Background
Public reporting of cardiac surgery outcomes has been available for many years in the USA. Whether public information regarding carotid endarterectomy or stenting outcomes is available has not been studied previously.
Methods
The Medicare Hospital Compare website was analyzed for carotid endarterectomy and stenting volume and complications data.
Results
Within a large metropolitan area, endarterectomy volume data was provided in less than half of hospitals, with no information provided on morbidity or mortality. No information was available on carotid stenting.
Conclusions
The quality of information available to patients in the USA contemplating a carotid revascularization procedure is suboptimal. Considering the volume of these procedures, greater transparency with regard to outcomes is desirable. Adoption of carotid procedure reporting practices as used in the UK should be considered.
Keywords
For several decades, it has been recognized that carotid endarterectomy (CEA) can have a narrow risk/benefit ratio for some patients, such as those with asymptomatic stenosis.
1
As a result, it has been recommended that hospitals monitor the CEA complication rate and provide this information to referring physicians.2
In addition to referring physicians, patients for whom a carotid revascularization procedure has been recommended, either CEA or carotid artery stenting (CAS), also have an interest in knowing the track record of their hospital or individual surgeon. Public reporting of data for surgical procedures such as coronary artery bypass grafting (CABG) has been mandatory in some states for several years.
3
This study assessed the quality of publically available information for patients contemplating a carotid revascularization procedure. The hypothesis is that data accessible to the general public would be sparse.Method
The Federal Government's Medicare Hospital Compare website (www.medicare.gov/hospitalcompare) was evaluated with regard to CEA and CAS.
4
Information was sought regarding procedural volumes at 30 hospitals within 50 miles of a single metropolitan area. It was also determined whether hospital or individual surgeon complication rates were provided. Finally, hospital characteristics (for profit status vs. nonprofit, Federal hospital vs. non-government) were evaluated in relation to public release of information. To supplement this website, a Google search was also conducted for this metropolitan area with the terms “best hospital for carotid endarterectomy,” “best hospital for carotid stenting,” and “best hospital for carotid surgery.”Results
A 12-month data collection period (encompassing months within 2011–2012) was evaluated. Information was available for CEA only (DRG codes 38 and 39, with or without complications or comorbidities).
Eight of 30 hospitals (27%) provided procedural volumes for both DRG codes, nine hospitals (30%) provided partial data, and 13 hospitals (43%) did not provide any information. During the 12-month period, procedural volumes per hospital ranged from 12 to 56. No information was provided regarding hospital periprocedural stroke/death rates. No information was provided regarding individual surgeon outcomes.
None of the four hospitals affiliated with a for profit health system provided complete data. Neither of two Veterans Affairs hospitals provided information on procedural volumes. No data were provided with regard to CAS procedural volumes or outcomes. The supplemental search did not uncover any other useful information regarding CEA or CAS complication rates.
Discussion
The present study found that the quality of data available to patients considering a carotid revascularization procedure was quite poor. Information on CEA volumes was provided in less than half of hospitals and no periprocedural mortality or stroke information was provided at any of the listed hospitals. Furthermore, there was no information available with regard to CAS outcomes.
There have been arguments both for and against public reporting of medical outcomes. Proponents of public reporting argue that patients have the right to know which hospitals are above average, average, or below average, especially with regard to major procedures such as coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).
3
Several states have adopted a policy of mandatory reporting for cardiac procedures. In Pennsylvania, for example, a Consumer Guide to CABG Surgery has been available for many years.5
However, in a survey of patients who had undergone recent CABG, only 12% knew about the guide and less than 1% of patients could correctly identify the rating of their hospital or surgeon.6
Opponents of public reporting argue that current models do not perform adequate risk adjustment and that higher postsurgical mortality could reflect a population with a greater burden of comorbidities.
7
In addition, public reporting can have unintended consequences, such as leading some surgeons or interventional specialists to avoid high-risk patients so that “their numbers look good.” In one study of patients undergoing PCI, states with mandatory reporting had lower rates of overall intervention compared with states without intervention.8
The authors commented that avoidance of high-risk patients in states with mandatory reporting of outcomes may have affected clinical practice.With regard to carotid procedures, a publication similar to the state-wide registries of CABG is not available. For patients with asymptomatic carotid stenosis, it has been recommended in the past that the 30-day periprocedure stroke and death rate should be <3%.
