Carotid artery stenting for asymptomatic stenosis is associated with decreased 30-day readmission at very high volume centers

Endovascular carotid artery stenting (CAS) is a common treatment for carotid artery stenosis and stroke prevention. Previous studies have shown that high procedural volume centers are associated with improved patient outcomes. Unplanned 30-day readmissions, which are associated with significant expenses, are increasingly used as a metric of patient outcome. Despite prior studies evaluating associations between procedural volume and multiple outcomes, the association between very high CAS volume and short-term (30-day) readmission has not yet been evaluated in a large multicenter study. The National Readmissions Database (NRD) was analyzed retrospectively from 2010 to 2015 to evaluate the association between hospital procedural volume and patient outcomes in asymptomatic and symptomatic CAS patients. Very high volume centers (VHVC) were defined as the top 10% hospitals in terms of procedural volume, performing >= 79 procedures a year. Univariate and multivariate analyses of patient and hospital characteristics evaluated associations with short-term (30-day) readmissions (SR), long-term (90-day) readmissions (LR), index mortality, discharge disposition, major complications, and neurological complications. A total of 36,128 asymptomatic patients and 8,390 symptomatic patients who underwent CAS were identified. Asymptomatic CAS patients treated at VHVCs were associated with decreased likelihood of SR (OR 0.88, 95% CI 0.80-0.95, p = 0.003) and LR (OR 0.91, 95% CI 0.85-0.99, p = 0.037) compared to asymptomatic patients at non-VHVCs. There was no significant difference in SR or LR between symptomatic CAS patients treated at a VHVC vs. non-VHVC. Our findings provide additional evidence to support the role of experience in improved CAS treatment outcomes.

The Relationship Between Carotid Revascularization Procedural Volume and Perioperative Outcomes in Australia and New Zealand

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) prevent stroke in selected patients. However, each intervention carries a risk of perioperative complications including stroke or death (S/D). We aimed to determine the relationship between operator volume, hospital volume, and the perioperative risk of S/D in carotid revascularization in Australia and New Zealand. Retrospective analysis was performed on prospectively collected data extracted from the Australasian Vascular Audit between 2010 and 2017. Annual caseload volume was analyzed in quintiles (Q) using multivariate regression to assess its impact on perioperative S/D. Carotid endarterectomy procedures (n = 16 765) demonstrated higher S/D rates for lower-volume operators (2.21% for Q1-Q3 [1-17 annual cases] vs 1.76% for Q4-Q5 [18-61 annual cases]; odds ratio [OR]: 1.28; 95% CI: 1.001-1.64; P = .049). Carotid artery stenting procedures (n = 1350) also demonstrated higher S/D rates for lower-volume operators (2.63% for Q1-Q3 [1-11 annual cases] vs 0.37% for Q4-Q5 [12-31 annual cases]; OR: 6.11; 95% CI: 1.27-29.33; P = .024). No significant hospital volume-outcome effect was observed for either procedure. An inverse relationship was demonstrated between operator volume and perioperative S/D rates following CEA and CAS. Consideration of minimum operator thresholds, restructuring of services and networked referral pathways of care in Australia and New Zealand, would likely result in improved patient outcomes.

Risk factors associated with 30-day hospital readmission after carotid endarterectomy

OBJECTIVE

The current study evaluated all-cause 30-day readmissions after carotid endarterectomy.

METHODS

Patients undergoing carotid endarterectomy were selected from the Cerner Health Facts® database using ICD-9-CM procedure codes from their index admission. Readmission within 30 days of discharge was determined. Chi-square analysis determined characteristics of the index admission (demographics, diagnoses, postoperative medications, and laboratory results) associated with readmission. Multivariate logistic regression models were used to identify characteristics independently associated with readmission.

RESULTS

In total, 5257 patients undergoing elective carotid endarterectomy were identified. Readmission within 30 days was 3.1%. After multivariable adjustment, readmission was associated with end-stage renal disease (OR: 3.21, 95% CI: 1.01-10.2), hemorrhage or hematoma (OR: 2.34, 95% CI: 1.15-4.77), procedural complications (OR: 3.07, 95% CI: 1.24-7.57), use of bronchodilators (OR: 1.48, 95% CI: 1.03-2.11), increased Charlson index scores (OR: 1.22, 95% CI: 1.08-1.38), and electrolyte abnormalities (hyponatremia < 135 mEq/L (OR: 1.69, 95% CI: 1.07-2.67) and hypokalemia less than 3.7 mEq/L (OR: 2.26, 95% CI: 1.03-4.98)).

