Defining the burden, scope, and future of vascular acute care surgery

Understanding the Scope of Acute Care Vascular Surgery at a Tertiary Academic Medical System

OBJECTIVE

The restructuring of non-elective general surgery and nationwide implementation of the acute care surgery paradigm has improved patient outcomes and healthcare resource utilization. Although vascular surgery maintains one of the highest acuity rates among surgical specialties, the acute care vascular surgery (ACVS) practice model has not been widely accepted. In the present study, we investigate the scope and burden of ACVS at a tertiary academic medical system.

METHODS

All vascular surgical procedures performed at three hospitals comprising a large tertiary academic medical system were retrospectively queried through electronic medical records. Data were collected on procedure, acuity, timing of intervention, primary service, admission type, and total costs and charges. Patients were stratified by acuity of surgical intervention, with ACVS being defined as urgent or emergent operation.

RESULTS

A total of 12,689 vascular surgeries were performed from 2018 to 2022. ACVS procedures comprised 22.1% this total (n=2,803; 12.5% urgent, 9.6% emergent), with an annual burden ranging from 19.1% to 28.3%. Vascular surgeons served as primary surgeon in 91.3% of ACVS and co-surgeon in 8.7%. Fourteen separate surgical specialties requested acute vascular assistance, with the most frequently consulting specialties including trauma/acute care surgery (n=109, 3.9%) and cardiac surgery (n=74, 2.6%). ACVS cases were more frequently performed after-hours (30.7% vs 11.6%) and on weekends (27.1% vs 2.0%) compared with elective vascular procedures (p<0.0001 each). The majority of ACVS cases originated from inpatient (n=2,353, 85.0%) and emergency department (n=379, 13.5%) consultations. Overall, ACVS generated $37.5 million in charges, accounting for 14% of total procedure-related charges over the study period.

CONCLUSIONS

ACVS comprises a substantial portion of modern vascular practice, and is associated with significant human and healthcare resource expenditure. These data support the development of practice models dedicated to acute vascular surgical care.

Implementation of a vascular acute care surgery model is associated with improved surgeon efficiency and 2-year mortality after lower extremity intervention

OBJECTIVE

Vascular surgeons work long, unpredictable hours with repeated exposure to high-stress situations. Inspired by general surgery acute care surgery models, we sought to organize the care of vascular emergencies with the implementation of a vascular acute care surgery (VACS) model. Within this model, a surgeon is in-house without elective cases and assigned for consultations and urgent operative cases on a weekly basis. This study examined the impact of a VACS model on postoperative mortality and surgeon efficiency.

METHODS

This was a retrospective cohort analysis of institutional Vascular Quality Initiative data from July 2014 to July 2023. Patients undergoing lower extremity bypass, peripheral vascular intervention, or amputation were included. There was a washout period from January 2020 to January 2022 to account for COVID-19 pandemic practice abnormalities. Patients were separated into pre- or post-VACS groups. The primary clinical outcomes were 30-day and 2-year mortality. Secondary clinical outcomes included 30-day complications and 30-day and 1-year major adverse limb events (MALE). Separate analyses of operating room data from July 2017 to February 2024 and fiscal data from fiscal year 2019 to fiscal year 2024 were conducted. A washout period from January 2020 to January 2022 was applied. Efficiency outcomes included monthly relative value units (RVUs) per clinical fraction full-time equivalent (cFTE) and daytime (0730-1700, Monday-Friday) operating room minutes. Patient factors and operative efficiency were compared using appropriate statistical tests. Regression modeling was performed for the primary outcomes.

