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The impact of the present on admission indicator on the accuracy of administrative data for carotid endarterectomy and stenting.

ABSTRACT: Administrative data are often hampered by coding errors, absent data, and the difficulty of distinguishing pre-existing conditions from perioperative complications. We evaluated whether the introduction of the present on admission (POA) indicator improved outcome analysis of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) using administrative data.State inpatient databases from California (2005-2008), New York (2008), and New Jersey (2008) were used to identify patients undergoing CAS and CEA. We first analyzed morbidity data without the POA indicator, using International Classification of Diseases, Ninth Revision complication codes (eg, 997.02, iatrogenic cerebrovascular infarction or hemorrhage, postoperative stroke) and diagnosis codes (eg, 433.11, occlusion and stenosis of the carotid artery with cerebral infarction). Then, we applied the POA indicator to both diagnosis and complication codes and calculated the proportion of events that were labeled POA. Symptom status and perioperative stroke rate were compared using these coding approaches.We identified 21,639 patients who underwent CEA and 3688 patients who underwent CAS. Without the POA indicator, the complication code for stroke indicated a postoperative stroke rate of 1.4% for CEA and 2.4% for CAS. After applying the POA indicator, 54% (CEA) and 62% (CAS) of these strokes were labeled POA. These POA strokes were either preoperative or intraoperative events. Proportion of symptomatic patients ranged from 7% to 16% for CEA and from 5% to 22% for CAS. Perioperative stroke rate was the lowest in the POA method (1.1% CEA, 1.8% CAS) compared with two other methods without POA information (1.4% and 9.5% CEA and 2.4% and 16.4% CAS). Kappa indicated a poor (0.2) to fair (0.7) agreement between these approaches.Administrative data has known limitations for assignment of symptom status and nonfatal perioperative outcomes. Given the uncertain timing of POA events as preoperative vs intraoperative and its apparent underestimation of the perioperative stroke rate, the use of administrative data even with the POA indicator for symptom status and non-fatal outcomes after CEA and CAS is hazardous.

SUBMITTER: Fokkema M

PROVIDER: S-EPMC3874266 | biostudies-literature | 2014 Jan

REPOSITORIES: biostudies-literature

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The impact of the present on admission indicator on the accuracy of administrative data for carotid endarterectomy and stenting.

Fokkema Margriet M Hurks Rob R Curran Thomas T Bensley Rodney P RP Hamdan Allen D AD Wyers Mark C MC Moll Frans L FL Schermerhorn Marc L ML

Journal of vascular surgery 20130828 1

<h4>Background</h4>Administrative data are often hampered by coding errors, absent data, and the difficulty of distinguishing pre-existing conditions from perioperative complications. We evaluated whether the introduction of the present on admission (POA) indicator improved outcome analysis of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) using administrative data.<h4>Methods</h4>State inpatient databases from California (2005-2008), New York (2008), and New Jersey (200 ...[more]

PMID: 23993438

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Project description:BackgroundThe Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) found a higher risk of stroke after carotid artery stenting and a higher risk of myocardial infarction (MI) after carotid endarterectomy.Methods and resultsCardiac biomarkers and ECGs were performed before and 6 to 8 hours after either procedure and if there was clinical evidence of ischemia. In CREST, MI was defined as biomarker elevation plus either chest pain or ECG evidence of ischemia. An additional category of biomarker elevation with neither chest pain nor ECG abnormality was prespecified (biomarker+ only). Crude mortality and risk-adjusted mortality for MI and biomarker+ only were assessed during follow-up. Among 2502 patients, 14 MIs occurred in carotid artery stenting and 28 MIs in carotid endarterectomy (hazard ratio, 0.50; 95% confidence interval, 0.26 to 0.94; P=0.032) with a median biomarker ratio of 40 times the upper limit of normal. An additional 8 carotid artery stenting and 12 carotid endarterectomy patients had biomarker+ only (hazard ratio, 0.66; 95% confidence interval, 0.27 to 1.61; P=0.36), and their median biomarker ratio was 14 times the upper limit of normal. Compared with patients without biomarker elevation, mortality was higher over 4 years for those with MI (hazard ratio, 3.40; 95% confidence interval, 1.67 to 6.92) or biomarker+ only (hazard ratio, 3.57; 95% confidence interval, 1.46 to 8.68). After adjustment for baseline risk factors, both MI and biomarker+ only remained independently associated with increased mortality.ConclusionsIn patients randomized to carotid endarterectomy versus carotid artery stenting, both MI and biomarker+ only were more common with carotid endarterectomy. Although the levels of biomarker elevation were modest, both events were independently associated with increased future mortality and remain an important consideration in choosing the mode of carotid revascularization or medical therapy.Clinical trial registrationURL: http://www.ClinicalTrials.gov. Unique identifier: NCT00004732.

