Adding more fuel to the atherectomy fire

In this issue of the Journal of Vascular Surgery, Brown et al¹ publish data from the 2014 Medicare Provider Utilization and Payment Data Public Use File showing a rapid increase in the use of peripheral vascular interventions (PVI) in many hospital referral regions. This shift was significantly correlated with changes in PVI payments, which were mostly driven by changes in atherectomy payments, and most prominent among office-based laboratories (OBLs). Overall, their data show that physicians who practice in OBLs are much more likely to use atherectomy and receive higher reimbursement than physicians that practice in the hospital setting, and that the rapid increase in PVI use we have seen in recent years is driven largely by high reimbursement behaviors.

This article is one in a recent series of publications about the purported overuse of atherectomy that dissenters interpret as eschewing the use of atherectomy technology.^2-5 As one of the authors of those publications, I can assure you that this is not the case. Atherectomy has its time and place; it is even endorsed by the 2018 Society for Cardiovascular Angiography and Interventions as an appropriate adjunct for treating highly calcified lesions in the femoropopliteal segment.⁶ Within the United States, the average physician uses atherectomy in 55% of his or her femoropopliteal PVI cases.⁵ That said, the repeated evidence showing strong associations of atherectomy—which is reimbursed nearly 300% times higher than stent in the outpatient setting—are concerning.¹

The physicians who try to argue that the association of atherectomy with OBLs (and by extension, reimbursement) is just a coincidence tend to offer one of three rationalizations. First, they suggest that high-volume users of atherectomy are treating patients who specifically benefit from atherectomy. However, the use of atherectomy is significantly higher for patients being treated for claudication than for patients being treated for chronic limb-threatening ischemia.⁵ Second, there is an argument that the high levels of atherectomy use only affect nonvascular surgeons. This is simply not true—the rate of atherectomy growth is approximately the same for vascular surgeons compared with cardiologists.² Finally, some physicians argue that atherectomy results in better outcomes. However, numerous studies have failed to show a benefit of atherectomy for the treatment of PAD over either plain balloon angioplasty, drug-coated balloon angioplasty, or stenting.^7,8 Atherectomy has also been associated with a higher risk for major adverse limb events and amputation in real-world settings.⁹

Based on the data provided by Brown et al,¹ the question of whether atherectomy is being overused by some individuals is no longer up for debate. Now there is a much bigger question—what to do about it. The Centers for Medicare and Medicaid Services are no doubt aware of the patterns and reimbursement concerns around atherectomy, and it is important that we make a coordinated move to address the issue before it is addressed for us. The use of individualized physician report cards may be one way to do this; if we can inform high-volume users that they are operating outside the range of normal, perhaps we can bring outlier use down closer to the median.¹⁰ The development of an OBL certification program may help; a joint initiative between the Society for Vascular Surgery and the American College of Surgeons is currently in the works. It is also critical that the Society for Vascular Surgery publish professional guidelines about the appropriate use of atherectomy and other controversial technologies in the treatment of peripheral artery disease. If we can use the data presented here to come together as a society rather than reinciting old arguments, we will commit to taking a major step toward providing patients with the best care possible, and expecting our peers to do the same.