TY - JOUR
T1 - Operator experience and carotid stenting outcomes in medicare beneficiaries
AU - Nallamothu, Brahmajee K.
AU - Gurm, Hitinder S.
AU - Ting, Henry H.
AU - Goodney, Philip P.
AU - Rogers, Mary A.M.
AU - Curtis, Jeptha P.
AU - Dimick, Justin B.
AU - Bates, Eric R.
AU - Krumholz, Harlan M.
AU - Birkmeyer, John D.
N1 - Funding Information:
National Institutes of Health (NIH) was established in 1948 by an act of Congress to promote CVD research. The early work of Paul Dudley White, Ancel Keys, and international colleagues on the Seven Countries Study and other efforts in the 1950s framed CVD behavioral and physiological risk factors and the basis for population prevention. The National Conference on Cardiovascular Diseases (1964) and a President's Commission further propelled prevention research and policy.
PY - 2011/9/28
Y1 - 2011/9/28
N2 - Context: Although the efficacy of carotid stenting has been established in clinical trials, outcomes of the procedure based on operator experience are less certain in clinical practice. Objective: To assess association between outcomes and 2 measures of operator experience: annual volume and experience at the time of the procedure among new operators who first performed carotid stenting after a national coverage decision by the Centers for Medicare & Medicaid Services (CMS). Design, Setting, and Patients: Observational study using administrative data on fee-for-service Medicare beneficiaries aged 65 years or older undergoing carotid stenting between 2005 and 2007. Main Outcome Measure: Thirty-day mortality stratified by very low, low, medium, and high annual operator volumes (<6, 6-11, 12-23, and ≥24 procedures per year, respectively) and treatment early vs late during a new operator's experience (1st to 11th procedure and 12th procedure or higher). Results: During the study period, 24 701 procedures were performed by 2339 operators. Of these, 11 846 were performed by 1792 new operators who first performed carotid stenting after the CMS national coverage decision. Overall, 30-day mortality was 1.9% (n= 461) and rate of failure to use an embolic protection device was 4.8% (n= 1173) . The median annual operator volume among Medicare beneficiaries was 3.0 per year (interquartile range, 1.4-6.5) and 11.6% of operators performed 12 or more procedures per year during the study period. Observed 30-day mortality was higher among patients treated by operators with lower annual volumes (2.5% [95% CI, 2.1%-2.9%], 1.9% [95% CI, 1.6%-2.3%], 1.6% [95% CI, 1.3%-1.9%], and 1.4% [95% CI, 1.1%-1.7%] across the 4 categories; P<.001) and among patients treated early (2.3%; 95% CI, 2.0%-2.7%) vs late (1.4%; 95% CI, 1.1%-1.9%; P<.001) during a new operator's experience. After multivariable adjustment, patients treated by very low-volume operators had a higher risk of 30-day mortality compared with patients treated by high-volume operators (adjusted odds ratio, 1.9;95%CI, 1.4-2.7; P=.001). Similarly, we found a higher risk of 30-day mortality in patients treated early vs late during a new operator's experience (adjusted odds ratio, 1.7;95%CI, 1.2-2.4; P=.001). Conclusion: Among older patients undergoing carotid stenting, lower annual operator volume and early experience are associated with increased 30-day mortality.
AB - Context: Although the efficacy of carotid stenting has been established in clinical trials, outcomes of the procedure based on operator experience are less certain in clinical practice. Objective: To assess association between outcomes and 2 measures of operator experience: annual volume and experience at the time of the procedure among new operators who first performed carotid stenting after a national coverage decision by the Centers for Medicare & Medicaid Services (CMS). Design, Setting, and Patients: Observational study using administrative data on fee-for-service Medicare beneficiaries aged 65 years or older undergoing carotid stenting between 2005 and 2007. Main Outcome Measure: Thirty-day mortality stratified by very low, low, medium, and high annual operator volumes (<6, 6-11, 12-23, and ≥24 procedures per year, respectively) and treatment early vs late during a new operator's experience (1st to 11th procedure and 12th procedure or higher). Results: During the study period, 24 701 procedures were performed by 2339 operators. Of these, 11 846 were performed by 1792 new operators who first performed carotid stenting after the CMS national coverage decision. Overall, 30-day mortality was 1.9% (n= 461) and rate of failure to use an embolic protection device was 4.8% (n= 1173) . The median annual operator volume among Medicare beneficiaries was 3.0 per year (interquartile range, 1.4-6.5) and 11.6% of operators performed 12 or more procedures per year during the study period. Observed 30-day mortality was higher among patients treated by operators with lower annual volumes (2.5% [95% CI, 2.1%-2.9%], 1.9% [95% CI, 1.6%-2.3%], 1.6% [95% CI, 1.3%-1.9%], and 1.4% [95% CI, 1.1%-1.7%] across the 4 categories; P<.001) and among patients treated early (2.3%; 95% CI, 2.0%-2.7%) vs late (1.4%; 95% CI, 1.1%-1.9%; P<.001) during a new operator's experience. After multivariable adjustment, patients treated by very low-volume operators had a higher risk of 30-day mortality compared with patients treated by high-volume operators (adjusted odds ratio, 1.9;95%CI, 1.4-2.7; P=.001). Similarly, we found a higher risk of 30-day mortality in patients treated early vs late during a new operator's experience (adjusted odds ratio, 1.7;95%CI, 1.2-2.4; P=.001). Conclusion: Among older patients undergoing carotid stenting, lower annual operator volume and early experience are associated with increased 30-day mortality.
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U2 - 10.1001/jama.2011.1357
DO - 10.1001/jama.2011.1357
M3 - Article
C2 - 21954477
AN - SCOPUS:80053208237
SN - 0098-7484
VL - 306
SP - 1338
EP - 1343
JO - JAMA
JF - JAMA
IS - 12
ER -