Physician Reimbursement for Vascular Surgery Procedures and Vascular Laboratory Studies Before and After the Affordable Care Act.

OBJECTIVES: The Patient Protection and Affordable Care Act (ACA), fully implemented by 2015, has significantly increased the number of Americans with health insurance. However, its impact on physician reimbursement (PR) is not well studied. Our objective was to determine the ACA's impact on the professional component of PR for selected vascular surgery (VS) procedures and vascular laboratory (VL) studies at our institution. METHODS: PR for the following 5 VS procedures and 4 VL studies were obtained from our billing department: CPT 34803 (Endovascular aortic repair, EVAR), 35301 (carotid endarterectomy, CEA), 35656 (lower extremity bypass, LEB), 36010 (introduction of catheter into vena cava, ICVC), 36200 first, 93922 (ankle brachial index, ABI), 93925 (lower extremity arterial duplex, LEA duplex), 93970 (lower extremity venous duplex, LEV Duplex), and 93990 (hemodialysis duplex). The data was organized by payer: Medicare, Medicaid, Commercial Insurers (CI), and Other. PR was studied pre-ACA (January 2008 through December 2009) and post-ACA (January 2015 through December 2016). The post-ACA PR and inflation adjusted reimbursement (IAR) in 2016 dollars using the consumer price index (CPI) were calculated and compared using one-sample t-test. The percent difference between the post-ACA PR and IAR was also compared. RESULTS: PR for 1,637 VS procedures and 16,333 VL studies was analyzed. The post-ACA PR was significantly lower than the IAR for most Medicare and Medicaid procedures. For EVAR, post-ACA reimbursement was overall on par with the IAR but significantly lower for Medicare. For CEA, post-ACA reimbursement was overall lower than IAR. For LEB, overall average PR was lower than IAR, with statistically significant lower Medicare and Medicaid (P < 0.001) payments. For ICAo, overall PR was significantly lower than the IAR and this was true across all insurance types. In contrast, for ICV, the post-ACA reimbursement was higher than IAR for all payers but did not reach statistical significance (P = 0.25). The post-ACA PR was significantly higher than the IAR for most VL studies, except for Medicare PR. The percent change for VS procedures were mostly negative for the Medicaid and Medicare groups. This results in potential annual shortcomings of $2, 862 and $20,923 respectively. CONCLUSION: When comparing reimbursement before and after ACA implementation, Medicare and Medicaid PR for most VS procedures has not kept up with inflation. However, for most VL procedures, PR has exceeded inflation. Further efforts are needed to support Vascular Surgery reimbursement including higher valuation of the Medicare Conversion factor.

The financial and employment effects of coronavirus disease 2019 on physicians in the United States.

Although the coronavirus disease 2019 (COVID-19) pandemic has created havoc with the U.S healthcare system and physicians, the financial and contractual implications for physicians are now beginning to come to the forefront. Financial assistance from the federal government has mainly been received by hospitals, which have borne the brunt of the COVID-19 illness. Some physician groups have, or are, receiving assistance through a few programs, although the accelerated and advance payments have been suspended. Employed surgeons are now being furloughed, terminated, or persuaded to agree to a significant cut in pay, forego bonuses, or take leave without pay as healthcare systems and some physician groups have started to experience the consequences of halting elective procedures. Newly hired surgeons might be forced in a few cases to agree to delays in starting their employment, new amendments, changes in employment status, and other terms for fear of losing their employment. In the present report, we have explained some agreement terminology and options available to allow physicians to understand the terms of their employment agreement and make their decisions after consulting with an expert healthcare attorney.

COVID-19 financial resources for physicians.

The appropriate focus in managing the COVID-19 pandemic in the United States has been addressing access and delivery of care to the population affected by the outbreak. All sectors of the U.S. economy have been significantly affected, including physicians. Physician groups of all specialties and sizes have experienced the financial effects of the pandemic. Hospitals have received billions of dollars to support and enable them to manage emergencies and cover the costs of the disruption. However, many vascular surgeons are under great financial pressure because of the postponement of all nonemergency procedures. The federal government has announced a myriad of programs in the form of grants and loans to reimburse physicians for some of their expenses and loss of revenue. It is more than likely that unless the public health emergency subsides significantly, many practices will experience dire consequences without additional financial assistance. We have attempted to provide a concise listing of such programs and resources available to assist vascular surgeons who are small businesses in accessing these opportunities.

