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Kuehnl A, Kallmayer M, Bohmann B, Lohe V, Moser R, Naher S, Kirchhoff F, Eckstein HH, Knappich C. Association between hospital ownership and patient selection, management, and outcomes after carotid endarterectomy or carotid artery stenting : - Secondary data analysis of the Bavarian statutory quality assurance database. BMC Surg 2024; 24:158. [PMID: 38760789 PMCID: PMC11100040 DOI: 10.1186/s12893-024-02448-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND This study analyses the association between hospital ownership and patient selection, treatment, and outcome of carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS The analysis is based on the Bavarian subset of the nationwide German statutory quality assurance database. All patients receiving CEA or CAS for carotid artery stenosis between 2014 and 2018 were included. Hospitals were subdivided into four groups: university hospitals, public hospitals, hospitals owned by charitable organizations, and private hospitals. The primary outcome was any stroke or death until discharge from hospital. Research was funded by Germany's Federal Joint Committee Innovation Fund (01VSF19016 ISAR-IQ). RESULTS In total, 22,446 patients were included. The majority of patients were treated in public hospitals (62%), followed by private hospitals (17%), university hospitals (16%), and hospitals under charitable ownership (6%). Two thirds of patients were male (68%), and the median age was 72 years. CAS was most often applied in university hospitals (25%) and most rarely used in private hospitals (9%). Compared to university hospitals, patients in private hospitals were more likely asymptomatic (65% vs. 49%). In asymptomatic patients, the risk of stroke or death was 1.3% in university hospitals, 1.5% in public hospitals, 1.0% in hospitals of charitable owners, and 1.2% in private hospitals. In symptomatic patients, these figures were 3.0%, 2.5%, 3.4%, and 1.2% respectively. Univariate analysis revealed no statistically significant differences between hospital groups. In the multivariable analysis, compared to university hospitals, the odds ratio of stroke or death in asymptomatic patients treated by CEA was significantly lower in charitable hospitals (OR 0.19 [95%-CI 0.07-0.56, p = 0.002]) and private hospitals (OR 0.47 [95%-CI 0.23-0.98, p = 0.043]). In symptomatic patients (elective treatment, CEA), patients treated in private or public hospitals showed a significantly lower odds ratio compared to university hospitals (0.36 [95%-CI 0.17-0.72, p = 0.004] and 0.65 [95%-CI 0.42-1.00, p = 0.048], respectively). CONCLUSIONS Hospital ownership was related to patient selection and treatment, but not generally to outcomes. The lower risk of stroke or death in the subgroup of electively treated patients in private hospitals might be due to the right timing, the choice of treatment modality or actually to better structural and process quality.
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Affiliation(s)
- Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Vanessa Lohe
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rebecca Moser
- Landesarbeitsgemeinschaft zur datengestützten, einrichtungsübergreifenden Qualitätssicherung in Bayern, Munich, Germany
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Gasior SA, O'Donnell JPM, Davey M, Clarke J, Jalali A, Ryan É, Aherne TM, Walsh SR. Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 65:690-699. [PMID: 36682406 DOI: 10.1016/j.ejvs.2023.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 12/02/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS. METHODS A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed. RESULTS Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA. CONCLUSION Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.
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Affiliation(s)
- Sara A Gasior
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland.
| | - John P M O'Donnell
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Matthew Davey
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James Clarke
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | | | - Éanna Ryan
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Thomas M Aherne
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stewart R Walsh
- Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
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Risco JR, Kelly AG, Holloway RG. Prognostication in neurology. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:175-193. [PMID: 36055715 DOI: 10.1016/b978-0-323-85029-2.00003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Prognosticating is central to primary palliative care in neurology. Many neurologic diseases carry a high burden of troubling symptoms, and many individuals consider health states due to neurologic disease worse than death. Many patients and families report high levels of need for information at all disease stages, including information about prognosis. There are many barriers to communicating prognosis including prognostic uncertainty, lack of training and experience, fear of destroying hope, and not enough time. Developing the right mindset, tools, and skills can improve one's ability to formulate and communicate prognosis. Prognosticating is subject to many biases which can dramatically affect the quality of patient care; it is important for providers to recognize and reduce them. Patients and surrogates often do not hear what they are told, and even when they hear correctly, they form their own opinions. With practice and self-reflection, one can improve their prognostic skills, help patients and families create honest roadmaps of the future, and deliver high-quality person-centered care.
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Affiliation(s)
- Jorge R Risco
- Department of Neurology, University of Rochester, Rochester, NY, United States
| | - Adam G Kelly
- Department of Neurology, University of Rochester, Rochester, NY, United States
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, NY, United States.
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Sastry RA, Pertsch NJ, Sagaityte E, Poggi JA, Toms SA, Weil RJ. Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis. Neurosurgery 2021; 89:653-663. [PMID: 34320217 DOI: 10.1093/neuros/nyab250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 06/17/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially. OBJECTIVE To evaluate rates of adverse outcomes after CAS and CEA in a large national database. METHODS We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n = 81 361) or CEA (n = 2830), from 2011 to 2018, in the American College of Surgeons' National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n = 2821) cohorts through logistic regression. RESULTS In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients. CONCLUSION In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Nathan J Pertsch
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Emilija Sagaityte
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jonathan A Poggi
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
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Bagley JH, Priest R. Carotid Revascularization: Current Practice and Future Directions. Semin Intervent Radiol 2020; 37:132-139. [PMID: 32419725 DOI: 10.1055/s-0040-1709154] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Carotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.