CONCLUSIONS

Factors associated with readmission following carotid endarterectomy included younger age, increased comorbidity burden, end-stage renal disease, electrolyte disorders, the use of bronchodilators, and complications including bleeding (hemorrhage or hematoma). Of note, in this real-world study, only 40% of the patients received protamine, despite evidence-based literature demonstrating the reduced risk of bleeding complications. As healthcare moves towards quality of care-driven reimbursement, physician modifiable targets such as protamine utilization to reduce bleeding are greatly needed to reduce readmission, and failure to reduce preventable physician-driven complications after carotid interventions may be associated with decreased reimbursement.

Impact of hospital volume on long-term neurological outcome in patients undergoing carotid artery stenting

BACKGROUND

The impact of hospital volume on long-term outcome after carotid artery stenting (CAS) remains unknown.

OBJECTIVES

We designed a nationwide cohort study to elucidate the impact of hospital volume on the incidence of stroke after CAS.

METHODS

The Taiwan National Health Insurance Research database was used to identify all patients admitted for CAS from 2008 to 2012. We defined high-volume hospitals as those performing more than 20 CAS per year. The primary outcome was new ischemic stroke after discharging from the index CAS. Propensity score-matching was performed to create two matched groups for comparison.

RESULTS

A total of 3,248 patients underwent 3,576 CAS procedures were enrolled. There were 56 hospitals performing CAS during the study period. Among these 3,248 patients, 2,226 (68.5%) were performed in high-volume hospitals. A propensity score-matching created two groups with 1,000 patients in each group. During a median of 2.06 years follow-up, 35 (3.5%) and 52 (5.2%) patients in high-volume hospitals and low-volume hospitals developed new ischemic stroke 30 days after discharging from the index CAS, respectively (for low-volume hospitals, HR 1.50, 95%CI 1.06-2.12, P = 0.023). The use of embolic protection device did not result in different periprocedural or postdischarge strokes. The periprocedural (within 30 days after CAS) ischemic stroke or all-cause mortality rates during follow-up period were similar between two groups.

CONCLUSIONS

CAS performed in high-volume hospitals was associated with less new ischemic stroke after discharging from the index CAS, compared to those in low-volume hospitals. © 2017 Wiley Periodicals, Inc.

Clinical Outcome of Carotid Artery Stenting According to Provider Specialty and Volume

BACKGROUND

Several studies have demonstrated better outcomes for carotid endarterectomy with high-volume hospitals and providers. However, only a few studies have reported on the impact of operator specialty/volume on the perioperative outcome of carotid artery stenting (CAS). This study will analyze the correlation of CAS outcomes and provider specialty and volume.

METHODS

Prospectively collected data of CAS procedures done at our institution during a 10-year period were analyzed. Major adverse events (MAEs; 30-day stroke, myocardial infarction, and death) were compared according to provider specialty (vascular surgeons [VSs], interventional cardiologists [ICs], interventional radiologists [IRs], interventional vascular medicine [IVM]), and volume (≥5 CAS/year vs. <5 CAS/year).

RESULTS

Four hundred fourteen CAS procedures (44% for symptomatic indications) were analyzed. Demographics/clinical characteristics were somewhat similar between specialties. MAE rates were not significantly different between various specialties: 3.1% for IC, 6.3% for VS, 7.1% for IR, 6.7% for IVM (P = 0.3121; 6.3% for VS and 3.8% for others combined, P = 0.2469). When physicians with <5 CAS/year were excluded: the MAE rates were 3.1% for IC, 4.7% for VS, and 6.7% for IVM (P = 0.5633). When VS alone were compared with others, and physicians with <5 CAS/year were excluded, the MAE rates were 4.7% for VS vs. 3.6% for non-VS (P = 0.5958). The MAE rates for low-volume providers, regardless of their specialty, were 9.5% vs. 4% for high-volume providers (P = 0.1002). Logistic regression analysis showed that the odds ratio of MAE was 0.4 (0.15-1.1, P = 0.0674) for high-volume providers, while the odds ratio for VS was 1.3 (0.45-3.954, P = 0.5969).

CONCLUSIONS

Perioperative MAE rates for CAS were similar between various providers, regardless of specialties, particularly for vascular surgeons with similar volume to nonvascular surgeons. Low-volume providers had higher MAE rates.