RESULTS

There were 972 and 257 patients in the pre- and post-VACS groups, respectively. Pre-VACS patients were younger (66.8 ± 12.0 vs 68.7 ± 12.7 years; P = .03) with higher rates of coronary artery disease (34.6% vs 14.8%; P < .01), hypertension (88.4% vs 82.2%; P = .01), and tobacco history (84.4% vs 78.2%; P = .02). Thirty-day mortality (2.4% pre-vs 0.8% post-VACS; P = .18) and Kaplan-Meier estimation of 2-year mortality remained stable after VACS (P = .07). VACS implementation was not associated with 30-day mortality but was associated with lower 2-year mortality hazard on multivariable Cox regression (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.9; P = .01). Operative efficiency improved post-VACS (median, 850.0; interquartile range [IQR], 765.7-916.3 vs median, 918.0; IQR, 881.0-951.1 RVU/cFTE-month; P = .03). Daytime operating minutes increased (469.1 ± 287.5 vs 908.2 ± 386.2 minutes; P < .01), whereas non-daytime minutes (420.0; IQR, 266.0-654.0 vs 469.5; IQR, 242.0-738.3 minutes; P = .40) and weekend minutes (129.0; IQR, 0.0-298.0 vs 113.5; IQR, 0.0-279.5 minutes; P = .59) remained stable.

CONCLUSIONS

A VACS model leads to improvement in surgeon operative efficiency while maintaining patient safety. The adoption of a vascular acute care model has a positive impact on the delivery of comprehensive vascular care.

Novel Electronic Health Records-Based Consultation Workflow Improves Time to Operating Room for Vascular Surgery Patients in an Acute Setting

BACKGROUND

Inefficient clinical workflows can have downstream effects of increased costs, poor resource utilization, and worse patient outcomes. The surgical consultation process can be complex with unclear communication, potentially delaying care for patients requiring time-sensitive intervention in an acute setting. A novel electronic health records (EHR)-based workflow was implemented to improve the consultation process. After implementation, we assessed the impact of this initiative in patients requiring vascular surgery consultation.

METHODS

An EHR-driven consultation workflow was implemented at a single institution, standardizing the process across all consulting services. This order-initiated workflow automated notification to clinicians of consult requests, communication of patient data, patient addition to consultants' lists, and tracking consult completion. Preimplementation (1/1/2020-1/31/2022) and postimplementation (2/1/2022-12/4/2022) vascular surgery consultation cohorts were compared to evaluate the impact of this initiative on timeliness of care.

RESULTS

There were 554 inpatient vascular surgery consultations (255 preimplementation and 299 postimplementation); 45 and 76 consults required surgery before and after implementation, respectively. The novel workflow resulted in placement of a consult note 32 min faster than preimplementation (preimplementation: 462 min, postimplementation: 430 min, P = 0.001) for all vascular surgery consults. Furthermore, vascular surgery patients with ASA class III or IV status requiring an urgent or emergent operation were transported to the operating room 63.3% faster after implementation of the workflow (preimplementation: 284 min, postimplementation: 180 min, P = 0.02). There were no differences in procedure duration, postoperative disposition, or intraoperative complication rates.

CONCLUSIONS

We implemented a novel workflow utilizing the EHR to standardize and automate the consultation process in the acute inpatient setting. This institutional initiative significantly improved timeliness of care for vascular surgery patients, including decreased time to operation. Innovations such as this can be further disseminated across shared EHR platforms across institutions, representing a powerful tool to increase the value of care in vascular surgery and healthcare overall.

Medical center reimbursement for vascular procedures has increased over time while professional reimbursement has declined

OBJECTIVE

The United States healthcare system uses different methods for assigning medical center reimbursement (MCR) and professional reimbursement (PR) for clinical services. We hypothesized that PR has not increased proportionately to MCR for the same vascular services.

METHODS

MCR and PR were compared for commonly performed inpatient and outpatient vascular procedures between 2012 and 2021. MCR was calculated using the Medicare inpatient prospective payment system and outpatient prospective payment system. MCR is based on the Centers for Medicare and Medicaid Services definition and criteria for comorbidities and the occurrence of complications; thus, changes in MCR were reported as a range based on the degree of comorbidities and complications using the Diagnosis Related Group. PR was calculated using the Medicare physician fee schedule, which assigns a numerical work relative value unit to each surgical service, with final compensation determined by an annually adjusted conversion factor to yield a final dollar amount. The expected reimbursement based on the observed inflation during the study period using the consumer price index was calculated and compared to the actual reimbursement.

