An Institutional Approach to Maintenance of Excellent Outcomes for Carotid Endarterectomy in a Setting with Moderate-to-Low Procedure Volume

Background: Institutions and surgeons with high procedure volumes have been reported to have lower morbidity and mortality rates for patients undergoing carotid endarterectomy. Demonstrating comparable results is essential for centers with moderate or low volume. If comparable results cannot be demonstrated, a low- to moderate-volume center should not perform the procedure. Study design: A prospective study of a program to achieve and sustain excellent outcomes after carotid endarterectomy was conducted at a single institution with low-to-moderate volumes. Results of this effort from January 1997 through December 2005 are reported. Key features of our approach include institutional control over which and how many surgeons can perform carotid endarterectomy. Surgeons must be experienced carotid surgeons and consistently perform more than 12 procedures annually and be continuously monitored. Surgical outcomes were independently audited through a mandated institutional carotid endarterectomy data registry. Surgeons with poor outcomes are barred from doing carotid endarterectomies; and annually updated outcomes data are posted on the Internet. Results: This approach was used for 555 carotid endarterectomies in 503 patients. Our outcomes-with total death and disabling stroke rate of 1.6%-compare favorably with, and are not statistically different from, published benchmarks, despite volumes at our institution ranging from 44 to 81 patients annually and the participation of 8 surgeons during the study period. Conclusions: Surgeons should perform carotid endarterectomies only if excellent outcomes can be demonstrated. We conclude that by using an approach like ours, even institutions with moderate-to-low carotid endarterectomy volumes can achieve excellent outcomes. We propose that all institutions should assume responsibility for ensuring excellent carotid endarterectomy outcomes using a comprehensive outcomes-based approach with independent auditing similar to that presented here.