Underuse of Preoperative Testing Before Index Peripheral Vascular Interventions for Claudication in the Outpatient Setting

BACKGROUND: Guidelines across vascular surgery, cardiology, and radiology specialties recommend appropriate preoperative testing prior to revascularization for claudication. We aimed to identify patient and physician characteristics associated with the absence of preoperative testing before peripheral vascular interventions (PVIs) performed for claudication. METHODS: Using 100% Medicare fee-for-service claims data, we identified all patients undergoing an index PVI for claudication between 01/2017 and 12/2024. We used CPT codes to identify preoperative testing, which included noninvasive physiologic studies (ABI, pulse volume recordings PVRs), near infrared thermography, duplex ultrasound, MRA of the abdomen and pelvis with runoff, CTA of the abdomen and pelvis with runoff, MRA of the lower extremity, or CTA of the lower extremity. Lack of preoperative testing was defined as no preoperative test within 3 months prior to index PVI. We evaluated the associations of patient and physician characteristics with the lack of preoperative testing using multivariable hierarchical logistic regression. We performed sensitivity analyses defining lack of preoperative testing as no testing within 6 and 12 months prior to index PVI. RESULTS: Of 167,406 patients undergoing index PVI for claudication by 3,771 physicians, 27.4% received no preoperative testing. The odds of receiving no preoperative testing significantly increased over time (adjusted odds ratio aOR 1.02 per year, 95% confidence interval 95% CI 1.02-1.03). Patients without preoperative testing were more likely to be age ≤ 64 years (versus age 65-74, aOR 1.06, 95% CI 1.01-1.11), Black (versus White, aOR 1.10, 95% CI 1.05-1.15), or Hispanic (versus White, aOR 1.20, 95% CI 1.11-1.31), and to receive an iliac intervention (aOR 1.29, 95% CI 1.22-1.36). Patients treated by physicians of cardiology (aOR, 1.98; 95% CI, 1.87-2.10), radiology (aOR, 1.20; 95% CI, 1.09-1.33), and other nonvascular surgery specialties (aOR, 1.27; 95% CI, 1.13-1.42) had higher odds of not receiving preoperative testing compared to patients treated by vascular surgeons. Sensitivity analyses using 6 and 12 months as the time cutoff for testing prior to PVI did not substantially change the results. CONCLUSION: Compliance with society guidelines for preoperative testing prior to outpatient PVI for claudication varies substantially by patient and physician characteristics. Cross-specialty adherence will help ensure patients with claudication receive consistent, evidence-based, high-value care.