Changes in the use of carotid revascularization among the medicare population
Philip P Goodney1, F Lee Lucas, Lori L Travis
1Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03766, USA. philip.goodney@hitchcock.org
Insights
Carotid revascularization procedures slightly decreased overall, but carotid artery stenting (CAS) use dramatically increased from 1998 to 2004. Further research is needed to determine if CAS is replacing carotid endarterectomy (CEA) or expanding indications.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Health Services Research
Background:
- Carotid endarterectomy (CEA) has been the standard surgical treatment for symptomatic carotid artery stenosis.
- Carotid artery stenting (CAS) has emerged as an alternative revascularization technique.
- Population-based trends in the utilization of CEA versus CAS remain incompletely understood.
Purpose of the Study:
- To examine national trends in the use of CEA and CAS among Medicare beneficiaries.
- To determine if the increasing adoption of CAS has influenced the utilization rates of CEA.
Main Methods:
- Retrospective cohort study utilizing Medicare beneficiary data from 1998 to 2004.
- Carotid revascularization procedures (CEA and CAS) were identified using Current Procedural Terminology codes.
- Exclusion criteria were applied to differentiate carotid procedures from peripheral artery interventions.
Main Results:
- A total of 134,194 carotid revascularization claims were identified (124,808 CEA, 9,386 CAS).
- Overall carotid revascularization incidence decreased by 11% (388.1 to 345.8 per 100,000 beneficiaries).
- CEA incidence declined by 17% (373.4 to 309.3 per 100,000), while CAS incidence surged by 149% (14.6 to 36.4 per 100,000).
Conclusions:
- Despite an overall slight decrease in carotid revascularization rates, CAS utilization significantly increased between 1998 and 2004.
- It is unclear whether the rise in CAS represents a direct substitution for CEA or an expansion of indications.
- Further investigation is warranted to clarify the evolving role of CAS versus CEA in clinical practice and its implications for healthcare costs.
Hypothesis:
It remains unknown if the increasing use of carotid artery stenting (CAS) has caused a change in the population-based use of carotid endarterectomy (CEA). We sought to examine national trends in carotid revascularization.
Design:
Retrospective cohort study.
Setting:
Academic research.
Patients:
All Medicare beneficiaries (MCBEs) between January 1, 1998, through December 31, 2004.
Main Outcome Measures:
We examined the frequency of CEA and CAS using Current Procedural Terminology codes for CEA, peripheral stent insertion, and cerebrovascular disease. To exclude patients who underwent stenting of a peripheral artery other than the carotid artery, we excluded all patients with a primary diagnostic code for peripheral vascular disease.
Results:
We identified 134 194 claims for carotid revascularization (9386 claims for CAS and 124 808 claims for CEA). The overall incidence of carotid revascularization procedures decreased slightly between 1998 and 2004, from 388.1 to 345.8 procedures per 100 000 MCBEs (11% decrease, P < .02). Between 1998 and 2004, the incidence of CEA decreased from 373.4 to 309.3 procedures per 100 000 MCBEs (17% decrease, P < .01), while the incidence of CAS increased from 14.6 to 36.4 procedures per 100 000 MCBEs (149% increase, P < .01).
Conclusions:
While rates of carotid revascularization in the Medicare population slightly decreased between 1998 and 2004, the use of CAS dramatically increased. Whether this represents a substitution of CAS for CEA vs a broadening of indications for carotid revascularization using CAS is unknown but is of interest to patients and third-party payers and requires future investigation.
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