August 18th, 2011
Are Interventionalists Getting Too Far “A Head”?
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?
- 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).
- 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).
- 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”)?