PAD Treatment Cost, Quality Dependent on Provider
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Patients with peripheral arterial disease (PAD) who require endovascular lower-extremity revascularization experience better 1-year outcomes and more efficiently delivered care if treated by an interventional radiologist compared with a vascular surgeon. Interventional cardiologists also saw better outcomes than vascular surgeons with the exception of ICU use and average 1-year procedural cost, according to a study published in the January 2012 issue of the Journal of Vascular and Interventional Radiology.
For the retrospective analysis, Timothy P. Murphy, MD, of Rhode Island Hospital (Providence, RI), and colleagues studied data from the Centers for Medicare and Medicaid Services on 14,608 PAD patients who underwent endovascular lower-extremity revascularization between 2005 and 2007.
Interventionalists Rank Superior
Of all patients studied, 5,489 index procedures were performed by interventional cardiologists, 5,358 by vascular surgeons, 3,565 by interventional radiologists, and 196 by other specialists.
Outcomes were consistently better across several measures when procedures were performed by either an interventional radiologist or an interventional cardiologist (table 1).
Table 1. Adjusted Odds Ratios of Treatment Outcomes by Specialty
|
Mortality |
ICU Use |
Transfusion (95% CI) |
Repeat Intervention (95% CI) |
Vascular Surgeons (Reference) |
1.00 |
1.00 |
1.00 |
1.00 |
Interventional Radiologists |
0.81 |
0.68a |
0.81 |
0.63a |
Interventional Cardiologists |
0.81 |
0.96 |
0.69 |
0.41 |
a P < 0.001 compared with vascular surgeons.
In addition, patients treated by vascular surgeons had longer hospital stays on average (3.4 days) than those treated by interventional radiologists (2.9 days; 95% CI 2.7-3.1) and interventional cardiologists (2.6 days; 95% CI 2.4-2.8).
The adjusted average 1-year cost per patient was lowest for interventional radiologists ($17,640), with the costs being similar for interventional cardiologists ($19,096) and vascular surgeons ($19,012).
Rethinking Hospital Credentials
Dr. Murphy told TCTMD in a telephone interview that interventionalists were expected to have better outcomes because they spend more time on catheter-based procedures than vascular surgeons.
“It really relates to inadequate training and experience of a lot of the surgeons who have been doing endovascular procedures during [the study] time, and also the transference of skills,” he said. “Obviously we all want to go to the providers with the best skills who can offer the best outcomes with the lowest cost.”
Given these findings, Dr. Murphy said that hospitals should reconsider their privileging and credential requirements to include outcomes and not merely procedural volume.
“I think the trend toward looking at outcomes in order to determine maintenance of privileges and maintenance of credentials is going to be increasingly important in the future,” he said. “The fact is that surgeons are doing substantially more endovascular low-extremity revascularizations than radiologists and yet they have worse outcomes. So if one were just to look at procedural volumes for maintenance of privileges, there could easily be a threshold that could be fixed where surgeons could maintain their privileges and radiologists could be disenfranchised.”
Not All Interventionalists Created Equal
Although interventional radiologists perform more cost-effective procedures, William A. Gray, MD, of Columbia University Medical Center (New York, NY), noted the disparity in revascularization rates between the interventionalist groups, with the cardiologists’ rate less than half of the vascular surgeons’ and just under half of the radiologists.’
“If you look at the cost, no question that the radiologists appear to do things for less money, but that has to be balanced against the repeat intervention rate,” he said in a telephone interview with TCTMD. “So I think it’s a little bit disingenuous for the radiologists to say that they can do it cheaper than everybody else when the results have to be factored into that.”
Regarding the cost differences, Dr. Murphy said it would be hard to determine a solid explanation with the information provided in the database, but he did propose that differing cost structures in the cardiology and radiology labs could be key.
When disparity occurs between groups in a study, Dr. Gray said 3 explanations usually come to mind. First, there could be a difference in patients not able to be identified in the data analysis. While these authors “made every effort” to include what they could, information like Rutherford classification or other comorbidities would be important to consider, he added. In addition, the presenting symptom might be different or there could be a “fundamental difference between the groups” that could be related to training, approach, philosophy, or expertise.
“The authors would like to conclude that [procedural success] is related to a specialty difference, but they don’t really raise the possibility that the specialty difference may in fact relate to a patient difference,” he said. “I think part of that is played out in the nuance that [interventional radiologists] claim a lower cost rate but they have higher rates of reintervention than the cardiologists who had higher costs. Unfortunately it’s a little bit slanted in its view.”
Dr. Gray praised the authors for initiating conversation on this issue, but said he would like to see a prospective study looking at “outcomes by patient severity, by the anatomic area being treated, and by specialty.”
Overall, he called the study “hypothesis-generating and thought-provoking” and said it begs the question as to whether vascular surgeons have adequate catheter-based skills or perhaps are just treating different patients.
Study Details
Baseline characteristics were similar between the patient groups as per information that was available through Medicare. Slightly more than half the patients were male and the majority of patients ranged in age from 65 to 85 years.
Source:
Zafar AM, Dhangana R, Murphy TP, et al. Lower-extremity endovascular interventions for Medicare beneficiaries: Comparative effectiveness as a function of provider specialty. J Vasc Interv Radiol. 2012;23:3-9.
- Dr. Gray reports no relevant conflicts of interest.
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Read Full BioDisclosures
- Dr. Murphy reports receiving research support from Abbott Vascular and Cordis/Johnson and Johnson and serving as a consultant to Microvention/Terumo.
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