Variation in Ultrasound Diagnostic Thresholds for Carotid Stenosis in the United States.

BACKGROUND: Individuals with carotid stenosis enter surveillance or are considered for surgery on the basis of disease severity assessed by ultrasound. However, there is variation in the ultrasound diagnostic thresholds used to determine disease severity. Our objective was to describe this variation and its potential impact on patients. METHODS: To describe the variation in carotid ultrasound diagnostic thresholds, we examined testing protocols from 338 accredited vascular testing centers in the United States. To determine the potential impact of this variation, we applied the range of thresholds to carotid ultrasound parameters from 2 groups: a population-based sample ≥65 years of age in the Cardiovascular Health Study (n=4791), and a cohort of patients who underwent surgery for asymptomatic carotid stenosis in the Vascular Quality Initiative registry (n=28 483). RESULTS: Internal carotid artery peak systolic velocity was used by all centers to assess disease severity, with 60 distinct thresholds in use. The peak systolic velocity threshold for moderate (≥50%) stenosis ranged from 110 to 245 cm/s (median, 125; 5th and 95th percentile, 125 and 150), and the threshold for severe (≥70%) stenosis ranged from 175 to 340 cm/s (median, 230; 5th and 95th percentile, 230 and 275). In the population-based sample, the 5th percentile threshold would assign a diagnosis of moderate carotid stenosis to twice as many individuals as the 95th percentile threshold (7.9% versus 3.9%; relative risk, 2.01 [CI, 1.70-2.38]). In the surgical cohort, 1 in 10 (9.8%) patients had peak systolic velocity values that warranted the diagnosis of severe carotid stenosis at centers in the 5th percentile, but not in the 95th. CONCLUSIONS: The diagnostic threshold for carotid stenosis varies considerably. Whether or not a person is said to have moderate stenosis and enters surveillance, and whether or not they have severe stenosis and are candidates for surgery, can depend on which center performs their ultrasound.

Outcomes of rotational atherectomy in complex lesions of the superficial femoral artery.

BACKGROUND: The effectiveness of rotational atherectomy in the treatment of complex superficial femoral artery (SFA) lesions remains poorly defined. Outcomes of SFA lesions treated with rotational atherectomy were analyzed. METHODS: This retrospective review assessed all patients who underwent rotational atherectomy of the SFA at a single institution between 2015 and 2018. The data of all patients were deidentified, and the study was approved by the Institutional Review Board. Informed consent was not obtained for this retrospective analysis. Main outcomes were Kaplan-Meier primary patency rate, freedom from major amputation, and 2-year survival rate. The effect of drug-coated balloon angioplasty (DCBA) on patency and time to death was investigated with univariate regression. The safety profile for atherectomy and DCBA was assessed by the 30-day incidence of major amputation and all-cause mortality. RESULTS: Fifty-three patients (mean age, 70.2 ± 9.8 years; 73% male; 65% critical limb-threatening ischemia; 47 [90%] current or former smokers; seven [13%] with prior failed ipsilateral endovascular intervention) underwent rotational atherectomy (Jetstream; Boston Scientific, Marlborough, Mass) with mean follow-up of 543 days. Forty-six (87%) patients underwent DCBA (Lutonix; BD Bard, Covington, Ga) after atherectomy. Mean lesion length was 13.2 ± 9.0 cm. Thirty-one (58%) lesions were TransAtlantic Inter-Society Consensus C or D class. At 1-month follow-up, 39 of 45 (87%) patients experienced improvement in symptoms and Rutherford class. An improvement in ankle-brachial index was also noted in 13% of patients without improvement of symptoms, with no patients progressing to surgical bypass or major amputation. Mean ankle-brachial index increased from 0.54 ± 0.035 to 0.90 ± 0.031 at 1 month after intervention (P < .001) and remained constant out to 18 months. Mean toe pressure increased from 36 ± 3.8 mm Hg to 67 ± 4.5 mm Hg at 1 month after intervention (P < .001) and remained constant out to 18 months. Kaplan-Meier primary patency rate was 75% (95% confidence interval, 61%-85%) at 12 months and 65% (51%-77%) at 24 months. There was a trend toward improved primary patency after adjunctive DCBA compared with plain balloon angioplasty at 1 year (75% vs 43%; P = .1082). There was no significant difference in mortality between adjunctive DCBA and plain balloon angioplasty at 2 years (11% vs 0%). The 2-year incidence of major amputation in critical limb-threatening ischemia patients was 3.9% (1.2%-6.5%). One patient died and none underwent amputation within 30 days. CONCLUSIONS: Rotational atherectomy with adjunctive DCBA of long SFA lesions has excellent long-term patency. Two-year major amputation and mortality rates are low, and the technique has an exceptional safety profile.

The financial evolution of endovascular aneurysm repair delivery in contemporary practice.

