Increasing the number of integrated vascular surgery residency positions is important to address the impending shortage of vascular surgeons in the United States.

OBJECTIVE: The demand for vascular surgeons is expected to far exceed the current supply. In an attempt to decrease the training duration and to address the impending shortage, integrated vascular surgery residencies were approved and have expanded nationally. Meanwhile, vascular fellowships have continued to matriculate approximately 120 trainees annually. We sought to evaluate the supply and demand for integrated vascular residency positions as well as changes in the quality of applicants. METHODS: We conducted a retrospective review of national data compiled by the Association of American Medical Colleges and the National Resident Matching Program regarding integrated vascular surgery residency programs (2008-2015) and fellowships (2007-2016). Variables reviewed included the total number of applicants, sex, U.S. vs international medical school enrollment, applications per program, and applicants per position. In addition, we conducted a retrospective review of applicants to the University of Massachusetts Medical School integrated vascular surgery residency program from 2008 to 2015 to examine these variables and United States Medical Licensing Examination Step 1 and Step 2 CK scores over time. RESULTS: The number of vascular surgery integrated residency positions increased from 4 in 2008 to 56 in 2015. Concurrently, the number of integrated residency applicants grew from 112 in 2008 to 434 in 2015. This increase has been predominantly driven by a 575% increase in U.S. graduate applicants and a 170% increase in women applicants. The percentage of international medical graduates has decreased by 17% during the study period. The total number of applicants per residency position increased from 5.9 to 7.8. Meanwhile, the number of vascular surgery fellowship positions remained stable with an applicant to position ratio near 1:1. At the University of Massachusetts Medical School, the mean United States Medical Licensing Examination Step 1 (226 to 235) and Step 2 CK (237 to 243) scores among integrated residency applicants have improved annually and typically exceed the national average among U.S. applicants who have matched in their preferred specialty. CONCLUSIONS: Since the approval of a primary certificate in vascular surgery and the subsequent rollout of integrated vascular residency programs, the number of residency programs and the quality of residency applicants have continued to increase. Demand from medical school applicants vastly outweighs the current supply of training positions by eightfold. In contrast, demand from fellowship applicants matches the supply of fellowship positions. The matriculation of additional trainees must be met with continued expansion of the integrated vascular surgery residency pathway to manage future public health needs.

A multidisciplinary approach to vascular surgery procedure coding improves coding accuracy, work relative value unit assignment, and reimbursement.

BACKGROUND: Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement. METHODS: This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy. RESULTS: During period 1, traditional coding resulted in a 4.4% (P = .004) loss in reimbursement and a 5.4% (P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding. CONCLUSIONS: Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement.

Creating and Maintaining a Successful Service Line in an Academic Medical Center at the Dawn of Value-Based Care: Lessons Learned From the Heart and Vascular Service Line at UMass Memorial Health Care.

The service line (SL) model has been proven to help shift health care toward value-based services, which is characterized by coordinated, multidisciplinary, high-quality, and cost-effective care. However, academic medical centers struggle with how to effectively set up SL structures that overcome the organizational and cultural challenges associated with simultaneously delivering the highest-value care for the patient and advancing the academic mission. In this article, the authors examine the evolution of UMass Memorial Health Care's heart and vascular service line (HVSL) from 2006 to 2011 and describe the impact on its success of multiple strategic decisions. These include key academic physician leadership recruitments and engagement via a matrixed governance and management model; development of multidisciplinary teams; empowerment of SL leadership through direct accountability and authority over programs and budgets; joint educational and training programs; incentives for academic achievement; and co-localization of faculty, personnel, and facilities. The authors also explore the barriers to success, including the need to overcome historical departmental-based silos, cultural and training differences among disciplines, confusion engendered by a matrixed reporting structure, and faculty's unfamiliarity with the financial and organizational skills required to operate a successful SL. Also described here is the impact that successful implementation of the SL has on creating high-quality services, increased profitability, and contribution to the financial stability and academic achievement of the academic medical center.

Developing a complex endovascular fenestrated and branched aortic program.

