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Who doesn't receive carotid endarterectomy when appropriate?
Ronnie D Horner1, Eugene Z Oddone, Karen M Stechuchak
1National Institute of Neurological Disorders and Stroke/NIH, Neuroscience Center Building, Room 2149, 6001 Executive Boulevard, Rockville, MD 10852, USA. rh266m@noh.gov
Journal of Vascular Surgery
|January 14, 2004
Summary
Many patients suitable for carotid endarterectomy (CEA) do not receive it. Factors include asymptomatic disease, lower stenosis, patient aversion to surgery, and provider doubts about CEA efficacy.
Area of Science:
- Vascular Surgery
- Health Services Research
- Clinical Decision Making
Background:
- Carotid endarterectomy (CEA) is a procedure to prevent stroke in patients with significant carotid artery stenosis.
- Identifying barriers to CEA is crucial for optimizing stroke prevention strategies.
- Patient and provider perceptions significantly influence treatment decisions.
Purpose of the Study:
- To determine clinical and nonclinical factors associated with the failure to perform CEA in patients with appropriate indications.
- To analyze patient and physician perceptions of CEA risks and benefits.
Main Methods:
- Prospective cohort study at five Veterans Affairs medical centers.
- Inclusion criteria: ≥50% carotid stenosis, no prior CEA, appropriate candidate status.
- Data collection via medical record review and interviews; primary outcome: CEA receipt within 6 months.
Main Results:
- 66.8% of appropriate candidates did not undergo CEA.
- Patients not receiving CEA were more likely to be asymptomatic (68.7% vs. 45.7%), have high aversion to surgery, and have providers perceiving low stroke risk (<5%) or low efficacy (<5%).
- Multivariable analysis identified asymptomatic disease, <70% stenosis, high patient aversion, and low provider-perceived efficacy as significant factors.
Conclusions:
- In the VA system, appropriate CEA candidates not receiving surgery were less likely to have symptomatic disease or high-grade stenosis.
- High patient aversion to surgery and low provider-perceived efficacy were strongly associated with non-receipt of CEA.
- These findings highlight the impact of patient preferences and provider beliefs on treatment decisions for carotid artery disease.