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Auditing Carotid Endarterectomy: A Regional Experience

Published online by Cambridge University Press:  02 December 2014

J. Max Findlay ,
Linda Nykolyn ,
Tracey B. Lubkey ,
John H. Wong ,
Mikael Mouradian  and
Ambikaipakan Senthilselvan
J. Max Findlay
Affiliation:
Division of Neurosurgery, University of Alberta, Clinical Quality Resource and Risk Management Department, Capital Health Authority, Alberta, Canada
Linda Nykolyn
Affiliation:
Division of Neurosurgery, University of Alberta, Clinical Quality Resource and Risk Management Department, Capital Health Authority, Alberta, Canada
Tracey B. Lubkey
Affiliation:
Division of Neurosurgery, University of Alberta, Clinical Quality Resource and Risk Management Department, Capital Health Authority, Alberta, Canada
John H. Wong
Affiliation:
Division of Neurosurgery, University of Calgary, Alberta, Canada
Mikael Mouradian
Affiliation:
Division of Neurology, University of Alberta, Alberta, Canada
Ambikaipakan Senthilselvan
Affiliation:
Epidemiology Program, Department of Public Health, University of Alberta, Alberta, Canada
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Abstract

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Background:

Proof from randomized controlled trials that carotid endarterectomy (CEA) is efficacious in stroke prevention has resulted in a large resurgence of its use in recent years. We wished to determine if patients in our region were being selected and treated with complication rates consistent with the randomized trials.

Methods:

We have completed four audits of CEAs performed in our region since 1994, each followed by feed-back of results to the participating surgeons. Operations for > 70% symptomatic stenosis were considered appropriate, those for 50%-69% symptomatic and > 60% asymptomatic stenosis were considered uncertain and all others, including those in medically or neurologically unstable patients, were designated inappropriate. In part 4, the referral source and nature of the patients was also determined.

Results:

Part 1 (April 1994 - September 1995) found that of 291 CEAs performed 33% were appropriate, 48% were uncertain and 18% were inappropriate, and 40% of patients who underwent CEA were asymptomatic. In part 2 (September 1996 - September 1997) appropriate indications significantly improved to 49% of 184 CEAs (P=0.005), uncertain indications remained nearly the same at 47%, inappropriate indications fell to 4% (P=0.00002), and asymptomatic patients remained at 40%. The results of part 3 (October 1997 - October 1998) remained nearly the same as part 2 (249 CEAs, 47% appropriate, 51% uncertain, 2% inappropriate, 45% asymptomatic). Part 4 (October 1999 - October 2000) results were significantly better than part 3, appropriate indications increasing from 47% to 58% of 222 CEAs (P=0.02), and an elimination of inappropriate operations (P=0.03). Stroke and death complications declined over the study period from an overall rate of 5.2% in part 1 to 2.3% in part 4. In part 4 the majority of patients (69%) were referred to surgeons directly from general practitioners, including 58 (73%) of the 80 asymptomatic patients who underwent CEA.

Interpretation:

Regular auditing and feedback of results and information to surgeons has resulted in significant and continued improvements in the surgical performance of CEAin our region. Since the majority of patients are referred directly to surgeons by general practitioners, it is important that this group of physicians be familiar with current CEA guidelines.

Résumé:

RÉSUMÉ:Introduction:

La preuve basée sur des études contrôlées randomisées que l’endartérectomie carotidienne (EAC) est efficace dans la prévention de l’accident vasculaire cérébral a entraîné une augmentation importante de son utilisation ces dernières années. Nous voulions déterminer si le taux de complications en relation avec le choix et le traitement des patients de notre région était comparable à celui des études randomisées.

Méthodes:

Nous avons complété 4 évaluations d’EACs effectuées dans notre région depuis 1994, chacune étant suivie de la communication des résultats aux chirurgiens participants. Les chirurgies effectuées pour des sténoses symptomatiques de plus de 70% étaient considérées comme appropriées, celles effectuées pour des sténoses symptomatiques de 50% à 69% et pour des sténoses asymptomatiques de plus de 60% étaient considérées comme incertaines et toutes les autres, incluant celles effectuées chez des patients instables au point de vue neurologique étaient considérées comme inappropriées. Dans la quatrième partie, la source de référence et la nature des patients étaient également examinées.

Résultats:

La première partie de l’étude (avril 1994 à septembre 1997) a montré que, des 291 EACs, 33% étaient appropriées, 48% étaient incertaines et 18% étaient inappropriées. 40% des patients qui ont subi une EAC étaient asymptomatiques. Dans la deuxième partie (septembre 1996 à septembre 1997), le taux d’indications appropriées s’est amélioré significativement, soit 49% de 184 EACs (P = 0,005), celui des indications incertaines est demeuré pratiquement le même, soit 47%, celui des indications inappropriées est tombé à 4% (P= 0,00002) et le taux de patients asymptomatiques est resté à 40%. Les résultats de la troisième partie (octobre 1997 à octobre 1998) sont demeurés pratiquement les mêmes que pendant la deuxième partie (249 EACs, 47% appropriées, 51% incertaines, 2% inappropriées, 45% asymptomatiques). Les résultats de la quatrième partie (octobre 1999 à octobre 2000) étaient significativement améliorés par rapport à ceux de la troisième partie. Cependant, les indications appropriées ont augmenté de 47% à 58% de 222 EACs ( P= 0,02) et on a observé une élimination des chirurgies inappropriées (P = 0,03). Les accidents vasculaires cérébraux et les décès découlant de la chirurgie ont diminué au cours de la période de l’étude, le taux étant passé de 5,2% dans la première partie à 2,3% dans la quatrième. Dans la quatrième partie, la majorité des patients (69%) étaient référés aux chirurgiens directement par les généralistes, dont 58 (73%) des 80 patients asymptomatiques qui ont subi une EAC.

Interprétation:

Une évaluation régulière et une communication des résultats aux chirurgiens a entraîné une amélioration significative et soutenue du succès chirurgical de l’EAC dans notre région. Comme la majorité des patients sont référés directement aux chirurgiens par les généralistes, il est important que ce groupe de médecins soit familier avec les lignes directrices sur l’EAC.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 29 , Issue 4 , November 2002 , pp. 326 - 332
Copyright
Copyright © The Canadian Journal of Neurological 2002

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