Carotid Endarterectomy Among Medicare Beneficiaries

Abstract

Background and Purpose-We sought to examine the appropriateness and the surgical outcomes of carotid endarterectomy (CE) in unselected community hospitals to identify opportunities for improvement. Methods-We performed a retrospective review of all CEs performed on Medicare beneficiaries in Georgia in 1993 (nϭ1945). Conclusions regarding appropriateness were based on current guidelines as interpreted by a physician reviewer and were supported by the aggregate results of structured, blinded overreading by clinicians with relevant expertise. Adverse outcomes were confirmed and rated as to severity by a physician. Outcomes were correlated with demography, vascular anatomic findings, comorbidity, surgical techniques, and hospital characteristics. Results-The majority of the patients (51%) were asymptomatic at presentation. CEs were performed appropriately in 96.1% of the cases in accordance with current guidelines. There was no significant difference in the rate of appropriateness between the symptomatic (96%) and the asymptomatic patients (96.4%). Survival without stroke or myocardial infarction (MI) was 94.3%. The 30-day mortality was 1.9%; moderate to severe strokes occurred in 1.8%, stroke-related death in 0.7%, MI in 1.1%, and MI-related death in 0.5%. Those hospitals performing Ͻ10 CEs in the observed year had a statistically significant higher morbidity and mortality as well as an increase in less severe complications such as hematomas, wound dehiscence, wound infection, and pneumonia than did hospitals with higher volume of CEs.. Older patients and women had statistically significantly higher morbidity and mortality. Patients with a Charlson Severity Index score of Ն1 had a risk for adverse outcomes 3.4 times higher than patients with a score of 0 after adjustment for age and sex. Conclusions-The great majority of CEs performed in Georgia on Medicare patients were appropriate, according to current guidelines. Slightly more than half of the patients were asymptomatic as defined in the Asymptomatic Carotid Atherosclerosis Study. In hospitals performing ϽCEs in the index year, we noted higher morbidity and mortality, as well as an increase in less severe complications. This relationship between the volume of surgery and outcome was confirmed in the analysis of the 30-day mortality for all Medicare cases (nϭ10 569) performed in Georgia from 1991 to 1995. This was the most important opportunity for improvement identified in this study. In view of the increased use of CE, it is important to continue to monitor the patterns of practice for this procedure to improve outcomes. (Stroke. 1998;29:46-52.)

Risk factors associated with major cerebrovascular complications after intracranial stenting

“…Interventionalists at high enrollment sites likely performed more intracranial angioplasty and stenting procedures before enrollment in the registry than interventionalists at low enrollment sites. A similar procedural learning curve has previously been demonstrated to influence clinical outcomes in carotid endarterectomy [22][23][24] and carotid stenting 25,26 with a decrease in periprocedural complications associated with more procedural experience. If this learning curve is not achieved with stenting for intracranial arterial stenosis, the high rate of periprocedural complications may outweigh any potential benefit of stenting.…”

A Systematic Review of the Associations between Age and Sex and the Operative Risks of Carotid Endarterectomy

“…Of these, 7 papers reported risks in older patients but did not compare their results to younger patients in the same centre(s) and were therefore excluded. Among the 62 remaining eligible papers [35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97], there were no differences in the associations between either age or sex and overall 30-day stroke rate, death rate or combined stroke and death rate between studies reporting the associations as their primary aim and those which reported them as a subanalysis along with other risk factors (fig. 1, 2) and so data from both types of study are combined in the analyses below.…”

Common Reasons That Asymptomatic Patients Who Are 65 Years and Older Receive Carotid Imaging

“…3,11 Although the evidence in support of efficacy of carotid revascularization to reduce recurrent cerebrovascular events among patients with symptomatic carotid disease is strong, the majority of revascularization procedures are performed in patients with asymptomatic carotid artery disease, in whom the evidence for clinical benefit is more modest and long-term outcomes are of paramount importance. 3,12,13 Therefore, ensuring that patients selected for revascularization will live long enough to benefit is critical, and improving patient selection for carotid imaging will ultimately improve the selection of revascularization recipients.…”