OBJECTIVE: The fiscal impact of endovascular repair (EVR) of aortic aneurysms and the requisite device costs have previously highlighted the tenuous long-term financial sustainability among Medicare beneficiaries. The Centers for Medicare & Medicaid Services have since reclassified EVR remuneration paradigms with new Medicare Severity Diagnosis-Related Groups (MS-DRGs) intended to better address the procedure's cost profile. The impact of this change remains unknown. The purpose of this analysis was to compare EVR-specific costs and revenue among Medicare beneficiaries both before and after this change. METHODS: All infrarenal EVRs performed in fiscal years (FYs) 2014 and 2015, before the MS-DRG change, and those performed in FYs 2017 and 2018, after the MS-DRG change, were identified using the DRG codes 238 (n = 108) and 269 (n = 84), respectively. We then identified those who were treated according to the instructions for use guidelines with a single manufacturer's device and billed to Medicare (n = 23 in FY14-15; n = 22 in FY17-18). From these cohorts, we determined total procedure technical costs, technical revenue, and net technical margin in conjunction with the hospital finance department. Results were then compared between these two groups. RESULTS: The two cohorts demonstrated similar demographic profiles (FY14-15 vs FY17-18 cohort: age, 78 years vs 74 years; median length of stay, 1.0 day vs 1.0 day). Mean total technical costs were slightly higher in the FY17-18 group ($24,511 in FY14-15 vs $26,445 in FY17-18). Graft implants continued to account for a significant portion of the total cost, with the device cost accounting for 56% of the total procedure costs in both cohorts. Net revenue was greater in the FY17-18 group by $5800 ($30,698 in FY14-15 vs $36,498 in FY17-18), resulting in an increased overall margin in the FY17-18 group compared with the FY14-15 group ($6188 in FY14-15 vs $10,053 in FY17-18). CONCLUSIONS: Device costs remain the single greatest cost driver associated with EVR delivery. DRG reclassification of EVR to address total procedure and implant costs appears to better address the requisite associated procedure costs and may thereby better support long-term fiscal sustainability of this procedure for hospitals and health systems alike.

The Society for Vascular Surgery Alternative Payment Model Task Force report on opportunities for value-based reimbursement in care for patients with peripheral artery disease.

The Society for Vascular Surgery Alternative Payment Model (APM) Taskforce document explores the drivers and implications for developing objective value-based reimbursement plans for the care of patients with peripheral arterial disease (PAD). The APM is a payment approach that highlights high-quality and cost-efficient care and is a financially incentivized pathway for participation in the Quality Payment Program, which aims to replace the traditional fee-for-service payment method. At present, the participation of vascular specialists in APMs is hampered owing to the absence of dedicated models. The increasing prevalence of PAD diagnosis, technological advances in therapeutic devices, and the increasing cost of care of the affected patients have financial consequences on care delivery models and population health. The document summarizes the existing measurement methods of cost, care processes, and outcomes using payor data, patient-reported outcomes, and registry participation. The document also evaluates the existing challenges in the evaluation of PAD care, including intervention overuse, treatment disparities, varied clinical presentations, and the effects of multiple comorbid conditions on the cost potentially attributable to the vascular interventionalist. Medicare reimbursement data analysis also confirmed the prolonged need for additional healthcare services after vascular interventions. The Society for Vascular Surgery proposes that a PAD APM should provide patients with comprehensive care using a longitudinal approach with integration of multiple key medical and surgical services. It should maintain appropriate access to diagnostic and therapeutic advancements and eliminate unnecessary interventions. It should also decrease the variability in care but must also consider the varying complexity of the presenting PAD conditions. Enhanced quality of care and physician innovation should be rewarded. In addition, provisions should be present within an APM for high-risk patients who carry the risk of exclusion from care because of the naturally associated high costs. Although the document demonstrates clear opportunities for quality improvement and cost savings in PAD care, continued PAD APM development requires the assessment of more granular data for accurate risk adjustment, in addition to largescale testing before public release. Collaboration between payors and physician specialty societies remains key.

Medicare reimbursement of lower extremity bypass does not cover cost of care for most patients with critical limb ischemia.

