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Hicks CW, Conte MS, Dun C, Makary MA. Appropriateness of Care Measures: A Novel Approach to Quality. Ann Vasc Surg 2024; 107:186-194. [PMID: 38582205 DOI: 10.1016/j.avsg.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/18/2024] [Indexed: 04/08/2024]
Abstract
The clinical judgment of a physician is one of the most important aspects of medical quality, yet it is rarely captured with quality measures in use today. We propose a novel approach using individualized physician benchmarking that measures the appropriateness of care that a physician delivers by looking at their practice pattern in a specific clinical situation. A prime application of our novel approach to appropriateness measures is the surgical management of peripheral artery disease and claudication. We discuss 4 potential consensus metrics for the treatment of claudication that explore appropriateness of care of claudication management and are meaningful, actionable, and quantifiable. Given the multitude of medical specialties involved in the care of patients with peripheral artery disease and the consequences of both preemptive and delayed care, it is in all of our interests to promote data transparency with confidential communications to outlier physicians while advocating for evidence-based management.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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2
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Wiske C, Chervonski E, Rockman CB, Jacobowitz GR, Sadek M. Venous ablation procedures by provider type, including advanced practice providers. J Vasc Surg Venous Lymphat Disord 2024; 12:101872. [PMID: 38518987 DOI: 10.1016/j.jvsv.2024.101872] [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: 12/14/2023] [Revised: 01/17/2024] [Accepted: 03/07/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE The necessary training and certification of providers performing venous ablation has become a topic of debate in recent years. As venous interventions have shifted away from the hospital, the diversity of provider backgrounds has increased. We aimed to characterize superficial venous ablation practice patterns associated with different provider types. METHODS We analyzed Medicare Fee-For-Service data from 2010 through 2018. Procedures were identified by their Current Procedural Terminology code and included radiofrequency ablation, endovenous laser ablation, chemical adhesive ablation (ie, VenaSeal; Medtronic, Inc), and mechanochemical ablation. These procedures were correlated with the practitioner type to identify provider-specific trends. RESULTS Between 2010 and 2018, the number of ablation procedures increased by 107% from 114,197 to 236,558 per year (P < .001). Most procedures were performed by surgeons without vascular board certification (28.7%; 95% confidence interval [CI], 28.7%-28.8%), followed by vascular surgeons (27.1%; 95% CI, 27.0%-27.2%). Traditionally noninterventional specialties, which exclude surgeons, cardiologists, and interventional radiologists, accounted for 14.1% (95% CI, 14.1%-14.2%), and APPs accounted for 3.5% (95% CI, 3.4%-3.5%) of all ablation procedures during the study period. The total number of ablations increased by 9.7% annually (95% CI, 9.7%-9.8%), whereas procedures performed by APPs increased by 62.0% annually (95% CI, 61.6%-62.4%). There were significant differences between specialties in the use of nonthermal ablation modalities: APPs had the highest affinity for nonthermal ablation (odds ratio [OR], 2.60; 95% CI, 2.51-2.69). Cardiologists were also more likely to use nonthermal ablation (OR, 1.62; 95% CI, 1.59-1.66). Similarly, the uptake of new nonthermal technology (ie, chemical adhesives) was greatest among APPs (OR, 3.57; 95% CI, 3.43-3.70) and cardiologists (OR, 1.86; 95% CI, 1.81-1.91). Vascular surgeons were less likely to use nonthermal modalities (OR, 0.95; 95% CI, 0.92-0.97), including new nonthermal technology in the first year of availability (OR, 0.93; 95% CI, 0.90-0.95). CONCLUSIONS The use of venous procedures has increased rapidly during the past decade, particularly as endovenous ablations have been performed by a wider practitioner base, including APPs and noninterventionalists. Practice patterns differ by provider type, with APPs and cardiologists skewing more toward nonthermal modalities, including more rapid uptake of new nonthermal technology. Provider-specific biases for specific ablation modalities might reflect differences in training, skill set, the need for capital equipment, clinical privileges, or reimbursement. These data could help to inform training paradigms, the allocation of resources, and evaluation of appropriateness in a real-world setting.
