Using a Vascular Database to Change Surgeon Behavior in Managing Patients Undergoing Carotid Endarterectomy: A 5-year Prospective Study of 598 Patients

Abstract

Background: Several databases for carotid endarterectomy (CEA) exist (eg, Society for Vascular Surgery and National Surgical Quality Improvement Program); however, they are not linked with explicit quality-improvement methodology. During a 5-year period, we tested whether collecting data and actually using it methodically could improve CEA outcomes in a nonacademic heart and vascular center with several disparate private practice groups. If successful, we theorized that such a model, based on the Vascular Study Group of Northern New England (VSGNNE), could encourage creation of a Southern Vascular Study Group for Quality Improvement. Methods: With permission of the VSGNNE, we applied its data collection system and quality-improvement methodology to study and improve patient management amongst vascular surgeons in three separate nonacademic practices. Although we studied all major vascular procedures, the first study was focused on CEA. A dedicated study coordinator assisted in data collection and analysis. Problematic outcomes were discussed quarterly to identify methods to improve them. A consensus for improvement was achieved and applied immediately. We focused explicitly on combined stroke/death rates, postoperative bleeding, returns to the operating room, hospital length of stay (LOS), and managing cardiovascular risk factors (ie, preoperative and postoperative antiplatelet agents, statins, and β-blockers). On a yearly basis, we informed the referring physicians of our outcomes. Results: Between 2004 and 2009, 598 patients underwent CEA for symptomatic (31%) and asymptomatic (69%) carotid stenosis. Combined stroke/death rate remained consistently low at 1.0% (6 of 598). Significant improvement was achieved in several areas: preoperative and postoperative antiplatelet use increased from 93% to 100%, preoperative coverage with statins went from 48% to 83%, and appropriate β-blockade also improved from 31% to 56%. Postoperative hematomas requiring return to the operating room were essentially eliminated. LOS was reduced from 2.45 to 1.2 days (P < .01) in 4 years. As outcomes became transparent to referring physicians, the annual surgical volume rose from 102 CEAs in 2005 to 161 CEAs in 2008. Conclusions: A systematic program for both data collection and quality improvement, based on the previously successful VSGNNE, is applicable and effective in another geographic region and amongst nonacademic practices. This study encourages the formation of a Southern Vascular Study Group for Quality Improvement for both academic and nonacademic vascular surgeons.