Can randomized trial outcomes for carotid endarterectomy be achieved in community-wide practice?

The benefit of carotid endarterectomy (CEA) is dependent upon achieving procedural outcomes comparable to those observed in randomized trials. We have extensively examined outcomes of the procedure in the community with a complete medical record (hospital chart) review of over 20,000 Medicare patients undergoing CEA in 10 states. In patients with comparable indications, overall risk of stroke or death of 6.9% in our Medicare studies was comparable to the 6.5% combined event rate in the North American Symptomatic Carotid Endarterectomy Trial. In asymptomatic patients, however, the overall Medicare study result of 3.8% was inferior to the benchmark perioperative combined event rate of 1.5% achieved in the Asymptomatic Carotid Atherosclerosis Study. Our data demonstrated that the randomized trial benchmarks could be achieved or even exceeded at a statewide level. Our studies also documented that evidence-based processes that can reduce perioperative stroke and death (eg, perioperative antiplatelet therapy, patching) are underutilized in the community. Overall process and outcomes assessment show considerable room for improvement. All surgeons performing CEA should use a system-based approach to ensure that all evidence-based processes are employed for patients undergoing CEA and should use indication stratification to document their own outcomes for the procedure.