Practice patterns surrounding the use of tibial interventions for claudication in the Medicare population |
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| Affiliation: | 1. Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD;2. Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD;3. Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD;4. Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA;1. Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT;2. Department of Psychiatry, Yale School of Medicine, New Haven, CT;3. Department of Cardiology, Veterans Affairs Connecticut Healthcare System, West Haven, CT;4. Department of Surgery, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands;5. Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands;1. Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md;2. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md;3. Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md;1. Department of Sports and Exercise, Máxima Medical Centre, Veldhoven, Noord-Brabant, The Netherlands;2. Department of Nutrition and Movement Sciences, Faculty of Health, Medicine and Life Sciences, Maastricht University Maastricht, Maastricht, Limburg, The Netherlands;3. Department of Vascular Surgery, Máxima Medical Centre, Veldhoven, Noord-Brabant, The Netherlands;4. Department of Mathematics and Computer Science, Faculty of Statistics, Eindhoven University of Technology, Eindhoven, Noord-Brabant, The Netherlands;1. Department of Vascular Surgery, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK;2. Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan;3. Department of Surgery, University of California at San Francisco, San Francisco, CA;1. Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA;2. Division of Vascular Surgery, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI;3. Division of Vascular Surgery, Department of Surgery, Howard University College of Medicine, Washington, DC;1. Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD;2. The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;3. Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD;4. Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY;5. Division of Vascular Surgery, Department of Surgery, Centre Hospitalier de l’Université de Montréal, Montreal, Québec, Canada |
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| Abstract: | ObjectiveAt present, no data are available to support the use of tibial interventions in the treatment of claudication. We characterized the practice patterns surrounding tibial peripheral vascular interventions (PVIs) for patients with claudication in the United States.MethodsUsing 100% Medicare fee-for-service claims from 2017 to 2019, we conducted a retrospective analysis of all patients who underwent an index PVI for claudication. Patients with any previous PVI, acute limb ischemia, or chronic limb-threatening ischemia in the preceding 12 months were excluded. The primary outcome was the receipt or delivery of tibial revascularization during an index PVI for claudication, defined as tibial PVI with or without concomitant femoropopliteal PVI. Univariable comparisons and multivariable hierarchical logistic regression were used to assess the patient and physician characteristics associated with the use of tibial PVI for claudication.ResultsOf 59,930 Medicare patients who underwent an index PVI for claudication between 2017 and 2019, 16,594 (27.7%) underwent a tibial PVI (isolated tibial PVI, 38.5%; tibial PVI with concomitant femoropopliteal PVI, 61.5%). Of the 1542 physicians included in our analysis, the median physician-level tibial PVI rate was 20.0% (interquartile range, 9.1%-37.5%). Hierarchical logistic regression suggested that patient-level characteristics associated with tibial PVI for claudication included male sex (adjusted odds ratio [aOR], 1.23), increasing age (aOR, 1.30-1.96), Black race (aOR, 1.47), Hispanic ethnicity (aOR, 1.86), diabetes (aOR, 1.36), no history of hypertension (aOR, 1.12), and never-smoking status (aOR, 1.64; P < .05 for all). Physician-level characteristics associated with tibial PVI for claudication included early-career status (aOR, 2.97), practice location in the West (aOR, 1.75), high-volume PVI practice (aOR, 1.87), majority of practice in an ambulatory surgery center or office-based laboratory setting (aOR, 2.37), and physician specialty. The odds of vascular surgeons performing tibial PVI were significantly lower compared with radiologists (aOR, 2.98) and cardiologists (aOR, 1.67; P < .05 for all). The average Medicare reimbursement per patient was dramatically higher for physicians performing high rates of tibial PVI (quartile 4 vs quartile 1-3, $12,023.96 vs $692.31 per patient; P < .001).ConclusionsTibial PVI for claudication was performed more often by nonvascular surgeons in high-volume practices and high-reimbursement settings. Thus, a critical need exists to reevaluate the indications, education, and reimbursement policies surrounding these procedures. |
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| Keywords: | Centers for Medicare and Medicaid Clinical guidelines Endovascular surgery Intermittent claudication Peripheral artery disease Peripheral vascular interventions |
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