OBJECTIVE: Lower extremity bypass surgery remains an important treatment option for patients with critical limb ischemia (CLI), but is resource intensive. We sought to evaluate the cost and Medicare reimbursement for lower extremity bypass surgery in patients with CLI. METHODS: Hospital cost accounting systems were queried for total technical and professional costs incurred and reimbursement received for patients with CLI undergoing lower extremity bypass at our center between 2011 and 2017. Patients were identified by assignment to Diagnosis-Related Group (DRG) 252, 253, or 254 (other vascular procedure with major complication/comorbidity, with complication/comorbidity, and without complication/comorbidity, respectively). Additional clinical data were incorporated from the Vascular Quality Initiative clinical registry. For non-Medicare patients, reimbursement was indexed to Medicare rates. Contribution margins (reimbursement minus cost) from technical and professional services were analyzed for each patient and summarized by DRG. We compared technical, professional, and total costs; reimbursement; and contribution margins across DRGs using univariate statistics and evaluated factors associated with total contribution margin using median quantile regression. RESULTS: We analyzed 68 patients with hemodynamically confirmed CLI (46% rest pain, 54% tissue loss), of whom 25% received a prosthetic graft. Mean age was 66.1 ± 11.6 years, 69% were male, 49% diabetic, 44% current smokers, and 4% on dialysis. In general, total infrainguinal bypass cost was adequately compensated for patients assigned only the most complex DRG 252 (median, $2490; interquartile range [IQR], -$1,621 to $10,080). In the majority of patients with less complex DRG 253 (median, -$3,100; IQR, -$8499 to $109) and DRG 254 (median, -$4902; IQR, -$9259 to $1059), reimbursement did not cover the cost of care. Both technical costs and professional costs varied significantly with the complexity of DRG. Although reimbursement from technical services increased alongside increasing complexity of DRG, there was insignificant variation in professional reimbursement as DRG complexity increased. On multivariable modeling, longer length of stay (-$2547 per additional day) and preoperative dialysis (-$5555) were significantly associated with negative margins. CONCLUSIONS: For the majority of patients with CLI, current Medicare reimbursement does not adequately cover the cost of providing care after open bypass surgery. As commercial insurers move toward Medicare reimbursement rates, more granular risk stratification profiles are needed to ensure open surgical care for patients with CLI remains financially sustainable.

Long-Term Outcomes of Mesenteric Stenting and Analysis of In-Stent Restenosis Duplex Velocity Criteria.

BACKGROUND: Endovascular therapy for chronic mesenteric ischemia (CMI) is the mainstay of treatment. Duplex velocity criteria within stented mesenteric vessels are not well established. We describe single-center outcomes of mesenteric stenting for CMI and analyze duplex velocities associated with in-stent restenosis (ISR). METHODS: We performed a single-center retrospective review of patients undergoing mesenteric stenting for CMI (2012-2018). Primary outcome was reintervention for recurrence of CMI symptoms. Secondary outcomes were occlusion or bypass grafting. Duplex velocities in those with recurrent symptoms, corresponding with clinically significant ISR, were identified. Receiver operating characteristic (ROC) curves were created to identify velocity thresholds for ISR. RESULTS: Mesenteric stents were placed in 61 patients (71 arteries). Mean age was 72 years (range, 49-92), and the majority were female (55%). Thirty-two (45%) celiac (CA) stents and 39 (55%) superior mesenteric artery (SMA) stents were placed. Ten patients had SMA and CA stents placed. Twenty-five stents were covered (35%). Freedom from reintervention at 1, 2, and 3 years was 83%, 73%, and 60%. Freedom from occlusion or bypass grafting at 1, 2, and 3 years was 100%, 86%, and 86%. No significant difference in patency was seen between covered and bare-metal stents (OR 0.45; 95% CI: 0.15-1.33; P = 0.1383). Median survival was 6.1 years. For CA stents, a peak systolic velocity (PSV) of 440 cm/s corresponded with clinically significant ISR with 100% sensitivity and 86% specificity. For SMA stents, a PSV of 341 cm/s corresponded with clinically significant ISR with only 80% sensitivity and 52% specificity. CONCLUSIONS: A PSV of 440 cm/s for CA stents was indicative of clinically significant ISR with excellent sensitivity and specificity. This should be used in conjunction with clinical findings to identify patients that may benefit from repeat intervention. A similar threshold could not be identified for SMA stents and warrants further collaborative investigation.

Reasons for diagnostic delays of axial spondyloarthritis.

OBJECTIVE: Introduction: The probability of development of axial spondyloarthritis (axSpA) is estimated to be above 90% among patients with chronic back pain, presence of HLA B27 antigen and positive family history of ankylosing spondylitis (AS), psoriasis, reactive arthritis, inflammatory bowel disease or uveitis. The nonradiographic axSpA and ankylosing spondylitis diseases' activity has a comparable impact on the patients' quality of life and from the practical point of view the approach to treatment of each of them is the same. The aim: The attempt to identify the reasons of diagnostic delays of AS among patients hospitalized in the Rheumatology and Connective Tissue Diseases Department in Lublin and to suggest the ways of improving the accuracy of diagnostic track among other healthcare providers than rheumatologists. PATIENTS AND METHODS: Material and methods: We performed a retrospective analysis of the records of 82 patients' with the established diagnosis of AS, hospitalized in the Rheumatology and Connective Tissue Diseases Department in Lublin in 2000-2019, and of 45 years of age and older. RESULTS: Results: From among 82 patients (28 women and 54 men) the diagnosis of AS after 45 years of age was established in 25 patients (10 women and 15 men) - group t, and in the other 57 patients (group n) the diagnosis was established before 45 years of age. On average the age at the time of diagnosis in the whole group (t+n) was 40,7±10,2 (18-76) years, the age at the beginning of inflammatory back pain (age of axial symptoms) was 30,9±8,5 (13-51) years and the diagnostic delay (period between first axial symptoms and diagnosis establishment) was 9,75±9,5 (0-46) years. We did not find any statistically significant associations between sex and age at the moment of diagnosis, age of the beginning of axial symptoms and the time of diagnostic delay. There was no significant difference of incidence of enthesitis, uveitis, arthritis, prevalence of family history of spondyloarthritis and CRP level between group t and n. Antigen HLA B27 was more frequently present in group t. CONCLUSION: Conclusions: Instead of the recognition progress and worldwide popularization of knowledge about axSpA, the diagnostic delays in this field are still estimated to last many years, the patients are looking for other specialists' help, and they can be not knowledgeable of the inflammatory back pain criteria. Currently, HLA B27 antigen and C-reactive protein are the two most commonly used biomarkers for diagnostic and disease activity monitoring purposes of axSpA and magnetic resonance is the only "imaging biomarker". The presence of extra-axial symptoms does not improve the diagnostic sensitivity.

