Costs Of Carotid Endarterectomy Research Articles

Cost-effectiveness of transcarotid artery revascularization versus carotid endarterectomy

ObjectiveRecent 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. MethodsWe 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. ResultsFor 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. ConclusionsThis 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.

Improving the Quality of Carotid Endarterectomy and Carotid Artery Stenting: Identifying Hospital-Level Structural Factors that Affect Outcomes in the Prevention of Thromboembolic Strokes

Introduction - Carotid Endarterectomy (CEA) and Carotid Artery Stenting (CAS) effectively reduce long-term stroke risk. Peri-procedural factors affecting outcome have been studied extensively. However, factors relating to the organisation of hospitals (structural factors) may also impact on the quality of patient care. The aim of this study was to examine the evidence that hospital structural factors may affect outcome following CEA or CAS. Methods - A systematic review was conducted of published studies from 2005 onwards. Three independent reviewers screened titles, abstracts and extracted data from papers, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Structural factors assessed were: Size of the population served by the Vascular Unit; number of hospital beds; availability of dedicated Vascular beds; impact of clearly defined pathways of care; size of the Surgical Intensive Care Unit (SICU) as a proxy for availability of care; and specialty of doctors performing the vascular procedure. Primary outcomes were: mortality; stroke; combined mortality/stroke; serious cardiac complications; length of hospital stay (LOS); and procedural cost. Results - Seventeen retrospective cohort studies from six countries, with a total of 95,100 patients, were included. CEA outcomes were reported in fourteen studies, CAS outcomes in two studies and both CEA and CAS outcomes in one study. Vascular Units providing services to larger populations (>75,000 people) had reduced mortality (p<0.0001) and stroke rates (p=0.001) following CEA, compared with those serving smaller populations. Larger hospitals providing CEA also had significantly reduced mortality (p<0.0001), stroke rate (p=0.0008) and cardiac events (p=0.01), compared with smaller hospitals (up to 130 beds). Provision of dedicated Vascular beds was associated with reduced mortality (p=0.0008) and fewer cardiac events (p=0.03) following CEA. Clearly defined pathways of care also appeared to reduce stroke and cardiac event rates (p=0.004) and the costs of CEA (by more than $600 (USD) per patient). Larger SICU availability (>6 beds) was associated with decreased mortality (p<0.0001) and stroke rate (p=0.001) compared with smaller units, whilst the presence of a dedicated Intensivist was also associated with significantly lower mortality (p=0.0002) following CEA. Patients treated by Vascular Surgeons versus non-Vascular Surgeons (Neuro-, Cardio-thoracic and ‘General’ Surgeons) had significantly lower stroke and mortality/stroke rates, as well as shorter LOS, following CEA. CAS outcomes were not influenced by interventionalist’s specialty but CAS was significantly cheaper when performed by a Vascular Surgeon (p<0.0001). Conclusion - Hospital structural factors significantly affect outcomes of Carotid intervention, but data on CAS were limited. These findings can improve the future configuration of Vascular services and may help reduce the procedural risks and costs of CEA and CAS.

Hospital costs of ischemic stroke and TIA in the Netherlands

There have been no ischemic stroke costing studies since major improvements were implemented in stroke care. We therefore determined hospital resource use and costs of ischemic stroke and TIA in the Netherlands for 2012. We conducted a retrospective cost analysis using individual patient data from a national diagnosis-related group registry. We analyzed 4 subgroups: inpatient ischemic stroke, inpatient TIA, outpatient ischemic stroke, and outpatient TIA. Costs of carotid endarterectomy and costs of an extra follow-up visit were also estimated. Unit costs were based on reference prices from the Dutch Healthcare Insurance Board and tariffs provided by the Dutch Healthcare Authority. Linear regression analysis was used to examine the association between hospital costs and various patient and hospital characteristics. A total of 35,903 ischemic stroke and 21,653 TIA patients were included. Inpatient costs were €5,328 ($6,845) for ischemic stroke and €2,470 ($3,173) for TIA. Outpatient costs were €495 ($636) for ischemic stroke and €587 ($754) for TIA. Costs of carotid endarterectomy were €6,836 ($8,783). Costs of inpatient days were the largest contributor to hospital costs. Age, hospital type, and region were strongly associated with hospital costs. Hospital costs are higher for inpatients and ischemic strokes compared with outpatients and TIAs, with length of stay (LOS) the most important contributor. LOS and hospital costs have substantially declined over the last 10 years, possibly due to improved hospital stroke care and efficient integrated stroke services.

