1
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Harish KB, Chervonski E, Speranza G, Maldonado TS, Garg K, Sadek M, Rockman CB, Jacobowitz GR, Berland TL. Prior authorization requirements in the office-based laboratory setting are administratively inefficient and threaten timeliness of care. J Vasc Surg 2024; 79:1195-1203. [PMID: 38135169 DOI: 10.1016/j.jvs.2023.10.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/12/2023] [Accepted: 10/30/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the administrative and clinical impacts of prior authorization (PA) processes in the office-based laboratory (OBL) setting. METHODS This single-institution, retrospective analysis studied all OBL PAs pursued between January 2018 and March 2022. Case, PA, and coding information was obtained from the practice's scheduling database. RESULTS Over the study period, 1854 OBL cases were scheduled; 8% (n = 146) required PA. Of these, 75% (n = 110) were for lower extremity arterial interventions, 19% (n = 27) were for deep venous interventions, and 6% (n = 9) were for other interventions. Of 146 PAs, 19% (n = 27) were initially denied but 74.1% (n = 7) of these were overturned on appeal. Deep venous procedures were initially denied, at 43.8% (n = 14), more often than were arterial procedures, at 11.8% (n = 13). Of 146 requested procedures, 4% (n = 6) were delayed due to pending PA determination by a mean 14.2 ± 18.3 working days. An additional 6% (n = 8) of procedures were performed in the interest of time before final determination. Of the seven terminally denied procedures, 57% (n = 4) were performed at cost to the practice based on clinical judgment. CONCLUSIONS Using PA appeals mechanisms, while administratively onerous, resulted in the overturning of most initial denials.
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Affiliation(s)
| | | | | | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Caron B Rockman
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Todd L Berland
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
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2
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Pyun AJ, Goodney PP, Eldrup-Jorgensen J, Wadzinski J, Secemsky EA, Cigarroa JE. Device regulation and surveillance in vascular care: Challenges and opportunities. Catheter Cardiovasc Interv 2024. [PMID: 38639136 DOI: 10.1002/ccd.31053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 04/02/2024] [Indexed: 04/20/2024]
Abstract
Cardiovascular devices are essential for the treatment of cardiovascular diseases including cerebrovascular, coronary, valvular, congenital, peripheral vascular and arrhythmic diseases. The regulation and surveillance of vascular devices in real-world practice, however, presents challenges during each individual product's life cycle. Four examples illustrate recent challenges and questions regarding safety, appropriate use and efficacy arising from FDA approved devices used in real-world practice. We outline potential pathways wherein providers, regulators and payors could potentially provide high-quality cardiovascular care, identify safety signals, ensure equitable device access, and study potential issues with devices in real-world practice.
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Affiliation(s)
- Alyssa J Pyun
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, California, USA
| | - Philip P Goodney
- Heart and Vascular Center, Dartmouth Health, Lebanon, New Hampshire, USA
- The Society for Vascular Surgery's Patient Safety Organization (SVS-PSO) and Vascular Quality Initiative (VQI), Chicago, Illinois, USA
| | - Jens Eldrup-Jorgensen
- The Society for Vascular Surgery's Patient Safety Organization (SVS-PSO) and Vascular Quality Initiative (VQI), Chicago, Illinois, USA
| | - James Wadzinski
- The Society for Vascular Surgery's Patient Safety Organization (SVS-PSO) and Vascular Quality Initiative (VQI), Chicago, Illinois, USA
| | - Eric A Secemsky
- Division of Vascular Interventions, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Joaquin E Cigarroa
- Division of Cardiovascular Medicine, Department of Medicine, Oregon Health Sciences University (OHSU), Portland, Oregon, USA
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3
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Smith JA, Yang L, Chen L, Kumins N, Cho JS, Harth K, Wong V, Kashyap V, Colvard B. Trends and outcomes associated with intravascular ultrasound use during femoropopliteal revascularization in the Vascular Quality Initiative. J Vasc Surg 2023; 78:209-216.e1. [PMID: 36944390 DOI: 10.1016/j.jvs.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Intravascular ultrasound (IVUS) use in lower extremity interventions is growing in popularity owing to its imaging in the axial plane, superior detail in imaging lesion characteristics, and its enhanced ability to delineate lesion severity and extent compared with catheter angiograms. However, there are conflicting data regarding whether IVUS affects outcomes. The purpose of this study was to assess the effect associated with IVUS implementation in femoropopliteal interventions. METHODS This retrospective cohort study used Vascular Quality Initiative data. Patients undergoing an index endovascular femoropopliteal revascularization from 2016 to 2021 were included. Patients were differentiated by whether or not IVUS was used to assess the femoropopliteal segment during intervention (no IVUS, IVUS). Propensity score matching, based on preoperative demographics and measures of disease severity was used. Primary outcomes were major