Participation by radiologists and other specialists in percutaneous vascular and nonvascular interventions: findings from a seven-state database

Nationwide Trends in Tube-Related Genitourinary Interventions for Medicare Beneficiaries

PURPOSE

To evaluate national trends in tube-related genitourinary interventions, with specific attention to primary operator specialty.

METHODS

Using a 5% national sample of Medicare claims data from 2005 to 2015, all claims associated with nephrostomy tube, nephro-ureteral tube, and ureteral stent placement and exchange were identified. The annual volume of the nine billable procedures were analyzed to evaluate trends in the number of procedures performed and primary operator specialty over time. The Charleston Comorbidity Index (CCI) was used to evaluate patient comorbidities and to determine differences in patient populations treated by interventional radiologists and urologists.

RESULTS

The total volume of tube-related genitourinary interventions has increased over the course of the study period, representing 455.0 services per 100,000 Medicare Fee-for-Service beneficiaries in 2005 to 607.2 services in 2015, an increase of 33.4%. Interventional radiologists performed the majority of all procedures in all procedure types and for each year (>90%) with the exception of nephro-ureteral catheter placement or ureteral stent placement, for which urologists performed the overwhelming majority of procedures each year (>85%). Interventional radiologists performed 63% of their total number of procedures on patients with a CCI = 3 or higher, and urologists performed 42% of their total number of procedures on patients with a CCI = 3 or higher (P < .01).

CONCLUSION

Tube-related genitourinary interventions have demonstrated persistent growth over the 2005 to 2015 decade. Interventional radiologists are the dominant providers for the majority of these interventions compared with urologists while delivering care to a patient population with a higher number of comorbidities.

Evaluation of the Statewide Variability in the Current Role of Different Specialties in Lower Extremity Endovascular Revascularization for Medicare Beneficiaries

PURPOSE

To evaluate the statewide variability in the role of different specialties in lower extremity endovascular revascularization (LEER) and associated submitted charges of care and actual reimbursement for Medicare beneficiaries.

METHODS

The 2015 "Medicare Provider Utilization and Payment Data: Physician and Other Supplier" data includes provider-specific information regarding the type of service, submitted average charges of care, and actual average Medicare reimbursements per Healthcare Common Procedure Coding System (HCPCS) code per provider. All HCPCS codes related to LEER were identified. The role of vascular surgery (VS), interventional cardiology (IC), and interventional radiology (IR) in each HCPCS-specific intervention was investigated.

RESULTS

In 2015, 4113 providers submitted claims for iliac (n = 13,659), femoropopliteal (n = 52,344), and tibioperoneal (n = 32,688) endovascular revascularizations. In the facility setting, VS performed most of these procedures (52%), followed by IC (32%) and IR (8%). In the outpatient-based lab setting, the proportions were 46%, 36%, and 13%, respectively. Substantial statewide variability in the role of different specialties in LEER was noted. In Maine, Vermont, and Hawaii, all facility claims were submitted by VS, while more than 70% of the claims in Arizona and Utah were submitted by IC. The highest share of LEER for IR was observed in Montana and North Dakota (50%). There was substantial statewide variability in the submitted charges.

CONCLUSION

Currently, less than 10% of LEER procedures are being performed by IR. The statewide variability in the submitted charges of care by providers and actual reimbursement for Medicare beneficiaries were investigated in this study.

Evolving roles of radiologists, nephrologists, and surgeons in endovascular hemodialysis access maintenance procedures

PURPOSE

The aim of this study was to evaluate the changing relative roles of radiologists, nephrologists, and surgeons performing endovascular hemodialysis access maintenance procedures.

METHODS

Medicare Physician Supplier Procedure Summary Master Files from 2001 through 2008 were analyzed for procedure codes for hemodialysis access angiography, angioplasty, percutaneous thrombectomy, and open surgical interventions. Using physician specialty code data, component procedure volume for all 3 endovascular services was extracted for radiologists, nephrologists, and surgeons. Percentage changes were calculated for all groups. National trends in percutaneous and open interventions were compared.

RESULTS

Between 2001 and 2008, the total Medicare fee-for-service component procedure volume for dialysis access angiography, angioplasty, and percutaneous thrombectomy increased by 102%, 171%, and 52%, respectively. In 2008, radiologists performed 50% of angiography, 47% of angioplasty, and 46% of declotting procedures, down from 82%, 82%, and 84%, respectively, in 2001. In contrast, nephrologists increased from 4%, 5%, and 4% to 22%, 27%, and 21% of services, and surgeons increased from 7%, 5%, and 4% to 22%, 19%, and 16%. As percutaneous procedures increased in frequency, open surgical interventions declined by 43%.

