Abstract
BackgroundTo update appropriateness ratings for carotid endarterectomy using the best clinical evidence and to develop a tool to audit the procedure's use.MethodsA nine-member expert panel drawn from all the Canadian Specialist societies that are involved in the care of patients with carotid artery disease, used the RAND Appropriateness Methodology to rate scenarios where carotid endarterectomy may be performed. A 9-point rating scale was used that permits the categorization of the use of carotid endarterectomy as appropriate, uncertain, or inappropriate. A descriptive analysis was undertaken of the final results of the panel meeting. A database and code were then developed to rate all carotid endarterectomies performed in a Western Canadian Health region from 1997 to 2001.ResultsAll scenarios for severe symptomatic stenosis (70–99%) were determined to be appropriate. The ratings for moderate symptomatic stenosis (50–69%) ranged from appropriate to inappropriate. It was never considered appropriate to perform endarterectomy for mild stenosis (0–49%) or for chronic occlusions. Endarterectomy for asymptomatic carotid disease was thought to be of uncertain benefit at best. The majority of indications for the combination of endarterectomy either prior to, or at time of coronary artery bypass grafting were inappropriate. The audit tool classified 98.0% of all cases.ConclusionsThese expert panel ratings, based on the best evidence currently available, provide a comprehensive and updated guide to appropriate use of carotid endarterectomy. The resulting audit tool can be downloaded by readers from the Internet and immediately used for hospital audits of carotid endarterectomy appropriateness.
Highlights
To update appropriateness ratings for carotid endarterectomy using the best clinical evidence and to develop a tool to audit the procedure's use
Guidelines and appropriateness ratings often need to be developed in different countries, which may guide the clinical audit of interventions and outcomes
The objectives of this paper were: firstly, to describe the development of contemporary appropriateness ratings for carotid endarterectomy according to a panel of Canadian experts; and secondly, to develop an audit tool for chart review based on these ratings
Summary
To update appropriateness ratings for carotid endarterectomy using the best clinical evidence and to develop a tool to audit the procedure's use. Evidence for efficacy of an intervention may be clearly established, but its expected effectiveness outside of a clinical trial setting, the values of decision makers, and resources available at a given point in time may all affect how that intervention is brought into generalized clinical care [1] These may vary across different countries and decision-makers and this may lead to different (page number not for citation purposes). In spite of the proliferation of the highest level of evidence available to guide patient management, controversy still exists as to what constitutes appropriate use of the procedure, especially in those with asymptomatic disease [11,12] This may explain some of the marked variation in the rate of usage of CE between countries and regions [13,14]
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