Developing a neurosurgical carotid endarterectomy practice

ELSEVIER

DEVELOPING A NEUROSURGICAL CAROTID ENDARTERECTOMY PRACTICE

Harbaugh BE. Developing a neurosurgical carotid endarterectomy practice. Surg Neuroi 1996;46:54.5-8. During the 1984-85 academic year, our neurosurgical service performed 60 carotid endarterectomy (CEA) procedures. By 1989 the annual number of CEAs performed by the neurosurgical service had fallen to six procedures, primarily because of the loss of patient referrals to an aggressive and well-trained vascular surgery group. At that time, an effort was begun to establish a neurosurgical cerebrovascular service and to compete more effectively for patients with extracranial cerebrovascular disease. Protocols for assuring rapid neurosurgical evaluation, improving communications with referring physicians, and developing innovative surgical and perioperative management protocols for CEA patients were instituted. By use of these strategies the annual number of CEAs performed on our neurosurgical service has increased substantially; from six CEAs done in academic year 1988-89 to 107 CEAs done in academic year 1994-95. The number of CEAs will surpass 120 for the present academic year. This presentation reviews the causes of the precipitous decline in the number of CEAs done by our neurosurgical service from 1985-89 and outlines strategies I have found effective for reestablishing neurosurgeons in the care of patients with surgically treatable extracranial cerebrovascular disease. 0 1996 by Elsevier Science Inc.

BACKGROUND During my residency training at Dartmouth nearly all of the CEAs at our institution were performed by the neurosurgical service. AI1 members of the neurosurgical section performed the operation using general anesthesia, EEG monitoring, and selective shunting. In 1984, the vascular laboratory, which

had previously been under the direction of radiology, was taken over by vascular surgery. Initially this did not seem to make a big difference. Over the next several years, however, two young, talented, and aggressive vascular surgeons were recruited. Because few vascular laboratories existed in the community hospitals, most patients with suspected carotid artery disease were referred to vascular surgery for carotid duplex evaluation. This resulted 0 1996 by Elsevier Science 655 Avenue of the Americas,

Inc. New

York,

NY 10010

in many of our endarterectomy patients being diverted to vascular surgery. As a result of the events outlined above, by 1989 nearly all of the carotid endarterectomies (CEAs) being performed at this institution were being done by the vascular surgeons. During the 1988-89 academic year, our section of neurosurgery did only six CEAs-one-tenth the number done in the 1984-85 academic year. Neurosurgical super-specialization and the development of the cerebrovascular surgery program at Dartmouth was begun in March 1989. One of the primary objectives was to reestablish the neurosurgery section in carotid artery surgery. This has been a very successful endeavor as evidenced by the fact that I will perform more than 120 CEAs during the current academic year. In reviewing my experience over the last 6 years I think that the following measures have been responsible for establishing a busy neurosurgical CEA practice, even though

our vascular

laboratory

is managed

by a

well-trained and aggressive vascular surgery group. The suggestions listed below may be helpful to other neurosurgeons who wish to establish a CBA practice. The first section below lists steps that can be taken by any neurosurgeon or neurosurgical group trying to establish a CEA practice. Suggestions in the second section require the cooperation of other physicians and may be more appropriate for a larger

practice

group

or neurosurgeons

in an aca-

demic medical center environment. The only assumptions made are that the neurosurgeons to whom these suggestions are addressed are technically competent in carotid artery surgery and have a strong desire to establish a CEA practice.

SUGGESTIONS The following neurosurgical

suggestions practitioner

can be instituted or group.

