Kumamaru Hiraku, Jalbert Jessica J, Nguyen Louis L, Gerhard-Herman Marie D, Williams Lauren A, Chen Chih-Ying, Seeger John D, Liu Jun, Franklin Jessica M, Setoguchi Soko
From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.).
Stroke. 2015 May;46(5):1288-94. doi: 10.1161/STROKEAHA.114.006276. Epub 2015 Mar 19.
After the 2005 National Coverage Determination to reimburse carotid artery stenting (CAS) for Medicare beneficiaries, the number of CAS procedures increased and carotid endarterectomy (CEA) decreased. We evaluated trends in surgeons' past-year CEA case-volume and 30-day mortality after CEA, and their association before and after the National Coverage Determination.
In a retrospective cohort study of patients undergoing CEA (2001-2008) and CAS (2005-2008) using Medicare data, we described yearly trends of CEA and CAS rates, patient characteristics, and 30-day mortality after CEA. We used logistic regression adjusting for patient- and surgeon-level factors to assess the effect of surgeon case volume on 30-day mortality after CEA.
We identified 454 717 CEA and 27 943 CAS patients. Patients undergoing CEA in recent years were older and had more comorbidities than earlier years. CEA rates per 10 000 beneficiaries declined from 18.1 in 2002 to 12.7 in 2008, whereas median surgeon past-year case-volume declined from 27 to 21. The CAS rates peaked at 2.3 per 10 000 beneficiaries in 2006 but declined to 1.8 in 2008, resulting in declining overall revascularization procedure rates during 2005 to 2008. Thirty day post-CEA mortality was 1.40% (95% confidence interval, 1.34-1.47) in 2001 to 2002 and 1.17% (1.10-1.24) in 2007 to 2008. Surgeon's past-year case-volume of <10 was associated with higher 30-day mortality consistently during 2001 to 2008.
The rate of CEA procedures decreased substantially during 2001 to 2008, as did surgeon past-year case-volume. The postprocedural mortality in Medicare beneficiaries was high compared with trial patients but somewhat improved over time. Those operated by lower past-year case-volume surgeons had increased mortality.
2005年国家医保覆盖范围确定为医疗保险受益人报销颈动脉支架置入术（CAS）后，CAS手术数量增加，颈动脉内膜切除术（CEA）数量减少。我们评估了外科医生过去一年的CEA病例数量趋势以及CEA术后30天死亡率，及其在国家医保覆盖范围确定前后的关联。
在一项使用医疗保险数据对接受CEA（2001 - 2008年）和CAS（2005 - 2008年）患者进行的回顾性队列研究中，我们描述了CEA和CAS发生率、患者特征以及CEA术后30天死亡率的年度趋势。我们使用逻辑回归，对患者和外科医生层面的因素进行调整，以评估外科医生病例数量对CEA术后30天死亡率的影响。
我们识别出454717例CEA患者和27943例CAS患者。近年来接受CEA手术的患者比早年的患者年龄更大，合并症更多。每10000名受益人的CEA发生率从2002年的18.1降至2008年的12.7，而外科医生过去一年的病例数量中位数从27降至21。CAS发生率在2006年达到每10000名受益人2.3的峰值，但在2008年降至1.8，导致2005年至2008年期间总体血运重建手术率下降。2001年至2002年CEA术后30天死亡率为1.40%（95%置信区间，1.34 - 1.47），2007年至2008年为1.17%（1.10 - 1.24）。在2001年至2008年期间，外科医生过去一年病例数量<10始终与较高的30天死亡率相关。
2001年至2008年期间CEA手术率大幅下降，外科医生过去一年的病例数量也下降。医疗保险受益人的术后死亡率与试验患者相比很高，但随着时间推移有所改善。由过去一年病例数量较少的外科医生进行手术的患者死亡率增加。
