Hospital Referral Guidelines

Michigan Health and Safety Coalition Hospital Referral Guideline for Carotid Endarterectomy Surgery*

• In collaboration with the Michigan Vascular Society, all Michigan surgeons and hospitals performing carotid endarterectomy surgery should collect risk-adjusted morbidity and mortality data and should participate in audits of data quality and accuracy as required. (See Appendix A for a list of codes.)

• All Michigan surgeons performing carotid endarterectomy surgery should work with the Michigan Vascular Society to actively participate in designing and implementing a process improvement strategy that uses data. Active participation includes:

1. attending regularly scheduled meetings and developing processes by which data will be collected and data quality will be ensured;
2. convening a panel of vascular surgery experts who will develop hospital referral guidelines related to management of carotid disease that addresses endovascular techniques including carotid angioplasty and carotid stenting;
3. reviewing, analyzing, using and refining the vascular data;
4. examining and validating the relationship between health outcomes and carotid endarterectomy volume and between health outcomes and use of carotid angioplasty and carotid stenting techniques to manage carotid artery occlusive disease;
5. identifying risk-adjusted morbidity and mortality indicators that reflect differences in quality of care;
6. sharing information across surgical programs and learning from successful programs perhaps using the Northern New England Cardiovascular model of rounding by inter-hospital teams to identify best practices;
7. developing, implementing, evaluating, and periodically updating measurable evidence-based quality of care indicators, hospital and physician-specific standards and guidelines, best practices and clinical protocols;
8. evaluating hospital and physician-specific performance relative to agreed upon standards and guidelines;
9. educating physicians and hospitals about quality of care indicators, standards, guidelines, protocols and best practices as well as their hospital-specific patient outcomes;
10. sharing data and disseminating hospital and physician-specific performance information with physicians, hospitals, purchasers, consumers, and others in an appropriate manner that communicates the quality of Michigan vascular surgery programs and reassures purchasers and payers; and
11. identifying innovative models to cover the costs of data collection, analysis and use.

• Hospitals should collect additional quality of care indicator data such as total volume of carotid endarterectomy operations and interventions performed by each physician to treat carotid artery occlusive disease (include endarterectomies, angioplasties, and stents), as well as ancillary staff experience and competence measures.

• Only hospitals with annual volumes of at least 50 should perform carotid endarterectomy surgeries.

• Hospitals should require that their medical staff implement appropriateness criteria and use the criteria to conduct clinical case review of carotid endarterectomy surgeries

Future direction of Coalition work related to the Carotid Endarterectomy Surgery Guideline

The guideline should be reviewed and updated no later than December 31, 2003.

* This is meant to be a guideline and not a standard of care; this guideline represents the best of an evidence-based review at this time; the guideline is based on the principles of CQI and is not intended to be used in a punitive manner; this guideline needs to be taken as a whole, and not have selected parts be used without considering the entire content of the guideline.