Medicare Analysis Reassures on PCI in Ambulatory Surgery Centers

WASHINGTON, DC—A glimpse into PCI outcomes for Medicare patients treated at ambulatory surgical centers (ASCs) shows that, after the Centers for Medicare & Medicaid Services (CMS)’s decision to reimburse the procedures, adverse events at these facilities were comparable to when care was provided in outpatient hospital settings.

While the proportion of procedures done in ASCs was small, the analysis is timely given predictions of a 21% increase in volume over the next 10 years, said Katerina Dangas, BMBCh (Beth Israel Deaconess Medical Center, Boston, MA), presenting the findings here last week at Society for Cardiovascular Angiography and Interventions (SCAI) 2025 Scientific Sessions.

At 30 days, there were low rates of adverse events no matter where patients were treated.

“We see less than 1% all-cause mortality, less than 1% stroke, less than 1% pericardial effusion as well as bleeding and transfusion in both groups,” she said. “The key takeaway from our adjusted comparison is that for the hard endpoints of mortality, hospital admission, MI, stroke, and pericardial effusion, we don't see higher rates of adverse events for PCI in the ASC setting, which may suggest sound patient selection.”

To TCTMD, Dangas said the findings are reassuring, “but they really would need to be validated in datasets that are nationally representative of all payers, and include the characteristics that we weren't able to account for: most importantly, procedural indication, angiographic risk, symptom severity, and medication adherence.”

One difference that did stand out was a higher rate of repeat PCI in the ASC group versus those treated in hospital outpatient departments (P < 0.001), but the numbers are too small to draw firm conclusions about why that may be the case.

Differences by Geography and Technologies Used

CMS finalized a ruling in late 2019 that allowed for payments for certain angioplasty and stenting procedures performed outside the hospital setting starting in 2020. The new analysis included 408,060 patients (mean age 75 years; 35% women) who underwent outpatient PCI from 2020 to 2022. Of those, less than 2% were treated at ASCs.

Compared with outpatient hospital settings, a greater percentage of those receiving PCI in an ASC were classified as socially vulnerable (36.6% vs 21.9%). Geographically, the southern United States had a much higher proportion of ASC-treated patients than all other regions.

While comorbidities were relatively evenly matched between patients at ASCs versus hospital outpatient settings, there was a slightly higher percentage of patients with a prior acute MI within the previous year being treated at hospitals and a higher percentage of those with peripheral vascular disease treated at an ASC.

Atherectomy was less likely at an ASC than in the outpatient hospital setting (2.4% vs 6.8%). Similarly, rates of intravascular ultrasound (IVUS) or fractional flow reserve (FFR) were about three times higher in patients managed in outpatient hospitals compared with ASCs, while rates of multivessel PCI were about twice as high. Notably, though, during the study period Medicare did not reimburse for IVUS or FFR.

At 30 days, rates of all-cause hospitalization and acute MI were slightly higher in the outpatient hospital group, which Dangas said again may reflect a degree of patient selection or procedural staging that the analysis couldn’t fully capture.

The study also found that between 2018 and 2022, the number of PCI procedures done in an ASC increased from 0.01 to 0.87 cases per 10,000 person-years.

Dangas said the potential for cost savings and the ability to provide care to underserved communities amid an aging population likely account for some of the shift.

“It is really intriguing the idea that underserved communities may be a sweet spot for ASCs,” noted David A. Cox, MD (Sanger Heart & Vascular Institute, Charlotte, NC), who served as moderator of the SCAI press conference prior to the presentation.

He added that it’s not surprising to see the South represented so heavily among the ASCs in the analysis because these facilities are a recognized regional phenomenon that are not found as widely in other parts of the country, a fact that Dangas added is driven largely by fewer regulatory restrictions at the state level in those areas.

“We see our study as an important first look at Medicare data on a national level,” she said, adding that evaluation of large national registries with ASC data would be an important next step in clarifying some of the differences seen in the Medicare population.