Optimal resources for carotid endarterectomy.

This review compares the results and costs of carotid endarterectomy (CE) done by a single surgeon over a 1-year period working at both a university hospital (UH) and a community hospital (CH). Hospital and financial records of 157 patients were reviewed, 78 at UH and 79 at CH. The patient populations were matched for age, associated illnesses, and presenting symptoms. The principles of patient management were identical at both hospitals except that shunting requirements were determined by electroencephalographic monitoring at UH. There were no differences in the complication rates, and the combined stroke/mortality rate was 0.6%. The cost of CE was 56% greater on a per patient basis at UH ($3918 versus $6126, p less than 0.001) and 23% greater on a per diem basis at UH ($611 versus $755, p less than 0.001). Patients stayed longer at UH (8.2 days versus 6.6 days at CH, p less than 0.03). These differences are largely explained by three types of delays at UH. First, patients with cardiovascular accidents at UH were kept in the hospital before surgery until maximum improvement occurred whereas patients at CH were allowed to convalesce at home before CE. Patients operated on after a cardiovascular accident spent an average of 17.6 days in UH while a similar group spent only 7.3 days in hospital at CH (p less than 0.03). Second, delays in obtaining angiograms of greater than 2 hospital days occurred in 28% of patients at UH compared with only 10% at CH (p less than 0.05). Third, delays in scheduling operating room time of greater than 2 hospital days occurred in 17% of patients at UH and in only 7% of patients at CH (p less than 0.05). When there were no delays, the cost of treating patients at each hospital was identical, $3483 at CH and $3520 at UH. UH must accept the fact that equally good results can be obtained at CH, and although the potential exists for equal costs at both types of hospitals, the CH provides the service at a lower cost. UH administrators must address these inefficiences if the UH is to compete effectively in the current marketplace.