Significant Association of Annual Hospital Volume With the Risk of Inhospital Stroke or Death Following Carotid Endarterectomy but Likely Not After Carotid Stenting

Background—

Associations between hospital volume and the risk of stroke or death following carotid endarterectomy (CEA) and carotid artery stenting (CAS) on a national level in Germany were analyzed.

Methods and Results—

Secondary data analysis using microdata from the nationwide statutory German quality assurance database on all surgical or endovascular carotid interventions on the extracranial carotid artery between 2009 and 2014. Hospitals were categorized into empirically determined quintiles according to the annual case volume. The resulting volume thresholds were 10, 25, 46, and 79 for CEA and 2, 6, 12, and 26 for CAS procedures. The primary outcome was any stroke or death before hospital discharge. For risk-adjusted analyses, a multilevel regression model was applied. The analysis included 161 448 CEA and 17 575 CAS procedures. In CEA patients, the crude risk of stroke or death decreased monotonically from 4.2% (95% confidence interval, 3.6%–4.9%) in low-volume hospitals (first quintile 1–10 CEA per year) to 2.1% (2.0%–2.2%) in hospitals providing ≥80 CEA per year (fifth quintile; P <0.001 for trend). The overall risk of any stroke or death in CAS patients was 3.7% (3.5%–4.0%), but no trend on annual volume was seen ( P =0.304). Risk-adjusted analyses confirmed a significant inverse relationship between hospital volume (categorized or continuous) and the risk of stroke or death after CEA but not CAS procedures.

Conclusions—

An inverse volume–outcome relationship in CEA-treated patients was demonstrated. No significant association between hospital volume and the risk of stroke or death was found for CAS.

Transradial Versus Transfemoral Carotid Artery Stenting: A 16-Year Single-Center Experience

AIMS

Limited data exist on radial access in carotid artery stenting (CAS). This single-center study was performed to compare the outcome and complication rates of transradial (TR) and transfemoral (TF) CAS.

METHODS AND RESULTS

The clinical and angiographic data of 775 consecutive patients with high risk for carotid endarterectomy, treated between 1999 and 2016 by CAS with cerebral protection, were evaluated. Patients were divided into 2 groups according to vascular access: TR (n = 101; 13%) and TF (n = 674). Primary combined end-point: in-hospital major adverse cardiac and cerebral events. Secondary end-points: angiographic outcome of the procedure and crossover rate to another puncture site. Angiographic success was achieved in all 775 patients, the crossover rate was 4.9% in the TR and 0% in the TF group (P < 0.05). TR was performed at the right side in 97% of cases. The incidence of in-hospital major adverse cardiac and cerebral events was 2% in the TR and 3.6% in the TF group (P = ns).

CONCLUSIONS

The TR approach for CAS is safe and efficacious, with acceptable cross-over rate. In both groups, vascular complications rarely occurred.

Volume-outcome relationship for peripheral endovascular interventions: a review of existing literature

The incidence and prevalence of peripheral vascular disease has been increasing. When coexistent with coronary artery disease (CAD), it has shown to predict higher mortality along with poorer quality-of-life consequently leading to a marked increase in healthcare costs. Broadly, there has been an increase in utilization of endovascular techniques in the management of peripheral vascular diseases. An inverse relation between volume and outcomes has been noted in these procedures. Additionally, improved resource utilization has also been noted with higher hospital and operator volumes. This has led to proposals to regionalize these procedures to high volume hospitals. There have also been calls to introduce the idea of having a set threshold of procedures for providers. This review presents an overview of published literature on the volume-outcome relationship affecting the outcomes of peripheral endovascular procedures.

Association between hospital case volume and mortality in non-elderly pneumonia patients stratified by severity: a retrospective cohort study

Background

The characteristics and aetiology of pneumonia in the non-elderly population is distinct from that in the elderly population. While a few studies have reported an inverse association between hospital case volume and clinical outcome in elderly pneumonia patients, the evidence is lacking in a younger population. In addition, the relationship between volume and outcome may be different in severe pneumonia cases than in mild cases. In this context, we tested two hypotheses: 1) non-elderly pneumonia patients treated at hospitals with larger case volume have better clinical outcome compared with those treated at lower case volume hospitals; 2) the volume-outcome relationship differs by the severity of the pneumonia.

