Assessment of Patterns of Atherectomy Use

Background

Atherectomy has become the fastest growing catheter‐based peripheral vascular intervention performed in the United States, and overuse has been linked to increased reimbursement, but the patterns of use have not been well characterized.

Methods and Results

We used Blue Cross Blue Shield of Michigan Preferred Provider Organization and Medicare fee‐for‐service professional claims data from the Michigan Value Collaborative for patients undergoing office‐based laboratory atherectomy in 2019 to calculate provider‐specific rates of atherectomy use, reimbursement, number of vessels treated, and number of atherectomies per patient. We also calculated the rate that each provider converted a new patient visit to an endovascular procedure within 90 days. Correlations between parameters were assessed with simple linear regression. Providers completing ≥20 office‐based laboratory atherectomies and ≥20 new patient evaluations during the study period were included. A total of 59 providers performing 4060 office‐based laboratory atherectomies were included. Median professional reimbursement per procedure was $4671.56 (interquartile range [IQR], $2403.09–$7723.19) from Blue Cross Blue Shield of Michigan and $14 854.49 (IQR, $9414.80–$18 816.33) from Medicare, whereas total professional reimbursement from both payers ranged from $2452 to $6 880 402 per year. Median 90‐day conversion rate was 5.0% (IQR, 2.5%–10.0%), whereas the median provider‐level average number of vessels treated per patient was 1.20 (IQR, 1.13–1.31) and the median provider‐level average number of treatments per patient was 1.38 (IQR, 1.26–1.63). Total annual reimbursement for each provider was directly correlated with new patient‐procedure conversion rate ( R 2 =0.47; P <0.001), mean number of vessels treated per patient ( R 2 =0.31; P <0.001), and mean number of treatments per patient ( R 2 =0.33; P <0.001).

Conclusions

A minority of providers perform most procedures and are reimbursed substantially more per procedure compared with most providers. Procedural conversion rate, number of vessels, and number of treatments per patient represent potential policy levers to curb overuse.

Tissue-engineered autologous grafts for facial bone reconstruction

Facial deformities require precise reconstruction of the appearance and function of the original tissue. The current standard of care-the use of bone harvested from another region in the body-has major limitations, including pain and comorbidities associated with surgery. We have engineered one of the most geometrically complex facial bones by using autologous stromal/stem cells, native bovine bone matrix, and a perfusion bioreactor for the growth and transport of living grafts, without bone morphogenetic proteins. The ramus-condyle unit, the most eminent load-bearing bone in the skull, was reconstructed using an image-guided personalized approach in skeletally mature Yucatán minipigs (human-scale preclinical model). We used clinically approved decellularized bovine trabecular bone as a scaffolding material and crafted it into an anatomically correct shape using image-guided micromilling to fit the defect. Autologous adipose-derived stromal/stem cells were seeded into the scaffold and cultured in perfusion for 3 weeks in a specialized bioreactor to form immature bone tissue. Six months after implantation, the engineered grafts maintained their anatomical structure, integrated with native tissues, and generated greater volume of new bone and greater vascular infiltration than either nonseeded anatomical scaffolds or untreated defects. This translational study demonstrates feasibility of facial bone reconstruction using autologous, anatomically shaped, living grafts formed in vitro, and presents a platform for personalized bone tissue engineering.