Overuse of early peripheral vascular interventions for claudication

Abstract

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.)

Predicting 10-year risk of recurrent cardiovascular events andcardiovascular interventions in patients with established cardiovascular disease: results from UCC-SMART and REACH

“…Although this could also be true for coronary restenosis, restenosis is reported more often after peripheral interventions [40,41,43]. Additionally, in patients with a new diagnosis of claudication, indication for early peripheral vascular interventions depended on the treating physician [44]. It could be hypothesized that in patients with established PAD, indication for peripheral (re-)intervention might also rely partly on clinician IR = Incidence rate (per 100 person-years).…”

Statistical determination of clinical outliers and public shaming

“…We read with interest the article by Hicks et al 1 examining early peripheral vascular interventions for claudication. This study of 194,974 Medicare patients treated by 5664 physicians is encouraging as it documents that only 3.5% of patients had an intervention within 6 months of diagnosis, suggesting widespread acceptance of recommended treatment guidelines.…”

“…The Choosing Wisely campaign was created as an initiative of the American Board of Internal Medicine in 2012 with the mission to promote conversations between clinicians and patients to reduce low-value care. 1 While the aim of Choosing Wisely is important, the initiative is not actionable. Improving Wisely is a new initiative that takes the aims of Choosing Wisely a step further.…”

Regarding “Limitations in the Analysis of Atherectomy Using Medicare Big Data”

“…I would like to bring to the attention of the readers current publications with analysis of Medicare fee for service claims to identify patients diagnosed with claudication for the first time between 2015 and 2017 by Hicks et al 4 Using 2018 Medicare claims-based data they were able to identify outlier physicians with a high early peripheral vascular intervention rate that was more than 2 standard deviations above the mean. A high percentage of these services were delivered in ambulatory surgery center or office settings using atherectomy.…”