Editor’s Choice – Carotid Stenosis Treatment: Variation in International Practice Patterns

OBJECTIVES:

The aim was to determine current practice for the treatment of carotid stenosis among 12 countries participating in the International Consortium of Vascular Registries (ICVR).

METHODS:

Data from the United States Vascular Quality Initiative (VQI) and the Vascunet registry collaboration (including 10 registries in Europe and Australasia) were used. Variation in treatment modality of asymptomatic versus symptomatic patients was analysed between countries and among centres within each country.

RESULTS:

Among 58,607 procedures, octogenarians represented 18% of all patients, ranging from 8% (Hungary) to 22% (New Zealand and Australia). Women represented 36%, ranging from 29% (Switzerland) to 40% (USA). The proportion of carotid artery stenting (CAS) among asymptomatic patients ranged from 0% (Finland) to 26% (Sweden) and among symptomatic patients from 0% (Denmark) to 19% (USA). Variation among centres within countries for CAS was highest in the United States and Australia (from 0% to 80%). The overall proportion of asymptomatic patients was 48%, but varied from 0% (Denmark) to 73% (Italy). There was also substantial centre level variation within each country in the proportion of asymptomatic patients, most pronounced in Australia (0-72%), Hungary (5-55%), and the United States (0-100%). Countries with fee for service reimbursement had higher rates of treatment in asymptomatic patients than countries with population based reimbursement (OR 5.8, 95% CI 4.4-7.7).

CONCLUSIONS:

Despite evidence about treatment options for carotid artery disease, the proportion of asymptomatic patients, treatment modality, and the proportion of women and octogenarians vary considerably among and within countries. There was a significant association of treating more asymptomatic patients in countries with fee for service reimbursement. The findings reflect the inconsistency of the existing guidelines and a need for cooperation among guideline committees all over the world.

Link: https://www.ncbi.nlm.nih.gov/pubmed/28274551

Variation in clinical practice in carotid surgery in nine countries 2005-2010. Lessons from VASCUNET and recommendations for the future of national clinical audit

OBJECTIVES:

The aim of the study was to analyse variation in carotid surgical practice, results and effectiveness in nine countries.

PATIENTS AND METHODS:

A total of 48,185 carotid endarterectomies (CEAs) and 4602 carotid artery stenting (CAS) procedures were included in the comparison. A theoretical effectiveness of CEA provision for each country was estimated.

RESULTS:

92.6% of the CEAs were performed according to the inclusion criteria based on the current European recommendations and had a theoretical benefit for the patient. The indication for surgery was symptomatic stenosis in 60.1% and this proportion varied between 31.4% in Italy and 100% in Denmark. The overall combined stroke and death rate in symptomatic patients was 2.3%. This varied between rates of 0.9% in Italy and 3.8% in Norway. The overall combined stroke and death rate in asymptomatic patients was 0.9%. It was lowest in Italy at 0.5%, and highest in Sweden at 2.7%. We estimated that the stroke prevention rate per 1000 CEAs varied from 72.9 in Italy to 130.8 in Denmark.

CONCLUSIONS:

There is significant variation in clinical practice across the participating countries. The theoretical stroke prevention potential of CEA seems to vary between participating countries due to differences in the inclusion criteria.

Link: https://www.ncbi.nlm.nih.gov/pubmed/22633072

Outcome following carotid endarterectomy: lessons learned from a large international vascular registry

OBJECTIVES:

The aim of the study was to assess if technical and patient-related factors are related to outcome after carotid surgery.

DESIGN:

Vascunet is a collaboration of national and regional registries with 10 contributing countries.

PATIENTS AND METHODS:

Data from 48,035 carotid endarterectomies (CEAs) performed in 383 centres, during 2003-2007, were merged into a common database.

RESULTS:

CEA was performed without patch (34%), with patch (40%) or with eversion (26%) in 74% for symptomatic and in 26% for asymptomatic disease. Overall (in-hospital and 30-day) mortality was 0.45%. Type of CEA or anaesthesia did not affect mortality, nor did contralateral occlusion. Mortality was higher in patients above the age of 75 years, for both genders (p < 0.05). The overall (in-hospital) stroke rate was 1.9%, the method of anaesthesia did not affect stroke rate. It was higher in patients with contralateral occlusion (4.6% vs. 2.5%, p = 0.002). Standard CEA without patch had a higher stroke rate than when a patch was used (2.3 vs. 1.7%, p = 0.015). Female patients >75 years had a higher stroke rate than younger women (2.0% vs. 1.6%, p = 0.078); this difference was not observed in men.

CONCLUSIONS:

Although there are limitations with registry data, the large number of cases involved provides useful information on outcomes, supplementing data from the randomised clinical trials (RCTs).

Link: https://www.ncbi.nlm.nih.gov/pubmed/21450496