Why the OBL/ASC Is Critical in the Treatment of the CLI Patient

On Saturday morning, interventional radiologist Dr Bret Wiechmann presented a discussion about the importance of office-based labs (OBLs) and ambulatory surgery centers (ASCs) when treating patients with critical limb ischemia (CLI). He began by reviewing the statistics on the numbers of people worldwide with peripheral arterial disease (PAD) and CLI: 202 million worldwide have PAD, and 11% of those have CLI. Dr Wiechmann then presented information on regional variations in the care of those who undergo amputation, along with the geographic distribution of vascular surgeons. 

Talking about access to care, Dr Wiechmann noted that financial barriers, transportation issues, lack of awareness/knowledge, and variation in care lead to amputations. Quoting from a 2011 article by Henry et al in the Journal of Vascular Surgery, he said that “race, income, and insurance status are useful indicators of socioeconomic status and access to care. … patients who identify as Black or Native American, have low income, and those who have Medicare or Medicaid are at higher risk for major amputations … these findings suggest there are gaps in access to care.” 

Looking at trends in office-based intervention, Dr Wiechmann noted that currently, outpatient facilities perform approximately 25% of all lower extremity arterial revascularization procedures in the United States; one-third of all endovascular procedures (448K/1.3M) are done in a nonhospital setting, with a 4.7% compound annual growth rate over 10 years. As the volume of OBL lower extremity procedures increase, the Centers for Medicare and Medicaid Services will place a greater scrutiny on payments to ensure cost-effectiveness.

Dr Wiechmann spoke of the advantages of OBLs, stating that they have fewer layers of bureaucracy, fewer administrative processes, and fewer unnecessary delays, as well as less inertia and inactivity and less cost.

“In 2023, it’s no longer about ‘can we do this?’,” Dr Wiechmann concluded. “It’s about providing more access to expert vascular care.” Hospitals are no longer able to handle the volume of CLTI patients and are often short staffed. An increasingly older patient population with CLTI means there are limited bodies to do the work (patient:provider mismatch). 

OBLs and ASCs are an agile solution, with more physician autonomy, a potentially broader reach than hospitals, and higher patient satisfaction. OBLs as a site of service for CLTI provide more access to care for CLTI patients, especially those in rural areas and those with low socioeconomic status. OBLs and ASCs make good clinical sense for CLTI patients and good financial sense for the healthcare system.