This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (121)  • Contact me when this article is cited  Related Content  • Related letter  • Related articles  • Similar articles in JAMA  Topic Collections  • Surgery  • Surgical Interventions  • Vascular Surgery  • Alert me on articles by topic  Social Bookmarking   What's this?

Randall D. Cebul, MD; Richard J. Snow, DO, MPH; Richard Pine, MD; Norman R. Hertzer, MD; Donald G. Norris, MD

JAMA. 1998;279:1282-1287.

Context.— While trials have demonstrated that carotid endarterectomy is superior to best medical therapy, most recently among asymptomatic patients, uses and outcomes of the procedure in more representative settings have not been established.

Objectives.— To profile the use and outcomes of carotid endarterectomy in a representative sample of Ohio's Medicare beneficiaries and to examine the relationships between provider-specific procedural volumes and patient outcomes.

Design.— Retrospective cohort using Medicare Provider Analysis and Review files supplemented by detailed reviews of medical records on a random sample of patients.

Setting.— Ohio hospitals performing carotid endarterectomy.

Patients.— A random sample of 678 charts of the 4120 non–health maintenance organization Medicare beneficiaries who underwent carotid endarterectomy between July 1, 1993, and June 30, 1994.

Main Outcome Measures.— Nonfatal stroke or death within 30 days of surgery.

Results.— The reviewed patients were similar to all eligible patients in sociodemographic characteristics and 30-day mortality rates. Among the 678 patients, indications for surgery were asymptomatic carotid stenosis in 167 (24.6%), transient ischemic attack in 294 (43.4%), completed stroke in 62 (9.1%), and nonspecific symptoms in 155 (22.9%). Thirty-two patients (4.7%) died or suffered nonfatal strokes by 30 days postoperatively. In univariate analyses, rates varied by hospital volume (P=.004) but not surgeons' volume (P=.47), although power to detect this difference was limited. Patients at higher- and lower-volume hospitals had similar indications and distributions of comorbidities. In analyses controlling for indications, comorbid conditions, and surgeon's volume, being operated on in a higher-volume hospital conferred a 71% reduction in risk for 30-day stroke or death (odds ratio, 0.29; 95% confidence interval, 0.12-0.69; P=.006).

Conclusions.— Almost half (47.5%) of the carotid endarterectomies among Ohio's Medicare population are performed on persons who are asymptomatic or who have nonspecific symptoms. These results highlight the importance of identifying patients and providers having the most favorable outcome profiles. The higher rate of adverse outcomes observed in lower-volume hospitals deserves further investigation, as it does not appear to be due to differences in patient selection.

From the Departments of Epidemiology and Biostatistics (Drs Cebul, Snow, and Pine) and Medicine (Dr Cebul), Institute for Public Health Sciences, Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio; the Department of Vascular Surgery, Cleveland Clinic Foundation (Dr Hertzer); and Peer Review Systems, Inc, Westerville, Ohio (Drs Snow, Pine, and Norris).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

RELATED LETTER

Outcomes After Carotid Endarterectomy
David M. Kent, Seemant Chaturvedi, Randall D. Cebul, Richard J. Snow, Richard Pine, Norman R. Hertzer, David E. Wennberg, F. L. Lucas, John D. Birkmeyer, and Elliott S. Fisher
JAMA. 1998;280(14):1228-1229.
EXTRACT | FULL TEXT  

RELATED ARTICLES

Variation in Carotid Endarterectomy Mortality in the Medicare Population: Trial Hospitals, Volume, and Patient Characteristics
David E. Wennberg, F. L. Lucas, John D. Birkmeyer, Carl E. Bredenberg, and Elliott S. Fisher
JAMA. 1998;279(16):1278-1281.
ABSTRACT | FULL TEXT  

Stroke Treatment: Promising but Still Struggling
Louis R. Caplan
JAMA. 1998;279(16):1304-1306.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Risk factors associated with major cerebrovascular complications after intracranial stenting
Nahab et al.
Neurology 2009;72:2014-2019.
ABSTRACT | FULL TEXT  

Screening for Carotid Artery Stenosis: An Update of the Evidence for the U.S. Preventive Services Task Force
Wolff et al.
ANN INTERN MED 2007;147:860-870.
ABSTRACT | FULL TEXT  

Factors Influencing the Volume-Outcome Relationship in Gastrectomies: A Population-Based Study
Smith et al.
Ann. Surg. Oncol. 2007;14:1846-1852.
ABSTRACT | FULL TEXT  

Has evidence changed practice?: Appropriateness of carotid endarterectomy after the clinical trials
Halm et al.
Neurology 2007;68:187-194.
ABSTRACT | FULL TEXT  

Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients
Yadav et al.
NEJM 2004;351:1493-1501.
ABSTRACT | FULL TEXT  

Carotid Revascularization for Prevention of Stroke: Carotid Endarterectomy and Carotid Artery Stenting
Brott et al.
Mayo Clin Proc. 2004;79:1197-1208.
ABSTRACT  

Reporting Standards for Carotid Artery Angioplasty and Stent Placement
Higashida et al.
Stroke 2004;35:e112-e134.
FULL TEXT  

Importance of the imaging modality in decision making about carotid endarterectomy
Kennedy et al.
Neurology 2004;62:901-904.
ABSTRACT | FULL TEXT  