Methods

We conducted the study using the Japanese Diagnosis Procedure Combination database. Patients aged 18–64 years discharged from the participating hospitals between July to December 2010 were included. The hospitals were categorized into four groups (very-low, low, medium, high) based on volume quartiles. The association between hospital case volume and in-hospital mortality was evaluated using multivariate logistic regression with generalized estimating equations adjusting for pneumonia severity, patient demographics and comorbidity score, and hospital academic status. We further analyzed the relationship by modified A-DROP pneumonia severity score calculated using the four severity indices: dehydration, low oxygen saturation, orientation disturbance, and decreased systolic blood pressure.

Results

We identified 8,293 cases of pneumonia at 896 hospitals across Japan, with 273 in-hospital deaths (3.3%). In the overall population, no significant association between hospital volume and in-hospital mortality was observed. However, when stratified by pneumonia severity score, higher hospital volume was associated with lower in-hospital mortality at the intermediate severity level (modified A-DROP score = 2) (odds ratio (OR) of very low vs. high: 2.70; 95% confidence interval (CI): 1.12–6.55, OR of low vs. high: 2.40; 95% CI:0.99–5.83). No significant association was observed for other severity strata.

Conclusions

Hospital case volume was inversely associated with in-hospital mortality in non-elderly pneumonia patients with intermediate pneumonia severity. Our result suggests room for potential improvement in the quality of care in hospitals with lower volume, to improve treatment outcomes particularly in patients admitted with intermediate pneumonia severity.

The impact of patient age and comorbidities on the occurrence of "never events" in cerebrovascular surgery: an analysis of the Nationwide Inpatient Sample

OBJECT

As health care administrators focus on patient safety and cost-effectiveness, methodical assessment of quality outcome measures is critical. In 2008 the Centers for Medicare and Medicaid Services (CMS) published a series of "never events" that included 11 hospital-acquired conditions (HACs) for which related costs of treatment are not reimbursed. Cerebrovascular procedures (CVPs) are complex and are often performed in patients with significant medical comorbidities.

METHODS

This study examines the impact of patient age and medical comorbidities on the occurrence of CMS-defined HACs, as well as the effect of these factors on the length of stay (LOS) and hospitalization charges in patients undergoing common CVPs.

RESULTS

The HACs occurred at a frequency of 0.49% (1.33% in the intracranial procedures and 0.33% in the carotid procedures). Falls/trauma (n = 4610, 72.3% HACs, 357 HACs per 100,000 CVPs) and catheter-associated urinary tract infections (n = 714, 11.2% HACs, 55 HACs per 100,000 CVPs) were the most common events. Age and the presence of ≥ 2 comorbidities were strong independent predictors of HACs (p < 0.0001). The occurrence of HACs negatively impacts both LOS and hospital costs. Patients with at least 1 HAC were 10 times more likely to have prolonged LOS (≥ 90th percentile) (p < 0.0001), and 8 times more likely to have high inpatient costs (≥ 90th percentile) (p < 0.0001) when adjusting for patient and hospital factors.

CONCLUSIONS

Improved quality protocols focused on individual patient characteristics might help to decrease the frequency of HACs in this high-risk population. These data suggest that risk adjustment according to underlying patient factors may be warranted when considering reimbursement for costs related to HACs in the setting of CVPs.

US nationwide trends in carotid revascularization: is there a clinical opportunity cost associated with the introduction of novel medical devices?

OBJECTIVES

Nationwide practice patterns during the implementation of novel technology, such as carotid angioplasty and stenting (CAS) and embolic protection devices (EPD), and the clinical impact thereof have received less attention.

METHODS

The Nationwide Inpatient Sample, constituting a 20% representative sample of non-federal US hospitals, was analyzed from years 1998 to 2007. Hospital outcome was stratified into in-hospital mortality (IHM), long-term facility discharge, and home/ short-term facility discharge (HSF).

RESULTS

Discharge outcome improved for CAS over the decade. However, this improvement occurred in two phases with a period of worsening (2003-2005) in between. During this transition period, the risk of IHM following CAS was increased (RR 1.29-2.43) and was lower for good outcome (HSF: RR 0.97-0.99) when compared with 2002/2003. During the same transition period, carotid endarterectomy (CEA) was associated with a lower risk of IHM (RR 0.75-1.00), but also a lower risk of HSF (RR 0.98-0.99).

CONCLUSIONS

The results lead to the hypothesis that the nationwide introduction of CAS-EPD may have been associated with temporary increases in in-hospital mortality and discharge morbidity. If such 'clinical opportunity costs' exist with the widespread introduction and adoption of new medical technology with proven efficacy in randomized trials, effective mechanisms are needed for mitigation or prevention during the transition period.

