Author + information
- W. Schuyler Jones, MD∗ (, )
- Xiaojuan Mi, PhD,
- Sreekanth Vemulapalli, MD,
- Eric D. Peterson, MD, MPH,
- Laura G. Qualls, MS,
- Manesh Patel, MD and
- Lesley H. Curtis, PhD
- ↵∗Duke Clinical Research Institute, Duke University Medical Center, Box 3126, Durham, North Carolina 27710
We appreciate the opportunity to respond to a letter written by Dr. Carr regarding our article published in the Journal in March 2015 (1). We believe our methods, results, and interpretation were a balanced, descriptive report of current trends and the landscape of peripheral vascular intervention (PVI) in the U.S. Medicare population. Our main findings include: 1) a stabilization in the rate of PVIs in the United States and a shift in care location from inpatient settings to outpatient settings and office-based clinics; 2) increasing numbers of atherectomy procedures, which are associated with higher Medicare expenditures than angioplasty and stenting procedures; and 3) the likelihood of neutralization of cost savings for Medicare due to more expensive procedures.
We would like to address Dr. Carr’s points of clarification directly. First, our primary intent in highlighting the increase in atherectomy procedures in office-based clinics was actually due to the fact that changes to the Outpatient Prospective Payment System (OPPS) occurred in 2008 and that these procedures were reimbursed by Medicare after that time, a point seemingly similar to that stated by Dr. Carr. Our further emphasis on the increase in atherectomy was based on the increased costs to Medicare and the limited evidence supporting its use, therefore we think that this focus was warranted.
Second, mean costs in our analysis were derived from the sum of expenditures by Medicare and by Medicare beneficiaries. These data were thoroughly investigated, and in the online supplement, these costs were reported separately for atherectomy alone and for atherectomy plus stenting. We believe our conclusions that atherectomy procedures were associated with higher costs to Medicare and to Medicare beneficiaries than those with stenting or angioplasty procedures are firm.
Third, our analysis purposefully eliminated surgical revascularization procedures as there had been a well-documented reduction in surgical revascularization over the past 2 decades, an occurrence that pre-dated the changes to the OPPS (2,3). Our primary intent was to evaluate the impact of changes in OPPS, and because endovascular revascularization was more commonly performed in outpatient settings (and surgical revascularization was infrequently performed in outpatient settings), we thought that the impact of the changes in OPPS on the trends and costs of endovascular revascularization would be more apparent.
Fourth, although we agree that patients in our study who received atherectomy appear to be sicker than those patients undergoing angioplasty or stenting, there is no evidence that atherectomy is more effective for patients with critical limb ischemia, as Dr. Carr states. We also disagree with Dr. Carr that “differences in patient populations could also indicate an improved access to care (i.e., patients were treated who would otherwise have been treated surgically or who would not have undergone revascularization at all).” In fact, these data are limited by an inability to evaluate whether access to care was affected by the changes in OPPS.
Fifth, we highlighted the paucity of data supporting use of atherectomy because we think that more studies are needed in PAD patients to guide decision making. We also do not think that Dr. Carr’s statement that “[D]ata clearly demonstrate that PTA alone in the femoropopliteal artery segment is not a satisfactory procedure” should prompt clinicians to use atherectomy more. Like all complex decision making, multiple factors likely contribute to the findings in our study, including patient-specific factors and clinician expertise, but we were unable to address these issues in the current study.
In conclusion, we agree with Dr. Carr that most physicians work hard to improve the care of their patients and make good clinical decisions. However, as seen in many aspects of medicine, the use of more expensive treatment modalities in the absence of evidence to support their use is often associated with variation and should be examined. In the case of PVI, we concluded that changes to the OPPS, although designed to improve efficiency and reduce costs, likely contributed to more use of atherectomy and neutralization of cost savings to the Medicare system.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation