Cardiologists use self-referral to make inroads in peripheral vascular interventions

Self-referral accounts for the dramatic increase in cardiologists' share and volume of percutaneous peripheral vascular interventions, according to researchers at Thomas Jefferson University.

Dr. David Levin and colleagues examined Medicare Part B databases for 1997 through 2002. They tallied CPT-4 surgical procedure codes for several procedures:

• percutaneous transluminal angioplasty of noncardiac peripheral arteries

• transcatheter placement of noncardiac intravascular stents

• endovascular aortic stent-graft placement

In 2002, radiologists performed more than 72,000 of these procedures, cardiologists over 62,000, and vascular surgeons nearly 18,000.

During the five-year period examined, total procedure volume increased by 95%. The rate of increase among radiologists was 29%, while cardiologists' volume shot up 181% and vascular surgeons performed 400% more procedures.

"The most surprising finding was the amazingly rapid growth in utilization among cardiologists, particularly because they are not as well trained in these interventional procedures as radiologists," lead researcher Levin told Diagnostic Imaging.

The biggest reason for this growth is self-referral, said Levin, emeritus radiology chair at Jefferson.

From 1997 to 2002, radiologists saw their share of the market decline from nearly 65% to just above 40%. Cardiologists saw their share increase from 25% to nearly 37%. Vascular surgeons also experienced an increase in market share, from 4% to 10%.

Levin summed up the increase by cardiologists succinctly: drive-by angiograms.

"Cardiologists may start out doing a heart catheterization, and while they are putting the catheter up the right iliac artery, they may find a plaque. They pull the catheter out, do a renal angiogram, find a stenosis, and then go ahead and dilate the vessel," he said.

The risk of damaging the artery is one of several reasons to not dilate arteries unnecessarily. Another is the risk of converting an atherosclerotic plaque that was stable into an unstable lesion.

"Hospital credential committees and administrators shouldn't be allowing untrained physicians to do these procedures," Levin said. "If they really stand for quality, then they should be taking steps to ensure that procedures like these are performed only by the best-trained doctors."

Levin presented his results at the 2004 RSNA meeting.

For more information from the online Diagnostic Imaging archives:

MSCT angio advances in peripheral vessels

Utilization management involves more people in imaging choices

Utilization review takes aim at imaging expenses