PERIPHERAL Hospital Variation in Carotid Stenting Outcomes

Fro Am Div Ma Ca Po Ca of ww va Am So ha co Re (Co of of oth Ma OBJECTIVES The aim of this study was to examine variation in outcomes for patients receiving carotid artery stenting (CAS) across a sample of U.S. hospitals and assess the extent to which this variation was attributable to differences in case mix and procedural volume. BACKGROUND As CAS is increasingly being used throughout the United States, assessing hospital variation in CAS outcomes is critical to understanding and improving the quality of care for patients with carotid artery disease. METHODS Hospitals participating in the National Cardiovascular Data Registry–Carotid Artery Endarterectomy and Revascularization Registry contributing more than 5 CAS procedures from 2005 through 2013 were eligible for inclusion. We estimated unadjusted and risk-standardized rates of in-hospital stroke or death for each participating hospital using a previously validated prediction model and applying hospital-level random effects. RESULTS There were 188 hospitals contributing 19,381 CAS procedures during the period of interest. Unadjusted and riskstandardized in-hospital strokeordeath rates ranged from0%to18.8%and1.2%to4.7%, respectively.Operator andhospital volumes were not significant predictors of outcomes after adjustment for case mix (p 1⁄4 0.15 and p 1⁄4 0.09, respectively). CONCLUSIONS CAS outcomes vary 4-fold among hospitals, even after adjustment for differences in case mix. Future work is needed to identify the sources of this variation and develop initiatives to improve patient outcomes. (J Am Coll Cardiol Intv 2015;8:858–63) © 2015 by the American College of Cardiology Foundation. m the *Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; ySaint Luke’s Miderica Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri; zSt. Joseph Mercy Hospital–Michigan Heart ision, Ann Arbor, Michigan; xDepartment of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, ssachusetts; kJohn Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana; {Division of rdiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and the #Department of Health Care licy (Biostatistics), Harvard Medical School, Boston, Massachusetts. This research was supported by the American College of rdiology Foundation’s National Cardiovascular Data Registry (NCDR). The views expressed in this manuscript represent those the author(s) and do not necessarily represent the official views of the NCDR or its associated professional societies identified at w.ncdr. com. The CARE Registry is an initiative of the American College of Cardiology Foundation, The Society for Cardioscular Angiography and Interventions, the Society of Interventional Radiology, the American Academy of Neurology, the erican Association of Neurological Surgeons/Congress of Neurological Surgeons, the Society for Vascular Medicine, and the ciety of Vascular and Interventional Neurology. Dr. Aronow is a nonpaid consultant for Silk Road Medical, Inc. Dr. Rosenfield s received research grants from Abbott Vascular, Bard Peripheral Vascular, Medtronic/Invatec, and Atrium; has received nsulting/advisory board fees from Abbott Vascular, Boston Scientific, Complete Conference Management, Harvard Clinical search Institute, Contego, Micell, and Becker Ventures; has equity in Lumen Biomedical, Medical Stimulation Corp, Angioguard rdis), and Micell; and has served on the Board of Directors of VIVA Physicians (501C3). Dr. Normand is on the Board of Directors Frontier Science Technology and Research Foundation. Dr. Spertus has received a research contract from the American College Cardiology Foundation to analyze the NCDR Registry. Dr. Yeh is an investigator at the Harvard Clinical Research Institute. All er authors have reported that they have no relationships relevant to the contents of this paper to disclose. nuscript received August 31, 2014; revised manuscript received January 14, 2015, accepted January 28, 2015. AB BR E V I A T I O N S