Measuring Carotid Revascularization Quality

> Holy Grail: something that you want very much but that is very hard to get or achieve> > —Merriam-WebsterBecause US health care pivots from volume-based to value-based strategies, there is growing emphasis on optimizing quality, safety, and appropriate utilization. Accordingly, to improve, we must be able to measure our performance. In this issue of Circulation: Cardiovascular Interventions , Kuehnl et al provide a timely publication, from the German national database, that informs our quest for the Holy Grail of measureable quality and safety for internal carotid artery revascularization.1See Article by Kuehnl et al The authors analyzed 182 033 procedures involving internal carotid artery revascularization, performed in Germany between 2009 and 2014. Because of mandatory reporting requirements, 99.1% of the data were available for analysis. They arbitrarily split the German hospitals into quintiles based on the case volumes for carotid endarterectomy (CEA; n=161 448) and carotid stenting (CAS; n=17 575) and then looked for correlations between hospital case volume and their safety end point, in-hospital death, and stroke.Not surprisingly, their data, consistent with other observations,2 confirmed an inverse relationship between hospital CEA case volume and inpatient death and stroke, but, similar to other reports,3 failed to confirm an inverse safety relationship for CAS hospital volume. This is counterintuitive. A high-risk, complex …