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 PVSS6. Regional Variation in Carotid Revascularization Is Specialty-Driven

​Jessica B. Wallaert, Jack L. Cronenwett, David H. Stone, Richard J. Powell, Brian Nolan, Randall R. DeMartino, Philip P. Goodney
Dartmouth Hitchcock Medical Center, Lebanon, NH.

OBJECTIVES: Advances in medical therapy and endovascular techniques have caused uncertainty regarding the role of carotid revascularization. We hypothesized that these advances affect regional utilization of carotid endarterectomy (CEA) and carotid artery stenting (CAS).

METHODS: We used Medicare claims (2002-2010) to calculate annual rates of CAS and CEA and examined changes by procedure type. To assess regional preferences surrounding CAS, we calculated, within hospital referral regions, the proportion of revascularizations comprised by CAS and examined determinants of high CAS utilization.
 
RESULTS: The annual number of carotid revascularizations decreased by 30% over 8 years (3.2 to 2.3 per 1000, p=0.005). While rates of CEA declined 37% (3.0 to 1.9 per 1000, p=0.005), CAS utilization changed little (0.39 to 0.32 per 1000, p=NS, Figure 1). The proportion of carotid revascularizations that were CAS varied across the United States, from 0.4% (Marquette, MI) to 44% (St. Joseph, MI) of all carotid revascularizations. In multivariable models accounting for age, sex and race, regions with the highest density of cardiologists had the highest utilization of CAS (OR 2.7, 95% CI 1.4-5.1, p=0.002).
 
CONCLUSIONS: Even though CEA has decreased by 37% over 8 years, utilization of CAS has remained constant. Patients living in regions with the highest density of cardiologists are most likely to receive CAS. Future efforts to define the role carotid revascularization will require a multidisciplinary approach to ensure uniform health policy implementation.
 
AUTHOR DISCLOSURES: J. L. Cronenwett: Nothing to disclose; R. R. DeMartino: Nothing to disclose; P. P. Goodney: Nothing to disclose; B. Nolan: Nothing to disclose; R. J. Powell: Nothing to disclose; D. H. Stone: Nothing to disclose; J. B. Wallaert: Nothing to disclose.
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Posted April 2013

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