Statewide Assessment of Hospital-Based Stroke Prevention and Treatment Services in North Carolina: Changes Over the Last 5 Years
Camilo and Goldstein
Stroke 2003;34:2945-2950.
ABSTRACT | FULL TEXT  

Systematic Review of the Risks of Carotid Endarterectomy in Relation to the Clinical Indication for and Timing of Surgery
Bond et al.
Stroke 2003;34:2290-2301.
ABSTRACT | FULL TEXT  

Financing Graduate Medical Education: Sorting Out the Confusion
Covey and Friedlaender
JBJS 2003;85:1594-1604.
FULL TEXT  

Revisiting the Appropriateness of Carotid Endarterectomy
Halm et al.
Stroke 2003;34:1464-1471.
ABSTRACT | FULL TEXT  

The volume-outcome relationship: from Luft to Leapfrog
Shahian and Normand
Ann. Thorac. Surg. 2003;75:1048-1058.
ABSTRACT | FULL TEXT  

Implementation of a Voluntary Hospitalist Service at a Community Teaching Hospital: Improved Clinical Efficiency and Patient Outcomes
Auerbach et al.
ANN INTERN MED 2002;137:859-865.
ABSTRACT | FULL TEXT  

To What Extent Should Quality of Care Decisions Be Based on Health Outcomes Data?: Application to Carotid Endarterectomy
Samsa et al.
Stroke 2002;33:2944-2949.
ABSTRACT | FULL TEXT  

Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature
Halm et al.
ANN INTERN MED 2002;137:511-520.
ABSTRACT | FULL TEXT  

Female Sex as a Risk Factor for In-Hospital Mortality Among Children Undergoing Cardiac Surgery
Chang et al.
Circulation 2002;106:1514-1522.
ABSTRACT | FULL TEXT  

The appropriate use of carotid endarterectomy
Barnett et al.
CMAJ 2002;166:1169-1179.
ABSTRACT | FULL TEXT  

Carotid Stenting and Endarterectomy: A Clinical and Cost Comparison of Revascularization Strategies
Gray et al.
Stroke 2002;33:1063-1070.
ABSTRACT | FULL TEXT  

An Unjustified Return to the Past * Response
Ballotta et al.
Stroke 2002;33:879-881.
FULL TEXT  

Association of Surgical Specialty and Processes of Care With Patient Outcomes for Carotid Endarterectomy
Hannan et al.
Stroke 2001;32:2890-2897.
ABSTRACT | FULL TEXT  

Geographic Variation in the Rate of Carotid Endarterectomy in Canada Editorial Comment
Feasby et al.
Stroke 2001;32:2417-2422.
ABSTRACT | FULL TEXT  

Results of carotid endarterectomy with prospective neurologist follow-up
Chaturvedi et al.
Neurology 2000;55:769-772.
ABSTRACT | FULL TEXT  

Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy
O'Neill et al.
Neurology 2000;55:773-781.
ABSTRACT | FULL TEXT  

Institutional Peer Review Can Reduce the Risk and Cost of Carotid Endarterectomy
Olcott IV et al.
Arch Surg 2000;135:939-942.
ABSTRACT | FULL TEXT  

Cerebrovascular Monitoring During Carotid Endarterectomy
Babikian and Cantelmo
Stroke 2000;31:1799-1801.
FULL TEXT  

EFFECT OF OPERATIVE VOLUME ON MORBIDITY, MORTALITY, AND HOSPITAL USE AFTER ESOPHAGECTOMY FOR CANCER
Swisher et al.
J. Thorac. Cardiovasc. Surg. 2000;119:1126-1134.
ABSTRACT | FULL TEXT  

Power Doppler Imaging: Initial Evaluation as a Screening Examination for Carotid Artery Stenosis
Bluth et al.
Radiology 2000;215:791-800.
ABSTRACT | FULL TEXT  

Changing Patterns of Resident Operative Experience From 1990 to 1997
Parsa et al.
Arch Surg 2000;135:570-575.
ABSTRACT | FULL TEXT  

Selective Referral to High-Volume Hospitals: Estimating Potentially Avoidable Deaths
Dudley et al.
JAMA 2000;283:1159-1166.
ABSTRACT | FULL TEXT  

ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery)
Eagle et al.
J Am Coll Cardiol 1999;34:1262-1347.
FULL TEXT  

Risk neutralization in cardiac operations: detection and treatment of associated carotid disease
Gott et al.
Ann. Thorac. Surg. 1999;68:850-856.
ABSTRACT | FULL TEXT  

Evidence based cardiology: Prevention of ischaemic stroke
Barnett et al.
BMJ 1999;318:1539-1543.
FULL TEXT  

Outcomes After Carotid Endarterectomy
Kent et al.
JAMA 1998;280:1228-1229.
FULL TEXT  

Dear Editor-in-Chief:
Roubin
Am. J. Neuroradiol. 1998;20:1378-1381.
FULL TEXT  

Variability in Use and Outcomes of Carotid Endarterectomy
JWatch General 1998;1998:3-3.
FULL TEXT  

Stroke Treatment: Promising but Still Struggling
Caplan
JAMA 1998;279:1304-1306.
FULL TEXT