title: Comparative effectiveness of carotid revascularization therapies: evidence from a National Hospital Discharge Database.
abstract: OBJECTIVE
  Clinical equipoise of carotid revascularization therapies remains controversial. We sought to determine whether adverse outcomes after carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) were similar using propensity score-matched analysis of retrospective data from a large hospital discharge database.
  
  
  METHODS
  All CEA and CAS cases were identified from the 2006 to 2011 Premier Perspective Database and subjected to 1:1 propensity score matching using 33 clinical covariates associated with carotid revascularization. A primary composite end point of peri- or postoperative mortality, stroke, or acute myocardial infarction and a modified composite end point excluding acute myocardial infarction were used to compare our findings with recent prospective controlled trials. Multivariate regression and Cox-proportional hazard ratio survival analysis were performed to compare revascularization therapy outcomes.
  
  
  RESULTS
  After 1:1 propensity score matching, 24 004 (12 002 CEA and CAS) asymptomatic and 3506 (1753 CEA and CAS) symptomatic procedures were included. The risk of the primary composite end point was significantly higher after CAS than CEA in both asymptomatic (odds ratio, 1.40 [1.19-1.65]; P<0.0001) and symptomatic (odds ratio=2.31 [1.78-3.00]; P<0.0001) presentations, irrespective of age (P=0.28) or sex (P=0.35). Similar findings were observed using the modified composite end point for both asymptomatic (odds ratio, 1.49 [1.25-1.78]; P<0.0001) and symptomatic (odds ratio, 3.02 [2.25-4.07]; P<0.0001) presentations. Acute myocardial infarction risk was not significantly different between revascularization therapies, regardless of clinical presentation (P=0.71 and 0.24).
  
  
  CONCLUSIONS
  Among individuals undergoing carotid artery revascularization from a large sample of US hospitals, CAS was associated with higher risk of perioperative mortality, stroke, and unfavorable discharges compared with CEA for all ages and clinical presentations.
authors.affiliation: From the Department of Radiology (R.J.M., J.S.M., D.F.K., H.J.C.), Department of Biostatistics (T.M.T.), and Department of Neurosurgery, College of Medicine (G.L., D.F.K., H.J.C.), Mayo Clinic, Rochester, MN. mcdonald.robert@mayo.edu.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: McDonald
authors.affiliation: From the Department of Radiology (R.J.M., J.S.M., D.F.K., H.J.C.), Department of Biostatistics (T.M.T.), and Department of Neurosurgery, College of Medicine (G.L., D.F.K., H.J.C.), Mayo Clinic, Rochester, MN.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: McDonald
authors.affiliation: From the Department of Radiology (R.J.M., J.S.M., D.F.K., H.J.C.), Department of Biostatistics (T.M.T.), and Department of Neurosurgery, College of Medicine (G.L., D.F.K., H.J.C.), Mayo Clinic, Rochester, MN.
authors.forename: Terry M
authors.initials: TM
authors.lastname: Therneau
authors.affiliation: From the Department of Radiology (R.J.M., J.S.M., D.F.K., H.J.C.), Department of Biostatistics (T.M.T.), and Department of Neurosurgery, College of Medicine (G.L., D.F.K., H.J.C.), Mayo Clinic, Rochester, MN.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Lanzino
authors.affiliation: From the Department of Radiology (R.J.M., J.S.M., D.F.K., H.J.C.), Department of Biostatistics (T.M.T.), and Department of Neurosurgery, College of Medicine (G.L., D.F.K., H.J.C.), Mayo Clinic, Rochester, MN.
authors.forename: David F
authors.initials: DF
authors.lastname: Kallmes
authors.affiliation: From the Department of Radiology (R.J.M., J.S.M., D.F.K., H.J.C.), Department of Biostatistics (T.M.T.), and Department of Neurosurgery, College of Medicine (G.L., D.F.K., H.J.C.), Mayo Clinic, Rochester, MN.
authors.forename: Harry J
authors.initials: HJ
authors.lastname: Cloft
mesh_terms: D000368:Aged; D002548:Cerebral Revascularization / Q000379:methods / Q000639:trends*; D016208:Databases, Factual / Q000639:trends*; D016894:Endarterectomy, Carotid / Q000379:methods / Q000639:trends*; D019317:Evidence-Based Medicine / Q000379:methods / Q000639:trends*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000639:trends*; D011446:Prospective Studies; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: angioplasty; carotid stenosis; comparative effectiveness research; endarterectomy, carotid; health policy; outcome assessment (health care); stenting, carotid