Association of Clinical Setting With Sociodemographics and Outcomes Following Endovascular Femoropopliteal Artery Revascularization in the United States.

IF 6.9 2区 医学
Aishwarya Raja, Rishi K Wadhera, Eunhee Choi, Siyan Chen, Changyu Shen, Jose F Figueroa, Robert W Yeh, Eric A Secemsky
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引用次数: 0

Abstract

Background: After the Centers for Medicare and Medicaid Services modified reimbursement rates for outpatient peripheral vascular intervention in 2008 with the intent of improving access to care, providers began to increasingly perform peripheral vascular interventions in privately owned office-based clinics. Little is known about the characteristics of patients treated in this setting and their long-term outcomes as compared with those treated in hospital-based centers.

Methods: In this retrospective cohort study, Medicare beneficiaries ≥66 years undergoing outpatient femoropopliteal peripheral vascular interventions in office-based clinics and hospital-based centers from 2015 to 2017 were identified. Sociodemographics, comorbidities, and institutional characteristics were compared across sites. Multivariable Cox proportional hazards models were used to estimate the adjusted associations between practice site location and outcomes. The primary outcome was the composite of major amputation or death analyzed through the end of follow-up.

Results: Among 134 869 patients, 29.9% were treated in office-based clinics and 70.1% in hospital-based centers. Patients treated in office-based clinics were more often Black (16.9% versus 11.9%), dually enrolled in Medicaid (26.3% versus 19.6%), and residents of lower-resourced regions (32.6% versus 25.6%). Over a median follow-up time of 800 days (interquartile range, 531-1119 days), patients treated in office-based clinics had reduced risks of major amputation or death compared with outpatients treated in hospital-based centers (hazard ratio, 0.92 [95% CI, 0.89-0.95]). They also had lower adjusted all-cause mortality (hazard ratio, 0.93 [95% CI, 0.90-0.96]), major lower extremity amputation (hazard ratio, 0.84 [95% CI, 0.79-0.89]), and all-cause hospitalization (hazard ratio, 0.86 [95% CI, 0.84-0.88]). These findings persisted after stratification by critical limb ischemia, race, dual enrollment, and regional socioeconomic status, as well as among operators treating patients in both clinical settings.

Conclusions: In this large nationwide analysis of Medicare beneficiaries, office-based clinics treated a more socioeconomically disadvantaged population compared with hospital-based centers. Long-term outcomes were comparable between locations. As such, these clinics appear to be selecting lower-risk patients for outpatient peripheral vascular interventions, although there remains the possibility of unmeasured confounding.

美国血管内股骨头动脉血运重建术后临床环境与社会人口统计学特征和疗效的关系。
背景:2008 年,美国联邦医疗保险与医疗补助服务中心(Centers for Medicare and Medicaid Services)为提高医疗服务的可及性,调整了门诊外周血管介入治疗的报销比例,此后,越来越多的医疗机构开始在私人诊所进行外周血管介入治疗。与在医院中心接受治疗的患者相比,人们对在这种环境下接受治疗的患者的特征及其长期疗效知之甚少:在这项回顾性队列研究中,确定了 2015 年至 2017 年期间在门诊诊所和医院中心接受股骨头外周血管介入治疗的≥66 岁的医疗保险受益人。对不同地点的社会人口统计学、合并症和机构特征进行了比较。采用多变量 Cox 比例危险模型来估计执业地点与结果之间的调整关联。主要结果是随访结束时分析的主要截肢或死亡的复合结果:在134 869名患者中,29.9%在诊所接受治疗,70.1%在医院中心接受治疗。在诊所接受治疗的患者多为黑人(16.9% 对 11.9%)、双重医疗补助(26.3% 对 19.6%)和资源较少地区的居民(32.6% 对 25.6%)。中位随访时间为 800 天(四分位间范围为 531-1119 天),与在医院中心接受治疗的门诊患者相比,在诊所接受治疗的患者发生大截肢或死亡的风险较低(危险比为 0.92 [95% CI, 0.89-0.95])。他们的调整后全因死亡率(危险比为 0.93 [95% CI,0.90-0.96])、主要下肢截肢率(危险比为 0.84 [95% CI,0.79-0.89])和全因住院率(危险比为 0.86 [95% CI,0.84-0.88])也更低。按严重肢体缺血、种族、双重参保、地区社会经济状况以及在两种临床环境中治疗患者的操作者进行分层后,这些结果依然存在:在这项针对医疗保险受益人的全国性大型分析中,与医院中心相比,诊所治疗的社会经济地位较低的人群更多。不同地点的长期疗效相当。因此,这些诊所似乎选择了风险较低的患者进行门诊外周血管介入治疗,尽管仍有可能存在未测量的混杂因素。
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来源期刊
Circulation. Cardiovascular Quality and Outcomes
Circulation. Cardiovascular Quality and Outcomes Medicine-Cardiology and Cardiovascular Medicine
CiteScore
9.80
自引率
2.90%
发文量
357
期刊介绍: Circulation: Cardiovascular Quality and Outcomes, an American Heart Association journal, publishes articles related to improving cardiovascular health and health care. Content includes original research, reviews, and case studies relevant to clinical decision-making and healthcare policy. The online-only journal is dedicated to furthering the mission of promoting safe, effective, efficient, equitable, timely, and patient-centered care. Through its articles and contributions, the journal equips you with the knowledge you need to improve clinical care and population health, and allows you to engage in scholarly activities of consequence to the health of the public. Circulation: Cardiovascular Quality and Outcomes considers the following types of articles: Original Research Articles, Data Reports, Methods Papers, Cardiovascular Perspectives, Care Innovations, Novel Statistical Methods, Policy Briefs, Data Visualizations, and Caregiver or Patient Viewpoints.
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