Delay to carotid endarterectomy in patients with symptomatic carotid artery stenosis
A G den Hartog1, F L Moll1, H B van der Worp2
1Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands.
Insights
Implementing process improvements reduced delays for carotid endarterectomy (CEA) after symptomatic carotid artery stenosis. However, most patients still experienced delays exceeding 14 days, highlighting the need for uniform "index event" definitions in research.
Area of Science:
- Vascular Surgery
- Neurology
- Health Services Research
Background:
- Guidelines recommend carotid revascularization within 2 weeks of a symptomatic carotid artery stenosis event.
- The definition of
- index event
- (first vs. most recent) can impact delay calculations.
- Delays in carotid endarterectomy (CEA) can affect patient outcomes.
Purpose of the Study:
- To evaluate the delay between the index event and CEA over 6 years.
- To assess the impact of defining the index event as either the first or most recent event on these delays.
- To analyze the effect of process improvements on reducing CEA delays.
Main Methods:
- Observational study of 555 patients with symptomatic carotid stenosis (≥50%) undergoing CEA.
- Data collected between 2007 and 2012.
- Analysis of delays before and after in-hospital process changes introduced in 2010.
Main Results:
- Median delay from the first event to CEA decreased from 53 to 21 days; from the most recent event, it decreased from 45 to 17 days.
- Patients referred by general practitioners and those with ischemic stroke had shorter delays.
- Despite improvements, most patients still had delays exceeding 14 days in 2012.
Conclusions:
- Process improvements significantly reduced delays to CEA.
- The definition of the index event substantially influences reported delays.
- Standardizing the "index event" definition is crucial for consistent research findings.
Objective:
In patients with recently symptomatic carotid artery stenosis, guidelines recommend carotid revascularization within 2 weeks of the index event. The "index event" may be defined as either the first or the most recent event. The delay between the index event and carotid endarterectomy (CEA) over a period of 6 years in a single centre was evaluated and the effect of defining the index event as either the first or the most recent event was assessed.
Design:
Observational study.
Methods:
555 consecutive patients with symptomatic carotid stenosis ≥ 50% treated with CEA between 2007 and 2012 were assessed. In 2010, changes to the in-hospital process of care to reduce delays in referral and CEA were introduced. These changes included, for example, improving access to physicians, imaging, and operating rooms. The delay from symptoms to surgery was expressed in days.
Results:
The median time between the first event and surgery was reduced from 53 days (interquartile range [IQR] 30-78) in 2007 to 21 days (IQR 12-45) in 2012, and between the most recent event and CEA from 45 days (IQR 28-67) to 17 days (IQR 9-28). Patients referred directly by their general practitioner more often underwent CEA within 2 weeks than patients referred by specialists from other hospitals. Compared to patients with transient ischaemic attack or ocular symptoms, patients with ischaemic stroke more often underwent CEA within 2 weeks.
Conclusions:
A small change in the process of care significantly reduced the delay from the index event to CEA, but in 2012 it still exceeded 14 days in the majority of patients. The definition of the "index event" has a large impact on the total duration of delay, and should therefore be uniform across studies.
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