Balancing Quality and Quantity in Optimizing Health Care Resource Utilization

We applaud the efforts of Stonko and colleagues¹ to improve health care resource utilization in the treatment of chronic venous insufficiency. The investigators provided peer-benchmarked reports to all Medicare physicians who performed endovenous thermal ablation (EVTA), placing each physician’s EVTA use per patient in a percentile relative to their peers. Stonko and colleagues¹ describe their report card intervention as a quality improvement initiative that is associated with a significant reduction in waste related to the use of EVTA.

The Institute of Medicine defines health care quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”² The Institute of Medicine further defines health care quality as having 6 domains: effectiveness, efficiency, equity, patient centeredness, safety and timeliness; effectiveness is defined as “providing care processes and achieving outcomes as supported by scientific evidence.”²

The Society for Vascular Surgery (SVS) and American Venous Forum (AVF) Clinical Practice Guidelines (CPGs) for the care of patients with varicose veins and associated chronic venous diseases support treatment of all pathological sources of venous hypertension in advanced venous disease states to promote ulcer healing, prevent recurrence, and improve quality of life.³ The CPGs recommend classifying patients using the Clinical Manifestations, Etiology, Anatomic Distribution and Pathophysiology (CEAP) classification, the most widely accepted system for classifying chronic venous insufficiency. Treatment recommendations and guidelines for chronic venous insufficiency are most often based on the Clinical Manifestations (C) portion of CEAP. C0 disease is no visible or palpable signs of venous disease, and C1 is telangiectasias or reticular veins. The SVS/AVF CPGs do not support the treatment of C0 or C1 disease. C2 disease is varicose veins (≥3 mm), and C3 is edema. For C2 to C3 disease, the SVS/AVF CPGs recommend EVTA over conservative therapy on the basis of superior cost-effectiveness and patient quality of life with EVTA. C4a is skin pigmentation, C4b is lipodermatosclerotic changes, C5 is healed venous ulcer, and C6 is active venous ulcer. For C4 to C6 disease, the SVS Venous Ulcer CPGs recommend ablation of all incompetent superficial veins, in addition to standard compressive therapy, to prevent, treat, and reduce risk of recurrence of venous ulceration.⁴

Despite treatment recommendations being based on CEAP classification, diagnosis billing codes, such as the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) coding system used by Stonko and colleagues,¹ do not correlate with CEAP classification and often are vague. For example, ICD-10 code I87393 is “chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity.”⁵ The authors classified the diagnosis codes into 2 categories: (1) pain, swelling, and inflammation, and (2) ulceration.¹ Although swelling is consistent with C3 and inflammation could be considered C4a and/or C4b, patients with pain could be any C class. The vague nature of the ICD-10 codes makes the true severity of chronic venous insufficiency in the patients included in this study largely unknown.

More than 5% of patients with chronic venous insufficiency present with advanced stage disease (CEAP ≥3), of whom more than 90% have multimodal reflux involving more than 1 superficial vein (great saphenous vein, short saphenous vein, anterior accessory saphenous vein, and/or perforator).⁶ Repetitive care of the consequences of untreated venous reflux in patients with CEAP C4 to C6 disease encompasses nearly 2% of US health care spending.⁴ In the present study,¹ more than 90% of procedures were performed for pain (unclear C), swelling (C3), or inflammation (C4). Thus, with the exception of the indication of pain (for which the C classification is unclear), this cohort is consistent with the 5% of patients who present with advanced chronic venous insufficiency. As the literature indicates, most of these patients have multimodal reflux and thus the more than 3.4 EVTAs per patient performed by the 69 (4.4%) outlier physicians in this study may be reasonable.¹

Related to quality in health care is the concept of appropriateness. The RAND Corporation defines appropriateness as, “The expected health benefit (e.g., increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g., mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin that the procedure is worth doing, exclusive of cost.”⁷ Both underuse (failure to deliver a health service that is appropriate) and overuse (delivery of health services that are inappropriate) can occur. The authors allude to the concept of overuse when describing their intervention as being associated with a significant reduction in waste.¹

To determine whether the outlier physicians truly were performing procedures that represented waste or overuse, more granularity regarding the indications for the procedures would be required—namely, the CEAP classification of the patients being treated. As acknowledged by the authors,¹ it is possible that physicians who were outliers treated a higher proportion of patients with advanced and/or multimodal disease. It is also possible that the inlier physicians were undertreating patients, possibly because of a lack of understanding of the venous hypertensive threshold that must be overcome to adequately treat patients. The AVF, the SVS, the American Vein and Lymphatic Society, and the Society of Interventional Radiology published Appropriate Use Criteria (AUC) for chronic lower extremity venous disease in 2020.⁸ In general, the AUC findings mirror the CPGs; the AUC found EVTA in symptomatic patients with C2 to C6 disease to be appropriate and treatment of truncal reflux in both asymptomatic and symptomatic C1 disease to be rarely appropriate. The most rigorous method for determining whether outlier practice patterns represent waste or overuse would be to apply the AUC to each procedure to determine the degree of appropriateness. Unfortunately, administrative claims data lacks the granularity to perform this analysis.

Finally, as the authors acknowledge,¹ this study design does not allow for a causal link to be drawn between the benchmarked reports and decline in procedures. Although the authors are to be commended for performing a sensitivity analysis that included codes for the newly introduced chemical ablation and adhesive procedures, the authors did not distinguish whether the new procedures were performed by inlier or outlier physicians. Data suggest that the adhesive procedure itself leads to fewer secondary procedures compared with thermal techniques.⁹ Thus, it is possible that the outlier physicians who reclassified as inliers were those treating patients with advanced disease state with multimodal reflux and using newer technology that enables high-quality outcomes with fewer procedures.

As health care costs in the US continue to increase year over year, strategies to maximize quality and cost-effectiveness are critical. Stonko and colleagues¹ have taken a laudable first step toward this goal in the area of chronic venous insufficiency treatment. However, it is not simply decreasing the number of interventions, but high-quality, appropriate treatment of symptomatic chronic venous insufficiency in advanced disease states that will optimize resource utilization and decrease costs of health care in the US. Future initiatives that build on this pilot work will require granular assessments of procedural indications and quality of care, in addition to quantity of procedures.

Published: December 14, 2021. doi:10.1001/jamanetworkopen.2021.38907

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 O’Banion LA et al. JAMA Network Open.

Corresponding Author: Karen Woo, MD, PhD, Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, 200 UCLA Medical Plaza, Ste 526, Los Angeles, CA 90095 (kwoo@mednet.ucla.edu).

Conflict of Interest Disclosures: Dr O’Banion reported receiving grants from Medtronic as a Primary Site Investigator in SPECTRUM Clinical Trial at University of California San Francisco–Fresno outside the submitted work. No other disclosures were reported.