RESUMO
BACKGROUND: Stroke is a leading cause of death worldwide, with carotid atherosclerosis accounting for 10-20% of cases. In Brazil, the Public Health System provides care for roughly two-thirds of the population. No studies, however, have analysed large-scale results of carotid bifurcation surgery in Brazil. METHODS: This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2019 in the country through web scraping of publicly available databases. RESULTS: Between 2008 and 2019, 37,424 carotid bifurcation revascularization procedures were performed, of which 22,578 were CAS (60.34%) and 14,846 (39.66%) were CEA. There were 620 in-hospital deaths (1.66%), 336 after CAS (1.48%) and 284 after CEA (1.92%) (P = 0.032). Governmental reimbursement was US$ 77,216,298.85 (79.31% of all reimbursement) for CAS procedures and US$ 20,143,009.63 (20.69%) for CEA procedures. The average cost per procedure for CAS (US$ 3,062.98) was higher than that for CEA (US$ 1,430.33) (P = 0.008). CONCLUSIONS: In Brazil, the frequency of CAS largely surpassed that of CEA. In-hospital mortality rates of CAS were significantly lower than those of CEA, although both had mortality rates within the acceptable rates as dictated by literature. The cost of CAS, however, was significantly higher. This is a pioneering analysis of carotid artery disease management in Brazil that provides, for the first time, preliminary insight into the fact that the low adoption of CEA in the country is in opposition to countries where utilization rates are higher for CEA than for CAS.
Assuntos
Estenose das Carótidas/terapia , Endarterectomia das Carótidas/tendências , Procedimentos Endovasculares/tendências , Padrões de Prática Médica/tendências , Saúde Pública/tendências , Stents/tendências , Brasil/epidemiologia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/economia , Estenose das Carótidas/mortalidade , Redução de Custos/tendências , Análise Custo-Benefício/tendências , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/economia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/mortalidade , Custos Hospitalares/tendências , Mortalidade Hospitalar/tendências , Humanos , Padrões de Prática Médica/economia , Saúde Pública/economia , Pesquisa em Sistemas de Saúde Pública , Estudos Retrospectivos , Stents/economia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Recent studies have demonstrated that transcarotid artery revascularization (TCAR) has comparable outcomes to the surgical gold standard, carotid endarterectomy (CEA). However, few studies have analyzed the cost of TCAR, and no study has evaluated its cost-effectiveness. The purpose of this study is to conduct a cost-effectiveness analysis comparing TCAR with CEA for carotid artery stenosis. METHODS: We built a Markov microsimulation using transition probabilities and utilities from existing literature for symptomatic patients undergoing TCAR or CEA. Costs were derived from literature then converted to 2019 dollars. The model included six health states with monthly cycle lengths: surgery, death, alive after surgery, alive after myocardial infarction, alive after stroke, and alive after stroke and death. Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a 5-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness. RESULTS: For symptomatic patients, CEA cost $7821 for 2.85 QALYs, whereas TCAR cost $19154 for 2.92 QALYs, leading to an ICER of $152,229 per QALY gained in the TCAR arm. Sensitivity analysis demonstrated that our model was most sensitive to probability of restenosis, costs of TCAR, and costs of CEA. Probabilistic sensitivity analysis demonstrated TCAR would be considered cost-effective in 49% of iterations. CONCLUSIONS: This study found that, although 5-year costs for TCAR were greater than CEA, TCAR afforded greater QALYs than CEA. TCAR became cost-effective at 6 years of follow-up.
Assuntos
Estenose das Carótidas/economia , Estenose das Carótidas/terapia , Endarterectomia das Carótidas/economia , Procedimentos Endovasculares/economia , Custos de Cuidados de Saúde , California , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/mortalidade , Análise Custo-Benefício , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Cadeias de Markov , Modelos Econômicos , Infarto do Miocárdio/etiologia , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Recidiva , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The purpose of this study is to determinate the cost-effectiveness of carotid endarterectomy (CEA) versus transfemoral stenting (TFS) and transcervical stenting (TCS) in a short- and long-term basis in symptomatic and asymptomatic patients. METHODS: From January 2003 to December 2014, patients from the vascular department, with symptomatic or asymptomatic carotid stenosis, who were clinically and anatomically suitable for TFS, TCS, or CEA, were included. Prospective cost data for each individual procedure and complication during follow-up were obtained from the diagnosis-related group. The quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios were estimated. Analysis of data was by treatment received. All statistical tests were two-sided. The significance level was 5%. RESULTS: A total of 349 patients were enrolled: 61 for CEA (17.5%), 159 for TFS (45.5%), and 129 for TCS (37%). A total of 220 (63%) patients were symptomatic and 129 (37%) were asymptomatic. The median procedural cost and overall cost were lower on CEA (5499 and 5595, respectively). However, QALYs, for symptomatic patients, were better on TCS (7.3), whereas for asymptomatic patients, QALYs were better on CEA (9.6). Cost-effectiveness for symptomatic patients was better with TCS (803/QALY), and for asymptomatic patients, it was with CEA (654/QALY). CONCLUSIONS: TFS and TCS were associated with clinical outcomes equivalent to CEA on both symptomatic and asymptomatic patients. Cost-effectiveness ratios for symptomatic patients were better on TCS, whereas the CEA showed the best results in asymptomatic patients.