by any

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BETTER SERVICE FOR REFERRING PHYSICIANS Referring physicians should get a better and more rapid evaluation of a patient with suspected cerebrovascular disease from a neurosurgeon, rather than from a vascular surgeon. We have an advantage in that we know much more about the brain and are competent to evaluate all patients with known or suspected cerebrovascular disease. If you are affiliated with a neurologist who wilf refer p~tient~ to you and who ~~11see p~tient~ expeditiously, that is ideal. Unfortunately, this is often not the case. In many cases we must be our own neurologists. If a vascular surgeon can evaluate and treat a patient before that same patient can get a neurology clinic appointment the patient will usually go to vascular surgery even if their evaluation lacks neurofogic sophistication. Initially, one is likely to see only patients with symptomatic carotid artery disease but if they do well the asymptomatic patients will follow. COMMUNICATIONS Many referring physicians do not associate neurosurgeons with CEA. We need to let them know that we do this procedure and have been involved in CEA since its inception. If I have referring physicians who send me patients with other problems, but not with carotid artery disease, I make a point of letting them know that CEA is a part of my practice and that I would welcome such referrals. They are often surprised and pleased to have an alternate referral pathway for their patients. Once a referral is made, frequent and timely follow-up communication with the referring physician is essential. If our service is better the word will get around. Making presentations on CEA at hospital conferences, state medical society meetings, or other places with an audience of primary care physicians is also of considerable value. If a local radio or television station has any medical programming, volunteering to talk about stroke prevention and CEA may generate many patient referrals. We should convince patients and primary care doctors that CEA is a cerebrovascular procedure, not a peripheral vascular procedure. INNOVATION Referring physicians, patients, and third-party payers need a reason to change established referral patterns. This will not happen if we offer the same service as other surgeons. Being as good is not good enough. I think it is unlikely that we can significantly improve on the clinical outcome of patients treated by well-trained vascular surgeons,

Harbaugh

especially as they will usually be doing more asymptomatic patients than we are. However, if our outcome statistics are equal to the vascular surgeons and we are superior to them in other areas this will be a reason to change established patterns of referral. For example, I have been performing almost all CEAs with local anesthesia and discharging most patients home within 24 hours [l-3]. I have also used a transverse incision for al1 but the highest carotid bifurcations because of better cosmetic results 131. All of this is different from my training as a resident. The changes in my practice were made because I believe that these innovations would increase the value of CEA. By being willing to critically evaluate and eliminate those aspects of care that added considerable cost without documented benefit, we have been able to decrease the costs of care for our CEA patients by more than 40% while improving patient outcomes 131. I am not advocating that a11 neurosurgeons should do this operation “my way,” but rather that each neurosurgeon be willing to critically review his or her practice and not be satisfied with the status quo. If insurers note that our operating room time is one-half that of the competitors, or that our patients go home 1-2 days earlier, or that they don’t require invasive monitoring postoperatively, patients will be directed our way. The patients themselves will compare notes and if one surgeon’s patients go home sooner, have fewer postoperative interventions, and a more cosmetic incision-this will be noticed. Obviously, we should not pursue innovations that compromise patient care simply for gimmickry and it should be kept in mind that what works for one surgeon may not work for another. However, I believe that there is much that we can do to offer a superior product to the third-party payers and referring physicians while simultaneously improving patient care. JOIN THE JSCVS The Joint Section on Cerebrovascular (JSCVS) of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons has been in the forefront of developing methods to get neurosurgeons back in the CEA market. The support of the neurosurgical community in joining this organization will benefit all of us.

SUGGESTIONSFOR~ARGER GROUPS The following suggestions will require collaboration with other physicians and might be more appropri-

Neurosurgical Carotid Endarterectomy

Practice

ate for larger neurosurgical groups or for neurosurgeons in an academic medical center setting. SUPERSPECIALIZATION For neurosurgeons practicing in larger groups or in an academic medical center it is imperative that one or two surgeons specialize in cerebrovascular disease. Technique matters greatly in CEA and we will be competing with surgeons who operate on blood vessels on a daily basis. By superspecializing, the vascular neurosurgeon will gain increased experience and expertise and will be recognized by referring physicians as the expert in vascular disease of the brain. In addition, by making one or two people responsible for developing a CEA practice, they become accountable for the success or failure of the effort. COLLABORATION WITH MEDICAL NEUROLOGISTS There is nothing that will help us more in developing a CEA practice than establishing close collaboration with well-trained neurologists who have a special interest in cerebrovascular disease, who will see patients on an urgent basis, and who support surgical intervention for atherosclerotic carotid artery disease. Optimally, this collaboration can be used to establish stroke units and cerebrovascular disease centers that are directed by medical neurologists and neurosurgeons. It is important that referring physicians begin to think of carotid artery disease as a subset of diseases of the central nervous system and not as a subset of peripheral vascular diseases. RESEARCH Neurosurgeons need to stay at the forefront of research in the evaluation and treatment of cerebrovascular disease. It is essential that we are involved in clinical studies such as NASCET, ACAS, and their spin-off studies. This should be communicated to referring physicians. Such advertising is a legitimate means of documenting the expertise of the neurosurgeon in evaluating and treating patients with carotid artery disease. Although some referring physicians may not want their patients to be “guinea pigs,” most referring physicians respect efforts to conduct clinical research and will reward those involved in the long run. We also need to serve as a cerebrovascular disease reference source for the medical community. We need to know the CEA literature better than anyone else and we need to be willing to share this knowledge with primary care physicians and other health care professionals. I have put in many hours and many miles delivering continuing medical edu-