amputation-free survival (AFS), femoropopliteal reintervention-free survival (RFS), and primarily patent survival (PPS) at 12 months. RESULTS IVUS use grew steadily throughout the study period, comprising 0.6% of interventions in 2016 and increasing to 8.2% of interventions by 2021; growth was most dramatic in ambulatory surgical center or office-based laboratory settings where IVUS use grew from 4.4% to 43% to 47% of interventions. In unmatched cohorts, patients receiving interventions using IVUS tended to have lower prevalence of multiple cardiovascular comorbidities (eg, congestive heart failure, hypertension, diabetes, and dialysis dependence) and presented more often with claudication and less often with chronic limb-threatening ischemia (CLTI). Intraoperatively, IVUS was used more often in complex femoropopliteal lesions (Transatlantic Intersociety grade D vs A), and more often in conjunction with stenting and/or atherectomy. IVUS use was associated with improved AFS, but similar RFS and PPS at 12 months. However, in multivariable analysis IVUS was not associated with any of the primary outcomes independently; rather, all outcomes were influenced primarily by CLTI, dialysis dependence, and prior major amputation status; technical outcomes (ie, RFS and PPS loss) were further driven by complexity of lesion (worse in Transatlantic Intersociety grade D vs A lesions) and treatment setting (ie, ambulatory surgical center or office-based laboratory setting associated with increased hazard for RFS and PPS loss). CONCLUSIONS IVUS implementation in femoropopliteal interventions is growing, with rapid adoption among interventions in ambulatory surgical centers and office-based laboratories. IVUS was not associated with an effect on technical outcomes at 12 months; improvement in major AFS was observed; however, multivariable analysis suggests this finding may be an effect of confounding by multiple factors highly associated with IVUS use, namely, in patients with lower prevalence of CLTI, dialysis dependence, and prior major amputations, thus conveying baseline lower risk for major amputation and death.
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Affiliation(s)
- Justin A Smith
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH.
| | - Lucy Yang
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lin Chen
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Norman Kumins
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Karem Harth
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Virginia Wong
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Vikram Kashyap
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
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4
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Sorber R, Dun C, Kawaji Q, Abularrage CJ, Black JH, Makary MA, Hicks CW. Reprint of: Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia. J Vasc Surg 2023; 77:1720-1731.e3. [PMID: 37225352 PMCID: PMC10756146 DOI: 10.1016/j.jvs.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Despite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. METHODS We evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. RESULTS A total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). CONCLUSIONS Early PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.
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Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Chen Dun
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Qingwen Kawaji
- Department of Plastics and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
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5
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Jiang D, Kuchta K, Morcos O, Lind B, Yoon W, Qamar A, Trenk A, Lee CJ. Revascularizations and limb outcomes of hospitalized patients with diabetic peripheral arterial disease in the contemporary era. J Vasc Surg 2023; 77:1155-1164.e2. [PMID: 36563711 DOI: 10.1016/j.jvs.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Concomitant diabetes mellitus and peripheral artery disease (PAD) is a complex disease process. This retrospective analysis of the National Inpatient Sample sought to understand trends in limb outcomes of this unique and prevalent cohort of patients. METHODS The National Inpatient Sample was queried between 2003 and 2017 for hospitalizations of patients with both type 2 diabetes mellitus and PAD. Trends in hospitalizations, limb outcomes, vascular interventions, and costs were analyzed. RESULTS There were 10,303,673 hospitalizations of patients with concomitant diabetes mellitus and PAD that were identified between 2003 and 2017. The prevalence of hospitalizations associated with this disease process increased from 1644 to 3228 per 100,000 hospitalizations, a 96.4% increase. This included an increase of 288 to 587 per 100,000 hospitalizations of patients aged 18 to 49 years old, which was accompanied by a 10.8% increase in minor amputations. Nontraumatic lower extremity amputations decreased overall. Black and Hispanic ethnicity were associated with an increased risk for amputation, along with Medicaid insurance and lower income quartile. Inpatient endovascular revascularization has increased over time with an associated decrease in open revascularization procedures. Amputation-related hospital costs significantly increased from $6.6 billion in 2003 to $14.8 billion in 2017. CONCLUSIONS An alarming increase of disease prevalence, negative in-hospital limb outcomes, and costs are seen in the current era in this analysis of patients with concurrent diabetes and PAD.
