Abstract：
OBJECTIVE: Controversy exists regarding the value and limitations of different sites of service for peripheral artery disease treatment. We aimed to examine practice patterns associated with peripheral vascular interventions (PVIs) performed in the office-based laboratory (OBL) vs outpatient hospital site of service using a nationally representative database.
METHODS: Using 100% Medicare fee-for-service claims data, we identified all patients undergoing PVI for claudication or chronic limb-threatening ischemia (CLTI) between January 2017 and December 2022. We evaluated the associations of patient and procedure characteristics with site of service using multivariable hierarchical logistic regression. We used multinomial regression models to estimate the relative risk ratios (RRRs) of site of service and intervention type (angioplasty, stent, or atherectomy) and intervention anatomic level (iliac, femoropopliteal, or tibial) after adjusting for baseline patient characteristics and clustering by physician.
RESULTS: Of 848,526 PVI, 485,942 (57.3%) were performed in an OBL. OBL use increased significantly over time from 48.3% in 2017 to 65.5% in 2022 (P < .001). Patients treated in OBLs were more likely to be Black (adjusted odds ratio [aOR], 1.14; 95% confidence interval [CI], 1.11-1.18) or other non-White race (aOR, 1.13; 95% CI, 1.08-1.18), have fewer comorbidities, and undergo treatment for claudication vs CLTI (aOR, 1.30; 95% CI, 1.26-1.33) compared with patients treated in outpatient hospital settings. Physicians with majority practice (>50% procedures) in an OBL were more likely to practice in urban settings (aOR, 21.58; 95% CI, 9.31-50.02), specialize in radiology (aOR, 18.15; 95% CI, 8.92- 36.92), and have high-volume PVI practices (aOR, 2.15; 95% CI, 2.10-2.29). The median time from diagnosis to treatment was shorter in OBLs, particularly for patients with CLTI (29 vs 39 days; P < .001). The OBL setting was the strongest predictor of patients receiving an atherectomy alone (adjusted RRR [aRRR] 6.67; 95% CI, 6.59-6.76) or atherectomy + stent (aRRR, 10.84; 95% CI, 10.64-11.05), and these findings were consistent in subgroup analyses stratified by PVI indication. The OBL setting was also associated with higher risk of tibial interventions for both claudication (aRRR, 3.18; 95% CI, 3.11-3.25) and CLTI (aRRR, 1.89; 95% CI, 1.86-1.92). The average reimbursement (including professional and facility fees) was slightly higher for OBLs compared with the hospital ($8742/case vs $8459/case; P < .001). However, in a simulated cohort resetting the OBL\'s intervention type distribution to that of the hospital, OBLs were associated with a hypothetical cost savings of $221,219,803 overall and $2602 per case.
CONCLUSIONS: The OBL site of service was associated with greater access to care for non-White patients and a shorter time from diagnosis to treatment, but more frequently performed high-cost interventions compared with the outpatient hospital setting. The benefit to patients from improved access to peripheral artery disease care in OBL settings must be balanced with the potential limitations of receiving differential care.
METHODS: Using 100% Medicare fee-for-service claims data, we identified all patients undergoing PVI for claudication or chronic limb-threatening ischemia (CLTI) between January 2017 and December 2022. We evaluated the associations of patient and procedure characteristics with site of service using multivariable hierarchical logistic regression. We used multinomial regression models to estimate the relative risk ratios (RRRs) of site of service and intervention type (angioplasty, stent, or atherectomy) and intervention anatomic level (iliac, femoropopliteal, or tibial) after adjusting for baseline patient characteristics and clustering by physician.
RESULTS: Of 848,526 PVI, 485,942 (57.3%) were performed in an OBL. OBL use increased significantly over time from 48.3% in 2017 to 65.5% in 2022 (P < .001). Patients treated in OBLs were more likely to be Black (adjusted odds ratio [aOR], 1.14; 95% confidence interval [CI], 1.11-1.18) or other non-White race (aOR, 1.13; 95% CI, 1.08-1.18), have fewer comorbidities, and undergo treatment for claudication vs CLTI (aOR, 1.30; 95% CI, 1.26-1.33) compared with patients treated in outpatient hospital settings. Physicians with majority practice (>50% procedures) in an OBL were more likely to practice in urban settings (aOR, 21.58; 95% CI, 9.31-50.02), specialize in radiology (aOR, 18.15; 95% CI, 8.92- 36.92), and have high-volume PVI practices (aOR, 2.15; 95% CI, 2.10-2.29). The median time from diagnosis to treatment was shorter in OBLs, particularly for patients with CLTI (29 vs 39 days; P < .001). The OBL setting was the strongest predictor of patients receiving an atherectomy alone (adjusted RRR [aRRR] 6.67; 95% CI, 6.59-6.76) or atherectomy + stent (aRRR, 10.84; 95% CI, 10.64-11.05), and these findings were consistent in subgroup analyses stratified by PVI indication. The OBL setting was also associated with higher risk of tibial interventions for both claudication (aRRR, 3.18; 95% CI, 3.11-3.25) and CLTI (aRRR, 1.89; 95% CI, 1.86-1.92). The average reimbursement (including professional and facility fees) was slightly higher for OBLs compared with the hospital ($8742/case vs $8459/case; P < .001). However, in a simulated cohort resetting the OBL\'s intervention type distribution to that of the hospital, OBLs were associated with a hypothetical cost savings of $221,219,803 overall and $2602 per case.
