Carotid Stenosis surgery, Needed or Not

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Old 03-03-2017, 10:00 AM
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Default Carotid Stenosis surgery, Needed or Not

A very troubling article in the Journal of the American Medical Association [JAMA] which analyzed the likelihood that a patient with carotid stenosis, narrowing of the artery in the neck leading to the brain, would have a surgical intervention.

Records of patients in the TRICARE military health insurance system were reviewed. Within that insurance there are both fee for service [FFS] doctors and salaried doctors. Obviously one of these kinds of doctors makes more money if there is an operation, the other does not. Only patients seen by a specialist with a confirmed diagnosis were included.

The result summary:

Quote:
Conclusions and Relevance - Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.
The authors attempted to control for some variation in the patients who were enrolled in the FFS vs Salaried systems. After adjusting for these differences the FFS patients had 150% to 200% more surgeries than the salaried patients.

But you ask, didn't those who received surgery do better? Maybe those salaried doctors were not sending patients who needed operations to the OR? The authors also looked at outcome data.

Outcomes were evaluated at 30 days, one year, and two years:

Quote:
For all patients, those in the FFS group had a higher odds than those in the Salaried group of stroke at 30 days (OR, 1.981; P < .001), 1 year (OR, 1.599; P < .001), and 2 years (OR, 1.486; P < .001) (Table 5). Odds of all-cause mortality were also higher in the FFS group than the Salaried group for all patients at 30 days (OR, 1.976; P = .39), 1 year (OR, 1.673; P = .005), and 2 years (OR, 1.777; P < .001)

Caveats.. Who needs surgery is not settled and doctors can see the same patient and make differing recommendations even if they do not have a financial stake in the outcome. Additionally it could have been that patients seen by FFS doctors were sicker and therefore needed more surgery. But the majority of patients had no symptoms and even with no symptoms the FFS patients had 150% of the surgeries of the salaried patients.

My conclusion is you should get more than one opinion before having carotid stenosis surgery. This is not to suggest that the surgeon is consciously thinking about dollars when recommending surgery. It can all be a subconscious influence of being aware of the need to generate billings to keep the practice afloat, or pay for the next trip to Tahiti.
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Old 03-03-2017, 07:55 PM
valuemkt valuemkt is offline
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Default Carotid

Well, my dad was never given the surgical option and he had a debilitating stroke at 78....luckily it affected his lower body and not his mind. His positive attitude helped him live six years after the stroke...
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Old 03-03-2017, 09:08 PM
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Well, my dad was never given the surgical option and he had a debilitating stroke at 78....luckily it affected his lower body and not his mind. His positive attitude helped him live six years after the stroke...
Not all strokes are caused by a clogged carotid artery.
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Old 03-04-2017, 05:22 AM
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This is scary stuff. I don't get nervous when plumbers chef's etc disagree but when its doctors or lawyer or even my accountant then I'm getting a little worried
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Old 03-04-2017, 06:19 AM
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Originally Posted by blueash View Post
A very troubling article in the Journal of the American Medical Association [JAMA] which analyzed the likelihood that a patient with carotid stenosis, narrowing of the artery in the neck leading to the brain, would have a surgical intervention.

Records of patients in the TRICARE military health insurance system were reviewed. Within that insurance there are both fee for service [FFS] doctors and salaried doctors. Obviously one of these kinds of doctors makes more money if there is an operation, the other does not. Only patients seen by a specialist with a confirmed diagnosis were included.

The result summary:



The authors attempted to control for some variation in the patients who were enrolled in the FFS vs Salaried systems. After adjusting for these differences the FFS patients had 150% to 200% more surgeries than the salaried patients.

But you ask, didn't those who received surgery do better? Maybe those salaried doctors were not sending patients who needed operations to the OR? The authors also looked at outcome data.

Outcomes were evaluated at 30 days, one year, and two years:




Caveats.. Who needs surgery is not settled and doctors can see the same patient and make differing recommendations even if they do not have a financial stake in the outcome. Additionally it could have been that patients seen by FFS doctors were sicker and therefore needed more surgery. But the majority of patients had no symptoms and even with no symptoms the FFS patients had 150% of the surgeries of the salaried patients.

My conclusion is you should get more than one opinion before having carotid stenosis surgery. This is not to suggest that the surgeon is consciously thinking about dollars when recommending surgery. It can all be a subconscious influence of being aware of the need to generate billings to keep the practice afloat, or pay for the next trip to Tahiti.
Everyone, please be very, VERY careful in interpreting the results of this single study. I have not read this particular article, but there are many questions that arise

First, surgical vs. medical management of carotid stenosis is somewhat controversial to start with. Vascular surgeons believe in surgery, it is what they are trained to do, and it has very little to do with "Tahiti".

