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‘Good Outcomes Not Good Enough’
A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.
Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”
He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.
He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.
“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”
Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.
She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.
As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.
She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.
Anton Sidawy, MD, MPH, FACS, professor and chair of the Department of Surgery at the George Washington University Medical Center, discussed how SVS is working with the American College of Surgeons to develop certification for vascular surgery centers. He addressed the need for organizations such as SVS to take the initiative in defining quality and value for the field, in no small part because payment models are shifting from the rewarding of volume to the rewarding of value.
Defining value may come from many sources: government, private insurers, and the public. Unless SVS has a strong voice in defining value, it may find itself not pleased with the results, according to Dr. Sidawy.
Then Fred A. Weaver, MD, chair of the SVS Patient Safety Organization and professor of surgery and chief of the vascular surgery division at Keck School of Medicine of University of Southern California, described the current state of the Vascular Quality Initiative. This is an SVS database whose 12 registries have gathered demographic, clinical, procedural and outcomes data from more than 500,000 vascular procedures performed in North America in 18 regional quality groups.
Currently, the VQI is comprised of 571 centers in the United States and Canada, with one in Singapore. Of particular importance, the makeup of the practitioners involved in the VQI is very diverse in specialty training, with only 41% of the membership being vascular surgeons.
In the near future, three more VQI registries are coming, according to Dr. Weaver: An ultrasound registry (in concert with the Society of Vascular Ultrasound); Venous Stenting; and Vascular Medicine (in concert with the American Heart Association).
Dr. Weaver emphasized how tracking outcomes is crucial for both vascular surgeons and certified vascular surgery centers to assess and improve their performance and how the VQI is critical to these endeavors.
Finally, Larry Kraiss, MD, chair of the SVS Quality Council and professor and chief of the vascular surgery division at the University of Utah, presented the goals of the new SVS council and described how the council is expanding the quality mission to include appropriate use criteria in addition to the long-standing clinical practice guidelines the SVS produces.
Dr. Kraiss elaborated how Appropriate Use Criteria (AUC) perform a substantially different role than that of Clinical Practice Guidelines (CPG).
Since 2006, SVS has developed 13 active guidelines, with more on the way. Guidelines provide positive yes/no statements with regard to treatment decision-making. However, many patients fall outside the guidelines, often due to comorbidities or other confounding factors, and appropriate use criteria are vital in these cases to evaluate where on a spectrum the patient fits for making a decision with regard to performing an operation or the use of a device.
Appropriate use criteria can be developed through the use of risk assessment to determine where on the spectrum of safety and effectiveness a particular patient falls with regard to a particular procedure or device. A major role of the new SVS Quality Council is to develop appropriate use criteria using outcome tools such as VQI and to provide recommendations as to how individuals and institutions could improve their performance by taking into account risk factors and assess infrastructural needs.
“The SVS board has authorized development of AUC in particular areas,” said Dr. Kraiss. “This process with be closely tied with updating the CPG. The first commissioned AUC will be to address intermittent claudication. But I invite the membership to participate in this process, especially on the panels, which can have up to 17 members, and we envision AUC coming out in carotid intervention, AAA management, and venous disease,” he added.
A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.
Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”
He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.
He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.
“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”
Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.
She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.
As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.
She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.
Anton Sidawy, MD, MPH, FACS, professor and chair of the Department of Surgery at the George Washington University Medical Center, discussed how SVS is working with the American College of Surgeons to develop certification for vascular surgery centers. He addressed the need for organizations such as SVS to take the initiative in defining quality and value for the field, in no small part because payment models are shifting from the rewarding of volume to the rewarding of value.
Defining value may come from many sources: government, private insurers, and the public. Unless SVS has a strong voice in defining value, it may find itself not pleased with the results, according to Dr. Sidawy.
Then Fred A. Weaver, MD, chair of the SVS Patient Safety Organization and professor of surgery and chief of the vascular surgery division at Keck School of Medicine of University of Southern California, described the current state of the Vascular Quality Initiative. This is an SVS database whose 12 registries have gathered demographic, clinical, procedural and outcomes data from more than 500,000 vascular procedures performed in North America in 18 regional quality groups.
Currently, the VQI is comprised of 571 centers in the United States and Canada, with one in Singapore. Of particular importance, the makeup of the practitioners involved in the VQI is very diverse in specialty training, with only 41% of the membership being vascular surgeons.
In the near future, three more VQI registries are coming, according to Dr. Weaver: An ultrasound registry (in concert with the Society of Vascular Ultrasound); Venous Stenting; and Vascular Medicine (in concert with the American Heart Association).
Dr. Weaver emphasized how tracking outcomes is crucial for both vascular surgeons and certified vascular surgery centers to assess and improve their performance and how the VQI is critical to these endeavors.
Finally, Larry Kraiss, MD, chair of the SVS Quality Council and professor and chief of the vascular surgery division at the University of Utah, presented the goals of the new SVS council and described how the council is expanding the quality mission to include appropriate use criteria in addition to the long-standing clinical practice guidelines the SVS produces.
Dr. Kraiss elaborated how Appropriate Use Criteria (AUC) perform a substantially different role than that of Clinical Practice Guidelines (CPG).
Since 2006, SVS has developed 13 active guidelines, with more on the way. Guidelines provide positive yes/no statements with regard to treatment decision-making. However, many patients fall outside the guidelines, often due to comorbidities or other confounding factors, and appropriate use criteria are vital in these cases to evaluate where on a spectrum the patient fits for making a decision with regard to performing an operation or the use of a device.
Appropriate use criteria can be developed through the use of risk assessment to determine where on the spectrum of safety and effectiveness a particular patient falls with regard to a particular procedure or device. A major role of the new SVS Quality Council is to develop appropriate use criteria using outcome tools such as VQI and to provide recommendations as to how individuals and institutions could improve their performance by taking into account risk factors and assess infrastructural needs.
“The SVS board has authorized development of AUC in particular areas,” said Dr. Kraiss. “This process with be closely tied with updating the CPG. The first commissioned AUC will be to address intermittent claudication. But I invite the membership to participate in this process, especially on the panels, which can have up to 17 members, and we envision AUC coming out in carotid intervention, AAA management, and venous disease,” he added.
A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.
Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”
He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.
He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.
“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”
Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.
She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.
As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.
She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.
Anton Sidawy, MD, MPH, FACS, professor and chair of the Department of Surgery at the George Washington University Medical Center, discussed how SVS is working with the American College of Surgeons to develop certification for vascular surgery centers. He addressed the need for organizations such as SVS to take the initiative in defining quality and value for the field, in no small part because payment models are shifting from the rewarding of volume to the rewarding of value.
Defining value may come from many sources: government, private insurers, and the public. Unless SVS has a strong voice in defining value, it may find itself not pleased with the results, according to Dr. Sidawy.
Then Fred A. Weaver, MD, chair of the SVS Patient Safety Organization and professor of surgery and chief of the vascular surgery division at Keck School of Medicine of University of Southern California, described the current state of the Vascular Quality Initiative. This is an SVS database whose 12 registries have gathered demographic, clinical, procedural and outcomes data from more than 500,000 vascular procedures performed in North America in 18 regional quality groups.
Currently, the VQI is comprised of 571 centers in the United States and Canada, with one in Singapore. Of particular importance, the makeup of the practitioners involved in the VQI is very diverse in specialty training, with only 41% of the membership being vascular surgeons.
In the near future, three more VQI registries are coming, according to Dr. Weaver: An ultrasound registry (in concert with the Society of Vascular Ultrasound); Venous Stenting; and Vascular Medicine (in concert with the American Heart Association).
Dr. Weaver emphasized how tracking outcomes is crucial for both vascular surgeons and certified vascular surgery centers to assess and improve their performance and how the VQI is critical to these endeavors.
Finally, Larry Kraiss, MD, chair of the SVS Quality Council and professor and chief of the vascular surgery division at the University of Utah, presented the goals of the new SVS council and described how the council is expanding the quality mission to include appropriate use criteria in addition to the long-standing clinical practice guidelines the SVS produces.
Dr. Kraiss elaborated how Appropriate Use Criteria (AUC) perform a substantially different role than that of Clinical Practice Guidelines (CPG).