In 2008, the top priority in our division's 5-year strategic plan was "to become an internationally recognized center of excellence for the endovascular treatment of complex aortic pathology extending from the aortic valve to the external iliac artery." Five components were identified as "most critical" to achieve this strategic priority: (1) training at centers of excellence in complex endovascular repair; (2) industry partnership to improve access to developing technologies; (3) a fully integrated team approach with one leader involved in all steps of all cases; (4) prospective data collection; and (5) development and implementation of a physician-sponsored investigational device exemption for juxtarenal, pararenal, and thoracoabdominal aneurysms. We have now performed 49 repairs (16 commercially manufactured devices, 33 physician-modified devices) for 3 common iliac, 20 juxtarenal, 9 pararenal, and 17 thoracoabdominal aneurysms, using 142 fenestrations, branches, and scallops. All patients had complete 30-day follow-up for calculation of 30-day events. Kaplan-Meier analysis was used to calculate 1-year events. In 5 years, we developed a successful complex endovascular aortic program that uses fenestrated/branched repair techniques. A focused team strategic planning approach to program development is an effective way for vascular surgery divisions to gain experience and expertise with new complex technologies while ensuring acceptable patient outcomes.

Follow-up compliance after endovascular abdominal aortic aneurysm repair in Medicare beneficiaries.

OBJECTIVE: Lifelong imaging follow-up is essential to the safe and appropriate management of patients who undergo endovascular abdominal aortic aneurysm repair (EVAR). We sought to evaluate the rate of compliance with imaging follow-up after EVAR and to identify factors associated with being lost to imaging follow-up. METHODS: We identified a 20% sample of continuously enrolled Medicare beneficiaries who underwent EVAR between 2001 and 2008. Using data through 2010 from Medicare Inpatient, Outpatient, and Carrier files, we identified all abdominal imaging studies that may have been performed for EVAR follow-up. Patients were considered lost to annual imaging follow-up if they did not undergo any abdominal imaging study within their last 2 years of follow-up. Multivariable models were constructed to identify independent factors associated with being lost to annual imaging follow-up. RESULTS: Among 19,962 patients who underwent EVAR, the incidence of loss to annual imaging follow-up at 5 years after EVAR was 50%. Primary factors associated with being lost to annual imaging follow-up were advanced age (age 65-69 years, reference; age 75-79 years: hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.15-1.32; age 80-85 years: HR, 1.45; 95% CI, 1.35-1.55; age >85 years: HR, 2.03; 95% CI, 1.88-2.20) and presentation with an urgent/emergent intact aneurysm (HR, 1.27; 95% CI, 1.20-1.35) or ruptured aneurysm (HR, 1.84; 95% CI, 1.63-2.08). Additional independent factors included several previously diagnosed chronic diseases and South and West regions of the United States. CONCLUSIONS: Annual imaging follow-up compliance after EVAR in the United States is significantly below recommended levels. Quality improvement efforts to encourage improved compliance with imaging follow-up, especially in older patients with multiple comorbidities and in those who underwent EVAR urgently or for rupture, are necessary.

Institutional differences in carotid artery duplex diagnostic criteria result in significant variability in classification of carotid artery stenoses and likely lead to disparities in care.

BACKGROUND: The indications for carotid revascularization are based almost exclusively on the results of carotid duplex ultrasonography. Noninvasive vascular laboratories show large variation in the diagnostic criteria used to classify degree of carotid artery stenosis. We hypothesize that variability of these diagnostic criteria causes significant variation in stenosis classification directly affecting the number of revascularizations and associated costs. METHODS AND RESULTS: The diagnostic criteria to interpret carotid duplex ultrasounds were obtained from 10 New England institutions. All carotid duplex scans performed at our institution were reviewed from 2008 to 2012. Using the diagnostic criteria from each institution, the degree of stenosis that would have been reported was classified as 70% to 99% asymptomatic, 80% to 99% asymptomatic, and 50% to 99% symptomatic. We then calculated the theoretical number of carotid revascularization procedures that this cohort would be offered using each institution's diagnostic criteria and the costs of these procedures based on reimbursement rates. Among 10 614 patients who underwent 15 534 carotid duplex scans, 31 025 arteries were reviewed. Application of the 10 institutions' criteria to the patients from our institution yielded marked variation in the number classified as 70% to 99% asymptomatic (range, 186-2201), 80% to 99% asymptomatic (range, 78-426), and 50% to 99% symptomatic (range, 157-781). If revascularizations were based on these results, costs would range from $2.2 to $26 million, $0.9 to $5.0 million, and $1.9 to $9.2 million, respectively. CONCLUSIONS: Differences in diagnostic criteria to interpret carotid ultrasound result in significant variation in classification of carotid artery stenosis, likely leading to differences in the number and subsequent costs of revascularizations. This theoretical model highlights the need for standardization of carotid duplex criteria.

Derivation and validation of a practical risk score for prediction of mortality after open repair of ruptured abdominal aortic aneurysms in a US regional cohort and comparison to existing scoring systems.

