An Updated Physician Workforce Model Predicts a Shortage of Vascular Surgeons for the Next 20 Years.

BACKGROUND: Concern regarding the adequacy of the vascular surgery workforce persists. We aimed to predict future vascular surgery workforce size and capacity using contemporary data on the US population and number, productivity, and practice patterns of vascular surgeons. METHODS: The workforce size needed to maintain current levels of access was estimated to be 1.4 vascular surgeons/100,000 population. Updated population estimates were obtained from the US Census Bureau. We calculated future vascular surgery workforce needs based on the estimated population for every 10 years from 2020 to 2050. American Medical Association Physician Masterfile data from 1997 to 2017 were used to establish the existing vascular surgery workforce size and predict future workforce size, accounting for annual rates of new certificates (increased to an average of 133/year since 2013), retirement (17%/year), and the effects of burnout, reduced work hours, transitions to nonclinical jobs, or early retirement. Based on Medical Group Management Association data that estimate median vascular surgeon productivity to be 8,481 work relative value units (wRVUs)/year, excess/deficits in wRVU capacity were calculated based on the number of anticipated practicing vascular surgeons. RESULTS: Our model predicts declining shortages of vascular surgeons through 2040, with workforce size meeting demand by 2050. In 2030, each surgeon would need to increase yearly wRVU production by 22%, and in 2040 by 8%, to accommodate the workload volume. CONCLUSIONS: Our model predicts a shortage of vascular surgeons in the coming decades, with workforce size meeting demand by 2050. Congruence between workforce and demand for services in 2050 may be related to increases in the number of trainees from integrated residencies combined with decreases in population estimates. Until then, vascular surgeons will be required to work harder to accommodate the workload. Burnout, changing practice patterns, geographic maldistribution, and expansion of health care coverage and utilization may adversely affect the ability of the future workforce to accommodate population needs.

Reimbursement Policies for Carotid Duplex Ultrasound that are Based on International Classification of Diseases Codes May Discourage Testing in High-Yield Groups.

BACKGROUND: To curb increasing volumes of diagnostic imaging and costs, reimbursement for carotid duplex ultrasound (CDU) is dependent on "appropriate" indications as documented by International Classification of Diseases (ICD) codes entered by ordering physicians. Historically, asymptomatic indications for CDU yield lower rates of abnormal results than symptomatic indications, and consensus documents agree that most asymptomatic indications for CDU are inappropriate. In our vascular laboratory, we perceived an increased rate of incorrect or inappropriate ICD codes. We therefore sought to determine if ICD codes were useful in predicting the frequency of abnormal CDU. We hypothesized that asymptomatic or nonspecific ICD codes would yield a lower rate of abnormal CDU than symptomatic codes, validating efforts to limit reimbursement in asymptomatic, low-yield groups. MATERIAL AND METHODS: We reviewed all outpatient CDU done in 2011 at our institution. ICD codes were recorded, and each medical record was then reviewed by a vascular surgeon to determine if the assigned ICD code appropriately reflected the clinical scenario. CDU findings categorized as abnormal (>50% stenosis) or normal (<50% stenosis) were recorded. Each individual ICD code and group 1 (asymptomatic), group 2 (nonhemispheric symptoms), group 3 (hemispheric symptoms), group 4 (preoperative cardiovascular examination), and group 5 (nonspecific) ICD codes were analyzed for correlation with CDU results. RESULTS: Nine hundred ninety-four patients had 74 primary ICD codes listed as indications for CDU. Of assigned ICD codes, 17.4% were deemed inaccurate. Overall, 14.8% of CDU were abnormal. Of the 13 highest frequency ICD codes, only 433.10, an asymptomatic code, was associated with abnormal CDU. Four symptomatic codes were associated with normal CDU; none of the other high frequency codes were associated with CDU result. Patients in group 1 (asymptomatic) were significantly more likely to have an abnormal CDU compared to each of the other groups (P < 0.001, P < 0.001, P = 0.020, P = 0.002) and to all other groups combined (P < 0.001). CONCLUSIONS: Asymptomatic indications by ICD codes yielded higher rates of abnormal CDU than symptomatic indications. This finding is inconsistent with clinical experience and historical data, and we suggest that inaccurate coding may play a role. Limiting reimbursement for CDU in low-yield groups is reasonable. However, reimbursement policies based on ICD coding, for example, limiting payment for asymptomatic ICD codes, may impede use of CDU in high-yield patient groups.