Since 2006, SVS has developed 13 active guidelines, with more on the way. Guidelines provide positive yes/no statements with regard to treatment decision-making. However, many patients fall outside the guidelines, often due to comorbidities or other confounding factors, and appropriate use criteria are vital in these cases to evaluate where on a spectrum the patient fits for making a decision with regard to performing an operation or the use of a device.
Appropriate use criteria can be developed through the use of risk assessment to determine where on the spectrum of safety and effectiveness a particular patient falls with regard to a particular procedure or device. A major role of the new SVS Quality Council is to develop appropriate use criteria using outcome tools such as VQI and to provide recommendations as to how individuals and institutions could improve their performance by taking into account risk factors and assess infrastructural needs.
“The SVS board has authorized development of AUC in particular areas,” said Dr. Kraiss. “This process with be closely tied with updating the CPG. The first commissioned AUC will be to address intermittent claudication. But I invite the membership to participate in this process, especially on the panels, which can have up to 17 members, and we envision AUC coming out in carotid intervention, AAA management, and venous disease,” he added.
Change Doesn’t Come Easy! But Is Needed
In selecting the subject of his presidential address, SVS President Michel Makaroun, MD, decided to focus on the inadequacy of vascular manpower to meet the demands and needs of the public.
In introducing the subject, he quoted a favorite saying from Mark Twain that gave him the topic of his address, “I am in favor of progress; it’s change I don’t like.” He then proceeded to outline why changes are necessary and what the Society for Vascular Surgery is doing to help implement them.
“You are all familiar with the highlights of the problem: It is in our numbers! A problem with multiple facets, including unfilled jobs, increasing demand, maldistribution and a demographic cliff of our membership,” Dr. Makaroun said.
The manifestations of this shortage are multiple. The number of advertised jobs far exceeds the number of graduates. There is also a significant maldistribution of the workforce. “We are concentrated in the northeast, and many populous states including Texas, Florida and California are well below average,” he said.
Additionally, many community hospitals, in both suburban areas or small towns completely lack any access to vascular surgical care, even in states with seemingly adequate numbers.
The shortage problem in vascular surgery will get worse before it gets better, he added, saying “Our pipeline is simply not large enough to overcome an older retiring generation of vascular surgeons, with nearly half retiring before 65.”
“Change does not come easy!” Dr. Makaroun warned.
“We cannot ignore in the discussion of workforce issues, the major shifts, change and uncertainty we are experiencing in health care delivery, education and the generational change of our newest members,” he said.
More than 10% of vascular surgeons now practice primarily if not exclusively in ambulatory facilities. This direction is gathering steam and reduces the pool of vascular surgeons available to accept hospital practices and cover emergencies, particularly in underserved communities.
Despite this movement, nearly two-thirds of SVS members are currently employed by hospital systems that are getting larger and larger, making it essential to navigate an ever more complex decision-making process in employment, compensation and spectrum of activities. Practice environments are becoming more corporate and bureaucratic.
Dr. Makaroun pointed out that the current landscape of our manpower has a clear two tiers divided by hospital size and location. “The most pressing concern is the inability of our specialty to provide vascular surgery services to the multitude of hospitals located in smaller communities.
“The SVS established a task force to study our manpower issues last fall. The taskforce was divided into three workgroups to focus on different areas of the problem.
The first workgroup, under the leadership of Malachi Sheehan III, MD, and Jeffrey Jim, MD, focused on the obvious solution: a campaign to increase training programs and available positions. Unfortunately, this is only aspirational, since reality fails the SVS in this effort. The pool of general surgery graduates is finite, with competition from several specialties that are more analogous to modern general surgery than vascular surgery.
Increasing the number of integrated programs is less efficient because of a 5- to 6-year lag between initiation of a new program and graduation, but it can tap into an almost unlimited pool of applicants from medical school, and more recently some very qualified international medical graduates. This makes it potentially a far more effective solution for the long term, Dr. Makaroun said.
The workgroup attempted to contact all hospitals with a general surgery program and no associated vascular fellowship. Help in navigating the process of securing financing and applying for a new program was offered. A session was conducted at VAM for interested potential sites to start discussing the process, and representatives from 27 hospitals were there expressing interest.
The second workgroup, under the leadership of Rick Powell, MD, and Andy Schanzer, MD, was tasked with analyzing and understanding the entire spectrum of surgeons’ clinical activities and producing a valuation study that illustrates the economic and vital impact of vascular surgery for hospitals and patients. “The work of this group is essential to promote a healthier relationship between our specialty and our institutions, making vascular surgery more attractive for future recruits,” according to Dr. Makaroun.
The third workgroup under the leadership of Will Jordan, MD, and Tim Sarac, MD, had the toughest job, said Dr. Makaroun. It was tasked with thinking outside the box and suggesting methods to address the most glaring need: the community hospitals, where most of the advertised jobs are, jobs that are being shunned by graduates of current training programs.
Dr. Makaroun cited the difficulties of recruitment of vascular surgeons to community hospital systems in small towns and rural areas, and he reminded people that recent general surgery graduates continue to offer vascular surgery services in such communities. Unfortunately, this is without any additional vascular training and most hospitals grant privileges without a VSB certificate when the need is demonstrated. “You all appreciate that recent graduates of general surgery programs do not have the breadth or depth of exposure to modern vascular surgery that an older generation did,” he added.
The workgroup explored many options to provide relief to community hospitals. But probably the most efficient, according to Dr. Makaroun, is to consider strategies that tap into new constituencies. One consideration to be explored is to offer a 3-year vascular surgery training opportunity to the dozens of qualified candidates in preliminary surgical positions unable to locate a categorical spot to finish their training. This process will lead to VSB certification, but will take some time to establish through the ACGME structure.
The workgroup developed an outline of a proposal for a community vascular surgery training program, as a first step. It has been sketched and will be part of the task force report submitted for review by the Executive Board of the Society.
The goals of the new pathway would be to improve local vascular care in underserved communities, while increasing the referral of appropriate cases to vascular centers. It would provide stress relief to isolated vascular surgeons, and where none exist, plant the seeds of a better work environment for vascular surgery graduates to reconsider this currently undesirable career choice.
The program is designed to offer an additional year of vascular surgery training to general surgery graduates already committed to a community practice, many of whom are already planning to offer vascular services anyway. The program will individualize training but focus only on low-complexity procedures, both open and endovascular, and more importantly the clinical situations that dictate referral, said Dr. Makaroun.
To maintain quality, the program will mandate the availability of mentorship, support and real-time advice after completion of the program, through a regional “sponsoring vascular surgery service.” This service will also be responsible for retrospective peer review and root cause analysis of complications. In addition, the association with a sponsoring institution will facilitate and increase referrals of appropriate patients to higher level of care at a vascular surgery center.
“The suggested program graduates will not be board-certified and will be performing mostly general surgery and low-complexity vascular cases part- time in smaller communities. They will also require supervision by the board-certified graduates of the current training pathways, working in a regional vascular center, typically in a larger urban center. Instead of competing they will actually complement our current trainees and provide an extension of their reach.” Dr. Makaroun stated.
“We must find a way to fill the vacuum now before the reality on the ground permanently excludes our specialty from this primary level of vascular care,” Dr. Makaroun said. “It is time for another bold step to preserve the legacy of our specialty in meeting the needs of our patients and the public.
“Progress is made through change even if we don’t like it!” Dr. Makaroun concluded.
In selecting the subject of his presidential address, SVS President Michel Makaroun, MD, decided to focus on the inadequacy of vascular manpower to meet the demands and needs of the public.
In introducing the subject, he quoted a favorite saying from Mark Twain that gave him the topic of his address, “I am in favor of progress; it’s change I don’t like.” He then proceeded to outline why changes are necessary and what the Society for Vascular Surgery is doing to help implement them.
“You are all familiar with the highlights of the problem: It is in our numbers! A problem with multiple facets, including unfilled jobs, increasing demand, maldistribution and a demographic cliff of our membership,” Dr. Makaroun said.
The manifestations of this shortage are multiple. The number of advertised jobs far exceeds the number of graduates. There is also a significant maldistribution of the workforce. “We are concentrated in the northeast, and many populous states including Texas, Florida and California are well below average,” he said.
Additionally, many community hospitals, in both suburban areas or small towns completely lack any access to vascular surgical care, even in states with seemingly adequate numbers.
