CHANGING PRACTICE AND COSTS OF CAROTID ENDARTERECTOMY IN TORONTO, CANADA

Background and Purpose-During our annual audits of carotid endarterect omy (CEA) in Toronto metropolitan hospitals, we have been aware of maj or changes in the practice of this operation in recent years. To evalu ate 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 yea rs for which we have complete data. Methods-We evaluated 757 consecuti ve patients, of whom 600 had CEA procedures in 3 teaching hospitals, a nd 190 procedures in 2 community hospitals in metropolitan Toronto. We estimated costs using a specially designed computer program, Transiti onal System Incorporated, including surgical complications, in patient s admitted between January 1994 and December 1996. Results-There was a significant decrease in length of stay in both groups of hospitals, m ainly 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 $). Conclusions-Major c hanges 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 figure s 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 y ears.