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US nationwide trends in carotid revascularization: is there a clinical opportunity cost associated with the introduction of novel medical devices?
Author(s) -
Choi J. H.,
PileSpellman J.,
Brisman J. L.
Publication year - 2014
Publication title -
acta neurologica scandinavica
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.967
H-Index - 95
eISSN - 1600-0404
pISSN - 0001-6314
DOI - 10.1111/ane.12152
Subject(s) - medicine , carotid endarterectomy , relative risk , emergency medicine , clinical trial , randomized controlled trial , revascularization , hospital discharge , endarterectomy , intensive care medicine , carotid arteries , confidence interval , myocardial infarction
Objectives Nationwide practice patterns during the implementation of novel technology, such as carotid angioplasty and stenting ( CAS ) and embolic protection devices ( EPD ), and the clinical impact thereof have received less attention. Methods The Nationwide Inpatient Sample, constituting a 20% representative sample of non‐federal US hospitals, was analyzed from years 1998 to 2007. Hospital outcome was stratified into in‐hospital mortality ( IHM ), long‐term facility discharge, and home/ short‐term facility discharge ( HSF ). Results Discharge outcome improved for CAS over the decade. However, this improvement occurred in two phases with a period of worsening (2003–2005) in between. During this transition period, the risk of IHM following CAS was increased ( RR 1.29–2.43) and was lower for good outcome ( HSF : RR 0.97–0.99) when compared with 2002/2003. During the same transition period, carotid endarterectomy ( CEA ) was associated with a lower risk of IHM ( RR 0.75–1.00), but also a lower risk of HSF ( RR 0.98–0.99). Conclusions The results lead to the hypothesis that the nationwide introduction of CAS ‐ EPD may have been associated with temporary increases in in‐hospital mortality and discharge morbidity. If such ‘clinical opportunity costs’ exist with the widespread introduction and adoption of new medical technology with proven efficacy in randomized trials, effective mechanisms are needed for mitigation or prevention during the transition period.