Patients with IC found to receive more “aggressive” surgical management in high-competition regions

Demonstrating the “susceptibility” of care delivery to regional market competition, M Libby Weaver (University of Virginia Health System, Charlottesville, USA) recently presented the case that intermittent claudication (IC) is a “novel and underdefined” driver of practice variation in management of patients.

SPEAKING AT THE 2023 SOUTHERN Association for Vascular Surgery (SAVS) annual meeting (18–21 January, Rio Grande, Puerto Rico), Weaver began by outlining guidelines set out by the Society for Vascular Surgery (SVS), who published recent appropriate use criteria for the management of

IC, which recommends best medical therapy (BMT) and lifestyle modifications as first-line treatments prior to revascularisation.

Atherectomy and tibial-level interventions are specifically “advised against” in the treatment of IC, the presenter noted. Despite guidelines, Weaver continued, high market competition is incentivising physicians to treat patients by aggressive means. She noted how two thirds of interventional procedures for claudication include revascularisation and atherectomy, with an indication of claudication as a “predictor” of independent atherectomy use. Although characteristics such as physician specialty and practice setting have “known” associations with atherectomy and tibial interventions, Weaver made it clear that the causal relationship between IC management and regional competition has “not been explored”.

Examining IC patients undergoing initial endovascular peripheral vascular intervention (PVI) in the SVS Vascular Quality Initiative (VQI) from 2010–2022, the researchers assigned the HerfindahlHirschman Index (HHI)—a measure of regional physician market competition—to each centre based on Census Core-Based Statistical Area, assigning four predefined categories: very high competition (VHC), high competition (HC), moderate competition (MC), and low competition (LC).

VSGBI President’s Symposium spotlights data-driven financial incentives for PAD revascularisation

The President’s Symposium at the 2022 Vascular Society of Great Britain and Ireland (VSGBI) annual scientific meeting (23–25 November, Brighton, UK) featured Rob Sayers’ (University of Leicester, Leicester, UK) presentation titled ‘CLTI CQUIN has raised the profile of PAD and will lead to fewer amputations’. Sayers’ take-home message for delegates was that the National Health Service’s (NHS) Commissioning for Quality and Innovation (CQUIN) for chronic limb-threatening ischaemia (CLTI) will prove a valuable package of measures when it comes to raising awareness of peripheral arterial disease (PAD) and improving outcomes for patients, but that the question now lies in “how best we measure [these improvements]”.

THE CQUIN, SAYERS BEGAN BY outlining, was started in April 2022, and the premise of it is for the NHS to give “financial rewards for excellence [in the hope] that that translates into better patient outcomes”. The presenter noted, with relevance to the VSGBI audience, that their society had made sure to inform all its members of the CQUIN at its launch, and that the society’s own PAD quality improvement framework (QIF) is complementary in its patient outcome focus.

Then providing background to the CQUIN process, Sayers shared that “you are more likely to be successful if your bid is patient-focused [and it is easy to implement],” adding that it is “competitive”. The resulting financial incentive that a successful bid bestows “depends on the size of your unit,” Sayers proceeded, and in the case of the CLTI CQUIN, “most [units] will receive between £500,000 and £1.5 million”.

Speaking to the merits of the CLTI

CQUIN, Sayers described it as a “wellwritten and clear proposal,” adding that there are benefits for patients. Moreover, the successful application could perhaps be set against the backdrop of “a lot of support from the NHS for various vascular services [… which were] particularly hard-hit by the pandemic.”

Regarding the conditions of the CLTI CQUIN funding, “it requires you to revascularise patients within five days of referral,” Sayers detailed for the symposium audience. “If you revascularise 60% of your patients within five days, you get the full payment and if you revascularise less than 40% you do not get any money at all”. The amount awarded for achieving results in between these benchmark figures is graduated, Sayers expanded.

Data monitoring is key to the CQUIN’s operation, delegates then heard. This is carried out “by local commissioners who compare data such as HES [Hospital Episode

Their inclusion criteria identified 24,669 PVIs, revealing patients undergoing PVI in LC regions were more likely to be younger, white race, self-paid/ uninsured, and active smokers. Continuing, Weaver drew awareness to the “distinct treatment patterns” that became apparent when analysing index peripheral procedures, noting that the odds of patients being on BMT increased with greater market competition, designating a 1.07 increase per class step up in competition quartile.

The probability of undergoing aortoiliac interventions also decreased with increasing competition, but their results showed higher odds of receiving tibial and multi-level interventions in VHC versus LC centres. Primary stenting decreased as competition increased, while likelihood of undergoing atherectomy increased with HC. In subgroup analysis limited to patients undergoing single-artery femoropopliteal intervention with TASC A or B lesions, compliance with BMT remained higher and current smoking status lower in VHC centres. However, odds of undergoing balloon angioplasty and primary stenting only were higher in LC/MC/HC centres, while likelihood of receiving atherectomy remained significantly higher among VHC centres, suggesting disease severity is not a primary driver of these treatment differences, Weaver noted.

Statistics], and NVR [National Vascular Registry…] so if you were tempted to underreport, that would be spotted,” Sayers cautioned.

Moving on to address how the CQUIN can help patients, Sayers underlined that the goal is to “raise awareness of PAD and the PAD QIF, and CLTI, among clinicians and managers”. This then increases the chance of reinvestment to improve services, such as limb salvage clinics.

As of April 2023, the CQUIN will be up for renewal, Sayers conveyed, and the decision will be based on a number of factors, including whether participating units themselves “found [it] worthwhile”. However, there are limitations when it comes to how successful the CQUIN may be at achieving improved outcomes: “It requires very reliable data capture,” Sayers admitted. It “may [also be argued that] the targets are challenging” and “not particularly evidence-based,” he furthered.

Sayers rounded off his presentation by taking a long and wide view of VSGBI’s role in putting patients at the heart of members’ work and calling future presidents to prioritise data gathering to facilitate this. Maintaining relationships with exam boards so that the specialty adheres to “very good” professional standards was also among

Sayers’ pieces of advice. “There is no doubt that the society needs to continue to foster its good relationship with NHS England,” he asserted, before opining that “work with commissioners” can “no doubt” serve as a solution to the problem of the post-COVID-19 vascular services backlog.

Audience questions centred on data monitoring and the quality of datasets, which reflected Sayers’ message that this is pivotal in the success of measures like those comprising the CLTI CQUIN.

In addition, Sayers was posed the question of whether “in order to ensure the development and appropriate investment in CLTI management, do you think some units will need to take one for the team and fail?” The presenter responded by referring to the “current data” from the CQUIN— “there are 55 units in England that are eligible for the CQUIN scheme [of whom] about 10–12 are currently below the threshold of 40% and [there are] probably another 5% [whose data] we do not [have]”. He reiterated that the CQUIN is “about improving your service to improve outcomes for patients”, and concluded, therefore, that those units that are currently falling short have the choice “whether they want to try to improve things for patients,” rather than it being about ‘taking one for the team’.