VESS02. Twenty-Year National Trends in Peripheral Vascular Procedures Among Medicare Patients

Abstract

The advent and evolution of catheter-based therapies, such as atherectomy, has led to a dramatic increase in peripheral endovascular procedures with a concomitant decrease in open surgical bypasses and lower extremity amputations. The purpose of this analysis was to characterize secular changes in real-world interventions among patients undergoing vascular procedures. We analyzed trends in peripheral endovascular procedures, lower extremity bypass operations, and major lower extremity amputations (above knee/below knee) among Medicare beneficiaries from 1998 to 2017. Queried endovascular procedures included atherectomy, stenting, and balloon angioplasty. We used 100% samples of Medicare Part B claims to ascertain procedure rates per 1000 beneficiaries and compared them annually over a 20-year interval. Over the 20-year study interval, there were approximately 32 million Medicare enrollees annually. The rate of endovascular procedures increased by 99% over the first 10 years (11.5 vs 5.7 per 1000 beneficiaries; P < .001) and has increased by an additional 19% thereafter (13.8 vs 11.5; P < .001). The nonatherectomy procedure rate (diagnostic, balloon angioplasty, and stent placement) increased by 80% over the first 10 years (10.3 vs 5.7; P < .001) and has remained stable during the last 10 years (10.5 vs 10.6; P = .01). The rate of atherectomy has continually increased, specifically by 250% during the last 10 years (3.3 vs 0.95; P < .001; Fig). By comparison, lower extremity bypass has continually declined over time with an observed 50% decrease over the first 10 years (1 vs 2; P < .001) and an additional 42% over the last 10 years (0.58 vs 1.00; P < .001). Likewise, the rate of major amputations has declined by 35% over the first 10 years (1.1 vs 1.7; P = .01) and seems to have plateaued since 2011 at 0.9 amputations per 1000 Medicare beneficiaries. Over the last 20 years, we have seen an exponential increase in catheter-based interventions, largely driven by a rise in atherectomy. There has been a decrease in major limb amputations over the same interval. It does not seem that the sharp increase in atherectomy correlates with a sustained decline in amputation rates. Rather, the timing of the upstroke in atherectomy rates coincides with the year when Medicare reimbursement increased for office-based atherectomy (* in the Fig). Accordingly, current practice paradigms should more closely evaluate patients most likely to derive maximum benefit from aggressive endovascular interventions.