Endovenous Therapy Procedures for Lower Extremity Venous Disease Increasingly Performed by Nonvascular Specialties


March 20, 2019—A recent study of Medicare beneficiaries found that endovenous therapy (EVT) procedures are being increasingly performed by physicians not traditionally associated with the treatment of venous disease. The study was published by John T. Baber Jr, MD, et al in the Journal of Vascular Surgery (JVS): Venous and Lymphatic Disorders (2019;7:203–209).

Data were compiled from the Medicare Provider Utilization and Payment Data Public Use Files (2012–2014). These data were evaluated to identify all Medicare beneficiaries treated for lower extremity venous reflux using laser or radiofrequency ablation techniques.

For this study, the researchers developed a new measure called a “utilization index” (UI) to evaluate treatment intensity of providers. The UI is calculated as the average number of EVT procedures performed per patient per year. Using these data, the researchers were able to report UI numbers for each provider, specialty, and site of service (facility vs outpatient) that performed EVT procedures during the study period.

Within the study period, 2,828 providers performed 405,232 EVT procedures. Researchers found that vascular surgeons performed the most EVT procedures (22.6%), followed by cardiologists (19.3%), general surgeons (13.5%), radiologists (9.3%), and other surgical specialties (7.7%). However, the data also revealed that nearly 30% of EVT procedures had been performed by providers not typically associated with vascular procedures, including podiatrists, dermatologists, and orthopedic surgeons, among many others. Most EVT procedures were performed in an outpatient versus an inpatient setting (94% vs 6%).

Using the UI data, the study authors found the average number of EVT procedures ranged from one to four per patient per year. Among all specialties evaluated, vascular surgeons had the lowest UI at 1.32. An online-only supplementary figure shows the numbers of EVT providers in the study by training specialty, as well as the mean UI and standard deviation for each specialty.

A multivariate regression analysis was performed to identify provider characteristics associated with a UI above the 75th percentile, defined as UI > 1.8. The factor that most strongly correlated with a high UI was a high annual volume of EVT procedures (odds ratio [OR], 8.68; confidence interval [CI], 7.59–9.91), according to the researchers. Other factors strongly associated with a high UI included delivery service in an outpatient setting (OR, 2.62; CI, 1.97–3.47) and training in a field other than surgery, cardiology, or radiology (OR, 3.35; CI, 2.74–4.09).

In an announcement from the Society for Vascular Surgery (SVS), Dr. Baber, first author of the study commented, “This relatively newfound interest in venous disease may be a result of the comparatively high reimbursement relative to the effort for outpatient venous procedures."

In JVS: Venous and Lymphatic Disorders, the authors highlighted a take-home message for the study: “This study indicates that high-volume providers and those not traditionally associated with management of lower extremity chronic venous disease are more likely to perform more EVT procedures per patient and raises the question of financially driven, potentially inappropriate utilization of EVT.”

Dr. Baber reiterated this message in the SVS announcement. “These [nonvascular] providers treat venous disease with greater intensity, with an average UI that is significantly higher than those who specialize in venous disease. In light of the comparatively high reimbursements for endovenous procedures, it would be naïve to attribute this variation to anything other than financial motivations.”


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