4/6/2017 Master Title Vascular Surgeons are an Essential Hospital, No Disclosures Operating Room and Regional Resource Gregory L. Moneta MD Professor and Chief Division of Vascular Surgery Oregon Health & Science University Knight Cardiovascular Institute Portland, Oregon USA Outline • Separation General and Vascular Surgery • Hospital economics • Colleagues • Referring Hospitals 1
4/6/2017 Bruce A. Perler, M.D.: 2016 Binkley Visiting Professor Are We Happy? Ann Surg 2009; 250:463-71 2016 SVS Presidential Address • Personal Anecdotes • Emphasized commitment of vascular surgeons to their patients • Satisfaction of providing patient care • Value of what we do for our patients Hospital Administration Surgical Colleagues 2
4/6/2017 Small Hospitals Vascular Surgery/ General Surgery Femoral Popliteal Bypass Rene Leriche Jean Kunlin Alexis Carrel 3
4/6/2017 Abdominal Aortic Reconstruction Carotid Endarterectomy Rudolph Matas Charles Dubost Jacques Oudot HHG Eastcott Michael DeBakey Edwin Jack Wylie Vascular Surgery/ General Surgery (1918-1982 ) • Pomona College • Harvard Medical School • UCSF General Surgery • Endarterectomy • First Vascular Fellowship (Malcolm Perry, 1962) • First certificate of special competence in vascular surgery, 1982 4
4/6/2017 Total Vascular Cases 2001 and 2012: General Surgery (GSR) vs Vascular Surgery Residents (VSR) (+161%) 800 700 600 2001 500 2012 400 (-40%) 300 200 100 0 Charles Dotter VSR GSR GSR Bill Cook Ann Vasc Surg 2016;33:98-102 Endovascular Cases: Major Open Vascular Procedures 2001 and 2012 General Surgery (GSR) vs Vascular Surgery Residents (VSR) Vascular and General Surgery Residents (+12%) 50 (+8%) 45 40 35 30 (-43%) (-61%) (-49%) 25 2001 2012 20 15 (-79%) 10 5 0 Open Open Bypass Bypass CEA CEA VSR AAA GSR AAA VSR GSR VSR GSR Ann Vasc Surg 2016;33:98-102 Ann Vasc Surg 2016;33:98-102 5
4/6/2017 Open Vascular Cases: Vascular vs General Surgery Residents FY16: OHSU Knight Cardiovascular Institute Revenue • OHSU Operating Budget: $2.2 billion • $125 Million Margin Ann Vasc Surg 2016;33:98-102 Margin, Revenue, Costs Hospital Margin and RVU Production • Margin = Revenue – (Direct + Indirect Costs) • Relationship between hospital margin and professional fees generated is not • Revenue = Payments for preadmission testing straightforward. + payments for operative services + payments for postoperative care • Each specialty: -Requires different amounts of OR time • Direct Costs = Nursing costs + OR costs + facility costs -Generate different amounts of RVUs per case • Indirect Costs = Overhead for depreciation, -Perform different numbers of cases per year operations/administration, maintenance, etc. 6
4/6/2017 Margin Units (mu) RVUs by Surgical Service • Relative margin, NOT in Dollars; but margin units (mu) • Indexed to Neurosurgery where NS = 1 million mus • Relative hospital margin per RVU = total annual specialty mus / annual specialty RVUs • Relative hospital margin per case = total annual mus/ total cases performed by specialty • Hospital margin per OR HR per specialty = total annual relative hospital margin/ total specialty OR hrs Relative Hospital Margin vs Total Cases/Year Relative Hospital Margin vs Annual RVUs 7
4/6/2017 Relative Hospital Margin vs Annual OR Hours Surgical Colleagues Vascular Surgery/ General Surgery 8
4/6/2017 Background To determine the frequency and • Vascular surgeons may provide assistance with nonvascular procedures. nature of intraoperative consults • The frequency and nature of intraoperative performed by vascular surgeons consultations has not been quantified. • Hospital administrators may not be aware of the importance of a vascular surgery program with respect to other specialties. • Trainee exposure to open, complex abdominal operations is decreasing, despite the ongoing need for assistance with challenging nonvascular operations. Intraoperative Consultations Variables Analyzed • Oregon Health & Science University • Demographics • Operation / Indication • January 2006 – January 2014 – Gender, age – Expected/Unexpected • Co-morbidities • 225 Intraoperative consultations in support of – Bleeding, dissection, reconstruction – CAD nonvascular operations. – Vessel(s) involved – DM • Inclusion criteria – vascular surgeon called to the – Anatomical location – Tobacco OR by a nonvascular surgeon. – EBL, operative time – BMI • Pre-operative Features – RVUs • Exclusion criteria – Cancer – No operative note/dictation • Post-operative – Prior radiation – Advice only without technical participation – Prior surgery – ICU stay – Co-surgeon or involvement in planning of the operation – Hospital stay – Consulting service – Mortality – Spine exposures – Anesthesia or Cath Lab complications J Vasc Surg 2015; 62: 177-82. J Vasc Surg 2015; 62: 177-82. 9