[Uwarunkowania opóznienia rozpoznan osiowych spondyloartropatii zapalnych].

OBJECTIVE: Wstep: Prawdopodobienstwo rozwoju osiowej postaci spondyloartropatii zapalnej (axSpA) wynosi ponad 90% u chorych z przewleklym bólem kregoslupa, obecnym antygenem HLA B27 i dodatnim wywiadem rodzinnym w kierunku zesztywniajacego zapalenia stawów kregoslupa (ZZSK), luszczycy, reaktywnego zapalenia stawów, chorób zapalnych jelit lub zapalenia blony naczyniowej oka. Aktywnosc choroby w postaci nieradiologicznej axSpA i ZZSK podobnie wplywa na jakosc zycia a z praktycznego punktu widzenia podejscie do leczenia jest jednakowe. Cel pracy: Próba identyfikacji przyczyn spóznionych rozpoznan ZZSK wsród chorych hospitalizowanych w Klinice Reumatologii i Ukladowych Chorób Tkanki Lacznej w Lublinie oraz sugestie dotyczace poprawy sciezki diagnostycznej, zwlaszcza wsród lekarzy innych specjalnosci niz reumatolodzy. PATIENTS AND METHODS: Material i metody: Retrospektywnej analizie poddano historie chorób 82 pacjentów z ustalonym rozpoznaniem ZZSK hospitalizowanych w Klinice Reumatologii i Ukladowych Chorób Tkanki Lacznej w Lublinie w latach 2000-2019, którzy ukonczyli 45. rok zycia. RESULTS: Wyniki: Sposród 82 chorych (28 kobiet i 54 mezczyzn) rozpoznanie ZZSK po 45. roku zycia postawiono u 25 chorych (10 kobiet i 15 mezczyzn) - grupa t (30,4%), u pozostalych 57 chorych (grupa n) rozpoznanie ustalono przed 45. rokiem zycia. Sredni wiek w chwili rozpoznania w calej grupie (t+n) wynosil 40,7±10,2 (18-76) roku, wiek, w którym pojawil sie zapalny ból kregoslupa (wiek objawów osiowych) wynosil 30,9±8,5 (13-51) roku a opóznienie rozpoznania (okres od pojawienia sie objawów osiowych do ustalenia rozpoznania) 9,7±9,5 (0-46) roku. Nie stwierdzono istotnych statystycznie zaleznosci miedzy plcia a wiekiem w chwili rozpoznania, wiekiem pojawienia sie objawów osiowych i opóznieniem rozpoznania. Nie zaobserwowano istotnych zaleznosci miedzy czestoscia wystepowania zapalenia przyczepów sciegnistych, blony naczyniowej oka, stawów obwodowych, chorób z kregu spondyloartropatii zapalnych w rodzinie oraz stezenia CRP miedzy grupa t i n. Antygen HLA B27 czesciej obecny byl w grupie t. CONCLUSION: Wnioski: Mimo postepu w diagnostyce i wiekszego upowszechniania wiedzy na temat spondyloartropatii zapalnych, opóznienia w rozpoznaniu tych chorób sa wieloletnie, poniewaz pacjenci bardzo czesto poszukuja pomocy u innych specjalistów, którzy moga byc niezaznajomieni z kryteriami bólu zapalnego kregoslupa. W chwili obecnej jedynymi biomarkerami wykorzystywanymi w diagnostyce i monitorowaniu aktywnosci spondyloartropatii zapalnych jest odpowiednio obecnosc antygenu HLA B27 i stezenie CRP a jedynym "biomarkerem obrazowym" jest rezonans magnetyczny. Wystepowanie objawów pozaosiowych nie poprawia czulosci diagnostycznej.

Disparity in Medicaid physician payments for vascular surgery.