The shortage problem in vascular surgery will get worse before it gets better, he added, saying “Our pipeline is simply not large enough to overcome an older retiring generation of vascular surgeons, with nearly half retiring before 65.”
“Change does not come easy!” Dr. Makaroun warned.
“We cannot ignore in the discussion of workforce issues, the major shifts, change and uncertainty we are experiencing in health care delivery, education and the generational change of our newest members,” he said.
More than 10% of vascular surgeons now practice primarily if not exclusively in ambulatory facilities. This direction is gathering steam and reduces the pool of vascular surgeons available to accept hospital practices and cover emergencies, particularly in underserved communities.
Despite this movement, nearly two-thirds of SVS members are currently employed by hospital systems that are getting larger and larger, making it essential to navigate an ever more complex decision-making process in employment, compensation and spectrum of activities. Practice environments are becoming more corporate and bureaucratic.
Dr. Makaroun pointed out that the current landscape of our manpower has a clear two tiers divided by hospital size and location. “The most pressing concern is the inability of our specialty to provide vascular surgery services to the multitude of hospitals located in smaller communities.
“The SVS established a task force to study our manpower issues last fall. The taskforce was divided into three workgroups to focus on different areas of the problem.
The first workgroup, under the leadership of Malachi Sheehan III, MD, and Jeffrey Jim, MD, focused on the obvious solution: a campaign to increase training programs and available positions. Unfortunately, this is only aspirational, since reality fails the SVS in this effort. The pool of general surgery graduates is finite, with competition from several specialties that are more analogous to modern general surgery than vascular surgery.
Increasing the number of integrated programs is less efficient because of a 5- to 6-year lag between initiation of a new program and graduation, but it can tap into an almost unlimited pool of applicants from medical school, and more recently some very qualified international medical graduates. This makes it potentially a far more effective solution for the long term, Dr. Makaroun said.
The workgroup attempted to contact all hospitals with a general surgery program and no associated vascular fellowship. Help in navigating the process of securing financing and applying for a new program was offered. A session was conducted at VAM for interested potential sites to start discussing the process, and representatives from 27 hospitals were there expressing interest.
The second workgroup, under the leadership of Rick Powell, MD, and Andy Schanzer, MD, was tasked with analyzing and understanding the entire spectrum of surgeons’ clinical activities and producing a valuation study that illustrates the economic and vital impact of vascular surgery for hospitals and patients. “The work of this group is essential to promote a healthier relationship between our specialty and our institutions, making vascular surgery more attractive for future recruits,” according to Dr. Makaroun.
The third workgroup under the leadership of Will Jordan, MD, and Tim Sarac, MD, had the toughest job, said Dr. Makaroun. It was tasked with thinking outside the box and suggesting methods to address the most glaring need: the community hospitals, where most of the advertised jobs are, jobs that are being shunned by graduates of current training programs.
Dr. Makaroun cited the difficulties of recruitment of vascular surgeons to community hospital systems in small towns and rural areas, and he reminded people that recent general surgery graduates continue to offer vascular surgery services in such communities. Unfortunately, this is without any additional vascular training and most hospitals grant privileges without a VSB certificate when the need is demonstrated. “You all appreciate that recent graduates of general surgery programs do not have the breadth or depth of exposure to modern vascular surgery that an older generation did,” he added.
The workgroup explored many options to provide relief to community hospitals. But probably the most efficient, according to Dr. Makaroun, is to consider strategies that tap into new constituencies. One consideration to be explored is to offer a 3-year vascular surgery training opportunity to the dozens of qualified candidates in preliminary surgical positions unable to locate a categorical spot to finish their training. This process will lead to VSB certification, but will take some time to establish through the ACGME structure.
The workgroup developed an outline of a proposal for a community vascular surgery training program, as a first step. It has been sketched and will be part of the task force report submitted for review by the Executive Board of the Society.
The goals of the new pathway would be to improve local vascular care in underserved communities, while increasing the referral of appropriate cases to vascular centers. It would provide stress relief to isolated vascular surgeons, and where none exist, plant the seeds of a better work environment for vascular surgery graduates to reconsider this currently undesirable career choice.
The program is designed to offer an additional year of vascular surgery training to general surgery graduates already committed to a community practice, many of whom are already planning to offer vascular services anyway. The program will individualize training but focus only on low-complexity procedures, both open and endovascular, and more importantly the clinical situations that dictate referral, said Dr. Makaroun.
To maintain quality, the program will mandate the availability of mentorship, support and real-time advice after completion of the program, through a regional “sponsoring vascular surgery service.” This service will also be responsible for retrospective peer review and root cause analysis of complications. In addition, the association with a sponsoring institution will facilitate and increase referrals of appropriate patients to higher level of care at a vascular surgery center.
“The suggested program graduates will not be board-certified and will be performing mostly general surgery and low-complexity vascular cases part- time in smaller communities. They will also require supervision by the board-certified graduates of the current training pathways, working in a regional vascular center, typically in a larger urban center. Instead of competing they will actually complement our current trainees and provide an extension of their reach.” Dr. Makaroun stated.
“We must find a way to fill the vacuum now before the reality on the ground permanently excludes our specialty from this primary level of vascular care,” Dr. Makaroun said. “It is time for another bold step to preserve the legacy of our specialty in meeting the needs of our patients and the public.
“Progress is made through change even if we don’t like it!” Dr. Makaroun concluded.
In selecting the subject of his presidential address, SVS President Michel Makaroun, MD, decided to focus on the inadequacy of vascular manpower to meet the demands and needs of the public.
In introducing the subject, he quoted a favorite saying from Mark Twain that gave him the topic of his address, “I am in favor of progress; it’s change I don’t like.” He then proceeded to outline why changes are necessary and what the Society for Vascular Surgery is doing to help implement them.
“You are all familiar with the highlights of the problem: It is in our numbers! A problem with multiple facets, including unfilled jobs, increasing demand, maldistribution and a demographic cliff of our membership,” Dr. Makaroun said.
The manifestations of this shortage are multiple. The number of advertised jobs far exceeds the number of graduates. There is also a significant maldistribution of the workforce. “We are concentrated in the northeast, and many populous states including Texas, Florida and California are well below average,” he said.
Additionally, many community hospitals, in both suburban areas or small towns completely lack any access to vascular surgical care, even in states with seemingly adequate numbers.
The shortage problem in vascular surgery will get worse before it gets better, he added, saying “Our pipeline is simply not large enough to overcome an older retiring generation of vascular surgeons, with nearly half retiring before 65.”
“Change does not come easy!” Dr. Makaroun warned.
“We cannot ignore in the discussion of workforce issues, the major shifts, change and uncertainty we are experiencing in health care delivery, education and the generational change of our newest members,” he said.
More than 10% of vascular surgeons now practice primarily if not exclusively in ambulatory facilities. This direction is gathering steam and reduces the pool of vascular surgeons available to accept hospital practices and cover emergencies, particularly in underserved communities.
Despite this movement, nearly two-thirds of SVS members are currently employed by hospital systems that are getting larger and larger, making it essential to navigate an ever more complex decision-making process in employment, compensation and spectrum of activities. Practice environments are becoming more corporate and bureaucratic.
Dr. Makaroun pointed out that the current landscape of our manpower has a clear two tiers divided by hospital size and location. “The most pressing concern is the inability of our specialty to provide vascular surgery services to the multitude of hospitals located in smaller communities.
“The SVS established a task force to study our manpower issues last fall. The taskforce was divided into three workgroups to focus on different areas of the problem.
The first workgroup, under the leadership of Malachi Sheehan III, MD, and Jeffrey Jim, MD, focused on the obvious solution: a campaign to increase training programs and available positions. Unfortunately, this is only aspirational, since reality fails the SVS in this effort. The pool of general surgery graduates is finite, with competition from several specialties that are more analogous to modern general surgery than vascular surgery.
Increasing the number of integrated programs is less efficient because of a 5- to 6-year lag between initiation of a new program and graduation, but it can tap into an almost unlimited pool of applicants from medical school, and more recently some very qualified international medical graduates. This makes it potentially a far more effective solution for the long term, Dr. Makaroun said.
