Diagnosis Of Claudication Research Articles

Association Between Regional Market Competition and Early Femoropopliteal Interventions for Claudication

ObjectivesRegional market competition is known to impact practice patterns in surgical care. We aimed to investigate the association of regional market competition with the utilization of early peripheral vascular interventions (PVI) for the treatment of claudication, and the subsequent impact on clinical outcomes. MethodsWe conducted a retrospective analysis of 100% Medicare fee-for-service claims data from 01/2019 to 12/2021 to identify patients with a new diagnosis of claudication. We calculated the Herfindahl-Hirschman Index for all sites of service performing PVI according to Health Service Area. Multivariable logistic regression and Cox proportional hazards models were used to assess the association of regional market competition with early (<6 months) PVI for claudication, and progression to chronic limb-threatening ischemia (CLTI), repeat PVI, and major amputation. ResultsWe identified 300,492 patients with a new diagnosis of claudication (mean age 73.8 years, 51.6% male, 11.1% Black), of which 6.1% underwent an early PVI for claudication. Most patients (72.4%) were treated in low-competition markets. After adjusting for patient characteristics, patients treated in moderate-competition markets had the highest odds of receiving an early PVI. Regional market competition was not associated with conversion to CLTI or repeat PVI (P>0.05), but patients treated in high- (aHR 0.70, 95%CI 0.56-0.86) and moderate- (aHR 0.82, 95%CI 0.69-0.92) competition markets had lower hazards of major amputation compared to patients treated in low-competition markets. Early PVI was significantly associated with worse clinical outcomes after adjusting for all factors including market competition (all, P<0.05). ConclusionsThere is a complex interplay between regional market competition, early PVI utilization, and subsequent clinical outcomes for patients with claudication. Early PVI continues to demonstrate a strong association with unfavorable clinical outcomes even when accounting for market competition.

Reprint of: Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia

ObjectiveDespite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. MethodsWe evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. ResultsA total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). ConclusionsEarly PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.

Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia

ObjectiveDespite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. MethodsWe evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. ResultsA total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). ConclusionsEarly PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.

Characterizing patient-reported claudication treatment goals to support patient-centered treatment selection and measurement strategies

ObjectivePatient-reported outcomes (PRO) have been increasingly emphasized for peripheral artery disease (PAD). Patient-defined treatment goals and expectations, however, are poorly understood and might not be achievable or aligned with guidelines or clinical outcomes. We evaluated the patient-reported treatment goals among patients with claudication and the associations between patient characteristics, goals, and PAD-specific PRO scores. MethodsPatients with a diagnosis of claudication were prospectively recruited. Patient-defined treatment goals and outcomes related to walking distance, duration, and speed were quantified using multiple-choice survey items. Free-text items were used to identify activities other than walking distance, duration, or speed associated with symptoms and treatment goals. The peripheral artery disease quality of life and walking impairment questionnaire instruments were included as PRO. The treatment goal categories were compared with the PRO percentile scores using 95% confidence intervals (CIs), categorical tests, and logistic regression models. Associations between the patient characteristics and PRO were evaluated using linear and ordinal logistic regression models. ResultsA total of 150 patients meeting the inclusion criteria were included in the present study. Of these 150 patients, 144 (96%) viewed the entire survey. Their mean age was 70.0 ± 11.3 years, and 32.9% were women. Most of the respondents had self-reported their race as White (n = 135), followed by Black (n = 3), Asian (n = 2), Native American (n = 2), and other/unknown (n = 2). Two participants self-reported Hispanic ethnicity. The primary treatment goals were an increased walking distance or duration without stopping (62.0%), the ability to perform a specific activity or task (23.0%), an increased walking speed (8.0%), or other/none of the above (7.0%). The specific activities associated with symptoms or goals included outdoor recreation (38.5%), labor-related tasks (30.7%), sports (26.9%), climbing stairs (23.1%), uphill walking (19.2%), and shopping (6%). Among the patients choosing an increased walking distance and duration as the primary goals, 64% had indicated that a distance of ≥0.5 mile (2640 ft) and 59% had indicated a duration of ≥30 minutes would be a minimum increase consistent with meaningful improvement. Increasing age was associated with lower odds of a distance improvement goal of ≥0.5 mile (odds ratio [OR], 0.68 per 5 years; 95% CI, 0.51-0.92; P = .012) or duration improvement goal of ≥30 minutes (OR, 0.76 per 5 years; 95% CI, 0.58-0.99; P = .047). Patient characteristics associated with PAD Quality of Life percentile scores included age, ankle brachial index, and gender. Ankle brachial index was the only patient characteristic associated with the walking impairment questionnaire percentile scores. ConclusionsPatients define treatment goals according to their desired activities and expectations, which may influence their goals and perceived outcomes. Patients’ expectations of minimum increases in walking distance and duration consistent with meaningful improvement exceeded reported minimum important difference criteria for many patients and would not be captured using common clinic-based walking tests. Patient age was associated with both treatment goals and PRO scores, and the related floor and ceiling effects could influence sensitivity to PRO changes for younger and older patients, respectively. Heterogeneity in treatment goals supports consideration of tailored decision-making and outcomes informed by patient characteristics and perspectives.

SS24. The Diagnosis Of Claudication Is Influenced By Patients' Sex

PAD afflicts 18% of the elderly and the prevalence varies with PAD stage and patients' sex. Women, for instance, dominate when diagnosis is based on ABI only, but for intermittent claudication (IC) that requires a subjective component the prevalence is higher among men. The purposes of this study was to evaluate if utilization of common diagnostic criteria for IC results in dissimilar types of IC for women and men and also to identify any possible difference in perception of IC symptoms between the sexes. Eight thousand women and men, aged 59-89 years, were selected at random and invited to participate. The 5040 subjects who accepted had ABI measured and completed questionnaires covering medical history, current medication, PAD symptoms and walking ability. A subset of subjects with IC at that time was followed up using the same questionnaires and also performed a walking test, underwent duplex scanning of leg arteries, ABI assessment and echocardiography. They were also interviewed in detail about their symptoms. The point-prevalence of IC was 6.5% for women and 7.2% for men (P=.09) in the cohort and the mean ABI among IC subjects was 0.7 (SD 0.2). A fifth (19%) of women with IC had ABI<0.5 compared to 7% for men. Men with IC reported having DM, stroke and a smoking history more often than women, who in turn reported hypertension more frequently. Women with IC had problems with a lower (P<0.01) walking speed (P<0.01) more often than men, and a larger proportion of them experienced joint problems (P=0.018) and heart palpitations (P=0.002) In this study the prevalence of IC tended to be more common among men using classic IC definitions, but this may be a consequence of sex differences in presentation of symptoms. Accordingly, IC prevalence and consequences of IC may be underestimated in women and this needs to be considered when assessing IC in epidemiological studies, clinical trials and as indication for revascularization.