Assuntos
Estenose das Carótidas/economia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/instrumentação , Procedimentos Endovasculares/economia , Custos Hospitalares , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Estenose das Carótidas/complicações , Análise Custo-Benefício , Endarterectomia das Carótidas/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Estudos Prospectivos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Espanha , Stents/economia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE/BACKGROUND: The cost-effectiveness of screening depends on the cost of screening, prevalence of asymptomatic carotid artery stenosis (ACAS), and the potential effect of medical intervention in reducing the risk of stroke. The aim of the study was to determine the threshold values for these parameters in order for screening for ACAS to be cost-effective. METHODS: The clinical effect and cost-effectiveness of ultrasound screening for ACAS with subsequent initiation of preventive therapy versus not screening was assessed in a Markov model with a lifetime perspective. Key parameters, including stroke risk, all cause mortality, and costs, were based on contemporary published data, population statistics, and data from an ongoing screening program in Uppsala county (population 300,000), Sweden. Prevalence of ACAS (2%) and the rate of best medical treatment (BMT; 40%) were based on data from a male Swedish population recently screened for ACAS. The required stroke risk reduction from BMT, incremental cost-efficiency ratio (ICER), absolute risk reduction for stroke (ARR), and number needed to screen (NNS) were calculated. RESULTS: Screening was cost-effective at an ICER of 5744 per incremental quality adjusted life year (QALY) gained. ARR was 135 per 100,000 screened, NNS was 741, and QALYs gained were 6700 per 100,000 invited. At a willingness to pay (WTP) threshold of 50,000 per QALY the minimum required stroke risk reduction from BMT was 22%. The assumed degree of stroke risk reduction was the most important determinant of cost-efficiency. CONCLUSION: A moderate (22%) reduction in the risk of stroke was required for an ACAS screening strategy to be cost-effective at a WTP of 50,000/QALY. Targeting populations with a higher prevalence of ACAS could further improve cost-efficiency.
Assuntos
Estenose das Carótidas , Endarterectomia das Carótidas/estatística & dados numéricos , Programas de Rastreamento , Acidente Vascular Cerebral/prevenção & controle , Idoso , Doenças Assintomáticas/economia , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/economia , Estenose das Carótidas/epidemiologia , Análise Custo-Benefício , Humanos , Masculino , Cadeias de Markov , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Programas de Rastreamento/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Prevalência , Acidente Vascular Cerebral/etiologia , Suécia/epidemiologiaRESUMO
BACKGROUND: The U.S. Centers for Medicare and Medicaid Services (CMS) has defined a set of high-risk criteria to help define patients who are appropriate for carotid artery stenting (CAS), but these criteria have never been validated. We aimed to validate the CMS high-risk criteria in a nationally representative cohort of patients undergoing CAS and carotid endarterectomy (CEA). METHODS: All patients undergoing CAS (with embolic protection) or CEA in the Vascular Quality Initiative (VQI) database (2013-2016) were included. Patients were stratified as being at normal risk (Nr) or high risk (Hr) for undergoing CEA on the basis of CMS criteria. Thirty-day and 2-year stroke outcomes were compared for CAS vs CEA in both the Nr and Hr groups using 1:1 coarsened exact matching and multivariable Cox proportional hazards modeling. RESULTS: A total of 51,942 patients (CAS, 7030; CEA, 44,912) underwent carotid revascularization during the study period. Thirty-day (Nr, 1.7% vs 1.0%; Hr, 2.5% vs 1.4%) and 2-year (Nr, 1.9% vs 1.0%; Hr, 2.4% vs 1.3%) stroke occurred more frequently after CAS vs CEA on crude analysis (P < .001). After matching 2920 pairs of patients on 18 preoperative variables, the risk of 30-day and 2-year stroke remained higher after CAS in the Hr group (30-day risk: hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.26-2.85; 2-year risk: HR, 1.65; 95% CI, 1.05-2.60) but was similar for CAS vs CEA in the Nr group (30-day risk: HR, 0.97; 95% CI, 0.48-1.95; 2-year risk: HR, 1.49; 95% CI, 0.76-2.90). CONCLUSIONS: These data suggest that the utility of CAS in Nr patients may be underappreciated, whereas the potential benefit of CAS in Hr patients may be overestimated. Re-evaluation of the criteria for identifying patients at high risk for CEA and the national guidelines on the indications for CAS is strongly indicated.
Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Medicare/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Medição de Risco , Stents , Estenose das Carótidas/economia , Custos e Análise de Custo , Humanos , Incidência , Complicações Pós-Operatórias/economia , Fatores de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: Asymptomatic internal carotid artery occlusion (CO) presents a clinical dilemma, and presently, the natural history, stroke risk, and optimal management remain ill defined. This study compared outcomes, including neurovascular events (NVEs) and health care costs, between patients with CO and patients with asymptomatic carotid artery stenosis (CS). METHODS: A prospectively maintained database was queried to identify patients with CO and CS with at least >50% carotid stenosis by duplex. We identified and reviewed 622 consecutive patients with asymptomatic carotid artery disease at one academic medical center between 2011 and 2013. Patients with CO (n = 97) were identified and propensity matched by age and gender in a 1:2 ratio with CS patients (n = 194) for further analyses. Univariate and multivariate models were used to analyze baseline characteristics, clinical variables, and 1-year follow-up data from the date of diagnosis. Multivariate analysis was performed by multiple linear regression modeling. Institutional Review Board approval was obtained. RESULTS: Follow-up data were available for 99% of matched patients. CO patients were younger (72 vs 75 years; P < .01) and more likely male (67% vs 53%; P = .01) compared with CS patients. After propensity matching, baseline characteristics were similar between groups, with a trend toward higher use of statin therapy among patients with CO. Antiplatelet therapy was used in 79% of patients with CS and in 74% of patients with CO (P = .45). The rate of NVE among CO patients was higher than among CS patients at 1 year of follow-up (14% vs 7%; P = .03). Among those with NVE, neither antiplatelet therapy (64% vs 77%; P = .49) nor statin therapy (86% vs 77%; P = .58) appeared to have a significant effect. Health care costs ($14,361 vs $12,142; P = .44) and hospital admission rate (63% vs 71%; P = .18) were similar between groups. Not surprisingly, the rate of vascular procedures was higher in the CS group (55% vs 27%; P = .04). CONCLUSIONS: Patients with asymptomatic CO experience more NVEs compared with similar patients with moderately severe CS. Further study of preventative strategies, including intensity of medical therapy, is warranted.
