CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

August 18th, 2011

Are Interventionalists Getting Too Far “A Head”?

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Nallamothu and colleagues have performed an observational analysis of Medicare data on fee-for-service beneficiaries undergoing carotid stenting between 2005 and 2007 in 306 hospital referral regions (HRRs). First, they determined how often carotid stenting was performed by different specialists (i.e., cardiologists, surgeons, radiologists) within each HRR, then they compared utilization rates and 30-day outcomes of the procedure across HRRs.

What did they find?

  1. Although only about one-third of the operators were cardiologists, they performed over half (52%) of the procedures; surgeons performed 28%, and radiologists performed 18% (see the graph in the report published in Archives of Internal Medicine).
  2. Utilization rates for carotid stenting were significantly higher in HRRs where cardiologists performed most of the procedures than in HRRs where most of the procedures were performed by other specialists (P<0.001).
  3. Risk-standardized outcomes did not differ across HRRs based on physician specialty.

Conclusion: Hospital referral regions where cardiologists perform most procedures have higher population-based utilization rates with similar outcomes.

Are markets where cardiologists are performing most procedures overutilizing carotid stenting, or are markets where surgeons or radiologists perform most of them underutilizing it (i.e., does involvement of cardiologists in the care of these patients lead to a greater recognition of carotid disease in the general population and subsequent referral for carotid stenting)?

Which is it?

A “Heart Team” approach is advocated for decisions regarding surgical versus percutaneous treatment of multivessel CAD and aortic stenosis. Should we adopt such an approach to promote multidisciplinary decision making about carotid stenting (i.e., the “Head Team Approach”)?

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4 Responses to “Are Interventionalists Getting Too Far “A Head”?”

  1. Xavier Prida, MD says:
    August 18, 2011 at 9:40 pm

    Are cardiologists performing carotid stenting cardiologists?

  2. Janet Sue Hedtke, BS, RN says:
    August 18, 2011 at 10:20 pm

    How about adding stroke data for the same population…

  3. Renn Holness, MBBS,FRCS,DABNS says:
    August 19, 2011 at 10:12 am

    This is similar to neurosurgeons performing endoscopic sinus surgery for ENT disease ;just because “we are there” does not justify it! It would be interesting to see if % of pts stented by cardiologists who fit the accepted criteria for intervention ! I suspect many are asymptomatic and do not fit the criteria.With recent DB/Cont studies showing that stenting has higher risks (immediate & long term ) than endarterectomy it is hard to justify someone embarking on a procedure which is outside his/her field .Only in the USA!

    Competing interests pertaining specifically to this post, comment, or both:
    no conflicts ;

  4. Renn Holness, MBBS,FRCS,DABNS says:
    August 19, 2011 at 10:21 am

    Patient who merit stenting of their carotids should have the procedure performed by someone who is part of a team of neurointerventionalists (surgeon,radiologist fellowship trained in this field) who have the backup in the event a complication occurs which requires their expertise . I see no justification for othet individuals performing this procedure ….simple to do but consequences can be devastating .This area is one of the best studied in terms of indications and results with well established evidence based guidelines.

    Competing interests pertaining specifically to this post, comment, or both:
    none