Addition of Efficiency Measures to Current Accuracy Measures in the Vascular Laboratory Can Be Used for Future Accreditation and Payment Models.

BACKGROUND: The Medicare Access and CHIP Reauthorization Act (MACRA) brings with it increased regulatory requirements not traditionally addressed by standard vascular laboratory accreditation, which is based on accuracy. The new quality improvement project of the Intersocietal Accreditation Commission (IAC) may satisfy an improvement activity (IA) of the MACRA. We hypothesize that other IAs in the MACRA such as timeliness of test results or patient care quality performance requirements can be met by analyzing data already being collected by the vascular laboratory. After a process improvement strategy, we chose to review progress in our vascular laboratory related to time to interpretation (TI), patient check-in to study completion (study time), wait time for first available outpatient venous duplex scan (wait time), technologist productivity, and critical results reporting. METHODS: Data from our hospital-based vascular laboratory were collected from 2010 to 2016. TI was collected through our reporting software VascuPro (Consensus Medical), and study time and wait time were obtained from electronic medical records (EMR) (Epic). Technologist productivity was calculated by commercially available productivity tools, and compliance with critical results reporting was calculated quarterly as per our quality assurance program. Appropriateness of carotid duplex scan testing was performed by expert review of International Classification of Disease codes used to request the test. RESULTS: TI analysis comprised 91,352 studies with a mean of 3.3 hr between test completion and final interpretation. The TI improved from 5.0 to 2.1 hr on weekdays and was longer on weekends (4.9 hr; P < 0.001). The study time improved from 29.8 to 27.2 min and was 14.9 min shorter on the weekends (P < 0.001). The wait time ranged from a mean of 1-2.08 days. Technologist productivity improved from 90.7% to 93.6%. Critical results reporting quarterly audits showed a 100% compliance rate. On expert review, the International Classification of Disease code on carotid duplex scan requests in the EMR was deemed inaccurate in 17.4% of cases. CONCLUSIONS: TI and study time improved; wait time and critical results reporting remained steady. Most of the data are readily available in a vascular laboratory standard EMR. The plan-do-study-act (PDSA or Shewhart Cycle) principle is critical to process improvement and needed as we transition from traditional accreditation mostly based on test accuracy to one demanding efficiency, timeliness, patient satisfaction, productivity, accountability, and appropriateness of testing. Process improvement studies will improve patient care and satisfaction, increase efficiency and throughput, while satisfying changing IAC standards and preparing for upcoming regulatory requirements of the MACRA.

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.

Variability in Noninvasive Vascular Laboratory Experience of Vascular Surgery Training Programs Based on Survey of Trainees Suggests the Need for a Standardized Curriculum.

BACKGROUND: Although a Registered Physician in Vascular Interpretation certification is required for vascular surgery board certification, no standardized noninvasive vascular laboratory (NIVL) curriculum for vascular surgery trainees exists. The purpose of this study is to investigate the NIVL experience of trainees and understand what helps them feel well prepared. METHODS: Current trainees in all 0 + 5 and 5 + 2 vascular surgery training programs (114) were surveyed. The most complete survey from each program was included in the analysis. Programs were divided into those in which trainees felt well prepared (WP) and those in which trainees felt unprepared (UP) for the Physician Vascular Interpretation (PVI) examination. Responses for the 2 groups were compared. RESULTS: Responses from 61 of the 114 programs (53.5%) were analyzed. Most programs devote <0.5 days per week to the NIVL (52.5%), assign lectures and textbook reading (55.7% and 47.5%), and provide hands-on experience with vascular technologists (60.7%) and attending surgeons (52.5%). Respondents from 15 programs (24.6%) took a PVI examination review course. The first-time PVI examination pass rate was 92.9% (13 of 14 trainees). The WP group reported higher rates of a structured curriculum for the NIVL (100% vs. 33.3%, P = 0.0001), one-on-one time with vascular technologists (78.6% vs. 44.4%, P = 0.05), mandatory lectures (78.6% vs. 33.3%, P = 0.004), and assigned articles (64.3% vs. 11.1%, P = 0.002). CONCLUSIONS: There is wide variation in NIVL experience among vascular surgery training programs. Many trainees feel unprepared for the PVI examination, especially those without a structured curriculum. These results suggest that a structured NIVL curriculum that includes dedicated time with vascular technologists, lectures, and articles should be established.

