VEITHsymposium

NEW YORK – Vascular surgeons are the only specialty qualified to treat all vascular disorders with open surgery and/or endovascular treatment, including the thoracic aorta, according to the updated “Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery.”

The guidelines, published in May’s Journal of Vascular Surgery, were last updated in 2008, said Keith D. Calligaro, MD, who spoke on their importance and potential benefits to vascular surgeons during his presentation at the VEITHsymposium.

The thoracic aorta component of the guidelines addresses scope of practice concerns between vascular and thoracic surgeons, said Dr. Calligaro, who is a clinical professor of surgery, University of Pennsylvania, and chief of vascular surgery and endovascular therapy at Pennsylvania Hospital, both in Philadelphia.

The guidelines relied on training requirements to provide some of the data to define vascular surgeons and privileges. The open vascular surgery training requirements still are defined by the Residency Review Committee for surgery, and those requirements include 250 major open vascular cases during training, including 30 open abdominal operations, 25 carotid, 45 peripheral open surgery cases, and 10 complex vascular surgeries, said Dr. Calligaro. “In terms of endovascular treatment, the training requirements are over 100 diagnostic caths and over 80 therapeutic interventions, and during training you would have had to have done more than 20 EVARs [endovascular aneurysm repairs].” That number jumped up from five EVARs in the previous guidelines.

Ultimately, “the SVS is basically saying ‘you need to be a vascular surgeon to perform vascular surgery,’ and you need have to have completed an Accreditation Council for Graduate Medical Education–accredited vascular residency.

“So if you are a general surgeon or a heart surgeon and you go to a new hospital and say ‘I want to do vascular,’ the vascular surgeon at that institution can refer to this document and say ‘no, the SVS is saying [the surgeon doesn’t] have the training.’ And I think that’s a pretty gutsy and important call,” said Dr. Calligaro.

It is a different case for endovascular surgery, he said. In this case, the requirement is to have completed an ACGME-accredited program in either vascular surgery, interventional radiology, or interventional cardiology to indicate the appropriate level of training. But SVS agreed with the recommendation by the American College of Cardiology that cardiologists not only had to complete 1 year of coronary interventions but also 1 year of peripheral intervention training, as well.

“So if you are at your hospital and have a cardiologist who is starting to do peripheral vascular stuff, now at least you can wave part of this document and say ‘Hey, look, the most important vascular society in the country is saying that, unless this individual had a year of peripheral training, this cardiologist should not be allowed to do endovascular peripheral interventions,’ ” Dr. Calligaro said.

mlesney@mdedge.com

SOURCE: Calligaro KD et al. J Vasc Surg. 2018 May;67(5):1337-44.

NEW YORK – Vascular surgeons are the only specialty qualified to treat all vascular disorders with open surgery and/or endovascular treatment, including the thoracic aorta, according to the updated “Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery.”

The guidelines, published in May’s Journal of Vascular Surgery, were last updated in 2008, said Keith D. Calligaro, MD, who spoke on their importance and potential benefits to vascular surgeons during his presentation at the VEITHsymposium.

The thoracic aorta component of the guidelines addresses scope of practice concerns between vascular and thoracic surgeons, said Dr. Calligaro, who is a clinical professor of surgery, University of Pennsylvania, and chief of vascular surgery and endovascular therapy at Pennsylvania Hospital, both in Philadelphia.

The guidelines relied on training requirements to provide some of the data to define vascular surgeons and privileges. The open vascular surgery training requirements still are defined by the Residency Review Committee for surgery, and those requirements include 250 major open vascular cases during training, including 30 open abdominal operations, 25 carotid, 45 peripheral open surgery cases, and 10 complex vascular surgeries, said Dr. Calligaro. “In terms of endovascular treatment, the training requirements are over 100 diagnostic caths and over 80 therapeutic interventions, and during training you would have had to have done more than 20 EVARs [endovascular aneurysm repairs].” That number jumped up from five EVARs in the previous guidelines.

Ultimately, “the SVS is basically saying ‘you need to be a vascular surgeon to perform vascular surgery,’ and you need have to have completed an Accreditation Council for Graduate Medical Education–accredited vascular residency.

“So if you are a general surgeon or a heart surgeon and you go to a new hospital and say ‘I want to do vascular,’ the vascular surgeon at that institution can refer to this document and say ‘no, the SVS is saying [the surgeon doesn’t] have the training.’ And I think that’s a pretty gutsy and important call,” said Dr. Calligaro.