RESULTS

From 2012 to 2021, MCR for inpatient procedures increased 20% to 26% for carotid endarterectomy, 24% to 27% for femoral endarterectomy, 24% to 27% for femoropopliteal bypass with vein, 14% to 19% for thoracic endovascular aortic repair, and 15% for aortobifemoral bypass. During the same period, PR increased 3.3% for carotid endarterectomy but decreased for femoral endarterectomy (-5.0%), femoropopliteal bypass (-4.6%), thoracic endovascular aortic repair (-4.2%), and aortobifemoral bypass (-5.0%). Comparing the expected reimbursement, adjusted for inflation, to the actual reimbursement, PR experienced a 10% to 17% reduction but MCR outpaced inflation by 3.7% to 10%. For outpatient procedures, MCR increased 117% for tibial angioplasty, 24% for superficial femoral artery (SFA) stenting, 62% for tunneled dialysis catheter (TDC) insertion, and 24% for iliac stenting but decreased 0.43% for arteriovenous fistula (AVF) creation and 7.6% for radiofrequency ablation (RFA). PR increased 0.91% for SFA stenting but decreased for tibial angioplasty (-17%), AVF creation (-6.4%), TDC insertion (-7.1%), iliac stenting (-3.8%), and RFA (-22%). Comparing the expected reimbursement, adjusted for inflation, to the actual reimbursement, PR experienced a 13% to 32% reduction. In contrast, MCR outpaced inflation 7.5% to 88% for tibial angioplasty, SFA stenting, TDC insertion, and iliac stenting but experienced a reduction for AVF (-13%) and RFA (-19%).

CONCLUSIONS

MCR for commonly performed vascular procedures has increased and outpaced inflation. In contrast, PR for these same services has decreased across all procedure types. This decrease in PR was exacerbated when adjusted for inflation. This inequity in the reimbursement methods between MCR and PR poses a threat to the viability of the physician workforce. Either changes to the reimbursement methods or a reallocation of reimbursement to physicians are imperative to sustain physician practices.

Clinical and economic impact of COVID in Vascular Surgery at a Tertiary University 'Hub' Hospital of Italy

Background

Since the first cases of a novel respiratory disease were reported in December 2019, coronavirus disease (COVID-19) Emergency State (Cov-ES) caused a worldwide outbreak requiring a complete reorganization of the healthcare system and new management of its personnel; aim of this study was to analyze the clinical and financial impact of Cov-ES in the Department of Vascular Surgery at a Tertiary University “Hub” Hospital in northeast Italy.

Methods

Differences in clinical practice according to Diagnostic Related Group (DRG) and International Statistical Classification of Diseases (ICD) and Related Health Problems and the financial impact of Cov-ES were considered. Vascular procedures performed between March 2019 and December 2019 (Prepandemic) were compared to those performed in the period March–December 2020 (Pandemic). Prepandemic and pandemic reimbursements of all vascular activities and the top 3 vascular diagnoses were evaluated.

Results

Prepandemic versus pandemic era documented a decrease of vascular consultations performed (2,882 vs. 2,270, −21.2%). The number of total vascular procedures decreased from 997 to 797 (−20.1%) with a higher reduction observed in outpatient surgical activities (247 to 136, −45.0%, P = 0.0005) rather than inpatient surgical activities (750 vs. 661, 11.9%, P = 0.02). Length of hospital stay (LOS) increased from 3.3 ± 2.7 days in prepandemic to 5.3 ± 3.9 in the pandemic era (P = 0.004). Among patients with limb-threatening ischemia, the rate of major limb amputation was higher in the pandemic (3.3% vs. 5.4%, respectively, P = 0.02), and a higher rate of elective hospitalization procedures was performed as urgent/emerging setting after clinical deterioration (2.8 % vs. 6.4%, P = 0.0002). According to DRG classification, an increase of “complicated” limb-threatening ischemia (DRG 554) and aortic aneurysm (DRG 110) was observed prepandemic to pandemic (+84.2% and +25.0%, respectively). Total reimbursement for vascular activities between pandemic versus prepandemic was 4,646,108€ vs. 5,054,398€, respectively (−8.0%). Management of “complicated” limb-threatening ischemia (DRG 554) and aortic aneurysm (DRG 110) required a higher clinical and financial support that was translated into higher economic reimbursement during the pandemic (273,035€ vs. 150,005€, +82.0% and 749,250€ vs. 603,680€, +24.1%, respectively).