Carotid Artery Stenting: Operator and Institutional Learning Curves

Despite rapid growth in the frequency that carotid artery stenting (CAS) is performed, there remain concerns regarding the steep learning curve associated with this procedure. This article reviews the evidence base supporting operator and institutional CAS learning curves and discusses their implications for the establishment and maintenance of competencies. Attempts are made to delineate minimum volume thresholds to attain these goals and means to enhance procedural safety without compromising patient access.

Safety of carotid stenting (CAS) is based on institutional training more than individual experience in large-volume centres

BACKGROUND

Operator training is a key factor for the safety of carotid stenting (CAS). Whether institutional practice is associated with improved individual operator outcomes is debated.

OBJECTIVE

To evaluate the effect of the institutional experience on outcomes of new trainees with CAS, a retrospective analysis of a prospectively held database was performed.

METHODS

The overall study period, 2004-2012, was divided into two sequential time frames: 2004-April 2006 (leaders-team phase) and May 2006-2012 (expanded team phase). In the first frame, a single leader-operators team that first approached CAS and passed the original institutional learning curve, performed all the procedures; in the following expanded-team phase, five new trainees joined. Institutional CAS training for new trainees was based on a team-working approach including selection of patients, devices and techniques and collegial meetings with critical review and discussion of all procedural steps and imaging.

RESULTS

A total of 431 CAS procedures were performed in the leaders-team phase and 1026 in the sequential expanded-team phase. Periprocedural complication rates in the two time frames were similar: stroke/death (3.0% vs. 2.1%; P = 0.35), stroke (2.8% vs. 2.1%; P = 0.45) major stroke (0.9% vs. 0.6%, P = 0.49), death (0.2% vs. 0%; P = 0.29) during the leaders-team and expanded-team phase, respectively. However, rates of CAS failure requiring surgical conversions (3.7% vs. 0.8%; P < 0.0001) and mean contrast use (91.6 vs. 71.1 ml; P = 0.0001) decreased in the expanded phase. In the expanded-team frame (May 2006-2012), there was no mortality, and stroke rates were comparable between the leader and new operator teams: 2.6% vs. 1.2%; P = 0.17.

CONCLUSIONS

Institutional experience, including instruction on selection of patients and materials best suited for the procedure, is a primary factor driving outcomes of CAS. An effective team-working approach can reliably improve the training of new trainees preserving CAS safety and efficacy.

The current management of carotid atherosclerotic disease: who, when and how?

Ischaemic stroke represents a major health hazard in the western world, which has a severe impact on society and the health-care system. Roughly, 10% of all first ischaemic strokes can be attributed to significant atherosclerotic disease of the carotid arteries. Correct management of these lesions is essential in the prevention and treatment of carotid disease-related ischaemic events. The close relationship between diagnosis and medical and surgical management makes it necessary that all involved physicians and surgeons have profound knowledge of management strategies beyond their specific speciality. Continuous improvement in pharmacological therapy and operative techniques as well as frequently changing guidelines represent a constant challenge for the individual health-care professional. This review gives a thorough outline of the up-to-date evidence-based management of carotid artery disease and discusses its current controversies.

Cost-effectiveness of carotid artery stent placement versus endarterectomy in patients with carotid artery stenosis

OBJECT

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated that the risk of the primary composite outcome of stroke, myocardial infarction (MI), or death did not differ significantly in patients with an average surgical risk undergoing carotid artery stenting (CAS) and those undergoing carotid endarterectomy (CEA). However, the cost associated with CAS may limit its broad applicability. The authors' goal in this paper was to determine the cost-effectiveness of CAS with an embolic-protection device versus CEA in patients with moderate to severe carotid artery stenosis who are at average surgical risk.

METHODS

The probability of the primary outcome was obtained from the results of the CREST trial. The quality-adjusted life years (QALYs) associated with each treatment modality were estimated by adjusting for the incidence of each quality-adjusted outcome (QALY weights of ipsilateral stroke, MI, death, and postprocedure QALYs). The total cost associated with each intervention was derived from hospitalization cost and cost associated with primary outcomes including stroke, MI, and death in each group. Costs are expressed in US dollars accounting for inflation up to October 2010. Incremental cost-effectiveness ratios (ICERs) were estimated for the 4-year period after the procedure. All values are expressed as means and 95% confidence intervals.