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Affiliation(s)
- Clay Wiske
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY; Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.
| | | | - Caron B Rockman
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
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Pinto P, Fukaya E, Rodriguez LE, Obi A, Ting W, Aziz F, Nguyen K, Murphy EH, Ochoa Chaar CI. Variations and inconsistencies in venous ablation coverage policies between single-state and multistate carriers in the United States. J Vasc Surg Venous Lymphat Disord 2024; 12:101685. [PMID: 37703944 DOI: 10.1016/j.jvsv.2023.07.012] [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: 04/19/2023] [Revised: 07/02/2023] [Accepted: 07/05/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Vein ablation is a common and effective treatment for patients with chronic venous insufficiency. The overuse of vein ablation despite the existence of evidence-based guidelines has resulted in insurance companies developing restrictive policies for coverage that create barriers to appropriate care. This study compares the insurance coverage by single-state carriers (SSCs) and multistate carriers (MSCs), highlighting the variations and inconsistencies in the various policies. METHODS The American Venous Forum Venous Policy Navigator was reviewed for the various policies available in the United States. The policies were divided into SSCs and MSCs. The characteristics of the policies, including the anatomic and hemodynamic criteria for specific veins, duration of conservative treatment, disease severity, symptoms, and types of procedures covered, were compared between the two groups. SAS, version 9.4 (SAS Institute Inc) was used for statistical analysis. RESULTS A total of 122 policies were analyzed and divided between SSCs (n = 85; 69.7%) and MSCs (n = 37; 30.3%). A significant variation was found in the size requirement for great saphenous vein ablation. Although 48% of the policies did not specify a size criterion, the remaining policies indicated a minimal size, ranging from 3 to 5.5 mm. However, no significant differences were found between SSCs and MSCs. Similar findings were encountered for the small and anterior accessory saphenous veins. MSCs were more likely to define a saphenous reflux time >500 ms compared with SSCs (81.1% vs 58.8%; P = .04). A significant difference was found between the SSCs and MSCs in the criteria for perforator ablation in terms of size and reflux time. MSCs were significantly more likely to provide coverage for mechanochemical ablation than were SSCs (24.3% vs 8.2%; P = .03). SSCs were more likely to require ≥12 weeks of compression stocking therapy than were MSCs (76.5% vs 48.7%; P = .01). No significant differences were found in the clinical indications between the two groups; however, MSCs were more likely to mention major hemorrhage than were SSCs. CONCLUSIONS The results of this study highlight the variations in policies for venous ablation, in particular, the striking inconsistencies in size criteria. MSCs were more likely to cover mechanochemical ablation and require a shorter duration of conservative therapy before intervention compared with SSCs. Evidence-based guidance is needed to develop more coherent policies for venous ablation coverage.
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Affiliation(s)
- Paula Pinto
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, Yale University, New Haven, CT.
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | | | - Andrea Obi
- Division of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Windsor Ting
- Division of Vascular Surgery, The Mount Sinai Hospital, New York, NY
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA
| | - Khanh Nguyen
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Erin H Murphy
- Division of Vascular Surgery, Sanger Heart & Vascular Institute, Charlotte, NC
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, Yale University, New Haven, CT
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Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2023; 11:231-261.e6. [PMID: 36326210 DOI: 10.1016/j.jvsv.2022.09.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Abstract
The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence-based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Suman M Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, and Rex Vascular Specialists, UNC Health, Raleigh, NC
| | | | - Jose Almeida
- Miller School of Medicine, University of Miami, Miami, FL
| | | | - Ruth L Bush
- Central Texas Veterans Affairs Healthcare System and Texas A&M University College of Medicine, Temple, TX
| | | | - John Fish
- Department of Medicine, Jobst Vascular Institute, University of Toledo, Toledo, OH
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | | | | | - Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, Jackson, MS
| | - Raghu Kolluri
- Heart and Vascular Service, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Deol ZK. “The United State of Venous and Lymphatic Medicine ” – Uniting the Specialties to Form a More Perfect Union. J Vasc Surg Venous Lymphat Disord 2022; 11:668-670. [PMID: 36323402 DOI: 10.1016/j.jvsv.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 11/06/2022]
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Masuda EM. Moving ahead with Lokahi. J Vasc Surg Venous Lymphat Disord 2022; 10:986-992. [PMID: 35970574 DOI: 10.1016/j.jvsv.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/27/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Elna M Masuda
- Division of Vascular Surgery, Straub Medical Center, Hawaii Pacific Health, Honolulu, HI.
