メディケア頸動脈ステント留置術の全国適用決定が頸動脈血行再建術後の手技利用率と長期脳卒中リスクに及ぼす影響

In October 2023, Medicare expanded coverage for carotid stenting to include standard-risk beneficiaries, prompting substantial debate surrounding the potential impact on procedure utilization, most notably, for transfemoral carotid stenting (TFCAS). Since this coverage expansion, it remains unknown whether there has been a concordant change in carotid stenting utilization and resultant long-term stroke-risk. Therefore, our objective was to document trends in procedure utilization 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 (EHR) data. Truveta provides daily updated EHR data from over 800 hospitals and 100 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 6,473 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-value: <.001) and 38.4% for CEA (ITS p-value: .035). The procedure rate increased by 2.1% for TFCAS (ITS p-value: .365). Among asymptomatic patients, the freedom from stroke at 8 years for TCAR, CEA, and TFCAS was 87.2% (95%CI: 84.0%-90.5%), 86.3% (95%CI: 85.5%-87.2%), and 79.8% (95%CI: 77.6%-82.0%), respectively. Compared to 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 utilization 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 utilization surveillance to ensure optimal outcomes among patients undergoing carotid revascularization.