Carotid disease: Getting to the right decision

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Brianna Krafcik at NESVS 2023
The recent move by the Centers for Medicare & Medicaid Services (CMS) to expand coverage for carotid artery stenting brought with it the requirement for a shared decision-making interaction between physicians and patients as they establish which carotid revascularization treatment modality is best for their disease. Currently, a validated tool does not exist—but investigators at Dartmouth Hitchcock Medical Center are working on research aimed at changing that. 

Now that the decision has been made to expand Medicare coverage for carotid artery stenting to include patients who have symptomatic carotid stenosis ≥50% and asymptomatic ≥70%, the stage has been set. 

Yet, as Brianna M. Krafcik, MD, a vascular surgery resident at Dartmouth Health in Lebanon, New Hampshire, reflects, just over a year ago, long before the controversial move went under the spotlight, she and colleagues failed to garner much attention when they submitted a review paper that looked at the decision aids available to carotid stenosis patients considering intervention versus medical therapy. 

Now there is a need. A shared decision-making interaction has been mandated in CMS’ final decision memo. Amid the vacuum, the work of Krafcik and colleagues is suddenly taking center stage. This includes a paper recently presented at the 2023 New England Society for Vascular Surgery (NESVS) annual meeting in Boston (Oct. 6–8) that lays down some foundational pieces in the process toward creating such a tool—one that can be used across the multiple specialties treating carotid stenosis patients, and incorporate all options, including transcarotid artery revascularization (TCAR), approved in 2015 and not part of prior decision aids. 

“When we did the review paper—which is currently submitted for publication—more than a year ago, we only found four studies that looked at decision aid instruments with any kind of scientific method,” Krafcik explains in an interview. “I think that review paper shows that even those four instruments that have been studied, anecdotally and in the literature, it has been shown that they are pretty underutilized both by vascular surgeons and also interventional radiologists—for interventionalists who are working in carotid disease there is almost nothing. Medicare is asking for a decision aid that doesn’t exist, so the stage is set to create such an instrument.” 

The latest research from the Dartmouth group, led by Krafcik and senior author Jesse A. Columbo, MD, an assistant professor of surgery at Dartmouth, looks to plug a gap in qualitative data regarding patient understanding of carotid disease. 

They found that there is a “complicated interplay between patient values, understanding of the procedures, and preferred level of involvement in medical decision-making” that contributes to a patient’s ultimate decision. They carried out longitudinal perioperative semi-structured interviews with 20 carotid stenosis patients eligible for both carotid endarterectomy and transcarotid artery revascularization (TCAR)—10 for each procedure. 

“In the patient surveys, the most important source of information regarding the procedures was the vascular surgeon followed by any written materials they may have received, while TV or videos were generally less important,” Krafcik told NESVS 2023. “When patients were asked about their feelings towards shared decision-making, most would like to discuss all treatment options with the physician and make a decision together. However, only approximately 70% of patients agreed that they understood their carotid disease and the treatment options available. Patients reporting on factors important to them when considering procedures in general felt the surgeon’s experience with the procedure and the presence of long-term outcomes data were very important, while the length of the operation and size of the incision were less important.” 

Concluding, Krafcik and colleagues said in the present era of multiple treatment options, “patients should be presented with all available information when discussing carotid revascularization. A shared decision-making discussion consistent with the patients’ values and level of desired involvement improves patient satisfaction and compliance.” 

Krafcik tells Vascular Specialist the Dartmouth team are currently working with social scientists, the Vascular Quality Initiative (VQI) and other organizations in order to try to create a pilot instrument that can be studied “in an iterative way.” “From there, once we have a prototype, then we can study it for usability, accessibility and feasibility so it can then be scaled up to a multicenter study that takes into account different regions, education level and sociodemographic factors. That’s the long-term plan,” she added. 

Importantly, Krafcik explains, the goal is to create a decision feed that will have “buy-in” across the different specialties treating carotid stenosis. “If a patient were to see a cardiologist and be given this decision aid, and based on the information says, ‘I actually would prefer an open carotid endarterectomy,’ that the cardiologist would be OK saying, ‘Then, I’ll refer you to a vascular surgery colleague.’ I think now that more providers are going to be doing these procedures, our decision aid should encompass and have buy-in from all of the different specialties.” 

Krafcik says two things in particular from the study struck her— the impact that the surgeon has on patients and that not every patient wants to participate in shared decision-making or wants to participate in the same way. “A lot of the patients would, when I asked them to explain the procedure in their own words, reiterate what their surgeon told them,” she relates. “When asked why they decided, they said it seemed like their surgeon felt that this one was better than the other.” Preoperative conversations are time-limited, Krafcik adds, “so understanding first how involved the patient wants to be, how much info they want, and how they prefer to receive it is helpful in guiding the discussion, because there is not really a one-size fits-all preoperative discussion.” 

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