Second, most carotid stenosis are discovered by the patient's internist, either because he heard a bruit, the patient had symptoms, or they went for a screening ultrasound. The patient would be started on an anti-platelet agent and referred to a vascular surgeon. So who is "fee for service" and who is "on salary" The internist? The surgeon? Both? Neither? As you can imagine, this has a tremendous effect on this study

Third, is there a bias among the researchers? The very fact that the point of the study was to look at surgical rates in fee for service vs. salaried models suggests they were trying to prove an economic, not a medical point.

Fourth, what was the study size? If small, a single cowboy of a surgeon who is bringing 40-50% stenosis to the OR can skew the whole study.

Fifth, this is a study within a single insurance plan, which makes it problematic at best and subject to certain rules that might impact the study. Who gets a carotid duplex within this insurance plan. Just symptomatic patients? Any bruit? Or do they do routine screening. These rules will skew the patient base for the whole study.
About 20-25 years ago there was a "study" that showed(with p values < .001) that patients taking calcium channel blockers for hypertension were at far greater risk for stroke, heart attack and CHF. It must have been a slow news day because the study was picked up by the AP wire and then the excrement hit the fan. For the next 2 weeks the academic cardiologists were on the talk show and news circuit doing damage control, since thousands of people stopped taking their medication. Turns out the study was done entirely within the Harvard Medical Plan, a Boston based HMO. The problem was that this HMO had a "rule", that only patients with "complicated" HTN could be treated with a Ca++ channel blocker, otherwise they would get a diuretic and B-blocker. Therefore, the entire study was skewed to select the most severe cases of HTN to start with, so naturally all the complication rates were higher

Sixth, as far as outcome goes, what was the breakdown of percentage of stenosis? Generally, patients with high grade stenosis will do better with surgery and low grade stenosis can be treated medically. If I was trying to prove a point in a study, I'd lump them all together, especially if there were patients getting surgery for low grade stenosis.

Seventh, this was a retrospective study based on chart review---not the best type of study to start with.

Bottom line, if you happen to be discovered to have carotid stenosis, see a quality vascular surgeon; I doubt he will have "Tahiti" on his mind. For me personally, he would have to kidnap me to operate on a 50% stenosis, but with 90% I want my surgery yesterday.
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Old 03-04-2017, 08:10 AM
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Vascular docs cover more than one hospital. Our very good friend covers 8. Over 20 years I have watched him work tirelessly. When carotid surgery was recommended for my dad by his internist he sat down with us, pros and cons for over an hour. Half of vascular surgery is a add on or an emergency. As far as vacations he and his wife also a doctor took off 4 days last year to see their son graduate from college. Now that a vacation well worth it.
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Old 03-04-2017, 08:19 AM
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Vascular docs cover more than one hospital. Our very good friend covers 8. Over 20 years I have watched him work tirelessly. When carotid surgery was recommended for my dad by his internist he sat down with us, pros and cons for over an hour. Half of vascular surgery is a add on or an emergency. As far as vacations he and his wife also a doctor took off 4 days last year to see their son graduate from college. Now that a vacation well worth it.
Huh??? You mean he didn't do a few unnecessary procedures to pay for "Tahiti"??? I'm just shocked
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Old 03-04-2017, 09:12 AM
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golfing eagles;1368026]Everyone, please be very, VERY careful in interpreting the results of this single study. I have not read this particular article, but there are many questions that arise

First, surgical vs. medical management of carotid stenosis is somewhat controversial to start with. Vascular surgeons believe in surgery, it is what they are trained to do, and it has very little to do with "Tahiti".
Perhaps before rushing to pontificate, you could have read the article. In it you would have found that most of your questions are answered making your comments either moot or already discussed by the authors.
The article defines who saw the patients. Patients only seen and diagnosed and managed by internists were excluded from the data. The study is specifically designed to look at whether a doctor who is trained to do the intervention may be influenced by whether he is going to make more by operating than by managing in a non-operative manner. And the authors are careful in pointing out that the influence of personal financial gain may well be an unconscious motivation. The question is not whether is has very little to do with Tahiti, but whether is has anything at all which it should not.



