Improving Wisely Study Highlights Utilization in Vein Care

WHAT ARE THE KEY TAKEAWAYS SO FAR?

In 2018, the American Vein & Lymphatic Society partnered with the Improving Wisely collaborative at Johns Hopkins University and the Robert Wood Johnson Foundation to undertake a national review of publicly available Medicare claims data on vein ablations. The AVLS spoke with our two members who are serving as Principle Investigators for the Improving Wisely project - Margaret Mann, MD, FAVLS, FAAD and Marlin Schul, MD, MBA, RVT, FAVLS.

AVLS: Dr. Mann, Dr Schul – congratulations on the publication of the Phase I Improving Wisely paper. Please share some insight as to why the AVLS undertook the Improving Wisely project?

Marlin Schul, MD, MBA, RVT, FAVLS

Margaret Mann, MD, FAVLS, FAAD

Schul: Absolutely. As we all know, perceptions of procedure over-utilization in venous care have been around for years. We know that, but doing a data-driven analysis of that hypothesis has been the challenge. It’s not enough to just speculate, we need to address this issue and let the findings inform all of us as to our own practice data, and how our Society might address these trends in terms of education and awareness. We know that defining care guidelines and appropriateness is our collective future, and this is a step in that direction.

Mann: When the Society’s Board decided to make this investment in Improving Wisely, I was very pleased. As a Mohs surgeon, my data was part of the American College of Mohs Surgery’s own Improving Wisely project, and I was impressed at how the project impacted Mohs surgeons. The key to Improving Wisely is that it is a peer comparison, quality improvement project. When providers see their data compared to peers, they get a sense of whether their own practice patterns are in line with national averages, or if they might be above the median in terms of numbers of procedures. I want to emphasize, a higher provider utilization does not automatically equate with “overuse,” but shows how you compare to other vein providers. The Improving Wisely program is based on the concept that transparency through peer comparison reduces unnecessary variations, which in turn leads to improved patient safety and quality of care while also reducing costs.

AVLS: At a high level, what do the numbers show from Phase I of the study?

Mann: Using 2017 data, we had 2,462 NPIs in our study. The majority (96.4%) of patients underwent 1-5 ablations, 3.3% underwent 6-10 ablations, and 0.3% underwent ≥11 ablations. The median and mean physician ablation rates were 1.6 (IQR 1.3-2.2) and 1.9±0.8 ablations per patient annually, respectively. 106 physicians (4.3%) had an ablation rate ≥3.4, which is ≥2 standard deviations above the national mean.

Schul: As in any study, we needed to make adjustments in our analysis and addressed those. Overall, our median ablation number is in line with other studies that have been done, such as Baber, et al. and Crawford, et al. I want to emphasize, while this study is focused on defining a national ablation median, I also think we as the vein community need to be mindful of vein care underutilization as well. We know

Schul (con): the patients we see, and how interventions result in a better quality of life for our patients. Moving towards generally accepted standards of care is something that AVLS is working on across several of our Committees. We know we have knowledge gaps, and payors will only demand that we address those gaps.

AVLS: What is next for the Improving Wisely project, and how might the Society use these national findings to support, say, Guidelines and Advocacy?

Schul: On an almost weekly basis, we are engaged with both Medicare and private payors on vein coverage policies and LCDs. Having this data supports those efforts, as it shows that AVLS is committed to doing our part to ensure that each patient gets the right care they need for their clinical presentation. I’m excited to see our new PRO 2.0 Registry get up and running, as it will also serve as a powerful data source to move us towards data-driven care approaches and best practices.

Mann: Using the same metrics, but more recent claims periods, we will repeat the Improving Wisely analysis in 2020. NPIs will once again receive a confidential data report. This will allow providers to see if their ablation rates changed over time. I expect that our Guidelines Committee will look closely at the data, and I know payors are following the study as well. Also, we want to expand our analysis and will likely be looking at possible underutilization in ulcer care. I’m very curious to see what our 2020 analysis will reveal.

AVLS: Thank you, Drs. Mann and Schul for all your hard work and dedication to not only the Improving Wisely project, but also to the American Vein & Lymphatic Society.

The full study, “Significant Physician Practice Variability in the Utilization of Endovenous Thermal Ablation in the 2017 Medicare Population”, will be available for free at https://www.jvsvenous.org/article/S2213- 333X(19)30410-X/fulltext from October 15th through December 31st.