Carotid endarterectomy then and now: Outcome and cost-effectiveness of modern practice

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 I full day (P. = .005). Institution of "selective" angiography was associated with an immediate cost savings of approximately $2000 per case (T < .0001), and nurse practitioner oversight along with institution of defined clinical protocols with a $530 (T < .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.