Hispanic ethnicity is associated with increased costs after carotid endarterectomy and carotid stenting in the United States

ObjectiveWe have previously demonstrated an adverse impact of black race and Hispanic ethnicity on the outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS). The current study was undertaken to examine the influence of race and ethnicity on the cost of CEA and CAS. MethodsThe Nationwide Inpatient Sample (2005–2009) was queried using ICD-9 codes for CEA and CAS in patients with carotid artery stenosis. The primary outcome was total hospital charges. Multivariate analysis was performed using a generalized linear model adjusting for age, sex, race, comorbidities (Charlson index), high-risk status, procedure type, symptomatic status, year, insurance type, and surgeon and hospital operative volumes and characteristics. ResultsHispanic and black patients were more likely to have a symptomatic presentation, and were more likely to undergo either CEA or CAS by low-volume surgeons at low-volume hospitals (P < 0.05, all). They were also less likely to have private insurance or Medicare (P < 0.001). Overall, CEA was less expensive than CAS over the 4-y study period ($29,502 ± $104 versus $46,713 ± $409, P < 0.001). Total hospital charges after CEA were increased in both blacks ($39,562 ± $843) and Hispanics ($45,325 ± $735) compared with whites on univariate analysis ($28,403 ± $101, P < 0.001). After CAS, total hospital charges were similarly increased in both blacks ($51,770 ± $2085) and Hispanics ($63,637 ± $2766) compared with whites on univariate analysis ($45,550 ± $412, P < 0.001). On multivariable analysis, however, only Hispanic ethnicity remained independently associated with increased charges after both CEA (exponentiated coefficient 1.18; 95% CI [1.15–1.20]; P < 0.001) and CAS (exponentiated coefficient 1.17; 95% CI [1.09–1.24]; P < 0.001). ConclusionHispanic ethnicity was independently associated with increased hospital charges after both CEA and CAS. The increased charges seen in black patients were explained, in part, by decreased surgeon operative volume and increased postoperative complications. Further efforts are warranted to contain costs in minorities undergoing carotid revascularization.

Racial Disparities in the Cost of Carotid Endarterectomy and Carotid Stenting in the United States

Racial Disparities in the Cost of Carotid Endarterectomy and Carotid Stenting in the United States

Cost Analysis of Carotid Endarterectomy: Is Age a Factor?

Carotid endarterectomy (CEA) has been demonstrated to be safe and effective in elderly patients. Our aim was to analyze and compare outcome and cost of CEA in both elderly and younger patient groups. A total of 125 consecutive patients who underwent CEA were examined retrospectively and grouped according to age (<80 years old, n = 95; and >or=80 years old, n = 30). The actual total costs and itemized costs were analyzed, and diagnosis-related group (DRG) code payor mix were identified. Patient demographics and risk factors were similar except for a greater incidence of coronary artery disease (CAD) in the >or=80 group than in these <80 (43.3% vs. 21.1%, p < 0.05). Patients had similar minor complication rates; however, the >or=80 group had higher perioperative major complications (16.7% vs. 1.1%, p < 0.01). There were no deaths and there was one perioperative stroke, which occurred in the <80 group. Mean length of stay (LOS), intensive care unit (ICU) LOS, and ICU admissions were greater in the >or=80 group. Cost figures were normalized to a base value of 10 US dollars to maintain proprietary data. Actual total costs of CEA were 131.50 US dollars for the >or=80 group and $100 for the <80 group (p < 0.001). Significant cost differences were found in ICU room costs, and costs for clinical laboratory, radiology imaging, other specialty consults, operating room, and ancillary services in the >or=80 group compared with the <80 group. These results show that the cost of CEA in the elderly is significantly greater than that for younger patients. This difference can be attributed to a greater number of major complications in the more elderly group, who require increased ICU stay, and thus require more clinical laboratory, radiology imaging, and specialty consult service resources. Consideration should be given for a DRG modifier code to increase hospital reimbursement for increased associated costs in elderly patients undergoing CEA.

Cost of identifying patients for carotid endarterectomy.

The cost of carotid endarterectomy (CEA) usually considers only the cost of the preoperative investigations and the procedure for the individual patient but ignores the cost incurred in selecting a patient from a referred "pool" of potential candidates or the "total direct program cost." The aim of this study was to estimate the total direct program cost (workup and procedure) of CEA in a large major teaching hospital in Edinburgh, Scotland using a retrospective study design. Participants were patients with transient ischemic attacks and mild strokes referred to the neurovascular clinics for assessment, investigation, and possible CEA. The "workup" was defined as the clinical consultation, carotid duplex, 1 follow-up visit, and a catheter angiogram where indicated. We used data routinely collected from the neurovascular clinics during a 1-year period to estimate the workup cost of patients who might be suitable for CEA. The CEA procedure cost was estimated prospectively in a concurrent study. Estimated costs were applied to the proportions assessed at the different levels of investigation to determine the total direct program cost of CEA. A total of 790 new patients with symptoms suggestive of transient ischemic attacks and mild strokes were identified. Four hundred one (51%) patients were referred for carotid duplex. Duplex identified 78 (10%) with carotid stenosis of > or =70%. Of the total of 790 patients, 26 (3.3%) had catheter angiogram and 18 (2.3%) had CEA. The total direct program cost to investigate this cohort was about 207 000 pounds sterling, with 68% (140 000 pounds sterling) of the cost incurred before any surgery was performed. The cost of identifying suitable patients for carotid surgery is quite high, with more than 30% of the cost attributed to the initial consultation at the neurovascular clinics. The cost of preventing 1 stroke by CEA is in the region of 100 000 pounds sterling at 1997/1998 prices if all the costs incurred in the workup of a cohort for potential CEA are included.