OBJECTIVE: Scoring systems for predicting mortality after repair of ruptured abdominal aortic aneurysms (RAAAs) have not been developed or tested in a United States population and may not be accurate in the endovascular era. Using prospectively collected data from the Vascular Study Group of New England (VSGNE), we developed a practical risk score for in-hospital mortality after open repair of RAAAs and compared its performance to that of the Glasgow aneurysm score, Hardman index, Vancouver score, and Edinburg ruptured aneurysm score. METHODS: Univariate analysis followed by multivariable analysis of patient, prehospital, anatomic, and procedural characteristics identified significant predictors of in-hospital mortality. Integer points were derived from the odds ratio (OR) for mortality based on each independent predictor in order to generate a VSGNE RAAA risk score, which was internally validated using bootstrapping methodology. Discrimination and calibration of all models were assessed by calculating the area under the receiver-operating characteristic curve (C-statistic) and applying the Hosmer-Lemeshow test. RESULTS: From 2003 to 2009, 242 patients underwent open repair of RAAAs at 10 centers. In-hospital mortality was 38% (n = 91). Independent predictors of mortality included age >76 years (OR, 5.3; 95% confidence interval [CI], 2.8-10.1), preoperative cardiac arrest (OR, 4.3; 95% CI, 1.6-12), loss of consciousness (OR, 2.6; 95% CI, 1.2-6), and suprarenal aortic clamp (OR, 2.4; 95% CI, 1.3-4.6). Patient stratification according to the VSGNE RAAA risk score (range, 0-6) accurately predicted mortality and identified those at low and high risk for death (8%, 25%, 37%, 60%, 80%, and 87% for scores of 0, 1, 2, 3, 4, and ≥5, respectively). Discrimination (C = .79) and calibration (χ(2) = 1.96; P = .85) were excellent in the derivation and bootstrap samples and superior to that of existing scoring systems. The Glasgow aneurysm score, Hardman index, Vancouver score, and Edinburg ruptured aneurysm score correlated with mortality in the VSGNE cohort but failed to identify accurately patients with a risk of mortality >65%. CONCLUSIONS: Existing scoring systems predict mortality after RAAA repair in this cohort but do not identify patients at highest risk. This parsimonious VSGNE RAAA risk score based on four variables readily assessed at the time of presentation allows accurate prediction of in-hospital mortality after open repair of RAAAs, including identification of those patients at highest risk for postoperative mortality.

National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007.

OBJECTIVE: This study compared, at a national level, trends in utilization, mortality, and stroke after carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA) from 2005 to 2007. METHODS: The Nationwide Inpatient Sample (NIS) was queried for patient discharges with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CAS and CEA. The primary outcomes were in-hospital mortality, stroke, hospital charges, and discharge disposition. Subgroup analyses were performed to evaluate these outcomes by neurologic presentation using χ(2) and multivariable logistic regression. RESULTS: Of the 404,256 discharges for carotid revascularization, CAS utilization was 66% higher in 2006 than in 2005 (9.3% vs 14%, P = .0004). Crude mortality, stroke, and median charges remained higher for CAS than for CEA; discharge to home was more common after CEA. Results improved from 2005 to 2007. By logistic regression of the total cohort from 2005 to 2006, CAS was independently predictive of mortality (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.08-2.00; P < .0001). Independent predictors of stroke included CAS (OR, 1.43; 95% CI, 1.18-1.73; P < .0001) and symptomatic disease (OR, 2.4; 95% CI, 2.06-2.93;P < .0001). Among subgroups based on neurological presentation, regression showed that CAS significantly increased the odds of stroke in asymptomatic patients (OR, 1.6; 95% CI, 1.2-2.0; P = .0003). Among symptomatic patients, CAS increased the odds of in-hospital death (OR, 3.0; 95% CI, 1.7-5.1, P < .0001) and trended toward significance for stroke (OR, 1.7; 95% CI, 1.0-2.8; P = .0569). CONCLUSION: Utilization of CAS has increased from the years 2005 to 2007 with some improvements in the outcome. Despite improvements in outcome, resource utilization remains significantly higher for CAS than CEA.

Peripheral arterial interventions: trends in market share and outcomes by specialty, 1998-2005.