9
It is also documented that such a low complication rate is not uniformly achieved. Kresowik et al. reviewed 9745 procedures from 10 states and found that the overall stroke/death rate was 3.8%.10
In seven out of 10 states, the complication rate exceeded 3% (range 3.2–6.0%). In Ontario, analysis of over 1800 asymptomatic patients who underwent CEA revealed a complication rate of 4.7%.11
Some countries have adopted detailed reporting policies for a variety of surgical procedures. In the UK, the Vascular Services Quality Improvement Program (VSQIP) provides detailed information about the volumes and outcomes of individual surgeons with respect to CEA and abdominal aortic aneurysm repair.
12
This publicly available site has several collaborating professional organizations including the Vascular Society of Great Britain and Ireland, with physician involvement cited as a key factor in the success of public report cards.3
Since 2013, this public reporting of outcomes has been instituted at government level in England. Data submission for index vascular procedures including CEA has been made mandatory for individual surgeons to continue in clinical practice, through a process of revalidation. It is also mandatory for hospitals to enter complete data to be commissioned to undertake vascular procedures. There have been two full rounds of outcomes publication at both unit and surgeon level since 2013, with a further round due in the summer of 2015.As part of the process for ensuring robust data on outcomes are available for patients and for commissioners of health care, the proportion of cases entered into the National Vascular Registry (the database used to generate the information published on the VSQIP website) is analyzed at the unit level in comparison with the national Hospital Episode Statistics dataset. Over the last 3 years, for CEA, the level of data ascertainment has reached 95%. For CEA, one of the targets was to reduce waiting times from symptom to surgery. The publication of data has driven a reduction from an average of over 30 days to less than 14 days, with improvements year on year but no increase in perioperative risk.
In the USA, it is not clear, however, if public release of surgical information alters the selection of hospitals by individual patients. In the prior Pennsylvania survey, limited time to make a decision and reasonable travel distance were cited as factors limiting the usefulness of surgical report cards.
6
For patients with asymptomatic carotid stenosis, however, in which the stroke rate with optimal medical therapy is likely 1% per year or less, there should not be time pressure to make a decision regarding choice of hospital or surgeon. A survey of 510 Medicare recipients who had undergone recent major surgery found that 47% were “very likely” to use a list which provided comparative data on hospitals.13
In addition, 35% would switch to a hospital with a 1% lower surgical mortality.The present study has limitations. Only a single metropolitan area was assessed. It is possible that other locations may have more complete data but this is unlikely given the national structure of the Medicare website. In addition, reporting policies in other developed countries were not investigated.
In conclusion, the quality of publically available information on CEA and CAS outcomes in the USA is suboptimal. Patients and their families will likely need to “hope for the best” as the current reporting system for carotid procedures is very opaque. Given the large volume of carotid procedures performed on an annual basis, professional societies and policy makers in the US should consider adopting a system comparable with the UK Vascular Services model.
Conflict of Interest
None.
Funding
None.
References
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- Use of public performance reports: a survey of patients undergoing cardiac surgery.JAMA. 1998; 279: 1638-1642
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- Association of public reporting for percutaneous coronary intervention with utilization and outcomes among medicare beneficiaries with acute myocardial infarction.JAMA. 2012; 308: 1460-1468
- Carotid endarterectomy—an evidence-based review: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology.Neurology. 2005; 65: 794-801
- Multistate improvement in process and outcomes of carotid endarterectomy.J Vasc Surg. 2004; 39: 372-380
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- How do elderly patients decide where to go for major surgery? Telephone interview survey.BMJ. 2005; 331: 821
Article info
Publication history
Published online: July 10, 2015
Accepted:
June 4,
2015
Received:
June 4,
2015
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© 2015 European Society for Vascular Surgery. Published by Elsevier Inc.
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