Quote:
Second, most carotid stenosis are discovered by the patient's internist, either because he heard a bruit, the patient had symptoms, or they went for a screening ultrasound. The patient would be started on an anti-platelet agent and referred to a vascular surgeon. So who is "fee for service" and who is "on salary" The internist? The surgeon? Both? Neither? As you can imagine, this has a tremendous effect on this study
Yes, and that is discussed in the article. I would be interested in your opinion after you read the article. It compared FFS surgeons and salaried surgeons.

Quote:
Third, is there a bias among the researchers? The very fact that the point of the study was to look at surgical rates in fee for service vs. salaried models suggests they were trying to prove an economic, not a medical point.
Yes, the point of the article was to look at whether dollars not medical necessity are driving the decision to operate. That is the important issue being raised. I don't think that most patients want to have surgery so the doctor or medical organization can make more money if it is not needed. It would have been nice if the findings were that surgery rates were the same in the FFS vs Salaried situations. But they were not.

Quote:
Fourth, what was the study size? If small, a single cowboy of a surgeon who is bringing 40-50% stenosis to the OR can skew the whole study.
The article gives you the size of the groups. Here is the second sentence:

"Findings In this database study of 10 579 individuals with carotid artery stenosis, the adjusted odds of undergoing carotid endarterectomy or stenting were significantly higher in the fee-for-service setting than in the salary-based setting for both symptomatic and asymptomatic disease."

Quote:
Fifth, this is a study within a single insurance plan, which makes it problematic at best and subject to certain rules that might impact the study. Who gets a carotid duplex within this insurance plan. Just symptomatic patients? Any bruit? Or do they do routine screening. These rules will skew the patient base for the whole study.
Again, this looked at over 10,000 patients who were managed by subspecialists, whether the initial diagnosis was made by the generalist or elsewhere, they were confirmed with a diagnosis of stenosis [degree of stenosis not specified] not just a bruit. Once you read the study you will see that an additional 37,000 were diagnosed with stenosis by internists or other non-surgical providers and not referred for decision on surgery and managed medically by the primary care provider. So this study looked at the subgroup who were referred for a decision on surgery or not.



Quote:
Bottom line, if you happen to be discovered to have carotid stenosis, see a quality vascular surgeon; I doubt he will have "Tahiti" on his mind. For me personally, he would have to kidnap me to operate on a 50% stenosis, but with 90% I want my surgery yesterday
.

And after you have read this article you and I agree that some patients may need surgery [although the evidence for who that is changing as discussed briefly in this study and was being discussed here in NEJM 9 years ago]

Interesting reference in the article, showing another example of the potential economic influence in decision making:
"Falling birth rates have also been shown to trigger an increase in cesarean deliveries, a more lucrative procedure compared with vaginal delivery."

I am certain back when you were practicing you didn't jump to conclusions before you read the reports and examined the patient and took a history. Read the article please before you tell us all the reasons it is wrong.
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Old 03-04-2017, 09:45 AM
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Perhaps before rushing to pontificate, you could have read the article. In it you would have found that most of your questions are answered making your comments either moot or already discussed by the authors.
The article defines who saw the patients. Patients only seen and diagnosed and managed by internists were excluded from the data. The study is specifically designed to look at whether a doctor who is trained to do the intervention may be influenced by whether he is going to make more by operating than by managing in a non-operative manner. And the authors are careful in pointing out that the influence of personal financial gain may well be an unconscious motivation. The question is not whether is has very little to do with Tahiti, but whether is has anything at all which it should not.




Yes, and that is discussed in the article. I would be interested in your opinion after you read the article. It compared FFS surgeons and salaried surgeons.



Yes, the point of the article was to look at whether dollars not medical necessity are driving the decision to operate. That is the important issue being raised. I don't think that most patients want to have surgery so the doctor or medical organization can make more money if it is not needed. It would have been nice if the findings were that surgery rates were the same in the FFS vs Salaried situations. But they were not.



The article gives you the size of the groups. Here is the second sentence:

"Findings In this database study of 10 579 individuals with carotid artery stenosis, the adjusted odds of undergoing carotid endarterectomy or stenting were significantly higher in the fee-for-service setting than in the salary-based setting for both symptomatic and asymptomatic disease."



Again, this looked at over 10,000 patients who were managed by subspecialists, whether the initial diagnosis was made by the generalist or elsewhere, they were confirmed with a diagnosis of stenosis [degree of stenosis not specified] not just a bruit. Once you read the study you will see that an additional 37,000 were diagnosed with stenosis by internists or other non-surgical providers and not referred for decision on surgery and managed medically by the primary care provider. So this study looked at the subgroup who were referred for a decision on surgery or not.



