Duke neurologist calls for mandatory reporting of complication rates for carotid endarterectomy

May 06, 1997

DURHAM, N.C. -- Noting that surveys show physicians are generally poorly informed about the complication rates for a surgical procedure that clears blockages in neck arteries, a Duke neurologist has called for mandatory audits of these rates as a part of a hospital's official accreditation process.

Dr. Larry Goldstein said such audits will help doctors steer patients to surgeons or hospitals that have low rates of serious complications from the surgery aimed at heading off strokes.

The operation in question is a carotid endarterectomy -- a procedure that clears obstructions from the carotid artery in the neck, the major vessel that nourishes the brain. Blockages in this artery are a major cause of stroke.

The results of several recent studies have shown that the procedure is effective in preventing strokes. However, this surgical benefit depends on very low complication rates -- less than a 3 percent risk of stroke or death in asymptomatic patients and less than 6 percent in symptomatic patients. If a particular surgeon's complication rate exceeds those levels, the potential risks of the procedure outweigh the potential benefits, the researchers say.

"Despite overwhelming clinical data and several guidelines and policy statements, it is clear that data relating to surgical complication rates are not available to physicians referring their patients for carotid endarterectomy," Goldstein said. "Because of the failure of the current voluntary system, we feel that the auditing of complication rates be mandated as a condition of hospital certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

"If the JCAHO says it must be done, it will be done," he added.

While the JCAHO does not mandate the auditing of complication rates for specific procedures, individual hospitals can choose a particular invasive procedure as an example of how the hospital follows patient care processes.

Goldstein's "Call to Action" appears as an editorial in the May 6 edition of the journal Stroke. Co-authors include Dr. Wesley Moore, vascular surgeon at UCLA; Dr. James Robertson, neurosurgeon at University of Tennessee; and Dr. Seemant Chaturvedi, neurologist at Wayne State University.

When performing a carotid endarterectomy, surgeons make an incision in the neck, and the carotid artery is opened. The surgeon removes the atherosclerotic plaque or blood clots impeding the flow of blood to the brain. The surgeon then closes the artery with or without the addition of a "patch," depending on the size of the incision.

While there are many factors that affect the complication rates for patients afterthe surgery, the skill of the surgeon is critical, Goldstein said. It is critical for referring physicians to know the complication rates for the surgeons to whom they're sending patients.

"When physicians are deciding whether or not to recommend a carotid endarterectomy for their patients, they weigh the risks against the benefits," Goldstein said. "While we have a good understanding of which patients would benefit from the surgery, most physicians do not know the complication rates for the specific surgeon or hospital who will be doing the procedure. They cannot make in informed decision without all the pertinent information.

"If an agency with the clout of JCAHO certifies a hospital after auditing its complication rates, then patients will only be referred to surgeons who have demonstrated skills in performing the operation within established levels of complication rates," Goldstein said.

In 1995, Goldstein conducted a survey of more than 1,000 U.S. physicians and found that only 19 percent reported knowing the post-operative death rate and 15 percent knew the post-operative stroke rate for the hospital where they referred their patients for carotid endarterectomy. Furthermore, only about half of the neurologists and 60 percent of the surgeons reported knowing the complication rates, Goldstein said.

Also, a recent survey of hospitals with accredited surgical residency programs found that about 20 percent indicated they systematically monitor complication rates.

"Without knowing the rates, it's hard for doctors to make decisions. Without assurance that surgical complication rates are within acceptable limits, it is impossible to determine whether an individual should undergo the operation," Goldstein said.

Duke University

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