OBJECTIVE: Vascular surgeons (VS), interventional cardiologists (IC), and interventional radiologists (IR) perform peripheral arterial interventions (PAI). In this study, we reviewed market share trends and compared outcomes for each specialty using the National Inpatient Sample (NIS). METHODS: Patient discharges for PAI (1998-2005) were identified based on ICD9-CM procedure codes. The provider's specialty was identified by a specialty-specific algorithm and analyzed using SAS 9.1 (SAS Institute, Cary, NC). Market share trends and distribution of cases at teaching versus non-teaching hospitals were evaluated. Primary outcome measures were in-hospital mortality and iatrogenic arterial injuries (IAI). Multivariate logistic regression was performed to identify independent predictors of post-procedure morbidity and mortality. RESULTS: The number of cases identified was 23,825. From 1998 to 2005, IR's market share decreased six-fold (1998: 33% to 2005: 5.6%) whereas VS market share increased from 27% to 43% and IC from 10% to 29% (P < .05). A similar but more pronounced trend was observed at teaching hospitals. In-hospital mortality rate was highest for IR (2.1 IR% vs 1.2% VS and 0.6% IC; P < .001). Post-procedure IAI was highest in the IC group (1.3% vs IR 0.9% and 0.5% VS; P < .05). Compared with VS, the mortality rate was 1.62 times higher for IR patients (odds ratio [OR]: 1.62, 95% confidence interval [CI]: 1.16-2.24) and IAI was 2.44 times higher for IC (OR: 2.44, 95% CI: 1.63-3.66) and 1.75 times higher for IR (OR: 1.75, 95% CI: 1.08-2.81) patients. CONCLUSIONS: IR market share of PAI has precipitously declined while those of VS and IC have increased significantly. Vascular surgeons had the lowest overall morbidity and mortality of all groups. Increase in the number of endovascularly-trained VS with better access to fluoroscopy units may further increase VS's market share.

Endovascular treatment of ruptured abdominal aortic aneurysms in the United States (2001-2006): a significant survival benefit over open repair is independently associated with increased institutional volume.

OBJECTIVE: Endovascular aortic repair (EVAR) has gained wide acceptance for the elective treatment of abdominal aortic aneurysms (AAA), leading to interest in similar treatment of ruptured abdominal aortic aneurysms (RAAA). The purpose of this study was to evaluate national outcomes after EVAR for RAAA and to assess the effect of institutional volume metrics. METHODS: The Nationwide Inpatient Sample was used to identify patients treated with open or EVAR for RAAA, 2001-2006. Procedure volume was determined for each institution categorizing hospitals as low-, medium-, and high-volume. The primary outcome was in-hospital mortality. Secondary outcomes related to resource utilization. Multivariable logistic regression models were used to determine independent predictors of EVAR usage and mortality. RESULTS: From 2001 to 2006, an estimated 27,750 hospital discharges for RAAA occurred; 11.5% were treated with EVAR. EVAR utilization increased over time (5.9% in 2001 to 18.9% in 2006, P < .0001) while overall RAAA rates remained constant. EVAR had a lower overall in-hospital mortality than open repair (31.7% vs 40.7%, P < .0001), an effect which amplified when stratified by institutional volume. On multivariable regression, open repair independently predicted mortality (odds ratio [OR] 1.56; 95% confidence interval [CI] 1.29-1.89). EVAR usage for RAAA increased with age (>80 years) (OR 1.58; 95% CI 1.30-1.93), high elective EVAR volume (>40/y) vs medium (19-40/y) (OR 2.65; 95% CI 1.86-3.78) and low (<19/y) (OR 5.37; 95% CI 3.60-8.0). EVAR had a shorter length of stay (11.1 vs 13.8 days, P < .0001), higher discharges to home (65.1% vs 53.9%, P < .0001), and lower charges ($108,672 vs $114,784, P < .0001). CONCLUSIONS: In the United States, for RAAA, EVAR had a lower postoperative mortality than open repair. Higher elective open repair as well as RAAA volume increased this mortality advantage for EVAR. These results support regionalization of RAAA repair to high volume centers whenever possible and a wider adoption of endovascular repair of RAAA nationwide.

Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005.