Project description:ObjectivesThe purpose of this study was to compare health-related quality of life (HRQOL) outcomes in patients treated with carotid artery stenting (CAS) versus carotid endarterectomy (CEA).BackgroundIn CREST (Carotid Revascularization Endarterectomy versus Stenting Trial), the largest randomized trial of carotid revascularization to date, there was no significant difference in the primary composite endpoint, but rates of stroke and myocardial infarction (MI) differed between CAS and CEA. To help guide individualized clinical decision making, we compared HRQOL among patients enrolled in the CREST study. We also performed exploratory analyses to evaluate the association between periprocedural complications and HRQOL.MethodsWe measured HRQOL at baseline, and after 2 weeks, 1 month, and 1 year among 2,502 patients randomly assigned to either CAS or CEA in the CREST study. The HRQOL was assessed using the Medical Outcomes Study Short-Form 36 (SF-36) and 6 disease-specific scales designed to study HRQOL in patients undergoing carotid revascularization.ResultsAt both 2 weeks and 1 month, CAS patients had better outcomes for multiple components of the SF-36, with large differences for role physical function, pain, and the physical component summary scale (all p < 0.01). On the disease-specific scales, CAS patients reported less difficulty with driving, eating/swallowing, neck pain, and headaches but more difficulty with walking and leg pain (all p < 0.05). However, by 1 year, there were no differences in any HRQOL measure between CAS and CEA. In the exploratory analyses, periprocedural stroke was associated with poorer 1-year HRQOL across all SF-36 domains, but periprocedural MI or cranial nerve palsy were not.ConclusionsAmong patients undergoing carotid revascularization, CAS is associated with better HRQOL during the early recovery period as compared with CEA-particularly with regard to physical limitations and pain-but these differences diminish over time and are not evident after 1 year. Although CAS and CEA are associated with similar overall HRQOL at 1 year, event-specific analyses confirm that stroke has a greater and more sustained impact on HRQOL than MI. (Carotid Revascularization Endarterectomy versus Stenting Trial [CREST]; NCT00004732)

Project description:BackgroundCarotid-artery stenting and carotid endarterectomy are both options for treating carotid-artery stenosis, an important cause of stroke.MethodsWe randomly assigned patients with symptomatic or asymptomatic carotid stenosis to undergo carotid-artery stenting or carotid endarterectomy. The primary composite end point was stroke, myocardial infarction, or death from any cause during the periprocedural period or any ipsilateral stroke within 4 years after randomization.ResultsFor 2502 patients over a median follow-up period of 2.5 years, there was no significant difference in the estimated 4-year rates of the primary end point between the stenting group and the endarterectomy group (7.2% and 6.8%, respectively; hazard ratio with stenting, 1.11; 95% confidence interval, 0.81 to 1.51; P=0.51). There was no differential treatment effect with regard to the primary end point according to symptomatic status (P=0.84) or sex (P=0.34). The 4-year rate of stroke or death was 6.4% with stenting and 4.7% with endarterectomy (hazard ratio, 1.50; P=0.03); the rates among symptomatic patients were 8.0% and 6.4% (hazard ratio, 1.37; P=0.14), and the rates among asymptomatic patients were 4.5% and 2.7% (hazard ratio, 1.86; P=0.07), respectively. Periprocedural rates of individual components of the end points differed between the stenting group and the endarterectomy group: for death (0.7% vs. 0.3%, P=0.18), for stroke (4.1% vs. 2.3%, P=0.01), and for myocardial infarction (1.1% vs. 2.3%, P=0.03). After this period, the incidences of ipsilateral stroke with stenting and with endarterectomy were similarly low (2.0% and 2.4%, respectively; P=0.85).ConclusionsAmong patients with symptomatic or asymptomatic carotid stenosis, the risk of the composite primary outcome of stroke, myocardial infarction, or death did not differ significantly in the group undergoing carotid-artery stenting and the group undergoing carotid endarterectomy. During the periprocedural period, there was a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy. (ClinicalTrials.gov number, NCT00004732.)

Dataset Information

The impact of the present on admission indicator on the accuracy of administrative data for carotid endarterectomy and stenting.

Publications

The impact of the present on admission indicator on the accuracy of administrative data for carotid endarterectomy and stenting.

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