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Affiliation(s)
- David Jiang
- Department of Surgery, University of Chicago Medicine, Chicago, IL.
| | - Kristine Kuchta
- Cardiovascular Institute, NorthShore University HealthSystem, Evanston, IL
| | - Omar Morcos
- Cardiovascular Institute, NorthShore University HealthSystem, Evanston, IL
| | - Benjamin Lind
- Cardiovascular Institute, NorthShore University HealthSystem, Evanston, IL
| | - William Yoon
- Cardiovascular Institute, NorthShore University HealthSystem, Evanston, IL
| | - Arman Qamar
- Cardiovascular Institute, NorthShore University HealthSystem, Evanston, IL
| | - Alexander Trenk
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Cheong Jun Lee
- Cardiovascular Institute, NorthShore University HealthSystem, Evanston, IL
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6
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Sorber R, Dun C, Kawaji Q, Abularrage CJ, Black JH, Makary MA, Hicks CW. Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia. J Vasc Surg 2023; 77:836-847.e3. [PMID: 37276171 PMCID: PMC10242207 DOI: 10.1016/j.jvs.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. METHODS We evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. RESULTS A total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). CONCLUSIONS Early PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.
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Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Chen Dun
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Qingwen Kawaji
- Department of Plastics and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
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7
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Chow CY, Mathlouthi A, Zarrintan S, Swafford EP, Siracuse JJ, Malas MB. Outcomes of elective peripheral endovascular interventions for peripheral arterial disease performed in hospital outpatient departments, ambulatory surgical centers and office-based labs. J Vasc Surg 2023; 77:1732-1740. [PMID: 36738852 DOI: 10.1016/j.jvs.2023.01.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND A recent shift in the location where peripheral endovascular interventions (PVI) are performed has occurred, from traditional settings such as hospital outpatient departments (HOPD), to ambulatory surgical centers (ASC) and outpatient-based laboratories (OBL). Different settings may influence the safety and efficacy of the PVI, as well as how it is done. This study aims to compare the postprocedural outcomes and intraprocedural details between the three settings. METHODS The Vascular Quality Initiative database was queried for all elective infrainguinal PVIs for occlusive peripheral arterial disease between January 2016 and December 2021. The primary outcomes were rates of postprocedural hospital admissions, postprocedural medical complications, and access site complications. Secondary outcomes included technical success and intraprocedural details, such as types and number of devices used, amount of contrast, and fluoroscopy time. The χ2 test, analysis of variance, and multivariate logistic regression were used to analyze the outcomes. RESULTS A total of 66,101 PVI cases (HOPD, 57,062 [83.33%]; ASC, 4591 [6.95%]; OBL, 4448 [6.73%]) were included in the study. There were 445 cases requiring hospital admission (HOPD, 398 [0.70%]; ASC, 26 [0.57%]; OBL, 21 [0.47%]; P = .126). There were no significant differences in cardiac, pulmonary, or renal complications. Access site complications occurred in less than 1.7% of all cases and were significantly higher in OBLs when compared with ASCs (adjusted odds ratio [aOR], 3.70; 95% confidence interval [CI], 1.70-8.03; P = .001) and significantly lower in ASCs in comparison to HOPDs (aOR, 0.27; 95% CI, 0.18-0.41; P < .001). Technical success occurred in at least 92% of all cases, regardless of setting. There was a 16-fold increase in the use of atherectomy devices in an OBL vs HOPD setting (aOR, 16.79; 95% CI, 11.77-23.95; P < .001) and a five-fold increase in the use of atherectomy devices in an ASC vs HOPD setting (aOR, 5.37; 95% CI, 2.47-11.65; P < .001). There was a five-fold decrease in the use of special balloons in an OBL vs HOPD setting (aOR, 0.20; 95% CI, 0.10-0.39; P < .001) and a four-fold decrease when comparing ASCs with HOPDs (aOR, 0.25; 95% CI, 0.12-0.51; P < .001). CONCLUSIONS Elective PVIs performed in any outpatient setting proved to be safe and technically successful. However, there are significant differences in the way PVIs are performed in each setting, such as the greater use of atherectomy devices in OBLs and greater use of special balloons in HOPDs. Long-term studies are needed to evaluate the durability and reintervention outcomes and understand factors associated with practice pattern variability across these different settings.