The workgroup attempted to contact all hospitals with a general surgery program and no associated vascular fellowship. Help in navigating the process of securing financing and applying for a new program was offered. A session was conducted at VAM for interested potential sites to start discussing the process, and representatives from 27 hospitals were there expressing interest.
The second workgroup, under the leadership of Rick Powell, MD, and Andy Schanzer, MD, was tasked with analyzing and understanding the entire spectrum of surgeons’ clinical activities and producing a valuation study that illustrates the economic and vital impact of vascular surgery for hospitals and patients. “The work of this group is essential to promote a healthier relationship between our specialty and our institutions, making vascular surgery more attractive for future recruits,” according to Dr. Makaroun.
The third workgroup under the leadership of Will Jordan, MD, and Tim Sarac, MD, had the toughest job, said Dr. Makaroun. It was tasked with thinking outside the box and suggesting methods to address the most glaring need: the community hospitals, where most of the advertised jobs are, jobs that are being shunned by graduates of current training programs.
Dr. Makaroun cited the difficulties of recruitment of vascular surgeons to community hospital systems in small towns and rural areas, and he reminded people that recent general surgery graduates continue to offer vascular surgery services in such communities. Unfortunately, this is without any additional vascular training and most hospitals grant privileges without a VSB certificate when the need is demonstrated. “You all appreciate that recent graduates of general surgery programs do not have the breadth or depth of exposure to modern vascular surgery that an older generation did,” he added.
The workgroup explored many options to provide relief to community hospitals. But probably the most efficient, according to Dr. Makaroun, is to consider strategies that tap into new constituencies. One consideration to be explored is to offer a 3-year vascular surgery training opportunity to the dozens of qualified candidates in preliminary surgical positions unable to locate a categorical spot to finish their training. This process will lead to VSB certification, but will take some time to establish through the ACGME structure.
The workgroup developed an outline of a proposal for a community vascular surgery training program, as a first step. It has been sketched and will be part of the task force report submitted for review by the Executive Board of the Society.
The goals of the new pathway would be to improve local vascular care in underserved communities, while increasing the referral of appropriate cases to vascular centers. It would provide stress relief to isolated vascular surgeons, and where none exist, plant the seeds of a better work environment for vascular surgery graduates to reconsider this currently undesirable career choice.
The program is designed to offer an additional year of vascular surgery training to general surgery graduates already committed to a community practice, many of whom are already planning to offer vascular services anyway. The program will individualize training but focus only on low-complexity procedures, both open and endovascular, and more importantly the clinical situations that dictate referral, said Dr. Makaroun.
To maintain quality, the program will mandate the availability of mentorship, support and real-time advice after completion of the program, through a regional “sponsoring vascular surgery service.” This service will also be responsible for retrospective peer review and root cause analysis of complications. In addition, the association with a sponsoring institution will facilitate and increase referrals of appropriate patients to higher level of care at a vascular surgery center.
“The suggested program graduates will not be board-certified and will be performing mostly general surgery and low-complexity vascular cases part- time in smaller communities. They will also require supervision by the board-certified graduates of the current training pathways, working in a regional vascular center, typically in a larger urban center. Instead of competing they will actually complement our current trainees and provide an extension of their reach.” Dr. Makaroun stated.
“We must find a way to fill the vacuum now before the reality on the ground permanently excludes our specialty from this primary level of vascular care,” Dr. Makaroun said. “It is time for another bold step to preserve the legacy of our specialty in meeting the needs of our patients and the public.
“Progress is made through change even if we don’t like it!” Dr. Makaroun concluded.
Malnutrition leads to worse outcomes in frail elderly patients treated for PAD
Frailty increasingly has been seen as a factor in procedural outcomes, including vascular surgery. Nutrition factors among older adults have also become an issue of concern, and older adults undergoing interventions for peripheral arterial disease (PAD) may be at risk for malnutrition. At the Vascular Annual Meeting, Laura Drudi, MD, of McGill University, Montreal, reported on a study that she and her colleagues performed to determine the association between preprocedural nutritional status and all-cause mortality in patients being treated for PAD.
Dr. Drudi detailed their post hoc analysis of the FRAILED (Frailty Assessment in Lower Extremity arterial Disease) prospective cohort, which comprised two centers recruiting patients during July 1, 2015–Oct.1, 2016. Individuals who underwent vascular interventions for Rutherford class 3 or higher PAD were enrolled. Trained observers used the Mini Nutritional Assessment (MNA)–Short Form to assess the patients before their procedures. Scores less than or equal to 7 on a 14-point scale were considered malnourished, with scores of 8-11 indicated that patients were at risk for malnutrition.
The modified Essential Frailty Toolset (mEFT) was simultaneously used to measure frailty, with scores of 3 or less on a 5-point scale considered frail. The primary endpoint of the study was all-cause mortality at 12 months after the procedure. Results were available for a cohort of 148 patients (39.2% women) with a mean age of 70 years, and a mean body mass index of 26.7 kg/m2. Among these patients, 59 (40%) had claudication and 89 (60%) had chronic limb-threatening ischemia. A total of 98 (66%) patients underwent endovascular revascularization and 50 (34%) underwent open or hybrid revascularization.
Overall, 3% of subjects were classified as malnourished and 33% were at risk for malnutrition. There were 9 (6%) deaths at 12 months. Mini Nutritional Assessment–Short Form scores were modestly but significantly correlated with the mEFT scores (Pearson’s R = –0.48; P less than .001).
”We found that patients with malnourishment or at risk of malnourishment had a 2.5-fold higher crude 1-year mortality, compared with those with normal nutritional status,” said Dr. Drudi.
In the 41% of patients deemed frail, malnutrition was associated with all-cause mortality (adjusted odds ratio, 2.08 per point decrease in MNA scores); whereas in the nonfrail patients, MNA scores had little or no effect on mortality (adjusted OR, 1.05).
“Preprocedural nutritional status is associated with mortality in frail older adults undergoing interventions for PAD. Clinical trials are needed to determine whether pre- and postprocedural nutritional interventions can improve clinical outcomes in these vulnerable individuals,” Dr. Drudi concluded.
Frailty increasingly has been seen as a factor in procedural outcomes, including vascular surgery. Nutrition factors among older adults have also become an issue of concern, and older adults undergoing interventions for peripheral arterial disease (PAD) may be at risk for malnutrition. At the Vascular Annual Meeting, Laura Drudi, MD, of McGill University, Montreal, reported on a study that she and her colleagues performed to determine the association between preprocedural nutritional status and all-cause mortality in patients being treated for PAD.
Dr. Drudi detailed their post hoc analysis of the FRAILED (Frailty Assessment in Lower Extremity arterial Disease) prospective cohort, which comprised two centers recruiting patients during July 1, 2015–Oct.1, 2016. Individuals who underwent vascular interventions for Rutherford class 3 or higher PAD were enrolled. Trained observers used the Mini Nutritional Assessment (MNA)–Short Form to assess the patients before their procedures. Scores less than or equal to 7 on a 14-point scale were considered malnourished, with scores of 8-11 indicated that patients were at risk for malnutrition.
The modified Essential Frailty Toolset (mEFT) was simultaneously used to measure frailty, with scores of 3 or less on a 5-point scale considered frail. The primary endpoint of the study was all-cause mortality at 12 months after the procedure. Results were available for a cohort of 148 patients (39.2% women) with a mean age of 70 years, and a mean body mass index of 26.7 kg/m2. Among these patients, 59 (40%) had claudication and 89 (60%) had chronic limb-threatening ischemia. A total of 98 (66%) patients underwent endovascular revascularization and 50 (34%) underwent open or hybrid revascularization.
Overall, 3% of subjects were classified as malnourished and 33% were at risk for malnutrition. There were 9 (6%) deaths at 12 months. Mini Nutritional Assessment–Short Form scores were modestly but significantly correlated with the mEFT scores (Pearson’s R = –0.48; P less than .001).
”We found that patients with malnourishment or at risk of malnourishment had a 2.5-fold higher crude 1-year mortality, compared with those with normal nutritional status,” said Dr. Drudi.
In the 41% of patients deemed frail, malnutrition was associated with all-cause mortality (adjusted odds ratio, 2.08 per point decrease in MNA scores); whereas in the nonfrail patients, MNA scores had little or no effect on mortality (adjusted OR, 1.05).
