Better Clinical Care Contributing to Fewer Carotid Surgeries

Megan Brooks

September 21, 2017

NEW HAVEN, CT — Improvements in the prevention and clinical management of patients at risk for carotid disease have contributed to a decline in carotid revascularization procedures, according to a nationwide study that reviewed 16 years of Medicare beneficiary data[1]. The data also show improvement in outcomes of revascularization surgery.

"The results were not surprising and confirm what we suspected," Dr Judith Lichtman (Yale School of Public Health, New Haven, CT), told | Medscape Cardiology.

Lichtman said there are two trends that should be considered "good news."

First, the overall decline in revascularization procedures indicates the success of risk-factor prevention efforts for cardiovascular disease and stroke—in large part due to improvements in the management of blood pressure, cholesterol, and smoking—thereby reducing the population needing the procedures, Lichtman explained.

Second, "despite the lower hospital volume for the procedures, the outcomes are getting better for patients, suggesting improvements in the clinical management of patients undergoing the procedures," Lichtman added.

The study was published in the September 19, 2017 issue of the Journal of the American Medical Association.

The researchers analyzed US national trends in performance and outcomes of carotid endarterectomy and carotid artery stenting among Medicare beneficiaries from 1999 to 2014.

During the study period, 937,111 patients underwent carotid endarterectomy (mean age 75.8 years; 43% women) and 231,077 underwent carotid artery stenting (mean age 75.4 years; 49% women).

Carotid endarterectomy rates declined annually from 1999 to 2014, whereas carotid stenting rates increased from 1999 to 2006 and then declined thereafter.

In 1999, 81,306 patients underwent carotid endarterectomy. In 2014, that number had fallen to 36,325. National endarterectomy rates per 100,000 beneficiary-years fell from 298 in 1999–2000 to 128 in 2013–2014 (P<0.001).

The number of patients who underwent carotid artery stenting ranged from 10,416 in 1999 to 22,865 in 2006 (an increase per 100,000 beneficiary-years from 40 in 1999–2000 to 75 in 2005–2006 (P<0.001). But by 2014, there were 10,208 patients who underwent stenting and the rate decreased to 38 per 100,000 beneficiary-years (P<0.001).

Periprocedural and 1-year outcomes improved from 1999 to 2014.

"Despite lower hospital procedure volume over time, there were annual improvements in mortality and ischemic stroke outcomes for both procedures after accounting for demographic characteristics, comorbidities, and symptomatic status," the researchers note in their article.

Specifically, the data show a 2.90% (95% CI 2.63%–3.18%) adjusted annual decrease in 30-day ischemic stroke or death in patients who underwent carotid endarterectomy and a 1.13% (95% CI 0.71%–1.54%) decrease in those who had stenting.

An absolute decrease from 1999 to 2014 was observed for endarterectomy (1.4%; 95% CI 1.2%–1.5%) but not for stenting (−0.1%; 95% CI −0.5% to 0.4%).

There was a 2.17% (95% CI 2.00%–2.34%) adjusted annual decrease in the rate of 1-year ischemic stroke after endarterectomy and a 1.86% (95% CI 1.45%–2.26%) after stenting. The corresponding absolute decreases were 3.5% (95% CI 3.2%–3.7%) and 1.6% (95% CI 1.2%–2.1%), respectively.

Additional improvements were noted for in-hospital mortality, 30-day stroke, MI, death, and 30-day all-cause mortality as well as within demographic subgroups. Reductions in adverse outcomes were observed for both sexes and within most age and race subgroups, the researchers say.

The study was funded by the National Institute for Neurological Disorders and Stroke and the National Heart, Lung, and Blood Institute. Lichtman has no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

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