美国和加拿大颈动脉内膜切除术的兴衰

The fall and rise of carotid endarterectomy in the United States and Canada.

作者信息

Tu J V, Hannan E L, Anderson G M, Iron K, Wu K, Vranizan K, Popp A J, Grumbach K

机构信息

Institute for Clinical Evaluative Sciences, Department of Medicine, Sunnybrook Health Science Centre, University of Toronto, ON, Canada.

出版信息

N Engl J Med. 1998 Nov 12;339(20):1441-7. doi: 10.1056/NEJM199811123392006.

DOI:10.1056/NEJM199811123392006

PMID:9811920

Abstract

BACKGROUND

Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy in the prevention of stroke when the procedure is performed in regional centers of surgical excellence. However, the relative effects of these studies on the rates of carotid endarterectomy in the United States and Canada have been unclear.

METHODS

We calculated the annual rate of carotid endarterectomy in the U.S. states of California and New York and in the Canadian province of Ontario from 1983 through 1995. We also studied whether patients in the early 1990s were selectively referred to hospitals with high volumes of procedures and historically low in-hospital mortality rates.

RESULTS

Rates of carotid endarterectomy fell in all three regions from 1984 to 1989 (from 126 to 66 per 100,000 adults 40 years of age or older in California, from 65 to 40 per 100,000 in New York, and from 40 to 15 per 100,000 in Ontario), after the publication of studies demonstrating that the rates of complications of carotid endarterectomy were unacceptably high. However, the clinical trials of the 1990s, which showed benefit from carotid endarterectomy, were associated with a dramatic resurgence in the rates of the procedure from 1989 to 1995 (from 66 to 99 per 100,000 in California, from 40 to 96 per 100,000 in New York, and from 15 to 38 per 100,000 in Ontario). These increased rates were not associated with proportionally greater numbers of referrals of patients to hospitals with low mortality rates.

CONCLUSIONS

There have been a dramatic fall and rise in the rates of carotid endarterectomy in both the United States and Canada, which correlate with the publication of first unfavorable and then favorable clinical studies. The absence of selective referral of patients to centers with the lowest mortality rates raises questions about whether the benefits of carotid endarterectomy in the general population are similar to those demonstrated in the clinical trials.

摘要

背景

随机临床试验已证明，在具备卓越外科手术水平的区域中心进行颈动脉内膜切除术，对于预防中风具有疗效。然而，这些研究对美国和加拿大颈动脉内膜切除术发生率的相对影响尚不清楚。

方法

我们计算了1983年至1995年美国加利福尼亚州和纽约州以及加拿大安大略省的颈动脉内膜切除术年发生率。我们还研究了20世纪90年代早期的患者是否被选择性转诊至手术量高且历史住院死亡率低的医院。

结果

1984年至1989年，所有三个地区的颈动脉内膜切除术发生率均下降（加利福尼亚州每10万名40岁及以上成年人中，从126例降至66例；纽约州从每10万例中的65例降至40例；安大略省从每10万例中的40例降至15例），此前有研究表明颈动脉内膜切除术的并发症发生率高得令人无法接受。然而，20世纪90年代显示颈动脉内膜切除术有益的临床试验，与1989年至1995年该手术发生率的急剧回升相关（加利福尼亚州从每10万例中的66例升至99例；纽约州从40例升至96例；安大略省从15例升至38例）。这些上升的发生率与转诊至死亡率低的医院的患者数量成比例增加无关。