Abstract
During the 1984-1985 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, primarily because of the loss of patient referrals to an aggressive and well trained vascular surgery group.
At the time an effort was begun to establish a neurosurgical cerebrovascular service and to complete more effectively for patients with extracranial cerebrovascular disease. Protocols for assuring rapid neurosurgical evaluation, improving communications with referring physicians, and developing innovative surgical and preoperative management protocols for CEA patients were instituted. Collaboration with medical neurologists in developing a comprehensive care program for patients with ischemic cerebrovascular disease was begun which eventually led to development of a multidisciplinary cerebrovascular disease center.
By use of these strategies the annual number of CEAs performed on our neurosurgery service has increased substantially; from six CEAs done in academic year 1988-1989 to 80 CEAs done in academic year 1993-1994. The number of CEAs will surpass 100 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 to 1989 and outlines strategies I have found effective for re-establishing neurosurgeons in the care of patients with surgically treatable extracranial cerebrovascular disease.
Background
During my residency training at Dartmouth nearly all of the CEAs at our institution were performed by the neurosurgical service. All members of the neurosurgical section performed the operation using general anesthesia, EEG monitoring and selective shunting. In 1984, a new chief of vascular surgery was recruited. As part of his recruitment 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. However, over the next several years two additional vascular surgeons were recruited. Because few vascular laboratories existed in the community hospitals surrounding the medical center, most patients with suspected carotid artery disease were referred to vascular surgery for carotid duplex evaluation. Following this initial contact the vascular surgery section contacted the referring physicians and recruited surgical patients. This resulted in many of our endarterectomy patients being diverted to vascular surgery. Compounding our difficulties, a neurosurgeon here who had a special interest and expertise in cerebrovascular surgery left Dartmouth to go into private practice.
As a result of the events outlined above, by 1989 nearly all of the carotid endarterectomies being done at this institution were being done by the vascular surgeons. During the 1988-89 academic year our section of neurosurgery did only six carotid endarterectomies — 1/10 the number done in the 1984-85 academic year.
Neurosurgical subspecialization and the development of the cerebrovascular surgery program at Dartmouth was begun in March of 1989. One of the primary objectives was to re-establish 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 100 CEAs during this academic year. In reviewing my experience over the last six 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 CEA 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 academic 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 – Section I
The following suggestions can be instituted by any neurosurgical practitioner or group.
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 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 a neurologist who will subsequently refer surgical patients to us will see these patients expeditiously, that is ideal. If not, we should evaluate them ourselves. If the vascular surgeon can evaluate and treat a patient before that same patient could get a neurology clinic appointment the patient will usually go to vascular surgery even if their evaluation lacks neurological sophistication. Initially one will see only patients with symptomatic carotid artery disease but if we do well with them the asymptomatic patients will follow.
Communications
Many referring doctors 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 carotid endarterectomy is a part of my practice and that I would welcome such referrals. They are often surprised, and pleased, to have an alternative 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 than our competitors 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 the vascular surgeons. Being as good is not good enough. I think it is unlikely that we can significantly improve on the overall outcome of patients treated by well-trained vascular surgeons, 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 on their first postoperative day. I have also used a transverse incision for all but the highest carotid bifurcations because of better cosmetic results. 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.
If insurers note that our operating room time is half that of the competitors or that our patients go home a day or two earlier or that they don’t require invasive monitoring postoperatively they will direct patients to us if our outcomes are good. 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 or 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 Surgery (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.
Suggestions – Section II
The following suggestions will require collaboration with other physicians and might be more appropriate for larger neurosurgical groups or for neurosurgeons in an academic medical center setting.
Subspecialization
For neurosurgeons practicing in larger groups or in an academic medical center it is imperative that one or two surgeons subspecialize 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 subspecializing, the vascular neurosurgeon will increase his 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 code collaboration with well-trained neurologists who have a special interest in cerebrovascular disease. Optimally, this collaboration can be used to establish stroke units and cerebrovascular disease centers that are directed by medical neurologists and neurosurgeons. In this setting a vascular laboratory outside the control of vascular surgeon is feasible. Again, 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 and 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 being “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 reference source for the medical community regarding cerebrovascular disease. We need to know the CEA literature better than the vascular surgeons and we need to be willing to share this knowledge with the medical community. I have put in many hours and many miles delivering continuing medical education 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 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 angiography and/or three dimensional 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 our vascular surgery colleagues by controlling the vascular laboratories will disappear.
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 increased considerably. 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.