September 14, 2004 – A recent study led by a University of Alberta researcher indicates that a significant proportion of stroke prevention surgeries performed each year are unnecessary.
Dr. Thomas Feasby and a panel of surgeons, radiologists and stroke experts reviewed 3,167 carotid endarterectomies performed in Western Canada over a span of two years. The surgery involves cutting open the carotid artery in the neck to scrape the plaque inside. Plaque build-up causes the artery to narrow and can ultimately block the blood flow to the brain or cause a blood clot to form, causing stroke in both cases.
Feasby explained that four to five per cent of these surgeries result in complications including death or stroke. But those who don’t suffer complications experience an average hospital stay of two days and minimal pain. Patients are able to resume all of their normal activities within weeks, he added.
The study results indicated that 52 per cent of procedures were considered appropriate, 10 per cent were unnecessary and the remainder of the cases was uncertain.
But rather than rely on clinical tests, Feasby's team examined procedures that had been done outside of an ideal, controlled setting.
"What we wanted to see was what happens in the real world," he added.
The study results could help doctors free up resources, said Feasby.
"There's demand for this procedure, so there are waiting lists and we have an access issue as we do for many procedures in Canada," he said. "We'd do 10 per cent more appropriate cases by eliminating the inappropriate. That would have a number of beneficial effects. We'd improve the quality of our overall procedure, because we'd be doing more appropriate cases than inappropriate. We'd reduce the waiting lists by improving access, and that's a major issue in Canada."
In order to ensure that inappropriate stroke-prevention surgeries don't continue to needlessly put patients at risk and tie up resources, Feasby thinks "cockpit management" could do the trick. Just as a pilot must go through a checklist before take-off, a surgeon could be required to complete a checklist before a procedure. After all, well-intentioned doctors struggle to keep track of cutting-edge research.
"I think most doctors want to do the right thing for their patients--almost all do. I think most people would accept that. The problem is that they don't always know what the best thing to do is. There's plenty of evidence out there in many areas, but it's hard for the average practitioner to be aware of all the evidence and to be up to date completely—there's a big problem translating that evidence into practice," Feasby explained, noting that thousands of papers are published each year.
He added that a checklist might be seen by doctors as bureaucratic initially, but that it would also prevent doctors from bowing to pressure from patients to have procedures they don't need.
Outside of a checklist, a feedback system might also help doctors cut down on unnecessary surgeries. He cites the work done by U of A neurosurgeon Dr. Max Findlay as one excellent strategy. Findlay studied neurosurgeries being performed at the university, and discovered that 18 per cent were inappropriate. After giving feedback to surgeons, the rate was zero per cent after four cycles.
Feasby stressed that unnecessary procedures may be performed in other areas of the health care system also.
"Perhaps not just surgery, perhaps in diagnostic tests. For instance, you could consider MRI scanning. Big waiting lists--are they all appropriate? Probably not," he said.
"I think we just happened to study one that was of interest to us, and in a sense convenient for us, but there are many, many other potential targets. Maybe some are better, some are worse--we don't know. I don't think it should be looked at in isolation."
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