Responding to the NYT on the PAD controversy

On January 30, the New York Times published “Medicare Payments Surge for Stents to Unblock Blood Vessels in Limbs,” which questioned the medical necessity of many in-office interventions for peripheral artery disease and the motives of some doctors who perform them. (If you haven’t already, I encourage you to read the article at http://vsweb.org/NYTstents.)

Times reporters Julie Creswell and Reed Abelson analyzed Medicare payments, finding that the top 10 billing cardiologists made about half their Medicare reimbursements from office-based peripheral arterial procedures, with the implication that some doctors were taking advantage of an unregulated site-of-service.

The problem, though, goes beyond a handful of top billers. According to a citation from the Advisory Board Company, while the “number of procedures to open blockages in heart vessels fell by about 30 percent from 2005 to 2013…[o]ver the same time, the number of similar procedures for vessels outside the heart soared by almost 70 percent.”

The article struck a nerve. For several days, it was one of the most emailed articles on the New York Times website, and hundreds of SVS members throughout the world emailed us. Members were particularly outraged at the financial abuses reported. Many mentioned that they themselves had witnessed inappropriate care for asymptomatic PAD patients.

It was clear from the emails I received that our members want SVS to be on the right side of this issue, advocating for appropriate treatment of patients with PAD, and it makes me proud to be part of this community.

Over the past year, SVS has taken steps to address the issue of appropriateness.

Last June at our Vascular Annual Meeting, SVS held the Crawford Forum to discuss how we as a society can develop mechanisms to support appropriate vascular care and ethical decision-making. If you missed it, you can watch the entire symposium online at http://vsweb.org/Crawford.

Our Clinical Practice Council has seized upon appropriate care in office-based facilities as its current project and is working on constructive suggestions to ensure that site-of-service is not only convenient to patients but also provides high-quality, appropriate care.

Last month, we published in the Journal for Vascular Surgery “Practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication,” which emphasize inexpensive physiologic testing in diagnosing PAD and conservative measures such as risk-factor modification and exercise in treating asymptomatic patients and claudicants. You can review the guidelines at http://vsweb.org/LEguidelines.

In addition, our recommendations for Choosing Wisely, a program of the American Board of Internal Medicine Foundation to curb unnecessary tests and treatment, warns against stents and other non-surgical and surgical interventions in asymptomatic patients and claudicants until conservative treatments have been tried. SVS is also partnering with Consumer Reports to educate patients about this issue this spring.

Finally, SVS has partnered with several international vascular societies on the Global Vascular Guidelines for critical limb ischemia and recently agreed to participate in a multi-societal collaboration to develop guidelines for the management of PAD.

There is more work to do. Next month’s Vascular Specialist will include some of the feedback we received from our members as well as suggestions on how SVS can develop criteria for appropriateness. To share your thoughts, please email me at [email protected].

What follows is the text of the Lawrence letter to the New York Times:

To the Editor:

Most of my colleagues in vascular medicine want to provide the best treatment for their patients, but those who don’t should be exposed, as was done in “Medicare Bills Rise for Stents Put Into Limbs” (front page, Jan. 30). This article shows how inappropriate care can harm a patient and greatly increase the cost of health care, while grossly enhancing the income of those who overuse procedures.

Office-based procedures are not inherently bad, if standards for appropriate care are followed. The Society for Vascular Surgery recently held a national symposium to discuss ways to discourage inappropriate use of vascular procedures, and recently, we published evidence-based practice guidelines to encourage appropriate care of peripheral arterial disease.

These guidelines emphasize conservative measures as the first line of treatment for patients without symptoms or with vascular pain only when walking, reserving interventions and surgery for those with more severe problems. They also recommend inexpensive, noninvasive tests to determine whether the pain is truly vascular. These tests should be used in every patient.

Practice guidelines set standards for our members, but all physicians treating patients with vascular disease should also use them. Vascular specialists need an in-depth understanding of vascular disease, as well as technical skill, but they also need the ethics to treat patients like a brother or a sister, not the source of payment for a new car.

PETER F. LAWRENCE, Los Angeles

The writer, chief of vascular surgery at U.C.L.A., is president of the Society for Vascular Surgery.

