RS07 - Impact of the 2023 CMS policy change on carotid artery stenting utilization among Medicare beneficiaries

Objectives: On October 11, 2023, the Centers for Medicare and Medicaid Services (CMS) expanded the indications for carotid artery stenting (CAS) to include standard risk patients with symptomatic ≥50% and asymptomatic ≥70% carotid artery stenosis, providing surgeons an option between carotid endarterectomy (CEA) and CAS. This decision followed arguments both for and against the change by various societies, including opposition by the Society for Vascular Surgery. We sought to examine the impact of the change in CMS policy with utilization of CAS versus CEA.

Methods: We used 100% Medicare fee-for-service claims data to identify all patients who underwent CAS or a CEA between 1/1/17 and 12/31/24. CAS included both transfemoral and transcarotid revascularization. We evaluated the trends of utilization of CAS vs. CEA overall and stratified by symptomatic status and physician specialty. We conducted an interrupted time series analysis with the time break set at October 2023 to evaluate the impact of the CMS policy change on CAS utilization.

Results: There were 385,067 carotid revascularizations performed during the study period (mean age 75.1 years, 59.9% male, 3.5% Black race), including 45.0% for symptomatic vs. 55.0% for asymptomatic disease, and 77.1% CEA vs. 22.9% CAS. The proportion of cases performed for asymptomatic vs. symptomatic disease was relatively stable over time (2017: 57.1% vs. 2024: 56.6%), equivalent to a 0.3% (95% CI -0.8-0.2%) decrease in the proportional treatment of patients with asymptomatic disease per year (P=0.15). The proportion of carotid revascularizations performed using CAS significantly increased over time (2017: 13.0% vs. 2024: 37.5%; P< 0.001), equivalent to a 3.6% (95% CI 3.4-3.8%) proportional increase in the use of CAS per year (P < 0.001). There was a slight decrease in CEA use after the expansion of CAS in October 2023, but this was not statistically significant (Figure 1, P=0.46). The proportion of carotid revascularization procedures performed by vascular surgeons vs. other specialties increased from 42.5% in 2017 to 54.2% in 2024 (P < 0.001; Figure 2).

Conclusions: Despite societal concerns about the CMS decision to expand CAS indications, there has not been a major change in the balance between CEA vs. CAS performed before versus after October 2023. Encouragingly, vascular surgeons are performing an increasing proportion of carotid interventions, which may reflect a greater focus on specialized care for these procedures. Continued monitoring of these trends will be important to ensure optimal patient outcomes and appropriate use of carotid revascularization strategies.