How to Build a Multi Disciplinary University Based Vascular Practice in the Same Division and Under the Same Leadership

How to Build a Multi Disciplinary University Based Vascular Practice in the Same Division and Under the Same Leadership Ali F. AbuRahma, M.D. Professor of Surgery Chief, Vascular & Endovascular Surgery Director, Vascular Surgery Residency & Fellowship Programs Medical Director, Vascular Laboratory Co Director, Vascular Center of Excellence R. C. Byrd Health Sciences Center West Virginia University Charleston Area Medical Center Charleston, WV, USA

2010 West Virginia Vascular/Endovascular Surgery Symposium 3

The Modern Vascular/Endovascular Surgeon Over the past 25 yrs., our specialty has matured substantially, providing the most comprehensive Dx and Rx of the entire spectrum of vascular disease Today s vascular surgeons provide: Best open vascular techniques Most modern endovascular Rx and comprehensive medical Rx Several other specialties are engaging in the Rx of vascular pts. 4

The Modern Vascular/Endovascular Surgeon Availability of variable practice designs Increased reimbursement, compared to other surgical specialties Expanded to include minimally invasive interventions Increased no. of novel & complex procedures Increased demand for vasc. surgeons Due to projected needs, training of adequate no. of vasc. surgeons is crucial 5

Main Components of Vascular Surgery Open Procedures Endovascular Venous Diagnosis and Intervention Vascular Lab / Imaging 6

Endovascular Volume in Modern Practice Younger vasc. surgeons (<50 yrs) reported that 90% of their cases were endovascular While older vasc. surgeons ( 50 yrs) reported that 62% of their cases were endovascular (p<.001) (M. Matthews, et al, JVS, 2013) 8

How Do You Compete With Other Specialties Multidisciplinary team Clinical outcomes 10

History of Vascular Surgery in WV Background of VCOE WWII: U.S.A. came together as never before Beginning of era of contemporary surgery & 1 st in hx. of military conflict, surgical options existed improved survival after traumatic injury Development of first aid (medics) on front lines stabilize injured soldiers with arterial injuries Many soldiers had complex vasc. injuries & there were no centers or specialists focused on vasc. disease 11

Ashford General Hospital White Sulphur Springs, WV War dept. purchased The Greenbrier on Sept. 1, 1942 for $3.3 million Converted hotel into a 2000 bed hospital focusing on vascular surgery (1 st VCOE) and neurosurgical issues in soldiers. In 4 years over 24,000 soldiers were treated Nicknamed The Shangri La for Wounded Soldiers 12

Ashford General Hospital White Sulphur Springs, WV 13

VCOE/The Greenbrier Traumatic vascular injuries funneled into one center Center for vascular innovation New surgical techniques in Rx vascular fistulas, aneurysms, & post traumatic ischemia Initially, the team consisted of surgeons with extensive vascular experience Then added I.M. specialists to Rx other disorders: Chronic vasospastic syndromes Frostbite Buerger s disease DVT Post traumatic venous ulcers 14

Ashford Hospital/The Greenbrier Annual report of 1944: 183 pts. had surgery for art. aneurysms, AVF Led to publication of the largest series of art. vascular surgery in the world 15

Ashford Hospital became the undisputed VCOE in 1944 Development of our modern vascular specialty in 1970 s This VCOE concept proved: multidiscipline center of excellence improves outcome 16

CAMC VCOE/WVU, Charleston, WV Fast forward 50 yrs. later (1994) the concept of our modern VCOE was born Heterogeneity of C.V. practice patterns & outcomes were recognized The initial vision was to bring all C.V. MDs under one roof This didn t materialize In 1996, the focus shifted to medicine and vascular surgery 17

The Original CORE Team 1. Chief, Vascular Surgery 2. Chairman, Surgery 3. Interventional cardiologist/vascular interventionalist 4. Interventional radiology 5. Chairman, Credentialing Committee 6. COO/CAMC 7. In consultation with the dean of the Medical School of WVU/Charleston, WV campus 18

CORE Issues Discussed Increasing tension: radiologists, cardiologists, and vasc. surg. compete for leadership role in new field of vasc. intervention Radiologists: felt they owned field since they did early pioneering work, but were reluctant to do long term FU and not experienced in complex med. issues and complications Vasc. surgeons: extensive training in vasc. diseases, but lacked experience with catheter procedures Cardiologists: extensive catheter skills, but no training related to end organ Recognizing turf challenges, with support from CAMC, CDL suite was opened independently from radiology and cardiology in 1996 19

