Medical Editor

Several months ago we asked our readers to respond to an eleven-part questionnaire dealing with outpatient endovascular centers (OECs). Forty-three of you took the time to respond, and most answered nearly every question; we thank you for taking the time to do so. Moreover, about 30%-50% of participants provided valuable comments on why they answered as they did.

OECs are attracting governmental attention in California as the legislature is writing new rules and regulations to help the Board of Medical Examiners (BME) increase their OEC oversight. The BME includes several doctors, but non-medical members are numerous. The one qualification they all have in common is that they are political appointees, and when the BME members were publically scolded regarding OECs they pledged to serve their anointers with greater focus. I interpreted that as meaning that OECs and their owners will be in the BME’s crosshairs. That comes as no surprise from a state that sent Pete Stark to Congress for more than 30 years.

So what did our survey tell us? For openers, 95% supported the concept of the surgeon-owned OEC. Enhanced quality and efficiency were incentives mentioned by some responders, while others expressed concern about over-utilization and conflicts of interest. Without further elaboration one person said: "it has changed my life." Eighty-one percent did not believe that OECs caused a conflict of interest. In 19 of the responses (the second highest number), the majority praised better patient care and satisfaction, despite a minority voicing concern. A total of 25 respondents thought that fixed imaging systems were unnecessary and portable C-arms were at least "adequate." On the other hand, 26% of the 43 respondents thought that fixed imagers were the way to go, but none offered any comments in their defense.

When asked about the effect of increased OEC activity, 62% opined that hospital volumes and expertise would decline. That makes sense even considering more liberal indications for intervention and the "cherry-picking" of the easier cases by OECs. There are only so many cases to go around and usually the doctors, not the hospitals, decide where the procedure will be performed. It seems paradoxical that the hospitals will wind up caring for the more difficult, more acute cases, while maintaining less overall experience. This subject will doubtless attract increased attention from "regulators" in the future.

I was intrigued by the answer to the question about OEC and hospital priveleges and viewed it as a portmanteau for concerns about quality of care in general. Nearly all (40 out of 43) believed that OEC practitioners should have equivalent hospital privileges, (but only eight offered comments, the fewest). The reasons given were varied including: "of course, we should not sacrifice quality;" "privileges will be required for the occasional admission;" a simple and unqualified "absolutely."

Referring to the possibility of over-utilization in OECs, 34 respondents thought it was a reasonable concern, with 18 offering varied and provocative comments. In a follow-up question – are OECs necessary because hospital based -fees have been cut excessively? – 65% said yes, commenting further that the efficiency of OECs, such as shorter case turnover times, was as much a driver of better financial compensation as fee profiles. Praise for the better morale, efficiency, and workflow streamlining of the OEC work environment crept into many of the questions.

As far as outcomes are concerned, only 1 respondent thought they were worse in OECs, and 98% thought they were as good or better. Improved patient satisfaction was cited more than once. Of those who owned or worked in OECs, more than 80% stated that they earned more by doing cases there rather than in the hospital. The nub of the remuneration was captured by one particular response: "by a longshot."

The final question came full circle back to where the questionnaire started, "Should the SVS develop a position paper on OECs?" To some the answer, in light of the ambiguity and controversy that our little questionnaire has kindled, is a resounding "Yes." At the very least we need a more comprehensive interrogation of the issue with more and better questions and a thorough profile of current practices. Two-thirds of the respondents were in favor of some sort of document, saying that it would help promulgate guidelines and prevent abuse that would result in "killing the golden goose," according to one comment.

On the other hand, not all feelings about SVS involvement were so felicitious. One expressed being tired of the "SVS, AMA telling us how to take care of our patients; the government does that well enough." Perhaps the overall ambivalence is summarized by this answer: "by maintaining no position they (the SVS) will not alienate or disenfranchise their members who do have an OEC."

So there you have it. Vascular Specialist published an editorial piece on OECs, and we sought to measure the sentiments of our readers, the members of the SVS. OECs appear to fill an important role and seem to be here to stay. Whether they will continue to provide a marginal improvement in payments to the owner-providers remains to be seen. Equally uncertain is their continued economic viability if they come to resemble a revolving door that has patients returning over and over for "re-dos."

At that point, it won’t make much difference what SVS or AMA think about OECs and quality and patient satisfaction. The sound you will hear is the Treasury when it turns off the printing presses.

