The Influence of Procedure Setting on Tibial Endovascular Arterial Intervention Practice Patterns in the Medicare...

The purpose of this study is to investigate the influence of practice location on the type of tibial endovascular arterial intervention performed in the Medicare population. Furthermore, stratification of the frequency of the performance of each type of intervention between the primary subspecialty stakeholders in endovascular lower extremity care is investigated.

A retrospective analysis of claims data from the Centers for Medicare and Medicaid Service's (CMS) Physician/Supplier Procedure Summary files for each year between 2011 and 2022 was conducted. Physicians were grouped into 1 of 4 categories: radiologists, cardiologists, vascular surgeons, or other. Claims data were tabulated for all Current Procedural Terminology (CPT) codes corresponding to endovascular therapy in the tibial arterial segment. These CPT codes encompass the interventions of angioplasty alone (CPT 37228), atherectomy with or without angioplasty (CPT 37229), stent placement with or without angioplasty (CPT 37230), and atherectomy in combination with stent placement (CPT 37231). Chi-squared testing was utilized for univariable comparisons.

Atherectomy procedures were performed at a nearly two-fold higher rate in outpatient-based laboratories (OBLs) relative to hospital-based facilities (59.1% of procedures vs. 31.3%, odds ratio (OR): 1.87, P < 0.0001). After 2011 atherectomy rapidly accelerated with a per annum increase from 18,000 cases to over 45,000 per year. In 2011, balloon angioplasty was performed twice as frequently as atherectomy. By the year 2016 atherectomy with angioplasty eclipsed angioplasty. When analyzing location of service, the escalation in atherectomy occurred entirely in the OBL setting as the total number of atherectomies remained stable year over year between 2011 and 2022. Vascular surgeons performed tibial atherectomy at the lowest rate, but within an absolute rate of 1% relative to other disciplines for atherectomy without stent placement and within an absolute rate of 3% relative to other disciplines for tibial atherectomy with stent placement. Among all OBL cases, vascular surgery (41.5%) and cardiology (31.9%) performed the highest proportion of procedures relative to interventional radiology (22.0%) and other subdisciplines (4.5%), P < 0.001.

There was a rapid acceleration in the performance of tibial atherectomy between 2011 and 2022. This was driven entirely by OBL based atherectomy performed at essentially equal rates across subdisciplines. Patients treated in the OBL setting were nearly twice as likely to be treated with atherectomy relative to those in hospital settings. Future reimbursement models for infrainguinal endovascular arterial interventions should carefully identify to-facility cost of devices utilized and create an equivalent reimbursement to cost margin across clinically equivalent methods of treatment.