“Preprocedural nutritional status is associated with mortality in frail older adults undergoing interventions for PAD. Clinical trials are needed to determine whether pre- and postprocedural nutritional interventions can improve clinical outcomes in these vulnerable individuals,” Dr. Drudi concluded.
Frailty increasingly has been seen as a factor in procedural outcomes, including vascular surgery. Nutrition factors among older adults have also become an issue of concern, and older adults undergoing interventions for peripheral arterial disease (PAD) may be at risk for malnutrition. At the Vascular Annual Meeting, Laura Drudi, MD, of McGill University, Montreal, reported on a study that she and her colleagues performed to determine the association between preprocedural nutritional status and all-cause mortality in patients being treated for PAD.
Dr. Drudi detailed their post hoc analysis of the FRAILED (Frailty Assessment in Lower Extremity arterial Disease) prospective cohort, which comprised two centers recruiting patients during July 1, 2015–Oct.1, 2016. Individuals who underwent vascular interventions for Rutherford class 3 or higher PAD were enrolled. Trained observers used the Mini Nutritional Assessment (MNA)–Short Form to assess the patients before their procedures. Scores less than or equal to 7 on a 14-point scale were considered malnourished, with scores of 8-11 indicated that patients were at risk for malnutrition.
The modified Essential Frailty Toolset (mEFT) was simultaneously used to measure frailty, with scores of 3 or less on a 5-point scale considered frail. The primary endpoint of the study was all-cause mortality at 12 months after the procedure. Results were available for a cohort of 148 patients (39.2% women) with a mean age of 70 years, and a mean body mass index of 26.7 kg/m2. Among these patients, 59 (40%) had claudication and 89 (60%) had chronic limb-threatening ischemia. A total of 98 (66%) patients underwent endovascular revascularization and 50 (34%) underwent open or hybrid revascularization.
Overall, 3% of subjects were classified as malnourished and 33% were at risk for malnutrition. There were 9 (6%) deaths at 12 months. Mini Nutritional Assessment–Short Form scores were modestly but significantly correlated with the mEFT scores (Pearson’s R = –0.48; P less than .001).
”We found that patients with malnourishment or at risk of malnourishment had a 2.5-fold higher crude 1-year mortality, compared with those with normal nutritional status,” said Dr. Drudi.
In the 41% of patients deemed frail, malnutrition was associated with all-cause mortality (adjusted odds ratio, 2.08 per point decrease in MNA scores); whereas in the nonfrail patients, MNA scores had little or no effect on mortality (adjusted OR, 1.05).
“Preprocedural nutritional status is associated with mortality in frail older adults undergoing interventions for PAD. Clinical trials are needed to determine whether pre- and postprocedural nutritional interventions can improve clinical outcomes in these vulnerable individuals,” Dr. Drudi concluded.
Rivaroxaban tied to higher GI bleeding than other NOACs
SAN DIEGO – Patients on rivaroxaban had significantly higher rates of GI bleeding, compared with those taking apixaban or dabigatran, results from a large population-based study showed.
“This may be due to the fact that rivaroxaban is administered as a single daily dose as opposed to the other two non–vitamin K anticoagulants [NOACs], which are given twice daily,” lead study author Arnar B. Ingason said at the annual Digestive Disease Week. “This may lead to a greater variance in plasma drug concentration, making these patients more susceptible to bleeding.”
Mr. Ingason, a medical student at the University of Iceland, Reykjavik, said that although several studies have compared warfarin with NOACs, it remains unclear which NOAC has the most favorable GI profile. In an effort to improve the research in this area, he and his associates performed a nationwide, population-based study during March 2014–Jan. 2018 to compare the GI bleeding risk of patients receiving rivaroxaban to that of a combined pool of patients receiving either apixaban or dabigatran. They drew from the Icelandic Medicine Registry, which contains all outpatient drug prescriptions in the country. Next, the researchers linked the personal identification numbers of patients to the Landspitali University diagnoses registry, which includes more than 90% of all patients hospitalized for GI bleeding. They used 1:1 nearest neighbor propensity score for matching and Kaplan-Meier survival estimates and Cox regression to compare rates of GI bleeding. The study outcome of interest was any clinically relevant GI bleeding.
Mr. Ingason reported that the baseline characteristics were similar between the rivaroxaban group and the apixaban/dabigatran group. They matched for several variables, including age, sex, Charlson score, the proportion being anticoagulant naive, moderate to severe renal disease, moderate to severe liver disease, any prior bleeding, and any prior thrombotic events.
During the study period, 3,473 patients received rivaroxaban, 1,901 received apixaban, and 1,086 received dabigatran. After propensity score matching, the researchers compared 2,635 patients who received rivaroxaban with 2,365 patients who received either apixaban or dabigatran. They found that patients in the rivaroxaban group had significantly higher rates of GI bleeding, compared with in the apixaban/dabigatran group (1.2 and. 0.6 events per 100 patient-years, respectively). This yielded a hazard ratio of 2.02, “which means that patients receiving rivaroxaban are twice as likely to get GI bleeding compared to patients on apixaban or dabigatran,” Mr. Ingason said. When the researchers examined the entire unmatched cohort of patients, the rivaroxaban group also had significantly higher rates of GI bleeding, compared with the apixaban/dabigatran group (1.0 and 0.6 events per 100 patient-years; HR, 1.75).
Mr. Ingason and his colleagues observed that patients in the rivaroxaban group had higher rates of GI bleeding, compared with the apixaban/dabigatran group, during the entire follow-up period. At the end of year 4, the rivaroxaban group had a 4% cumulative event rate of GI bleeding, compared with 1.8% for the apixaban/dabigatran group, a highly significant difference at P = .0057).
When a meeting attendee asked Mr. Ingason why patients taking apixaban or dabigatran were combined into one group, he said that it was done to increase the power of their study. “Our theory was that rivaroxaban was different because it is administered as a single daily dose, while the others are given twice daily,” he said. The researchers reported having no financial disclosures.
SAN DIEGO – Patients on rivaroxaban had significantly higher rates of GI bleeding, compared with those taking apixaban or dabigatran, results from a large population-based study showed.
“This may be due to the fact that rivaroxaban is administered as a single daily dose as opposed to the other two non–vitamin K anticoagulants [NOACs], which are given twice daily,” lead study author Arnar B. Ingason said at the annual Digestive Disease Week. “This may lead to a greater variance in plasma drug concentration, making these patients more susceptible to bleeding.”
Mr. Ingason, a medical student at the University of Iceland, Reykjavik, said that although several studies have compared warfarin with NOACs, it remains unclear which NOAC has the most favorable GI profile. In an effort to improve the research in this area, he and his associates performed a nationwide, population-based study during March 2014–Jan. 2018 to compare the GI bleeding risk of patients receiving rivaroxaban to that of a combined pool of patients receiving either apixaban or dabigatran. They drew from the Icelandic Medicine Registry, which contains all outpatient drug prescriptions in the country. Next, the researchers linked the personal identification numbers of patients to the Landspitali University diagnoses registry, which includes more than 90% of all patients hospitalized for GI bleeding. They used 1:1 nearest neighbor propensity score for matching and Kaplan-Meier survival estimates and Cox regression to compare rates of GI bleeding. The study outcome of interest was any clinically relevant GI bleeding.
Mr. Ingason reported that the baseline characteristics were similar between the rivaroxaban group and the apixaban/dabigatran group. They matched for several variables, including age, sex, Charlson score, the proportion being anticoagulant naive, moderate to severe renal disease, moderate to severe liver disease, any prior bleeding, and any prior thrombotic events.
During the study period, 3,473 patients received rivaroxaban, 1,901 received apixaban, and 1,086 received dabigatran. After propensity score matching, the researchers compared 2,635 patients who received rivaroxaban with 2,365 patients who received either apixaban or dabigatran. They found that patients in the rivaroxaban group had significantly higher rates of GI bleeding, compared with in the apixaban/dabigatran group (1.2 and. 0.6 events per 100 patient-years, respectively). This yielded a hazard ratio of 2.02, “which means that patients receiving rivaroxaban are twice as likely to get GI bleeding compared to patients on apixaban or dabigatran,” Mr. Ingason said. When the researchers examined the entire unmatched cohort of patients, the rivaroxaban group also had significantly higher rates of GI bleeding, compared with the apixaban/dabigatran group (1.0 and 0.6 events per 100 patient-years; HR, 1.75).