Assuntos
Artéria Carótida Interna , Estenose das Carótidas/complicações , Acidente Vascular Cerebral/etiologia , Centros Médicos Acadêmicos , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/fisiopatologia , Estenose das Carótidas/economia , Estenose das Carótidas/fisiopatologia , Estenose das Carótidas/terapia , Bases de Dados Factuais , Feminino , Custos de Cuidados de Saúde , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ohio , Prognóstico , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/prevenção & controle , Grau de Desobstrução VascularRESUMO
OBJECTIVE: We aimed to identify factors associated with cost of carotid artery stenting (CAS). METHODS: Patient and hospital characteristics affecting cost of admission for CAS were identified using the Vizient national database of hospital-reported outcomes. Patients who underwent CAS for either asymptomatic or symptomatic carotid stenosis were identified using surgical Medicare Severity-Diagnosis Related Groups and appropriate International Classification of Diseases, Ninth Revision and Tenth Revision codes. RESULTS: There were 166 hospitals that reported outcomes from 7369 inpatient admissions for CAS. Each institution reported a mean value for cost related to patient care per admission for CAS; the average cost across all reporting institutions was $12,834.14 (standard error of the mean [SEM], 492.88). Institutions in the lowest 25th percentile with respect to frequency of intensive care unit admission after CAS had lower cost of admission than institutions above the 75th percentile ($10,971.30 [SEM, 460.67] vs $14,992.90 [964.29]; P = .002), without any differences in incidence of stroke during admission (2.2% [SEM, 0.3] vs 2.0% [0.4]; P = .877) or 30-day readmission (1.9% [SEM, 0.4] vs 2.5 [0.6]; P = .329). Admissions for patients with symptomatic stenosis were more expensive than those with asymptomatic stenosis ($20,462.10 [SEM, 819.93] vs $11,285.20 [347.11]; P < .001). Obesity was also associated with greater costs of admission ($14,176.20 [SEM, 597.13] vs $12,287.10 [395.73]; P < .001). CONCLUSIONS: Admission to an intensive care unit, symptomatic stenosis, and obesity were associated with increased costs in patients undergoing CAS. These data may aid in identifying opportunities to improve the cost-effectiveness of this procedure.
Assuntos
Angioplastia/economia , Estenose das Carótidas/economia , Estenose das Carótidas/terapia , Custos Hospitalares , Avaliação de Processos em Cuidados de Saúde/economia , Stents/economia , Angioplastia/efeitos adversos , Angioplastia/instrumentação , Doenças Assintomáticas , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/epidemiologia , Comorbidade , Análise Custo-Benefício , Bases de Dados Factuais , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos/economia , Humanos , Unidades de Terapia Intensiva/economia , Obesidade/economia , Obesidade/epidemiologia , Admissão do Paciente/economia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Several carotid endarterectomy techniques have been described, including conventional carotid endarterectomy (CCEA) performed with patch repair and eversion carotid endarterectomy (ECEA) performed with transection of the internal carotid artery. We describe our simplified technique of modified eversion carotid endarterectomy (mECEA) with longitudinal arteriotomy limited to the carotid bulb, without transection of the internal carotid artery and present our analysis of its safety, efficacy, and cost effectiveness. METHODS: A retrospective review of all carotid endarterectomies performed by 3 vascular surgeons over a 3-year period was completed. About 197 mECEA were performed during the study period. Follow-up data were obtained on 77.7% of patients. A comparison was made with the contemporary literature with respect to outcomes for both CCEA and ECEA. RESULTS: Between January 2012 and December 2014, a total of 197 mECEA were performed. The perioperative stroke and death rates for those undergoing mECEA was 0.5% and 0.5%, respectively. Late stroke and death rates were 3.0% and 5.1%, respectively. Perioperative rate of myocardial infarction was 1.0%. Early restenosis rates of >70% occurred in 1.4%, whereas late restenosis of >70% occurred in 2.7%. Mean operating time for those undergoing mECEA was 57.9 min. Average costs savings for mECEA compared to CCEA were $5,835. CONCLUSIONS: This simplified technique has comparable outcomes to those described in the contemporary literature for both CCEA and ECEA with respect to postoperative neurologic events as well as restenosis rates. In our institution, the short mean operative times with mECEA has led to reduced resource utilization.
