Surgeon Case Volume and 30-Day Mortality After Carotid Endarterectomy for Medicare Beneficiaries | Journal Scan

Mar 31, 2015
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Authors:
Kumamaru H, Jalbert JJ, Nguyen LL, et al.
Citation:
Surgeon Case Volume and 30-Day Mortality After Carotid Endarterectomy Among Contemporary Medicare Beneficiaries: Before and After National Coverage Determination for Carotid Artery Stenting. Stroke 2015;Mar 19:[Epub ahead of print].
Summary By:
Prashant Vaishnava, MD, FACC

Study Questions:

Since the 2005 National Coverage Determination to reimburse carotid artery stenting (CAS) for Medicare beneficiaries, what are trends in surgeons’ past-year carotid endarterectomy (CEA) case-volume and 30-day mortality after CEA?

Methods:

This was a retrospective analysis of patients undergoing inpatient CEA between 2001 and 2008 or inpatient CAS between 2005 and 2008. The outcome was all-cause mortality in the 30 days after CEA.

Results:

The sample included 454,717 patients and 8,648 performing surgeons for CEA; 27,943 patients underwent CAS during 2005 to 2008. There were a total of 5,758 deaths within 30 days of the CEA procedures (30-day mortality, 1.27%; 95% confidence interval [CI], 1.23-1.30). The unadjusted 30-day post-CEA mortality decreased from 1.40% in 2001 to 2002, to 1.17% in 2007 to 2008; median past-year case volume of performing surgeon also declined from 27 to 21. Surgeon’s past-year case-volume of <10 was associated with a higher 30-day mortality consistently during 2001 to 2008. Rates of CAS peaked at 2.3 per 10,000 beneficiaries in 2006, declining to 1.8 in 2008.

Conclusions:

From 2001 to 2008, the rate of CEA procedures has declined. The decrease in past-year case volumes of performing surgeons has also declined with a past-year case volume of <10 associated with higher 30-day mortality.

Perspective:

This is an important study that draws attention to the declining (and expected) rate of CEA since the National Coverage Determination for CAS. This decline may be associated with decreasing past-year case volume for past surgeon. That said, mortality following CEA declined over time. As the authors suggested, this may indicate that higher-risk patients were channeled toward CAS. The impact of lower surgeon case volume for a less frequently performed surgery cannot be discounted.

Keywords: Carotid Artery, Common, Carotid Stenosis, Endarterectomy, Carotid, Inpatients, Medicare, Mortality, Outcome Assessment, Health Care, Retrospective Studies, Stents, Surgeons, Cardiac Surgical Procedures


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