August 11, 2021

Supervised Exercise Therapy for PAD Not Widely Adopted Despite Reimbursement Approval and Guideline Recommendation

August 11, 2021—In a recent research letter published in Circulation: Cardiovascular Quality and Outcomes, Divakaran et al reported low utilization of supervised exercise therapy (SET) after reimbursement approval by the Centers for Medicare & Medicaid Services (CMS).

Key Findings

Medicare beneficiaries with symptomatic PAD were found to have low use of SET within the first 19 months after CMS reimbursement approval, despite a class IA guideline endorsement.
More effort is needed to increase enrollment and improve adherence for SET as a treatment option for patients with PAD.
During the study period, patients who underwent SET (n = 1,735) were significantly less likely to need endovascular or surgical revascularization when compared with a matched cohort (n = 6,940) (P < .001 for both).

SET has been shown to help patients reduce their symptoms and improve walking performance.¹ The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines gave it a class IA guideline endorsement in their 2016 guidelines for the management of patients with lower extremity peripheral artery disease (PAD).¹

Divakaran et al aimed to assess the uptake of SET as a treatment for PAD following its May 2017 approval for reimbursement by CMS for beneficiaries with intermittent claudication. Data were gathered from CMS between June 1, 2017, and December 31, 2018. A total of 129,699 patients were diagnosed with intermittent claudication during this period. Of that group, 1,735 (1.3%) were enrolled in SET. Only 89 (5.1%) of patients undergoing SET completed the full 36-session program.

Compared with patients not enrolled in SET (n = 127,964), the SET cohort was slightly older, more likely to be White, less likely to be Black, and less likely to be female.

Median follow-up was shorter for SET patients (153 days; interquartile range [IQR], 77-252 days) versus non-SET patients (244 days; IQR, 130-362 days).

The impact of SET was highlighted in a matched cohort analysis (n = 6,940 patients). Patients treated with SET had a significantly lower rate of endovascular (hazard ratio [HR], 0.49; 95% CI, 0.40-0.60; P < .001) or surgical (HR, 0.27; 95% CI, 0.18-0.42; P < .001) revascularization than the matched cohort group without SET.

Given the results of this analysis, study investigators suggested greater effort is needed to both increase enrollment and improve adherence to SET across the United States.

1. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e726–e779. doi: 10.1161/CIR. 0000000000000471

ENDOVASCULAR TODAY ASKS…

Lead author Sanjay Divakaran, MD, Associate Physician, Division of Cardiovascular Medicine at Brigham and Women’s Hospital, and co-author Eric Secemsky, MD, Director of Vascular Intervention at Beth Israel Deaconess Medical Center in Boston, Massachusetts, provided some further insight into what the study results mean for increased use of and adherence to SET, as well as plans for future studies on SET.

What type of campaign do you think would be most effective to further educate providers and patients on the reimbursement and benefit for SET when treating PAD?

Dr. Divakaran: We need a multipronged approach to increase awareness of all aspects of SET. Campaign strategies include informational material in clinics, procedure rooms, and hospital wards; continuing medical education courses for health care providers (including primary care providers and cardiovascular and vascular specialists); and patient-facing education opportunities such as support groups and home mailings from centers that provide SET and from insurers.

You note that even when patients were prescribed SET, few patients completed the full program. What potential options could be used to aid patients in following through with this plan?

Dr. Divakaran: There are many barriers that patients face for completing SET programs. The list includes competing work and family obligations/schedules, insurance co-payments, and inconvenient/few locations. If we can dramatically increase the number of available SET programs, we are likely to increase the probability that a more convenient location is available to a specific patient. Eliminating co-payments for patients is essential for improvement in access. Finally, we can learn how to incorporate telemedicine from cardiac and other rehabilitation programs to increase access and improve convenience.

What plans do you have for future studies surrounding SET?

Dr. Secemsky: We clearly need greater investment in establishing SET programs. Our study provides an opportunity to understand the early adoption of this program in the United States after reimbursement was approved, and we intend to continue this evaluation moving forward. Furthermore, we are very interested in examining real-world outcomes related to SET, as well as determining whether all PAD patients have equitable access to this important intervention.

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