[R01] Impact of Hospital Competition on Vascular Care for Older Adults
Ente: National Heart Lung and Blood Institute
Scadenza: 2031-05-31
Importo max: 737.415 EUR
Paese: US
Descrizione
Overtreatment is associated with increased costs of care and can be harmful to patients’ health. This proposal
aims to explore the cause behind two observed examples of overtreatment in vascular surgery that have
caught national attention. The first case is abdominal aortic aneurysm (AAA), and the second is an early
presentation of peripheral artery disease (PAD) called claudication.
AAA is among the top 15 causes of death in the US for older adults (65-89y). Annual surveillance is
recommended for small AAAs (4.0-5.4cm). Multiple RCTs have shown no benefit for surgical treatment of
small AAAs, and re-interventions rates are as high as 20% at 5 years after EVAR. However, recent
observational data shows increasing repair of aneurysms at small sizes that are not supported by guidelines.
Similarly, claudication affects approximately 8.5 million people in the United States. First line treatment
recommendations include behavioral modification, medication, and exercise, followed by interventions for
proximal disease (aortoiliac or femoropopliteal) Tibial interventions are not considered appropriate treatment
for claudication, but more patients are getting this intervention that is unlikely to offer benefits and may lead to
harmful amputations.
One possible hypothesis is that competition across surgeons, combined with fee for service payment models,
has created incentives to perform AAA and PAD surgery earlier than clinically recommended. Therefore, this
study will use innovative methods and data pooled from two national data sources [Vascular Quality Initiative
(VQI) data linked to Medicare and Veterans Health Administration (VHA) data] to examine the effect of market
competition at a granular level on small AAA repair and tibial interventions for PAD. We seek to address
whether market competition is associated with higher rates of inappropriate AAA and PAD care (Aim1),
whether early endovascular intervention is associated with superior event free survival, specifically, re
intervention free survival (RFS) for AAA and amputation free survival (AFS) for PAD (Aim 2), and examine
outcomes in two subgroups, specifically elderly (>75years) and frail adults, to determine whether competition is
disadvantageous for these two high-risk groups (Aim 3). At the conclusion of this study, we will understand
how market competition is driving appropriate use criteria for AAA and PAD care and whether it has a
deleterious effect on older and frail patients. Our study will inform how payers and health systems could
structure provider networks and reimbursement for vascular surgery and identify whether market competition
facilitates or compromises appropriate care for high-risk older patients.
Istituzione: STANFORD UNIVERSITY
PI: Shipra Arya, TODD H WAGNER
Progetto: 1R01HL185953-01
Settori: National Heart Lung and Blood Institute
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