[blueash]

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.

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.

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.

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."

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.

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.