Frequency of inappropriate endovenous truncal ablation therapy within the vascular quality initiative varicose vein registry.

objectiveChronic venous disease is a pervasive problem, with a spectrum of severity and an equally diverse range of potential treatment settings and proceduralists. The adoption of endovenous ablation (EVA) techniques has facilitated the growth in office-based and ambulatory procedures. Concurrently, the impact of external factors including market compensation and insurance policies is known to influence procedural patterns away from evidence-based therapy. Using the Vascular Quality Initiative Varicose Vein Registry (VQI-VVR), we aimed to investigate trends in EVA therapies and ascertain trends in compliance with appropriate use criteria. We hypothesized that variation would exist in venous disease treatment patterns, and that treatment location and insurance status would influence the likelihood of nonconformity with these guidelines.

methodsWe identified patients undergoing truncal vein EVA procedures from participating VQI centers between January 2015 and September 2022. Procedures limited to perforator ablation, remnant or recanalized veins, or stab phlebectomy alone were excluded, as well as procedures performed on patients failing to meet the VQI-VVR inclusion criteria. The primary objective was to evaluate practice variation and identify factors associated with noncompliance with 2020 American Venous Forum/Society for Vascular Surgery/American Vein and Lymphatic Society/Society of Interventional Radiology appropriate use criteria. Secondary objectives compared outcomes between patients treated in accordance with vs outside of the guideline recommendations.

resultsA total of 32,558 procedures were analyzed and stratified into appropriateness subgroups. Procedures in which all treated veins were guideline appropriate interventions comprised 90.1% of the cohort. Interventions with at least one treatment designated as rarely appropriate or never appropriate guideline therapy comprised 1.8% and 1.3% of the cohort, respectively. Comparative analysis between appropriate and the inappropriate (ie, rarely appropriate, and never appropriate) treatment revealed prior varicose vein intervention (odds ratio [OR], 2.4; 95% confidence interval [CI], 2.0-2.9; P < .0001) and non-White race (OR, 2.1; 95% CI, 1.7-4.2; P < .0001) was associated with receiving a never appropriate treatment. Office-based settings (OR, 2.7; 95% CI, 1.9-4.0; P < .0001) and bilateral interventions (OR, 1.9; 95% CI, 1.2-2.9]; P = .003) were associated with never appropriate treatment. Increasing the number of veins treated was positively associated with inappropriate treatment (3 [interquartile range (IQR), 1-2] vs 3 [IQR, 2-4]; P < .0001 and 2 [IQR, 1-2] vs 2 [IQR, 2-4]; P < .0001). Most patients were privately insured (70%); however, there was no association between insurance status and off-guideline therapy. Center-level analysis revealed that 38% of all inappropriate procedures occurred at four centers.

conclusionsAnalysis of the VQI-VVR registry demonstrates a low incidence of inappropriate EVA procedures. These findings underscore the importance of continued education and quality improvement efforts to ensure adherence to evidence-based guidelines for venous ablation.