US nationwide trends in carotid revascularization: is there a clinical opportunity cost associated with the introduction of novel medical devices?

Authors

  • J. H. Choi,

    1. Department of Neurology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
    2. Clinical Sciences, Janus Head Consulting, LLC, Mineola, NY, USA
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  • J. Pile-Spellman,

    1. Neurological Surgery P.C., Lake Success, NY, USA
    2. Neurosurgical Services, Winthrop University Hospital, Mineola, NY, USA
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  • J. L. Brisman

    Corresponding author
    1. Neurological Surgery P.C., Lake Success, NY, USA
    2. Neurosurgical Services, Winthrop University Hospital, Mineola, NY, USA
    • J. Brisman, Cerebrovascular and Endovascular Neurosurgery, Winthrop University Hospital, 1991 Marcus Avenue, Suite 108, Lake Success, NY 11042, USA

      Tel.: +516 442 2250

      Fax: +516 255 6230

      e-mail: jbrisman@nspc.com

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Abstract

Objectives

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.

Methods

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).

Results

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).

Conclusions

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.

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