RS25 - Early Peripheral Vascular Interventions for Claudication in High Reimbursement Settings are Associated with Higher Rates of Late Intervention and Progression to CLTI

Objectives: Despite societal guidelines that peripheral vascular interventions (PVI) should not be first line therapy for intermittent claudication, a significant number of patients undergo PVI for claudication within six months of diagnosis. The aim of this study was to investigate the association of early PVI for claudication with subsequent interventions.

Methods: 100% Medicare fee-for-service claims were used to identify all beneficiaries newly diagnosed with claudication between 1/1/2015-12/31/2017. The primary outcome was late PVI, defined as any infrainguinal PVI performed >6 months after claudication diagnosis (through 6/30/2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients receiving early ( < 6 months) PVI vs. those without early PVI. A hierarchical Cox proportional hazard model was used to evaluate patient and physician-level characteristics associated with increased late interventions.

Results: A total of 187,442 patients were newly diagnosed with claudication in the study period, of which 3.2% (6,069) underwent early PVI. After a median follow-up of 4.39 years (IQR 3.62, 5.17), 22.5% of early PVI patients underwent late PVI vs. 3.6% of patients who did not receive early PVI (P < 0.001) (Figure 1). Patients treated by high physician users of early PVI (quartile 4, physician outliers) were more likely to receive late PVI than patients treated by standard physician users (quartiles 1-3) (9.8% vs. 3.9%, P< 0.001) (Figure 2). Patients undergoing early PVI and patients treated by outlier physicians were more likely to convert to CLTI (both P< 0.001). After adjustment, patient factors associated with late PVI included receipt of early PVI (aHR 6.89, 95%CI:6.42-7.40) and Black race (vs. White, aHR 1.19, 95%CI:1.10-1.30). The only physician factor associated with late PVI was majority practice in an ASC/OBL where increasing proportion of ASC/OBL services was associated with significantly increased rates of late PVI (Q4 vs Q1, aHR 1.57, 95%CI:1.41-1.75).

Conclusions: Early PVI following diagnosis of claudication is associated with higher late PVI rates compared to patients treated with early medical management alone. High physician users of early PVI for claudication perform more late PVI than their peers, particularly those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do incentives surrounding delivery of these interventions in ambulatory intervention suites.