title: Regional variation in patient selection and treatment for carotid artery disease in the Vascular Quality Initiative.
abstract: Previous studies involving large administrative data sets have revealed regional variation in the demographics of patients selected for carotid endarterectomy (CEA) and carotid artery stenting (CAS) but lacked clinical granularity. This study aimed to evaluate regional variation in patient selection and operative technique for carotid artery revascularization using a detailed clinical registry.
  
  
  
  All patients who underwent CEA or CAS from 2009 to 2015 were identified in the Vascular Quality Initiative (VQI). Deidentified regional groups were used to evaluate variation in patient selection, operative technique, and perioperative management. χ2analysis was used to identify significant variation across regions.
  
  
  
  A total of 57,555 carotid artery revascularization procedures were identified. Of these, 49,179 patients underwent CEA (asymptomatic: median, 56%; range, 46%-69%; P < .01) and 8376 patients underwent CAS (asymptomatic: median, 36%; range, 29%-51%; P < .01). There was significant regional variation in the proportion of asymptomatic patients being treated for carotid stenosis <70% in CEA (3%-9%; P < .01) vs CAS (3%-22%; P < .01). There was also significant variation in the rates of intervention for asymptomatic patients older than 80 years (CEA, 12%-27% [P < .01]; CAS, 8%-26% [P < .01]). Preoperative computed tomography angiography or magnetic resonance angiography in the CAS cohort also varied widely (31%-83%; P < .01), as did preoperative medical management with combined aspirin and statin (CEA, 53%-77% [P < .01]; CAS, 62%-80% [P < .01]). In the CEA group, the use of shunt (36%-83%; P < .01), protamine (32%-89%; P < .01), and patch (87%-99%; P < .01) varied widely. Similarly, there was regional variation in frequency of CAS done without a protection device (1%-8%; P < .01).
  
  
  
  Despite clinical benchmarks aimed at guiding management of carotid disease, wide variation in clinical practice exists, including the proportion of asymptomatic patients being treated by CAS and preoperative medical management. Additional intraoperative variables, including the use of a patch and protamine during CEA and use of a protection device during CAS, displayed similar variation in spite of clear guidelines. Quality improvement projects could be directed toward improved adherence to benchmarks in these areas.
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, St. Elizabeth's Medical Center, Boston, Mass.
authors.forename: Katie E
authors.initials: KE
authors.lastname: Shean
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: John C
authors.initials: JC
authors.lastname: McCallum
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Soden
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Deery
authors.affiliation: Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill.
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Schneider
authors.affiliation: Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Nolan
authors.affiliation: Division of Vascular and Endovascular Surgery, NYU Langone Medical Center, New York, NY.
authors.forename: Caron B
authors.initials: CB
authors.lastname: Rockman
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation / Q000639:trends*; D019985:Benchmarking / Q000639:trends; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D016009:Chi-Square Distribution; D000072226:Computed Tomography Angiography / Q000639:trends; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000639:trends*; D005260:Female; D019983:Guideline Adherence / Q000639:trends; D054625:Healthcare Disparities / Q000639:trends*; D006801:Humans; D018810:Magnetic Resonance Angiography / Q000639:trends; D008297:Male; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000639:trends*; D011237:Predictive Value of Tests; D017064:Process Assessment, Health Care / Q000639:trends*; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States