VESS14 - Tibial Interventions for Claudication are Performed Often, but Not Often by Vascular Surgeons

Objectives: There has been no data to support the use of tibial interventions in the treatment of claudication to date. We aimed to characterize the existing practice patterns surrounding tibial peripheral vascular interventions (PVI) in patients with claudication in the United States.

Methods: Using 100% Medicare fee-for-service claims from 2017 to 2019, we conducted a retrospective analysis of all patients undergoing any index PVI for claudication. All patients who had any previous PVI, acute limb ischemia, or chronic limb-threatening ischemia in the preceding 12 months were excluded. The primary outcome was the receipt of tibial revascularization during index PVI for claudication, defined as tibial intervention with or without concomitant femoropopliteal intervention. Univariable comparisons and a multivariable hierarchical Cox proportional hazards model were used to assess patient and physician characteristics associated with tibial PVI for claudication.

Results: Of 46,078 Medicare patients who underwent index PVI for claudication between 2017 and 2019, 12,000 (26.0%) received tibial PVI, of which 38.0% (n=4,561) received isolated tibial PVI, and 72.0% (n=7,439) received tibial PVI in addition to femoropopliteal PVI. Of 1,128 physicians, the median physician-level tibial PVI rate was 12.5% (IQR 5.6%-23.5%, Figure 1). Hierarchical logistic regression suggested that patient characteristics associated with tibial PVI for claudication included male sex (adjusted odds ratio [aOR] 1.20), increasing age (aOR 1.29-1.91), Black race (aOR 1.50), Hispanic ethnicity (aOR 1.98), diabetes (aOR 1.36), no hypertension (aOR 1.12), and never-smoking (aOR 1.61; all, P< 0.05; Figure 2). Physician characteristics associated with tibial PVI for claudication included early-career status (aOR 3.22), practice location in the West (aOR 2.01), high-volume PVI practice (aOR 1.93), majority practice in an ASC/OBL setting (aOR 2.11), and physician specialty; vascular surgeons had lower odds of performing tibial PVI compared to radiologists (aOR 3.55) and cardiologists (aOR 1.74; all, P< 0.05; Figure 2). Median Medicare reimbursement per patient was dramatically higher for physicians performing high-volume tibial PVI than for physicians performing low-volume tibial PVI (quartile 4 vs quartile 1: $12,855.05 vs $779.13 per patient, P< 0.001).

Conclusions: Tibial PVI for claudication are performed more commonly by non-vascular physicians, in high-volume practices, and in high-reimbursement settings. This reveals a critical need to reevaluate the education and reimbursement policies surrounding these procedures that may not be indicated.