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cation presentations to any hospital or other medical organization that is interested. This is labor intensive but if one has taken the time to prepare a reasoned presentation for the primary care physicians, they will appreciate the effort and think of neurosurgery when the next CEA patient is seen. Likewise, we need to continue our efforts to develop alternatives to duplex as screening tools for carotid artery disease. Magnetic resonance (MR) angiography and/or computed tomography (CT) angiography may soon be able to replace duplex scanning as a cost-effective and minimally invasive means to image the carotid arteries. If this occurs the great advantage presently enjoyed by those who run vascular laboratories will disappear. INNOVATION The willingness to be innovative in attempting to improve our procedures is at least as important for the cerebrovascular neurosurgeon in a large group practice or academic medical center as it is for the neurosurgeon in a small group or solo practice. Unfortunately, innovation is often felt to be synonymous with more technology. I believe that a minimalist approach, as defined below, may be a better strategy for the CEA patient. MINIMALISM IN CEA A good deal of attention has been paid to minimalism in neurosurgery. Unfortunately, this term has come to be associated with a small incision. I believe that minimalism might more accurately be defined as that intervention that achieves the desired goal with minimal disruption of the patient’s homeostatic mechanisms. My practice of CEA is, I believe, a good example of such neurosurgical minimalism. CEA patients are frequently elderly, fragile patients, with numerous medical problems, and complex medical regimens. I have tried to make CEA as minimally disruptive to their normal routine as possible. CEA is a brief operation with minimal blood loss and a relatively superficial surgical target. Performing this procedure using a regional anesthesia and mobilizing the patient immediately postoperatively makes it a minimally disruptive procedure. I suspect that the risks inherent in general anesthesia and invasive monitoring are greater than the risks of the surgical procedure for these patients [l-3].

Academic medical centers are particularly susceptible to the belief that more technology, intensive intervention, and monitoring must produce better results. This hypothesis, like any other,

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should be tested. It may be found that the value of medical care can sometimes be increased by avoiding high technology solutions. Academic medical centers have been pioneers in developing high technology care. If they are to continue to thrive they must also lead in developing high value care. CEA AND THE MEDICAL MARKETPLACE In an era of managed and capitated care, the need for neurosurgeons will likely be related to the number of patients or “managed lives” for whom we offer a service. As previously noted, the patient population with athersclerotic carotid artery disease will grow over the next few decades and neurosurgeons may need to compete with other specialists for their care. The competition for these patients is likely to increase due to a growing interest by interventional radiologists and cardiologists in percutaneous, endovascular treatment of carotid stenosis. If we cannot offer a high value product, i.e., excellent treatment at low cost, neurosurgeons may not be able to effectively compete for these patients, even if we offer excellent care. However, if a surgical procedure of proven value, CEA, can be done with morbidity and costs that are competitive with percutaneous procedures it is likely that CEA will continue to be in demand in the future. I believe that our present perioperative regimen for CEA patients is safer, more effective, less expensive, and

T

HERE ARE MOUNTAIN,

can be applied to sicker patients therapy [3].

than endovascular

SUMMARY In an era when we are concerned about there being too many neurosurgeons we should be working to take back areas of clinical practice that we have lost. CEA is one such area. There will be more than 100,000 CEAs done in the United States this year and less than 10% of them will be done by neurosurgeons. I believe that with an aggressive approach to recruiting these patients this percentage can be considerably increased. Increasing our “market share” to 50% would keep an additional 200 neurosurgeons busy each year doing CEAs. The suggestions outlined here may help to achieve this goal. Robert

E. Harbaugh,

M.D., F.A.C.S.

Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire REFERENCES 1. Harbaugh RE. Carotid surgery using regional anesthesia. Techniques Neurosurgery 1996 (in press). 2. Harbaugh KS, Harbaugh RE. Early discharge after carotid endarterectomy. Neurosurgery 1995;37:219-25. 3. Harbaugh KS, Pikus HJ, Shumaker GS, Perron AD, Harbaugh RE. Increasing the value of carotid endarterectomy. J Neurovasc Dis 1996 (in press).

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