Variations in Practice Patterns for Peripheral Vascular Interventions Across Clinical Settings

Abstract

Peripheral vascular interventions (PVI) for lower extremity peripheral artery disease (PAD) have been increasing, particularly in the office-based setting. Our goal was to evaluate practice patterns for PVI by site of service using a contemporary real world dataset. The Vascular Quality Initiative PVI registry was queried from 2010-2021. Site of service was classified as hospital/inpatient, hospital/outpatient, and ambulatory/office based center. Patient demographics, comorbidities, procedural details, and peri-procedural outcomes were analyzed. There were 54,897 hospital/inpatient (43.2%), 64,105 hospital/outpatient (50.4%), and 8179 ambulatory/office based center (6.4%) PVI. When comparing the two outpatient settings, ambulatory/office based center patients were older than hospital/outpatient (mean age 70.7 vs. 68.7 years), more often female sex (41.4% vs 39.1%), never smokers (27.5% vs. 18.5%), primary Medicare (61.6% vs. 55.9%), non-ambulatory (6.5% vs. 4.7%), and less often with coronary artery disease (30.2% vs. 34.1%), chronic obstructive pulmonary disease (18.1% vs. 26.9%), congestive heart failure (13% vs 17.2%), and obesity (30.9% vs. 33.6%), and less often on a statin (71.4% vs. 76.1%), (P<.001). Ambulatory/office based center procedures were more likely for claudication (60.1% vs. 55.8%), more often involved femoro-popliteal (73.1%) vs. 64.6%) and infrapopliteal (36.7% vs. 24.3%), and less often iliac interventions (24.1% vs. 33.6%) (P<.001).Overall, atherectomy was used in 14.2% of hospital/inpatient, 19.4% of hospital/outpatient, and 63.4% of ambulatory/office based center procedures. Stents were used in 41.8% of hospital/inpatient, 45.1% of hospital/outpatient, and 48.8% of ambulatory/office based center procedures. However, stent grafts were used 12.5% of hospital/inpatient, 8.8% of hospital/outpatient, and only 1.3% of ambulatory/office based center procedures. On multivariable analysis, compared with hospital/inpatient, atherectomy use was associated with ambulatory/office based center setting (OR 10.9, 95% CI 10.3 - 11.5, P<.001) and hospital/outpatient setting (OR 1.57, 95% CI 1.51 - 1.62, P<.001). Peri-procedure complications including hematoma requiring intervention (0.3%), any stenosis/occlusion (0.2%), and distal embolization (0.6%) were quite low across all settings. There are substantial variations in both patient populations, procedural indications, and types of interventions undertaken during PVI across different locations. Ambulatory/office-based procedures more commonly treat claudicants, use atherectomy, and less often use stent grafts. Further research is warranted to investigate long-term trends in practice patterns, as well as long-term outcomes, for PVI in the ever-expanding ambulatory/office-based setting.