Significant physician practice variability in the utilization of endovenous thermal ablation in the 2017 Medicare population

Background: There has been a substantial increase in the use of procedures to treat lower extremity venous disease in the United States over the past decade. A specialty society-selected metric was applied to evaluate the use of endovenous thermal ablation (EVTA) in Medicare beneficiaries and factors associated with physician practice variations. We used confidential physician reports of this benchmark data to increase physician recognition of individualized usage relative to their peers. Methods: We used 100% Medicare fee-for-service claims data to identify all patients 18 years of age and older who underwent at least one lower extremity EVTA over a 1-year period (January 1, 2017, to December 31, 2017). A physician-specific annual rate of EVTA performed per patient was calculated. Individual physician results were shared confidentially with each provider billing Medicare for more than 10 ablations during the study period by mail, benchmarked to the distribution of use by their peers nationally. Hierarchical multivariable linear regression was used to identify patient and provider characteristics associated with high rates of thermal ablations per patient. Results: A total of 102,145 Medicare beneficiaries (median age, 72.1 years; 67.8% female) underwent an EVTA by 2462 physicians during the study period. The majority (96.4%) of patients underwent 1 to 5 ablations, 3.3% underwent 6 to 10 ablations, and 0.3% underwent 11 or more ablations. The median and mean physician ablation rates were 1.6 (interquartile range, 1.3-2.2) and 1.9 ± 0.8 ablations per patient annually, respectively. There were 106 physicians (4.3%) who had an ablation rate of 3.4 or greater, which is two or more standard deviations above the national mean. After adjusting for patient-level variables, characteristics independently associated with outlier physicians included specialties other than vascular surgery, fewer years in practice, and higher overall venous ablation practice volume (P ≤.03). Conclusions: Using a physician-generated metric of performance, the physician use EVTA performed annually per patient is highly variable, and this variability correlated with physician discipline, years in practice, and is more common in physicians who perform ablation the most. Our data show that there is considerable variability in the use of EVTA in Medicare beneficiaries, and that outlier physicians performing a high number of venous ablation procedures per patient are identifiable using a peer-benchmarked practice pattern measure via claims-based data.