OBJECTIVE: Carotid endarterectomy (CEA) remains the procedure of choice for treatment of patients with severe carotid artery stenosis. The role of carotid artery stenting (CAS) in this patient group is still being defined. Prior single and multicenter studies have demonstrated economic savings associated with CEA compared with CAS. The purpose of this study was to compare surgical outcomes and resource utilization associated with these two procedures at the national level in 2005, the first year in which a specific ICD-9 procedure code for CAS was available. METHODS: All patient discharges for carotid revascularization for the year 2005 were identified in the Nationwide Inpatient Sample based on ICD9-CM procedure codes for CEA (38.12) and CAS (00.63). The primary outcome measures of interest were in-hospital mortality and postoperative stroke; secondary outcome measures included total hospital charges and length of stay (LOS). All statistical analyses were performed using SAS version 9.1 (Cary, NC), and data are weighted according to the Nationwide Inpatient Sample (NIS) design to draw national estimates. Univariate analyses of categorical variables were performed using Rao-Scott chi(2), and continuous variables were analyzed by survey weighted analysis of variance (ANOVA). Multivariate logistic regression was performed to evaluate independent predictors of postoperative stroke and mortality. RESULTS: During 2005, an estimated 135,701 patients underwent either CEA or CAS nationally. Overall, 91% of patients underwent CEA. The mean age overall was 71 years. Postoperative stroke rates were increased for CAS compared with CEA (1.8% vs 1.1%, P < .05), odds ratio (OR) 1.7; (95% confidence interval [CI] 1.2-2.3). Overall, mortality rates were higher for CAS compared with CEA (1.1% vs 0.57%, P < .05) this difference was substantially increased in regard to patients with symptomatic disease (4.6% vs 1.4%, P < .05). By logistic regression, CAS trended toward increased mortality, OR 1.5; (95% CI .96-2.5). Overall, the median total hospital charges for patients that underwent CAS were significantly greater than those that underwent CEA ($30,396 vs $17,658 P < .05). CONCLUSIONS: Based on a large representative sample during the year 2005, CEA was performed with significantly lower in-hospital mortality, postoperative stroke rates, and lower median total hospital charges than CAS in US hospitals. As the role for CAS becomes defined for the management of patients with carotid artery stenosis, clinical as well as economic outcomes must be continually evaluated.

Integrated fellowship in vascular surgery and intervention radiology: a new paradigm in vascular training.

OBJECTIVE: To evaluate an integrated fellowship in vascular surgery and interventional radiology initiated to train vascular surgeons in endovascular techniques and to train radiology fellows in clinical aspects of vascular diseases. SUMMARY BACKGROUND DATA: The rapid evolution of endovascular techniques for the treatment of vascular diseases requires that vascular surgeons develop proficiency in these techniques and that interventional radiologists develop proficiency in the clinical evaluation and management of patients who are best treated with endovascular techniques. In response to this need the authors initiated an integrated fellowship in vascular surgery and interventional radiology and now report their interim results. METHODS: Since 1999 vascular fellows and radiology fellows performed an identical year-long fellowship in interventional radiology. During the fellowship, vascular surgery and radiology fellows perform both vascular and nonvascular interventional procedures. Both vascular surgery and radiology-based fellows spend one quarter of the year on the vascular service performing endovascular aortic aneurysm repairs and acquiring clinical experience in the vascular surgery inpatient and outpatient services. Vascular surgery fellows then complete an additional year-long fellowship in vascular surgery. To evaluate the type and number of interventional radiology procedures, the authors analyzed records of cases performed by all interventional radiology and vascular surgery fellows from a prospectively maintained database. The attitudes of vascular surgery and interventional radiology faculty and fellows toward the integrated fellowship were surveyed using a formal questionnaire. RESULTS: During the fellowship each fellow performed an average of 1,201 procedures, including 808 vascular procedures (236 diagnostic angiograms, 70 arterial interventions, 59 diagnostic venograms, 475 venous interventions, and 43 hemodialysis graft interventions) and 393 nonvascular procedures. On average fellows performed 20 endovascular aortic aneurysm repairs per year. There was no significant difference between the vascular surgery and radiology fellows in either the spectrum or number of cases performed. Eighty-eight percent (23/26) of the questionnaires were completed and returned. Both interventional radiologists and vascular surgeons strongly supported the integrated fellowship model and favored continuation of the integrated program. Vascular surgery and interventional radiology faculty members wanted additional training in clinical vascular surgery for the radiology-based fellows. With the exception of the radiology fellows there was uniform agreement that vascular surgery fellows benefit from training in nonvascular aspects of interventional radiology. CONCLUSIONS: Integration of vascular surgery and interventional radiology fellowships is feasible and is mutually beneficial to both disciplines. Furthermore, the integrated fellowship provides exceptional training for vascular surgery and interventional radiology fellows in all catheter-based techniques that far exceeds the minimum requirements for credentialing suggested by various professional societies. There is a clear need for cooperation and active involvement on the parts of the American Board of Radiology and the American Board of Surgery and its Vascular Board to create hybrid training programs that meet mutually agreed-on criteria that document sufficient acquisition of both the cognitive and technical skills required to manage patients undergoing endovascular procedures safely and effectively.