Medicare's policy on carotid stents limited use to hospitals meeting quality guidelines yet did not hurt disadvantaged

Utilization of Advanced Cardiovascular Therapies in the United States and Canada: An Observational Study of New York and Ontario Administrative Data

BACKGROUND

Endovascular aortic aneurysm repair (EVAR), left ventricular assist device (LVAD), and transcatheter aortic valve replacement (TAVR) are expensive cardiovascular technologies with potential to benefit large numbers of patients. There are few population-based studies comparing utilization between countries. Our objective was to compare patient characteristics and utilization patterns of EVAR, LVAD, and TAVR in Ontario, Canada, and New York State, United States.

METHODS AND RESULTS

We performed a retrospective cohort study using administrative data to identify all adults who received EVAR, LVAD, or TAVR in Ontario and New York between 2012 and 2015. We compared socio-demographics of EVAR, LVAD, and TAVR recipients in Ontario and New York. We compared standardized utilization rates between jurisdictions for each procedure. We identified 3295 EVAR recipients from Ontario and 6236 from New York (mean age 74.6 versus 74.5 years; P=0.61): 136 LVAD recipients from Ontario and 686 from New York (age, 57.4 versus 57.7 years; P=0.80): 1708 TAVR recipients from Ontario and 4838 from New York (age, 83.1 versus 83.1; P=1.0). A significantly smaller percentage of EVAR and TAVR recipients in Ontario were female compared to New York (EVAR, 15.8% versus 22.1% female; P<0.001; TAVR, 45.9% versus 51.8%; P<0.001), but for LVAD the percentage female was similar (21.3% versus 20.8%; P=0.99). Utilization was significantly higher in New York for all procedures: EVAR (12.8 procedures per-100 000 adults per-year in Ontario, 20.2 in New York; P<0.001); LVAD (0.3 in Ontario versus 1.3 in New York; P<0.001); and TAVR (6.6 in Ontario, 14.3 in New York; P<0.001). Higher utilization of EVAR and TAVR in New York relative to Ontario increased substantially with increasing age.

CONCLUSIONS

We observed significantly higher utilization of EVAR, LVAD, and TAVR in New York compared to Ontario. Our results highlight important differences in how 2 different countries are using advanced cardiovascular therapies.

Regional variation in patient selection and treatment for carotid artery disease in the Vascular Quality Initiative

OBJECTIVE

Previous studies involving large administrative data sets have revealed regional variation in the demographics of patients selected for carotid endarterectomy (CEA) and carotid artery stenting (CAS) but lacked clinical granularity. This study aimed to evaluate regional variation in patient selection and operative technique for carotid artery revascularization using a detailed clinical registry.

METHODS

All patients who underwent CEA or CAS from 2009 to 2015 were identified in the Vascular Quality Initiative (VQI). Deidentified regional groups were used to evaluate variation in patient selection, operative technique, and perioperative management. χ² analysis was used to identify significant variation across regions.

RESULTS

A total of 57,555 carotid artery revascularization procedures were identified. Of these, 49,179 patients underwent CEA (asymptomatic: median, 56%; range, 46%-69%; P < .01) and 8376 patients underwent CAS (asymptomatic: median, 36%; range, 29%-51%; P < .01). There was significant regional variation in the proportion of asymptomatic patients being treated for carotid stenosis <70% in CEA (3%-9%; P < .01) vs CAS (3%-22%; P < .01). There was also significant variation in the rates of intervention for asymptomatic patients older than 80 years (CEA, 12%-27% [P < .01]; CAS, 8%-26% [P < .01]). Preoperative computed tomography angiography or magnetic resonance angiography in the CAS cohort also varied widely (31%-83%; P < .01), as did preoperative medical management with combined aspirin and statin (CEA, 53%-77% [P < .01]; CAS, 62%-80% [P < .01]). In the CEA group, the use of shunt (36%-83%; P < .01), protamine (32%-89%; P < .01), and patch (87%-99%; P < .01) varied widely. Similarly, there was regional variation in frequency of CAS done without a protection device (1%-8%; P < .01).

CONCLUSIONS

Despite clinical benchmarks aimed at guiding management of carotid disease, wide variation in clinical practice exists, including the proportion of asymptomatic patients being treated by CAS and preoperative medical management. Additional intraoperative variables, including the use of a patch and protamine during CEA and use of a protection device during CAS, displayed similar variation in spite of clear guidelines. Quality improvement projects could be directed toward improved adherence to benchmarks in these areas.