Assuntos
Estenose das Carótidas/economia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/economia , Endarterectomia das Carótidas/métodos , Custos Hospitalares , Avaliação de Processos em Cuidados de Saúde/economia , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/economia , Infarto do Miocárdio/etiologia , Duração da Cirurgia , Recidiva , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Importance: Although many factors influence the management of carotid artery stenosis, it is not well understood whether a preference toward procedural management exists when procedural volume and physician compensation are linked in the fee-for-service environment. Objective: To explore evidence for provider-induced demand in the management of carotid artery stenosis. Design, Setting, and Participants: The Department of Defense Military Health System Data Repository was queried for individuals diagnosed with carotid artery stenosis between October 1, 2006, and September 30, 2010. A hierarchical multivariable model evaluated the association of the treatment system (fee-for-service physicians in the private sector vs salary-based military physicians) with the odds of procedural intervention (carotid endarterectomy or carotid artery stenting) compared with medical management. Subanalysis was performed by symptom status at the time of presentation. The association of treatment system and of management strategy with clinical outcomes, including stroke and death, was also evaluated. Data analysis was conducted from August 15, 2015, to August 2, 2016. Main Outcomes and Measures: The odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand. Results: Of 10â¯579 individuals with a diagnosis of carotid artery stenosis (4615 women and 5964 men; mean [SD] age, 65.6 [11.4] years), 1307 (12.4%) underwent at least 1 procedure. After adjusting for demographic and clinical factors, the odds of undergoing procedural management were significantly higher for patients in the fee-for-service system compared with those in the salary-based setting (odds ratio, 1.629; 95% CI, 1.285-2.063; P < .001). This finding remained true when patients were stratified by symptom status at presentation (symptomatic: odds ratio, 2.074; 95% CI, 1.302-3.303; P = .002; and asymptomatic: odds ratio, 1.534; 95% CI, 1.186-1.984; P = .001). Conclusions and Relevance: Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.
Assuntos
Estenose das Carótidas/economia , Estenose das Carótidas/cirurgia , Técnicas de Apoio para a Decisão , Endarterectomia das Carótidas/economia , Planos de Pagamento por Serviço Prestado/economia , Necessidades e Demandas de Serviços de Saúde/economia , Medicina Militar/economia , Papel do Médico , Mecanismo de Reembolso/economia , Salários e Benefícios , Stents/economia , Idoso , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estados Unidos , Procedimentos Desnecessários/economiaRESUMO
OBJECTIVES: The aim was to determine current practice for the treatment of carotid stenosis among 12 countries participating in the International Consortium of Vascular Registries (ICVR). METHODS: Data from the United States Vascular Quality Initiative (VQI) and the Vascunet registry collaboration (including 10 registries in Europe and Australasia) were used. Variation in treatment modality of asymptomatic versus symptomatic patients was analysed between countries and among centres within each country. RESULTS: Among 58,607 procedures, octogenarians represented 18% of all patients, ranging from 8% (Hungary) to 22% (New Zealand and Australia). Women represented 36%, ranging from 29% (Switzerland) to 40% (USA). The proportion of carotid artery stenting (CAS) among asymptomatic patients ranged from 0% (Finland) to 26% (Sweden) and among symptomatic patients from 0% (Denmark) to 19% (USA). Variation among centres within countries for CAS was highest in the United States and Australia (from 0% to 80%). The overall proportion of asymptomatic patients was 48%, but varied from 0% (Denmark) to 73% (Italy). There was also substantial centre level variation within each country in the proportion of asymptomatic patients, most pronounced in Australia (0-72%), Hungary (5-55%), and the United States (0-100%). Countries with fee for service reimbursement had higher rates of treatment in asymptomatic patients than countries with population based reimbursement (OR 5.8, 95% CI 4.4-7.7). CONCLUSIONS: Despite evidence about treatment options for carotid artery disease, the proportion of asymptomatic patients, treatment modality, and the proportion of women and octogenarians vary considerably among and within countries. There was a significant association of treating more asymptomatic patients in countries with fee for service reimbursement. The findings reflect the inconsistency of the existing guidelines and a need for cooperation among guideline committees all over the world.
