The Carotid Endarterectomy Task Force was established by the Joint Officers of the AANS/CNS in response to several recent trends in carotid endarterectomy (Figure 1). Following the publication of several editorials in the academic and public literature in the mid-1980s, there was a substantial decline in the overall number of carotid endarterectomies performed in the United States. Additionally at this time, several multi-center prospective randomized trials were initiated to determine the efficacy of carotid endarterectomy for patients with either symptomatic or asymptomatic carotid stenosis.
Coincident with the publication of three trials for symptomatic carotid stenosis in 1991 (NASCET, ECST, and VA Symptomatic Trial), there was a substantial increase in the number of endarterectomies performed in the United States from approximately 50,000 to 70,000 per year. Additionally, with the publication of the ACAS Trial for Asymptomatic Stenosis in 1994, there has been another increase in the performance of endarterectomy to more than 70,000 cases according to the most recently available data.
It can be assumed that this number has continued to increase in the interim with dissemination of the results of these trials. Throughout this interval, however, the number of endarterectomies performed by neurosurgeons has remained relatively constant at about 5,000 cases per year. From the stand-point of market share, therefore, endarterectomies performed by neurosurgeons have decreased from approximately 10 percent in 1990 to 6 percent in 1994. The basis for this discrepancy is uncertain, and represents one component of the Carotid Endarterectomy Task Force II effort.
Figure 2 shows the reimbursement per endarterectomy case for Medicare and private insurance. Medicare reimbursement has declined from approximately $1,500/ case in 1987 to current levels of $1,200/case, which have been stable since 1992. Based on neurosurgical practice survey data, reim-bursement for private insurance endarterectomy has increased from $2,525 in 1987 to $2,900 in 1992 (most recent data).
Because of the demographics of carotid artery disease, a significant proportion of cases can be assumed to be funded by Medicare. The overall impact of these trends for Medicare reimbursement are shown in Figure 3. In 1994, total Medicare reimburse-ment for carotid endarterectomy was $92.33 million; neurosurgeons were reimbursed $5.63 million and the remaining $86.7 million was paid to vascular, general, and cardiothoracic surgeons.
Carotid Endarterectomy Task Force I
In 1993, the Joint Officers commissioned Robert Spetzler, MD, to head the Carotid Endarterectomy Task Force I. The mission of this task force was “to increase the volume and improve the quality of extracranial vascular surgery done by neurosurgeons in the United States.” Surveys were sent to Program Directors and practicing neurosurgeons trained in carotid endarterectomy to identify particular problems and potential means to accomplish this mission. In its final report, the first Task Force delineated the following recommendations.
1. The Residency Review Committee (RRC) and American Board of Neurological Surgery (ABNS) make training in carotid endarterectomy mandatory.
2. Neurosurgeons become actively involved in ongoing stroke studies.
3. Neurosurgeons become involved in vascular laboratories.
4. Programs for continuing education in carotid endarterectomy be developed for neurosurgeons.
Carotid Endarterectomy Task Force II
In 1994, the Joint Officers commissioned Robert Ojemann, MD, and myself to form Carotid Endarterectomy Task Force II. The directive to Task Force II was to continue the mission described above by implementing those specific recommendations. In conjunction with the Joint Section on Cerebrovascular Disease, the following sub-committees were established.
a. RRC/ABNS (Robert Ojemann)
b. Development of Training Standards in Endarterectomy (L.N. Hopkins)
c. Assessment of Practice Patterns in Endarterectomy (Chris Loftus, Tom Origitano, Kevin McGrail)
d. Development of Practical Courses in Endarterectomy (Julian Bailes)
e. Education for Neurosurgeons (Issam Awad)
f. Education for Non-Neurosurgeons (Warren Selman)
g. Guidelines and Outcomes (Robert Harbaugh)
h. Practice Management for Carotid Endarterectomy (Richard Roski)
i. Public Relations (Linda Sternau)
A number of initiatives in each of these areas were developed.
Surveys of Practice Patterns in Carotid Endarterectomy
Over the past few years, two surveys were conducted to obtain a clearer picture of practice patterns with regard to carotid endarterectomy. In September 1994, a questionnaire was mailed to Neurosurgical Program Directors.
There were 91 respondents from 55 neurosurgical departments and 36 divisions. Among the respondents, 82 out of 91 Program Directors stated carotid endarterectomy was performed as a part of the residency training program. Among these 82 programs, 7 described neurosurgical involvement in carotid endarterectomy as “rarely” and an additional 7 initiated training in endarterectomy after 1990.
A more extensive survey was initiated in 1995 to determine details of endarterectomy training and identify specific impediments to performing endarterectomy at residency training programs in the United States. A total of 69 responses were obtained. In 58 percent of the programs, one or two faculty members performed endarterectomy, whereas only 16 percent of the training programs had more than three faculty members who trained residents in endarterectomy.