OBJECTIVE: Medicare reimbursements are standardized nationwide on the basis of resource-dependent inputs of physicians' time, intensity, practice costs, and malpractice costs, whereas Medicaid payments vary and are determined by individual states. Our objectives were to determine Medicaid reimbursement to physicians for common vascular procedures for the seven states in the Northeast that compose the New England Society for Vascular Surgery and to compare Medicaid payments with Medicare. METHODS: Using publicly available data, we obtained Medicaid physician payments in Connecticut, Massachusetts, Maine, New Hampshire, New York, Rhode Island, and Vermont for 10 commonly performed vascular surgery procedures. For comparison, Medicare physician payments for these procedures were adjusted for regional differences using Medicare geographic payment cost indices. Descriptive statistics were calculated by state; Wilcoxon signed rank test was used to compare fees, and one-way analysis of variance was used to compare variance. RESULTS: Medicaid payments varied widely by state. Within individual states (except Vermont), there was no relationship between Medicaid and Medicare payments. Medicaid reimbursement for common vascular procedures ranged from 25% to 91% of Medicare rates and had up to a threefold variation in payment among states for a single procedure. The mean Medicaid payment was 60% of Medicare payment. The greatest state-to-state variance in payment was for open abdominal aortic repair (standard deviation, $227.31); the least was for femoral artery exposure (standard deviation, $31.86). For a Medicaid-based, frequency-weighted analysis of services, New Hampshire exhibited the lowest payments (43% Medicare) and Vermont the highest (80% Medicare). CONCLUSIONS: Among the seven Northeast states considered, with the exception of Vermont, there is no logical relationship between Medicaid and Medicare payments. Because Medicare payments are determined by the Centers for Medicare and Medicaid Services with consideration of resource-based inputs, we conclude that in six of the seven states, Medicaid payments bear no relationship to resource utilization. With Medicaid expansion, access to vascular procedures may be limited by payments insufficient to meet resource needs.

Prospective assessment of cardiovascular risk parameters in patients with rheumatoid arthritis.

BACKGROUND: The study presents a prospective follow-up assessment of cardiovascular (CV) risk parameters in patients with rheumatoid arthritis (RA) in comparison with control subjects. METHODS: The study group consisted of 41 RA patients. The following parameters were assessed at subsequent visits [initial (T0), follow-up after 6 years (T6)]: traditional CV risk factors, carotid intima media thickness (cIMT), QTc duration, serum concentration of amino-terminal pro-brain natriuretic peptide (NT-proBNP). A comparative cIMT assessment was performed on 23 healthy controls of comparable age. RESULTS: The mean (SD) cIMT value in RA patients was significantly higher at T6 than at T0 [0.87 (0.21) vs 0.76 (0.15) mm, p < 0.001], the increase in patients with atherosclerotic plaques was noted. Patients with plaques were significantly older, had higher inflammatory parameters. The mean cIMT was significantly higher in RA patients than in controls at both T6, T0 visits. Certain traditional CV risk factors exacerbated during follow up. Unfavorable metabolic parameters and significantly higher cIMT were found in male patients than in female patients at T6. During follow-up, no significant differences in NT-proBNP, QTc were found. There were no significant relationships between cIMT, NT-proBNP, QTc and parameters of disease activity at T6. CONCLUSIONS: During the 6-year course of established RA, significant exacerbation of atherosclerosis was found, revealed by higher cIMT. A careful monitoring should be applied to patients with atherosclerotic plaques and of male gender due to higher burden of CV risk. In long-standing disease, traditional CV risk factors seem to play a key role, beyond the inflammatory activity.

[Methods of efficacy assessment of the knee joint radiosynoviorthesis- personal experience].

