Reintervention Following Outpatient Peripheral Artery Disease Procedures: Trading Convenience for Value?

Peripheral artery disease (PAD) represents a high volume, high-cost burden on the healthcare system. The Centers for Medicare and Medicaid Services has developed Bundled Payments Care Improvement-Advanced program, in which single payment is provided all services to be administered postsurgical 90-day episode of care. Factors associated with 30- reinterventions after PAD interventions would represent useful data both payors stake holders. We conducted national cohort study adults 65 years older Vascular Quality Initiative linked dataset who underwent an open, endovascular, or hybrid revascularization procedure between January 1, 2010, December 31, 2018. Procedures acute limb ischemia aneurysm indications were excluded. primary outcome was reintervention 30-day secondary outcome. Covariates interest included demographic, comorbidities, patient facility level characteristics. Multivariable Cox regression used determine association patient- facility-level characteristics risk reinterventions. Among 42,429 patients (71.3% 23.3% 5.4% hybrid), median (interquartile range) age 74 range, 69-80 years), 58.9% male, 84.3% White. Chronic limb-threatening operative indication 56.4%; 42.8% procedures completed outpatient setting (40.3% outpatient, 2.5% office-based laboratory). More than 70% chronic as inpatient, while 60% claudication done outpatient. rate 5.5% 14.5%. Compared inpatient procedures, laboratory had significantly higher rates (ref, inpatient; reintervention: hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.62-2.24]; HR, 1.41; CI, 1.25-1.60); 3.54; 3.17-3.94]; reintervention, 2.09; 1.82-2.41) Open approaches demonstrated lower compared endovascular at 30 90 days and, aortoiliac disease, other anatomic segments but no difference noted (Table). Although may convenient providers, significant subsequent reintervention. Additional work needed understand how improve longevity interventions.TableMultivariable analysis factors reinterventionsCovariate30-Day reintervention90-Day reinterventionAdjusted ratio95% intervalAdjusted intervalStandard demographics Age 70-74 vs 65-690.950.891.020.990.951.04 75-79 65-690.950.841.090.950.881.03 80-84 65-691.000.841.190.950.861.05 ≥85 65-690.990.911.080.880.820.94 Female male0.760.690.830.870.820.92 Non-White White1.050.931.191.050.971.14Comorbidities BMI ≥30 <300.950.871.030.930.890.98 Coronary disease0.990.881.121.101.041.15 Congestive heart failure0.990.891.090.940.890.99 obstructive pulmonary disease1.040.971.131.081.011.16 Diabetes mellitus1.030.941.141.050.991.10 ESRD dialysis1.461.311.631.381.261.50 Hypertension1.070.931.241.090.981.22 Microvascular disease1.010.901.141.010.921.11 Current smoker nonsmoker1.130.991.300.980.911.06 Prior nonsmoker1.080.971.201.010.941.08Patient-level Ischemic rest pain claudication1.171.011.361.101.001.20 Tissue loss claudication1.110.991.241.070.991.15 Femoropopliteal aortoiliac1.050.911.211.241.151.35 Tibial aortoiliac0.930.771.111.311.191.45 Aortoiliac + any outflow aortoiliac1.140.961.351.381.251.51 tibial aortoiliac1.030.821.301.341.171.54 LER0.930.851.020.990.941.04 Ambulation assistance ambulatory1.121.011.241.080.981.18 Wheelchair/bedridden ambulatory0.880.731.060.870.790.96 Homeless home0.000.000.000.430.111.67 Nursing home home0.880.681.140.820.730.91Facility-level Office/clinic inpatient3.543.173.942.091.822.41 Outpatient inpatient1.901.612.241.411.251.60 Hybrid endovascular0.440.340.580.740.650.85 endovascular0.460.380.560.780.690.89 Year 2013-2015 2010-20121.020.781.321.120.981.27 2016-2018 2010-20120.930.671.291.040.901.20 Distance care 5-10 miles <5 miles1.030.941.131.020.951.11 >10-20 miles1.000.881.140.980.901.07 >20-40 miles1.070.921.251.040.941.15 >40-60 miles1.070.911.271.050.941.18 >60 miles0.860.661.120.960.841.11BMI, body mass index; LER, extremity revascularization; ESRD, end stage renal disease.All variables table are model. new tab