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Comparison of Carotid Endarterectomy Outcomes from Ransomized Trials & Medicare Administrative Databases
Arch Neurol 54:826-832, Stukenborg,G.J., 1997
See this aricle in Pubmed

Article Abstract
Although carotid endarterectomy trials demonstrate the efficacy of the procedure,this evidence only applies to patients and hospitals with characteristics comparable to those of the trial participants.The importance of this consideration is demonstrated by the substantially higher odds of death experienced among Medicare patients receiving the procedure who had a level of comorbidity that exceeded that of the trial participants or who received their surgery in a hospital with a perioperative mortality rate that exceeded the experience of the hospitals in the trial.
 
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