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Stonko DP, Dun C, Walsh C, Shul M, Blebea J, Boyle EM, Makary MA, Hicks CW. Evaluation of a Physician Peer-Benchmarking Intervention for Practice Variability and Costs for Endovenous Thermal Ablation. JAMA Netw Open 2021; 4:e2137515. [PMID: 34905006 PMCID: PMC8672233 DOI: 10.1001/jamanetworkopen.2021.37515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE The frequency of use of endovenous thermal ablation (EVTA) to treat chronic venous insufficiency has increased rapidly in the US. Wide variability in EVTA use among physicians has been documented, and standard EVTA rates were defined in the 2017 Medicare database. OBJECTIVE To assess whether providing individualized physician performance reports is associated with reduced variability in EVTA use and cost savings. DESIGN, SETTING, AND PARTICIPANTS This prospective quality improvement study used data from all US Medicare patients aged 18 years or older who underwent at least 1 EVTA between January 1, 2017, and December 31, 2017, and between January 1, 2019, and December 31, 2019. All US physicians who performed at least 11 EVTAs yearly for Medicare patients in 2017 and 2019 were included in the assessment. INTERVENTION A performance report comprising individual physician EVTA use per patient with peer-benchmarking data was distributed to all physicians in November 2018. MAIN OUTCOMES AND MEASURES The mean number of EVTAs performed per patient was calculated for each physician. Physicians who performed 3.4 or more EVTA procedures per patient per year were considered outliers. The change in the number of procedures from 2017 to 2019 was analyzed overall and by inlier and outlier status. An economic analysis was also performed to estimate the cost savings associated with the intervention. RESULTS A total of 188 976 patients (102 222 in 2017 and 86 754 in 2019) who had an EVTA performed by 1558 physicians were included in the analysis. The median patient age was 72.2 years (IQR, 67.9-77.8 years); 67.3% of patients were female, and 84.9% were White. Among all physicians, the mean (SD) number of EVTAs per patient decreased from 2017 to 2019 (1.97 [0.85] vs 1.89 [0.77]; P < .001). There was a modest decrease in the mean number of EVTAs per patient among inlier physicians (1.83 [0.57] vs 1.78 [0.55]; P < .001) and a more substantial decrease among outlier physicians (4.40 [1.01] vs 3.67 [1.41] ; P < .001). Outliers in 2017 consisted of 90 physicians, of whom 71 (78.9%) reduced their EVTA use after the intervention. The number of EVTAs per patient decreased by a mean (SD) of 0.09 (0.46) procedures overall (median, 0.10 procedures [IQR, -0.10 to 0.30 procedures]; P < .001). The estimated cost savings associated with the decrease was $6.3 million in 2019. CONCLUSIONS AND RELEVANCE In this quality improvement study, substantial variability in the number of EVTAs performed per patient was observed across the US. When physicians were provided with a 1-time peer-benchmarked performance report card, the timing of the intervention was associated with a significant decrease in the number of EVTAs performed per patient, particularly among outlier physicians. This quality improvement initiative was associated with reduced variability in EVTA use in the US and a substantial savings for Medicare.
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Affiliation(s)
- David P. Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Chen Dun
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christi Walsh
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Marlin Shul
- Center for Vein Restoration, Dothan, Alabama
| | - John Blebea
- Central Michigan University College of Medicine, Mount Pleasant
| | | | - Martin A. Makary
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
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Pappas PJ, Lakhanpal S, Nguyen KQ, Fernandez E, Sufian S. Extended Center for Vein Restoration study assessing comparative outcomes for the treatment of chronic venous insufficiency in Medicare- and non-Medicare-eligible patients. J Vasc Surg Venous Lymphat Disord 2021; 9:1426-1436.e2. [PMID: 33965612 DOI: 10.1016/j.jvsv.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND We previously reported that chronic venous insufficiency treatment of Medicare-eligible patients achieved outcomes similar to those for non-Medicare-eligible patients. The goal of the present investigation was to assess the long-term treatment outcomes and the effect of race in a larger patient cohort. METHODS From January 2015 to December 2019, we retrospectively reviewed the data from 131,268 patients who had presented for a lower extremity venous evaluation. We divided the patients into two groups by age: group A was aged ≥65 years and group B, <65 years. The treatments analyzed in each group were axial thermal ablation (TA), axial Varithena ablation (VA), TA plus phlebectomy, VA plus phlebectomy, and TA or VA with phlebectomy and ultrasound-guided foam sclerotherapy (UGFS). The treatment outcomes were assessed using the revised venous clinical severity score (rVCSS) and Chronic Venous Insufficiency Quality of Life 20-item questionnaire (CIVIQ-20) scores at the initial consultation and 1, 6, and 12 months after completion of the treatment plan. RESULTS Of the 131,268 patients, 40,020 were in group A and 91,248 in group B, with an average age of 74.4 ± 6.6 and 49.9 ± 10.6 years, respectively. Of the 40,020 patients in group A, 15,697 (n = 25,234 limbs) had undergone TA and 1910 (n = 3222 limbs) had undergone VA. Of the 91,248 patients in group