Assuntos
Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/terapia , Endarterectomia das Carótidas/tendências , Procedimentos Endovasculares/tendências , Disparidades em Assistência à Saúde/tendências , Padrões de Prática Médica/tendências , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Austrália , Estenose das Carótidas/economia , Estenose das Carótidas/cirurgia , Distribuição de Qui-Quadrado , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/economia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Europa (Continente) , Planos de Pagamento por Serviço Prestado/tendências , Feminino , Fidelidade a Diretrizes/tendências , Disparidades em Assistência à Saúde/economia , Humanos , Seguro Saúde/tendências , Modelos Lineares , Masculino , Nova Zelândia , Razão de Chances , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/economia , Sistema de Registros , Fatores de Risco , Fatores Sexuais , Stents/tendências , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVE: Despite multiple landmark clinical trials, little data exists on real-world cost of carotid artery stenting (CAS) and carotid endarterectomy (CEA) to the United States healthcare system. We aim to study differences in actual hospitalization cost between patients who underwent CAS vs CEA in a nationally representative database. METHODS: We studied hospital discharge and billing records of all patients, in the Premier Perspective Database, who underwent CEA or CAS between the third quarter of 2009 and the first quarter of 2015. Nearest-neighbor 1:1 propensity score matching was performed, to account for differences in patient and hospital characteristics as well as clinical comorbidities of patients who underwent both procedures, for both symptomatic and asymptomatic cohorts using 32 variables. Pearson χ2, Student t-test, and nonparametric K-sample equality-of-medians tests were used to analyze the data, as appropriate. The primary outcome was total in-hospital cost, including fixed (administrative, capital and utilities) and variable costs (labor and supply). Cost data were presented as medians, inflation-adjusted for 2015 U.S. dollar and rounded to the nearest dollar. RESULTS: A total of 115,548 procedures were identified. The mean age was 71 and 69 years; 58% and 57% were male patients; and 81% and 77% were white among asymptomatic and symptomatic patients, respectively. After propensity score matching, 25,812 asymptomatic (12,906 CEA and 12,906 CAS) and 3864 symptomatic (1932 CEA and 1932 CAS) patients were included. Total hospitalization cost per CAS was 40% ($11,814 vs $8378; P < .001) and 37% ($19,426 vs $14,190; P < .001) higher than CEA among asymptomatic and symptomatic patients, respectively. Patients who underwent CAS incurred significantly higher total hospitalization cost despite stratifying by type of cost (fixed and variable), U.S. census regions and symptomatic status. Moreover, asymptomatic patients who underwent CAS performed by any surgical specialty incurred an average of $2717 to $4918 higher total hospitalization cost compared with patients who underwent CEA (all P < 001). Among symptomatic patients, those who underwent CAS performed by vascular, cardiac, and neurologic surgeons, incurred $2108 ($16,114 vs $14,006; P = .006), $7055 ($17,351 vs $10,296; P = .023) and $6479 ($27,290 vs $20,811; P = .002) higher total hospitalization cost compared with patients who underwent CEA, respectively. CONCLUSIONS: The total hospitalization cost incurred by patients who underwent CAS was significantly higher than for those who underwent CEA, despite matching cohort based on patient and hospital characteristics, and stratifying by symptomatic status, type of cost, hospital region, and surgeon specialty. Our findings could provide additional important information giving the ongoing controversy regarding the appropriate indication for CAS.
Assuntos
Angioplastia/economia , Estenose das Carótidas/economia , Estenose das Carótidas/terapia , Endarterectomia das Carótidas/economia , Custos Hospitalares , Avaliação de Processos em Cuidados de Saúde/economia , Stents/economia , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Angioplastia/instrumentação , Doenças Assintomáticas , Estenose das Carótidas/diagnóstico por imagem , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Técnicas de Apoio para a Decisão , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Seleção de Pacientes , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day. RESULTS: Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05). CONCLUSIONS: Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.
Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Tempo de Internação , Complicações Pós-Operatórias/etiologia , Idoso , Agendamento de Consultas , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/economia , Estenose das Carótidas/mortalidade , Distribuição de Qui-Quadrado , Redução de Custos , Bases de Dados Factuais , Endarterectomia das Carótidas/economia , Endarterectomia das Carótidas/mortalidade , Feminino , Preços Hospitalares , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Duração da Cirurgia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Indicadores de Qualidade em Assistência à Saúde , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , VirginiaRESUMO
BACKGROUND: Medical care in the United States has evolved into a more cost-conscious value-based health care system that necessitates a comparison of costs when there are alternative interventions considered to be acceptable in the treatment of a disease. This study compares the cost differences between regional anesthesia (RA) and general anesthesia (GA) for carotid endarterectomy (CEA). METHODS: Data from 346 consecutive patients who underwent CEA between January 2012 and September 2014 were retrospectively reviewed for the type of anesthesia used, outcomes data, and cost variables. Overall hospital day costs were compared between RA and GA. Medians and interquartile ranges were compared using Wilcoxon-Mann-Whitney test. A P < 0.05 was considered statistically significant using 2-sided tests. RESULTS: Median overall costs for GA were significantly higher than median costs for RA (medians [with interquartile ranges], $10,140 [$7,158-$12,658] versus $7,122 [$5,072-$8,511], P < 0.001). Median total operative time for GA was significantly longer than median time for RA (168 [144-188] versus 134 [115-147] min, P < 0.001). Median in-hospital length of stay (LOS) for GA was significantly longer compared with RA (2.0 vs 1.2 days, P < 0.001). Patients who received GA were also more likely to be admitted to the intensive care unit. CONCLUSIONS: Decreased cost, operating room expenses, postoperative resources, and overall LOS were observed for individuals who underwent RA for CEA as compared with GA. In summary, RA is more cost-effective and should be the optimal choice when clinically appropriate.
Assuntos
Anestesia por Condução/economia , Anestesia Geral/economia , Estenose das Carótidas/economia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/economia , Custos Hospitalares , Anestesia por Condução/efeitos adversos , Anestesia Geral/efeitos adversos , Estenose das Carótidas/diagnóstico por imagem , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Tempo de Internação/economia , Masculino , Modelos Econômicos , Salas Cirúrgicas/economia , Duração da Cirurgia , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Carotid endarterectomy (CEA) for asymptomatic patients with limited life expectancy may not be beneficial or cost-effective. The purpose of this study was to examine relationships among survival, outcomes, and costs within 2 years following CEA among asymptomatic patients. METHODS: Prospectively collected data from 3097 patients undergoing CEA for asymptomatic disease from Vascular Quality Initiative VQI registry were linked to Medicare. Models were used to identify predictors of 2-year mortality following CEA. Patients were classified as low, medium, or high risk of death based on this model. Next, we examined costs related to cerebrovascular care, occurrence of stroke, rehospitalization, and reintervention within 2 years following CEA across risk strata. RESULTS: Overall, 2-year mortality was 6.7%. Age, diabetes, smoking, congestive heart failure (CHF), chronic obstructive pulmonary disease, renal insufficiency, absence of statin use, and contralateral internal carotid artery (ICA) stenosis were independently associated with a higher risk of death following CEA. In-hospital costs averaged $7500 among patients defined as low risk for death, and exceeded $10,800 among high risk patients. Although long-term costs related to cerebrovascular disease were 2 times higher in patients deemed high risk for death compared with low risk patents ($17,800 vs. $8800, P = 0.001), high risk of death was not independently associated with a high probability of high cost. Predictors of high cost at 2 years were severe contralateral ICA stenosis, dialysis dependence, and American Society for Anesthesia Class 4. Both statin use and CHF were protective of high cost. CONCLUSIONS: Greater than 90% of patients undergoing CEA live long enough to realize the benefits of their procedure. Moreover, the long-term costs are supported by the effectiveness of this procedure at all levels of patient risk.