Socioeconomic Inequalities in the Utilization of Colorectal Stents for the Treatment of Malignant Bowel Obstruction

BACKGROUND

Colorectal stents are increasingly employed as a bridge to surgery or for palliative relief of malignant large bowel obstruction.

AIM

To explore determinants of inpatient colorectal stent utilization (CRSU).

METHODS

An analysis of the 2012 National Inpatient Sample was performed. International Classification of Diseases, 9th revision, codes were used to identify discharges associated with CRSU and patient/hospital factors for inclusion in a logistic regression model.

RESULTS

We identified 217,055 inpatient colonoscopies, approximating 1.1 million inpatient colonoscopies nationwide. Colorectal stents were placed in 1.4 % of all procedures. Across all racial groups, Medicare was the most common payer. Patients with commercial insurance had lower CRSU compared with Medicare patients [adjusted odds ratio (OR) 0.83, 95 % confidence interval (CI) 0.75-0.92]. No gender disparities were identified (OR 0.96, 95 % CI 0.89-1.03). In addition, no racial differences in CRSU existed between Caucasians versus African-Americans (OR 0.94, 95 % CI 0.83-1.06) and Caucasians versus Hispanics (OR 0.96, 95 % CI 0.83-1.1). Compared with patients living in less affluent neighborhoods, those residing in more affluent areas had higher CRSU (OR 1.65, 95 % CI 1.46-1.86). This displayed a linear relationship with the odds of CRSU increasing as household income increased. Less affluent patients also had the highest total charges and longest wait time to CRSU. CRSU was highest among patients treated in larger medical centers (OR 1.7, 95 % CI 1.51-1.93) and teaching hospitals (OR 3.9, 95 % CI 3.2-4.8).

CONCLUSION

Individuals from less affluent neighborhoods have lower colorectal stent utilization. This disparity is independent of race and likely related to poorer access to healthcare resources.

Impact of alternative medical device approval processes on costs and health

BACKGROUND

Medical devices are often introduced prior to randomized-trial evidence of efficacy and this slows completion of trials. Alternative regulatory approaches include restricting device use outside of trials prior to trial evidence of efficacy (like the drug approval process) or restricting out-of-trial use but permitting coverage within trials such as Medicare's Coverage with Study Participation (CSP).

METHODS

We compared the financial impact to manufacturers and insurers of three regulatory alternatives: (1) limited regulation (current approach), (2) CSP, and (3) restrictive regulation (like the current drug approval process). Using data for patent foramen ovale closure devices, we modeled key parameters including recruitment time, probability of device efficacy, market adoption, and device cost/price to calculate profits to manufacturers, costs to insurers, and overall societal impact on health.

RESULTS

For manufacturers, profits were greatest under CSP-driven by faster market adoption of effective devices-followed by restrictive regulation. Societal health benefit in total quality-adjusted life years was greatest under CSP. Insurers' expenditures for ineffective devices were greatest with limited regulation. Findings were robust over a reasonable range of probabilities of trial success.

CONCLUSIONS

Regulation restricting out-of-trial device use and extending limited insurance coverage to clinical trial participants may balance manufacturer and societal interests.

Decision to Adopt Medical Technology

Objective. To understand decision making concerning adoption and nonadoption of accelerated partial breast radiotherapy (RT) prior to long-term randomized trial evidence. Methods. A total of 36 radiation oncologists and surgeons were recruited through purposive and snowball sampling strategies from September 2010 through January 2013. Semistructured phone interviews were conducted and audio-recorded and lasted 20–45 minutes. Qualitative analysis was conducted using a framework approach, iteratively exploring key concepts and emerging issues raised by subjects. Interviews were transcribed and imported into Atlas.ti v6. Transcripts were independently coded by 3 researchers shortly after each interview, followed by consensus development on each coded transcript. Barriers and facilitators of adoption, practice patterns, and informational/educational sources concerning accelerated partial breast RT were all assessed to determine major themes. Results. Nearly half of physicians were surgeons (47%), and half were radiation oncologists (53%), with 61% overall in urban settings. Twenty-nine of the 36 physicians interviewed used brachytherapy-based partial breast RT. Five major factors were involved in physicians’ decisions to adopt accelerated partial breast RT: facilitators encouraging adoption (e.g., enthusiastic colleagues and patient convenience), financial and prestige incentives, pressures to adopt (e.g., potential declines in referrals), judgment concerning acceptable level of scientific evidence, and barriers (e.g., not having appropriate machinery or referral mechanism in place). If technology was adopted, clinical guideline adherence varied. Conclusions. Technology adoption is based on financial and social pressures, along with often-limited scientific evidence and what seems “best” for patients. For technology adoption and diffusion to be rational and evidence-based, we must encourage appropriate financial payment models to curb use outside of research studies and promote development of additional treatment registries until sufficient evidence is gathered.