CONCLUSIONS: The OBL site of service was associated with greater access to care for non-White patients and a shorter time from diagnosis to treatment, but more frequently performed high-cost interventions compared with the outpatient hospital setting. The benefit to patients from improved access to peripheral artery disease care in OBL settings must be balanced with the potential limitations of receiving differential care.
摘要：
目的：关于外周动脉疾病（PAD）治疗的不同服务地点的价值和局限性存在争议。我们旨在研究与在办公室实验室（OBL）进行的外周血管干预（PVI）相关的实践模式与使用全国代表性数据库的门诊医院服务站点。
方法：使用100%Medicare按服务收费索赔数据，我们确定了在2017年01月至2022年12月期间接受PVI治疗的所有患者的跛行或慢性威胁肢体缺血(CLTI).我们使用多变量分层逻辑回归评估了患者和手术特征与服务地点的关联。我们使用多项回归模型来估计服务地点和干预类型(血管成形术，支架动脉粥样硬化切除术)和干预水平(髂，股pop骨，胫骨)在调整基线患者特征和医生聚类后。
结果：848,526个PVI，在OBL中进行485,942(57.3%)。随着时间的推移，OBL的使用从2017年的48.3%显著增加到2022年的65.5%(P<0.001)。接受OBL治疗的患者更可能是黑人（aOR1.14，95CI1.11-1.18）或其他非白人种族（aOR1.13，95CI1.08-1.18），有较少的合并症，并接受跛行与CLTI（aOR1.30，95CI1.26-1.33）与在门诊医院接受治疗的患者相比。OBL中具有多数实践（>50％程序）的医师更有可能在城市环境中实践（aOR21.58，95CI9.31-50.02），专门从事放射学（aOR18.15，95CI8.92-36.92），并具有高容量PVI实践(aOR2.15，95CI2.10-2.29)。OBL从诊断到治疗的中位时间较短，特别是CLTI患者（29vs.39天,P<0.001)。OBL设置是接受单独动脉粥样斑块切除术（aRRR6.67，95CI6.59-6.76）或动脉粥样斑块切除术+支架（aRRR10.84，95CI10.64-11.05）的患者的最强预测指标，这些结果在按PVI指征分层的亚组分析中一致.OBL设置也与胫骨跛行(aRRR3.18,95CI3.11-3.25)和CLTI(aRRR1.89,95CI1.86-1.92)介入的风险较高相关。与医院相比，OBL的平均报销(包括手术和设施费)略高($8,742/例与$8,459/例；P<0.001）。然而,在将OBL的干预类型分布重置为医院的模拟队列中，OBL与假设的总体成本节省221,219,803美元和每例2,602美元相关。
结论：OBL服务站点与非白人患者获得护理的机会更大，从诊断到治疗的时间更短，但与门诊医院相比，更频繁地进行高成本的干预措施。在OBL环境中改善获得PAD护理对患者的益处必须与接受差别化护理的潜在局限性相平衡。
方法：使用100%Medicare按服务收费索赔数据，我们确定了在2017年01月至2022年12月期间接受PVI治疗的所有患者的跛行或慢性威胁肢体缺血(CLTI).我们使用多变量分层逻辑回归评估了患者和手术特征与服务地点的关联。我们使用多项回归模型来估计服务地点和干预类型(血管成形术，支架动脉粥样硬化切除术)和干预水平(髂，股pop骨，胫骨)在调整基线患者特征和医生聚类后。
结果：848,526个PVI，在OBL中进行485,942(57.3%)。随着时间的推移，OBL的使用从2017年的48.3%显著增加到2022年的65.5%(P<0.001)。接受OBL治疗的患者更可能是黑人（aOR1.14，95CI1.11-1.18）或其他非白人种族（aOR1.13，95CI1.08-1.18），有较少的合并症，并接受跛行与CLTI（aOR1.30，95CI1.26-1.33）与在门诊医院接受治疗的患者相比。OBL中具有多数实践（>50％程序）的医师更有可能在城市环境中实践（aOR21.58，95CI9.31-50.02），专门从事放射学（aOR18.15，95CI8.92-36.92），并具有高容量PVI实践(aOR2.15，95CI2.10-2.29)。OBL从诊断到治疗的中位时间较短，特别是CLTI患者（29vs.39天,P<0.001)。OBL设置是接受单独动脉粥样斑块切除术（aRRR6.67，95CI6.59-6.76）或动脉粥样斑块切除术+支架（aRRR10.84，95CI10.64-11.05）的患者的最强预测指标，这些结果在按PVI指征分层的亚组分析中一致.OBL设置也与胫骨跛行(aRRR3.18,95CI3.11-3.25)和CLTI(aRRR1.89,95CI1.86-1.92)介入的风险较高相关。与医院相比，OBL的平均报销(包括手术和设施费)略高($8,742/例与$8,459/例；P<0.001）。然而,在将OBL的干预类型分布重置为医院的模拟队列中，OBL与假设的总体成本节省221,219,803美元和每例2,602美元相关。
结论：OBL服务站点与非白人患者获得护理的机会更大，从诊断到治疗的时间更短，但与门诊医院相比，更频繁地进行高成本的干预措施。在OBL环境中改善获得PAD护理对患者的益处必须与接受差别化护理的潜在局限性相平衡。
