An Analysis of Endovenous Ablation Procedures by Provider Type, Including Advanced Practice Providers: A Study Using the Medicare Fee-for-service Database

The necessary training and certification of providers performing venous ablation has become a topic of debate in recent years. As venous interventions have shifted away from the hospital, the diversity of provider backgrounds has increased. We aimed to develop a better understanding of practice patterns associated with each provider type, with a focus on advanced practice providers (APPs). We analyzed Medicare fee-for-service data from 2010 through 2018. This database comprises over 1.5 million venous ablations during this time. Procedures were identified by their Current Procedural Terminology code, including those for radiofrequency ablation, endovenous laser ablation, chemical ablation (ie, VenaSeal, Medtronic, Inc. Minneapolis, MN), and mechanochemical ablation. The two-proportion Z-test was used to determine significance. Between 2010 and 2018, the number of ablation procedures rose nearly 90% from 129,171 to 245,220 per year (P < .001). Most providers were vascular surgeons (27.1%; 95% confidence interval [CI], 27.0%-27.2%). Noninterventional specialties (eg, family practice, pain management, preventative medicine) accounted for 14.1% (95% CI, 14.1%-14.2%), and APPs accounted for 3.5% (95% CI, 3.4%-3.5%) of all procedures. The total number of venous procedures increased by 8.3% annually (95% CI, 8.3%, 8.4%), whereas procedures performed by APPs grew at 62.0% (95% CI, 61.6%-62.4%). There were significant differences in the use of nonthermal ablation modalities by specialty (Table). Additionally, the uptake of new nonthermal technology (i,. chemical ablation), was greatest among APPs (odds ratio [OR], 3.57; 95% CI, 3.43-3.70) and cardiologists (OR, 1.58; 95%, CI 1.54-1.63), with vascular surgeons less likely to use the new technology in the first year after availability (OR, 0.89; 95% CI, 0.87-0.92). Venous procedures have grown rapidly over the past decade, particularly as endovenous ablations have been performed by a wider range of practitioners such as APPs and noninterventional specialties. There are significantly different practice patterns among provider types, with APPs and cardiologists skewing more toward nonthermal modalities and demonstrating more rapid uptake of new nonthermal technology. The biases among provider types for specific ablation modalities may reflect differences in training, skill set, or the need for capital equipment. Given the disparate practice patterns, additional evaluation is needed to corroborate the safety, efficacy and appropriateness of endovenous treatment in the real-world setting, and this may help to inform paradigms for provider training and certification.TablePractice patterns in endovenous ablation proceduresEndovenous ablation procedures (2010-2018)Nonthermal ablation modality useVenaSeal uptake in first yearNPercent of total (95% CI)Annualized growth (95% CI)OR (95% CI)Sig.OR (95% CI)Sig.APP55,1533.5% (3.4-3.5)62.0% (61.6-62.4)2.60 (2.51-2.69)