CONCLUSION

Nationally, endovascular hemodialysis access maintenance procedures have increased as open surgical interventions have declined. Nephrologists and surgeons have both experienced marked relative increases in endovascular procedure volumes as radiologists, previously by far the predominant providers of these services, now only perform approximately half.

National fluid shifts: fifteen-year trends in paracentesis and thoracentesis procedures

PURPOSE

The aim of this study was to evaluate national trends in paracentesis and thoracentesis procedures and the relative roles of specialty groups providing these services.

METHODS

Medicare Physician Supplier Procedure Summary Master Files from 1993 to 2008 were analyzed for paracentesis and thoracentesis procedure codes. Using physician specialty identifier codes, procedure volumes were extracted for radiologists, primary care physicians, and surgeons for both procedures. Volume data were extracted for gastroenterologists and pulmonary and critical care medicine physicians, respectively, for paracentesis and thoracentesis. Frequency by site of service was similarly evaluated. Relative changes were calculated.

RESULTS

Between 1993 and 2008, paracentesis procedures on Medicare fee-for-service beneficiaries increased by 133% (from 64,371 to 149,699), and thoracentesis procedures decreased by 14% (from 147,363 to 127,444). Services by radiologists increased by 964% (from 10,456 to 111,275) and 358% (from 14,531 to 66,602), respectively, while all other targeted groups experienced declines. For paracentesis, radiologist and gastroenterologist procedure shares changed from 16% and 32%, respectively, in 1993 to 74% and 6% in 2008. For thoracentesis, radiologist and pulmonary and critical care medicine physician shares changed from 10% and 49% to 52% and 27%. Relative shifts in site of service to the hospital outpatient setting occurred for both procedures.

CONCLUSIONS

Since 1993, paracentesis procedures on Medicare beneficiaries have more than doubled, while thoracentesis volumes have declined slightly. Radiologists now far exceed gastroenterologists and pulmonary and critical care medicine physicians, respectively, as the predominant providers of these services. Those shifts are likely attributable to both the incremental safety of imaging guidance and also the unfavorable economics of these procedures.

One-stage tubeless antegrade ureteric stenting: a safe and cost-effective option?

INTRODUCTION

Antegrade insertion of ureteric stent has become an established mode of management of upper tract obstruction secondary to ureteric pathology. It is conventionally performed as a two-stage procedure for various reasons but, more recently, a one-stage approach has been adopted.

PATIENTS AND METHODS

We discuss our experience of primary one-stage insertion of antegrade ureteric stent as a safe and cost-effective option for the management of these difficult cases in this retrospective observational case cohort study of patients referred to a radiology department for decompression of obstructed upper tracts. Data were retrieved from case notes and a radiology database for patients undergoing one-stage and two-stage antegrade stenting. It was followed by telephone survey of regional centres about the prevalent local practice for antegrade stenting. Outcome measures like hospital stay, procedural costs, requirement of analgesia/antimicrobials and complication rates were compared for the two approaches.

RESULTS

a one-stage approach was found to be suitable in most cases with many advantages over the two-stage approach with comparable or better outcomes at lower costs. Some of the limitations of the study were retrospective data collection, more than one radiologist performing stenting procedures and non-availability of interventional radiologist falsely raising the incidence of two-stage procedures.

CONCLUSIONS

In the absence of any clinical contra-indications and subject to availability of an interventional radiologist's support, one-stage antegrade stenting could easily be adopted as a routine approach for the management of benign or malignant ureteric obstruction.

The changing roles of radiologists, cardiologists, and vascular surgeons in percutaneous peripheral arterial interventions during a recent five-year interval

PURPOSE

This study aimed to determine the relative roles of radiologists, cardiologists, vascular surgeons, and other physicians in performing percutaneous peripheral arterial interventions and how these roles have changed over a recent 5-year period.

METHODS AND MATERIALS

The authors reviewed the Medicare Part B fee-for-service databases between 1997 and 2002 for the Current Procedural Terminology (4th ed.) (CPT-4) surgical procedure codes for percutaneous transluminal angioplasty (PTA) of noncardiac peripheral arteries (six codes), the transcatheter placement of noncardiac intravascular stents (two codes), and endovascular aortic stent graft placement (six codes). Using the Medicare physician specialty codes, procedure volume in each CPT-4 code was determined for radiologists, cardiologists, vascular surgeons, and other physicians. Percentage changes from 1997 to 2002 were calculated for PTA and intravascular stent placement procedures.