B, 35,220 (n = 53,717 limbs) had undergone TA and 2178 (n = 3672 limbs) had undergone VA. For the TA subgroups, all rVCSSs had significantly improved after treatment at each evaluation point (P ≤ .001). For the TA and VA plus phlebectomy with or without UGFS subgroup, the older patients (group A) required 6 months to develop the same degree of improvement as the younger patients (group B) at 1 month. When subdivided by race, all initial and 6-month rVCSSs and CIVIQ-20 scores within a race had improved and were better in group B, except for Asian and Hispanic patients (P ≤ .001). After TA or VA plus phlebectomy, with or without UGFS, the CIVIQ-20 outcomes had improved by 1 month in both groups, although the rVCSS lagged by 6 months in group A. No differences in the rVCSSs or CIVIQ-20 scores were observed between the groups treated with TA or VA. CONCLUSIONS Medicare-eligible beneficiaries demonstrated improved outcomes similar to those of non-Medicare-eligible beneficiaries after ablation. When TA or VA plus phlebectomy with or without UGFS were examined, group A required 6 months to demonstrate rVCSSs equivalent to those of group B at 1 month. The CIVIQ-20 scores had improved by 1 month in both groups, regardless of the treatment modality. The difference in rVCSSs appeared to be driven by African American and white patients because Hispanic and Asian patients demonstrated equivalent results regardless of age. Patients treated with TA or VA demonstrated equivalent results.
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Juneja AS, Jain S, Silpe J, Landis GS, Mussa FF, Etkin Y. Scoping review of non-thermal technologies for endovenous ablation for treatment of venous insufficiency. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:413-419. [PMID: 33881285 DOI: 10.23736/s0021-9509.21.11900-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of this review article is to compare the outcomes of newer non-thermal endovenous ablation techniques to thermal ablation techniques for the treatment of symptomatic venous insufficiency. EVIDENCE ACQUISITION Three independent reviewers screened PubMed® and EMBASE® databases to identify relevant studies. A total of 1173 articles were identified from database search that met our inclusion criteria. Two articles were identified through reference search. Removal of duplicates from our original search yielded 695 articles. We then screened these articles and assessed 173 full-text articles for eligibility. Subsequent to exclusion, 11 full-text articles were selected for final inclusion. EVIDENCE SYNTHESIS The non-thermal techniques are similar to thermal techniques in terms of a high technical success rate, closure rate at 12 months, change in Venous Clinical Severity Score and change in quality of life after procedure. However, the length of procedure is shorter for non-thermal modalities and patient comfort is improved with lower pain scores. Return to work may also be earlier after non-thermal ablation. The rates of bruising, phlebitis and paresthesia are higher after thermal ablation. CONCLUSIONS The non-thermal modalities are safe and effective in treating venous reflux and have shown improved patient comfort and shorter length of procedure which may make them favorable for use compared to the thermal modalities.
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Affiliation(s)
- Amandeep S Juneja
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Shelley Jain
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Jeffrey Silpe
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Gregg S Landis
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Firas F Mussa
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Yana Etkin
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA -
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Welch HJ, Schul MW, Monahan DL, Iafrati MD. Private payers' varicose vein policies are inaccurate, disparate, and not evidence based, which mandates a proposal for a reasonable and responsible policy for the treatment of venous disease. J Vasc Surg Venous Lymphat Disord 2021; 9:820-832. [PMID: 33684590 DOI: 10.1016/j.jvsv.2020.12.076] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
Varicose veins afflict more than one in five Americans, and although varicose veins may be an asymptomatic cosmetic concern in some, many others experience symptoms of pain, aching, heaviness, itching, and swelling. More advanced venous disease can result from untreated venous insufficiency. The complications of chronic venous disease, including bleeding, thrombosis, and ulceration, are seen in up to 2 million Americans annually. Numerous reports have documented venous disease adversely affects quality of life and that treatment of venous disease can improve quality of life. It has previously been documented that private insurers, and Centers for Medicare & Medicaid Services subcontractors for that matter, have disparate policies that in many instances are self-serving, contain mistakes, use outdated evidence, and disregard evidence-based guidelines. The two leading venous medical societies, the American Venous Forum and the American Venous and Lymphatic Society, have come together to review the varicose vein coverage policies of seven major U.S. private medical insurance carriers whose policies cover more than 150 million Americans. The authors reviewed the policies for venous disease and, if significant gaps or inconsistencies are found, we hope to point them out, and, finally, to propose a thoughtful and reasonable policy based on the best available evidence.
