The Influence of Procedure Setting on Femoral-Popliteal Endovascular Arterial Intervention Practice Patterns in the Medicare Population

Abstract

Objective

The purpose of this study is to investigate the influence of practice location on the type of femoral-popliteal endovascular arterial intervention performed in the Medicare population. Additionally, the study investigates the distribution of each intervention type among the primary subspecialty stakeholders in endovascular lower extremity care.

Methods

A retrospective analysis of claims data from the Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary files for each year between 2011 and 2022 was performed. Physicians were divided into four categories: radiologists, cardiologists, vascular surgeons, or others. Claims data were collected for all Current Procedural Terminology (CPT) codes corresponding to endovascular therapy in the femoral-popliteal arterial segment. These CPT codes include interventions such as angioplasty alone, atherectomy with or without angioplasty, stent placement with or without angioplasty, and atherectomy combined with stent placement. Chi-squared testing was used for univariable comparisons.

Results

A total of 292 453 femoral-popliteal segment procedures were included in the study. 16.7% (N = 48 705) of procedures were performed in an Office-based Laboratory or stand-alone outpatient ambulatory surgical centers (OBL) setting, while 83.3% (N = 243 401) took place in a hospital-based setting. Cardiologists performed 31.8% (N = 92 969), interventional radiologists 16.8% (N = 49 200), other specialties 4% (N = 11 730), and vascular surgeons 48.7% (N = 142 480) of all CMS-insured femoral-popliteal segment endovascular interventions during the study period. By 2016, atherectomy-based procedures surpassed angioplasty and stent-alone procedures within the CMS population. Cardiologists performed the highest number of atherectomy procedures, with or without stenting, in the femoral-popliteal segment (P < .001). However, the overall rate of atherectomy performed by cardiology compared to other subdisciplines was within 3 percentage points and not significantly different. Vascular surgeons performed atherectomy at the lowest rate, but within 4% of cardiologists. Atherectomy procedures were performed nearly twice as often in outpatient-based facilities compared to hospital-based facilities (57.3% vs 31.6%, OR 1.81, P < .0001). Vascular surgery (44.2%) and cardiology (29.2%) performed the most OBL-based cases, while interventional radiology accounted for 20.0% and other specialties 6.6% (P < .001).

Conclusions

There was a substantial increase in the use of atherectomy in the femoral-popliteal segment in the OBL setting for the CMS population between 2011 and 2022. The rate of atherectomy use is nearly two-fold higher in the OBL setting compared to hospital-based facilities.