1
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Liu KQ, Rangwala SD, Cheng J, Han JS, Ding L, Attenello FJ, Mack W. Carotid artery stenting for asymptomatic stenosis is associated with decreased 30-day readmission at very high volume centers. J Clin Neurosci 2023; 114:1-8. [PMID: 37276740 PMCID: PMC10527537 DOI: 10.1016/j.jocn.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/17/2023] [Accepted: 05/28/2023] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Kristie Q Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Shivani D Rangwala
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Justin Cheng
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jane S Han
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Li Ding
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Frank J Attenello
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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2
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Diyora B, Chheda R, Dhall G, Gupta P, Dewani K, Mulla M, Gaud D. Carotid Endarterectomy and Carotid Artery Stenting for Symptomatic Carotid Stenosis: An Experience of a Hybrid Neurosurgeon in a Developing Nation. Neurol India 2022; 70:94-101. [DOI: 10.4103/0028-3886.336326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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3
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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4
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Giurgius M, Horn M, Thomas SD, Shishehbor MH, Barry Beiles C, Mwipatayi BP, Varcoe RL. The Relationship Between Carotid Revascularization Procedural Volume and Perioperative Outcomes in Australia and New Zealand. Angiology 2021; 72:715-723. [PMID: 33535812 DOI: 10.1177/0003319721991717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Mary Giurgius
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Marco Horn
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia
| | - Shannon D Thomas
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
| | - Mehdi H Shishehbor
- Harrington Heart & Vascular Institute and Case Western Reserve University School of Medicine, University Hospitals, Cleveland, OH, USA
| | - C Barry Beiles
- Australasian Vascular Audit, Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - B Patrice Mwipatayi
- Department of Vascular Surgery, University of Western Australia, School of Surgery and Royal Perth Hospital, Perth, Australia
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
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5
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Braet DJ, Smith JB, Bath J, Kruse RL, Vogel TR. Risk factors associated with 30-day hospital readmission after carotid endarterectomy. Vascular 2021; 29:61-68. [PMID: 32628069 PMCID: PMC7782206 DOI: 10.1177/1708538120937955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Drew J. Braet
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| | - Jamie B. Smith
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Missouri
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| | - Robin L. Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Missouri
| | - Todd R. Vogel
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri
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6
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Munich SA, Levy EI. Commentary: The Potential Impact of "Take the Volume Pledge" on Outcomes After Carotid Artery Stenting. Neurosurgery 2020; 86:E133-E134. [PMID: 31329943 DOI: 10.1093/neuros/nyz055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/01/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Stephan A Munich
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
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7
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Mesman R, Faber MJ, Berden BJ, Westert GP. Evaluation of minimum volume standards for surgery in the Netherlands (2003–2017): A successful policy? Health Policy 2017; 121:1263-1273. [DOI: 10.1016/j.healthpol.2017.09.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/16/2017] [Accepted: 09/19/2017] [Indexed: 01/29/2023]
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8
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Factors affecting cardiovascular and cerebrovascular complications of carotid artery stenting in Northern Michigan: A retrospective study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:S18-S21. [DOI: 10.1016/j.carrev.2017.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 03/15/2017] [Accepted: 03/22/2017] [Indexed: 11/21/2022]
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9
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Hung CS, Yeh CF, Lin MS, Chen YH, Huang CC, Li HY, Kao HL. Impact of hospital volume on long-term neurological outcome in patients undergoing carotid artery stenting. Catheter Cardiovasc Interv 2017; 89:1242-1249. [PMID: 28296028 DOI: 10.1002/ccd.26989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 01/28/2017] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Chi-Sheng Hung
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Fan Yeh
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Hsien Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Chang Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Yuan Li
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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10
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AbuRahma AF, Campbell JE, Hariri N, AbuRahma J, Dean LS, Bates MC, Nanjundappa A, Stone PA, O'vil A. Clinical Outcome of Carotid Artery Stenting According to Provider Specialty and Volume. Ann Vasc Surg 2017; 44:361-367. [PMID: 28495538 DOI: 10.1016/j.avsg.2017.04.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/28/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Ali F AbuRahma
- Charleston Area Medical Center Vascular Center of Excellence, Charleston, WV; Department of Surgery, West Virginia University, Charleston, WV.
| | - John E Campbell
- Department of Surgery, West Virginia University, Charleston, WV
| | - Nizar Hariri
- Department of Surgery, West Virginia University, Charleston, WV
| | - Joseph AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV
| | - L Scott Dean
- CAMC Health Education and Research Institute, Charleston, WV
| | - Mark C Bates
- Charleston Area Medical Center Vascular Center of Excellence, Charleston, WV; Department of Surgery, West Virginia University, Charleston, WV
| | | | - Patrick A Stone
- Department of Surgery, West Virginia University, Charleston, WV
| | - Ace O'vil
- Department of Surgery, West Virginia University, Charleston, WV
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11
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Significant Association of Annual Hospital Volume With the Risk of Inhospital Stroke or Death Following Carotid Endarterectomy but Likely Not After Carotid Stenting. Circ Cardiovasc Interv 2016; 9:CIRCINTERVENTIONS.116.004171. [DOI: 10.1161/circinterventions.116.004171] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 09/21/2016] [Indexed: 11/16/2022]
Abstract
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.