The Impact of Burnout on the Obstetrics and Gynecology Workforce.

Although there has been discussion of a shortage of surgical specialties including OB/GYN, consensus is difficult because of the multiple variables involved in estimating both supply and demand. In addition, burnout has become more recognized as a variable that has not been taken into account in estimating a shortage of OB/GYNs. We estimate OB/GYN physician shortages of 17%, 24%, and 31% by 2030, 2040, and 2050, respectively. Here, we examine the impact of burnout on the OB/GYN workforce. Specifically, we address the associations of burnout, reduction in clinical productivity as well as early retirement. We also discuss the implications of the substantial increase of female OB/GYNs to ∼66% of workforce over the next 10 years and how this may impact the impending OB/GYN shortage. Finally, we briefly consider possible solutions to workforce issues causing burnout.

Common carotid artery end-diastolic velocity and acceleration time can predict degree of internal carotid artery stenosis.

OBJECTIVE: Whereas duplex ultrasound parameters for predicting internal carotid artery (ICA) stenosis are well defined, the use of common carotid artery (CCA) Doppler characteristics to predict ICA stenosis when the ICA cannot be insonated directly or accurately because of anatomy, calcification, or tortuosity has not been studied. The objective of this study was to identify CCA Doppler parameters that may predict ICA stenosis. METHODS: We reviewed all patients at our institution who underwent carotid duplex ultrasound (CDU) from 2008 to 2015 and also had a comparison computed tomography, magnetic resonance, or catheter angiogram. We excluded patients whose CDU examination did not correlate with the comparison study, those whose arteries were not visualized on the comparison study, and those with complete occlusion of the CCA. We collected CCA peak systolic velocity (PSV), end-diastolic velocity (EDV), and acceleration time (AT) in addition to CDU and comparison imaging interpretation of degree of stenosis. A multivariate model was used to identify predictors of ICA stenosis. RESULTS: There were 99 CDU examinations with corresponding comparison imaging included. For every increase of 10 cm/s in EDV in the CCA, the odds of a >50% ICA stenosis being present vs a ≤50% ICA stenosis decreased by 37% (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.41-0.97; P = .03). For every increase of 10 cm/s in EDV in the CCA, the odds of a 70% to 99% ICA stenosis being present vs a ≤50% ICA stenosis decreased by 48% (OR, 0.52; 95% CI, 0.28-0.94; P = .03). A CCA EDV of 19 cm/s or below was associated with a 64% probability of a 70% to 99% ICA stenosis. For every 50-millisecond increase in AT in the CCA, the odds of a >50% stenosis being present vs a ≤50% ICA stenosis increased by 56% (OR, 1.56; 95% CI, 1.03-2.35; P = .04). A CCA AT of 80 milliseconds or above was associated with a 69% probability of a >50% ICA stenosis. There was no correlation between CCA PSV and ICA stenosis. CONCLUSIONS: CCA EDV and AT are independent predictors of ICA stenosis and may be used in the setting of patients whose ICA cannot be directly insonated or when standard duplex ultrasound parameters of ICA PSV, EDV, or ICA/CCA ratio conflict.

Analysis of Compensation Disparities between Junior Academic and Private Practice Vascular Surgeons.

BACKGROUND: Compensation may be a significant factor for academic vascular surgeons seeking or changing employment. We compared compensation for academic and private practice vascular surgeons practicing for approximately similar duration. METHODS: Compensation data for academic and private practice vascular surgeons were obtained from the Association of American Medical Colleges (AAMC) and Medical Group Management Association (MGMA), respectively. Comparisons of nominal annual compensation data were made between Group 1 (assistant professor vascular surgeons versus private practice vascular surgeons in practice for 1-7 years), Group 2 (associate professor vascular surgeons versus private practice vascular surgeons in practice for 8-17 years), and Group 3 (professor vascular surgeons versus private practice vascular surgeons in practice for ≥18 years) from 2003 to 2012. RESULTS: In Group 1, there was a $54,500 difference in 2003 (P = 0.043) which increased to $110,500 by 2012 (P = 0.001). In Group 2, there was a $44,200 difference in 2007 (P = 0.016) which increased to $53,400 by 2010 (P = 0.034). In Group 3, there was no statistically significant difference in compensation (P ≥ 0.999). CONCLUSIONS: There is a significant and increasing disparity in compensation in favor of private practice vascular surgeons compared with assistant professor vascular surgeon faculty. Differences equalized with increasing seniority and experience. Compensation plans should be market based and in line with nonacademic benchmarks as well.

