Carotid endarterectomy in the elderly population: A statewide experience

Abstract

The practice of carotid endarterectomy (CEA) was examined in all Medicare patients undergoing operation in the state of Kentucky during 1983 and during the first 6 months of 1984. CEA was performed 738 times on 705 patients in 1983 by 98 surgeons in 41 hospitals. The average age of patients was 71 years, and only 15% had no symptoms of carotid disease. The stroke rate was 3.7%, and the combined stroke and mortality rate was 5.7%. In a follow-up period in 1984, the combined stroke and mortality rate was 4.3%. Patients who showed no symptoms of carotid disease had a combined stroke and mortality rate of 2.8%. Surgeons performing fewer than three CEAs per year had a tendency toward a higher complication rate than had surgeons performing more than 12 CEAs a year. Most stroke complications appeared as isolated events and did not seem to represent a practice pattern based on our follow-up into 1984.

A regional registry for quality assurance and improvement: The Vascular Study Group of Northern New England (VSGNNE)

“…The Cleveland Vascular Society, The Eastern Vascular Society, The Kentucky Vascular Society, and The South Carolina Vascular Surgical Society all formed database registries for member participation. [22][23][24][25] After initial enthusiasm, these were abandoned because of incomplete participation and missing information from data forms. Among reasons cited for failure was lack of perception of benefit by members and difficulty completing complex data forms.…”

Indications, Outcomes, and Provider Volumes for Carotid Endarterectomy

“…23 The overall 30-day nonfatal stroke or death rate observed in the current study (4.7%) compares favorably with that in other community-based series. [12][13][14]24,25 Indication-specific comparisons with the results of North American Symptomatic Carotid Endarterectomy Trial (NASCET) and ACAS are confounded by the older age of the current study population (73 years vs 65 and 67 years in NASCET and ACAS, respectively), making adverse outcomes more likely in the current study, but, because of the shorter life expectancy of study subjects, also less acceptable. 7,8 The 7.1% 30-day stroke or death rate observed among the 294 patients with TIA is higher than the 5.8% rate in NASCET.…”

“…While there are few studies of carotid endarterectomy in more representative settings of patient and provider selection, there is suggestive evidence for higher complication rates in some community settings [12][13][14] and, at least among Medicare beneficiaries, for an inverse relationship between procedural volumes and complication rates. 15,16 Because studies that have reported the volume-outcome relationship have been unable to accurately measure surgical indications or patients' comorbid illnesses, the relative importance of patient selection vs surgical or institutional proficiency has gone largely unexplored.…”

Death after Bowel Resection: Patient Disease, Not Surgeon Error

“…First, it is remarkable how often these discharge datasets and even chart entries are inaccurate or at least do not truly reflect what actually happened to the patient. For example, Richardson noted a 68% error rate when data from administrative sources was compared to chart review on the same patients with abdominal aortic aneurysms 15 or carotid disease, 16 noting there was "virtually no correlation between the data sources". 17 We have previously demonstrated that the hospital discharge data set at our institution missed 28% of the complications recorded in our surgical activity tracking system.…”