On January 30, the New York Times published “Medicare Payments Surge for Stents to Unblock Blood Vessels in Limbs,” which questioned the medical necessity of many in-office interventions for peripheral artery disease and the motives of some doctors who perform them. (If you haven’t already, I encourage you to read the article at http://vsweb.org/NYTstents.)

Times reporters Julie Creswell and Reed Abelson analyzed Medicare payments, finding that the top 10 billing cardiologists made about half their Medicare reimbursements from office-based peripheral arterial procedures, with the implication that some doctors were taking advantage of an unregulated site-of-service.

The problem, though, goes beyond a handful of top billers. According to a citation from the Advisory Board Company, while the “number of procedures to open blockages in heart vessels fell by about 30 percent from 2005 to 2013…[o]ver the same time, the number of similar procedures for vessels outside the heart soared by almost 70 percent.”

The article struck a nerve. For several days, it was one of the most emailed articles on the New York Times website, and hundreds of SVS members throughout the world emailed us. Members were particularly outraged at the financial abuses reported. Many mentioned that they themselves had witnessed inappropriate care for asymptomatic PAD patients.

It was clear from the emails I received that our members want SVS to be on the right side of this issue, advocating for appropriate treatment of patients with PAD, and it makes me proud to be part of this community.

Over the past year, SVS has taken steps to address the issue of appropriateness.

Last June at our Vascular Annual Meeting, SVS held the Crawford Forum to discuss how we as a society can develop mechanisms to support appropriate vascular care and ethical decision-making. If you missed it, you can watch the entire symposium online at http://vsweb.org/Crawford.

Our Clinical Practice Council has seized upon appropriate care in office-based facilities as its current project and is working on constructive suggestions to ensure that site-of-service is not only convenient to patients but also provides high-quality, appropriate care.

Last month, we published in the Journal for Vascular Surgery “Practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication,” which emphasize inexpensive physiologic testing in diagnosing PAD and conservative measures such as risk-factor modification and exercise in treating asymptomatic patients and claudicants. You can review the guidelines at http://vsweb.org/LEguidelines.

In addition, our recommendations for Choosing Wisely, a program of the American Board of Internal Medicine Foundation to curb unnecessary tests and treatment, warns against stents and other non-surgical and surgical interventions in asymptomatic patients and claudicants until conservative treatments have been tried. SVS is also partnering with Consumer Reports to educate patients about this issue this spring.

Finally, SVS has partnered with several international vascular societies on the Global Vascular Guidelines for critical limb ischemia and recently agreed to participate in a multi-societal collaboration to develop guidelines for the management of PAD.

There is more work to do. Next month’s Vascular Specialist will include some of the feedback we received from our members as well as suggestions on how SVS can develop criteria for appropriateness. To share your thoughts, please email me at [email protected].

What follows is the text of the Lawrence letter to the New York Times:

To the Editor:

Most of my colleagues in vascular medicine want to provide the best treatment for their patients, but those who don’t should be exposed, as was done in “Medicare Bills Rise for Stents Put Into Limbs” (front page, Jan. 30). This article shows how inappropriate care can harm a patient and greatly increase the cost of health care, while grossly enhancing the income of those who overuse procedures.

Office-based procedures are not inherently bad, if standards for appropriate care are followed. The Society for Vascular Surgery recently held a national symposium to discuss ways to discourage inappropriate use of vascular procedures, and recently, we published evidence-based practice guidelines to encourage appropriate care of peripheral arterial disease.

These guidelines emphasize conservative measures as the first line of treatment for patients without symptoms or with vascular pain only when walking, reserving interventions and surgery for those with more severe problems. They also recommend inexpensive, noninvasive tests to determine whether the pain is truly vascular. These tests should be used in every patient.

Practice guidelines set standards for our members, but all physicians treating patients with vascular disease should also use them. Vascular specialists need an in-depth understanding of vascular disease, as well as technical skill, but they also need the ethics to treat patients like a brother or a sister, not the source of payment for a new car.

PETER F. LAWRENCE, Los Angeles

The writer, chief of vascular surgery at U.C.L.A., is president of the Society for Vascular Surgery.

