Faculty Bibliography

The recent American College of Cardiology/American Heart Association guideline recommended carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients. This and the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) form the basis for seeking more liberalized indications and reimbursement for CAS. For the years 2005-2007, >130,000 carotid interventions/year were performed, 88.6% of which were CEAs and 11.4% were CAS. For the same years, each CAS procedure had on average $12,000-$13,500 more expensive mean total hospital charges than each CEA. If the percentages of CAS and CEA had been equal (ie, 50% CAS and 50% CEA), this would translate into an additional $2,000,000,000 in charges for these 3 years. It seems unreasonable to approve enhanced reimbursement for CAS at this time, especially since the large incremental costs would go to support CAS procedures that are inferior in most symptomatic patients and possibly unnecessary in most asymptomatic patients.

In recent years, many important discoveries have been made to challenge current policy, guidelines, and practice regarding how best to prevent stroke associated with atherosclerotic stenosis of the origin of the internal carotid artery. TheUnited States Center forMedicare andMedicaid Services (CMS), for instance, is calling for expert advice as to whether its current policies should be modified. Using a thorough review of literature, 41 leading academic stroke-prevention clinicians from the United States and other countries, have united to advise CMS not to extend current reimbursement indications for carotid angioplasty/stenting (CAS) to patients with asymptomatic carotid stenosis or to patients with symptomatic carotid stenosis considered to be at ""low or standard risk from carotid endarterectomy (CEA)."" It was concluded that such expansion of reimbursement indications would have disastrous health and economic consequences for the United States and any other country that may follow such inappropriate action. This was an international effort because the experts to best advise CMS are relatively few and scattered around the world. In addition, US health policy, practice, and research have tended to have strong influences on other countries.