United States Endovenous Ablation Practice Trends: 4-Year Review of Medicare Provider Utilization and Payment Database

Abstract

The exponential growth of endovenous ablation in the United States during the last few years has raised concerns of overuse from vascular societies and payers. The reasons for such growth are unclear (ie, increased awareness, less invasive procedure, or inappropriate overuse). In addition, physicians performing these procedures outside of their scope of practice raise concerns regarding adequacy of training. The Medicare Provider Utilization and Payment Database can be used to evaluate practice trends in Medicare beneficiaries. The Medicare Provider Utilization and Payment Database was queried for endothermal ablation Current Procedural Terminology codes 36475, 36476, 36478, and 36479 from 2012 through 2015. These results were imported into a relational database program. Queries were designed to ascertain the practice trends of all providers, inclusive of all specialties, and the data were exported to a spreadsheet program for analysis. Analysis for ablations per patient was calculated by assessing the number of beneficiaries that underwent at least one ablation by a provider in relation to the total number of ablations performed by that provider. Most saphenous vein ablations were done by vascular surgery (29%), cardiology (21%), and general surgery (14%) practitioners. The remaining one-third was performed by 41 other provider specialties. Regional variation was significant, with 47% of ablations being performed in the south (Florida, 10.4%; Texas, 9%). The southern region also had the highest growth with >127,000 cases added in 2015 (150% growth). Ablations per patient averaged 1.8 in the aggregate data set. Independent annual assessment of ablations per patient remained relatively constant: 2012, mean 1.8; 2013, mean 1.8; 2014, mean 1.8; and 2015, mean 1.9. Vascular surgery, cardiology, and general surgery specialties trended closer to the average, whereas the less represented specialties trended above the average. When the threshold was set to two ablations/patient for the year 2015, there were 295 providers above the threshold representing 20% of providers. Growth was noted during the 4 years with an increase in providers of 354 (16%), ablations of 37,682 (28%), and patients of 17,002 (23%). The provider and procedural growth rates during the time period of the database were 10% and 26%, respectively, for vascular surgery, 35% and 51% for cardiology, and −9% and −0.4% for general surgery. Endovenous ablation is performed by a wide variety of subspecialists with different levels of formal training for the management of chronic venous disease. There was an annual increase in the number of providers and ablations performed during this 4-year period of evaluation. Most ablations (64%) were performed by formally trained vascular surgeons, cardiologists, and general surgeons. The number of ablations per patient was higher than average in specialties without any vascular training. This data analysis can help establish better guidelines and governance for the use of endovenous ablation. As our health care system shifts from a fee-for-service to a value-based system and taxpayer-funded resources in Medicare patients become less available, it is important that practice trends be scrutinized using data-driven initiatives.