• Christian Lopez Ramos, Michael G Brandel, Robert C Rennert, Brian R Hirshman, Arvin R Wali, Jeffrey A Steinberg, David R Santiago-Dieppa, Mitchell Flagg, Scott E Olson, J Scott Pannell, and Alexander A Khalessi.
• Department of Neurosurgery, University of California, San Diego, La Jolla, California.
• Neurosurgery. 2020 Feb 1; 86 (2): 241249241-249.

BackgroundThe "Volume Pledge" aims to centralize carotid artery stenting (CAS) to hospitals and surgeons performing ≥10 and ≥5 procedures annually, respectively.ObjectiveTo compare outcomes after CAS between hospitals and surgeons meeting or not meeting the Volume Pledge thresholds.MethodsWe queried the Nationwide Inpatient Sample for CAS admissions. Hospitals and surgeons were categorized as low volume and high volume (HV) based on the Volume Pledge. Multivariable hierarchical regression models were used to examine the impact of hospital volume (2005-2011) and surgeon volume (2005-2009) on perioperative outcomes.ResultsBetween 2005 and 2011, 22 215 patients were identified. Most patients underwent CAS by HV hospitals (86.4%). No differences in poor outcome (composite endpoint of in-hospital mortality, postoperative neurological or cardiac complications) were observed by hospital volume but HV hospitals did decrease the likelihood of other complications, nonroutine discharge, and prolonged hospitalization. From 2005 to 2009, 9454 CAS admissions were associated with physician identifiers. Most patients received CAS by HV surgeons (79.2%). On multivariable analysis, hospital volume was not associated with improved outcomes but HV surgeons decreased odds of poor outcome (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.97; P = .028), complications (OR 0.56, 95% CI 0.46-0.71, P < .001), nonroutine discharge (OR 0.70, 95% CI 0.57-0.87; P = .001), and prolonged hospitalization (OR 0.52, 95% 0.44-0.61, P < .001).ConclusionMost patients receive CAS by hospitals and providers meeting the Volume Pledge threshold for CAS. Surgeons but not hospitals who met the policy's volume standards were associated with superior outcomes across all measured outcomes.Copyright © 2019 by the Congress of Neurological Surgeons.

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