Vogel Todd R, Dombrovskiy Viktor Y, Carson Jeffrey L, Haser Paul B, Graham Alan M
Division of Vascular Surgery, The Surgical Outcomes Research Group, Robert Wood Johnson Medical School, The University of Medicine and Dentistry, New Brunswick, New Jersey 08903-0019, USA.
J Vasc Surg. 2009 Dec;50(6):1320-4; discussion 1324-5. doi: 10.1016/j.jvs.2009.07.112. Epub 2009 Oct 17.
Lower extremity percutaneous transluminal angioplasty (LE PTA) is currently performed by a variety of endovascular specialists. We hypothesized that cardiologists (CRD) and vascular surgeons (VAS) may have different practice patterns, indications for intervention, and hospital resource utilization.
Using the State Inpatient Databases for New Jersey (2003-2007), patients with elective admission undergoing PTA procedures with indications of claudication, rest pain, and gangrene/ulceration were examined. Physician specialty was determined based on all procedures performed. We contrasted by specialty, the indication for LE PTA for the procedure, volume, and hospital resource utilization.
Of the 1887 cases of LE PTA, VAS performed 866 (45.9%) and CRD 1021 (54.1%) procedures. The mean patient age was 68.0 years (CRD) vs 70.7 years (VAS), P = .0163. Indications for intervention were compared for CRD vs VAS: claudication 80.7% vs 60.7%, (P < .002); rest pain 6.2% vs 16.0%, (P < .002); gangrene/ulceration 13.1% vs 23.3%, (P < .002). Stents (64.8% of cases) were utilized similarly among physicians (P = .18), and mean hospital length of stay were similar (2.38 days vs 2.41 days, P = .85). Hospital charges by indication varied between CRD vs VAS (all procedures: $49,748 vs $42,158 [P < .0001]). Revenue center charges were different between CRD vs VAS: medical surgical supply $19,128 vs $12,737, (P < .0001); pharmacy $1,959 vs $1,115, (P < .0001). Only 10.7% of CRD were high volume practitioners, compared with 36.8% among VAS (P < .05). High volume practitioners had significantly lower hospital charges ($41,730 vs $51,014, P < .001).
Cardiologists performing lower extremity angioplasty were more likely to treat patients with claudication than those with rest pain or gangrene/ulceration. Despite treating younger patients with less severe peripheral vascular disease, cardiologists used significantly greater hospital resources. High practitioner volume, regardless of specialty, was associated with lower hospital resource utilization. Reducing variations in indication and practitioner volume may offer substantial cost savings for lower extremity endovascular interventions.
目前下肢经皮腔内血管成形术（LE PTA）由多种血管腔内治疗专家实施。我们推测心脏病专家（CRD）和血管外科医生（VAS）可能有不同的操作模式、干预指征及医院资源利用情况。
利用新泽西州住院患者数据库（2003 - 2007年），对因间歇性跛行、静息痛和坏疽/溃疡等指征接受PTA手术的择期入院患者进行检查。根据所实施的所有手术确定医生专业。我们按专业对比了LE PTA手术的指征、手术量及医院资源利用情况。
在1887例LE PTA病例中，VAS实施了866例（45.9%），CRD实施了1021例（54.1%）手术。患者平均年龄为68.0岁（CRD）对比70.7岁（VAS），P = 0.0163。对比CRD和VAS的干预指征：间歇性跛行分别为80.7%和60.7%，（P < 0.002）；静息痛分别为6.2%和16.0%，（P < 0.002）；坏疽/溃疡分别为13.1%和23.3%，（P < 0.002）。医生之间使用支架的情况相似（占病例的64.8%）（P = 0.18），平均住院天数也相似（2.38天对比2.41天，P = 0.85）。不同指征的医院收费在CRD和VAS之间有所不同（所有手术：49,748美元对比42,158美元[P < 0.0001]）。CRD和VAS在收入中心收费方面存在差异：医疗手术用品分别为19,128美元和12,737美元，（P < 0.0001）；药房分别为1,959美元和1,115美元，（P < 0.0001）。CRD中只有10.7%是高手术量从业者，而VAS中这一比例为36.8%（P < 0.05）。高手术量从业者的医院收费显著更低（41,730美元对比51,014美元，P < 0.001）。
与治疗静息痛或坏疽/溃疡的患者相比，实施下肢血管成形术的心脏病专家更倾向于治疗间歇性跛行患者。尽管心脏病专家治疗的是外周血管疾病较轻的年轻患者，但他们使用的医院资源显著更多。无论专业如何，高手术量从业者与较低的医院资源利用相关。减少指征和从业者手术量的差异可能为下肢血管腔内干预带来可观的成本节约。