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Affiliation(s)
- Christopher Y Chow
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami, Miami, FL
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Sina Zarrintan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | | | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA.
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8
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Batchelor WB, Guzman E, Rodriguez CJ. Peripheral Vascular Interventions in Office-Based Laboratories: Good News for Disparities or Profit Margins? Circ Cardiovasc Qual Outcomes 2023; 16:e009631. [PMID: 36472192 DOI: 10.1161/circoutcomes.122.009631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | | | - Carlos J Rodriguez
- Department of Medicine (Cardiology), Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (C.J.R.)
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9
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George EL, Wagner TH, Arya S. Atherectomy Overuse: Do Policy Solutions Exist? J Am Heart Assoc 2022; 11:e027422. [DOI: 10.1161/jaha.122.027422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elizabeth L. George
- Department of Surgery, Division of Vascular Surgery Stanford University School of Medicine Stanford CA
- VA Palo Alto Health Care System, Surgical Service Line Palo Alto CA
| | - Todd H. Wagner
- Veterans Affairs Health Economic Resource Center Palo Alto CA
| | - Shipra Arya
- Department of Surgery, Division of Vascular Surgery Stanford University School of Medicine Stanford CA
- VA Palo Alto Health Care System, Surgical Service Line Palo Alto CA
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10
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Brown CS, Eton RE, Yaser JM, Syrjamaki JD, Corriere M, Henke PK, Englesbe MJ, Osborne NH. Assessment of Patterns of Atherectomy Use. J Am Heart Assoc 2022; 11:e023356. [DOI: 10.1161/jaha.121.023356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Atherectomy has become the fastest growing catheter‐based peripheral vascular intervention performed in the United States, and overuse has been linked to increased reimbursement, but the patterns of use have not been well characterized.
Methods and Results
We used Blue Cross Blue Shield of Michigan Preferred Provider Organization and Medicare fee‐for‐service professional claims data from the Michigan Value Collaborative for patients undergoing office‐based laboratory atherectomy in 2019 to calculate provider‐specific rates of atherectomy use, reimbursement, number of vessels treated, and number of atherectomies per patient. We also calculated the rate that each provider converted a new patient visit to an endovascular procedure within 90 days. Correlations between parameters were assessed with simple linear regression. Providers completing ≥20 office‐based laboratory atherectomies and ≥20 new patient evaluations during the study period were included. A total of 59 providers performing 4060 office‐based laboratory atherectomies were included. Median professional reimbursement per procedure was $4671.56 (interquartile range [IQR], $2403.09–$7723.19) from Blue Cross Blue Shield of Michigan and $14 854.49 (IQR, $9414.80–$18 816.33) from Medicare, whereas total professional reimbursement from both payers ranged from $2452 to $6 880 402 per year. Median 90‐day conversion rate was 5.0% (IQR, 2.5%–10.0%), whereas the median provider‐level average number of vessels treated per patient was 1.20 (IQR, 1.13–1.31) and the median provider‐level average number of treatments per patient was 1.38 (IQR, 1.26–1.63). Total annual reimbursement for each provider was directly correlated with new patient‐procedure conversion rate (
R
2
=0.47;
P
<0.001), mean number of vessels treated per patient (
R
2
=0.31;
P
<0.001), and mean number of treatments per patient (
R
2
=0.33;
P
<0.001).
Conclusions
A minority of providers perform most procedures and are reimbursed substantially more per procedure compared with most providers. Procedural conversion rate, number of vessels, and number of treatments per patient represent potential policy levers to curb overuse.
