Overuse of early peripheral vascular interventions for claudication

Caitlin W. Hicks, Courtenay M. Holscher, Peiqi Wang, James H. Black, Christopher J. Abularrage, Martin A. Makary

Research output: Contribution to journalArticle

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.

Original languageEnglish (US)
Pages (from-to)121-130.e1
JournalJournal of vascular surgery
Volume71
Issue number1
DOIs
StatePublished - Jan 2020

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Blood Vessels
Odds Ratio
Physicians
Physicians' Practice Patterns
Guideline Adherence
Exercise Therapy
Benchmarking
Fee-for-Service Plans
Information Dissemination
Medicare
Ambulatory Surgical Procedures
Life Style
Logistic Models
Guidelines

Keywords

  • Claudication
  • Peripheral vascular intervention
  • Utilization

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

Overuse of early peripheral vascular interventions for claudication. / Hicks, Caitlin W.; Holscher, Courtenay M.; Wang, Peiqi; Black, James H.; Abularrage, Christopher J.; Makary, Martin A.

In: Journal of vascular surgery, Vol. 71, No. 1, 01.2020, p. 121-130.e1.

Research output: Contribution to journalArticle

Hicks, Caitlin W. ; Holscher, Courtenay M. ; Wang, Peiqi ; Black, James H. ; Abularrage, Christopher J. ; Makary, Martin A. / Overuse of early peripheral vascular interventions for claudication. In: Journal of vascular surgery. 2020 ; Vol. 71, No. 1. pp. 121-130.e1.
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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.",
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AU - Holscher, Courtenay M.

AU - Wang, Peiqi

AU - Black, James H.

AU - Abularrage, Christopher J.

AU - Makary, Martin A.

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N2 - 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.

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KW - Peripheral vascular intervention

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