Multistate utilization, processes, and outcomes of carotid endarterectomy

Objectives: The purpose of this study was to describe variation in utilizat ion, care processes, and outcomes for carotid endarterectomy (CEA) procedur es in 10 states. Methods: We reviewed the medical records of Medicare patients who underwent 10,561 CEA procedures between Tune 1, 1995, and May 31, 1996, in 10 differ ent states to determine indications, care processes, and outcomes. This stu dy also included medical record review of hospital readmissions within 30 d ays of the procedure and identification of out-of-hospital deaths from the Medicare beneficiary fries. Results: Utilization rates of CEA varied from 25.7 to 38.4 procedures per 1 0,000 Medicare beneficiaries among states. The overall combined event rate (30-day stroke or mortality) was 5.2% for primary CEA alone (n = 9945). The mortality rate was 1.5%, and the nonfatal stroke rate was 3.7%. Combined e vent rates (CEA alone) by surgical indication were 7.7% for stroke (n = 103 7), 7.4% for transient ischemic attack (n = 1304), 5.3% for nonspecific sym ptoms (n = 3713), and 3.7% for asymptomatic patients (n = 3891). The combin ed event rates (CEA alone) among states ranged from 4.1% to 7.7% with the e vent rates in asymptomatic patients ranging from 2.3% to 6.7%. In a multiva riate analysis (correcting for indication), the use of preoperative antipla telet agents (odds ratio [OR], 0.70), intraoperative heparin (OR, 0.49), an d patch angioplasty (OR, 0.73) was significantly associated with lower comb ined event rates. There were significant differences among states in the us e of preoperative antiplatelet therapy (range, 56%-70%) and patch angioplas ty (range, 11%-49%). Combined event rates for repeat procedures (n = 380) a nd CEA combined with coronary artery bypass grafting (n = 236) were 6.3% an d 17.4%, respectively. Conclusions: The striking variation among states suggests that there is roo m for improvement in the utilization, care processes, and outcomes of CEA. All surgeons performing CEA should participate in outcome assessment and ad opt protocols that include the routine administration of antiplatelet agent s preoperatively, the use of heparin intraoperatively, and patch angioplast y of the endarterectomy site.