A comparison of clinical outcomes from carotid artery stenting among US hospitals

BACKGROUND

The Centers for Medicare and Medicaid Services require hospitals performing carotid artery stenting (CAS) to recertify the quality of their programs every 2 years, but currently this involves no explicit comparisons of postprocedure mortality across hospitals. Hence, the current recertification process may fail to identify hospitals that are performing poorly in relation to peer institutions. Our objective was to compare risk-standardized procedural outcomes across US hospitals that performed CAS and to identify hospitals with statistically high postprocedure mortality rates.

METHODS AND RESULTS

We conducted a retrospective cohort study of Medicare beneficiaries who underwent CAS from July 2009 to June 2011 at 927 US hospitals. Thirty-day risk-standardized mortality rates were calculated using the Hospital Compare statistical method, a well-validated hierarchical generalized linear model that included both patient-level and hospital-level predictors. Claims were examined from 22 708 patients undergoing CAS, with a crude 30-day mortality rate of 2.0%. Risk-standardized 30-day mortality rates after CAS varied from 1.1% to 5.1% (P<0.001 for the difference). Thirteen hospitals had risk-standardized mortality rates that were statistically (P<0.05) higher than the national mean. Conversely, 5 hospitals had risk-standardized mortality rates that were statistically (P<0.05) lower than the national mean.

CONCLUSIONS

We used administrative claims to identify several CAS hospitals with excessively high 30-day mortality after carotid stenting. When combined with information currently used by Medicare for CAS recertification, such as clinical registry data and program reports, clinical outcomes comparisons could enhance Medicare's ability to identify hospitals that are questionable candidates for recertification.

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 Versus Carotid Endarterectomy for Treatment of Asymptomatic Carotid Disease

In patients with asymptomatic carotid artery stenosis the optimal strategy to reduce the risk for stroke remains controversial. Although carotid endarterectomy was traditionally considered the gold standard for revascularization, emerging data suggest that carotid artery stenting is an appropriate alternative in many asymptomatic patients. This article summarizes the evidence base and related controversies regarding carotid endarterectomy versus carotid artery stenting for the revascularization of carotid disease in asymptomatic patients.

Understanding and benchmarking health service achievement of policy goals for chronic disease

BACKGROUND

Key challenges in benchmarking health service achievement of policy goals in areas such as chronic disease are: 1) developing indicators and understanding how policy goals might work as indicators of service performance; 2) developing methods for economically collecting and reporting stakeholder perceptions; 3) combining and sharing data about the performance of organizations; 4) interpreting outcome measures; 5) obtaining actionable benchmarking information. This study aimed to explore how a new Boolean-based small-N method from the social sciences-Qualitative Comparative Analysis or QCA-could contribute to meeting these internationally shared challenges.

METHODS

A 'multi-value QCA' (MVQCA) analysis was conducted of data from 24 senior staff at 17 randomly selected services for chronic disease, who provided perceptions of 1) whether government health services were improving their achievement of a set of statewide policy goals for chronic disease and 2) the efficacy of state health office actions in influencing this improvement. The analysis produced summaries of configurations of perceived service improvements.

RESULTS

Most respondents observed improvements in most areas but uniformly good improvements across services were not perceived as happening (regardless of whether respondents identified a state health office contribution to that improvement). The sentinel policy goal of using evidence to develop service practice was not achieved at all in four services and appears to be reliant on other kinds of service improvements happening.

CONCLUSIONS

The QCA method suggested theoretically plausible findings and an approach that with further development could help meet the five benchmarking challenges. In particular, it suggests that achievement of one policy goal may be reliant on achievement of another goal in complex ways that the literature has not yet fully accommodated but which could help prioritize policy goals. The weaknesses of QCA can be found wherever traditional big-N statistical methods are needed and possible, and in its more complex and therefore difficult to empirically validate findings. It should be considered a potentially valuable adjunct method for benchmarking complex health policy goals such as those for chronic disease.