Cull David L, Cole Terry, Miller Blair, Johnson Brent, Rawlinson Dustin, Walker Eric, Taylor Spence M
Greenville Hospital System-University Medical Center, University of South Carolina School of Medicine- Greenville Campus, Greenville, SC 29605, USA.
Ann Vasc Surg. 2011 Oct;25(7):887-94. doi: 10.1016/j.avsg.2011.05.021. Epub 2011 Aug 11.
Although duplex ultrasonography (DU) can readily identify progression of carotid stenosis, controversy regarding the natural history of asymptomatic carotid stenosis as well as the need and appropriate interval for carotid DU surveillance still exists. Furthermore, consensus has not yet been made in the surgical literature regarding the usefulness, cost-effectiveness, or timing of DU surveillance after carotid endarterectomy (CEA). The purpose of this study was to determine how often DU surveillance for asymptomatic carotid disease or postintervention stenosis resulted in any change in the patient's clinical management, how many strokes were prevented by DU surveillance, and the cost of such a DU surveillance program per stroke prevented.
We reviewed a 9-year vascular surgical database to identify all patients enrolled in a carotid DU surveillance program for asymptomatic carotid stenosis or following CEA between January 1, 2000, and December 31, 2008. The number of duplex scans and CEAs performed in those patients through March 2010 was also determined. The results of the Asymptomatic Carotid Atherosclerosis Study were then used to estimate the number of strokes prevented by CEA in the study population. Reimbursement data were assessed to calculate the average cost of each DU and the cost of the DU surveillance program for each stroke prevented.
During the study period, there were 11,531 carotid duplex scans performed on 3,003 patients (mean: 3.84 scans per patient) who had been enrolled in the DU surveillance program. CEA for asymptomatic carotid stenosis was performed on 225 (7.5%) patients. The DU surveillance program prevented approximately 13 strokes (871 carotid duplex scans per stroke prevented). The mean cost of each duplex scan was $332 ± 170. The total cost of the DU surveillance program was approximately $3,830,000 or $290,000 per stroke prevented.
Although a carotid DU surveillance program generates substantial revenue for a vascular surgery practice, it is costly and inefficient. A reappraisal of the "value" of carotid DU surveillance in stroke prevention is warranted. Consideration should be given to eliminating routine surveillance of postendarterectomy carotids in the absence of contralateral disease and limiting the number of DU surveillance studies for asymptomatic carotid disease.
尽管双功超声检查（DU）能够轻易识别颈动脉狭窄的进展情况，但对于无症状性颈动脉狭窄的自然病程以及颈动脉DU监测的必要性和合适间隔仍存在争议。此外，在外科手术文献中，对于颈动脉内膜切除术（CEA）后DU监测的有效性、成本效益或时机尚未达成共识。本研究的目的是确定对无症状性颈动脉疾病或干预后狭窄进行DU监测导致患者临床管理发生改变的频率、DU监测预防了多少中风以及每预防一次中风的此类DU监测计划的成本。
我们回顾了一个9年的血管外科数据库，以识别2000年1月1日至2008年12月31日期间参加颈动脉DU监测计划的所有无症状性颈动脉狭窄患者或CEA术后患者。还确定了这些患者截至2010年3月进行的双功扫描和CEA的数量。然后使用无症状性颈动脉粥样硬化研究的结果来估计研究人群中CEA预防的中风数量。评估报销数据以计算每次DU的平均成本以及预防每一次中风的DU监测计划的成本。
在研究期间，对参加DU监测计划的3003例患者进行了11531次颈动脉双功扫描（平均：每位患者3.84次扫描）。对225例（7.5%）无症状性颈动脉狭窄患者进行了CEA。DU监测计划预防了约13次中风（每预防一次中风需要进行871次颈动脉双功扫描）。每次双功扫描的平均成本为332美元±170美元。DU监测计划的总成本约为3830000美元，或每预防一次中风290000美元。
尽管颈动脉DU监测计划为血管外科实践带来了可观的收入，但成本高昂且效率低下。有必要重新评估颈动脉DU监测在预防中风方面的“价值”。应考虑在无对侧疾病的情况下取消对动脉内膜切除术后颈动脉的常规监测，并限制对无症状性颈动脉疾病的DU监测研究数量。
