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(Stroke. 2002;33:1458.)
© 2002 American Heart Association, Inc.

Letters to the Editor

Outcomes in Carotid Endarterectomy Performed by Vascular Surgeons or Neurosurgeons

Thomas E. Feasby, MD; James Kennedy, MB, MSc; Hude Quan, MD, PhD William A. Ghali, MD, MPH

University of Calgary, Calgary, Alberta, Canada

To the Editor:

The article on New York State carotid endarterectomy (CE) outcomes by Hannan et al¹ reports an admirably low adverse outcome rate across all cases studied but also shows, as their title suggests, a surprising difference in outcome favoring the patients of vascular surgeons versus neurosurgeons (adjusted odds ratio for adverse events in neurosurgeons relative to vascular surgeons, 3.17 [95% CI, 1.26 to 7.97]). The authors themselves point out several reasons why this result may be erroneous, such as a possibly higher rate of detecting postoperative strokes by neurosurgeons. Another important difference that might have influenced the result was that the proportion of asymptomatic patients was 67% for vascular surgeons and 53.3% for neurosurgeons; additionally, the adverse outcome rate for asymptomatic patients is lower in this and other series.² Perhaps more importantly, the study sample was clearly not representative of all CE procedures done in New York State. The authors studied a voluntary registry, including only 7% of the surgeons in the state doing CE, among whom the adverse event rate was substantially lower than for the rest of the state.

Most importantly, the authors acknowledge that this difference between surgeons was not found in four other studies of CE outcomes. Given the increasing recognition among research methodologists that Bayesian reasoning is required to interpret statistically significant findings from new research in the context of preexisting research,^3,4 we would propose that the finding of outcome differences across surgical specialties needs to be interpreted with great caution.

The study by Hannan et . . . [Full Text of this Article]

Edward L. Hannan, PhD; A. John Popp, MD; Mark R. Chassin, MD, MPP, MPH Ethan Halm, MD, MPH

Department of Health Policy, Management and Behavior, School of Public Health, University at Albany, Albany, New York