Elimination of medically unnecessary duplex venous scanning based on an established algorithm can result in significant cost savings under Medicare for the institution and the taxpayer.

OBJECTIVE: The utility of duplex venous scanning (DVS) for suspected deep venous thrombosis in the emergency department (ED) remains controversial. We aimed to measure potential cost savings and economic impact in our institution and nationally for unnecessary DVS in Medicare patients seen in the ED. METHODS: We have previously calculated that 15.3% of DVS studies can safely be avoided in patients with suspected deep venous thrombosis in our ED with adherence to our protocol. The Medicare database was queried for the number of DVS studies performed in the ED and charges/payments made in 2011. Cost savings at our institution and nationally by Medicare were computed with the 15.3% number. RESULTS: In the study period, 2087 DVS studies were performed in our ED across all payers; 572 Medicare patients had 249 (43%) bilateral and 323 (57%) unilateral studies. Annual savings at our institution, with use of our protocol, were estimated at $113,778. Eliminating unnecessary after-hours DVS for 306,307 Medicare beneficiaries would result in $5,285,090 savings annually. CONCLUSIONS: Increasing pressure for cost containment under a value-based payment model necessitates critical evaluation of resource utilization. Applying this schema for all noninvasive vascular tests is an opportunity for responsible management of finite resources, reducing wasteful care, and significant cost containment.

Diversity in membership and leadership positions in a regional vascular society.

PURPOSE: To determine diversity in the membership and analyze representation of private practitioners and ethnic and racial minorities/women in senior leadership roles in a regional vascular society. METHODS: The program book distributed at the 2008 annual meeting was used to compile information on membership categories, academic status, gender, and ethnic origin of members. Excluded from further analysis were all but active and senior members (n = 386). Officers for President and current President-Elect (P, n = 31), Secretary (S, n = 10), Treasurer (T, n = 11), and Councilor (C, n = 33) over a 30-year period were scrutinized for similar information. Members were considered to be "academic" if they worked full time at an academic medical center or as faculty at a teaching hospital with a vascular fellowship and national recognition. Private practice (PP) or academic practice (AP) was determined by personal knowledge, mailing address, e-mail address, and search engines. Ethnic and racial origin was determined by name, personal knowledge, or a web search. RESULTS: Of the 386 active and senior members in the society, 86% were white, 13.7% were of various ethnic/racial groups, and 5.7% were women. Sixty-eight percent of members were in PP. Female members were more likely to be in AP compared with male members (68.1% vs 29.6%, P <.0002). White males made up 89.4% of all officers and 94.2% of all senior positions over the 30 years of the society. Seventy officer positions were occupied by those in AP (82.3%) vs 15 positions (18%) for the PP group. For the senior positions, 92.3% were from the AP group compared with the 8% from the PP group. (P < .0036) White male academics (WMAs) (23.7% of membership) occupied 86% of all senior leadership and 57% of C positions compared with 13% and 42%, respectively, for the rest of the membership (P < .0041). Of the 33 C positions, 66.6% were filled by members in AP. Of these 22 AP Councilors, 11 (50%) then moved up to senior leadership positions compared with two of 11 (18%) PP councilors (P = .07). CONCLUSIONS: Ethnic and racial minorities and women are under represented in the membership compared with the general population, medical school graduates, and faculty. PPs and non-white male academics are under represented in senior leadership positions. With changing demographics, a predicted shortage of vascular surgeons, the need for role models in leadership positions and a push to culturally competent care, regional and national societies must change course and promote a more diverse membership and representative senior leadership.