Contemporary Trends In Physician Utilization Rates Of CEA And CAS For Asymptomatic Carotid Stenosis Among Medicare Beneficiaries
Rebecca Sorber, MD1, Michael S. Clemens, MD2, Peiqi Wang, MD1, James H. Black, III, MD1, Martin A. Makary, MD MPH1, Caitlin W. Hicks, MD MS1.
1The Johns Hopkins Hospital, Baltimore, MD, USA, 22240th Forward Resuscitative Surgical Team, Fort Bragg, NC, USA.
OBJECTIVES: Surgical intervention for asymptomatic carotid artery stenosis (ACAS) has become increasingly controversial over time with the optimization of best medical therapy. Despite this, most carotid revascularization procedures in the United States are performed for ACAS. This study assesses and defines contemporary trends in carotid revascularization rates for ACAS and characterizes outlier physicians performing a higher rate of asymptomatic revascularization compared to their peers.
METHODS: We used 100% Medicare fee-for-service claims to identify patients newly diagnosed with ACAS between 01/2011-06/2018. Patients with symptomatic stenoses, prior carotid revascularization, and surgeons performing ≤10 revascularizations during the study period were excluded. We used a hierarchical multivariable logistic regression model to evaluate patient and physician characteristics associated with CEA or CAS within 3 months of the initial diagnosis of ACAS. Temporal revascularization trends were assessed using the Cochran-Armitage Trend Test.
RESULTS: Overall, 795,512 patients (median age 73.9 years, 50.9% male, 87.6% white) had a first-time diagnosis of ACAS, of which 23,431 (3.0%) underwent revascularization within 3 months. Of these patients, 87.8% underwent CEA and 12.2% underwent CAS. There was a significant decline in overall revascularization rate over time (2011: 3.2% vs. 2018: 2.1%; P<0.001; Figure 1). Among 6,670 physicians identified, mean 3-month revascularization rate was 4.7%±7.1%. 350 physicians (5.2%) were identified as outliers with individual intervention rates ≥19% (>2 standard deviations above the mean). After adjusting for patient-level characteristics, physician-level variables associated with carotid revascularization for ACAS included male sex (adjusted OR:1.59, 95%CI:1.35-1.89), more years in practice (≥31 vs. <10 years, aOR:1.64, 95%CI:1.32-2.04), rural practice location (aOR:1.34, 95%CI:1.18-1.52), Southern practice location (vs. Northeastern, aOR:1.54, 95%CI:1.39-1.69), and lower ACAS patient volume (lower vs. upper tertile, aOR:2.62, 95%CI:2.39-2.89). Cardiothoracic surgeons had a 1.52-fold higher odds of revascularization compared to vascular surgeons (95%CI:1.36-1.68), whereas cardiologists and radiologists had lower intervention rates (both, P<0.05).
CONCLUSIONS: The current revascularization rate for ACAS within 3 months of diagnosis is <5% in the U.S., and has significantly decreased in recent years. However, there remain particular physician characteristics associated with higher rates of carotid revascularization. Outlier physicians may benefit from targeted peer-benchmarked feedback to improve their practice patterns for newly diagnosed ACAS. 
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