No Disclosures Operating Room and Regional Resource Gregory L. - - PowerPoint PPT Presentation

4/6/2017 1

Master Title

Gregory L. Moneta MD Professor and Chief Division of Vascular Surgery Oregon Health & Science University Knight Cardiovascular Institute Portland, Oregon USA

Vascular Surgeons are an Essential Hospital, Operating Room and Regional Resource

No Disclosures Outline

• Separation General and Vascular Surgery
• Hospital economics
• Colleagues
• Referring Hospitals

4/6/2017 2

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

Bruce A. Perler, M.D.: 2016 Binkley Visiting Professor

Ann Surg 2009; 250:463-71

Are We Happy?

Hospital Administration Surgical Colleagues

4/6/2017 3 Small Hospitals

Vascular Surgery/ General Surgery

Rene Leriche Alexis Carrel Jean Kunlin

Femoral Popliteal Bypass

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Abdominal Aortic Reconstruction

Rudolph Matas Charles Dubost Jacques Oudot

Carotid Endarterectomy

Michael DeBakey HHG Eastcott

Vascular Surgery/ General Surgery

Edwin Jack Wylie

(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

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Charles Dotter Bill Cook

100 200 300 400 500 600 700 800 GSR

Total Vascular Cases 2001 and 2012: General Surgery (GSR) vs Vascular Surgery Residents (VSR)

2012 2001 GSR VSR

(-40%) (+161%)

Ann Vasc Surg 2016;33:98-102

Endovascular Cases: Vascular and General Surgery Residents

Ann Vasc Surg 2016;33:98-102

Major Open Vascular Procedures 2001 and 2012 General Surgery (GSR) vs Vascular Surgery Residents (VSR)

5 10 15 20 25 30 35 40 45 50 Open AAA GSR Open AAA VSR Bypass GSR Bypass VSR CEA GSR CEA VSR 2001 2012

Ann Vasc Surg 2016;33:98-102

(-79%) (-43%) (-61%) (+8%) (-49%) (+12%)

4/6/2017 6 Open Vascular Cases: Vascular vs General Surgery Residents

Ann Vasc Surg 2016;33:98-102

FY16: OHSU Knight Cardiovascular Institute Revenue

• OHSU Operating Budget: $2.2 billion
• $125 Million Margin

Hospital Margin and RVU Production

• Relationship between hospital margin and

professional fees generated is not straightforward.

• Each specialty:
• Requires different amounts of OR time
• Generate different amounts of RVUs per case
• Perform different numbers of cases per year

Margin, Revenue, Costs

• Margin = Revenue – (Direct + Indirect Costs)
• Revenue = Payments for preadmission testing

+ payments for operative services + payments for postoperative care

• Direct Costs = Nursing costs + OR costs +

facility costs

• Indirect Costs = Overhead for depreciation,
• perations/administration, maintenance, etc.

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Margin Units (mu)

• 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

RVUs by Surgical Service

Relative Hospital Margin vs Total Cases/Year Relative Hospital Margin vs Annual RVUs

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Relative Hospital Margin vs Annual OR Hours Surgical Colleagues

Vascular Surgery/ General Surgery

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Background

• Vascular surgeons may provide assistance with

nonvascular procedures.

• The frequency and nature of intraoperative

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
• perations is decreasing, despite the ongoing

need for assistance with challenging nonvascular

• perations.

To determine the frequency and nature of intraoperative consults performed by vascular surgeons

Intraoperative Consultations

• Oregon Health & Science University
• January 2006 – January 2014
• 225 Intraoperative consultations in support of

nonvascular operations.

• Inclusion criteria – vascular surgeon called to the

OR by a nonvascular surgeon.

• Exclusion criteria

– No operative note/dictation – Advice only without technical participation – Co-surgeon or involvement in planning of the operation – Spine exposures – Anesthesia or Cath Lab complications

J Vasc Surg 2015; 62: 177-82.

Variables Analyzed

• Demographics

– Gender, age

• Co-morbidities

– CAD – DM – Tobacco – BMI

• Pre-operative Features

– Cancer – Prior radiation – Prior surgery – Consulting service

• Operation / Indication

– Expected/Unexpected – Bleeding, dissection, reconstruction – Vessel(s) involved – Anatomical location – EBL, operative time – RVUs

• Post-operative

– ICU stay – Hospital stay – Mortality

J Vasc Surg 2015; 62: 177-82.