Assuntos
Estenose das Carótidas/economia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/economia , Custos de Cuidados de Saúde , Melhoria de Qualidade/economia , Indicadores de Qualidade em Assistência à Saúde/economia , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Medicare , Modelos de Riscos Proporcionais , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: To curb increasing volumes of diagnostic imaging and costs, reimbursement for carotid duplex ultrasound (CDU) is dependent on "appropriate" indications as documented by International Classification of Diseases (ICD) codes entered by ordering physicians. Historically, asymptomatic indications for CDU yield lower rates of abnormal results than symptomatic indications, and consensus documents agree that most asymptomatic indications for CDU are inappropriate. In our vascular laboratory, we perceived an increased rate of incorrect or inappropriate ICD codes. We therefore sought to determine if ICD codes were useful in predicting the frequency of abnormal CDU. We hypothesized that asymptomatic or nonspecific ICD codes would yield a lower rate of abnormal CDU than symptomatic codes, validating efforts to limit reimbursement in asymptomatic, low-yield groups. MATERIAL AND METHODS: We reviewed all outpatient CDU done in 2011 at our institution. ICD codes were recorded, and each medical record was then reviewed by a vascular surgeon to determine if the assigned ICD code appropriately reflected the clinical scenario. CDU findings categorized as abnormal (>50% stenosis) or normal (<50% stenosis) were recorded. Each individual ICD code and group 1 (asymptomatic), group 2 (nonhemispheric symptoms), group 3 (hemispheric symptoms), group 4 (preoperative cardiovascular examination), and group 5 (nonspecific) ICD codes were analyzed for correlation with CDU results. RESULTS: Nine hundred ninety-four patients had 74 primary ICD codes listed as indications for CDU. Of assigned ICD codes, 17.4% were deemed inaccurate. Overall, 14.8% of CDU were abnormal. Of the 13 highest frequency ICD codes, only 433.10, an asymptomatic code, was associated with abnormal CDU. Four symptomatic codes were associated with normal CDU; none of the other high frequency codes were associated with CDU result. Patients in group 1 (asymptomatic) were significantly more likely to have an abnormal CDU compared to each of the other groups (P < 0.001, P < 0.001, P = 0.020, P = 0.002) and to all other groups combined (P < 0.001). CONCLUSIONS: Asymptomatic indications by ICD codes yielded higher rates of abnormal CDU than symptomatic indications. This finding is inconsistent with clinical experience and historical data, and we suggest that inaccurate coding may play a role. Limiting reimbursement for CDU in low-yield groups is reasonable. However, reimbursement policies based on ICD coding, for example, limiting payment for asymptomatic ICD codes, may impede use of CDU in high-yield patient groups.
Assuntos
Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Custos de Cuidados de Saúde , Reembolso de Seguro de Saúde/economia , Classificação Internacional de Doenças , Seleção de Pacientes , Ultrassonografia Doppler Dupla/economia , Assistência Ambulatorial/economia , Doenças Assintomáticas , Estenose das Carótidas/classificação , Estenose das Carótidas/economia , Redução de Custos , Análise Custo-Benefício , Humanos , Valor Preditivo dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença , Procedimentos Desnecessários/economiaRESUMO
BACKGROUND: Several studies have reported on the role of postoperative duplex ultrasound surveillance after carotid endarterectomy (CEA) with varying results. Most of these studies had a small sample size or did not analyze cost-effectiveness. METHODS: We analyzed 489 of 501 CEA patients with patch closure. All patients had immediate postoperative duplex ultrasound examination and were routinely followed up both clinically and with duplex ultrasound at regular intervals of 1 month, 6 months, 12 months, and every 12 months thereafter. A Kaplan-Meier analysis was used to estimate the rate of ≥50% and ≥80% post-CEA restenosis over time and the time frame of progression from normal to ≥50% or ≥80% restenosis. The cost of post-CEA duplex surveillance was also estimated. RESULTS: Overall, 489 patients with a mean age of 68.5 years were analyzed. Ten of these had residual postoperative ≥50% stenosis, and 37 did not undergo a second duplex ultrasound examination and therefore were not included in the final analysis. The mean follow-up was 20.4 months (range, 1-63 months), with a mean number of duplex ultrasound examinations of 3.6 (range, 1-7). Eleven of 397 patients (2.8%) with a normal finding on immediate postoperative duplex ultrasound vs 4 of 45 (8.9%) with mild stenosis on immediate postoperative duplex ultrasound progressed to ≥50% restenosis (P = .055). Overall, 15 patients (3.1%) had ≥50% restenosis, 9 with 50% to <80% and 4 with 80% to 99% (2 of these had carotid artery stenting reintervention), and 2 had late carotid occlusion. All of these were asymptomatic, except for one who had a transient ischemic attack. The mean time to ≥50% to <80% restenosis was 14.7 months vs 19.8 months for ≥80% restenosis after the CEA. Freedom from restenosis rates were 98%, 96%, 94%, 94%, and 94% for ≥50% restenosis and 99%, 98%, 97%, 97%, and 97% for ≥80% restenosis at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. Freedom from myocardial infarction, stroke, and deaths was not significantly different between patients with and without restenosis (100%, 93%, 83%, and 83% vs 94%, 91%, 86%, and 79% at 1 year, 2 years, 3 years, and 4 years, respectively; P = .951). The estimated charge of this surveillance was 3.6 × 489 (number of CEAs) × $800 (charge for carotid duplex ultrasound), which equals $1,408,320, to detect only four patients with ≥80% to 99% restenosis who may have been potential candidates for reintervention. CONCLUSIONS: This study shows that the value of routine postoperative duplex ultrasound surveillance after CEA with patch closure may be limited, particularly if the finding on immediate postoperative duplex ultrasound is normal or shows minimal disease.