Conclusions

During the pandemic, the main resources were employed for the treatment of limb-threatening ischemia, aortic aneurysm, and carotid stenosis. Inpatient activities documented an increase in major limb amputation and LOS. An increased reimbursement for each vascular procedure and for all “complicated” diagnoses revealed that the more serious and resource-demanding pathology occurred in this period.

Improving Code Status Documentation Rates Using Communication Skills Training in Vascular Surgery: A Quality Improvement Initiative

Introduction: Code status discussions are poorly understood by patients and variably performed by admitting providers, yet they are used as a quality metric. Surgical specialties, such as Vascular Surgery, admit patients with urgent and life-threatening illness. Surgical trainees are less likely to receive communication skills interventions when compared with nonsurgical specialties. Without a documented code status, nurses and physicians lack guidance on patient preference in the case of cardiopulmonary arrest and may deliver unwanted measures, which may also result in poor outcomes. Methods: We conducted a before-after Plan-Do-Study-Act quality improvement project between May 2018 and May 2019. A needs assessment included baseline code status documentation rates for the Vascular Surgery department admissions. A communication skills training (CST) and documentation intervention was provided to all Vascular Surgery trainees and advance practice providers (APPs). Departmental e-mails were sent over the 12-month intervention period, which demonstrated the code status documentation rates and served as reminders to document code status. Results: A total of 29 vascular surgery trainees and APPs received the intervention. At completion of the intervention, learners reported increased comfort initiating a code status discussion, making a recommendation for cardiopulmonary resuscitation (CPR) status, and having a strategy to discuss code status. A total of 2762 patient admissions were reviewed, with 1562 patient admissions occurring during the 12-month intervention period. The average code status documentation rate for the three months before the intervention was 7.8%. At the end of the 12-month intervention, documentation rates were 44.9% and 6 months after completion of the study period, average rates remained 45.2%. There was no change in admission rates during the study period. Discussion: CST and regular reminders increased vascular surgery residents' and APPs' comfort in engaging in code status discussions. After intervention, documentation of code status discussions increased with persistence up to six months after the intervention.

Financial implications of coronavirus disease 2019 on a tertiary academic vascular surgery practice

Background

The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on the healthcare system in the United States. The redistribution of resources and suspension of elective procedures and other services has resulted in financial stress across all service lines. The financial effects on the practice of vascular surgery have not yet been quantified. We hypothesized that vascular surgery divisions have experienced losses affecting the hospital and professional sides that will not be recoupable without significant productivity increases.

Methods

Administrative claims data for clinical services performed by the vascular surgery division at a tertiary medical center for March and April 2019 and for March and April 2020 were analyzed. These claims were separated into two categories: hospital claims (inpatient and outpatient) and professional claims (professional reimbursement for all services provided). Medicare reimbursement methods were used to assign financial value: diagnosis-related group for inpatient services, ambulatory payment classification for outpatient services, and the Medicare physician fee schedule for professional reimbursement and work relative value units (wRVUs). Reimbursements and productivity (wRVUs) were compared between the two periods. A financial model was created to determine the increase in future productivity over baseline required to mitigate the losses incurred during the pandemic.

Results

A total of 11,317 vascular surgery claims were reviewed. Hospital reimbursement during the pandemic decreased from $4,982,114 to $2,649,521 (−47%) overall (inpatient, from $3,505,775 to $2,128,133 [−39%]; outpatient, from $1,476,339 to $521,388 [−65%]) and professional reimbursement decreased from $933,897 to $430,967 (−54%) compared with the same period in 2019. Professional productivity as measured by wRVUs sustained a similar decline from 10,478 wRVUs to 5386 wRVUs (−51%). Modeling sensitivity analyses demonstrated that if a vascular division were able to increase inpatient and outpatient revenue to greater than prepandemic levels by 10%, 5%, or 3%, it would take 9, 19, or 31 months, respectively, for the hospital to recover their pandemic-associated losses. Similarly, professional reimbursement recovery would require 11, 20, or 36 months with corresponding increases in productivity.