.

And after you have read this article you and I agree that some patients may need surgery [although the evidence for who that is changing as discussed briefly in this study and was being discussed here in NEJM 9 years ago]

Interesting reference in the article, showing another example of the potential economic influence in decision making:
"Falling birth rates have also been shown to trigger an increase in cesarean deliveries, a more lucrative procedure compared with vaginal delivery."

I am certain back when you were practicing you didn't jump to conclusions before you read the reports and examined the patient and took a history. Read the article please before you tell us all the reasons it is wrong.
It appears that you both came to the same conclusions, that when patients saw a surgeon, surgery was more often suggested, other doctors offered medical intervention first and then a referral to a surgeon.

I am not a medical anything.
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Old 03-04-2017, 09:53 AM
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It appears that you both came to the same conclusions, that when patients saw a surgeon, surgery was more often suggested, other doctors offered medical intervention first and then a referral to a surgeon.

I am not a medical anything.
Gracie, you are misunderstanding the issue. Here it is :

All these patients saw a surgeon. But whether the surgeon was going to make more money by operating seemed to influence the recommendation. The fee for service doctors are paid by the insurance company for doing surgery. Paid a lot more for an hour of operating than an hour of office time. The salaried doctors are paid by a corporation for being there and are paid the same whether they operate or do not operate, they get a paycheck.

Yes, we agree some people need surgery. The question is whether the only factor in the choice is what the patient needs not what the surgeon gains.

Edit: By the way, you are a medical consumer and a tax payer, so this very much concerns you and everyone else.

Last edited by blueash; 03-04-2017 at 10:31 AM.
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Old 03-04-2017, 11:49 AM
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Gracie, you are misunderstanding the issue. Here it is :

All these patients saw a surgeon. But whether the surgeon was going to make more money by operating seemed to influence the recommendation. The fee for service doctors are paid by the insurance company for doing surgery. Paid a lot more for an hour of operating than an hour of office time. The salaried doctors are paid by a corporation for being there and are paid the same whether they operate or do not operate, they get a paycheck.

Yes, we agree some people need surgery. The question is whether the only factor in the choice is what the patient needs not what the surgeon gains.

Edit: By the way, you are a medical consumer and a tax payer, so this very much concerns you and everyone else.
Thank you for your reply. I'm not sure why you chose to be argumentative rather than informative, but yes, I should have read the article. You gave a pretty good synopsis, but I would hardly call raising legitimate methodology questions "pontificating"

Now that I read the article, there are still problems with it:

It remains a retrospective study, with all the inherent problems of such studies. The large number of patients is not unusual, since all you have to do is find a bunch of old charts. The Ca++ channel blocker study that led to a horrible conclusion was also retrospective and included thousands of patients. Retrospective studies are also more subject to researcher bias since you are not collecting data in real time but rather interpreting old data. Above all, retrospective studies are not double blinded.

The next problem is that all surgery was performed by MILITARY surgeons. There's an old saying that goes "there's a right way to do things, a wrong way to do things, and the army way to do things". The article does not spell out "the army way" Are the criteria by which a military vascular surgeon decides upon carotid endarterectomy different than civilian?

Next, military surgeons are indeed on straight "salary". In the real world, that is not the usual case---an employed surgeon usually gets a salary guarantee PLUS a productivity bonus, so I wonder if the odds ratio would be less with civilian employed surgeons.

If you look at the odds ratios in the data, it is about 1.6 for fee for service surgeons, certainly implying that financial gain may be a significant factor. But the odds ratio for smokers, regardless of payment model, was 1.9. Therefore, I could us their data and title an article "Vascular surgeons are far more likely to "punish" a smoker by "putting them under the knife" and my conclusion would be even more statistically valid. Do you think that is really the case? And if not, why is "Tahiti" more valid? The odds ratio for symptomatic patients was about 9. Yet progression to CVA is nowhere near 9x as great for symptomatic patients, so why is that? Perhaps the patient with symptoms is more eager to have something done?

Lastly, are there surgeons motivated by money? Of course there are. There are dermatologists and radiologists and internists with that motivation. There are also lawyers, plumbers and used car salesmen as well. I just don't think that money is the MAIN motivation for the MAJORITY of surgeons. I just didn't want a person with a legitimate need for surgical intervention to reject that treatment because he became convinced that the surgeon is just trying to make money.
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