Justin Bruhn posted: " Metric Category: Appropriateness About the Metric Definition The percentage of patients who underwent peripheral vascular intervention within 6 months after their first claudication diagnosis. Background I" Global Appropriateness Measures
The percentage of patients who underwent peripheral vascular intervention within 6 months after their first claudication diagnosis.
Background
Intermittent claudication refers to a cramping leg pain caused by arterial blood flow obstruction that is exacerbated by exercise and relieved with rest. It is a common condition, especially for patients 65 years and older, but only a small proportion of patients with claudication require revascularization. First-line interventions for claudication include lifestyle modifications (e.g., smoking cessation, exercise) and pharmacology optimization (e.g., statins, antiplatelets). Procedures for claudication are elective and aim to improve function, which is why the Society for Vascular Surgery and Choosing Wisely campaign recommend peripheral vascular intervention be limited to those patients whose severity is lifestyle-limiting and have failed first-line, non-procedural interventions. Early peripheral vascular interventions (e.g., surgical bypass, angiogram, angioplasty, or stent) can worsen profusion and their aggressive use represents overuse without medical necessity.
Metric Ratings
Evidence 4/5 Expert Consensus 5/5 Clinician Buy-in 5/5 Economic Impact 5/5 Reduction in Avoidable Harm 5/5 Applicability to Medicare Data 5/5 Applicability to Medicaid 4/5
The number of patients from the denominator who underwent an aortoiliac (CPT codes: 37220, 37221, 37222, 37223) or femoropopliteal peripheral vascular intervention (CPT codes: 37224, 37225, 37226, 37227) performed by the same physician within 6 months after their first claudication diagnosis (ICD-10-CM codes: I70.201 – I70.213).
Denominator
The number of patients diagnosed with claudication (ICD-10-CM codes: I70.201 – I70.213)for the first time by a given physician during the study period.
Inclusion Criteria
All patients aged 18 years or older who were diagnosed with claudication for the first time during the study period.
Exclusion Criteria
Patients who underwent any aortoiliac or femoropopliteal peripheral vascular intervention (CPT codes: 35472, 35473, 35452, 35454, 35491, 35492, 35474, 35456, 35493, 37205, 37206, 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227) before their first claudication diagnosis (ICD-10-CM codes: I70.201 – I70.219).
Patients with a diagnosis of chronic limb-threatening ischemia (ICD-10-CM codes: I70.22-I70.26, I70.8, I70.92, I72.4, I74.3, I74.5, I75.021, I75.022, L03.115, L03.116, L97, L98.499, I96, E11.52, E11.621, M79.609, M86.9, S91.329A, T81.89XA, T82.868A) before or within 6 months after the first claudication diagnosis ( ICD-10-CM codes: I70.201 – I70.213).
Patients who received the first claudication diagnosis from a nonproceduralist, defined as a physician who did not perform any peripheral vascular intervention during the study period.
Attribution
Physician performing the procedure
Recommended Study Period
2-3 years of data
Denominator Population (patient count)
Include:
✓ Patient age >= 18 at time of diagnosis
✓ Patients with any diagnosis code (ICD10), use primary and secondary codes : I70.201 – I70.213
✓ If there are diagnosis codes on different days for a patient, chose earliest diagnosis date in study period (index event)
✓ Include only claims with the following specialist/taxonomy for the provider: (……..)
Exclude:
✘ Exclude any patient whose first diagnosis (index event) was diagnosed by a "nonproceduralist". Identify a provider as a "nonproceduralist" when the provider has NO CLAIMS with the following procedure CPT Codes in the study period: (37720, 37221, 37222, 37223, 37224, 37225, 37226, 37227)
✘ Exclude any patient with a claim where procedure CPT Code is any of (35472, 35473, 35452, 35454, 35491, 35492, 35474, 35456, 35493, 37205, 37206, 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227) – BEFORE the first diagnosis date (index event)
✘ Exclude any patient with any diagnosis code (I70.22-I70.26, I70.8, I70.92, I72.4, I74.3, I74.5, I75.021, I75.022, L03.115, L03.116, L97, L98.499, I96, E11.52, E11.621, M79.609, M86.9, S91.329A, T81.89XA, T82.868A) – BEFORE or WITHIN 6 MONTHS AFTER first diagnosis date (index event)
Numerator Population (patient count)
Patients from the denominator population who also had claims with the following:
✓ Patient with any CPT procedure codes (37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227) – the procedure must be performed within 6 MONTHS AFTER the index event diagnosis date (denominator service date)
✓ Rendering physician on procedure claim must be the same as the rendering physician for the denominator diagnosis claim
Study period
✓ Recommended Study Period: 2 – 3 Years
✓ Please note that numerator logic requires at least 6 months after denominator diagnosis code date (date of index event)
✓ Please note that for some exclusions at least 6 months are needed prior and post diagnosis code date (date of index event)
✲ Diagnosis codes refer to ICD-10-CM codes. Use all available diagnosis codes, primary and secondary.
✲ Procedure codes refer to CPT Codes.
✲ GAM measures are created for individual physicians (NPI level). The measures are not intended for facilities or physician groups.
GAM Thresholds
GAM establishes clinical thresholds using the input of key physician leaders within a specialty and the GAM clinical team. GAM utilizes an elaborate consensus building process with final adjudication by our leadership team.
Sample Size: 10+
This threshold applies to a clinician with minimum number of 10 cases
Pattern of Concern: 5-15%
This constitutes the clinical threshold for a "pattern of concern"
Outlier: >15%
This constitutes the clinical threshold for an "outlier"
Authors describe their claims data analysis which revealed that early peripheral vascular intervention (PVI) for claudication occurred more frequently in ambulatory surgery centers or offices. Data also demonstrated increased incidence of early PVI for physicians who were male, had fewer years in practice, practice in rural locations, and saw fewer cases of claudication in practice.
Overview of recommendations from the Society for Vascular Surgery (SVS) that are consistent with the societies' guidelines and summarize procedures that should not, or should only rarely, be performed.
Authors evaluated 13 years of data for more than 16,000 patients and found that most treated with an endovascular approach did not meet guideline criteria for long-term freedom from recurrent intermittent claudication and preprocedural optimization of medical management was lacking for many.
Publication describing the intermittent claudication patterns for commercially insured non-Medicare patients which revealed shorter treatment times to intervention, many patients receiving multiple interventions, and increasing utilization of atherectomy, especially in the outpatient setting.
Article describes the authors' evaluation of Medicare claims data which demonstrated that black patients residing in low-income counties across the United States had significantly higher odds of undergoing peripheral vascular interventions (PVI) for claudication. PVI rates were higher for low-income counties, regardless of race.
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