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Affiliation(s)
- Harold J Welch
- Department of Vascular Surgery, Lahey Hospital and Medical Center, Burlington, Mass.
| | - Marlin W Schul
- Lafayette Regional Vein and Laser Center, Lafayette, Ind
| | | | - Mark D Iafrati
- Department of Vascular Surgery, Tufts Medical Center, Boston, Mass
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11
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Obi AT, Afridi S, Lurie F. Management and treatment outcomes of patients undergoing endovenous ablation are significantly different between Intersocietal Accreditation Commission-accredited and nonaccredited vein centers. J Vasc Surg Venous Lymphat Disord 2020; 9:346-351. [PMID: 32721587 DOI: 10.1016/j.jvsv.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The Intersocietal Accreditation Commission of vein centers was instituted in 2014, yet data regarding impact of accreditation on patients undergoing superficial vein interventions are lacking. This study was undertaken to identify differences in patient outcomes and utilization index as a measure of appropriate use in accredited compared with nonaccredited centers. METHODS This study was performed with a matched control design using prospectively collected data from two major U.S.-based venous registries: the Society for Vascular Surgery Vascular Quality Initiative Varicose Vein Registry and the American Vein & Lymphatic Society PRO Venous Registry. RESULTS A total of 39,001 patients treated between 2015 and 2018 in 192 centers were included in the study. The Vascular Quality Initiative Varicose Vein Registry provided information on 19,810 (50.8%) patients, and the American Vein & Lymphatic Society PRO Venous Registry provided information on 19,191 (49.2%) patients. Accredited centers were significantly more likely to treat patients with advanced venous disease as characterized by trophic skin changes (C4-C6, 38.1% vs 25.2%; P < .001). Percentage of patients treated 2 standard deviations above the Medicare-reported mean (3.4 utilization index) was significantly higher among patients treated at nonaccredited centers (3.3% vs 0.1%; P < .001). Venous Clinical Severity Score of those who were assessed between 1 month and 1 year after ablation decreased by 4.98 ± 4.01 in nonaccredited centers compared with 5.61 ± 3.64 in accredited centers (P < .001). Complications were low in both cohorts (nonaccredited centers, 71 [0.4%]; accredited centers, 17 [0.1%]; P < .001). One-year clinical follow-up was higher in nonaccredited centers (76.4% vs 31.5%; P < .001). CONCLUSIONS Venous registries are a powerful tool for capturing and identifying significant variations in procedure utilization and complications in low-risk procedures. Intersocietal Accreditation Commission accreditation was associated with reduced use of endovenous therapies, slightly lower complication rates, lower 1-year follow up, and greater improvement in Venous Clinical Severity Score.
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Affiliation(s)
- Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Sophia Afridi
- Department of Vascular Surgery, Jobst Vascular Institute, Promedica, Toledo, OH
| | - Fedor Lurie
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich; Department of Vascular Surgery, Jobst Vascular Institute, Promedica, Toledo, OH.
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12
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Lawrence PF. Venous appropriate use criteria are an important step in improving the quality of chronic venous disease care. J Vasc Surg Venous Lymphat Disord 2020; 8:499-500. [PMID: 32553648 DOI: 10.1016/j.jvsv.2020.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, Gonda Vascular Center, University of Los Angeles, Los Angeles, Calif.
