Reintervention Following Outpatient Peripheral Artery Disease Procedures: Trading Convenience for Value?

Abstract

Peripheral artery disease (PAD) represents a high volume, high-cost burden on the healthcare system. The Centers for Medicare and Medicaid Services has developed the Bundled Payments for Care Improvement-Advanced program, in which a single payment is provided for all services to be administered in a postsurgical 90-day episode of care. Factors associated with 30- and 90-day reinterventions after PAD interventions would represent useful data for both payors and stake holders. We conducted a national cohort study of adults 65 years and older in the Vascular Quality Initiative and Centers for Medicare and Medicaid Services linked dataset who underwent an open, endovascular, or hybrid revascularization procedure for PAD between January 1, 2010, and December 31, 2018. Procedures for acute limb ischemia and aneurysm indications were excluded. The primary outcome was 90-day reintervention and 30-day reintervention was a secondary outcome. Covariates of interest included demographic, comorbidities, and patient and facility level characteristics. Multivariable Cox regression was used to determine the association between patient- and facility-level characteristics and the risk of 30- and 90-day reinterventions. Among 42,429 patients (71.3% endovascular, 23.3% open, and 5.4% hybrid), median (interquartile range) age was 74 years (interquartile range, 69-80 years), 58.9% were male, and 84.3% were White. Chronic limb-threatening ischemia was the operative indication in 56.4%; 42.8% of the procedures were completed in the outpatient setting (40.3% outpatient, 2.5% office-based laboratory). More than 70% of procedures for chronic limb-threatening ischemia were completed as an inpatient, while 60% of the claudication interventions were done as an outpatient. The 30-day reintervention rate was 5.5% and the 90-day reintervention rate was 14.5%. Compared with inpatient procedures, PAD interventions completed in the outpatient or office-based laboratory setting had significantly higher 30- and 90-day reintervention rates (ref, inpatient; outpatient 30-day reintervention: hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.62-2.24]; outpatient 90-day reintervention: HR, 1.41; 95% CI, 1.25-1.60); office-based laboratory 30-day reintervention: HR, 3.54; 95% CI, 3.17-3.94]; office-based laboratory 90-day reintervention, HR, 2.09; 95% CI, 1.82-2.41) Open and hybrid approaches demonstrated lower risk of reintervention compared with endovascular procedures at 30 and 90 days and, compared with aortoiliac disease, all other anatomic segments of disease were associated with higher 90-day reintervention but no difference was noted at 30 days (Table). Although outpatient PAD interventions may be convenient for patients and providers, the outpatient setting is associated with a significant risk of subsequent 30- and 90-day reintervention. Additional work is needed to understand how to improve the longevity of outpatient PAD interventions.TableMultivariable analysis of factors associated with 30- and 90-day reinterventionsCovariate30-Day reintervention90-Day reinterventionAdjusted hazard ratio95% confidence intervalAdjusted hazard ratio95% confidence intervalStandard demographics Age 70-74 vs 65-690.950.891.020.990.951.04 Age 75-79 vs 65-690.950.841.090.950.881.03 Age 80-84 vs 65-691.000.841.190.950.861.05 Age ≥85 vs 65-690.990.911.080.880.820.94 Female vs male0.760.690.830.870.820.92 Non-White vs White1.050.931.191.050.971.14Comorbidities BMI ≥30 vs BMI <300.950.871.030.930.890.98 Coronary artery disease0.990.881.121.101.041.15 Congestive heart failure0.990.891.090.940.890.99 Chronic obstructive pulmonary disease1.040.971.131.081.011.16 Diabetes mellitus1.030.941.141.050.991.10 ESRD on dialysis1.461.311.631.381.261.50 Hypertension1.070.931.241.090.981.22 Microvascular disease1.010.901.141.010.921.11 Current smoker vs nonsmoker1.130.991.300.980.911.06 Prior smoker vs nonsmoker1.080.971.201.010.941.08Patient-level characteristics Ischemic rest pain vs claudication1.171.011.361.101.001.20 Tissue loss vs claudication1.110.991.241.070.991.15 Femoropopliteal vs aortoiliac1.050.911.211.241.151.35 Tibial vs aortoiliac0.930.771.111.311.191.45 Aortoiliac + any outflow vs aortoiliac1.140.961.351.381.251.51 Femoropopliteal + tibial vs aortoiliac1.030.821.301.341.171.54 Prior LER0.930.851.020.990.941.04 Ambulation with assistance vs ambulatory1.121.011.241.080.981.18 Wheelchair/bedridden vs ambulatory0.880.731.060.870.790.96 Homeless vs home0.000.000.000.430.111.67 Nursing home vs home0.880.681.140.820.730.91Facility-level or operative characteristics Office/clinic vs inpatient3.543.173.942.091.822.41 Outpatient vs inpatient1.901.612.241.411.251.60 Hybrid vs endovascular0.440.340.580.740.650.85 Open vs endovascular0.460.380.560.780.690.89 Year of procedure 2013-2015 vs 2010-20121.020.781.321.120.981.27 Year of procedure 2016-2018 vs 2010-20120.930.671.291.040.901.20 Distance to care 5-10 miles vs <5 miles1.030.941.131.020.951.11 Distance to care >10-20 miles vs <5 miles1.000.881.140.980.901.07 Distance to care >20-40 miles vs <5 miles1.070.921.251.040.941.15 Distance to care >40-60 miles vs <5 miles1.070.911.271.050.941.18 Distance to care >60 miles vs <5 miles0.860.661.120.960.841.11BMI, body mass index; LER, lower extremity revascularization; ESRD, end stage renal disease.All variables in the table are included in the model. 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