How Does Management of Tibial Disease Change in an OBL?

Written by Debra L. Beck, MSc

Currently about one-third of all endovascular procedures and 25% of all lower extremity arterial revascularization procedures are performed in an office-based setting. These numbers are expected to increase by a record setting 5% per year, over the next 10 years.

“The overall market is driven by improved patient access through reduced wait times, reduced procedure times, and improved patient satisfaction scores,” said Bret N. Wiechmann, MD, from Vascular and Interventional Physicians in Gainesville, Florida, in his ISET 2021 talk. “But as the volume of lower extremity procedures increases, CMS is going to be keeping a close eye on things to make sure that we're doing this in a cost-effective manner,” he added.

The question of how the management of tibial artery disease changes in an office-based setting can be approached in a few ways:

Does management change by technique?

In Dr. Wiechmann’s practice, there is no difference in management when treating a patient in the hospital or in an office-based lab. “I use angioplasty for long lesions. I use off-label coronary drug-eluting stents for bailout stenting for suboptimal angioplasty, typically in short- or mid-length lesions in the proximal tubule arteries. And we use atherectomy and plaque modification in specific instances, like heavy calcification or recurrent disease,” he said.
“One notable difference in our approach is that the Tack that we use is not available in the hospital for contractual reasons, but it's readily available in my office-based lab,” said Wiechmann. The Tack Endovascular System is a minimal metal implant for precision dissection repair in the mid/distal popliteal, tibial, and/or peroneal arteries.

Does management change by site of service? 

In data from 2018 on 204 outpatients undergoing endovascular tibial intervention, about 75% of whom had critical limb ischemia, there was no difference in major amputation at 3 years and a trend towards better patency in those treated in an OBL (D’Souza SM, et al. J Endovasc Ther. 2018). “They also noted no difference in 30-day complication rates, as well as 30-day mortality and a statistically significant difference in fewer unplanned admissions for those patients treated in the office space environment,” Wiechmann reported.

Does management change by specialty?

In 2014, the majority of atherectomy cases performed in the office-based lab were performed by vascular surgery and cardiology, with a smaller percentage in interventional radiology and general surgery. A controversial article from early this year looking at data from Medicare reimbursement from 2016 showed that of the 3,100 plus vascular surgeons who received compensation for Medicare for vascular services, the top 1% or 31 of those physicians received 15% of all the Medicare reimbursement (Scheaffer WW, et al. Ann Vasc Surg. 2021). The study looked at the practice pattern differences between the 1% and what they're referring to as the remaining workforce.

“So, in the 1% group, 85% of their payments came from endovascular therapy, and the vast majority of those were patients underwent lower extremity intervention. That differs substantially from the remaining workforce where only 30% of payments came from endovascular therapy,” said Weichmann. Of the lower extremity intervention in the 1% group, 80% of those patients had atherectomy, and that compares substantially differently than the 35% in the remaining workforce who used atherectomy. Forty-four percent of those were performed in the tibial arteries compared to only 27%.

While the 1% received the “vast majority” of their revenue from endovascular intervention, the remaining workforce had a more varied revenue stream, including billings for dialysis access and varicose vein therapy, among others. For some, the OBL is not only for interventional procedures; for others, it is, summarized Wiechmann.

“Switchers” to office-based settings

Another recent study looked at outcomes for 292 physicians who switched primarily from offering peripheral vascular interventions in the hospital-based setting to an OBL (Itoga NK, et al. J Vasc Surg. 2019). Outcomes were compared to a group of control physicians who maintained a primarily hospital-based practice.

A small increase was seen in the OBL switchers in the average number of peripheral vascular interventions per patient and repeat peripheral vascular interventions, along with a small uptick in the number of atherectomies per patient. However, there was also a lower rate of amputation above the ankle in those patients that had switched from hospital-based to office-based, and a significant decrease in hospitalizations as a result.

“Limitations of the study is that it's only a 20% Medicare sample, and the laterality was not captured in this data set. So, in other words, patients that may have been listed as a repeat intervention could have actually been a stage procedure for the opposite leg or a different segment disease,” Wiechmann related.

How does this differ from what we do now?

“We know that the total cost to the healthcare system is something that we always want to consider, and on a per case basis, the cost for similar procedures at the hospital is significantly higher than that of an ASC or an OBL….In fact, it can be anywhere from one third to half the cost for a procedure in the office, as compared to the hospital,” said Weichmann. Outpatient facility reimbursement is 33-50% of hospital reimbursements for similar procedures.

In summary...

Peripheral vascular procedures are migrating quickly to office-based settings. For some, the management may change—in particular, there seems to be a greater use of atherectomy in the office-based setting—but the outcomes do not appear to differ, or if anything, are improved. For the critics of atherectomy, it remains to be seen whether the added cost is justified, said Wiechmann.

“I do believe that the office-based lab provides opportunity for better access to care and a much more efficient system, where you are not subject to the emergency cases or add-on inpatient cases that can occur urgently. The total cost to the healthcare system remains to be seen as the denominator increases. As the trend continues toward moving patients to an outpatient environment, we want to know if the cost savings per case in the OBL in terms of that access and improved efficiency is offset by any added device and procedural costs.”