RESULTS

The estimated net costs for patients after treatment with CAS and CEA after consideration of the primary outcome were $18,335 and $13,276, respectively, from the definitive presimulation analysis. Postsimulation values were $19,210 (range $18,264-$20,156) and $14,080 (range $13,076-$15,084), respectively. Overall, QALYs for the CAS and CEA groups were 0.712 and 0.702, respectively (ranging from 0.0 [death] to 0.815 [no adverse events]). The estimated ICER for CAS versus CEA treatment was $229,429.

CONCLUSIONS

Although the CREST demonstrated equivalent results with CAS (compared with CEA) in patients at average surgical risk with severe carotid artery stenosis, broad applicability of CAS might be limited by the higher cost associated with this procedure.

Predictors of Neurological Events Associated With Carotid Artery Stenting in High-Surgical-Risk Patients

Background—

Comorbid and anatomic characteristics that portend higher procedural risk are well defined for carotid endarterectomy but less so for carotid artery stenting.

Methods and Results—

We pooled carotid stent data from 4 Cordis-sponsored trials (n=2104) with similar patient cohorts and end point determination to identify predictors of neurological death or stroke within 30 days of the procedure. Median age was 74 years (24% >80 years), 36% were women, and 24.2% were symptomatic in the previous 6 months. There were 88 (4.2%) neurological deaths or strokes at 30 days. Among symptomatic patients, the risk of adverse neurological outcome declined with increasing time between the incident neurological event and carotid stent procedure. In a logistic regression model that included preprocedural and procedural variables, significant multivariable predictors of 30-day neurological death or stroke were older age (continuous), black race, angiographically visible thrombus in symptomatic patients, procedural use of glycoprotein IIb/IIIa inhibitors, procedural transient ischemic attack, final residual stenosis >30%, and periprocedural use of protamine or vasopressors.

Conclusions—

In this pooled analysis, a number of preprocedural and procedural factors predicted higher risk of stroke and neurological death within 30 days of a carotid stent procedure. Identification of such predictors may help to guide patient selection and further refine procedural technique.

Carotid artery stent placement

In the past 3 years, there have been significant developments in the field of carotid revascularization, including: 1) the results of a large primary stroke prevention trial; 2) the emergence of novel platforms for emboli protection; 3) improved characterization of the high-risk carotid artery stent (CAS) patient; 4) completion of several very large post-market surveillance (PMS) trials of CAS in high-surgical-risk patients; and 5) the completion of 4 large randomized controlled trials comparing CAS with carotid endarterectomy in average-risk patients. The purpose of this review is to update the current status of revascularization therapies to reduce stroke in patients with extracranial carotid artery disease with a focus on the most recent developments regarding the role of CAS.

Rapid change in prescribing behavior in hospitals participating in get with the guidelines-stroke after release of the management of atherothrombosis with clopidogrel in high-risk patients (MATCH) clinical trial results

BACKGROUND AND PURPOSE

Physician prescribing patterns change slowly despite published randomized trials and consensus guidelines. We measure the effect of Management of Atherothrombosis With Clopidogrel in High-Risk Patients (MATCH) trial on discharge prescribing patterns for patients with stroke and those with transient ischemic attack in the Get With The Guidelines (GWTG)-Stroke Program.

METHODS

We analyzed discharge prescribing patterns of antithrombotic medications for patients admitted with ischemic stroke or transient ischemic attack at hospitals participating in GWTG-Stroke between October 2002 to January 2006. Clinical information by quarter was analyzed in relation to publication of the MATCH study. Frequency of discharge prescription of aspirin+clopidogrel post-MATCH publication was compared with the pre-MATCH period after adjusting for patient and hospital characteristics and clustering by hospital.

RESULTS

A total of 107 872 patients at 632 sites were eligible to receive antithrombotic therapy at discharge. Use of aspirin+clopidogrel therapy declined from 22.4% to 15.4% of patients after the publication of MATCH (adjusted OR 0.62, 95% CI 0.56 to 0.70, P<0.0001). Analysis by quarter revealed a rapid and sustained decrease in use of aspirin+clopidogrel therapy for the remainder of the study period.

CONCLUSIONS

A rapid and sustained reduction in the frequency of aspirin+clopidogrel use in ischemic stroke and transient ischemic attack was observed after publication of the MATCH trial in the absence of MATCH-specific GWTG-Stroke initiatives and preceding an American Heart Association guideline update.