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Consults (n=225) N % Age (mean, SD) 54.6 (16.6)

• Demographics

Male 133 59.1 Comorbidities CAD 17 7.6 DM 38 16.9 Current smoker 33 14.7 BMI <25 86 38.2 BMI ≥25 126 56.0 BMI >30 50 22.2 Preoperative Features Prior operation 163 72.4 Cancer 150 66.7 Radiation 18 8.0

Clinical Characteristics of the Patients

J Vasc Surg 2015; 62: 177-82.

45.8 11.1 17.3 7.1 18.7 5 10 15 20 25 30 35 40 45 50

Consulting Service

Intraoperative Consults (%) Surgical Oncology Urology Orthopedics Otolaryngology Other*

J Vasc Surg 2015; 62: 177-82.

Consulting Service

*General surgery, Neurosurgery, OB/GYN, Cardiothoracic, Pediatric, Colorectal, Trauma

Advance Notice for Intraoperative Consultation

18.7 81.3 10 20 30 40 50 60 70 80 90 Nature of Consult Intraoperative Consults (%) Expected Unexpected 14% Emergent

J Vasc Surg 2015; 62: 177-82.

Bleeding Dissection Reconstruction

44 16 5 24 31 47 44

Indication for Intraoperative Consults (n)

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70% 0.5% 13.8% 4.6% 10.7%

Anatomical Location of Intraoperative Consults

70%

Portal Vein 23% SMV 18% IVC 10%

Hepatic a. 7%

Iliac a. 6% Aorta 7% Carotid a. 7% Other* 24%

Vessels Involved

* Renal a., CIV, femoral a., IJV, SMA, ATA

Operative and Postoperative Data

• 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

• Postoperative course

– Mean ICU stay 2.9 days – Mean hospital stay 14.7 days – 30-day Mortality: 6.2%

J Vasc Surg 2015; 62: 177-82.

Overall Survival

Lost to Follow Up :16%

• Mean survival 4.7 ± 0.25 years
• 16 % lost to follow up

J Vasc Surg 2015; 62: 177-82.

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Northwestern University Series

• Intraoperative Vascular Surgery assistance
• January, 2010 to June, 2014
• Excluded trauma patients, IVC filter

placements

• 299 patients ( included 159 spine exposures,

52%)

JAMA Surg 2016;151:1032-1038

Northwestern University Series

• Men 49.5%, Mean age: 56.4 years
• 6.9% operative volume
• 1371 RVUs /year (21.1/case)
• 75% consults were preoperative
• 71% elective

JAMA Surg 2016;151:1032-1038

Northwestern University Series

(Consulting Services)

JAMA Surg 2016;151:1032-1038

70% 2.3% 10.0% 2.7% 2.0%

Northwestern Series: Anatomical Distribution

• f Operations

83% 70% 0.5% 13.8% 4.6% 10.7% 70%

NWU OHSU

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Types of Vascular Repairs

(Northwestern University report, n=110 repairs)

12% bypasses 16% patch angioplasties 72% primary repairs

JAMA Surg 2016;151:1032-1038

Distribution of Vascular Repairs

(Northwestern University report, n=110 repairs)

53% Venous 36% Arterial 12% combined arterial and venous

JAMA Surg 2016;151:1032-1038

Northwestern University Series

• 78% vascular repairs in an emergency

setting

• All were open repairs, no endovascular
• 99% all cases started before 6PM
• 5.3 % vascular portion of the case started

after 6PM

JAMA Surg 2016;151:1032-1038

University of Southern California

• Presented 2016 Western Vascular Society
• 76 Intraoperative consults for 3 years to 2016
• Excluded spine exposures
• 56% unplanned
• Cardiac Surgery, Urology, Orthopedics,

Hepatobiliary/Transplant primary services

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University of Southern California

28% Exposure 38% Reconstruction 34% hemorrhage

(Primary Reason for Consultation)

WVS Annual Meeting, September 2016

Distribution USC Vascular repairs

38% primary repair 6% endovascular repair 32% interposition graft 23% bypass WVS Annual Meeting, September 2016

University of Southern California

• 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

Vascular Trauma

4/6/2017 15

Vascular Trauma

• Major vascular injuries are infrequent: 1.6 %

adult, 0.6 % pediatric trauma patients.*

• No formal requirement for trauma center vascular

surgeons but it is now uncommon for general or trauma surgeons to repair major vascular injuries.

