BACKGROUND: Carotid endarterectomy (CE), when performed on appropriate patients, reduces the incidence of stroke, yet there are marked variations in rates of this procedure. We sought to determine reasons for the variation in CE rates in 4 Canadian provinces. METHODS: We identified all CEs performed in 4 Canadian provinces between January 2000 and December 2001, inclusive. From chart review and expert assessment, we determined the proportion of these procedures that were appropriate, inappropriate or of uncertain appropriateness, using the RAND/UCLA Appropriateness Method. We sought to determine the variation in rates by province and whether the variation was due to differences in type of hospital, surgical specialty or surgical volume. RESULTS: Overall, 1656 (52.3%) of the 3167 CEs studied were performed for appropriate indications. The proportions of appropriate procedures were 78.2% (176/225) in Saskatchewan, 58.7% (481/819) in Alberta, 49.1% (350/713) in Manitoba and 46.0% (649/1410) in British Columbia (p < 0.001 across provinces). Rates of appropriate procedures per 100 000 population ranged from 44.3 in Manitoba to 16.2 in Saskatchewan (p < 0.001 across provinces). CEs were more likely to be appropriate when performed by a neurosurgeon compared with all other surgeons (74.4% v. 49.4% were appropriate; p < 0.001), when performed by surgeons doing fewer than 31 procedures over 2 years compared with surgeons doing more than 31 (70.1% v. 49.5% were appropriate; p < 0.001) and when performed in hospitals doing fewer than 135 procedures per year compared with hospitals doing more than 135 (63.4% v. 49.1% were appropriate; p < 0.001). Overall, 10.3% of procedures were done for inappropriate reasons. INTERPRETATION: Our findings suggest some overuse (for inappropriate or uncertain indications) but also some underuse (low population rates in some regions). High rates of CE are associated with lower rates of appropriateness for both surgeons and hospitals. That 1 in 10 CEs is done inappropriately suggests the need for preoperative assessment of appropriateness.
BACKGROUND: Carotid endarterectomy (CE), when performed on appropriate patients, reduces the incidence of stroke, yet there are marked variations in rates of this procedure. We sought to determine reasons for the variation in CE rates in 4 Canadian provinces. METHODS: We identified all CEs performed in 4 Canadian provinces between January 2000 and December 2001, inclusive. From chart review and expert assessment, we determined the proportion of these procedures that were appropriate, inappropriate or of uncertain appropriateness, using the RAND/UCLA Appropriateness Method. We sought to determine the variation in rates by province and whether the variation was due to differences in type of hospital, surgical specialty or surgical volume. RESULTS: Overall, 1656 (52.3%) of the 3167 CEs studied were performed for appropriate indications. The proportions of appropriate procedures were 78.2% (176/225) in Saskatchewan, 58.7% (481/819) in Alberta, 49.1% (350/713) in Manitoba and 46.0% (649/1410) in British Columbia (p < 0.001 across provinces). Rates of appropriate procedures per 100 000 population ranged from 44.3 in Manitoba to 16.2 in Saskatchewan (p < 0.001 across provinces). CEs were more likely to be appropriate when performed by a neurosurgeon compared with all other surgeons (74.4% v. 49.4% were appropriate; p < 0.001), when performed by surgeons doing fewer than 31 procedures over 2 years compared with surgeons doing more than 31 (70.1% v. 49.5% were appropriate; p < 0.001) and when performed in hospitals doing fewer than 135 procedures per year compared with hospitals doing more than 135 (63.4% v. 49.1% were appropriate; p < 0.001). Overall, 10.3% of procedures were done for inappropriate reasons. INTERPRETATION: Our findings suggest some overuse (for inappropriate or uncertain indications) but also some underuse (low population rates in some regions). High rates of CE are associated with lower rates of appropriateness for both surgeons and hospitals. That 1 in 10 CEs is done inappropriately suggests the need for preoperative assessment of appropriateness.
Authors: Ethan A Halm; Mark R Chassin; Stanley Tuhrim; Larry H Hollier; A John Popp; Enrico Ascher; Herbert Dardik; Glenn Faust; Thomas S Riles Journal: Stroke Date: 2003-05-08 Impact factor: 7.914
Authors: P M Rothwell; M Eliasziw; S A Gutnikov; A J Fox; D W Taylor; M R Mayberg; C P Warlow; H J M Barnett Journal: Lancet Date: 2003-01-11 Impact factor: 79.321
Authors: H J M Barnett; D W Taylor; R B Haynes; D L Sackett; S J Peerless; G G Ferguson; A J Fox; R N Rankin; V C Hachinski; D O Wiebers; M Eliasziw Journal: N Engl J Med Date: 1991-08-15 Impact factor: 91.245
Authors: Sharon E Straus; Melissa Brouwers; David Johnson; John N Lavis; France Légaré; Sumit R Majumdar; K Ann McKibbon; Anne E Sales; Dawn Stacey; Gail Klein; Jeremy Grimshaw Journal: Implement Sci Date: 2011-12-09 Impact factor: 7.327
Authors: Joshua P Vogel; Julia E Moore; Caitlyn Timmings; Sobia Khan; Dina N Khan; Atkure Defar; Azmach Hadush; Marta Minwyelet Terefe; Luwam Teshome; Katherine Ba-Thike; Kyu Kyu Than; Ahmad Makuwani; Godfrey Mbaruku; Mwifadhi Mrisho; Kidza Yvonne Mugerwa; Lisa M Puchalski Ritchie; Shusmita Rashid; Sharon E Straus; A Metin Gülmezoglu Journal: PLoS One Date: 2016-11-02 Impact factor: 3.240
Authors: France Légaré; Antoine Boivin; Trudy van der Weijden; Christine Packenham; Sylvie Tapp; Jako Burgers Journal: Implement Sci Date: 2009-06-04 Impact factor: 7.327