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12
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Mendiz OA, Fava C, Lev G, Caponi G, Valdivieso L. Transradial Versus Transfemoral Carotid Artery Stenting: A 16-Year Single-Center Experience. J Interv Cardiol 2016; 29:588-593. [PMID: 27634206 DOI: 10.1111/joic.12342] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Oscar A Mendiz
- Department of Interventional Cardiology and Cardiovascular Surgery, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina
| | - Carlos Fava
- Department of Interventional Cardiology and Cardiovascular Surgery, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina
| | - Gustavo Lev
- Department of Interventional Cardiology and Cardiovascular Surgery, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina
| | - Gaspar Caponi
- Department of Interventional Cardiology and Cardiovascular Surgery, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina
| | - León Valdivieso
- Department of Interventional Cardiology and Cardiovascular Surgery, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina
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13
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Panaich SS, Patel N, Agnihotri K, Arora S, Savani C, Sonani R, Patel NJ, Patel SV, Solanki S, Schreiber T, Grines C, Badheka AO. Volume-outcome relationship for peripheral endovascular interventions: a review of existing literature. Expert Rev Pharmacoecon Outcomes Res 2016; 16:103-9. [PMID: 26732517 DOI: 10.1586/14737167.2016.1138859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
| | - Nilay Patel
- b Internal Medicine Department , Saint Peter's University Hospital , New Brunswick , NJ , USA
| | - Kanishk Agnihotri
- b Internal Medicine Department , Saint Peter's University Hospital , New Brunswick , NJ , USA
| | - Shilpkumar Arora
- c Internal Medicine Department , Mount Sinai St. Luke's Roosevelt Hospital , New York , NY , USA
| | - Chirag Savani
- d Epidemiology Department , New York Medical College , Valhalla , NY , USA
| | - Raj Sonani
- e Public Health Department , Emory University School of Medicine , Atlanta , GA , USA
| | - Nileshkumar J Patel
- f Cardiology Department , University of Miami Miller school of Medicine , Miami , FL , USA
| | - Samir V Patel
- g Internal Medicine Department , Western Reserve Health System , Youngstown , OH , USA
| | - Shantanu Solanki
- h Internal Medicine Department , Westchester Medical center at New York Medical College , Valhalla , NY , USA
| | | | - Cindy Grines
- i Cardiology Department , Detroit Medical Centre , Detroit , MI , USA
| | - Apurva O Badheka
- j Cardiology Department , The Everett Clinic , Everett , WA , USA
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14
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Jalbert JJ, Gerhard-Herman MD, Nguyen LL, Jaff MR, Kumamaru H, Williams LA, Chen CY, Liu J, Seeger JD, Rothman AT, Schneider P, Brott TG, Tsai TT, Aronow HD, Johnston JA, Setoguchi S. Relationship Between Physician and Hospital Procedure Volume and Mortality After Carotid Artery Stenting Among Medicare Beneficiaries. Circ Cardiovasc Qual Outcomes 2015; 8:S81-9. [DOI: 10.1161/circoutcomes.114.001668] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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15
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Kim LK, Yang DC, Swaminathan RV, Minutello RM, Okin PM, Lee MK, Sun X, Wong SC, McCormick DJ, Bergman G, Allareddy V, Singh H, Feldman DN. Comparison of Trends and Outcomes of Carotid Artery Stenting and Endarterectomy in the United States, 2001 to 2010. Circ Cardiovasc Interv 2014; 7:692-700. [DOI: 10.1161/circinterventions.113.001338] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Luke K Kim
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - David C. Yang
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Rajesh V. Swaminathan
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Robert M. Minutello
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Peter M. Okin
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Min Kyeong Lee
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Xuming Sun
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - S. Chiu Wong
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Daniel J. McCormick
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Geoffrey Bergman
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Veerasathpurush Allareddy
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Harsimran Singh
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
| | - Dmitriy N. Feldman
- From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital–University of Pennsylvania Health System,
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Kumamaru H, Tsugawa Y, Horiguchi H, Kumamaru KK, Hashimoto H, Yasunaga H. Association between hospital case volume and mortality in non-elderly pneumonia patients stratified by severity: a retrospective cohort study. BMC Health Serv Res 2014; 14:302. [PMID: 25016477 PMCID: PMC4105510 DOI: 10.1186/1472-6963-14-302] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 07/10/2014] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1138655, Japan.