• Graduating general surgery residents from 2005

to 2014 performed an average of 3-5 vascular trauma procedures.

*J Pediatr Surg 2010;45:1404-12

Iatrogenic Trauma

• A major source of trauma
• 252 patients at our level I trauma center that

required intervention:

• 86 (34%) penetrating trauma
• 81 (32%) blunt trauma
• 85 (34%) iatrogenic trauma

Am J Surg 2004; 187:590-593

Iatrogenic Vascular injuries

• 60% injuries from percutaneous intervention
• 40% intraoperative vascular injuries

Am J Surg 2004; 187:590-593

Small Hospitals

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Transfer to Vascular Surgery

• Review of OHSU Transfer Center and EPIC

Medical Records

• July 2014 – Oct 2015
• 235 requests for transfer to Vascular Surgery
• 154 (67%) actually transferred

Reasons for Transfer

0% 5% 10% 15% 20% Asx carotid stenosis Post op Hematoma Post op Hemorrhage Vascular Injury Dialysis Acess DVT Wounds TAAA AMI AAA RAAA Sym Carotid Stenosis CLI ALI

Hospital Size and Transfer Requests

< 100 beds 100 – 200 beds > 300 beds

26 Hospitals 84 Requests 14 Hospitals 62 Requests 8 Hospitals 76 Requests

Non- transferred Patients

(n = 78)

• 35% stayed at referring facility after

reassurance from consulting vascular surgeon

• 30% offered clinic referral
• 11% received further evaluation locally
• 60% ultimately followed-up in OHSU vascular

surgery clinic

4/6/2017 17 Transfers and Resulting Procedures at OHSU

• 72% of completed transfers (n= 154) resulted

in a procedure or surgical intervention:

• 20% within 8 hours
• 12% 8 -24 hours
• 67% at some point during index admission

Nonsurgical Interventions

Observation, anticoagulation wound care, antibiotics ward medical care Nonvascular Specialist Consult Imaging ICU medical care 5 10 15 20 25 30 35 Percent

Procedures and Origin of Transfer

• Large Hospitals were more likely to

transfer patients requiring a procedure or surgical intervention (47% large hospital transfers) vs Small and Medium- size Hospitals (18% of transfers), p= 0.041.

Transfer Associated Mortality

• No patient died during transfer or a direct

result of transfer.

• Mortality of transferred patients was 12%
• Intact aneurysms: 0%
• Ruptured aneurysms: 14%
• No difference in transfer time (58 vs 79

minutes, p=0.28) or from first call to arrival ( 231 vs 303 minutes) in surviving vs non- surviving patients.

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Summary

• Vascular surgery has effectively separated from

general surgery as general surgeons no longer receive meaningful training in vascular procedures as a result of fellowship training and emergence of endovascular procedures.

• Vascular procedures provide a greater return on

investment than most other surgical specialties.

• Vascular surgeons enable multiple specialties to

perform complex procedures primarily through their

• pen technical skills.

Summary

• Most intraoperative vascular consults are performed

for patients with cancer and previous operations.

• Most consults performed are not anticipated.
• Intraoperative consults equally involve vascular

reconstruction, assisting with hemorrhage control, and aiding in difficult dissections.

• Abdominal open approaches ( arterial and venous)

are most often needed.

• Endovascular techniques rarely appropriate.

Summary

• Transfers to vascular surgery are safe without

associated mortality and relatively equally distributed among small, medium-size and large hospitals.

• Nearly 3/4s of completed transfers to vascular

surgery result in performance of a procedure or a surgical intervention.

• 60% of transfer consultations not resulting in transfer

ultimately result in an outpatient evaluation by a vascular surgeon.

• Hospitals should support vascular surgery

programs to facilitate both elective and emergent support for referring institutions and non-vascular specialties/programs (neurosurgery, orthopedics, cancer, trauma) essential to the hospital’s bottom line.

• Vascular resident training programs should

ensure adequate trainee exposure to open complex abdominal operations and difficult dissections.

Recommendations

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Master Title

Columbia River, Oregon

Questions?

Knight Cardiovascular Institute Relative Position Relative Hospital Margin/OR HR vs RVU/OR HR

4/6/2017 20

Relative Hospital Margins

(per RVU, OR hour and Case)