The disproportionate growth of office-based atherectomy

Mukherjee, Dipankar; Hashemi, Homayoun; Contos, Brian

doi:10.1016/j.jvs.2016.08.112

Cited by 64 publications

(43 citation statements)

References 11 publications

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“…32,33 Increased utilization of atherectomy has been challenged as related to reimbursement models. 8 Reimbursement for atherectomy is higher than any other intervention for PAD in general and higher in the office setting than in the hospital setting for certain interventions. For example, in 2016, Medicare paid US$10 723 for femoral-popliteal atherectomy in the office setting versus US$9542 for hospital outpatient departments.…”

Section: Discussionmentioning

confidence: 99%

“…9 Mukherjee et al presented Medicare data from 2011 to 2014 on the unprecedented growth of OB atherectomy in the management of infrainguinal occlusive disease. 8 Generous Medicare physician and facility fees for atherectomy appear to be the main drivers for this change and this trend appears to continue beyond the 2014 time period. 8 There also appears to be an increasing number of repeat interventions on the same patient for lower extremity occlusive disease.…”

Section: Introductionmentioning

confidence: 99%

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High Reintervention and Amputation Rates After Outpatient Atherectomy for Claudication

Mukherjee

Contos

Emery

et al. 2018

Vasc Endovascular Surg

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Outpatient use of atherectomy for peripheral arterial disease has grown rapidly and outcomes are poorly understood. We analyzed outcomes of atherectomy done for claudication, comparing office and hospital outpatient settings. Analysis of Medicare Part B claims data was performed for incident femoral-popliteal or tibial-peroneal atherectomy from 2012 to 2014. Longitudinal analysis assessed services 18 months before, during, and up to 18 months after the incident peripheral vascular intervention (PVI). Differences between office-based and hospital outpatient-based settings were assessed using χ and Fisher exact tests. Comparing procedure settings, significant differences in race (femoral-popliteal: P = .04, tibial-peroneal: P = .001), chronic renal failure (femoral-popliteal: P = .002), and hypertension (femoral-popliteal: P = .01, tibial-peroneal: P = .006) were found. Nine hundred twenty-four patients undergoing femoral-popliteal atherectomy were analyzed (262 office based, 662 hospital outpatient based); 42.7% of office-based and 36.9% of hospital outpatient-based femoral-popliteal atherectomy patients had repeat PVI within 18 months ( P = .10). Major amputation was performed in 2.3% and 3.2% of patients in office and hospital outpatient settings, respectively ( P = .47). Four hundred twenty-three patients undergoing tibial-peroneal atherectomy were analyzed (202 office based, 221 hospital outpatient based); 46.5% of office-based and 38.9% of hospital outpatient-based tibial-peroneal atherectomy patients had repeat PVI within 1 year ( P = .11). Major amputation was performed in 5.0% and 8.1% of patients in office and hospital outpatient settings, respectively ( P = .19). Our study demonstrates higher than expected rates of major amputation for patients undergoing peripheral arterial atherectomy with regard to previously reported rates. Further studies may be required to prove the efficacy and safety of atherectomy for occlusive disease in the femoral-popliteal and tibial-peroneal segments to ensure outcomes are not worse than the natural history of medically managed claudicants.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

High Reintervention and Amputation Rates After Outpatient Atherectomy for Claudication

Mukherjee

Contos

Emery

et al. 2018

Vasc Endovascular Surg

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“…The majority of physicians included in the analysis were male (95.9% [n ¼ 5430]) and practiced in urban locations (92.6% [n ¼ 5243]; Table II). The median number of years in practice was 23 years (IQR, 16-30 years), and the median number of patients who received a new diagnosis of claudication during the study period was 22 (IQR, [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] Patient and physician characteristics associated with early PVI. Based on univariable logistic regression analysis, patient characteristics associated with higher early PVI rates included age 65 to 74 years, male sex, hypertension, and smoking (all P < .001; Table III).…”

Section: Resultsmentioning

confidence: 99%

“…In another study of Medicare claims for endovascular interventions, there was a 298% increase in atherectomy cases in the OBL setting from 2011 to 2014 compared with a 27% increase in the hospital outpatient setting. 26 These trends are particularly concerning, given that office-based PVI has been associated with a higher risk of repeated revascularization compared with PVI performed in other settings. 27 Other physician factors that were independently associated with higher early PVI rates for claudication included male sex, few years in practice, and lower volume claudication practice.…”

Section: Discussionmentioning

confidence: 99%

Overuse of early peripheral vascular interventions for claudication

Hicks

Holscher

Wang

et al. 2020

Journal of Vascular Surgery

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Objective: Guidelines from the Society for Vascular Surgery and the Choosing Wisely campaign recommend that peripheral vascular interventions (PVIs) be limited to claudication patients with lifestyle-limiting symptoms only after a failed trial of medical and exercise therapy. We sought to explore practice patterns and physician characteristics associated with early PVI after a new claudication diagnosis to evaluate adherence to these guidelines. Methods:We used 100% Medicare fee-for-service claims to identify patients diagnosed with claudication for the first time between 2015 and 2017. Early PVI was defined as an aortoiliac or femoropopliteal PVI performed within 6 months of initial claudication diagnosis. A physician-level PVI utilization rate was calculated for physicians who diagnosed >10 claudication patients and performed at least one PVI (regardless of indication) during the study period. Hierarchical multivariable logistic regression was used to identify physician-level factors associated with early PVI.Results: Of 194,974 patients who had a first-time diagnosis of claudication during the study period, 6286 (3.2%) underwent early PVI. Among the 5664 physicians included in the analysis, the median physician-level early PVI rate was low at 0% (range, 0%-58.3%). However, there were 320 physicians (5.6%) who had an early PVI rate $14% ($2 standard deviations above the mean). After accounting for patient characteristics, a higher percentage of services delivered in ambulatory surgery center or office settings was associated with higher PVI utilization (vs 0%-22%; 23%-47%: adjusted odds ratio [aOR], 1.23; 48%-68%: aOR, 1.49; 69%-100%: aOR, 1.72; all P < .05). Other risk-adjusted physician factors independently associated with high PVI utilization included male sex (aOR, 2.04), fewer years in practice (vs $31 years; 11-20 years: aOR, 1.23; 21-30 years: aOR, 1.13), rural location (aOR, 1.25), and lower volume claudication practice (vs $30 patients diagnosed during study period; #17 patients: aOR, 1.30; 18-29 patients: aOR, 1.35; all P < .05). Conclusions:Outlier physicians with a high early PVI rate for patients newly diagnosed with claudication are identifiable using a claims-based practice pattern measure. Given the shared Society for Vascular Surgery and Choosing Wisely initiative goal to avoid interventions for first-line treatment of claudication, confidential data-sharing programs using national benchmarks and educational guidance may be useful to address high utilization in the management of claudication. (J Vasc Surg 2020;71:121-30.)

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“…[1][2][3][4] As more and more procedures are being transitioned out of the traditional hospital setting into the outpatient setting, the move has raised some criticism as well as legitimate questions. These concerns range from the pervasive opinion that OBLs are simply in it for financial gain, with minimal regard for patient outcomes (ie, the increase in atherectomy usage due to reimbursement rates rather than indications), 5,6 to other important questions such as OBL patient selection. Are these simple cases that have been cherry-picked?…”

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confidence: 99%