Assuntos
Estenose das Carótidas/diagnóstico por imagem , Endarterectomia das Carótidas/economia , Ultrassonografia Doppler Dupla/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/economia , Estenose das Carótidas/cirurgia , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/economia , Recidiva , Estudos RetrospectivosRESUMO
OBJECTIVE: The introduction of carotid stenting has led to a rapid rise in the number of vascular specialists performing this procedure. The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) has shown that carotid stenting can be performed with an equivalent major event rate compared with carotid endarterectomy. However, there is still controversy about the appropriate training and experience required to safely perform this procedure. This observational study examined the performance of carotid stenting with regard to specialty and case volume. METHODS: From 2004 to 2011, inpatients diagnosed with carotid stenosis who had a carotid stenting procedure were extracted from the Nationwide Inpatient Sample database. The cohort was separated on the basis of the provider performing the procedure (surgeon vs interventionalist), hospital location, and volume. Surgeons were defined as providers who also performed either a carotid endarterectomy or femoral-popliteal bypass during the same time interval. Primary end points analyzed included stroke, myocardial infarction, and 30-day mortality. Length of stay and hospital costs were also analyzed as secondary outcomes. RESULTS: A total of 20,663 cases of carotid stenting were found; 15,305 (74%) cases were identified to be performed by a "surgeon," whereas 5358 (26%) were done by an "interventionalist." The majority of cases were done at hospitals in urban locations (96.51%) and designated teaching institutions (61.47%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% and 4.41%), myocardial infarction (2.10% and 2.13%), and mortality (0.84% and 1.03%) respectively. Qualitatively, volume per 10 cases was shown to decrease the risk of stroke. Adjusted multivariate analysis demonstrated no statistical significance between primary end point outcomes. However, length of stay (2.81 vs 3.08 days) and total charges ($48,087.61 and $51,718.77) were lower for procedures performed by surgeons. CONCLUSIONS: Surgeons are performing the majority of carotid stent procedures in the United States. The volume of cases performed by a provider, rather than the provider's specialty, appears to be a stronger predictor of adverse outcomes for carotid stenting. There were, however, significant cost differences between surgeons and interventionalists, which needs to be further evaluated at an institutional level.
Assuntos
Angioplastia/instrumentação , Estenose das Carótidas/terapia , Competência Clínica , Especialização , Stents , Cirurgiões , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Angioplastia/economia , Angioplastia/mortalidade , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/economia , Estenose das Carótidas/mortalidade , Redução de Custos , Bases de Dados Factuais , Feminino , Custos Hospitalares , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Hospitais de Ensino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/etiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents/economia , Acidente Vascular Cerebral/etiologia , Cirurgiões/economia , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVE: This study compared in-hospital mortality and resource utilization among vascular surgical patients at safety net public hospitals (SNPHs) with those at nonsafety net public hospitals (nSNPHs). METHODS: The National Inpatient Sample (2003-2011) was queried to identify surgical patients with peripheral arterial disease (PAD), carotid stenosis, or nonruptured abdominal aorta aneurysm based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. The cohort was then divided into SNPH and nSNPH groups according to the definition of SNPH used by the National Association of Public Hospitals. Clinical characteristics, length of stay, in-hospital mortality, and hospital charges were compared between groups. Advanced PAD was defined as that associated with rest pain or tissue loss. Statistical methods included bivariate χ(2) tests for categoric variables, t-tests for continuous variables, and multivariable linear and logistic regression to adjust for confounding variables (in-hospital mortality). RESULTS: We identified 306,438 patients operated on for PAD, carotid stenosis, and abdominal aortic aneurysm. Patients at SNPHs were younger, the percentage of female and minority patients was higher, and patients had a higher Elixhauser comorbidity index (P < .001). Nonelective admissions were more common among SNPH patients who presented with more advanced PAD (P > .05) and symptomatic carotid stenosis (P < .05). Patients at SNPHs had a significantly longer length of stay, higher hospital charges, and higher in-hospital mortality (P < .05 for all variables). Crude odds of mortality at SNPHs were 1.28 higher than at nSNPHs (95% confidence interval, 1.13-1.46; P < .001), but adjusted analyses revealed no statistically significant difference between the odds of in-hospital mortality at both hospital groups. CONCLUSIONS: Patients undergoing vascular surgery at SNPHs, despite being younger, had higher comorbidities, presented more urgently with more advanced disease, and incurred higher costs than the SNPH cohort despite similar adjusted odds of in-hospital mortality. Delayed presentation and higher comorbidities are most likely related to poor access to routine and preventive health care for the SNPH patients.