Several months ago we asked our readers to respond to an eleven-part questionnaire dealing with outpatient endovascular centers (OECs). Forty-three of you took the time to respond, and most answered nearly every question; we thank you for taking the time to do so. Moreover, about 30%-50% of participants provided valuable comments on why they answered as they did.

OECs are attracting governmental attention in California as the legislature is writing new rules and regulations to help the Board of Medical Examiners (BME) increase their OEC oversight. The BME includes several doctors, but non-medical members are numerous. The one qualification they all have in common is that they are political appointees, and when the BME members were publically scolded regarding OECs they pledged to serve their anointers with greater focus. I interpreted that as meaning that OECs and their owners will be in the BME’s crosshairs. That comes as no surprise from a state that sent Pete Stark to Congress for more than 30 years.

So what did our survey tell us? For openers, 95% supported the concept of the surgeon-owned OEC. Enhanced quality and efficiency were incentives mentioned by some responders, while others expressed concern about over-utilization and conflicts of interest. Without further elaboration one person said: "it has changed my life." Eighty-one percent did not believe that OECs caused a conflict of interest. In 19 of the responses (the second highest number), the majority praised better patient care and satisfaction, despite a minority voicing concern. A total of 25 respondents thought that fixed imaging systems were unnecessary and portable C-arms were at least "adequate." On the other hand, 26% of the 43 respondents thought that fixed imagers were the way to go, but none offered any comments in their defense.

When asked about the effect of increased OEC activity, 62% opined that hospital volumes and expertise would decline. That makes sense even considering more liberal indications for intervention and the "cherry-picking" of the easier cases by OECs. There are only so many cases to go around and usually the doctors, not the hospitals, decide where the procedure will be performed. It seems paradoxical that the hospitals will wind up caring for the more difficult, more acute cases, while maintaining less overall experience. This subject will doubtless attract increased attention from "regulators" in the future.

I was intrigued by the answer to the question about OEC and hospital priveleges and viewed it as a portmanteau for concerns about quality of care in general. Nearly all (40 out of 43) believed that OEC practitioners should have equivalent hospital privileges, (but only eight offered comments, the fewest). The reasons given were varied including: "of course, we should not sacrifice quality;" "privileges will be required for the occasional admission;" a simple and unqualified "absolutely."

Referring to the possibility of over-utilization in OECs, 34 respondents thought it was a reasonable concern, with 18 offering varied and provocative comments. In a follow-up question – are OECs necessary because hospital based -fees have been cut excessively? – 65% said yes, commenting further that the efficiency of OECs, such as shorter case turnover times, was as much a driver of better financial compensation as fee profiles. Praise for the better morale, efficiency, and workflow streamlining of the OEC work environment crept into many of the questions.

As far as outcomes are concerned, only 1 respondent thought they were worse in OECs, and 98% thought they were as good or better. Improved patient satisfaction was cited more than once. Of those who owned or worked in OECs, more than 80% stated that they earned more by doing cases there rather than in the hospital. The nub of the remuneration was captured by one particular response: "by a longshot."

The final question came full circle back to where the questionnaire started, "Should the SVS develop a position paper on OECs?" To some the answer, in light of the ambiguity and controversy that our little questionnaire has kindled, is a resounding "Yes." At the very least we need a more comprehensive interrogation of the issue with more and better questions and a thorough profile of current practices. Two-thirds of the respondents were in favor of some sort of document, saying that it would help promulgate guidelines and prevent abuse that would result in "killing the golden goose," according to one comment.

On the other hand, not all feelings about SVS involvement were so felicitious. One expressed being tired of the "SVS, AMA telling us how to take care of our patients; the government does that well enough." Perhaps the overall ambivalence is summarized by this answer: "by maintaining no position they (the SVS) will not alienate or disenfranchise their members who do have an OEC."

So there you have it. Vascular Specialist published an editorial piece on OECs, and we sought to measure the sentiments of our readers, the members of the SVS. OECs appear to fill an important role and seem to be here to stay. Whether they will continue to provide a marginal improvement in payments to the owner-providers remains to be seen. Equally uncertain is their continued economic viability if they come to resemble a revolving door that has patients returning over and over for "re-dos."

At that point, it won’t make much difference what SVS or AMA think about OECs and quality and patient satisfaction. The sound you will hear is the Treasury when it turns off the printing presses.

Several months ago we asked our readers to respond to an eleven-part questionnaire dealing with outpatient endovascular centers (OECs). Forty-three of you took the time to respond, and most answered nearly every question; we thank you for taking the time to do so. Moreover, about 30%-50% of participants provided valuable comments on why they answered as they did.

