US nationwide trends in carotid revascularization: is there a clinical opportunity cost associated with the introduction of novel medical devices?
Article first published online: 15 JUN 2013
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Acta Neurologica Scandinavica
Volume 129, Issue 2, pages 94–101, February 2014
How to Cite
US nationwide trends in carotid revascularization (Part II): is there a clinical opportunity cost associated with the introduction of novel medical devices? Acta Neurol Scand 2014: 129: 94–101. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd., , .
- Issue published online: 9 JAN 2014
- Article first published online: 15 JUN 2013
- Manuscript Accepted: 24 APR 2013
- carotid stenosis;
- carotid endarterectomy;
- carotid angioplasty and stenting
Nationwide practice patterns during the implementation of novel technology, such as carotid angioplasty and stenting (CAS) and embolic protection devices (EPD), and the clinical impact thereof have received less attention.
The Nationwide Inpatient Sample, constituting a 20% representative sample of non-federal US hospitals, was analyzed from years 1998 to 2007. Hospital outcome was stratified into in-hospital mortality (IHM), long-term facility discharge, and home/ short-term facility discharge (HSF).
Discharge outcome improved for CAS over the decade. However, this improvement occurred in two phases with a period of worsening (2003–2005) in between. During this transition period, the risk of IHM following CAS was increased (RR 1.29–2.43) and was lower for good outcome (HSF: RR 0.97–0.99) when compared with 2002/2003. During the same transition period, carotid endarterectomy (CEA) was associated with a lower risk of IHM (RR 0.75–1.00), but also a lower risk of HSF (RR 0.98–0.99).
The results lead to the hypothesis that the nationwide introduction of CAS-EPD may have been associated with temporary increases in in-hospital mortality and discharge morbidity. If such ‘clinical opportunity costs’ exist with the widespread introduction and adoption of new medical technology with proven efficacy in randomized trials, effective mechanisms are needed for mitigation or prevention during the transition period.