The estimated percentage of endarterectomies done by neurosurgeons compared to other services at training institutions formed a bimodal distribution (Figure 4).In most institutions, training directors estimated 15-20 percent of the total number of cases were performed by neurosurgeons. In about one-third of the training programs, neurosurgeons were estimated to be performing more than 50 percent of the cases at the institution. The case volume for endarterectomy training formed a similar distribution (Figure 5).
Most neurosurgical training programs performed less than 15-20 endarterectomies per year, with a second group of 18 institutions which reported performing more than 35 cases per year. A total of 47 out of 66 programs certified their residents in carotid endarterectomy (in one program neurosurgical residents were certified by vascular surgery). Nearly two-thirds of the respondents described vascular surgery as the primary competition for carotid endarterectomy, with the remaining one-third divided between cardiothoracic and general surgeons.
In most programs, endarterectomy was performed primarily for patients with symptomatic carotid stenosis. Only 40 percent of the respondents described routine endarterectomy for asymptomatic carotid stenosis. This observation may be explained by the frequency of referrals for endarterectomy, which were listed in decreasing order as 1) Neurology/Neurosurgery, 2) Family Practice, and 3) Cardiology. The relationship of neurosurgeons to a non-invasive vascular laboratory apparently played a major role in this referral pattern.
Only 4 percent of training programs had established vascular laboratories under the direction of neurosurgeons (Figure 6). In order of importance, the perceived impediments described for establishment of vascular laboratories included 1) presence of an existing laboratory — 50 percent, 2) cost — 21 percent, 3) time required — 14 percent, and 4) experience — 12 percent.
The conclusions of this survey can be summarized as follows:
- Although most neurosurgical programs teach residents carotid endarterectomy, the overall volume is small and relatively few faculty members perform the operation. Despite low case volumes, about 70 percent of programs certify neurosurgical residents in carotid endarterectomy.
- The main competitors for endarterectomy patients are vascular surgeons.
- Self-referral and referral from neurologists represent the main sources of patients for neurosurgical training programs.
- The majority of cases performed in training programs are for patients with symptomatic stenosis, although this survey preceded the publication of ACAS.
- Few neurosurgical departments maintain vascular diagnostic laboratories. Development of new laboratories is constrained by the presence of existing laboratories, and to a lesser extent by cost and effort. Because of these constraints, training in non-invasive diagnosis may not increase neurosurgical participation in vascular laboratories.
Initiatives
Based on the results of this survey and the recommendations of the first Task Force, the following programs have been developed.
ABNS and Residency Review Committee –Task Force II requested that the Residency Review Committee (RRC):1) enforce existing criteria for endarterectomy in U.S. training programs, and 2) ensure that administrative impediments do not inhibit resident training in endarterectomy. In response, the RRC agreed that:
- The following language will be used in notification letters when carotid endarterectomy training is identified as non-compliant with program requirements: “The committee wishes to call the Program Director’s attention to the requirement that residents must be afforded substantial experience in the management and surgical care of adult and pediatric patients which should include extracranial vascular disease.”
- A letter from the Program Director and hospital CEO is required as an attachment to program information forms stating that the educational experience for neurosurgery residents includes the Task Force opportunity to participate in carotid endarterectomy.
Education for Neurosurgeons–A central component of Task Force activity was the development of educational programs for neurosurgeons in training and in practice. Consequently, the practical courses were presented as follows:
- 1995 and 1996 AANS Annual Meetings
- 1995 and 1996 CNS Annual Meetings
- Allegheny General Hospital in June1 995
- St. Louis in January 1996
A variety of course formats were tried, including cadaver dissection, instruction in vascular non-invasive testing, observation of live procedures in the operating room, and small group case presentations. Experiences from these courses are being used in the current development of a Professional Development Program Course in carotid endarterectomy.
National Meetings Presentations–To increase exposure of all neurosurgeons to this topic, a major effort has been undertaken to include carotid endarterectomy as session topics in plenary sessions of the AANS, CNS, and CV Section Annual Meetings. Following is a list of presentations done thus far:
- Carotid Endarterectomy-CNS 1994
- Maximizing a Cerebrovascular Practice-CNS 1994
- Developing a Stroke Center-CNS 1995
- Carotid Endarterectomy-1996 CV Section Meeting
- Carotid Endarterectomy (Special Course) -AANS 1996
- Patient Selection in Carotid Endarterectomy -CNS 1996
- Technique of Carotid Endarterectomy-CNS 1996
- Outcome Analysis in Carotid Endarterectomy -CNS 1996
- Carotid Endarterectomy -(CV Section)-CNS 1996
Training Standards, Outcomes, and Guidelines–A draft was developed to establish uniform standards in the training of neurosurgeons for endarterectomy. The Task Force considered that training standards beyond current RRC requirements might have a negative impact and be used in adverse credentialing situations. Several guidelines for carotid endarterectomy have been published, but did not incorporate current data for clinical trials and did not reflect neurosurgical consensus for patient management.