Mr. Ingason and his colleagues observed that patients in the rivaroxaban group had higher rates of GI bleeding, compared with the apixaban/dabigatran group, during the entire follow-up period. At the end of year 4, the rivaroxaban group had a 4% cumulative event rate of GI bleeding, compared with 1.8% for the apixaban/dabigatran group, a highly significant difference at P = .0057).
When a meeting attendee asked Mr. Ingason why patients taking apixaban or dabigatran were combined into one group, he said that it was done to increase the power of their study. “Our theory was that rivaroxaban was different because it is administered as a single daily dose, while the others are given twice daily,” he said. The researchers reported having no financial disclosures.
SAN DIEGO – Patients on rivaroxaban had significantly higher rates of GI bleeding, compared with those taking apixaban or dabigatran, results from a large population-based study showed.
“This may be due to the fact that rivaroxaban is administered as a single daily dose as opposed to the other two non–vitamin K anticoagulants [NOACs], which are given twice daily,” lead study author Arnar B. Ingason said at the annual Digestive Disease Week. “This may lead to a greater variance in plasma drug concentration, making these patients more susceptible to bleeding.”
Mr. Ingason, a medical student at the University of Iceland, Reykjavik, said that although several studies have compared warfarin with NOACs, it remains unclear which NOAC has the most favorable GI profile. In an effort to improve the research in this area, he and his associates performed a nationwide, population-based study during March 2014–Jan. 2018 to compare the GI bleeding risk of patients receiving rivaroxaban to that of a combined pool of patients receiving either apixaban or dabigatran. They drew from the Icelandic Medicine Registry, which contains all outpatient drug prescriptions in the country. Next, the researchers linked the personal identification numbers of patients to the Landspitali University diagnoses registry, which includes more than 90% of all patients hospitalized for GI bleeding. They used 1:1 nearest neighbor propensity score for matching and Kaplan-Meier survival estimates and Cox regression to compare rates of GI bleeding. The study outcome of interest was any clinically relevant GI bleeding.
Mr. Ingason reported that the baseline characteristics were similar between the rivaroxaban group and the apixaban/dabigatran group. They matched for several variables, including age, sex, Charlson score, the proportion being anticoagulant naive, moderate to severe renal disease, moderate to severe liver disease, any prior bleeding, and any prior thrombotic events.
During the study period, 3,473 patients received rivaroxaban, 1,901 received apixaban, and 1,086 received dabigatran. After propensity score matching, the researchers compared 2,635 patients who received rivaroxaban with 2,365 patients who received either apixaban or dabigatran. They found that patients in the rivaroxaban group had significantly higher rates of GI bleeding, compared with in the apixaban/dabigatran group (1.2 and. 0.6 events per 100 patient-years, respectively). This yielded a hazard ratio of 2.02, “which means that patients receiving rivaroxaban are twice as likely to get GI bleeding compared to patients on apixaban or dabigatran,” Mr. Ingason said. When the researchers examined the entire unmatched cohort of patients, the rivaroxaban group also had significantly higher rates of GI bleeding, compared with the apixaban/dabigatran group (1.0 and 0.6 events per 100 patient-years; HR, 1.75).
Mr. Ingason and his colleagues observed that patients in the rivaroxaban group had higher rates of GI bleeding, compared with the apixaban/dabigatran group, during the entire follow-up period. At the end of year 4, the rivaroxaban group had a 4% cumulative event rate of GI bleeding, compared with 1.8% for the apixaban/dabigatran group, a highly significant difference at P = .0057).
When a meeting attendee asked Mr. Ingason why patients taking apixaban or dabigatran were combined into one group, he said that it was done to increase the power of their study. “Our theory was that rivaroxaban was different because it is administered as a single daily dose, while the others are given twice daily,” he said. The researchers reported having no financial disclosures.
REPORTING FROM DDW 2019
Remain Connected on Connect
How have you managed a possible infected aortitis, a severe focal stenosis or a fractured carotid stent? Give your input in discussions about these topics, and more, on your online community, SVSConnect. If you attended VAM last week, continue the discussions with other attendees. All SVS members can participate in discussions – log in here with your SVS credentials. Reach out to [email protected] or call 312-334-2300 with questions.
How have you managed a possible infected aortitis, a severe focal stenosis or a fractured carotid stent? Give your input in discussions about these topics, and more, on your online community, SVSConnect. If you attended VAM last week, continue the discussions with other attendees. All SVS members can participate in discussions – log in here with your SVS credentials. Reach out to [email protected] or call 312-334-2300 with questions.
How have you managed a possible infected aortitis, a severe focal stenosis or a fractured carotid stent? Give your input in discussions about these topics, and more, on your online community, SVSConnect. If you attended VAM last week, continue the discussions with other attendees. All SVS members can participate in discussions – log in here with your SVS credentials. Reach out to [email protected] or call 312-334-2300 with questions.
Subscribe to SVS Student Newsletters
The SVS has recently re-vamped its newsletters geared towards future vascular surgeons. These provide residents, students and vascular trainees with up-to-date information on upcoming events, awards and scholarships, open positions and more. These are sent on a bi-weekly and monthly basis, depending on what content you are interested in. Learn more and subscribe here. They will also be posted on the SVS future vascular surgeon’s Twitter and Facebook.
The SVS has recently re-vamped its newsletters geared towards future vascular surgeons. These provide residents, students and vascular trainees with up-to-date information on upcoming events, awards and scholarships, open positions and more. These are sent on a bi-weekly and monthly basis, depending on what content you are interested in. Learn more and subscribe here. They will also be posted on the SVS future vascular surgeon’s Twitter and Facebook.
The SVS has recently re-vamped its newsletters geared towards future vascular surgeons. These provide residents, students and vascular trainees with up-to-date information on upcoming events, awards and scholarships, open positions and more. These are sent on a bi-weekly and monthly basis, depending on what content you are interested in. Learn more and subscribe here. They will also be posted on the SVS future vascular surgeon’s Twitter and Facebook.
Apply for the Research Career Development Travel Award
The SVS Foundation developed the Research Career Development Travel Awards program to develop strong leaders in vascular surgery research. Recipients of the award will be assigned SVS research mentors who will provide guidance and discuss academic career advancement. They’ll also receive financial support to be used for travel, hotel accommodations and registration expenses for a research course. Applicants must be an SVS Candidate or Active Member who’s completed postgraduate clinical training in vascular surgery and has been in practice no more than seven years. Apply before August 15 to be considered.
The SVS Foundation developed the Research Career Development Travel Awards program to develop strong leaders in vascular surgery research. Recipients of the award will be assigned SVS research mentors who will provide guidance and discuss academic career advancement. They’ll also receive financial support to be used for travel, hotel accommodations and registration expenses for a research course. Applicants must be an SVS Candidate or Active Member who’s completed postgraduate clinical training in vascular surgery and has been in practice no more than seven years. Apply before August 15 to be considered.
The SVS Foundation developed the Research Career Development Travel Awards program to develop strong leaders in vascular surgery research. Recipients of the award will be assigned SVS research mentors who will provide guidance and discuss academic career advancement. They’ll also receive financial support to be used for travel, hotel accommodations and registration expenses for a research course. Applicants must be an SVS Candidate or Active Member who’s completed postgraduate clinical training in vascular surgery and has been in practice no more than seven years. Apply before August 15 to be considered.
Universal health care hearing: GOP hears what it wants to
While most Republicans used their time at the House Ways & Means Committee hearing on Medicare-for-all to trash the concept, one rogue member criticized the hearing as simply misguided.
“We are living a time of disruption,” Rep. David Schweikert (R-Ariz) said. “There is incredible technology that is about to crash the price of health care if this committee particularly is willing to challenge and do something that’s incredibly uncomfortable for those of us in elective office, and that is look incumbent providers, business, insurers, systems in the face and say ‘it’s time for the revolution.’
“Are we willing to talk to our hospitals, talk to our providers, talk to technology, talk to the FDA [Food and Drug Administration], and have the honest discussion that this is about to become your primary care physician,” he said, raising a smartphone in his hand. “We will be healthier because it is individualized to us instead of what is going here in the discussion of a collectivization of a system that is already pretty crappy.”