OECs are attracting governmental attention in California as the legislature is writing new rules and regulations to help the Board of Medical Examiners (BME) increase their OEC oversight. The BME includes several doctors, but non-medical members are numerous. The one qualification they all have in common is that they are political appointees, and when the BME members were publically scolded regarding OECs they pledged to serve their anointers with greater focus. I interpreted that as meaning that OECs and their owners will be in the BME’s crosshairs. That comes as no surprise from a state that sent Pete Stark to Congress for more than 30 years.

So what did our survey tell us? For openers, 95% supported the concept of the surgeon-owned OEC. Enhanced quality and efficiency were incentives mentioned by some responders, while others expressed concern about over-utilization and conflicts of interest. Without further elaboration one person said: "it has changed my life." Eighty-one percent did not believe that OECs caused a conflict of interest. In 19 of the responses (the second highest number), the majority praised better patient care and satisfaction, despite a minority voicing concern. A total of 25 respondents thought that fixed imaging systems were unnecessary and portable C-arms were at least "adequate." On the other hand, 26% of the 43 respondents thought that fixed imagers were the way to go, but none offered any comments in their defense.

When asked about the effect of increased OEC activity, 62% opined that hospital volumes and expertise would decline. That makes sense even considering more liberal indications for intervention and the "cherry-picking" of the easier cases by OECs. There are only so many cases to go around and usually the doctors, not the hospitals, decide where the procedure will be performed. It seems paradoxical that the hospitals will wind up caring for the more difficult, more acute cases, while maintaining less overall experience. This subject will doubtless attract increased attention from "regulators" in the future.

I was intrigued by the answer to the question about OEC and hospital priveleges and viewed it as a portmanteau for concerns about quality of care in general. Nearly all (40 out of 43) believed that OEC practitioners should have equivalent hospital privileges, (but only eight offered comments, the fewest). The reasons given were varied including: "of course, we should not sacrifice quality;" "privileges will be required for the occasional admission;" a simple and unqualified "absolutely."

Referring to the possibility of over-utilization in OECs, 34 respondents thought it was a reasonable concern, with 18 offering varied and provocative comments. In a follow-up question – are OECs necessary because hospital based -fees have been cut excessively? – 65% said yes, commenting further that the efficiency of OECs, such as shorter case turnover times, was as much a driver of better financial compensation as fee profiles. Praise for the better morale, efficiency, and workflow streamlining of the OEC work environment crept into many of the questions.

As far as outcomes are concerned, only 1 respondent thought they were worse in OECs, and 98% thought they were as good or better. Improved patient satisfaction was cited more than once. Of those who owned or worked in OECs, more than 80% stated that they earned more by doing cases there rather than in the hospital. The nub of the remuneration was captured by one particular response: "by a longshot."

The final question came full circle back to where the questionnaire started, "Should the SVS develop a position paper on OECs?" To some the answer, in light of the ambiguity and controversy that our little questionnaire has kindled, is a resounding "Yes." At the very least we need a more comprehensive interrogation of the issue with more and better questions and a thorough profile of current practices. Two-thirds of the respondents were in favor of some sort of document, saying that it would help promulgate guidelines and prevent abuse that would result in "killing the golden goose," according to one comment.

On the other hand, not all feelings about SVS involvement were so felicitious. One expressed being tired of the "SVS, AMA telling us how to take care of our patients; the government does that well enough." Perhaps the overall ambivalence is summarized by this answer: "by maintaining no position they (the SVS) will not alienate or disenfranchise their members who do have an OEC."

So there you have it. Vascular Specialist published an editorial piece on OECs, and we sought to measure the sentiments of our readers, the members of the SVS. OECs appear to fill an important role and seem to be here to stay. Whether they will continue to provide a marginal improvement in payments to the owner-providers remains to be seen. Equally uncertain is their continued economic viability if they come to resemble a revolving door that has patients returning over and over for "re-dos."

At that point, it won’t make much difference what SVS or AMA think about OECs and quality and patient satisfaction. The sound you will hear is the Treasury when it turns off the printing presses.

This issue's editorial is a calling card by our newest editorial board member, Dr. Joseph Mills of the University of Arizona. Demography is destiny. For a triad of reasons, Southern Arizona is at the epicenter of the global diabetes epidemic. The Arizona vascular surgery group led by Dr. Mills serves Native Americans, Americans of Hispanic heritage, and an increasing number of aging baby boomers and the already elderly that have relocated to or retired in the Sonoran desert.