TaskForce members are participating in new carotid endarterectomy guidelines through the American Heart Association Stroke Council. Outcome measures specific to carotid endarterectomy were identified as a means by which neurosurgeons could document surgical efficacy in local and national arenas.
Robert Harbaugh, MD, is participating in the New York State Consortium for Evaluation of the Effectiveness of Carotid Endarterectomies. This program (headed by John Popp, MD) may serve as a model for the development of national guidelines and outcome measures related to carotid endarterectomy.The CV Section is developing a similar outcome instrument for carotid endarterectomy. A database has been created that will enable neurosurgeons to quantify details of procedures and pertinent outcomes following surgery. This database will be adapted for use on NEUROSURGERY://ON-CALL®.
Stroke Center Development–Several neurosurgical centers (UCLA, Case Western, Dartmouth) have successfully increased their exposure to stroke patients and the volume of carotid endarterectomies through the establishment of multi-disciplinary stroke centers and implementation of Brain Attack programs.
The methodology of Stroke Center development was described in the AANS Bulletin (August 1995; R. Harbaugh). Materials to facilitate Stroke Center development (National Stroke Association, American Heart Association) were identified for access by interested neurosurgeons.
Education for Non-Neurosurgeons— Dissemination of material concerning stroke and cerebrovascular disease, results of clinical trials in endarterectomy, and current indication for surgery from practicing neurosurgeons to local physicians was identified as a critical component in establishing local referral patterns.
As a consequence, a brochure was developed for neurosurgeons to mail to referring physicians. “Update Carotid Endarterectomy” lists the results of recent trials in carotid endarterectomy and current indications for surgery. The brochure is in its second printing with more than 7,000 sold. In addition, a teaching slide set with a syllabus has been developed for neurosurgeons to use at hospital grand rounds and other public presentations. It describes an overview of the operative technique, results of clinical trials, and indications for surgery.
In addition, several neurosurgeons have become members of an American Heart Association Speaker Bureau, which subsidizes presentations of carotid endarterectomy and stroke prevention at meetings for internists, emergency physicians, family practitioners, etc.
Practice Management–An attempt was made to organize a management plan that would help neurosurgeons include carotid endarterectomy in managed care contracts. However, no action was taken because of the complexity of this project.
Screening for Carotid Disease–Several measures were considered to counteract the diversion of endarterectomy patients to other surgeons through non-neurosurgery vascular laboratories. Therefore, instruction in duplex and Transcranial Doppler Ultrasound (TCD) has been included in endarterectomy practical courses since 1994. Further, several neurosurgeons have been active in the International Committee for the Accreditation of Vascular Laboratories (ICAVL), which determines quality standards for laboratories. In addition, manufacturers were contacted regarding the development of low-cost magnetic resonance angiography (MRA) carotid imaging protocols or a low-cost office Doppler. Unfortunately, there has been little interest to date.
Public Relations–A marketing program was considered to improve public perception of the neurosurgeon’s role in treating carotid artery disease. However, informal consultation with a public relations firm suggested that national media exposure would be very expensive and that more effective measures could be undertaken on a local level. No further action was taken.
Liaisons with Stroke Neurologists— Because stroke neurologists were identified as the primary referral source for neurosurgical endarterectomies, strategies to ensure close relationships with these individuals were promoted. Several stroke neurologists were recruited as adjunct members of the Cerebrovascular Section. Tom Brott, MD, was appointed to the CV Section Executive Committee as an ex-officio member. In addition, Dr. Mayberg was appointed vice-chair of the American Heart Association Stroke Scientific Program. The CV Section Annual Meeting was planned to coincide with the American Heart Association Stroke Meeting to promote attendance and scientific presentation by neurosurgeons at AHA.
Future Considerations
A number of activities remain on the Task Force’s agenda. In the months ahead, some of the projects we hope to address include the following:
Carotid Angioplasty and Stenting— This new technology may potentially have a profound impact on carotid endarterectomies. Several Task Force members are involved in an effort to maintain neurosurgical presence in carotid angioplasty and stenting through initiatives of the Washington Committee and the CV Section. A position paper on carotid angioplasty and stenting was forwarded to HCFA and the FDA, and will be published in Neurosurgery. Neurosurgeons will be encouraged to actively partner with radiologists or cardiologists in angioplasty/stenting IRB protocols at their own institution, and participate in a forthcoming NIH trial.
Assessment of Task Force Efficacy— The Task Force will annually monitor the number of endarterectomies performed each year in neurosurgical training programs (ABNS data) and nationwide (Medicare data).
PDP Course in Carotid Endarterectomy — Using experience from prior courses in endarterectomy, a Professional Development Program course is now under development by Chris Loftus, MD.
Presentation of Task Force Initiatives to Senior Society — The ultimate success of efforts to increase the volume and improve the quality of extracranial vascular surgery by neurosurgeons lies in training a generation of residents who are technically capable and will aggressively seek to establish carotid endarterectomy referrals in practice. This mission should require the full understanding and support of Neurosurgical Program Directors.