Institutional peer review can reduce the risk and cost of carotid endarterectomy.

Surgeon-directed institutional peer review, associated with positive physician feedback, can decrease the morbidity and mortality rates associated with carotid endarterectomy. Case series. Tertiary care university teaching hospital. All patients undergoing carotid endarterectomy at our institution during a 5-year period ending August 1998. Stroke rate decreased from 3.8% (1993-1994) to 0% (1997-1998). The mortality rate decreased from 2.8% (1993-1994) to 0% (1997-1998). Length of stay decreased from 4.7 days (1993-1994) to 2.6 days (1997-1998). The total cost decreased from $13,344 (1993-1994) to $9548 (1997-1998). An objective, confidential peer review process that provides ongoing feedback of performance to surgeons and documents that performance in relationship with that of peers seems to be effective in reducing the morbidity and mortality rate associated with carotid endarterectomy. In addition, the review process lowered the hospital cost of performing carotid endarterectomy.

Is carotid endarterectomy cost-effective in symptomatic patients with moderate (50% to 69%) stenosis?

Objective: Recently published data from the North American Carotid Endarterectomy Trial revealed a benefit for carotid endarterectomy (CEA) in symptomatic patients with moderate (50% to 69%) carotid stenosis. This benefit was significant but small (absolute stroke risk reduction at 5 years, 6.5%; 22.2% vs 15.7%), and thus, the authors of this study were tentative in the recommendation of operation for these patients. To better elucidate whether CEA in symptomatic patients with moderate carotid stenosis is a proper allocation of societal resources, we examined the cost-effectiveness of this intervention. Methods: A decision-analytic Markov process model was constructed to determine the cost-effectiveness of CEA versus medical treatment for a hypothetical cohort of 66-year-old patients with moderate carotid stenosis. This model allowed the comparison of not only the immediate hospitalization but also the lifetime costs and benefits of these two strategies. Our measure of outcome was the cost-effectiveness ratio (CER), defined as the incremental lifetime cost per quality-adjusted life year saved. We assumed an operative stroke and death rate of 6.6% and a declining risk of ipsilateral stroke after the ischemic event with medical treatment (first year, 9.3%; second year, 4%; subsequent years, 3%). The hospitalization cost of CEA ($6420) and the annual costs of major stroke ($26,880), minor stroke ($798), and aspirin therapy ($63) were estimated from a hospital cost accounting system and the literature. Results: CEA for moderate carotid stenosis increased the survival rate by 0.13 quality-adjusted life years as compared with medical treatment at an additional lifetime cost of $580. Thus, CEA was cost-effective with a CER of $4462. Society is usually willing to pay for interventions with CERs of less than $60,000 (eg, CERs for coronary artery bypass grafting at $9100 and for dialysis at $53,000). CEA was not cost-effective if the perioperative risk was greater than 11.3%, if the ipsilateral stroke rate associated with medical treatment at 1 year was reduced to 4.3%, if the age of the patient exceeded 83 years, or if the cost of CEA exceeded $13,200. Conclusion: CEA in patients with symptomatic moderate carotid stenosis of 50% to 69% is cost-effective. Perioperative risk of stroke or death, medical and surgical stroke risk, cost of CEA, and age are important determinants of the cost-effectiveness of this intervention. (J Vasc Surg 1999;30:1024-33.)

How much does it cost? How much can be saved?

How much does it cost? How much can be saved?

Changing practice and costs of carotid endarterectomy in Toronto, Canada.