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Affiliation(s)
- Jacob H Bagley
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - Ryan Priest
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon
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Chiu RG, Siddiqui N, Mehta AI. For-Profit Hospitals and Neurosurgery. World Neurosurg 2020; 135:383-384. [PMID: 32143245 DOI: 10.1016/j.wneu.2019.12.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ryan G Chiu
- Department of Neurosurgery, University of Illinois Hospital and Clinics, Chicago, Illinois, USA
| | - Neha Siddiqui
- Department of Neurosurgery, University of Illinois Hospital and Clinics, Chicago, Illinois, USA; Carle Illinois College of Medicine, Champaign, Illinois, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois Hospital and Clinics, Chicago, Illinois, USA
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Lai Z, Guo Z, Shao J, Chen Y, Liu X, Liu B, Qiu C. A systematic review and meta-analysis of results of simultaneous bilateral carotid artery stenting. J Vasc Surg 2018; 69:1633-1642.e5. [PMID: 30578074 DOI: 10.1016/j.jvs.2018.09.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 09/04/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although staged procedures to treat bilateral carotid artery stenosis are mainstream, a growing number of articles on simultaneous bilateral carotid artery stenting (SBCAS) have been published. Thus, this meta-analysis was performed to evaluate the efficacy and safety of SBCAS. METHODS The PubMed and Embase databases were searched to identify all studies reporting SBCAS from January 1, 2000, to October 1, 2017. Patients' characteristics, comorbidities, technical success, deaths, and complications were collected and analyzed. Forest plots were drawn with either a random-effects model or fixed-effects model according to their heterogeneities. Publication biases were tested by funnel plots and linear regression test. RESULTS Overall, 333 patients with bilateral carotid stenosis in 10 retrospective studies were enrolled in this meta-analysis. The mean age was 67.4 years; 75% of the patients were male, and 85.6% of them were symptomatic. The mean severity of stenosis was 82.1%. The overall technical success rate reached 99.38% (95% confidence interval [CI], 96.58%-100.00%). The pooled incidences of periprocedural complications were as follows: hemodynamic depression, 46.12% (95% CI, 33.16%-59.35%); hyperperfusion syndrome, 3.33% (95% CI, 1.66%-5.55%); stroke, 3.20% (95% CI, 1.59%-5.36%); myocardial infarction (MI), 0.60% (95% CI, 0.00%-1.43%); and death, 1.20% (95% CI, 0.03%-2.38%). The occurrence of a periprocedural primary end point, defined as a combination of any stroke, MI, and death, affected 4.28% (95% CI, 2.37%-6.71%) of patients. For long-term patency, there were too few follow-up results available to evaluate. CONCLUSIONS Except for hyperperfusion syndrome, all other periprocedural complications including hemodynamic depression, stroke, and MI were comparable with the literature reporting unilateral carotid artery stenting. However, the analysis was based on retrospective studies. Further studies, including prospective and randomized controlled studies, are needed to confirm these results.
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Affiliation(s)
- Zhichao Lai
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Zhiwei Guo
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Jiang Shao
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yu Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Xiu Liu
- General Surgery, Puren Hospital of Beijing, Beijing, China
| | - Bao Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China.
| | - Chenyang Qiu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
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Texakalidis P, Giannopoulos S, Kokkinidis DG, Karasavvidis T, Rangel-Castilla L, Reavey-Cantwell J. Carotid Artery Endarterectomy Versus Carotid Artery Stenting for Patients with Contralateral Carotid Occlusion: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 120:563-571.e3. [PMID: 30189300 DOI: 10.1016/j.wneu.2018.08.183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Results from studies investigating the effect of contralateral carotid occlusion (CCO) in patients with carotid artery stenosis undergoing carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) are variable in the literature. We sought to determine whether CEA or CAS is the optimal revascularization approach for patients with CCO. METHODS This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess for heterogeneity. Subgroup and sensitivity analyses were performed as needed. RESULTS Five retrospective observational cohort studies comprising 6346 patients were included. Patients in the CEA group had a significantly lower risk of 30-day periprocedural mortality (odds ratio, 0.46; 95% confidence interval, 0.30-0.71; I2 = 0%). However, no significant differences were identified in terms of stroke, myocardial infarction (MI), and major adverse cardiovascular events (MACEs) between the 2 groups. Subgroup analyses of symptomatic and asymptomatic patients did not yield significant differences for stroke, MI, and death. CONCLUSIONS Patients with CCO can safely undergo both CAS and CEA with similar risks of stroke, MI, and MACE. However, patients treated with CEA have a lower risk of 30-day periprocedural mortality. Future studies can help further clarify the ideal approach for these patients.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurologic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
| | | | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | - John Reavey-Cantwell
- Department of Neurologic Surgery, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
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