Trends in Settings for Peripheral Vascular Intervention and the Effect of Changes in the Outpatient Prospective Payment System | Journal Scan

Study Questions:

What are the trends in the use and clinical setting of peripheral vascular interventions (PVIs), and how have reimbursement changes impacted the use and clinical setting of PVI?


Using a 5% national sample of Medicare fee-for-service beneficiaries between 2006 and 2011, the authors examined age- and sex-adjusted rates of PVI by year, type of procedure (angiography only, stenting, atherectomy, or surgical revascularization), and clinical setting. This study period was selected to assess the impact of the Centers for Medicare and Medicaid Services (CMS) modified reimbursement for outpatient hospital and office-based PVI starting in 2008.


Between 2006 and 2011, 39,339 Medicare beneficiaries underwent PVI for peripheral artery disease (PAD) at a rate of 401.4 to 419.6/100,000 patients (p = 0.17) and surgical revascularization at a rate of 115.5 to 77.8/100,000 patients (p < 0.001). PVI procedures included angioplasty alone (27.3%), atherectomy with or without angioplasty/stenting (22.4%), and stent implantation without atherectomy (50.3%). During the study period, inpatient PVI declined from 209.7 to 151.6/100,000 patients (p < 0.001), whereas outpatient hospital-based PVI (184.7 to 228.5/100,000 patients; p = 0.001) and office-based clinic PVI (6.0 to 37.8/100,000 patients; p = 0.008) increased. Between 2006 and 2011, the use of atherectomy increased twofold in the outpatient hospital setting and 50-fold in the office-based clinic setting. Mean expenditures for PVI were higher for atherectomy procedures than for angioplasty and stenting procedures. Between 2006 and 2011, total costs for outpatient atherectomy increased significantly, whereas inpatient atherectomy costs remained stable.


The authors concluded that between 2006 and 2011, the overall rate of PVI increased minimally. However, atherectomy procedures increased significantly in outpatient hospital and office-based settings. Driven by increased use in and altered payment for outpatient PVI, there were no effective cost savings to CMS.


This study examined the utilization of PVI in hospitalized and nonhospitalized settings before and after the implementation of revised CMS reimbursement. The revised reimbursement was intended to encourage cost savings by avoiding expensive hospital admissions. While use of inpatient PVI decreased following the CMS reimbursement change, increased use of more expensive atherectomy procedures instead of less expensive stenting procedures offset any potential cost savings. Due to limited head-to-head comparative trials, it is not clear which procedure is more effective. The authors and the accompanying editorialist (Paul Heidenreich) both suggest that physician practices may be influenced, at least partially, by the reimbursement patterns. Thankfully, there are two ongoing trials comparing atherectomy with angioplasty that have important patient-centered primary outcomes. In the meantime, physicians should discuss the risks, benefits, and associated costs of all treatment options with their PAD patients.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Peripheral Arterial Disease, Angiography, Atherectomy, Angioplasty, Stents, Centers for Medicare and Medicaid Services (U.S.), Fee-for-Service Plans, Health Expenditures, Cost Savings, Outpatients

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