He cited the recent Medicare Trustees Report showing that the hospital insurance trust fund (Medicare Part A) is 6.5 years from insolvency. “I don’t know why this hearing isn’t about Medicare itself and protecting Medicare itself instead of nationalization of health care. ... So defending the current system is absurd for all of us.”
The partisan nature of the June 12 hearing was clear.
Republican committee members focused their questioning on Grace-Marie Turner, president of the conservative Galen Institute and an outspoken opponent of Medicare-for-all. Less attention was paid to witnesses who offered alternatives to achieving greater health care coverage for the population.
Ranking member Kevin Brady (R-Texas) set the tone in his opening statement: “While our American health care system does have real problems, we should focus on improving what’s working and to fix what’s broken, rather than starting over with a massive new socialized medicine scheme that will leave many families worse off,” he said.
He noted that the federal government is on the cusp of yet another shutdown after three shutdowns in 2018. “The federal government can’t even keep its doors open. Can you really trust Washington with your life-and-death health care decisions? Make no mistake, Medicare-for-all guts quality health care in favor of delays and long waiting lines. It gives Washington politicians unlimited control over your health care. It cancels good quality health care plans for millions of workers, children, and the elderly and is so costly – tens of trillions of dollars – it will bankrupt America.”
Ms. Turner was regularly called upon to back up these talking points, using an analysis of a specific legislative proposal (H.R. 1384), in which she noted that under that specific Medicare-for-all bill, “Washington would be deciding what benefits people are eligible to receive. It will be deciding how much providers will be paid, so yes, it significantly limits choices of individuals and we see this, of course, in other countries as well.”
And while Republicans were using the testimony of Ms. Turner to back up their agenda, no one queried Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and president emeritus and senior fellow at the Institute for Healthcare Improvement, who testified in support of a Medicare-for-all program – that the true impact of any universal coverage plan is dependent upon the program’s design.
One common GOP criticism throughout the hearing was that there would be a 40% reduction in pay to physicians and hospitals because the higher payments rates from private insurers that currently help offset lower payments from Medicare and Medicaid would be lost.
“The rhetoric we are hearing about 40% cuts is not necessary,” Dr. Berwick testified. “We can have sensible payment under an expanded Medicare system. That’s rhetoric, not fact. That’s in the design.”
While most Republicans used their time at the House Ways & Means Committee hearing on Medicare-for-all to trash the concept, one rogue member criticized the hearing as simply misguided.
“We are living a time of disruption,” Rep. David Schweikert (R-Ariz) said. “There is incredible technology that is about to crash the price of health care if this committee particularly is willing to challenge and do something that’s incredibly uncomfortable for those of us in elective office, and that is look incumbent providers, business, insurers, systems in the face and say ‘it’s time for the revolution.’
“Are we willing to talk to our hospitals, talk to our providers, talk to technology, talk to the FDA [Food and Drug Administration], and have the honest discussion that this is about to become your primary care physician,” he said, raising a smartphone in his hand. “We will be healthier because it is individualized to us instead of what is going here in the discussion of a collectivization of a system that is already pretty crappy.”
He cited the recent Medicare Trustees Report showing that the hospital insurance trust fund (Medicare Part A) is 6.5 years from insolvency. “I don’t know why this hearing isn’t about Medicare itself and protecting Medicare itself instead of nationalization of health care. ... So defending the current system is absurd for all of us.”
The partisan nature of the June 12 hearing was clear.
Republican committee members focused their questioning on Grace-Marie Turner, president of the conservative Galen Institute and an outspoken opponent of Medicare-for-all. Less attention was paid to witnesses who offered alternatives to achieving greater health care coverage for the population.
Ranking member Kevin Brady (R-Texas) set the tone in his opening statement: “While our American health care system does have real problems, we should focus on improving what’s working and to fix what’s broken, rather than starting over with a massive new socialized medicine scheme that will leave many families worse off,” he said.
He noted that the federal government is on the cusp of yet another shutdown after three shutdowns in 2018. “The federal government can’t even keep its doors open. Can you really trust Washington with your life-and-death health care decisions? Make no mistake, Medicare-for-all guts quality health care in favor of delays and long waiting lines. It gives Washington politicians unlimited control over your health care. It cancels good quality health care plans for millions of workers, children, and the elderly and is so costly – tens of trillions of dollars – it will bankrupt America.”
Ms. Turner was regularly called upon to back up these talking points, using an analysis of a specific legislative proposal (H.R. 1384), in which she noted that under that specific Medicare-for-all bill, “Washington would be deciding what benefits people are eligible to receive. It will be deciding how much providers will be paid, so yes, it significantly limits choices of individuals and we see this, of course, in other countries as well.”
And while Republicans were using the testimony of Ms. Turner to back up their agenda, no one queried Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and president emeritus and senior fellow at the Institute for Healthcare Improvement, who testified in support of a Medicare-for-all program – that the true impact of any universal coverage plan is dependent upon the program’s design.
One common GOP criticism throughout the hearing was that there would be a 40% reduction in pay to physicians and hospitals because the higher payments rates from private insurers that currently help offset lower payments from Medicare and Medicaid would be lost.
“The rhetoric we are hearing about 40% cuts is not necessary,” Dr. Berwick testified. “We can have sensible payment under an expanded Medicare system. That’s rhetoric, not fact. That’s in the design.”
While most Republicans used their time at the House Ways & Means Committee hearing on Medicare-for-all to trash the concept, one rogue member criticized the hearing as simply misguided.
“We are living a time of disruption,” Rep. David Schweikert (R-Ariz) said. “There is incredible technology that is about to crash the price of health care if this committee particularly is willing to challenge and do something that’s incredibly uncomfortable for those of us in elective office, and that is look incumbent providers, business, insurers, systems in the face and say ‘it’s time for the revolution.’
“Are we willing to talk to our hospitals, talk to our providers, talk to technology, talk to the FDA [Food and Drug Administration], and have the honest discussion that this is about to become your primary care physician,” he said, raising a smartphone in his hand. “We will be healthier because it is individualized to us instead of what is going here in the discussion of a collectivization of a system that is already pretty crappy.”
He cited the recent Medicare Trustees Report showing that the hospital insurance trust fund (Medicare Part A) is 6.5 years from insolvency. “I don’t know why this hearing isn’t about Medicare itself and protecting Medicare itself instead of nationalization of health care. ... So defending the current system is absurd for all of us.”
The partisan nature of the June 12 hearing was clear.
Republican committee members focused their questioning on Grace-Marie Turner, president of the conservative Galen Institute and an outspoken opponent of Medicare-for-all. Less attention was paid to witnesses who offered alternatives to achieving greater health care coverage for the population.
Ranking member Kevin Brady (R-Texas) set the tone in his opening statement: “While our American health care system does have real problems, we should focus on improving what’s working and to fix what’s broken, rather than starting over with a massive new socialized medicine scheme that will leave many families worse off,” he said.
He noted that the federal government is on the cusp of yet another shutdown after three shutdowns in 2018. “The federal government can’t even keep its doors open. Can you really trust Washington with your life-and-death health care decisions? Make no mistake, Medicare-for-all guts quality health care in favor of delays and long waiting lines. It gives Washington politicians unlimited control over your health care. It cancels good quality health care plans for millions of workers, children, and the elderly and is so costly – tens of trillions of dollars – it will bankrupt America.”
Ms. Turner was regularly called upon to back up these talking points, using an analysis of a specific legislative proposal (H.R. 1384), in which she noted that under that specific Medicare-for-all bill, “Washington would be deciding what benefits people are eligible to receive. It will be deciding how much providers will be paid, so yes, it significantly limits choices of individuals and we see this, of course, in other countries as well.”
And while Republicans were using the testimony of Ms. Turner to back up their agenda, no one queried Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and president emeritus and senior fellow at the Institute for Healthcare Improvement, who testified in support of a Medicare-for-all program – that the true impact of any universal coverage plan is dependent upon the program’s design.
One common GOP criticism throughout the hearing was that there would be a 40% reduction in pay to physicians and hospitals because the higher payments rates from private insurers that currently help offset lower payments from Medicare and Medicaid would be lost.
“The rhetoric we are hearing about 40% cuts is not necessary,” Dr. Berwick testified. “We can have sensible payment under an expanded Medicare system. That’s rhetoric, not fact. That’s in the design.”
