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CAS, endarterectomy reduced stroke in Medicare beneficiaries
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The number of patients who had a stroke after carotid artery stenting or carotid endarterectomy declined over time, according to an analysis published in JAMA.
Use of CAS increased from 1999 to 2006 then declined until 2014 and use of carotid endarterectomy declined from 1999 to 2014.
Medicare beneficiaries
Judith H. Lichtman, PhD, MPH, associate professor and department chair of epidemiology and department chair of chronic disease epidemiology at Yale University School of Public Health, and colleagues analyzed data from patients who were enrolled in fee-for-service Medicare and underwent carotid endarterectomy (n = 937,111; mean age, 76 years; 43% women) or CAS (n = 231,077; mean age, 75 years; 49% women) from 1999 to 2014. Patients were excluded if they underwent both procedures.
Outcomes of interest were in-hospital mortality, revascularization rates per 100,000 beneficiary-years of fee-for-service enrollment, 30-day stroke, MI, 30-day stroke or death, 30-day all-cause mortality and 1-year stroke.
The number of patients who underwent carotid endarterectomy decreased from 81,306 in 1999 to 36,325 in 2014, as the national rate decreased from 298 per 100,000 beneficiary-years from 1999-2000 (95% CI, 297-300) to 128 per 100,000 beneficiary-years from 2013-2014 (95% CI, 127-129; P < .001).
The rate of patients who underwent CAS fluctuated from 10,416 in 1999 to 22,865 in 2006 and 10,208 in 2014. Between 1999-2000 and 2005-2006, the national rate of CAS increased from 40 to 75 per 100,000 beneficiary-years (P < .001), which then decreased annually to 38 per 100,000 beneficiary-years (P < .001).
The number of symptomatic patients in both groups increased over time (P < .001).
Although outcomes improved over time, the prevalence of hypertension increased from 67.1% to 81.2% in patients who underwent endarterectomy and from 61.5% to 70.2% in those who underwent CAS.
Decline in ischemic stroke
In adjusted analyses, the annual reduction for 30-day ischemic stroke or death in patients who underwent carotid endarterectomy was 2.9% (95% CI, 2.63-3.18) vs. 1.13% in those in the CAS group (95% CI, 0.71-1.54). The absolute decrease in the composite of ischemic stroke or death in the endarterectomy group from 1999 to 2014 was 1.4% (95% CI, 1.2-1.5). An absolute decrease over time was not seen in the CAS group (–0.1%; 95% CI, –0.6 to 0.4).
Ischemic stroke at 1 year decreased over time in patients after endarterectomy (absolute decrease, 3.5%; 95% CI, 3.2-3.7; adjusted annual reduction, 2.17%; 95% CI, 2-2.34) and CAS (absolute decrease, 1.6%; 95% CI, 1.2-2.1; adjusted annual reduction, 1.86%; 95% CI, 1.45-2.26).
In-hospital mortality, 30-day all-cause mortality, 30-day stroke, MI or death improved during the time period within demographic subgroups.
“Carotid artery stenting availability may have contributed to the reduction in carotid endarterectomy during early years of the study,” Lichtman and colleagues wrote. “Consistent with prior work, carotid artery stenting rates increased through 2006, presumably because of the expansion of Medicare reimbursement and the publication of clinical trial results.” – by Darlene Dobkowski
Disclosures: Lichtman reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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