Composition of the Early VCOE Team *Dr. M. Bates: Interventional vascular cardiologist *Dr. A. AbuRahma: Vascular surgeon Dr. J. Skeens: Interventional radiologist These 3 leaders, along with original CORE team, navigated difficult issues passed credentialing for endovasc. privileges @ CAMC In consultation with: Dr. Michael Jaff: Chairman, Dept of Vasc Med, Harvard Dr. Bruce Gray: Vasc Med Interventional Specialist, Greenville, SC Dr. Michael Bacharach, C.V. Disease Found., Sioux Falls, SD *Co Directors for VCOE 20

Our Model/CAMC/WVU, Charleston VCOE Model: Approved vascular fellowship/residency Intervent. radiology fellowship Intervent. cardiology fellowship with minimal 1 yr. in peripheral intervention Limited vasc. privileges for intervent. cardiology (renal/iliacs): minimal 3 mos. vasc. rotation 21

Early Guideline Requirements Requirements SCVIR SCAI ACC AHA SVS* 2008 SVS/ISCVS 1998 Angiograms 200 100/50 100 100 100 100/50 Interventions 25 50/25 50/25 50/25 50/25/20** 50/25 *Guidelines for hospital privileges in vasc. & endovasc. Surgery: Recommendations by the SVS, Calligaro KD, et al, JVS 2008;47:1-5. As primary interventionist **Endovascular aneurysm repair 22

Specific Requirements Cardiology Cardiology fellowship in credentialed program Full yr. dedicated vasc. intervent. fellowship after full yr. coronary intervent. fellowship Within 5 yrs., guidelines must follow current recommendations: full yr. of vasc. med. and full yr. of vasc. intervent. training (COCATS 3 Task Force 11 guidelines) (J Am Coll Cardiol 2008;51:398 404) 23

Specific Requirements Vasc. Med. Completion of 2 yr. vascular medicine and vascular intervent. fellowship that meets current criteria for vascular medicine and intervent. Boards Board certification in IM and both the ABVM vasc. med. and vasc. intervent. exams (Creager et al, JACC 2004; 44:941 57) 24

Specific Requirements Vasc. Surgery Board eligible training in vascular surgery via 5/2 traditional pathway or 0/5 programs Board certification in vascular surgery 25

Specific Requirements Intervent. Radiology Completion of accredited general radiology program and additional year or intervent. training Board certification in radiology and intervent. radiology (Creager et al, JACC 2004; 44:941 57) 26

Specific Requirements Cerebrovascular Disease Extracranial carotid angiography: 30 cases Intracranial carotid angiography: 20 cases (5 with over read) Carotid stenting: 25 cases ½as primary operator Acute stroke intervention: Cases TBD External carotid branch embolization for epistaxis: 1 case 27

Limited (Renal/Iliac) for Cardiology Cardiology intervent. fellowship 3 mos. documented vasc. med. or surgery training Case experience during fellowship 100 diagnostic angiograms 50 vasc. intervent. (10 renal and 10 iliac stenting) 28

Limited Credential Criteria for CT and GS Completed GS and/or CT surgical fellowship Board certification in GS and/or CT surgery Case experience: 25 proctored stent graft cases as primary operator Completion of credentialing courses for all FDA approved stent grafts Release by QA committee after 1 st 25 cases Window for this pathway should be limited to 3 Sept. 21, 2013 yrs. 2013 EVS Diversity Panel Luncheon 29

Our Present VCOE 11 MDs 6 Board certified vascular surgeons 2 Board certified cardiologists/vascular interventionalists 1 Board certified vascular medicine/interventionalist 1 Board certified interventional radiologist (neuro) 1 Board certified I.M./preventive medicine 30

Our Present VCOE All under one roof All are university employed (WVU) Practice at CAMC under one Division Chief 2 Co Directors of VCOE Initial VCOE center was on 2 nd floor of the CAMC Memorial campus Modern center (100 million) 31

Conclusions Multidisciplinary vascular practice improves outcome Delicate negotiations/? politics can help achieve this goal Ideally: 1 or 2 leaders and one team Emphasis on patient outcome/ hospital referral/revenue Thank you! 33

NEW RIVER GORGE BRIDGE, WV WORLD S 2 nd LONGEST SINGLE ARCH BRIDGE WHITE WATER RAFTING IN WV 72

Thank you! The Greenbrier, White Sulphur Springs, WV Sept. 21, 2013 2013 EVS Diversity Panel Luncheon 35