Impact of the Medicare carotid stenting national coverage determination on procedure utilization and long-term stroke...

In October 2023, Medicare expanded coverage for carotid stenting to include standard-risk beneficiaries, prompting substantial debate surrounding the potential impact on procedure use, most notably, for transfemoral carotid artery stenting (TFCAS). Since this coverage expansion, it remains unknown whether there has been a concordant change in carotid stenting use and resultant long-term stroke risk. Therefore, our objective was to document trends in procedure use of TFCAS, transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) in response to the coverage expansion and compare the respective long-term stroke risks.

We performed a retrospective study using Truveta electronic health record data. Truveta provides daily updated electronic health record data from >800 hospitals and >120 million patients. We studied patients who underwent TCAR, CEA, or TFCAS from January 2016 to December 2024. We calculated the procedure rate for each quarter and performed an interrupted time series (ITS) analysis to assess the change from Q3 2023 (Medicare policy change) to Q4 2024. We used Kaplan-Meier analysis and Cox regression to compare the long-term stroke risk among asymptomatic patients.

We identified 6473 TCAR patients (65.9% asymptomatic), 36,224 CEA patients (61.6% asymptomatic), and 11,626 TFCAS patients (50.1% asymptomatic). The procedure rate per 100,000 patients from Q3 2023 (Medicare policy change) to Q4 2024 decreased by 39.3% for TCAR (ITS P < .001) and 38.4% for CEA (ITS P = .035). The procedure rate increased by 2.1% for TFCAS (ITS P = .365). Among asymptomatic patients, the freedom from stroke at 8 years for TCAR, CEA, and TFCAS was 87.2% (95% confidence interval [CI], 84.0%-90.5%), 86.3% (95% CI, 85.5%-87.2%), and 79.8% (95% CI, 77.6%-82.0%), respectively. Compared with CEA, the adjusted hazard ratio of stroke was 0.83 (95% CI, 0.72-0.97) after TCAR and 1.41 (95% CI, 1.27-1.56) after TFCAS.

TFCAS use has remained largely unchanged since the Medicare coverage expansion, refuting any perception that the Medicare policy shift would substantially impact real-world carotid practice. Interestingly, TCAR and CEA rates have decreased over time, despite having a lower long-term stroke risk. These findings highlight the need for longitudinal procedure use surveillance to ensure optimal outcomes among patients undergoing carotid revascularization.