(PC114) The Influence of Procedure Setting on Femoral-Popliteal Endovascular Arterial Intervention Practice Patterns in the Medicare Population

Objectives: The purpose of this study is to investigate the influence of practice location on the
type of femoral popliteal endovascular arterial intervention performed in the Medicare
population. The frequency of the performance of each type of intervention between the primary
subspecialty stakeholders in endovascular lower extremity care is investigated.

Methods: A retrospective analysis of claims data from the Centers for Medicare and Medicaid
Service’s (CMS) Physician/Supplier Procedure Summary files for each year between 2011 and
2022 was conducted. Physicians were grouped into 1 of 4 categories: radiologists, cardiologists,
vascular surgeons, or other. Claims data was tabulated for all Current Procedural Terminology
(CPT) codes corresponding to endovascular therapy in the femoral-popliteal arterial segment.
These CPT codes encompass the interventions of angioplasty alone (CPT 37224), atherectomy
with or without angioplasty (CPT 37225), stent placement with or without angioplasty (CPT
37226), and atherectomy in combination with stent placement (CPT 37227). Chi-Squared testing
was utilized for univariable comparisons.

Results: There were 292,453 procedures corresponding to the femoral-popliteal segment CPT
codes in the study period. 16.7% (N=48,705) of procedures were performed in the ambulatory
outpatient facility (OBL) setting and 83.3% (N=243,401) in the Hospital based setting.
Cardiologists performed 31.8% (N=92,969), Interventional Radiologists 16.8% (N=49,200),
Other specialties 4% (N=11,730), and Vascular Surgeons 48.7% (N=142,480) of all CMS
insured femoral popliteal segment endovascular interventions in the study time period.
Cardiologists performed the highest frequency of atherectomy (P <.001). Vascular surgeons
performed atherectomy at the lowest rate of atherectomy but within 4% of cardiologists. As seen
in Figure 1, atherectomy procedures were performed at a nearly two-fold higher rate in
outpatient-based facilities relative to hospital-based facilities (57.3% of procedures Vs. 31.6%,
OR 1.81, P<.0001). Vascular surgery (44.2%) and Cardiology (29.2%) performed the most OBL
based cases relative to Interventional Radiology (20.0%) and Other Subdisciplines (6.6%),
P <.001). By 2016, atherectomy based procedures eclipsed angioplasty and stent alone based
procedures in the CMS population (Figure 2).

Conclusions: There was a very significant escalation in the utilization of atherectomy in the
femoral-popliteal segment in the OBL setting for the CMS population between 2011 and 2022.
There is a significantly higher rate of atherectomy utilization in the OBL setting relative to
hospital-based facilities. There exists significant potential that the high facility fee
reimbursement for atherectomy relative to angioplasty and stent has driven up the utilization of
an intervention which has higher cost in the absence of clinical benefit.