Jalbert Jessica J, Gerhard-Herman Marie D, Nguyen Louis L, Jaff Michael R, Kumamaru Hiraku, Williams Lauren A, Chen Chih-Ying, Liu Jun, Seeger John D, Rothman Andrew T, Schneider Peter, Brott Thomas G, Tsai Thomas T, Aronow Herbert D, Johnston Joseph A, Setoguchi Soko
From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., L.A.W., C.-Y.C., J.L., J.D.S., A.T.R., S.S.), Division of Cardiovascular Medicine (M.D.G.-H.), and Division of Vascular and Endovascular Surgery (L.L.N.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Consulting and Analytics, LASER Analytica, New York, NY (J.J.J.); Division of Cardiovascular Medicine, Massachusetts General Hospital, Boston (M.R.J.); Division of Vascular and Endovascular Surgery, Kaiser Permanente Medical Centre, Honolulu, HI (P.S.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Division of Cardiology, Denver VA Medical Center, University of Colorado (T.T.T.); Division of Cardiovascular Medicine, St Joseph Mercy Hospital, Ann Arbor, MI (H.D.A.); Global Health Outcomes, Lilly Research Laboratories, Eli Lilly and Company Indianapolis, IN (J.A.J.); and Department of Medicine, Duke Clinical Research Institute, Durham, NC (S.S.).
Circ Cardiovasc Qual Outcomes. 2015 Oct;8(6 Suppl 3):S81-9. doi: 10.1161/CIRCOUTCOMES.114.001668.
Clinical trials demonstrated the efficacy of carotid artery stenting (CAS) relative to carotid endarterectomy when performed by physicians with demonstrated proficiency. It is unclear how CAS performance may be influenced by the diversity in CAS and non-CAS provider volumes in routine clinical practice.
We linked Medicare claims to the Centers for Medicare and Medicaid Services' CAS Database (2005-2009). We assessed the association between 30-day mortality and past-year physician (0, 1-4, 5-9, 10-19, ≥20) and hospital (<10, 10-19, 20-39, ≥40) CAS volumes and past-year hospital coronary and peripheral stenting volumes (<200, 200-399, 400-849, ≥850) among beneficiaries at least 66 years of age. Unadjusted 30-day mortality risk was 1.8% (95% confidence interval [CI], 1.6-2.0) for 19 724 patients undergoing CAS by 2045 physicians in 729 hospitals. Median past-year CAS volume was 9 (interquartile range, 4-19) for physicians and 23 (interquartile range, 12-41) for hospitals. Compared to physicians performing ≥20 CAS in the past year, lower CAS volumes were associated with higher adjusted risks of 30-day morality (P value for trend < 0.05): 1.4 (95% CI, 0.9-2.3) for 0 past-year CAS, 1.3 (95% CI, 0.9-1.8) for 1 to 4, 1.1 (95% CI, 0.8-1.6) for 5 to 9, and 0.9 (95% CI, 0.7-1.4) for 10 to 19. An inverse relationship between 30-day mortality and past-year CAS hospital volume as well as past-year hospital non-CAS volume, past-year hospital non-CAS volume, and 30-day mortality was also noted.
Among Medicare patients, an inverse relationship exists between physician and hospital CAS volumes and hospital non-CAS stenting volume and 30-day mortality, even after adjusting for all pertinent patient- and hospital-level factors.
临床试验表明，由熟练掌握该技术的医生进行颈动脉支架置入术（CAS）时，其疗效相对于颈动脉内膜切除术更具优势。目前尚不清楚在常规临床实践中，CAS和非CAS医疗服务提供者数量的差异会如何影响CAS的实施效果。
我们将医疗保险理赔数据与医疗保险和医疗补助服务中心的CAS数据库（2005 - 2009年）进行了关联。我们评估了729家医院中2045名医生为19724例至少66岁的受益人实施CAS后，30天死亡率与医生过去一年的CAS手术量（0、1 - 4、5 - 9、10 - 19、≥20例）、医院过去一年的CAS手术量（<10、10 - 19、20 - 39、≥40例）以及医院过去一年的冠状动脉和外周支架置入手术量（<200、200 - 399、400 - 849、≥850例）之间的关联。19724例接受CAS手术的患者，其未调整的30天死亡风险为1.8%（95%置信区间[CI]，1.6 - 2.0）。医生过去一年的CAS手术量中位数为9例（四分位间距，4 - 19例），医院过去一年的CAS手术量中位数为23例（四分位间距，12 - 41例）。与过去一年实施≥20例CAS手术的医生相比，较低的CAS手术量与30天死亡调整风险较高相关（趋势P值<0.05）：过去一年CAS手术量为0例时，风险为1.4（95%CI，0.9 - 2.3）；1 - 4例时，风险为1.3（95%CI，0.9 - 1.8）；5 - 9例时，风险为1.1（95%CI，0.8 - 1.6）；10 - 19例时，风险为0.9（95%CI，0.7 - 1.4）。还注意到30天死亡率与医院过去一年的CAS手术量以及医院过去一年的非CAS手术量之间呈负相关。
在医疗保险患者中，即使在对所有相关患者和医院层面因素进行调整后，医生和医院的CAS手术量、医院非CAS支架置入手术量与30天死亡率之间仍存在负相关。