Conclusions

The COVID-19 pandemic has had profound and lasting effects on the world in terms of lives lost and financial hardships. The financial effects on vascular surgery divisions has resulted in losses ranging from 39% to 65% compared with the prepandemic period in the previous year. Because the complete mitigation of losses is not feasible in the short term, alternative and novel strategies are needed to financially sustain the vascular division and hospital during a prolonged recovery period.

Reduced length of stay and 30-day readmission rate on an inpatient vascular surgery service

As the cost of care for patients with specific diagnoses becomes fixed, hospitals must develop systems to reduce length of stay and optimize the use of hospital resources while maintaining a high quality of care. The goal of this study is to evaluate the implementation and efficacy of a system designed to reduce average length of stay on a vascular surgery service. To effectively reduce the average length of stay in our center, we restructured patient rounds, implemented multidisciplinary rounds, introduced clinical pathways to postoperative care, and expanded outpatient management of postoperative patients. A total of 1697 adult vascular surgery patients discharged while under the medical direction of a vascular surgeon between July 1, 2013, and June 30, 2016, were included in the study. Improving communication with critical staff and using procedural space outside of the main operating rooms led to a 2.8-day reduction in the length of stay (10.8 vs 8.0, P < .001). There was a trend toward a reduction in the 30-day readmission rate (12% vs 10%, respectively; P = .01) and no significant difference in the case-mix index as a measure of illness severity (2.5 vs 2.4, respectively; P = .15). Length of stay reductions were heterogeneous among the types of vascular diseases studied, with greater improvements seen in patients undergoing lower extremity amputation, lower extremity angiogram, and endovascular aneurysm repair for nonruptured abdominal aortic aneurysms. Less pronounced differences were observed in patients undergoing carotid artery endarterectomy or stenting and lower extremity bypasses. In conclusion, restructuring team rounds and instituting a multidisciplinary approach to discharge planning produced significant reductions in length of stay without a deleterious effect on patient care which may impact hospital profitability.

Early Treatment at a Referral Center Improves Outcomes for Patients with Acute Vascular Disease

BACKGROUND

Patients with acute vascular disease frequently need specialized management that may require transfer to a vascular referral center. Although transfer may be medically necessary, it can delay definitive care and is an indicator of incorrect triage to the initial hospital. Regionalization of acute vascular care could improve patient triage and subsequent outcomes. To evaluate the potential benefit from regionalization, we analyzed outcomes of patients treated for acute vascular disease at vascular referral centers.

METHODS

Using a statewide database capturing all inpatient admissions in Maryland during 2013-2015, patients undergoing noncardiac vascular procedures on an acute basis were identified. Patients admitted to a vascular referral center were stratified by admission status as direct or transfer. The primary outcome was inpatient mortality, and the secondary outcome was resource use. Patient groups were compared by univariable analyses, and the effect of admission status on mortality was assessed by multivariable logistic regression.

RESULTS

Of 4,873 patients with acute vascular disease managed at vascular referral centers, 2,713 (56%) were admitted directly, whereas 2,160 (44%) were transferred. Transfers to referral centers accounted for 71% of all interhospital transfers. The transfer-group patients were older, had more comorbidities, and higher illness severities. Patients who were transferred had higher mortality (14% vs. 9%, P < 0.0001), longer hospital lengths of stay, greater critical care-resource utilization, and higher costs. After adjusting for demographics, comorbidities, and illness severity, transfer status was independently associated with higher inpatient mortality.

CONCLUSIONS

Primary treatment at a referral center is independently associated with improved outcomes for patients with acute vascular disease. Direct admission or earlier triage to a specialty center may improve patient and system outcomes and could be facilitated by standardization and regionalization of complex acute vascular care.