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

ObjectiveThe 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.MethodsA 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.ResultsA 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).ConclusionsThere 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.