Trends in settings for peripheral vascular intervention and the effect of changes in the outpatient prospective payment system.
BACKGROUND
Peripheral vascular intervention (PVI) is an effective treatment option for patients with peripheral artery disease (PAD). In 2008, Medicare modified reimbursement rates to encourage more efficient outpatient use of PVI in the United States.


OBJECTIVE
The purpose of this study was to evaluate trends in the use and clinical settings of PVI and the effect of changes in reimbursement.


METHODS
Using a 5% national sample of Medicare fee-for-service beneficiaries from 2006 to 2011, we examined age- and sex-adjusted rates of PVI by year, type of procedure, clinical setting, and physician specialty.


RESULTS
A total of 39,339 Medicare beneficiaries underwent revascularization for PAD between 2006 and 2011. The annual rate of PVI increased slightly from 401.4 to 419.6 per 100,000 Medicare beneficiaries (p = 0.17), but the clinical setting shifted. The rate of PVI declined in inpatient settings from 209.7 to 151.6 (p < 0.001), whereas the rate expanded in outpatient hospitals (184.7 to 228.5; p = 0.01) and office-based clinics (6.0 to 37.8; p = 0.008). The use of atherectomy increased 2-fold in outpatient hospital settings and 50-fold in office-based clinics during the study period. Mean costs of inpatient procedures were similar across all types of PVI, whereas mean costs of atherectomy procedures in outpatient and office-based clinics exceeded those of stenting and angioplasty procedures.


CONCLUSIONS
From 2006 to 2011, overall rates of PVI increased minimally. However, after changes in reimbursement, PVI and atherectomy in outpatient facilities and office-based clinics increased dramatically, neutralizing cost savings to Medicare and highlighting the possible unintended consequences of coverage decisions.
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina. Electronic address: schuyler.jones@duke.edu.
W Schuyler
WS
Jones
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
Xiaojuan
X
Mi
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
Laura G
LG
Qualls
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Sreekanth
S
Vemulapalli
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Eric D
ED
Peterson
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Manesh R
MR
Patel
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Lesley H
LH
Curtis
D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000191:economics* / Q000706:statistics & numerical data; D017130:Angioplasty / Q000191:economics / Q000639:trends; D017073:Atherectomy / Q000191:economics / Q000639:trends; D004691:Endarterectomy / Q000191:economics / Q000639:trends; D018588:Fee-for-Service Plans; D005260:Female; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare / Q000191:economics*; D058729:Peripheral Arterial Disease / Q000191:economics* / Q000628:therapy*; D011445:Prospective Payment System; D015607:Stents / Q000191:economics / Q000639:trends; D014481:United States
Medicare; atherectomy; peripheral arterial disease; vascular surgical procedures