AIM: Surgery or stent for carotid artery disease? Depends on where you live

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For Medicare beneficiaries with carotid artery disease, methods of treatment--carotid endarterectomy and carotid artery stenting--vary greatly across specific regions of the U.S., according to a study published July 26 in the Archives of Internal Medicine.

To look at carotid stenosis treatment trends, Manesh R. Patel, MD, of the Duke University School of Medicine in Durham, N.C., and colleagues assessed Medicare claims of patients 65 years and older from the Centers for Medicare & Medicaid Services (CMS) database between Jan.1, 2003, and Dec. 31, 2006.

While various trials have shown that carotid endarterectomy (CEA) may be a recommended treatment for some patient populations ( CREST trial), researchers of the current study found that during 2003 and 2006, CEA dropped among Medicare beneficiaries from 3.2 per 1,000 patients per year to 2.6 per 1,000 patients per year.

However, the researchers found that 30-day mortality rates were better in patients who received CEA compared to carotid artery stenting (CAS), 1.2 percent versus 2.3 percent. These rates at one year were also better in those receiving CEA, 6.8 percent versus 10.3 percent.

The results showed that there was a nine-fold difference between the highest and lowest rate of CEA use across various regions in 2003-2004 and a seven-fold difference in 2005-2006.

Additionally, Patel and colleagues found that Alabama, Kentucky, Mississippi, Tennessee (East South Central), Illinois, Indiana, Michigan, Ohio, Wisconsin (East North Central), Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota and South Dakota (West North Central) saw the highest CEA use.

In contrast, the New England, Mountain and Pacific areas saw the lowest rates of both CEA and CAS procedures.

“Significant geographic variation was seen in the use of carotid endarterectomy and carotid stenting among Medicare beneficiaries and variation in the carotid imaging modalities used before revascularization,” the authors concluded.

“Moreover, men and patients with a prior diagnosis of peripheral vascular disease were more likely to undergo carotid revascularization, and patients with a prior diagnosis of coronary artery disease or a prior carotid endarterectomy were more likely to undergo carotid stenting. These findings suggest that the development of consensus regarding clinical criteria for carotid imaging, such as a national standard for appropriate use criteria, is required.”