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OBJECTIVES - Within the context of bundled-payment care models, the optimal use of computed tomographic arteriography (CTA) for peripheral arterial occlusive disease is ill-defined. We have previously described a linear cost-efficacy equation regarding the use of non-selective axial imaging compared to catheter-directed imaging. The purpose of this study is to use data from a contemporary vascular and endovascular surgical practice to better define a subset of patients who would benefit from CTA as compared to catheter-directed imaging for the anatomical workup of peripheral arterial disease.
METHODS - Outpatient lower extremity endovascular cases were analyzed over a consecutive 36-month period. Patient clinical, demographic, anatomical and procedural data including costs were recorded. Medicare charges for CTA were used to generate hypothetical charges assuming subgroup populations underwent CTA, and that diagnostic cases would not have undergone catheter-based procedures. A multivariate model was constructed to describe cases where there would be a resource-utilization benefit to CTA prior to revascularization.
RESULTS - A total of 551 cases were identified. The mean age was 67±0.5 years, and 50% of patients presented with critical limb ischemia. Absent femoral pulses were present in 14% of cases. Multivariate analysis failed to demonstrate physical exam factors and comorbidities associated with non-percutaneous revascularization. Non-white racial status was associated with avoidance of open revascularization (O.R. = 0.669, 95% C.I. = 0.467 - 0.959, P = 0.0286), presumptively driven by a lower incidence of inflow disease and a higher incidence of Diabetes Mellitus. Use of CTA in the non-white racial population would not have impacted total per-patient charges (\,614.51 current versus \,244.38 with CTA, P = 0.179).
CONCLUSIONS - The economic basis for non-selective use of CTA in the anatomic workup of peripheral arterial occlusive disease is dependent on the ratio of diagnostic to interventional cases. In the authors’ current practice, CTA use is resource utilization neutral, and as such does not represent a significant avenue for savings. Furthermore, in our practice, non-white patients would be even less likely to benefit from non-selective CTA based on the higher rates of percuraneous revascularization observed in these patients.