National variation in preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery for asymptomatic carotid artery stenosis
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AuthorsArous, Edward J.
Simons, Jessica P.
Beck, Adam W.
Stone, David H.
Hoel, Andrew W.
Messina, Louis M.
UMass Chan AffiliationsDepartmetn of Surgery, Division of Vascular and Endovascular Surgery
Document TypeJournal Article
Aged, 80 and over
Ultrasonography, Doppler, Duplex
MetadataShow full item record
AbstractOBJECTIVE: Carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis is among the most common procedures performed in the United States. However, consensus is lacking regarding optimal preoperative imaging, carotid duplex ultrasound criteria, and ultimately, the threshold for surgery. We sought to characterize national variation in preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery for asymptomatic CEA. METHODS: The Society for Vascular Surgery Vascular Quality Initiative (VQI) database was used to identify all CEA procedures performed for asymptomatic carotid artery stenosis between 2003 and 2014. VQI currently captures 100% of CEA procedures performed at > 300 centers by > 2000 physicians nationwide. Three analyses were performed to quantify the variation in (1) preoperative imaging, (2) carotid duplex ultrasound criteria, and (3) threshold for surgery. RESULTS: Of 35,695 CEA procedures in 33,488 patients, the study cohort was limited to 19,610 CEA procedures (55%) performed for asymptomatic disease. The preoperative imaging modality used before CEA varied widely, with 57% of patients receiving a single preoperative imaging study (duplex ultrasound imaging, 46%; computed tomography angiography, 7.5%; magnetic resonance angiography, 2.0%; cerebral angiography, 1.3%) and 43% of patients receiving multiple preoperative imaging studies. Of the 16,452 asymptomatic patients (89%) who underwent preoperative duplex ultrasound imaging, there was significant variability between centers in the degree of stenosis (50%-69%, 70%-79%, 80%-99%) designated for a given peak systolic velocity, end diastolic velocity, and internal carotid artery-to-common carotid artery ratio. Although 68% of CEA procedures in asymptomatic patients were performed for an 80% to 99% stenosis, 26% were performed for a 70% to 79% stenosis, and 4.1% were performed for a 50% to 69% stenosis. At the surgeon level, the range in the percentage of CEA procedures performed for a < 80% asymptomatic carotid artery stenosis is from 0% to 100%. Similarly, at the center level, institutions range in the percentage of CEA procedures performed for a < 80% asymptomatic carotid artery stenosis from 0% to 100%. CONCLUSIONS: Despite CEA being an extremely common procedure, there is widespread variation in the three primary determinants-preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery-of whether CEA is performed for asymptomatic carotid stenosis. Standardizing the approach to care for asymptomatic carotid artery stenosis will mitigate the significant downstream effects of this variation on health care costs.
SourceJ Vasc Surg. 2015 Oct;62(4):937-44. doi: 10.1016/j.jvs.2015.04.438. Epub 2015 Jun 8. Link to article on publisher's site
Permanent Link to this Itemhttp://hdl.handle.net/20.500.14038/30638
Related ResourcesLink to Article in PubMed
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Institutional differences in carotid artery duplex diagnostic criteria result in significant variability in classification of carotid artery stenoses and likely lead to disparities in careArous, Edward J.; Baril, Donald T.; Robinson, William P. III; Aiello, Francesco A.; Hevelone, Nathanael D.; Arous, Elias J.; Messina, Louis M.; Schanzer, Andres (2014-05-01)BACKGROUND: The indications for carotid revascularization are based almost exclusively on the results of carotid duplex ultrasonography. Noninvasive vascular laboratories show large variation in the diagnostic criteria used to classify degree of carotid artery stenosis. We hypothesize that variability of these diagnostic criteria causes significant variation in stenosis classification directly affecting the number of revascularizations and associated costs. METHODS AND RESULTS: The diagnostic criteria to interpret carotid duplex ultrasounds were obtained from 10 New England institutions. All carotid duplex scans performed at our institution were reviewed from 2008 to 2012. Using the diagnostic criteria from each institution, the degree of stenosis that would have been reported was classified as 70% to 99% asymptomatic, 80% to 99% asymptomatic, and 50% to 99% symptomatic. We then calculated the theoretical number of carotid revascularization procedures that this cohort would be offered using each institution's diagnostic criteria and the costs of these procedures based on reimbursement rates. Among 10614 patients who underwent 15534 carotid duplex scans, 31025 arteries were reviewed. Application of the 10 institutions' criteria to the patients from our institution yielded marked variation in the number classified as 70% to 99% asymptomatic (range, 186-2201), 80% to 99% asymptomatic (range, 78-426), and 50% to 99% symptomatic (range, 157-781). If revascularizations were based on these results, costs would range from $2.2 to $26 million, $0.9 to $5.0 million, and $1.9 to $9.2 million, respectively. CONCLUSIONS: Differences in diagnostic criteria to interpret carotid ultrasound result in significant variation in classification of carotid artery stenosis, likely leading to differences in the number and subsequent costs of revascularizations. This theoretical model highlights the need for standardization of carotid duplex criteria.
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