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Peripheral vascular intervention outcomes vary by clinical care location
Rates of all-cause mortality, major lower-extremity amputation and repeat revascularization among Medicare patients who underwent peripheral vascular intervention differed with clinical care settings, according to published data.
For the study, the researchers evaluated data on 30-day and 1-year rates of all-cause mortality, major lower-extremity amputation, repeat revascularization and all-cause hospitalization from Medicare beneficiaries who underwent an index peripheral vascular intervention from 2010 to 2012.
“Modifications in reimbursement rates by Medicare in 2008 have led to peripheral vascular interventions being performed more commonly in outpatient and office-based clinics. The objective of this study was to determine the effects of this shift in clinical care setting on clinical outcomes after [peripheral vascular intervention],” Ryan S. Turley, MD, from the department of surgery at Duke University School of Medicine, and colleagues wrote.
Of the 218,858 patients included in the study, 38.7% underwent peripheral vascular intervention in inpatient hospital settings, 53.3% in outpatient hospital settings and 8% in office-based clinics.
Variance by setting
Results revealed higher 1-year rates of all-cause mortality among patients who underwent peripheral vascular intervention in inpatient settings vs. outpatient settings and office-based clinics (23.6% vs. 10.4% and 11.7%; P < .001). Similar results were seen for 1-year rates of major lower-extremity amputation (10.1% vs. 3.7% and 3.5%; P < .001) and all-cause repeat hospitalization (63.3% vs. 48.5% and 48%; P < .001). Rates of repeat revascularization, however, were lower among those treated in inpatient settings, as compared with outpatient hospital settings and office-based clinics (25.1% vs. 26.9% vs. 38.6%; P < .001).
In adjusted analyses, the researchers found that patients treated in office-based clinics had an increased likelihood of repeat revascularization and were nearly twice as likely to undergo atherectomy as those treated in inpatient and outpatient hospital settings (41.2% vs. 20.7% and 22.8%; P < .001). Additionally, adjusted analyses linked treatment in an inpatient setting with greater all-cause mortality, all-cause hospitalization and major lower-extremity amputation at 1 year across physician specialties. The researchers also noted a significant interaction effect between location of index revascularization and geographic region on occurrence of all-cause hospitalization, repeat revascularization and lower-extremity amputation.
“Outcomes were consistently worse in patients treated in inpatient hospital settings, calling into question whether opportunity existed to treat these patients differently. Furthermore, we observed associations between index [peripheral vascular intervention] in office-based clinics, the use of treatment modalities with higher reimbursement (namely atherectomy), and the subsequent need for repeat revascularization,” the researchers wrote. “These findings support the need for better measures of quality and appropriateness to ensure consistent and proper [peripheral vascular intervention] procedures in all settings.”
Call to action
Joshua A. Beckman, MD, and Esther S.H. Kim, MD, both from Vanderbilt Heart and Vascular Institute in Nashville, Tennessee, echoed the researchers’ conclusions in an accompanying editorial.
“As they state, this study should serve as a call to action for practitioners of vascular disease across the United States to work collaboratively in fostering the development of high-quality randomized controlled trials to determine the most clinically effective and most cost-effective treatment options for patients with [peripheral artery disease],” they wrote. “Until that evidence base exists, the community must also continue collaborations in developing and disseminating appropriate use criteria, guidelines and standards based on the high-quality data we have now.” – by Melissa Foster
Disclosure: Turley reports no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures. Beckman reports serving as a consultant to Abbott Vascular and being a board member of VIVA Physicians Group. Kim reports no relevant financial disclosures.