Jabbour Gabriel, Yadavalli Sai Divya, Strauss Sabrina, Sanders Andrew P, Rastogi Vinamr, Eldrup-Jorgensen Jens, Powell Richard J, Davis Roger B, Schermerhorn Marc L
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
medRxiv. 2023 Nov 17:2023.11.16.23298660. doi: 10.1101/2023.11.16.23298660.
With the recent expansion of the Centers for Medicare and Medicaid Services (CMS) coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. This study evaluates the tfCAS learning curve using VQI data.
We analyzed tfCAS patient data from 2005-2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. Primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/MI, 30-day mortality, and in-hospital stroke/TIA. The relationship between outcomes and procedure counts was analyzed using Cochran Armitage test and a generalized linear model with restricted cubic splines, validated using generalized estimating equations.
We analyzed 43,147 procedures by 2,476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2% to 1.7%), in-hospital stroke/death/MI (5.8% to 1.7%), 30-day mortality (4.6% to 2.8%), in-hospital stroke/TIA (5.0% to 1.1%) (all p-values<0.05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1% to 1.6%), in-hospital stroke/death/MI (2.6% to 1.6%), 30-day mortality (1.7% to 0.4%), and in-hospital stroke/TIA (2.8% to 1.6%) with increasing physician experience (all p-values<0.05). The in-hospital stroke/death rate remained above 2% until 13 procedures.
In-hospital stroke/death and 30-day mortality rates post-tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. With the recent CMS coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased post-operative complications.
随着医疗保险和医疗补助服务中心（CMS）覆盖范围的近期扩大，经股动脉颈动脉支架置入术（tfCAS）有望在颈动脉疾病管理中发挥更大作用。现有关于tfCAS学习曲线的研究主要在十多年前进行，可能无法充分描述医生经验对治疗结果的当前影响。本研究使用血管质量倡议（VQI）数据评估tfCAS学习曲线。
我们分析了2005年至2023年的tfCAS患者数据。每位医生的手术按时间顺序分为12组，从手术例数1 - 25例到351例以上。主要结局是住院期间卒中/死亡率；次要结局是住院期间卒中/死亡/心肌梗死、30天死亡率以及住院期间卒中/短暂性脑缺血发作（TIA）。使用 Cochr an Armitage检验和带有受限立方样条的广义线性模型分析结局与手术例数之间的关系，并使用广义估计方程进行验证。
我们分析了2476名医生的43147例手术。在有症状的患者中，住院期间卒中/死亡率（手术例数1 - 25例到351例以上：5.2%至1.7%）、住院期间卒中/死亡/心肌梗死率（5.8%至1.7%）、30天死亡率（4.6%至2.8%）、住院期间卒中/TIA率（5.0%至1.1%）均有所下降（所有p值<0.05）。住院期间卒中/死亡率在235例手术之前一直高于4%。同样，在无症状患者中，随着医生经验增加，住院期间卒中/死亡率（2.1%至1.6%）、住院期间卒中/死亡/心肌梗死率（2.6%至1.6%）、30天死亡率（1.7%至0.4%）以及住院期间卒中/TIA率（2.8%至1.6%）均有所下降（所有p值<0.05）。住院期间卒中/死亡率在13例手术之前一直高于2%。
tfCAS术后住院期间卒中/死亡率和30天死亡率随着医生经验增加而降低，显示出与先前报告一致的漫长学习曲线。鉴于VQI可能未纳入医生的早期病例，学习曲线可能被低估。随着CMS近期对tfCAS覆盖范围的扩大，大量医生将进入学习曲线的早期阶段，可能导致术后并发症增加。