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Affiliation(s)
- Craig S. Brown
- Section of General Surgery, Department of Surgery University of Michigan Ann Arbor MI
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Ryan E. Eton
- Section of General Surgery, Department of Surgery University of Michigan Ann Arbor MI
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Jessica M. Yaser
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - John D. Syrjamaki
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Matthew A. Corriere
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
- Section of Vascular Surgery, Department of Surgery University of Michigan Ann Arbor MI
| | - Peter K. Henke
- Section of Vascular Surgery, Department of Surgery University of Michigan Ann Arbor MI
| | - Michael J. Englesbe
- Section of General Surgery, Department of Surgery University of Michigan Ann Arbor MI
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Nicholas H. Osborne
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
- Section of Vascular Surgery, Department of Surgery University of Michigan Ann Arbor MI
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Follow the Data: It Is Time to Incentivize the Use of Drug-Eluting Stents and Balloons. J Vasc Interv Radiol 2022; 33:1159-1160. [PMID: 36182253 DOI: 10.1016/j.jvir.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022] Open
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12
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Hicks CW. Atherectomy overuse is a real problem. J Vasc Surg 2022; 76:786-787. [PMID: 35995485 PMCID: PMC9835721 DOI: 10.1016/j.jvs.2022.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
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13
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Eberhardt RT, Bonaca MP, Abu Daya H, Garcia LA, Gupta K, Mena-Hurtado C, Rogers RK, Sethi SS, Young MN, Piazza G. Call for Formalized Pathways in Vascular Medicine Training: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 79:2129-2139. [PMID: 35618351 DOI: 10.1016/j.jacc.2022.03.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/10/2022] [Accepted: 03/21/2022] [Indexed: 11/28/2022]
Abstract
The burden of vascular diseases and complexity of their management have been growing. Vascular medicine specialists may help to bridge gaps in care, especially as part of multidisciplinary teams. However, there is a limited number of vascular medicine specialists because of constraints in training. Despite established pathways for training in vascular medicine, there are obstacles that restrict completion of training in dedicated programs. A key factor is lack of funding as a result of inadequate recognition by key national accrediting and credentialing organizations. A concerted effort is required to overcome the obstacles to expand vascular medicine training programs and ultimately the pool of vascular medicine specialists. Well-trained vascular medicine specialists will be well positioned to ease the burden of vascular disease and optimize patient outcomes.
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Affiliation(s)
- Robert T Eberhardt
- Division of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.
| | - Marc P Bonaca
- Department of Medicine-Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA. https://twitter.com/MarcBonaca
| | - Hussein Abu Daya
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA. https://twitter.com/Dr_AbuDaya
| | - Lawrence A Garcia
- Division of Cardiovascular Medicine, Department of Medicine, Tufts University School of Medicine, St Elizabeth's Medical Center, Boston, Massachusetts, USA
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - R Kevin Rogers
- Department of Medicine-Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sanjum S Sethi
- Columbia Interventional Cardiovascular Care, Division of Cardiology, Columbia University Irving Medical School/New York-Presbyterian Hospital, New York, New York, USA. https://twitter.com/sanjum
| | - Michael N Young
- Cardiology Division, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA. https://twitter.com/mnyoung1
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Nfor T, Dababneh E, Jan MF, Khitha J, Allaqaband SQ, Bajwa T, Mewissen MW. National trends and variability of atherectomy use for peripheral vascular interventions from 2010 to 2019. J Vasc Surg 2022; 76:778-785. [PMID: 35367566 DOI: 10.1016/j.jvs.2022.03.864] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/16/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Small, older studies suggest atherectomy devices have become common in peripheral vascular interventions (PVI) despite the paucity of strong clinical guidelines. We analyzed the 10-year trends in the use of atherectomy for PVI across the United States and identified main predictors of atherectomy use. METHODS Using the Vascular Quality Initiative Registry, we identified all patients who had endovascular PVI for occlusive lower-extremity arterial disease from 2010 to 2019. Procedures in which an atherectomy device was recorded as the primary or secondary device were classified as the atherectomy group. We calculated frequency of atherectomy use over time and across geographic regions. Using regression modeling, we identified factors that were independently associated with atherectomy use. RESULTS There were 205,377 procedures on 152,693 unique patients. Over 10 years, 16.6% of PVI procedures used atherectomy, increasing from 8.5% in 2010 to 19.7% in 2019, Ptrend <0.0001. Across 17 geographic regions, there was a significant difference in the prevalence of atherectomy use, ranging from 8.2% to 29%. The strongest predictor of atherectomy use was the procedure being done in an office setting (OR 10.08, 95% CI 9.17-11.09) or ambulatory center (OR 4.0, 95% CI 3.65-4.39) vs hospital setting. The presence of severe (OR 2.6, 95% CI 2.4-2.85) or moderate (OR 1.5, 95% CI 1.4-1.69) lesion calcification was also predictive of atherectomy use. Other predictors included elective status, insurance provider, lesion length, prior PVI, claudication symptoms, and diabetes mellitus. CONCLUSIONS Atherectomy use in PVI significantly increased between 2010 and 2019. There is wide regional variability in the use of atherectomy that seems to be driven more strongly by non-clinical factors.
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Affiliation(s)
- Tonga Nfor
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA.
| | - Ehab Dababneh
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - M Fuad Jan
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Jayant Khitha
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Suhail Q Allaqaband
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Tanvir Bajwa
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Mark W Mewissen
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
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