REPORTING FROM A HOUSE WAYS & MEANS COMMITTEE HEARING
Cardiothoracic & Vascular Surgeons Providing Alternative Perspectives
Cardiothoracic and vascular surgeons will – together – head for the top during the Aortic Summit, from 2 to 4:30 p.m. Saturday.
The event is presented in collaboration with the Society of Thoracic Surgeons. A similar summit at the 2017 VAM attracted hundreds of surgeons.
Several topics important to both groups of surgeons will be examined from both the cardiothoracic and vascular perspectives, said Ali Azizzadeh, MD, co-moderator with Keith Allen, MD, a member of both SVS and the STS. The session is recommended by the Society for Vascular Nursing.
“We do look at issues in different ways,” said Dr. Azizzadeh said of vascular and cardiothoracic surgeons. “We all have different tools and skill sets. That’s why it’s good to look at an issue from both perspectives and also look at the devices that apply to the other’s field.”
Speakers will cover the latest indications for procedures in patients with aortic dissection, which will segue into discussion of access complications and other issues that can occur with devices. Topics also will include alternative and newer methods of access.
Speakers and attendees also will discuss the newest technology currently in trials, recently approved, or in investigation, worldwide, he said.
The two groups will collaborate, for what Dr. Azizzadeh believes is the first time, on pulmonary embolism. “This is a hot area for innovation,” he said. “There are lots of new techniques and procedures to address currently unmet needs. Medical centers around the country are assembling multidisciplinary teams, referred to as Pulmonary Embolism Response Team or PERT – to be able to take care of these sick patients. It’s a trend for the future.”
Tickets are required and are available at the registration counter. An additional fee applies: $75 for SVS Candidate members-in-training, nonmember medical students and vascular and general surgery residents, and allied health professionals; $100 for SVS Candidate members; $150 for SVS members and $200 for nonmember physicians.
Topics and speakers include:
• Optimal Management of Uncomplicated Acute Type B Aortic Dissection, Faisal Bakaeen, MD.
• Optimal Management of Chronic Type B Aortic Dissection, Adam Beck, MD.
• Alternate Non-Femoral Vascular Access for Large Endovascular Devices, Keith Allen, MD.
• Managing Vascular Access Complications, Ross Milner, MD.
• Innovative Devices: Cardiothoracic, by Grayson Wheatly III, MD.
• Innovative Devices: Vascular, by Ali Azizzadeh, MD.
• Pulmonary Embolism Teams: Cardiothoracic perspective, by Lishan Aklog, MD.
• Pulmonary Embolism Teams: Vascular perspective, by Naveed Saqib, MD.
A discussion period will follow each set of presentations.
“It’s going to be a great session to review the latest topics that apply to both cardiothoracic and vascular surgery,” said Dr. Azizzadeh.
Saturday, June 15
2-4:30 p.m.
Gaylord National, National Harbor 2
Aortic Summit
Cardiothoracic and vascular surgeons will – together – head for the top during the Aortic Summit, from 2 to 4:30 p.m. Saturday.
The event is presented in collaboration with the Society of Thoracic Surgeons. A similar summit at the 2017 VAM attracted hundreds of surgeons.
Several topics important to both groups of surgeons will be examined from both the cardiothoracic and vascular perspectives, said Ali Azizzadeh, MD, co-moderator with Keith Allen, MD, a member of both SVS and the STS. The session is recommended by the Society for Vascular Nursing.
“We do look at issues in different ways,” said Dr. Azizzadeh said of vascular and cardiothoracic surgeons. “We all have different tools and skill sets. That’s why it’s good to look at an issue from both perspectives and also look at the devices that apply to the other’s field.”
Speakers will cover the latest indications for procedures in patients with aortic dissection, which will segue into discussion of access complications and other issues that can occur with devices. Topics also will include alternative and newer methods of access.
Speakers and attendees also will discuss the newest technology currently in trials, recently approved, or in investigation, worldwide, he said.
The two groups will collaborate, for what Dr. Azizzadeh believes is the first time, on pulmonary embolism. “This is a hot area for innovation,” he said. “There are lots of new techniques and procedures to address currently unmet needs. Medical centers around the country are assembling multidisciplinary teams, referred to as Pulmonary Embolism Response Team or PERT – to be able to take care of these sick patients. It’s a trend for the future.”
Tickets are required and are available at the registration counter. An additional fee applies: $75 for SVS Candidate members-in-training, nonmember medical students and vascular and general surgery residents, and allied health professionals; $100 for SVS Candidate members; $150 for SVS members and $200 for nonmember physicians.
Topics and speakers include:
• Optimal Management of Uncomplicated Acute Type B Aortic Dissection, Faisal Bakaeen, MD.
• Optimal Management of Chronic Type B Aortic Dissection, Adam Beck, MD.
• Alternate Non-Femoral Vascular Access for Large Endovascular Devices, Keith Allen, MD.
• Managing Vascular Access Complications, Ross Milner, MD.
• Innovative Devices: Cardiothoracic, by Grayson Wheatly III, MD.
• Innovative Devices: Vascular, by Ali Azizzadeh, MD.
• Pulmonary Embolism Teams: Cardiothoracic perspective, by Lishan Aklog, MD.
• Pulmonary Embolism Teams: Vascular perspective, by Naveed Saqib, MD.
A discussion period will follow each set of presentations.
“It’s going to be a great session to review the latest topics that apply to both cardiothoracic and vascular surgery,” said Dr. Azizzadeh.
Saturday, June 15
2-4:30 p.m.
Gaylord National, National Harbor 2
Aortic Summit
Cardiothoracic and vascular surgeons will – together – head for the top during the Aortic Summit, from 2 to 4:30 p.m. Saturday.
The event is presented in collaboration with the Society of Thoracic Surgeons. A similar summit at the 2017 VAM attracted hundreds of surgeons.
Several topics important to both groups of surgeons will be examined from both the cardiothoracic and vascular perspectives, said Ali Azizzadeh, MD, co-moderator with Keith Allen, MD, a member of both SVS and the STS. The session is recommended by the Society for Vascular Nursing.
“We do look at issues in different ways,” said Dr. Azizzadeh said of vascular and cardiothoracic surgeons. “We all have different tools and skill sets. That’s why it’s good to look at an issue from both perspectives and also look at the devices that apply to the other’s field.”
Speakers will cover the latest indications for procedures in patients with aortic dissection, which will segue into discussion of access complications and other issues that can occur with devices. Topics also will include alternative and newer methods of access.
Speakers and attendees also will discuss the newest technology currently in trials, recently approved, or in investigation, worldwide, he said.
The two groups will collaborate, for what Dr. Azizzadeh believes is the first time, on pulmonary embolism. “This is a hot area for innovation,” he said. “There are lots of new techniques and procedures to address currently unmet needs. Medical centers around the country are assembling multidisciplinary teams, referred to as Pulmonary Embolism Response Team or PERT – to be able to take care of these sick patients. It’s a trend for the future.”
Tickets are required and are available at the registration counter. An additional fee applies: $75 for SVS Candidate members-in-training, nonmember medical students and vascular and general surgery residents, and allied health professionals; $100 for SVS Candidate members; $150 for SVS members and $200 for nonmember physicians.
Topics and speakers include:
• Optimal Management of Uncomplicated Acute Type B Aortic Dissection, Faisal Bakaeen, MD.
• Optimal Management of Chronic Type B Aortic Dissection, Adam Beck, MD.
• Alternate Non-Femoral Vascular Access for Large Endovascular Devices, Keith Allen, MD.
• Managing Vascular Access Complications, Ross Milner, MD.
• Innovative Devices: Cardiothoracic, by Grayson Wheatly III, MD.
• Innovative Devices: Vascular, by Ali Azizzadeh, MD.
• Pulmonary Embolism Teams: Cardiothoracic perspective, by Lishan Aklog, MD.
• Pulmonary Embolism Teams: Vascular perspective, by Naveed Saqib, MD.
A discussion period will follow each set of presentations.
“It’s going to be a great session to review the latest topics that apply to both cardiothoracic and vascular surgery,” said Dr. Azizzadeh.
Saturday, June 15
2-4:30 p.m.
Gaylord National, National Harbor 2
Aortic Summit
