Study Evaluates Variation in International Practice Patterns for Carotid Stenosis Treatment
March 28, 2017—In European Journal of Vascular and Endovascular Surgery (EJVES), Maarit Venermo, MD, and Grace J. Wang, MD, et al published a study on the variation in international practice patterns in the treatment of carotid stenosis (2017;53:511–519). The aim was to determine current practice for the treatment of carotid stenosis among 12 countries participating in the International Consortium of Vascular Registries.
The investigators used data from the United States Vascular Quality Initiative and the Vascunet registry collaboration (including 10 registries in Europe and Australasia). Variation in treatment modality of asymptomatic versus symptomatic patients was analyzed between countries and among centers within each country.
As summarized in EJVES, the study evaluated 58,607 procedures. Patients between 80 and 89 years of age represented 18% of all patients, ranging from 8% (Hungary) to 22% (New Zealand and Australia). Women represented 36%, ranging from 29% (Switzerland) to 40% (United States). 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% (United States). Variation among centers 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 center level variation within each country in the proportion of asymptomatic patients, which was most pronounced in Australia (0% to 72%), Hungary (5% to 55%), and the United States (0% to 100%). Countries with fee-for-service reimbursement had higher rates of treatment in asymptomatic patients than countries with population-based reimbursement (odds ratio, 5.8; 95% confidence interval, 4.4–7.7).
The investigators concluded that despite evidence about treatment options for carotid artery disease, the proportion of asymptomatic patients, treatment modality, and the proportion of women and patients who were 80 to 89 years of age 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 throughout the world, advised the investigators in EJVES.