RESULTS

Between 1997 and 2002, the total Medicare procedure volume in the eight procedure codes relating to PTA and stent placement increased by 95%. In 2002, radiologists performed 72,657 of these procedures, cardiologists 62,901, vascular surgeons 17,895, and other physicians 19,666. Over the 5-year interval, procedure volume among radiologists increased 29%, among cardiologists by 181%, among vascular surgeons by 398%, and among other physicians by 195%. Radiologists' share in the total pool of procedures in 2002 was 42.0% (down from 63.3% in 1997), cardiologists' 36.3% (up from 25.2% in 1997), vascular surgeons' 10.3% (up from 4.0% in 1997), and other physicians' 11.4% (up from 7.5% in 1997). Trend data were not available for endovascular aortic stent graft procedures.

CONCLUSION

Between 1997 and 2002, procedure volume in percutaneous peripheral arterial interventions grew at faster rates among cardiologists, vascular surgeons, and other physicians than it did among radiologists. As a result, radiologists' share of this market declined during the interval. However, procedure volume among radiologists continued to grow over the 5 years, and in 2002, they still had the largest share among the four physician specialty groups. Thus, despite the erosion, interventional radiologists still maintain a strong position in this rapidly growing field.

National trends in gastrointestinal access procedures: an analysis of Medicare services provided by radiologists and other specialists

PURPOSE

To evaluate national trends in enteral access services by radiologists and other specialists.

MATERIALS AND METHODS

Medicare data from 1997 to 2000 were analyzed for trends in gastrointestinal access services. Current Procedural Terminology codes for gastrostomy placement and maintenance services were selected. Utilization was analyzed by physician specialty. Targeted service analysis was performed for interventional radiologists.

RESULTS

For sampled enteral access procedures, annual services to Medicare beneficiaries increased from 279,509 to 283,353 (+1.4%). These were most often performed by gastroenterologists (48.6%), surgeons (25.1%), radiologists (7.4%), and others (18.9%). Total procedures by radiologists increased 29.6% whereas procedures by gastroenterologists, surgeons, and other nonradiologists changed +6.9%, -4.9%, and -10.2%, respectively. For new gastrostomy accesses, radiologist volume increased 46.9% whereas gastroenterologist, surgeon, and other volumes changed +7.9%, -5.0%, and -21.5%, respectively. For maintenance services, radiologist volume increased 21.8% whereas gastroenterologist, surgeon, and other volumes changed +3.1%, -4.7%, and +7.9%, respectively. Analyzed for frequency, relative value, and physician time, enteral access services account for less than 1% of all services provided by interventional radiologists.

CONCLUSIONS

Although the number of gastrointestinal access services provided to Medicare beneficiaries has remained static, radiologists have experienced a marked relative increase in volume, particularly for new gastrostomy procedures. This increase is largely at the expense of surgeons and other nongastroenterologists. However, radiologists still provide only a small portion of gastrointestinal access services nationwide, and these services account for only a small portion of all procedures performed by interventionalists. Therefore, the potential for enteral access service growth in interventional radiology is high.

Clinical services in interventional radiology: results from the national Medicare database and a Society of Interventional Radiology membership survey

PURPOSE

To evaluate trends in evaluation and management (E & M) services performed by interventional radiologists.

MATERIALS AND METHODS

Recent national Medicare physician utilization data (1997-2000) were analyzed for trends in E & M services provided by interventional radiologists. The results were evaluated in conjunction with a recent Society of Interventional Radiology (SIR) membership survey in which 165 interventional radiology (IR) practices answered questions about clinical service issues.

RESULTS

Despite the perception of frequent clinical services by interventional radiologists, paid Medicare claims for E & M services have increased only minimally, from 9,472 to 9,662 (+2.0%), and have lagged behind non-E & M procedural services, which have increased from 2,283,111 to 2,527,323 (+10.7%). The relative value unit (RVU) impact of E & M encounters has increased from 14,422 to 14,893 (+3.2%) while the RVU impact of procedural services has increased from 2,262,991 to 3,723,486 (+64.5%). E & M services account for only 0.39% of all Medicare claims, 0.49% of service RVUs, and 0.68% of all reimbursable time spent by interventionalists. However, when surveyed, interventional radiologists perceived that E & M services are much more frequent: 92% provide clinical services and indicate that 6.6% +/- 5.4 of physician time is spent providing E & M services.

CONCLUSION

Despite perceptions by interventional radiologists that E & M services are common, Medicare claims for such services are infrequent and growth lags behind that of IR services overall. These discrepancies may be explained in part by practice and billing infrastructures that do not effectively translate actual clinical services into successful claims.