4/6/2017 Clinical Characteristics of the Patients Consulting Service Consults (n=225) 50 N % 45 45.8 Age (mean, SD) 54.6 (16.6) - Demographics 40 Surgical Oncology Intraoperative Consults (%) Male 133 59.1 Urology 35 Comorbidities Orthopedics CAD 17 7.6 30 Otolaryngology DM 38 16.9 Other* Current smoker 33 14.7 25 *General surgery, Neurosurgery, OB/GYN, BMI <25 86 38.2 Cardiothoracic, Pediatric, Colorectal, Trauma 20 BMI ≥ 25 126 56.0 18.7 BMI >30 50 22.2 17.3 15 Preoperative Features 10 Prior operation 163 72.4 11.1 Cancer 150 66.7 5 7.1 Radiation 18 8.0 0 Consulting Service J Vasc Surg 2015; 62: 177-82. J Vasc Surg 2015; 62: 177-82. Advance Notice for Intraoperative Consultation Indication for Intraoperative Consults (n) 90 Expected 80 81.3 Unexpected 44 Intraoperative Consults (%) 70 Bleeding 60 50 24 14% Emergent 16 40 5 30 Reconstruction 44 20 47 Dissection 18.7 10 31 0 Nature of Consult J Vasc Surg 2015; 62: 177-82. 10
4/6/2017 Anatomical Location of Intraoperative Consults Vessels Involved 10.7% 0.5% Other* 4.6% Portal Vein 24% 23% 70% 70% Carotid a. 7% SMV Aorta 18% 7% 13.8% Iliac a. IVC 6% 10% Hepatic a. 7% * Renal a., CIV, femoral a., IJV, SMA, ATA Operative and Postoperative Data Overall Survival • Operative course – Mean total EBL: 1.7 L – Mean Vascular EBL: 327ml – Mean procedural OR time: 7.9 hrs – Mean Vascular RVUs: 30.9 – Mean Nonvascular RVUs: 46.0 -Mean survival 4.7 ± 0.25 years -16 % lost to follow up • Postoperative course Lost to Follow Up :16% – Mean ICU stay 2.9 days – Mean hospital stay 14.7 days – 30-day Mortality: 6.2% J Vasc Surg 2015; 62: 177-82. J Vasc Surg 2015; 62: 177-82. 11
4/6/2017 Northwestern University Series Northwestern University Series • Men 49.5%, Mean age: 56.4 years • Intraoperative Vascular Surgery assistance • 6.9% operative volume • January, 2010 to June, 2014 • 1371 RVUs /year (21.1/case) • Excluded trauma patients, IVC filter placements • 75% consults were preoperative • 299 patients ( included 159 spine exposures, • 71% elective 52%) JAMA Surg 2016;151:1032-1038 JAMA Surg 2016;151:1032-1038 Northwestern University Series Northwestern Series: Anatomical Distribution (Consulting Services) of Operations 2.0% 10.7% 2.3% 0.5% 2.7% 4.6% 83% 70% 70% 70% 10.0% 13.8% NWU OHSU JAMA Surg 2016;151:1032-1038 12
4/6/2017 Types of Vascular Repairs Distribution of Vascular Repairs (Northwestern University report, n=110 repairs) (Northwestern University report, n=110 repairs) 12% combined 12% bypasses arterial and venous 16% patch angioplasties 53% Venous 36% Arterial 72% primary repairs JAMA Surg 2016;151:1032-1038 JAMA Surg 2016;151:1032-1038 Northwestern University Series University of Southern California • Presented 2016 Western Vascular Society • 78% vascular repairs in an emergency setting • 76 Intraoperative consults for 3 years to 2016 • All were open repairs, no endovascular • Excluded spine exposures • 99% all cases started before 6PM • 56% unplanned • 5.3 % vascular portion of the case started • Cardiac Surgery, Urology, Orthopedics, after 6PM Hepatobiliary/Transplant primary services JAMA Surg 2016;151:1032-1038 13
4/6/2017 University of Southern California Distribution USC Vascular repairs (Primary Reason for Consultation) 28% Exposure 34% 23% bypass hemorrhage 38% primary repair 38% Reconstruction 32% 6% interposition endovascular graft repair WVS Annual Meeting, September 2016 WVS Annual Meeting, September 2016 University of Southern California Vascular Trauma • Mean Vascular RVUs per case: 23.8 • 9% 30-day mortality (6.2 % OHSU, 1.7% NWU) • 5 ECMO related deaths WVS Annual Meeting, September 2016 14
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