Popliteal Artery Cystic Adventitial Disease: Early Lessons in Treatment.

BACKGROUND: We present 6 patients who had operative repair of symptomatic popliteal cystic adventitial disease (pCAD). Developmental theories for pCAD and surgical alternatives are presented. METHODS: All patients who had repair of pCAD over the past 3 years are included. RESULTS: Three patients had cyst excision alone, whereas the remaining 3 had cyst and artery excision with interposition vein grafting. Cyst recurrence occurred in 2 patients who had cyst excision alone. Four of the patients had a patent communication between the cyst and the joint capsule. CONCLUSIONS: Our small series suggests that the articular (synovial) theory of development may be the most likely and that cyst and artery excision with interposition vein grafting may be preferred over cyst excision alone.

Isolated Great Saphenous Vein Thrombus Is Associated with High Rates of Complications regardless of Management.

BACKGROUND: Isolated great saphenous vein thrombus (GSVT) is generally regarded as benign, and treatment is heterogeneous. Complications include thrombus propagation, new saphenous vein thrombosis, deep vein thrombosis (DVT), pulmonary embolism (PE), and symptom persistence. Our objective was to review our institution's experience with isolated GSVT to understand its natural history, the frequency of complications, real-world treatment, and the impact of proximity to the saphenofemoral junction (SFJ), on the rate of complications. METHODS: Records of patients who had lower extremity venous duplex (LEVD) demonstrating GSVT without concomitant DVT between July 2008 and June 2014 were reviewed. Demographic, medical, management, outcomes, and follow-up LEVD data were collected. RESULTS: Of 605 patients with acute GSVT, 67 limbs in 61 patients with isolated GSVT were the study group; 14.8% of patients had a hypercoagulable state, 31.1% had prior GSVT or DVT, and 23.0% of patients had malignancy; 28.4% of GSVT were observed, 13.4% were treated with aspirin/NSAIDs, and 58.2% were anticoagulated; 38.8% of limbs remained symptomatic following treatment at a mean follow-up period of 761 days; 37 limbs had GSVT <5 cm of the SFJ (group 1), and 30 had GSVT >5 cm from the SFJ (group 2). Seven patients developed PE, all in group 1 (P = 0.02). Twenty-nine limbs (43.3%) had follow-up LEVD at a mean of 23 days. In this subset, 13 patients at the initial scan (44.8%) had thrombus <5 cm of the SFJ (group 1) and 16 (55.2%) had thrombus >5 cm from the SFJ (group 2). Five limbs (17.2%) had GSVT propagation/new superficial vein thrombosis (SVT), and 6 (20.7%) developed new DVT. There was no GSVT propagation/new SVT in group 1, whereas 5 limbs (31.2%) had GSVT propagation/new SVT in group 2 (P = 0.048). DVT occurred in 2 limbs (15.3%) in group 1 and 4 limbs (25%) in group 2. CONCLUSIONS: Isolated GSVT tends to affect patients with hypercoagulable states, prior venous thromboembolism, malignancy, or recent surgery. Management is heterogeneous, and type of treatment does not seem to affect outcomes. Patients with GSVT have significant risk of persistent symptoms, recurrence, DVT, and PE. GSVT within 5 cm of the SFJ seemed to be associated with an increased rate of PE. GSVT more than 5 cm from the SFJ seemed to be associated with propagation/new SVT. Proximity to the SFJ did not impact occurrence of DVT.

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.

Comparison of time utilization in an academic inpatient versus an outpatient vascular laboratory.

