Relationship Between Physician and Hospital Procedure Volume and Mortality After Carotid Artery Stenting Among Medicare Beneficiaries

Abstract

Background— Clinical trials demonstrated the efficacy of carotid artery stenting (CAS) relative to carotid endarterectomy when performed by physicians with demonstrated proficiency. It is unclear how CAS performance may be influenced by the diversity in CAS and non-CAS provider volumes in routine clinical practice. Methods and Results— We linked Medicare claims to the Centers for Medicare and Medicaid Services’ CAS Database (2005–2009). We assessed the association between 30-day mortality and past-year physician (0, 1–4, 5–9, 10–19, ≥20) and hospital (<10, 10–19, 20–39, ≥40) CAS volumes and past-year hospital coronary and peripheral stenting volumes (<200, 200–399, 400–849, ≥850) among beneficiaries at least 66 years of age. Unadjusted 30-day mortality risk was 1.8% (95% confidence interval [CI], 1.6–2.0) for 19 724 patients undergoing CAS by 2045 physicians in 729 hospitals. Median past-year CAS volume was 9 (interquartile range, 4–19) for physicians and 23 (interquartile range, 12–41) for hospitals. Compared to physicians performing ≥20 CAS in the past year, lower CAS volumes were associated with higher adjusted risks of 30-day morality (P value for trend < 0.05): 1.4 (95% CI, 0.9–2.3) for 0 past-year CAS, 1.3 (95% CI, 0.9–1.8) for 1 to 4, 1.1 (95% CI, 0.8–1.6) for 5 to 9, and 0.9 (95% CI, 0.7–1.4) for 10 to 19. An inverse relationship between 30-day mortality and past-year CAS hospital volume as well as past-year hospital non-CAS volume, past-year hospital non-CAS volume, and 30-day mortality was also noted. Conclusions— Among Medicare patients, an inverse relationship exists between physician and hospital CAS volumes and hospital non-CAS stenting volume and 30-day mortality, even after adjusting for all pertinent patient- and hospital-level factors.

Supply and Distribution of Vascular Access Physicians in the United States: A Cross-Sectional Study

“…HRRs are a common measure of healthcare markets; their boundaries are based on actual patient utilization, reflecting the geographic extent of healthcare markets for tertiary care (18). They are appropriate for studies of ESKD services because patients with ESKD receive a significant amount of specialized nondialysis care in tertiary care settings (19).…”

Predictors of adverse in-hospital events after carotid endarterectomy

“…Данная закономерность объясняется нередким наличием многососудистого поражения венечного русла с высокими показателями SYNTAX Score и значительным количеством пациентов с высоким функциональным классом стенокардии, что увеличивает риск неблагоприятных событий в 3 раза в общей выборке. Так, ИМ возникает вследствие гемодинамических перестроек, связанных с развитием брадикардии при раздражении каротидного гломуса и блуждающего нерва, восстановления нормального тока крови после коррекции стеноза ВСА, а также искусственной гипертонии для компенсации церебрального кровообращения во время работы с поражен-ной сонной артерией [26]. Поэтому кардиологический статус каждого больного должен обязательно учитываться при выборе хирургической стратегии лечения.…”

Comparative Effectiveness of Carotid Artery Stenting Versus Carotid Endarterectomy Among Medicare Beneficiaries

“…We selected the most experienced physician when >1 physician was listed (9.0% and 2.2% for SVS-VR and CARE CAS procedures, respectively, and 29.7% and 33.7% for SVS-VR and CARE CEA procedures, respectively). We counted procedures performed on Medicare patients and categorized past-year procedural volume as low (<5 CAS/ CEA), medium (CAS: 5-9; CEA: 5-20), or high (CAS ≥10; CEA: ≥21) as guided by the distribution, our previous work, 12,13 as well as SAPPHIRE and CREST volume benchmarks. 3,4 Physician identifiers were missing for 15.7% SVS-VR and 15.8% CARE CAS procedures and 6.0% of SVS-VR and 9.1% of CARE CEA procedures.…”