Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
240th Forward Resuscitative Surgical Team, Fort Bragg, NC.
Ann Vasc Surg. 2021 Feb;71:132-144. doi: 10.1016/j.avsg.2020.08.118. Epub 2020 Sep 3.
Carotid revascularization for asymptomatic carotid artery stenosis (ACAS) has become increasingly controversial in the past few decades as the best medical therapy has improved. The aim of this study was to assess and define contemporary trends in the rate of carotid revascularization procedures for ACAS in the United States and to characterize outlier physicians performing a higher rate of asymptomatic revascularization compared to their peers.
We used 100% Medicare fee-for-service claims to identify all patients who were newly diagnosed with ACAS between 01/2011-06/2018. Patients with symptomatic carotid artery stenosis, those with prior carotid revascularization, and surgeons who performed ≤10 CEAs during the study period were excluded. We used a hierarchical multivariable logistic regression model to evaluate patient and physician characteristics associated with undergoing a carotid endarterectomy or carotid artery stent procedure within 3 months after the initial diagnosis of ACAS. We also assessed temporal trends in carotid revascularization rates over time using the Cochran-Armitage Trend Test.
Overall, 795,512 patients (median age 73.9 years, 50.9% male, 87.6% white) had a first-time diagnosis of ACAS during the study period, of which 23,481 (3.0%) underwent carotid revascularization within 3 months. There was a significant decline in overall carotid artery revascularization rates over time (2011: 3.2% vs. 2018: 2.1%; P < 0.001). The median and mean physician-specific carotid revascularization rates were 2.0% (IQR 0.0%-6.3%) and 4.7% ± 7.1%, respectively. Three-hundred and fifty physicians (5.2%) had carotid revascularization rates ≥19%, which was more than 2 standard deviations above the mean. After adjusting for patient-level characteristics, physician-level variables associated with carotid revascularization for newly diagnosed ACAS included male sex (adjusted OR 1.59, 95% CI 1.35-1.89), more years in practice (≥31 vs. <10 years, aOR 1.64, 95% CI 1.32-2.04), rural practice location (aOR 1.34, 95% CI 1.18-1.52), Southern region practice location (versus Northeast, aOR 1.54, 95% CI 1.39-1.69), and lower volume of ACAS patients (lower versus upper tertile, aOR 2.62, 95% CI 2.39-2.89). Cardiothoracic surgeons had a 1.52-fold higher odds of carotid revascularization compared to vascular surgeons (95% CI 1.36-1.68), whereas cardiologists and radiologists had lower intervention rates (both, P < 0.05).
The current early revascularization rate for newly diagnosed ACAS is <5% among proceduralists in the United States, and has been decreasing steadily since 2014. There are particular physician-level characteristics that are associated with higher rates of carotid revascularization that cannot be fully contextualized without high-level contemporary outcomes data to guide decision making in ACAS.
随着最佳医疗治疗的改善，过去几十年来，无症状颈动脉狭窄（ACAS）的颈动脉血运重建越来越受到争议。本研究旨在评估和定义美国无症状颈动脉血运重建手术率的当代趋势，并确定与同行相比进行更高比例无症状血运重建的异类医生。
我们使用 100%的医疗保险按服务收费数据，确定 2011 年 1 月至 2018 年 6 月期间新诊断为 ACAS 的所有患者。排除有症状性颈动脉狭窄、有颈动脉血运重建史和研究期间进行的颈动脉内膜切除术（CEA）≤10 例的外科医生。我们使用分层多变量逻辑回归模型评估与 3 个月内接受颈动脉内膜切除术或颈动脉支架置入术相关的患者和医生特征。我们还使用 Cochran-Armitage 趋势检验评估颈动脉血运重建率随时间的时间趋势。
总体而言，795512 例患者（中位年龄 73.9 岁，50.9%为男性，87.6%为白人）在研究期间首次诊断为 ACAS，其中 23481 例（3.0%）在 3 个月内行颈动脉血运重建。颈动脉血运重建总发生率呈下降趋势（2011 年：3.2%，2018 年：2.1%；P<0.001）。医生特定的颈动脉血运重建率中位数和平均值分别为 2.0%（IQR 0.0%-6.3%）和 4.7%±7.1%。350 名医生（5.2%）的颈动脉血运重建率≥19%，超过平均值 2 个标准差。调整患者水平特征后，与新诊断的 ACAS 行颈动脉血运重建相关的医生水平变量包括男性（调整后的 OR 1.59，95% CI 1.35-1.89）、更长的从业年限（≥31 年与<10 年，aOR 1.64，95% CI 1.32-2.04）、农村执业地点（aOR 1.34，95% CI 1.18-1.52）、南部地区执业地点（与东北部相比，aOR 1.54，95% CI 1.39-1.69）和较低的 ACAS 患者量（与上三分位相比，aOR 2.62，95% CI 2.39-2.89）。心胸外科医生进行颈动脉血运重建的可能性是血管外科医生的 1.52 倍（95% CI 1.36-1.68），而心脏病专家和放射科医生的介入率较低（均为 P<0.05）。
目前，美国介入医生新诊断为 ACAS 的早期血运重建率<5%，自 2014 年以来一直稳步下降。有一些医生水平特征与更高的颈动脉血运重建率相关，如果没有高水平的当代结果数据来指导 ACAS 的决策，这些特征就无法完全进行背景化。
