Variations in Lower Extremity Use Endovascular Interventions and Atherectomy by Indication, Site of Service and Geographic Region
Tommy Chiou1, Karen Woo2, Laura Gascue1, John Romley1, Peter Lawrence2.
1USC Schaeffer Center for Health Policy, Los Angeles, CA, USA, 2UCLA, Los Angeles, CA, USA.
OBJECTIVES:To examine use of endovascular interventions(EVI) for claudication(EVClaud) and limb threatening ischemia(EVLTI) in the Medicare population. METHODS:The Medicare 20% sample was queried from 2011-2014 for all EVI performed for claudication and limb threatening ischemia(LTI), defined as ischemic rest pain, ulceration, and gangrene.
RESULTS: 85,562 EVI were performed for claudication(57%) and LTI(43%). 61% of claudication procedures had physiologic testing performed within 6 months pre-operatively, compared to 65% for LTI procedures. Between 2011 and 2014, the proportion of EVClaud performed in the office (vs inpatient/outpatient) increased from 9% to 22% and from 6% to 18% for EVLTI. Between 2011 and 2014, the proportion of office EVClaud vs EVLTI which included atherectomy increased from 65% to 78% and 74% to 85%, respectively. In the inpatient setting, the proportion of EVClaud which included atherectomy decreased slightly from 40% to 37% and remained stable at 50% for EVLTI. 8% of EVClaud were isolated to the tibial arteries. There is marked variation in the percent of EVI performed for claudication across Hospital Referral Regions(Figure). The HRR at the 90th percentile(HRR90) performed 73% of EVI for claudication and 29 EVClaud per 10,000 beneficiaries/year compared to 39% and 5 for the HRR at the 10th percentile(HRR10), indicating significant regional variation between highest and lowest deciles. The HRR90 for atherectomy use in EVClaud had 63% utilization compared to 11% in the HRR10, making the 90th/10th percentile ratio 5.7. In EVLTI, HRR90 for atherectomy use had 77% utilization compared to 27% in HRR10, making the 90th/10th percentile ratio 2.9, indicating less regional variation in atherectomy use for EVLTI compared to EVClaud.
CONCLUSIONS: In the Medicare population, the incidence of pre-procedure physiologic testing prior to EVI is low and an inappropriately high percentage of procedures isolated to the tibial arteries are performed for claudication. Significant variation in the utilization of EVI and atherectomy for the treatment of claudication compared to LTI exist across procedure setting and HRR. Future investigation must identify the drivers responsible for these variations and the impact of these variations on outcomes such as patient reported outcomes, physiologic improvement, repeat procedures for restenosis and amputation rates. 
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