OBJECTIVE: Introduction: Radiosynoviorthesis (RS) is local method of treatment of remittent joint effusions among patients who obtained general improvement after disease modifying anti-rheumatic drugs therapy but one or a few joints stay resistant to this treatment and intraarticular corticosteroids injections. The aim: The attempt to identification methods of efficacy assessment of the 90yttrium knee joint RS. PATIENTS AND METHODS: Material and methods: The study group consisted of 43 patients with rheumatoid arthritis (RA) and 19 patients with inflammatory spondyloarthropaties (SPA) where 8 patients were treated for ankylosing spondylitis (AS), 4 for psoriatic arthritis (PsA) and 7 due to undifferentiated inflammatory spondyloarthropaties (USPA). The efficacy of RS was measured subjectively by the patient, physically by the physician and with the help of chosen scores (DAS28), questionnaires (HAQ), laboratory parameters [ESR, level of CRP, osteoprotegerin (OPG), serum amyloid A (SAA), hialuronic acid (HA)] and three-phase bone scintigraphy of affected knee joints. RESULTS: Results: In RA patients very good results - no knee effusion were obtained in 25 (58,1%) joints, good results - minimal effusion in 10 (23,3%) knees and lack of improvement in 8 (18,6%) patients. Cumulatively very good and good results were obtained in 35 (81,4%) treated knee joints. In SPA patients very good results were noted in 12 (63,2%), good in 5 (26,3%), lack of improvement in 2 (10,5%) patients. Cumulatively very good and good results were obtained in 17 (89,5%) treated knee joints. We observed favorable profile changes of chosen scores (DAS28), questionnaires (HAQ), laboratory parameters (ESR, CRP, OPG, SAA, HA) and results of three-phase bone scintigraphy of knee joints. CONCLUSION: Conclusions: 90Yttrium RS is effective treatment of recurrent knee joints effusion in patients with RA i SPA. RS despite being local treatment decreases unspecific inflammatory process and systemic disease activity among patients with RA i SPA. The anatomic period of affected knee joints has negative correlation with treatment efficacy. 90Yttrium RS is safe procedure, favourable profile changes of cartilage and bone turn-over markers after therapy indicates protective influence of RS on these structures. The treatment response based on physical examination, subjective patient's evaluation, acute phase laboratory parameter levels and appropriate scores, questionnaires and imaging exams is fast and long-lasting.

[Mondor's disease or systemic sclerosis - diagnostic and therapeutic dilemmas].

In this article we have presented a case of 31-year-old male with thickening of the skin and tender cord of superficial veins of the penis and laboratory findings of the high titer of PM/Scl-100 antibodies in the serum. The patient was referred to the Rheumatology Department due to suspected systemic sclerosis. The HRCT scan of his lungs revealed fibrous degeneration and ground-glass opacity in the lower lobes. Capillaroscopy showed abnormalities, which were not typical for systemic sclerosis. In Doppler ultrasound examination of penis, superficial dorsal and circumflex veins thrombosis and inflammatory infiltration were observed. Taking into account the entire clinical picture, the patient was diagnosed with rare penile Mondor's disease and was under surveillance for systemic sclerosis.

Reimbursement in hospital-based vascular surgery: Physician and practice perspective.

OBJECTIVE: The purpose of this study was to determine change in value of a vascular surgery division to the health care system during 6 years at a hospital-based academic practice and to compare physician vs hospital revenue earned during this period. METHODS: Total revenue generated by the vascular surgery service line at an academic medical center from 2010 through 2015 was evaluated. Total revenue was measured as the sum of physician (professional) and hospital (technical) net revenue for all vascular-related patient care. Adjustments were made for work performed, case complexity, and inflation. To reflect the effect of these variables, net revenue was indexed to work relative value units (wRVUs), case mix index, and consumer price index, which adjusted for work, case complexity, and inflation, respectively. Differences in physician and hospital net revenue were compared over time. RESULTS: Physician work, measured in RVUs per year, increased by 4%; case complexity, assessed with case mix index, increased by 10% for the 6-year measurement period. Despite stability in payer mix at 64% to 69% Medicare, both physician and hospital vascular-related revenue/wRVU decreased during this period. Unadjusted professional revenue/wRVU declined by 14.1% (P = .09); when considering case complexity, physician revenue/wRVU declined by 20.6% (P = .09). Taking into account both case complexity and inflation, physician revenue declined by 27.0% (P = .04). Comparatively, hospital revenue for vascular surgery services decreased by 13.8% (P = .07) when adjusting for unit work, complexity, and inflation. CONCLUSIONS: At medical centers where vascular surgeons are hospital based, vascular care reimbursement decreased substantially from 2010 to 2015 when case complexity and inflation were considered. Physician reimbursement (professional fees) decreased at a significantly greater rate than hospital reimbursement for vascular care. This trend has significant implications for salaried vascular surgeons in hospital-based settings, where the majority of revenue generated by vascular surgery care is the technical component received by the facility. Appropriate care for patients with vascular disease is increasingly resource intensive, and as a corollary, reimbursement levels must reflect this situation if high-quality care is to be maintained.

Carotid endarterectomy should not be based on consensus statement duplex velocity criteria.

