Individual Surgeon Report Cards for Rate of Carotid Endarterectomies in Asymptomatic Patients: An Improving Wisely Performance Metric for Carotid Disease

Abstract

Introduction - Prior randomized trials have demonstrated that carotid endarterectomy (CEA) can reduce stroke risk in asymptomatic patients. However, subsequent improvements in medical management have challenged this notion. The aim of our study was to describe surgeon-specific CEA rates for asymptomatic versus symptomatic patients in the United States, and to identify factors associated with potential overuse of asymptomatic CEA. Methods - We studied all patients undergoing an initial CEA in the Medicare Claims database between 01/2014 – 12/2016. The database includes National Provider Identification (NPI) numbers for surgeons. Patients with any prior CEA and surgeons who performed ≤ 10 CEAs during the study period were excluded. For each individual surgeon, we calculated the proportion of patients undergoing CEA for asymptomatic vs. symptomatic carotid disease. Multivariable logistic regression was performed to identify surgeon covariates associated with performing a very high proportion (100%) of CEA in asymptomatic patients. Results - Overall, 108,391 patients (median age 75 years, 62% male) underwent CEA by 2,983 surgeons during the study period, of whom 89.5% (N=97,007) were asymptomatic. The majority of surgeons performing CEA were vascular surgeons (64.1%, N=1,912), followed by general surgeons (24.0%, N=716) and cardiac surgeons (11.9%, N=355). The median number of CEA cases performed by a single surgeon over the 2-year study period was 28 (range 11-331), of which the median proportion of asymptomatic CEA procedures was 93.8% (IQR 87.6-100%). More than half (56.3%, N=1,679) of surgeons performed CEA for asymptomatic disease in ≥90% of their cases. 17.6% (N=514) of surgeons performed CEA for asymptomatic disease in 100% of their cases, including 12.9% of vascular surgeons and 25.0% of non-vascular surgeons (Figure 1). Individual surgeon factors that were independently associated with operating exclusively on asymptomatic patients included low-volume vs. high-volume CEA practice [OR 6.4 (95%CI 4.3-9.5)] and non-vascular surgical specialty [OR 2.1 (95%CI 1.7-2.6)]. Conclusion - Carotid endarterectomy is performed primarily for asymptomatic carotid disease by the majority of surgeons in the US. One quarter of non-vascular surgeons perform carotid endarterectomy only in asymptomatic patients, suggesting that vascular surgeons user stricter criteria for the operation than non-vascular surgeons. These findings underscore the potential broad implications of the results of the CREST-2 trial, which seeks to better inform our understanding of the benefits of CEA versus modern medical management for asymptomatic carotid disease.