Lower extremity angioplasty: Impact of practitioner specialty and volume on practice patterns and healthcare resource utilization

Division of Vascular Surgery, The Surgical Outcomes Research Group, Robert Wood Johnson Medical School, The University of Medicine and Dentistry, New Brunswick, New Jersey 08903-0019, USA.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter (Impact Factor: 3.02). 10/2009; 50(6):1320-4; discussion 1324-5. DOI: 10.1016/j.jvs.2009.07.112
Source: PubMed


Lower extremity percutaneous transluminal angioplasty (LE PTA) is currently performed by a variety of endovascular specialists. We hypothesized that cardiologists (CRD) and vascular surgeons (VAS) may have different practice patterns, indications for intervention, and hospital resource utilization.
Using the State Inpatient Databases for New Jersey (2003-2007), patients with elective admission undergoing PTA procedures with indications of claudication, rest pain, and gangrene/ulceration were examined. Physician specialty was determined based on all procedures performed. We contrasted by specialty, the indication for LE PTA for the procedure, volume, and hospital resource utilization.
Of the 1887 cases of LE PTA, VAS performed 866 (45.9%) and CRD 1021 (54.1%) procedures. The mean patient age was 68.0 years (CRD) vs 70.7 years (VAS), P = .0163. Indications for intervention were compared for CRD vs VAS: claudication 80.7% vs 60.7%, (P < .002); rest pain 6.2% vs 16.0%, (P < .002); gangrene/ulceration 13.1% vs 23.3%, (P < .002). Stents (64.8% of cases) were utilized similarly among physicians (P = .18), and mean hospital length of stay were similar (2.38 days vs 2.41 days, P = .85). Hospital charges by indication varied between CRD vs VAS (all procedures: $49,748 vs $42,158 [P < .0001]). Revenue center charges were different between CRD vs VAS: medical surgical supply $19,128 vs $12,737, (P < .0001); pharmacy $1,959 vs $1,115, (P < .0001). Only 10.7% of CRD were high volume practitioners, compared with 36.8% among VAS (P < .05). High volume practitioners had significantly lower hospital charges ($41,730 vs $51,014, P < .001).
Cardiologists performing lower extremity angioplasty were more likely to treat patients with claudication than those with rest pain or gangrene/ulceration. Despite treating younger patients with less severe peripheral vascular disease, cardiologists used significantly greater hospital resources. High practitioner volume, regardless of specialty, was associated with lower hospital resource utilization. Reducing variations in indication and practitioner volume may offer substantial cost savings for lower extremity endovascular interventions.

Download full-text


Available from: Viktor Y Dombrovskiy, Jun 09, 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: The recent escalation in lower extremity revascularization procedures suggests a concomitant increase in peripheral arterial disease (PAD) screening. We hypothesized that self-referring physicians would show the greatest growth in noninvasive physiologic testing for PAD and similar trends for revascularization procedures. We compared utilization rates for self-referring specialties (vascular surgery, interventional radiology, and cardiology) with the utilization rate for a referral-based specialty (diagnostic radiology), assuming the latter to be "basal"--that is, responsive only to changes in demographics and medical knowledge. We analyzed 100% procedure-specific claims for services provided to Medicare Part B beneficiaries during 6 years over an 8-year span (2000-2007). We extracted all Current Procedural Terminology codes for lower extremity vascular noninvasive physiologic studies, peripheral arterial stent placement, and transluminal angioplasty. Utilization volumes were adjusted per 100,000 beneficiaries. Compound annual growth rates were calculated. Utilization of both noninvasive physiologic and revascularization services increased steadily over the study period. Growth rates of diagnostic services provided by interventional radiologists (7%) and vascular surgeons (8%) were slightly higher than the basal rate (7%), with cardiologists (14%) at the top of the list. For revascularization procedures, vascular surgery showed the greatest growth (28%), a rate more than twice that of cardiology (13%); radiology experienced a decrease in volumes (-2%). Self-referring specialists are screening large volumes of Medicare beneficiaries for lower extremity PAD at an accelerated rate compared with testing done by those who do not self-refer. Similar trends exist for endovascular interventions.
    No preview · Article · Aug 2011 · American Journal of Roentgenology
  • [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the effect of physician volume and specialty and hospital volume on population-level outcomes after endovascular repair of aortoiliac occlusive disease (AIOD). A retrospective cross-sectional analysis of all inpatients undergoing endovascular repair of AIOD. Physician volume was classified as low (<17 procedures per year [<50th percentile]) or high (≥17 procedures per year). Physicians were defined as surgeons if they performed at least 1 carotid, aortic, or iliac endarterectomy; open aortic repair; above- or below-knee amputation; or aortoiliac-femoral bypass. Hospital volume was low (<116 procedures per year [<50th percentile]) or high (≥116 procedures per year). Eight hundred eighteen inpatients who underwent endovascular repair of AIOD in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from January 2003 through December 2007. National hospital database. In-hospital complications and mortality, length of stay, and cost. Of the 818 procedures, 59.0% of high-volume physicians were surgeons and 65.0% practiced at high-volume hospitals. Unadjusted complication rates were significantly higher for low-volume compared with high-volume physicians (18.7% vs 12.6%; P = .02); rates were not significantly different by physician specialty (P = .88) or hospital volume (P = .16). Shorter length of stay was associated with high-volume physicians (P = .001), high-volume hospitals (P = .001), and surgeon providers (P = .03), whereas decreased cost was associated with physician specialty (P = .004). On multivariate analysis, high physician volume was associated with significantly lower complications (P = .04); high hospital volume, with shorter length of stay (P = .002); and nonsurgeons, with higher costs (P = .05). Overall, volume at the physician and hospital levels appears to be a robust predictor of patient outcomes after endovascular interventions for AIOD. Surgeons performing endovascular procedures for AIOD have a decreased associated hospital cost compared with nonsurgeons.
    No preview · Article · Aug 2011 · Archives of surgery (Chicago, Ill.: 1960)
  • [Show abstract] [Hide abstract]
    ABSTRACT: Lower-extremity endovascular interventions are increasingly being performed by vascular surgeons (VSs) and interventional cardiologists (ICs) in addition to interventional radiologists (IRs). Regardless of specialty, well trained, experienced, and dedicated operators are expected to offer the best outcomes. To examine specialty-specific trends, outcomes of percutaneous lower-extremity revascularizations in Medicare beneficiaries were compared according to physician specialty types providing the service. Medicare Standard Analytical Files that contain longitudinal data of all services (physician, inpatient, outpatient) provided to a 5% sample of Medicare beneficiaries were studied. All claims for percutaneous angioplasty, atherectomy, and stent implantation of lower-extremity arteries during the years 2005–2007 were extracted, and the following outcomes were assessed: mortality, transfusion, intensive care unit (ICU) use, length of stay, and subsequent revascularization or amputation. Outcomes were compared by using regression models adjusted for age, sex, race, emergency department admission, and comorbid conditions. Most outcomes were significantly worse if the service was provided by vascular surgeons compared with other vascular specialists. The in-hospital mortality rate for procedures performed by VSs was 19% higher than for those performed by others, but this difference was not significant (P =.351). Adjusted average 1-year procedure costs were significantly lower for IRs ($17,640) than for VSs ($19,012) or ICs ($19,096). Medicare data show that endovascular lower-extremity revascularization by vascular surgeons results in more transfusion and ICU use, longer hospital stay, more repeat revascularization procedures or amputations, and higher costs compared with procedures performed by interventional radiologists.
    No preview · Article · Nov 2011 · Journal of vascular and interventional radiology: JVIR
Show more