OBJECTIVE: Randomized trials support carotid endarterectomy (CEA) in asymptomatic patients with ≥60% internal carotid artery (ICA) stenosis. The widely referenced Society for Radiologists in Ultrasound Consensus Statement on carotid duplex ultrasound (CDUS) imaging indicates that an ICA peak systolic velocity (PSV) ≥230 cm/s corresponds to a ≥70% ICA stenosis, leading to the potential conclusion that asymptomatic patients with an ICA PSV ≥230 cm/s would benefit from CEA. Our goal was to determine the natural history stroke risk of asymptomatic patients who might have undergone CEA based on consensus statement PSV of ≥230 cm/s but instead were treated medically based on more conservative CDUS imaging criteria. METHODS: All patients who underwent CDUS imaging at our institution during 2009 were retrospectively reviewed. The year 2009 was chosen to ensure extended follow-up. Asymptomatic patients were included if their ICA PSV was ≥230 cm/s but less than what our laboratory considers a ≥80% stenosis by CDUS imaging (PSV ≥430 cm/s, end-diastolic velocity ≥151 cm/s, or ICA/common carotid artery PSV ratio ≥7.5). Study end points included freedom from transient ischemic attack (TIA), freedom from any stroke, freedom from carotid-etiology stroke, and freedom from revascularization. RESULTS: Criteria for review were met by 327 patients. Mean follow-up was 4.3 years, with 85% of patients having >3-year follow-up. Four unheralded strokes occurred during follow-up at <1, 17, 25, and 30 months that were potentially attributable to the index carotid artery. Ipsilateral TIA occurred in 17 patients. An additional 12 strokes occurred that appeared unrelated to ipsilateral carotid disease, including hemorrhagic events, contralateral, and cerebellar strokes. Revascularization was undertaken in 59 patients, 1 for stroke, 12 for TIA, and 46 for asymptomatic disease. Actuarial freedom from carotid-etiology stroke was 99.7%, 98.4%, and 98.4% at 1, 3, and 5 years, respectively. Freedom from TIA was 98%, 96%, and 95%, freedom from any stroke was 99%, 96%, and 93%, and freedom from revascularization was 95%, 86%, and 81% at 1, 3, and 5 years, respectively. CONCLUSIONS: Patients with intermediate asymptomatic carotid stenosis (ICA PSV 230-429 cm/s) do well with medical therapy when carefully monitored and intervened upon using conservative CDUS criteria. Furthermore, a substantial number of patients would undergo unnecessary CEA if consensus statement CDUS thresholds are used to recommend surgery. Current velocity threshold recommendations should be re-evaluated, with potentially important implications for upcoming clinical trials.

[Contemporary use of radiosynoviorthesis in chronic polyarthrtitis].

Radiosynoviorthesis is used for local treatment of recurrent joint effusions, leads to necrosis of inflamed synovium due to beta radiation energy served after intraarticular radionuclide administration. The aim of the therapy is destruction and fibrosis of abnormal, hypertrophic synovial membrane and then full recovery of its normal function after local corticosteroids and systemic modifying drugs failure. Radiosynoviorthesis is effective in different type of peripheral arthritis like rheumatoid arthritis, inflammatory spondyloarthtropaties, gout, chondrocalcinosis, pigmented villo-nodular synovitis, recurrent knee effusion after total joint replacement, idiopathic knee joint effusion, osteoarthritis and secondary prevention of intraarticular bleeding in haemophilia. The absolute contraindications are: pregnancy and breastfeeding, uncontrolled coagulation disorders in haemophilic patients, septic skin changes around area of joint puncture, septic arthritis, raptured Baker's cyst. The commonly used radioisotypes in Europe are: 90Yttrium, 186Rhenium, 169Erbium. The favourable results could be reached on average in 60-80% of treated joints regardless of radionuclide used. The efficacy of radiosynoviorthesis is comparable with surgical synovectomy and in some selected situations both methods could be combined. If the primary failure of radiosynoviorthesis appeared procedure could be repeated, good results are obtained very frequently regardless of poor primary effect. Radiosynoviorthesis is safe, effective, simple and patient-friendly procedure, working fast in different type of arthtritis. The team consisted of rheumatologist, orthopedic surgeon and nuclear medicine specialist is essential for proper indications for local radiation therapy.

[Clinical and ultrasound assessment of the disease activity in patients with rheumatoid arthritis].

INTRODUCTION: Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease, leading to irreversible joint destruction and deformities. The adequate assessment of the disease activity enables the correct choice of therapy and evaluation of the treatment efficacy. The aim of the study was to compare different methods of assessment of the disease activity, using clinical data and ultrasonography (US) of joints, in patients with RA, in daily clinical practice. MATERIAL AND METHODS: The study group consisted of 68 patients with RA. The clinical assessment of the disease activity was performed using the Disease Activity Score based on evaluation of 28 joints (DAS28). Ultrasonography (US) examination of joints was performed in 24 small joints, evaluating hypertrophy and vascularity of the synovium. Ability to perform daily activities was measured using the modified Health Assessment Questionnaire (M-HAQ) Results: There were statistically significant correlations between the grade of synovial vascularity of joints and parameters of clinical activity [tender joints count (TJC), swollen joints count (SJC), DAS28] and laboratory acute phase parameters (ESR, CRP). The grade of synovial hypertrophy was significantly associated with SJC and DAS28, and not with laboratory parameters. M-HAQ value was significantly associated only with TJC. CONCLUSIONS: In RA patients an assessment of the disease activity should be performed taking into consideration several parameters, clinical activity, laboratory parameters, US and quality of life assessment. US examination enables verification of synovial inflammatory activity, which is not always possible in clinical examination.

The financial implications of endovascular aneurysm repair in the cost containment era.