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Modrall JG, Chung J, Kirkwood ML, Baig MS, Tsai SX, Timaran CH, Valentine RJ, Rosero EB. Low rates of complications for carotid artery stenting are associated with a high clinician volume of carotid artery stenting and aortic endografting but not with a high volume of percutaneous coronary interventions. J Vasc Surg 2014; 60:70-6. [DOI: 10.1016/j.jvs.2014.01.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 01/17/2014] [Accepted: 01/20/2014] [Indexed: 11/30/2022]
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Wen T, He S, Attenello F, Cen SY, Kim-Tenser M, Adamczyk P, Amar AP, Sanossian N, Mack WJ. The impact of patient age and comorbidities on the occurrence of "never events" in cerebrovascular surgery: an analysis of the Nationwide Inpatient Sample. J Neurosurg 2014; 121:580-6. [PMID: 24972123 DOI: 10.3171/2014.4.jns131253] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Brinjikji W, Kallmes DF, Lanzino G, Cloft HJ. Carotid revascularization treatment is shifting to low volume centers. J Neurointerv Surg 2014; 7:336-40. [DOI: 10.1136/neurintsurg-2014-011180] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 03/21/2014] [Indexed: 11/03/2022]
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Choi JH, Pile-Spellman J, Brisman JL. US nationwide trends in carotid revascularization: is there a clinical opportunity cost associated with the introduction of novel medical devices? Acta Neurol Scand 2014; 129:94-101. [PMID: 23772989 DOI: 10.1111/ane.12152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2013] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- J. H. Choi
- Department of Neurology; State University of New York; Downstate Medical Center; Brooklyn NY USA
- Clinical Sciences; Janus Head Consulting; LLC; Mineola NY USA
| | - J. Pile-Spellman
- Neurological Surgery P.C.; Lake Success NY USA
- Neurosurgical Services; Winthrop University Hospital; Mineola NY USA
| | - J. L. Brisman
- Neurological Surgery P.C.; Lake Success NY USA
- Neurosurgical Services; Winthrop University Hospital; Mineola NY USA
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Wayangankar SA, Aronow HD. Carotid Artery Stenting: Operator and Institutional Learning Curves. Interv Cardiol Clin 2014; 3:91-103. [PMID: 28582158 DOI: 10.1016/j.iccl.2013.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
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.
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22
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Trinh QD, Bianchi M, Sun M, Sammon J, Schmitges J, Shariat SF, Sukumar S, Jeldres C, Zorn K, Perrotte P, Rogers CG, Peabody JO, Montorsi F, Menon M, Karakiewicz PI. Discharge patterns after radical prostatectomy in the United States of America. Urol Oncol 2013; 31:1022-32. [DOI: 10.1016/j.urolonc.2011.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2011] [Revised: 10/10/2011] [Accepted: 10/13/2011] [Indexed: 11/24/2022]
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Safety of carotid stenting (CAS) is based on institutional training more than individual experience in large-volume centres. Eur J Vasc Endovasc Surg 2013; 45:424-30. [PMID: 23481410 DOI: 10.1016/j.ejvs.2013.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 02/05/2013] [Indexed: 12/15/2022]
Abstract
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.
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Ritter JC, Tyrrell MR. The current management of carotid atherosclerotic disease: who, when and how? Interact Cardiovasc Thorac Surg 2013; 16:339-46. [PMID: 23197661 PMCID: PMC3568792 DOI: 10.1093/icvts/ivs453] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 08/30/2012] [Accepted: 09/07/2012] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Jens C Ritter
- Department of Vascular Surgery, King's Health Partners, Kings College Hospital, London, UK.
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Kakisis J, Avgerinos E, Antonopoulos C, Giannakopoulos T, Moulakakis K, Liapis C. The European Society for Vascular Surgery Guidelines for Carotid Intervention: An Updated Independent Assessment and Literature Review. Eur J Vasc Endovasc Surg 2012; 44:238-43. [DOI: 10.1016/j.ejvs.2012.04.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 04/19/2012] [Indexed: 11/16/2022]
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Khan AA, Chaudhry SA, Sivagnanam K, Hassan AE, Suri MFK, Qureshi AI. Cost-effectiveness of carotid artery stent placement versus endarterectomy in patients with carotid artery stenosis. J Neurosurg 2012; 117:89-93. [PMID: 22577748 DOI: 10.3171/2012.3.jns111266] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Asif A Khan
- Zeenat Qureshi Stroke Research Center and Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55414, USA
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George JC, White CJ. Carotid artery stenting lessons From CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial). JACC Cardiovasc Interv 2011; 3:988-90. [PMID: 20850102 DOI: 10.1016/j.jcin.2010.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Vogel TR. Response to Letter to the Editor. Vasc Endovascular Surg 2011. [DOI: 10.1177/1538574410379659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Todd R. Vogel
- UMDNJ/Robert Wood Johnson Medical School, Division of Vascular Surgery, New Brunswick, NJ, USA,
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Predictors of Neurological Events Associated With Carotid Artery Stenting in High-Surgical-Risk Patients. Circ Cardiovasc Interv 2010; 3:577-84. [DOI: 10.1161/circinterventions.110.950097] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Abstract
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.
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Menon BK, Frankel MR, Liang L, Labresh KA, Ellrodt G, Hernandez AF, Fonarow GC, Schwamm LH, Smith EE. 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. Stroke 2010; 41:2094-7. [PMID: 20634476 DOI: 10.1161/strokeaha.110.584151] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Bijoy K Menon
- University of Calgary, Hotchkiss Brain Institute, Calgary, Alberta, Canada.
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