Physician specialty and variation in carotid revascularization technique selected for Medicare XXXX .

@entity1 @entity2998
OBJECTIVE: @entity2998 ( @entity2998 ) has become an alternative to carotid endarterectomy (CEA) for select @entity1 with @entity2998 . We hypothesized that the choice of @entity2998 vs CEA varies as a function of treating physician specialty, which would result in regional variation in the relative use of these treatment types. METHODS: We used Medicare claims (2002-2010) to calculate annual rates of @entity2998 and CEA and examined changes by procedure type over time. To assess regional preferences surrounding @entity2998 , we calculated the proportion of revascularizations by @entity2998 , across hospital referral regions, defined according to the Dartmouth Atlas of Healthcare. We then examined relationships between @entity1 factors, physician specialty, and regional use of @entity2998 . RESULTS: The annual number of all carotid revascularization procedures decreased by 30% from 2002 to 2010 (3.2 to 2.3 per 1000; P = .005). Whereas rates of CEA declined by 35% during these 8 years (3.0 to 1.9 per 1000; P < .001), @entity2998 utilization increased by 5% during the same interval (0.30 to 0.32 per 1000; P = .014). Variation in utilization of carotid revascularization varied across the Unites States, with some regions performing as few as 0.7 carotid procedure per 1000 beneficiaries (Honolulu, Hawaii) and others performing nearly 8 times as many (5.3 per 1000 in Houma, La). Variation in procedure type (CEA vs @entity2998 ) was evident as well, as the proportion of carotid revascularization procedures that were constituted by @entity2998 varied from 0% (Casper, Wyo, and Meridian, Miss) to 53% (Bend, Ore). The majority of @entity2998 procedures were performed by cardiologists (49% of all @entity2998 cases), who doubled their rates of @entity2998 during the study period from 0.07 per 1000 in 2002 to 0.15 per 1000 in 2010. CONCLUSIONS: Variation in rates of carotid revascularization exists. Whereas rates of carotid revascularization have declined by more than 30% in recent years, utilization of @entity2998 has increased. The proportion of all carotid revascularization procedures performed as @entity2998 varies markedly by geographic region, and regions with the highest proportion of cardiologists perform the most @entity2998 procedures. Evidence-based guidelines for carotid revascularization will require a multidisciplinary approach to ensure uniform adoption across specialties that care for @entity1 with @entity2998 .