PURPOSE: Efficient, cost-effective services in vascular laboratories (VLs) will be required in tomorrow's health care environment. Inpatient VLs (IPVL) are burdened with complex patients, excessive workload, and a high percentage of bedside tests. Outpatient VLs (OPVL) are therefore presumed to be more productive and efficient. We compared time utilization in OPVLs and IPVL to test this hypothesis. METHODS: Vascular sonographers at an academic IPVL and OPVL were asked to track their daily activities during five consecutive weekdays. Test type, scan time, delays in patient arrival, preparation for the test, computer entry, and administrative time (patient- and non-patient-related) were logged. RESULTS: Delay in patient arrival and non-patient-related administration activities were both significantly greater in the OPVL (p < 0.01 and 0.03, respectively). Actual scan time occupied only 38.8% of the technologist's day, with the rest spent on patient- and non-patient-related activities. CONCLUSIONS: No appreciable differences were noted between IPVL and OPVL in most of the efficiency parameters measured. General administration time and delay in patient arrival were greater in the OPVL. Thus, OPVL were not more efficient than IPVL. In order to maximize efficiency in the OPVL, non-patient-related activities, which occupy over a quarter of the daily workday, must be shifted from technologists to support staff. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:540-544, 2016.

Talent management and physician leadership training is essential for preparing tomorrow's physician leaders.

Talent management and leadership development is becoming a necessity for health care organizations. These leaders will be needed to manage the change in the delivery of health care and payment systems. Appointment of clinically skilled physicians as leaders without specific training in the areas described in our program could lead to failure. A comprehensive program such as the one described is also needed for succession planning and retaining high-potential individuals in an era of shortage of surgeons.

Essentials of negotiating for employment in a changing environment.

Evolving changes in health care in the United States are causing new graduates and self-employed physicians to consider employment with large groups and health systems. Familiarity with the principles, proper conduct, and mechanics of negotiating an employment agreement will be important for vascular surgeons making such a decision. The various components of compensation packages and contract language need to be critically evaluated. To facilitate an understanding of the complexities involved in employment contracts, strategies to avoid making negotiating mistakes are discussed.

Single-specialty versus multispecialty vascular surgery group model.

The shift in employment options for vascular surgeons in the current era of major health care reform is being widely debated. After the decision to seek hospital employment or independent practice, the choice of then practicing in a single-specialty or a multispecialty practice remains a difficult decision. Although the trend is toward medium-sized to large-sized groups, only 1.2% of medical practices currently have >11 physicians. Barring the large multispecialty groups, such as Kaiser Permanente, Cleveland Clinic, or Mayo Clinic, most vascular practices are constituted as small groups. Which format prospers will depend on adroit management of financial and intellectual capital and nimbleness in adapting to rapidly changing market conditions. In this report, two practicing vascular surgeons debate the merits of single or multispecialty practice, with a commentary to follow.

Trends in a changing vascular practice environment for members of the Society for Vascular Surgery.

OBJECTIVE: To survey the Society for Vascular Surgery (SVS) membership with regard to practice trends related to work effort, employment status, practice ownership, endovascular cases, and anticipated changes in practice in the near future. METHODS: A survey questionnaire was developed to gather information about member demographics and practice, hours worked, full-time (FT) or part-time status, employment status, practice ownership, competition for referrals, proportion of endovascular vs open procedures, and anticipated changes in practice in the next 3 years. We used SurveyMonkey and distributed the survey to all active vascular surgeon (VS) members of the SVS. RESULTS: The response rate was 207 of 2230 (10.7%). Two thirds were in private practice, and 21% were in solo practice. Twenty-four percent were employed by hospitals/health systems. Those VS under the age of 50 years were more likely to exclusively practice vascular surgery compared with VS over the age of 50 years (P = .0003). Sixty-eight of the physicians (32.7%) were between 50 and 59 years old, 186 (90.3%) were men, 192 (92.8%) worked FT (>36 hours of patient care per week), and almost two thirds worked >60 hours per week. Those in physician-owned practices worked >40 hours of patient care per week more often than did FT employed VS (P = .012). Younger VS (age <50 years) more frequently reported >50% of their workload being endovascular compared with older VS (age ≥50 years; P < .001). Eighty percent of FT VS planned to continue their current practice over the next 3 years. Of the 43.6% indicating loss of referrals, 82% pointed to cardiologists as the competition. CONCLUSIONS: The current workforce is predominately male and works FT; one-third is between the ages of 50 and 59 years. Younger VS (age <50 years) are more likely to exclusively practice VS and have a higher caseload of endovascular procedures. Those in physician-owned practices are more likely to put in >40 hours of patient care per week than are FT employed VS. Longitudinal surveys of SVS members are imperative to help tailor educational, training, and practice management offerings, guide governmental activities, advocate for issues important to members, improve branding initiatives, and sponsor workforce analyses.