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13
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Hicks CW, Makary MA. Reply. J Vasc Surg 2020; 72:1154. [PMID: 32251774 DOI: 10.1016/j.jvs.2020.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
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Masuda E, Ozsvath K, Vossler J, Woo K, Kistner R, Lurie F, Monahan D, Brown W, Labropoulos N, Dalsing M, Khilnani N, Wakefield T, Gloviczki P. The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. J Vasc Surg Venous Lymphat Disord 2020; 8:505-525.e4. [PMID: 32139328 DOI: 10.1016/j.jvsv.2020.02.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Stimulated by published reports of potentially inappropriate application of venous procedures, the American Venous Forum and its Ethics Task Force in collaboration with multiple other professional societies including the Society for Vascular Surgery (SVS), American Vein and Lymphatic Society (AVLS), and the Society of Interventional Radiology (SIR) developed the appropriate use criteria (AUC) for chronic lower extremity venous disease to provide clarity to the application of venous procedures, duplex ultrasound imaging, timing, and reimbursements. METHODS The AUC were developed using the RAND/UCLA Appropriateness Method, a validated method of developing appropriateness criteria in health care. By conducting a modified Delphi exercise and incorporating best available evidence and expert opinion, AUC were developed and scored. RESULTS There were 119 scenarios rated on a scale of 1 to 9 by an expert panel, with 1 being never appropriate and 9 being appropriate. The majority of scenarios consisted of symptomatic indications were deemed appropriate for venous intervention. For scenarios with anatomically short segments of reflux and/or no symptoms, the indications were rated less appropriate. For the indication of edema, a wide dispersion of ratings was observed especially for short segments of saphenous reflux or stenting for iliac/ inferior vena cava disease, noting that there are multifactorial causes of edema, some of which could coexist with venous disease and possibly impact effectiveness of treatment. Several scenarios were considered never appropriate, including treatment of saphenous veins with no reflux, iliac vein or inferior vena cava stenting for iliac vein compression as an incidental finding by imaging with minimal or no symptoms or signs, and incentivizing sonographers to find reflux. CONCLUSIONS The AUC statements are intended to serve as a guide to patient care, particularly in areas where high-quality evidence is lacking to aid clinicians in making day-to-day decisions for common venous interventions. This may also prove useful when applied on a population level, such as practice patterns, and not necessarily to dictate decision making for individual cases. As a product of a collaborative effort, it is hoped that this could be utilized by physicians and multiple stakeholders committed toward improving patient care and to identify and stimulate future research priorities.
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Affiliation(s)
- Elna Masuda
- Straub Medical Center, Hawaii Pacific Health, Honolulu, Hawaii.
| | | | | | - Karen Woo
- Department of Surgery, University of California, Los Angeles, Los Angeles, Calif
| | | | | | | | - William Brown
- William Beaumont Hospital and Wayne State University School of Medicine, Bingham Farms, Mich
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15
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Guillaume GM, Meeus P, Dalcq V, van der Borght L, Vuylsteke ME, de Maeseneer MG. Influence of reimbursement policies on phlebological surgical practice in Belgium between 2007 and 2017. INT ANGIOL 2020; 39:267-275. [PMID: 32083430 DOI: 10.23736/s0392-9590.20.04305-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To date, it is unclear how treatment of patients with chronic venous disease (CVD) is influenced by national reimbursement systems. In Belgium, catheters or fibers used for endovenous thermal ablation (EVTA) are reimbursed only once in a lifetime. The potential impact of the Belgian public health insurance reimbursement policy on surgical practice in phlebology needs to be investigated. METHODS Billing data available from the Belgian National Institute for Health and Disability Insurance (NIHDI) were used for analyzing the distribution of specific surgical procedures for treating varicose veins and their relative use from 2007 to 2017. The potential influence of age, sex, social status and geographical origin of insured patients on surgical practice in Belgium were studied. RESULTS The annual intervention rate was 343 per 100,000 insured individuals for 2017 with a slight annual increase over the period 2007-2017 (+ 0.83% per year). Patients with limited resources, benefiting from a preferential reimbursement system, had a significantly lower intervention rate than those having the usual system (P<0.001). There was a large geographical variation in the use of care, ranging from 172 to 549 per 100.000 insured in 2017. The number of classic surgical procedures decreased (-6.17% per year) in the period 2015-2017) while EVTA, newly reimbursed in Belgium since 2012, increased during the same period (+ 3.6% per year). This evolution was more pronounced in the north (Flanders) than in the south (Wallonia) of the country. Bilateral treatment increased considerably from 2012 and stabilized at 33% of all surgical interventions in 2016 and 2017. CONCLUSIONS Available data of the NIHDI in Belgium highlight remarkable differences in the use of care for CVD, depending on social status and geographical origin of insured patients. The introduction of EVTA techniques has been adopted more rapidly in the north of the country and has led to an increased percentage of bilateral procedures.
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Affiliation(s)
| | - Pascal Meeus
- National Institute for Health and Disability Insurance, Federal Government, Brussels, Belgium
| | - Virginie Dalcq
- National Institute for Health and Disability Insurance, Federal Government, Brussels, Belgium
| | - Lisbeth van der Borght
- National Institute for Health and Disability Insurance, Federal Government, Brussels, Belgium
| | - Marc E Vuylsteke
- Department of Vascular Surgery, Sint-Andries Ziekenhuis Tielt, Belgium
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