Compensation based on work relative value unit for cardiovascular surgeons in Iran: A mixed method study

BACKGROUND

Work relative value unit (wRVU) is a tool for assessing surgeons' performance, compensation, and productivity. It appears that wRVU for cardiovascular procedures does not consider complexity and its value for lengthy operations is low. The aim of the study is to determine wRVU for cardiovascular procedures in Iran according to the proposed approach.

MATTERIALS AND METHODS

This study was conducted as a mixed method in teaching hospitals in Tabriz in the period of September 2020 to December 2021. According to Hospital Information System and expert opinions, six procedures in cardiovascular surgery were included in the study. They were compared with 18 procedures in neurosurgery, orthopedics, and otorhinolaryngology in terms of the operation time and wRVU/min. Then, we calculated new wRVUs for the selected procedures based on surgeons' opinions, time measurements, and anesthetists' points of view by content analysis in qualitative and statistical analysis in quantitative parts.

RESULTS

Among the six cardiac procedures, the wRVU for five was under-estimated. The wRVU/min value ranged from 0/28 to 1/15 in the studied procedures. Findings demonstrate no significant relationship between the length of operations and the wRVU announced by the Ministry of Health and Medical Education (P value >0/05). Compared to studied procedures in four specialties, thoracoabdominal aortic aneurysm repair has the longest surgery time at 417 minutes. According to anesthesiologists, cardiovascular; orthopedics; ear, nose, and tongue; and neurosurgery specialties obtained 4/2, 2/9, 2/8, and 4, respectively, in terms of surgery duration, complexity, risk, and physical effort.

CONCLUSION

Despite policymakers' attempts to bring justice to payments, it seems that there has been little progress in paying cardiovascular surgeons. Improper payment to cardiovascular surgeons will affect the future of the workforce in this specialty. Today, the need to reconsider the wRVUs in heart specialty is felt more than before.

Complications and Management of the Thoracic Endovascular Aortic Repair

Endovascular treatment in thoracic aortic diseases has increased in use exponentially since Dake and colleagues first described the use of a home-made transluminal endovascular graft on 13 patients with descending thoracic aortic aneurysm at Stanford University in the early 1990s. Thoracic endovascular aneurysm repair (TEVAR) was initially developed for therapy in patients deemed unfit for open surgery. Innovations in endograft engineering design and popularization of endovascular techniques have transformed TEVAR to the predominant treatment choice in elective thoracic aortic repair. The number of TEVARs performed in the United States increased by 600% from 1998 to 2007, while the total number of thoracic aortic repairs increased by 60%. As larger multicenter trials and meta-analysis studies in the 2000s demonstrate the significant decrease in perioperative morbidity and mortality of TEVAR over open repair, TEVAR became incorporated into standard guidelines. The 2010 American consensus guidelines recommend TEVAR to be “strongly considered” when feasible for patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms. Nowadays, TEVAR is the predominant treatment for degenerative and traumatic descending thoracic aortic aneurysm repair. Although TEVAR has been shown to have decreased early morbidity and mortality compared with open surgical repair, endovascular manipulation of a diseased aorta with endovascular devices continues to have significant risks. Despite continued advancement in endovascular technique and devices since the first prospective trial examined the complications associated with TEVAR, common complications, two decades later, still include stroke, spinal cord ischemia, device failure, unintentional great vessel coverage, access site complications, and renal injury. In this article, we review common TEVAR complications with some corresponding radiographic imaging and their management.