Increasingly, health plans, employers, and accreditation agencies are looking for providers of “valued care.” However, the definition of this term is still elusive among payers, employers, consumers, and regulators in markets around the world. Even more importantly, the precise relationship between cost and quality is not yet established in many fields of medicine. As practitioners who perform endovascular procedures that often utilize advanced (and costly) technology, we are at the forefront of this discussion.

In the superficial femoral artery (SFA), we now have multiple technologies that can be used and randomized trials demonstrating the benefits of some of these approaches. However, there remains a disconnect in that many of the approval trials excluded the most common lesions we treat. We also lack head-to-head comparisons of advanced technology beyond that of basic angioplasty. Some institutions have gone so far as to remove physicians from the procurement process, thus limiting choice by cost, while others are attempting data-driven cost containment.

Certainly, there are different physician-based and institutional care drivers based on facility locations, which have led to regional or site-based treatment approaches, as evidenced by the extensive and climbing use of atherectomy in office-based labs in the United States and the decreased utilization of this same technology in the hospital setting. Similar findings are seen with atherectomy devices in Europe, where they are frequently used in “reimbursement countries” and rarely or not used at all in “nonreimbursement countries.”

American physicians often look to their European colleagues, who typically have access to devices years before those in the United States, for a possible idea as to the future landscape, and this is true both from a technologic standpoint and possibly that of reimbursement. However, there is no one predictive model, as there are many different usage patterns among various countries that have “universal health care.”

As the Guest Chief Medical Editors of this issue of Endovascular Today, we tried to take a global look at several key elements of the discussion of which factors truly drive SFA care. Our goal was to engage true experts in candid discussions and take controversy head on, including interviews with physicians on the front lines dealing with quality metrics and reimbursement for treatment, as well as what to expect from tomorrow’s iterative advances in technology. For example, we explored a leading vascular physician’s new role as hospital president, where a multitude of different care drivers are encountered. We looked at regional differences in care delivery based on reimbursement models. We sought practical input on how to define and treat real-world calcified lesions, as well as develop credentialing standards for these cases. We asked for help better understanding confounding factors such as the nature of calcium and how it is evaluated and scored. We invited insights into how today’s multitude of device options are best combined, including in vessel preparation and pairing balloon and stenting therapies, with and without drug coatings, and we sought opinions as to what we can expect from the next generation of drug delivery.

These are just a few of the many questions that will shape the future of SFA therapy. It is vital that we hold all involved to a high standard, including practitioners, providers, payers, and industry—as well as patients. We hope this issue emphasizes the need to further develop the relationship between efficiency measures and quality measures to separate true health care efficiency and value from cost of care.

Gary M. Ansel, MD, FACC
Koen Deloose, MD

Guest Chief Medical Editors