Clinical evaluation of suspected deep vein thrombosis guides the decision to anticoagulate prophylactically but does not impact the decision to perform after hours duplex venous scanning or increase its yield.

OBJECTIVE: The utility of after-hours duplex venous scanning (DVS) for suspected deep vein thrombosis (DVT) in emergency department (ED) patients has been debated. Availability of safe prophylactic low molecular weight heparin, cost containment efforts, and retention of scarce sonographers have to be balanced against 24/7 demand for services. We determined the incidence of DVT in DVS ordered after-hours, correlation between Wells' score and prophylactic anticoagulation as well as urgently performed DVS, and complications of delaying DVS until regular hours. METHODS: Records of all ED encounters between July 1, 2009 and June 30, 2010 associated with a DVS ordered after-hours were reviewed. The decisions to prophylactically anticoagulate and whether to perform DVS urgently or delayed until regular hours were at the discretion of the ED physician and a vascular surgeon. DVS findings, number of urgent and delayed studies, Wells' scores, D-dimers, and outcomes were recorded. RESULTS: DVT was found in 12% (22) of 181 DVS ordered after-hours. DVT was found in 19% of 42 DVS done urgently and in 10% of 139 DVS delayed an average 10 hours 17 minutes (P = NS). All patients had Wells' scores and 43 had D-dimers. Furthermore, 76% of patients with a Wells' score ≥3 had prophylactic anticoagulation whereas only 39% of patients with a Wells' score <3 had prophylactic anticoagulation (P = .0001). In contrast, 36% of patients with a Wells' score ≥3 had urgent DVS and 20% of patients with a Wells' score <3 had urgent DVS (P = NS). Prophylactic anticoagulation was given to 86% of patients eventually found to have DVT vs 40% of patients eventually found to have no DVT (P < .0001). There were no pulmonary emboli or bleeding complications. CONCLUSIONS: The incidence of DVT in ED patients who had urgent after-hours DVS was no different than in those whose DVS was delayed until regular hours. High pretest probability can be achieved with clinical evaluation prior to DVS, and this guided the decision to prophylactically anticoagulate but did not impact the decision to perform urgent DVS. Most patients eventually found to have DVT did receive prophylactic anticoagulation, and delay of DVS did not result in complications. We believe that most patients in whom there is high clinical suspicion for DVT can safely get prophylactic anticoagulation and delayed DVS. Patients in whom there is low clinical suspicion should not get urgent DVS.

Use, misuse, and underuse of work relative value units in a vascular surgery practice.

Health care reform is forcing "alignment" between hospitals and physicians. The acceleration of employment of physicians by hospitals is bringing into focus contractual terms where compensation is tied to clinical productivity. Physician productivity is being almost entirely defined by work relative value units (WRVUs). However, vascular surgeons may bring value to a health system in ways that are unique and separate from clinical revenue as measured by WRVUs. Incentives for physicians should also be tied to behaviors that are desired, such as quality of care, efficiency, patient outcomes, patient satisfaction scores, teaching, and research, depending on the specific environment. Vascular surgeons must be aware of proper use and misuse of WRVUs and have access to the most appropriate benchmarks in negotiations for employment. With increasing employment of physicians by hospitals and focus on "alignment," a more comprehensive measure of physician productivity is necessary.

Changing practice paradigms: negotiating your future.

There are many recent and ongoing changes in the practice of medicine from a business standpoint as well as in overall practice management. Economic and lifestyle desires have pushed many physicians to a decision point of whether or not to join a large multispecialty group or to sell their practice and become an employee of a hospital system. There are advantages and disadvantages to both options; however, deciding on the most appropriate path for each individual can be a daunting task. At our recent breakfast session at the vascular annual meeting in Chicago, Illinois, in June 2011, we brought to light these topics to try and help enlighten physicians on which option may be right for them. There is no single answer/option that will fit every practice, but discussion for various practice management designs are outlined and critiqued. This article cannot fully discuss each view in the allotted space, but it is designed to encourage thought and discussion among the vascular surgical community as a whole.