Impact of the 2023 Centers for Medicare & Medicaid Services policy change on carotid artery stenting use among Medicare beneficiaries.

OBJECTIVE

On 11 October 2023, the Centers for Medicare & Medicaid Services expanded the indications for carotid artery stenting to include standard risk patients with symptomatic ≥50% and asymptomatic ≥70% carotid artery stenosis, providing surgeons an option between carotid endarterectomy and carotid artery stenting. This decision followed arguments both for and against the change by various professional societies, including opposition by the Society for Vascular Surgery. We sought to examine the impact of the change in policy with use of carotid artery stenting versus carotid endarterectomy.

METHODS

We used 100% Medicare fee-for-service claims data to identify all patients who underwent carotid artery stenting or carotid endarterectomy between 1 January 2017 and 30 September 2024. Patients without 12 months of continuous Medicare enrollment before the procedure and/or younger than 18 years of age were excluded. Carotid artery stenting included both transfemoral and transcarotid revascularization. We evaluated the trends in use of carotid artery stenting compared with carotid endarterectomy overall and stratified by symptomatic status using hierarchical logistic regression models adjusting for patient and physician-level characteristics. We conducted an interrupted time series analysis with the time break set at October 2023 to evaluate the impact of the Centers for Medicare & Medicaid Services policy change on carotid artery stenting use.

RESULTS

There were 395,092 carotid revascularizations performed during the study period (median age 75.1 years, 59.9% male, 3.5% Black race), including 45.0% for symptomatic compared with 55.0% for asymptomatic disease, and 76.7% carotid endarterectomy compared with 23.3% carotid artery stenting. The proportion of carotid revascularizations performed using carotid artery stenting significantly increased over time (2017: 13.0% vs 2024: 37.99%; P < .001), including for both symptomatic (2017: 15.6% vs 2024: 40.9%; P < .001) and asymptomatic patients (2017: 11.0% vs 2024: 21.9%; P < .001). After adjusting for patient and treating physician-level variables, the use of carotid artery stenting vs carotid endarterectomy increased by 28% per year since 2017 overall (adjusted odds ratio, 1.28; 95% confidence interval, 1.28-1.29), including 25% in symptomatic patients (adjusted odds ratio, 1.25, 95% confidence interval, 1.24-1.27) and 31% in asymptomatic patients (adjusted odds ratio, 1.31, 95% confidence interval, 1.30-1.32). Based on the interrupted time series analysis, there was a significant decrease in carotid endarterectomy use (P = .001) and increase in carotid artery stenting use (P = .003) after the Centers for Medicare & Medicaid Services policy change on carotid artery stenting use in October 2023.

CONCLUSION

There has been a significant increase in carotid artery stenting use with a concomitant decline in carotid endarterectomy use since the Centers for Medicare & Medicaid Services decision to expand carotid artery stenting indications. Continued monitoring of these trends will be important to ensure optimal patient outcomes and appropriate use of carotid revascularization strategies.