Assuntos
Recursos em Saúde/economia , Custos Hospitalares , Mortalidade Hospitalar , Hospitais Públicos/economia , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Indicadores de Qualidade em Assistência à Saúde/economia , Provedores de Redes de Segurança/economia , Procedimentos Cirúrgicos Vasculares/economia , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/cirurgia , Estenose das Carótidas/economia , Estenose das Carótidas/mortalidade , Estenose das Carótidas/cirurgia , Distribuição de Qui-Quadrado , Comorbidade , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/economia , Endarterectomia das Carótidas/mortalidade , Feminino , Recursos em Saúde/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos/economia , Hospitais Públicos/estatística & dados numéricos , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Doença Arterial Periférica/economia , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/cirurgia , Estudos Retrospectivos , Fatores de Risco , Provedores de Redes de Segurança/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricosRESUMO
BACKGROUND: The choice of carotid artery endarterectomy (CEA) or carotid artery stenting (CAS), as surgical and interventional treatment of atherosclerotic carotid stenosis, respectively, has been controversial in decades, especially for asymptomatic patients with carotid stenosis. Age and the diameter of impaired carotid artery might be 2 important factors to decide whether CEA or CAS should be performed. Besides, contrast-enhanced ultrasound (CEUS) has been confirmed as an effective method to predict the risk of stroke by classifying the carotid plaque into 4 grades. The role of CEUS in the choice of CEA or CAS still remains unclear. METHODS: A retrospective analysis of 38 patients who underwent CEA with primary closure and 36 patients who underwent CAS in our hospital from October 2008 to January 2013 is conducted. Preoperative CEUS was performed to all patients, and data were collected and analyzed. All CEAs were performed with transverse incision. RESULTS: The hospital stay was longer for the endarterectomy group than the stenting group (15.39 versus 10.91 d, P < 0.001), with an approximately two-third reduction of hospital costs (¥23686.21 versus ¥60855.34, P < 0.001). The overall incidence of perioperative complications in the endarterectomy group was 7.9%, with no statistically significant difference in the group with internal carotid artery greater than or equal to 5 mm and in the group with internal carotid artery less than 5 mm (9.1% versus 6.3%, P = 0.75). No restenosis occurred in either of the subgroups during the follow-up. In patients older than 70 years, the perioperative complications were 0% in CEA and 10.53% in CAS (P = 0.42); the long-term restenosis was 0% in CEA and 5.26% in CAS (P = 0.67). In patients younger than 70 years, the perioperative complications were 11.5% in CEA and 23.53% in CAS (P = 0.31); the long-term restenosis was 0% in CEA and 0% in CAS (P > 0.01). For patients with grade 4 plaque in CEUS, the incidence of adverse events in the CAS group was significantly higher than that in the CEA group (7.14% versus 55.56%, P < 0.05). CONCLUSIONS: There were no significant differences in perioperative complications or restenosis rate between the CAS group and the CEA group in this study. Neither the diameter of impaired carotid artery or age could be considered as an indication of applying CEA or CAS. However, CEUS might be used as a perioperative assessment method to decide whether CEA or CAS should be performed to different patients. The higher the grade of plaque enhancement, the higher the risk of adverse events and restenosis for CAS might occur.
Assuntos
Estenose das Carótidas/terapia , Endarterectomia das Carótidas/métodos , Stents , Idoso , Estenose das Carótidas/economia , Análise Custo-Benefício , Endarterectomia das Carótidas/economia , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Stents/economiaRESUMO
BACKGROUND: The indications for carotid revascularization are based almost exclusively on the results of carotid duplex ultrasonography. Noninvasive vascular laboratories show large variation in the diagnostic criteria used to classify degree of carotid artery stenosis. We hypothesize that variability of these diagnostic criteria causes significant variation in stenosis classification directly affecting the number of revascularizations and associated costs. METHODS AND RESULTS: The diagnostic criteria to interpret carotid duplex ultrasounds were obtained from 10 New England institutions. All carotid duplex scans performed at our institution were reviewed from 2008 to 2012. Using the diagnostic criteria from each institution, the degree of stenosis that would have been reported was classified as 70% to 99% asymptomatic, 80% to 99% asymptomatic, and 50% to 99% symptomatic. We then calculated the theoretical number of carotid revascularization procedures that this cohort would be offered using each institution's diagnostic criteria and the costs of these procedures based on reimbursement rates. Among 10 614 patients who underwent 15 534 carotid duplex scans, 31 025 arteries were reviewed. Application of the 10 institutions' criteria to the patients from our institution yielded marked variation in the number classified as 70% to 99% asymptomatic (range, 186-2201), 80% to 99% asymptomatic (range, 78-426), and 50% to 99% symptomatic (range, 157-781). If revascularizations were based on these results, costs would range from $2.2 to $26 million, $0.9 to $5.0 million, and $1.9 to $9.2 million, respectively. CONCLUSIONS: Differences in diagnostic criteria to interpret carotid ultrasound result in significant variation in classification of carotid artery stenosis, likely leading to differences in the number and subsequent costs of revascularizations. This theoretical model highlights the need for standardization of carotid duplex criteria.