Within Dr. Mills' patient catchment area is the Tohono O'odham Nation (Pima Indian Community) with perhaps the highest incidence of diabetes of any population in the world. When he talks about diabetic gangrene, he knows whereof he speaks. Recall that more than 80% of non-traumatic major leg amputations occur in diabetics. And diabetics aren't the only groups that have a complex pathogenesis of the foot lesions that lead to amputation.

Age, comorbidities such as renal failure, and multilevel, infrapopliteal and even intrapedal occlusive disease increase the challenge of selecting and performing the best revascularization procedures; remember that you may only get one chance.

Arterial calcification is more pervasive than ever and experienced surgeons are often defeated by it in their revascularization attempts; calcification unquestionably makes everything harder. Anyone who confronts these patients on a regular basis knows how difficult it is to get the feet healed and the patient back to an independent ambulatory life.

Dr. Mills sees the way forward through a better understanding of the interaction of arterial pathology, infection, severity of foot ulceration, patient comorbidities and selection of the right clinical treatment. Short of one or more large-scale prospective randomized trials to perfect our treatment paradigms, Dr. Mills suggests that a well-performed, all-inclusive registry, perhaps via the VQI, may be the best way forward.

I, for one, agree with him.

This issue's editorial is a calling card by our newest editorial board member, Dr. Joseph Mills of the University of Arizona. Demography is destiny. For a triad of reasons, Southern Arizona is at the epicenter of the global diabetes epidemic. The Arizona vascular surgery group led by Dr. Mills serves Native Americans, Americans of Hispanic heritage, and an increasing number of aging baby boomers and the already elderly that have relocated to or retired in the Sonoran desert.

Within Dr. Mills' patient catchment area is the Tohono O'odham Nation (Pima Indian Community) with perhaps the highest incidence of diabetes of any population in the world. When he talks about diabetic gangrene, he knows whereof he speaks. Recall that more than 80% of non-traumatic major leg amputations occur in diabetics. And diabetics aren't the only groups that have a complex pathogenesis of the foot lesions that lead to amputation.

Age, comorbidities such as renal failure, and multilevel, infrapopliteal and even intrapedal occlusive disease increase the challenge of selecting and performing the best revascularization procedures; remember that you may only get one chance.

Arterial calcification is more pervasive than ever and experienced surgeons are often defeated by it in their revascularization attempts; calcification unquestionably makes everything harder. Anyone who confronts these patients on a regular basis knows how difficult it is to get the feet healed and the patient back to an independent ambulatory life.

Dr. Mills sees the way forward through a better understanding of the interaction of arterial pathology, infection, severity of foot ulceration, patient comorbidities and selection of the right clinical treatment. Short of one or more large-scale prospective randomized trials to perfect our treatment paradigms, Dr. Mills suggests that a well-performed, all-inclusive registry, perhaps via the VQI, may be the best way forward.

I, for one, agree with him.

This issue's editorial is a calling card by our newest editorial board member, Dr. Joseph Mills of the University of Arizona. Demography is destiny. For a triad of reasons, Southern Arizona is at the epicenter of the global diabetes epidemic. The Arizona vascular surgery group led by Dr. Mills serves Native Americans, Americans of Hispanic heritage, and an increasing number of aging baby boomers and the already elderly that have relocated to or retired in the Sonoran desert.

Within Dr. Mills' patient catchment area is the Tohono O'odham Nation (Pima Indian Community) with perhaps the highest incidence of diabetes of any population in the world. When he talks about diabetic gangrene, he knows whereof he speaks. Recall that more than 80% of non-traumatic major leg amputations occur in diabetics. And diabetics aren't the only groups that have a complex pathogenesis of the foot lesions that lead to amputation.

Age, comorbidities such as renal failure, and multilevel, infrapopliteal and even intrapedal occlusive disease increase the challenge of selecting and performing the best revascularization procedures; remember that you may only get one chance.

Arterial calcification is more pervasive than ever and experienced surgeons are often defeated by it in their revascularization attempts; calcification unquestionably makes everything harder. Anyone who confronts these patients on a regular basis knows how difficult it is to get the feet healed and the patient back to an independent ambulatory life.

Dr. Mills sees the way forward through a better understanding of the interaction of arterial pathology, infection, severity of foot ulceration, patient comorbidities and selection of the right clinical treatment. Short of one or more large-scale prospective randomized trials to perfect our treatment paradigms, Dr. Mills suggests that a well-performed, all-inclusive registry, perhaps via the VQI, may be the best way forward.

I, for one, agree with him.