OBJECTIVE: Endovascular aneurysm repair (EVAR) is associated with significant direct device costs. Such costs place EVAR at odds with efforts to constrain healthcare expenditures. This study examines the procedure-associated costs and operating margins associated with EVAR at a tertiary care academic medical center. METHODS: All infrarenal EVARs performed from April 2011 to March 2012 were identified (n = 127). Among this cohort, 49 patients met standard commercial instruction for use guidelines, were treated using a single manufacturer device, and billed to Medicare diagnosis-related group (DRG) 238. Of these 49 patients, net technical operating margins (technical revenue minus technical cost) were calculated in conjunction with the hospital finance department. EVAR implant costs were determined for each procedure. DRG 238-associated costs and length of stay were benchmarked against other academic medical centers using University Health System Consortium 2012 data. RESULTS: Among the studied EVAR cohort (age 75, 82% male, mean length of stay, 1.7 days), mean technical costs totaled $31,672. Graft implants accounted for 52% of the allocated technical costs. Institutional overhead was 17% ($5495) of total technical costs. Net mean total technical EVAR-associated operating margins were -$4015 per procedure. Our institutional costs and length of stay, when benchmarked against comparable centers, remained in the lowest quartile nationally using University Health System Consortium costs for DRG 238. Stent graft price did not correlate with total EVAR market share. CONCLUSIONS: EVAR is currently associated with significant negative operating margins among Medicare beneficiaries. Currently, device costs account for over 50% of EVAR-associated technical costs and did not impact EVAR market share, reflecting an unawareness of cost differential among surgeons. These data indicate that EVAR must undergo dramatic care delivery redesign for this practice to remain sustainable.

A model for predicting the risk of carotid artery disease.

OBJECTIVE: To develop a model for the identification of individuals at risk for carotid stenosis (CS) that could be useful in a clinical setting when trying to decide whether screening is worthwhile. BACKGROUND: Evidence that aggressive medical therapy and life style changes reduce the risk of stroke in individuals with CS is increasing and has led to a renewed interest in screening for CS. METHODS: Data on demographics and risk factors were obtained from 2,885,257 individuals who had carotid Duplex scans by Life Line Screening between 2003 and 2008. Multivariable logistic regression analysis was used to identify independent risk factors for CS (>50% stenosis). A scoring system was developed where risk factors were assigned a weighted score. Predictive ability was assessed by calculating C statistics and r2. RESULTS: In the screened cohort, 71,004 patients (2.4%) had CS. Independent risk factors include advanced age, smoking, peripheral arterial disease, high blood pressure, coronary artery disease, diabetes, cholesterol, and abdominal aortic aneurysm. African Americans, Asians, and Hispanics had reduced risk than whites. Exercise and consumption of fruit, vegetables, and nuts had a modest protective effect. A predictive scoring system was created that identifies individuals with CS more efficiently (C statistic = 0.753) than previously published models. CONCLUSIONS: We provide a model that enables identification of individuals who have a high probability of having CS. This model can be helpful in designing targeted screening programs that are cost-effective.

Efficacy of radiosynoviorthesis and its impact on chosen inflammatory markers.

Radiosynoviorthesis is used for the local treatment of recurrent joint effusions and leads to synovium necrosis after radionuclide administration. This procedure provides opportunity to full recovery of normal synovium function after local corticosteroids and systemic modifying drugs failure.

The Relationship between Platelet Indices and Ultrasound, Clinical, Laboratory Parameters of Disease Activity in Patients with Rheumatoid Arthritis.

(1) Background: A proper assessment of disease activity is crucial for the management of a patient with rheumatoid arthritis (RA). Platelets seem to be involved in joint inflammation pathophysiology. Platelet indices (PIs) are markers of platelet activation, and include platelet count (PC), mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PCT). The purpose of the study was to assess the relationship between PIs and disease activity markers, both systemic (clinical, laboratory) and local (ultrasound, US), in patients with RA; (2) Methods: The study group consisted of 131 consecutive RA patients. The following assessments were performed: joint counts, Disease Activity Score (DAS28), complete blood cell counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and US of 24 small joints; (3) Results: Mean values of PIs remained within the normal reference ranges. Values of PC, PCT, PDW were significantly associated with disease activity markers, both clinical (DAS28, joint counts) and laboratory (CRP, ESR). In patients with high disease activity, PC, PCT were significantly higher and PDW lower. PC was positively correlated with Power Doppler US (PDUS) score. In patients with features of RA severity (antibodies positivity, extra-articular manifestations) PC and PCT were positively associated with all US parameters (Grey Scale US, PDUS, Global scores); (4) Conclusions: In patients with RA, PC and PCT may serve as positive disease activity markers and PDW may serve as a negative marker. PIs may be used as reliable, inexpensive markers of RA systemic activity; they may also serve as markers of local inflammation in the joints affected by RA.