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Routine Post Transcarotid Artery Revascularization Surveillance Is Not Justified Or Cost Effective
Ali AbuRahma, MD,
Robert Cragon, MD, Zachary AbuRahma, DO, Kory Dees, MD, Suy Sen Hung Fong, MD, Noah Dargy, MD, Christina Veith, DO, Scott Dean, PhD, MBA, Elaine Mattox, RN, Ed.D.
Charleston Area Medical Center, Charleston, WV, USA.
BACKGROUND: Few previous studies reported on the value of post operative TFCAS surveillance. To our knowledge there has been no study analyzing the cost effectiveness of post TCAR surveillance (PTS). Therefore, this study will analyze if routine PTS is cost effective.
METHODS: This is a retrospective analysis of patients who underwent TCAR during eight years in our institution. All patients had an immediate post operative duplex ultrasound (DUS) repeated at 1, 6, and every 12 months. Previously validated carotid DUS criteria were used to define ≥50% and ≥80% in-stent restenosis. Hospital charges for carotid DUS were captured to estimate charges for long-term PTS. The mean number duplex exams were used to calculate cost charge for surveillance. Similar calculations were done using the actual global reimbursement based on presumption of a pair mix consisting of 70% Medicare/Medicaid and 30% other insurance.
RESULT: 301 TCAR patients with mean age of 71 years were analyzed. During a mean follow-up of 30 months (range 0-108) there were a total of 21 patients with >50% in-stent restenosis (7%). Nine of the 21 (3.1%) were associated with >80%, 7 were asymptomatic and 2 were symptomatic (ipsilateral strokes). The rates of freedom from >50% restenosis at 12, 24, and 36 months were 94%, 90%, and 89% while the rate of freedom from >80% restenosis were 97%, 96%, and 95% respectively. (Figure 1) The total number of duplex exams during this period was 938 with a mean duplex exam of 3.12 per patient. Estimated hospital charges for each DUS exam was $1,085 when multiplied by the mean number of duplex exams, multiplied by the number of TCAR procedures totaling $
1,017,730. Meanwhile, the estimated reimbursement for the hospital was $290 per exam for the total reimbursement of $
272,345. Based on the SVS Guidelines recommendation that most of the asymptomatic (>70%-80%) restenosis should be treated medically and do not need reintervention, this surveillance would have detected only two patients associated with >80% restenosis which if underwent reintervention may have prevented potential two strokes at the cost of $1,017,730.
CONCLUSION: PTS is probably not cost effective and should be done selectively.
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