median time from onset of symptoms to surgery for all patients was 79 days (interquartile range [IQR], 34-161). The shortest wait times were observed in stroke patients (49 [IQR, 27-81] days) and inpatient referrals (66 [IQR, 25-103] days). Only 7 of the 92 symptomatic patients (8%) received care within the recommended 2 weeks. The median surgical wait time for all patients was 14 days (IQR, 8-25 days). In the multivariable analysis, significant predictors of longer wait times included retinal TIA (P = .003), outpatient referrals (P = .004), and distance from the center (P = .008). Patients who presented to the emergency department had the shortest delays in seeing a vascular surgeon and subsequently undergoing CEA (P < .0001). There was no difference between surgeons for wait times to be seen in the clinic; however, there were significant differences among surgeons once the decision was made to proceed with CEA.
  
  
  CONCLUSIONS
  Our wait times for CEA currently do not fall within the recommended 2-week guideline nor does it appear feasible within the current system. Important factors contributing to delays include outpatient referrals, living farther from the hospital, and presenting with a retinal TIA (amaurosis fugax). Our findings also suggest better scheduling practices once a decision is made to operate can modestly improve overall and surgical wait times for CEA.
authors.affiliation: Division of Vascular and Endovascular Surgery, Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada. pjetty@ottawahospital.on.ca
authors.forename: Prasad
authors.initials: P
authors.lastname: Jetty
authors.forename: Don
authors.initials: D
authors.lastname: Husereau
authors.forename: Dalibor
authors.initials: D
authors.lastname: Kubelik
authors.forename: Sudhir
authors.initials: S
authors.lastname: Nagpal
authors.forename: Tim
authors.initials: T
authors.lastname: Brandys
authors.forename: George
authors.initials: G
authors.lastname: Hajjar
authors.forename: Andrew
authors.initials: A
authors.lastname: Hill
authors.forename: Michael
authors.initials: M
authors.lastname: Sharma
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D002546:Ischemic Attack, Transient / Q000453:epidemiology / Q000517:prevention & control*; D008297:Male; D015999:Multivariate Analysis; D009864:Ontario / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011314:Preventive Health Services / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012111:Residence Characteristics / Q000706:statistics & numerical data; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control*; D013997:Time Factors; D014850:Waiting Lists