During our annual audits of carotid endarterectomy (CEA) in Toronto metropolitan hospitals, we have been aware of major changes in the practice of this operation in recent years. To evaluate the effect of changing practice on costs of carotid endarterectomy, we have therefore compared the effects of changes in length of stay, complication rates, and other variables on cost during the last 3 years for which we have complete data. We evaluated 757 consecutive patients, of whom 600 had CEA procedures in 3 teaching hospitals, and 190 procedures in 2 community hospitals in metropolitan Toronto. We estimated costs using a specially designed computer program, Transitional System Incorporated, including surgical complications, in patients admitted between January 1994 and December 1996. There was a significant decrease in length of stay in both groups of hospitals, mainly due to preoperative outpatient evaluation but also due to lower complication rates, which probably reflect an increase in asymptomatic surgery in both hospital groups. Costs fell from approximately $8000 per procedure to $5000 in asymptomatic patients and from approximately $10,000 to $7000 in symptomatic patients (Can $). Major changes in the management of patients undergoing CEA have resulted in a significant decrease in both length of hospital stay and utilization of postoperative intensive care. At the same time, complication rates have significantly fallen, although our mortality and morbidity figures remain slightly higher than those from published multicenter trials. Future changes in surgical practice in Canada, including noninvasive carotid imaging, should produce even lower costs within the next few years.

Is routine duplex ultrasound surveillance after carotid endarterectomy cost-effective?

Background: Although duplex ultrasound surveillance of patients after carotid endarterectomy (CEA) is routinely performed, the use of this policy has been questioned. We evaluated the cost-effectiveness of this strategy. Methods: Using a decision-analytic Markov model that depicts the natural history of patients after CEA, we compared a strategy of duplex ultrasound surveillance to a strategy of no surveillance. Probability estimates were derived from the literature and costs were obtained from the hospital's cost accounting system. Sensitivity analyses were performed to test the robustness and stability of our base-case conclusion to variations in the underlying assumptions. Results: Using baseline estimates we determined that duplex ultrasound surveillance after CEA reduced the incidence of stroke; however, this required significant additional expense, which resulted in an incremental cost-effectiveness ratio of $126,950. This ratio could decrease to a more acceptable level (less than $100,000) if a subset of patients could be identified whose rate of progression to greater than 80% stenosis exceeded 6% per year or whose stroke rate associated with uncorrected asymptomatic stenosis exceeded 2.6% per year. Also, the cost-effectiveness ratio was reduced to less than $100,000 if patients were younger than 55 years old at the time of initial CEA or if the cost of CEA could be reduced to less than $7,000. Conclusions: Duplex ultrasound surveillance after CEA is associated with an unfavorable cost-effectiveness ratio. However, this strategy may be cost-effective in younger patients or in those patients who have a more progressive form of disease. (Surgery 1998;124:343-52)

Is routine duplex ultrasound surveillance after carotid endarterectomy cost-effective?

Background: Although duplex ultrasound surveillance of patients after carotid endarterectomy (CEA) is routinely performed, the use of this policy has been questioned. We evaluated the cost-effectiveness of this strategy. Methods: Using a decision-analytic Markov model that depicts the natural history of patients after CEA, we compared a strategy of duplex ultrasound surveillance to a strategy of no surveillance. Probability estimates were derived from the literature and costs were obtained from the hospital's cost accounting system. Sensitivity analyses were performed to test the robustness and stability of our base-case conclusion to variations in the underlying assumptions. Results: Using baseline estimates we determined that duplex ultrasound surveillance after CEA reduced the incidence of stroke; however, this required significant additional expense, which resulted in an incremental cost-effectiveness ratio of $126,950. This ratio could decrease to a more acceptable level (less than $100,000) if a subset of patients could be identified whose rate of progression to greater than 80% stenosis exceeded 6% per year or whose stroke rate associated with uncorrected asymptomatic stenosis exceeded 2.6% per year. Also, the cost-effectiveness ratio was reduced to less than $100,000 if patients were younger than 55 years old at the time of initial CEA or if the cost of CEA could be reduced to less than $7,000. Conclusions: Duplex ultrasound surveillance after CEA is associated with an unfavorable cost-effectiveness ratio. However, this strategy may be cost-effective in younger patients or in those patients who have a more progressive form of disease. (Surgery 1998;124:343-52)

Con: General anesthesia and regional anesthesia are equally acceptable choices for carotid endarterectomy

Con: General anesthesia and regional anesthesia are equally acceptable choices for carotid endarterectomy

Cost-Effective Carotid Endarterectomy in Community Practice

The purpose of this study was to compare hospital charges for carotid endarterectomy on a surgeon-specific basis. The cost of carotid endarterectomy is influenced by preoperative evaluation, operating time, use of the intensive care unit, length of hospital stay, and surgical results. Length of stay and average hospital charges for 18 doctors performing 344 carotid endarterectomies at three hospitals were analyzed. Outcome data were also reviewed. The results demonstrated a wide variation in hospital charges among surgeons. Surgeons using the most cost-effective measures achieved comparable or superior outcomes. In an era of managed care, severe cost constraints mandate that surgeons perform similar studies in their own communities so that cost-effective clinical pathways can be developed. With the use of appropriate guidelines, carotid endarterectomy can be performed at relatively low cost without sacrificing quality.