On January 30, the New York Times published “Medicare Payments Surge for Stents to Unblock Blood Vessels in Limbs,” which questioned the medical necessity of many in-office interventions for peripheral artery disease and the motives of some doctors who perform them. (If you haven’t already, I encourage you to read the article at http://vsweb.org/NYTstents.)

Times reporters Julie Creswell and Reed Abelson analyzed Medicare payments, finding that the top 10 billing cardiologists made about half their Medicare reimbursements from office-based peripheral arterial procedures, with the implication that some doctors were taking advantage of an unregulated site-of-service.

The problem, though, goes beyond a handful of top billers. According to a citation from the Advisory Board Company, while the “number of procedures to open blockages in heart vessels fell by about 30 percent from 2005 to 2013…[o]ver the same time, the number of similar procedures for vessels outside the heart soared by almost 70 percent.”

The article struck a nerve. For several days, it was one of the most emailed articles on the New York Times website, and hundreds of SVS members throughout the world emailed us. Members were particularly outraged at the financial abuses reported. Many mentioned that they themselves had witnessed inappropriate care for asymptomatic PAD patients.

It was clear from the emails I received that our members want SVS to be on the right side of this issue, advocating for appropriate treatment of patients with PAD, and it makes me proud to be part of this community.

Over the past year, SVS has taken steps to address the issue of appropriateness.

Last June at our Vascular Annual Meeting, SVS held the Crawford Forum to discuss how we as a society can develop mechanisms to support appropriate vascular care and ethical decision-making. If you missed it, you can watch the entire symposium online at http://vsweb.org/Crawford.

Our Clinical Practice Council has seized upon appropriate care in office-based facilities as its current project and is working on constructive suggestions to ensure that site-of-service is not only convenient to patients but also provides high-quality, appropriate care.

Last month, we published in the Journal for Vascular Surgery “Practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication,” which emphasize inexpensive physiologic testing in diagnosing PAD and conservative measures such as risk-factor modification and exercise in treating asymptomatic patients and claudicants. You can review the guidelines at http://vsweb.org/LEguidelines.

In addition, our recommendations for Choosing Wisely, a program of the American Board of Internal Medicine Foundation to curb unnecessary tests and treatment, warns against stents and other non-surgical and surgical interventions in asymptomatic patients and claudicants until conservative treatments have been tried. SVS is also partnering with Consumer Reports to educate patients about this issue this spring.

Finally, SVS has partnered with several international vascular societies on the Global Vascular Guidelines for critical limb ischemia and recently agreed to participate in a multi-societal collaboration to develop guidelines for the management of PAD.

There is more work to do. Next month’s Vascular Specialist will include some of the feedback we received from our members as well as suggestions on how SVS can develop criteria for appropriateness. To share your thoughts, please email me at [email protected].

What follows is the text of the Lawrence letter to the New York Times:

To the Editor:

Most of my colleagues in vascular medicine want to provide the best treatment for their patients, but those who don’t should be exposed, as was done in “Medicare Bills Rise for Stents Put Into Limbs” (front page, Jan. 30). This article shows how inappropriate care can harm a patient and greatly increase the cost of health care, while grossly enhancing the income of those who overuse procedures.

Office-based procedures are not inherently bad, if standards for appropriate care are followed. The Society for Vascular Surgery recently held a national symposium to discuss ways to discourage inappropriate use of vascular procedures, and recently, we published evidence-based practice guidelines to encourage appropriate care of peripheral arterial disease.

These guidelines emphasize conservative measures as the first line of treatment for patients without symptoms or with vascular pain only when walking, reserving interventions and surgery for those with more severe problems. They also recommend inexpensive, noninvasive tests to determine whether the pain is truly vascular. These tests should be used in every patient.

Practice guidelines set standards for our members, but all physicians treating patients with vascular disease should also use them. Vascular specialists need an in-depth understanding of vascular disease, as well as technical skill, but they also need the ethics to treat patients like a brother or a sister, not the source of payment for a new car.

PETER F. LAWRENCE, Los Angeles

The writer, chief of vascular surgery at U.C.L.A., is president of the Society for Vascular Surgery.