Overuse of early peripheral vascular interventions for claudication
Overuse of early peripheral vascular interventions for claudication
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DOI：
10.1016/j.jvs.2019.05.005
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发表时间：
2020-01-01
影响因子：
4.3
通讯作者：
Makary, Martin A.
中科院分区：
文献类型：
--
作者：
Hicks, Caitlin W.;Holscher, Courtenay M.;Makary, Martin A.
目的：血管外科学会和“明智选择”运动的指南建议，仅在药物和运动疗法试验失败后，才将外周血管介入治疗 (PVI) 仅限于有生活方式限制症状的跛行患者。我们试图探索新的跛行诊断后与早期 PVI 相关的实践模式和医生特征，以评估对这些指南的遵守情况。方法：我们使用 100% 医疗保险按服务付费索赔来识别 2015 年至 2017 年间首次诊断为跛行的患者。早期 PVI 被定义为在初次跛行诊断后 6 个月内进行的主髂或股腘 PVI。计算了在研究期间诊断出> 10名跛行患者并至少进行过一次PVI（无论适应症）的医生的医生级PVI利用率。使用分层多变量逻辑回归来确定与早期 PVI 相关的医生层面因素。结果：在研究期间首次诊断为跛行的 194,974 名患者中，6286 名 (3.2%) 接受了早期 PVI。在参与分析的 5664 名医生中，医生级别早期 PVI 率中位数较低，为 0%（范围为 0%-58.3%）。然而，有 320 名医生 (5.6%) 的早期 PVI 率 >= 14%（高于平均值 >= 2 个标准差）。考虑到患者特征后，门诊手术中心或办公室环境中提供的服务比例越高，PVI 使用率越高（相对于 0%-22%；23%-47%：调整后优势比 [aOR]，1.23；48%-68%：aOR，1.49；69%-100%：aOR，1.72；所有 P < .05）。与高 PVI 使用率独立相关的其他风险调整医生因素包括男性（aOR，2.04）、执业年数较少（对比 >= 31 年；11-20 岁：aOR，1.23；21-30 岁：aOR，1.13）、农村地区（aOR，1.25）和较少的跛行实践量（对比研究期间诊断的 >= 30 名患者；
Objective: Guidelines from the Society for Vascular Surgery and the Choosing Wisely campaign recommend that peripheral vascular interventions (PVIs) be limited to claudication patients with lifestyle-limiting symptoms only after a failed trial of medical and exercise therapy. We sought to explore practice patterns and physician characteristics associated with early PVI after a new claudication diagnosis to evaluate adherence to these guidelines.Methods: We used 100% Medicare fee-for-service claims to identify patients diagnosed with claudication for the first time between 2015 and 2017. Early PVI was defined as an aortoiliac or femoropopliteal PVI performed within 6 months of initial claudication diagnosis. A physician-level PVI utilization rate was calculated for physicians who diagnosed >10 claudication patients and performed at least one PVI (regardless of indication) during the study period. Hierarchical multivariable logistic regression was used to identify physician-level factors associated with early PVI.Results: Of 194,974 patients who had a first-time diagnosis of claudication during the study period, 6286 (3.2%) underwent early PVI. Among the 5664 physicians included in the analysis, the median physician-level early PVI rate was low at 0% (range, 0%-58.3%). However, there were 320 physicians (5.6%) who had an early PVI rate >= 14% (>= 2 standard deviations above the mean). After accounting for patient characteristics, a higher percentage of services delivered in ambulatory surgery center or office settings was associated with higher PVI utilization (vs 0%-22%; 23%-47%: adjusted odds ratio [aOR], 1.23; 48%-68%: aOR, 1.49; 69%-100%: aOR, 1.72; all P < .05). Other risk-adjusted physician factors independently associated with high PVI utilization included male sex (aOR, 2.04), fewer years in practice (vs >= 31 years; 11-20 years: aOR, 1.23; 21-30 years: aOR, 1.13), rural location (aOR, 1.25), and lower volume claudication practice (vs >= 30 patients diagnosed during study period;