It is a different case for endovascular surgery, he said. In this case, the requirement is to have completed an ACGME-accredited program in either vascular surgery, interventional radiology, or interventional cardiology to indicate the appropriate level of training. But SVS agreed with the recommendation by the American College of Cardiology that cardiologists not only had to complete 1 year of coronary interventions but also 1 year of peripheral intervention training, as well.

“So if you are at your hospital and have a cardiologist who is starting to do peripheral vascular stuff, now at least you can wave part of this document and say ‘Hey, look, the most important vascular society in the country is saying that, unless this individual had a year of peripheral training, this cardiologist should not be allowed to do endovascular peripheral interventions,’ ” Dr. Calligaro said.

mlesney@mdedge.com

SOURCE: Calligaro KD et al. J Vasc Surg. 2018 May;67(5):1337-44.

NEW YORK – Vascular surgeons are the only specialty qualified to treat all vascular disorders with open surgery and/or endovascular treatment, including the thoracic aorta, according to the updated “Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery.”

The guidelines, published in May’s Journal of Vascular Surgery, were last updated in 2008, said Keith D. Calligaro, MD, who spoke on their importance and potential benefits to vascular surgeons during his presentation at the VEITHsymposium.

The thoracic aorta component of the guidelines addresses scope of practice concerns between vascular and thoracic surgeons, said Dr. Calligaro, who is a clinical professor of surgery, University of Pennsylvania, and chief of vascular surgery and endovascular therapy at Pennsylvania Hospital, both in Philadelphia.

The guidelines relied on training requirements to provide some of the data to define vascular surgeons and privileges. The open vascular surgery training requirements still are defined by the Residency Review Committee for surgery, and those requirements include 250 major open vascular cases during training, including 30 open abdominal operations, 25 carotid, 45 peripheral open surgery cases, and 10 complex vascular surgeries, said Dr. Calligaro. “In terms of endovascular treatment, the training requirements are over 100 diagnostic caths and over 80 therapeutic interventions, and during training you would have had to have done more than 20 EVARs [endovascular aneurysm repairs].” That number jumped up from five EVARs in the previous guidelines.

Ultimately, “the SVS is basically saying ‘you need to be a vascular surgeon to perform vascular surgery,’ and you need have to have completed an Accreditation Council for Graduate Medical Education–accredited vascular residency.

“So if you are a general surgeon or a heart surgeon and you go to a new hospital and say ‘I want to do vascular,’ the vascular surgeon at that institution can refer to this document and say ‘no, the SVS is saying [the surgeon doesn’t] have the training.’ And I think that’s a pretty gutsy and important call,” said Dr. Calligaro.

It is a different case for endovascular surgery, he said. In this case, the requirement is to have completed an ACGME-accredited program in either vascular surgery, interventional radiology, or interventional cardiology to indicate the appropriate level of training. But SVS agreed with the recommendation by the American College of Cardiology that cardiologists not only had to complete 1 year of coronary interventions but also 1 year of peripheral intervention training, as well.

“So if you are at your hospital and have a cardiologist who is starting to do peripheral vascular stuff, now at least you can wave part of this document and say ‘Hey, look, the most important vascular society in the country is saying that, unless this individual had a year of peripheral training, this cardiologist should not be allowed to do endovascular peripheral interventions,’ ” Dr. Calligaro said.

mlesney@mdedge.com

SOURCE: Calligaro KD et al. J Vasc Surg. 2018 May;67(5):1337-44.

NEW YORK – A clever strategy to evaluate long term outcomes in patients undergoing endovascular abdominal aortic aneurysm repair identified a 20% rate of reintervention, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation by Philip P. Goodney, MD.

In this video interview with Dr. Goodney, an associate professor of vascular surgery at Geisel School of Medicine at Dartmouth, Hanover, N.H., he explains how Medicare data were employed to track patients long term, even when they had moved to other hospital systems.

The main message from the long-term follow-up is that there is a persistent risk of recurrence and need for reintervention, according to Dr. Goodney. The hypothesis was that there would be an early risk of failure, followed by a diminishing need for reintervention over time, but this was not what was observed.Rather, the findings suggest that the rate of reinterventions was relatively steady over the course of follow-up, suggesting that patients should be informed of a persistent risk. However, Dr. Goodney reports that age was not a predictor of reintervention, so that older patients were at no greater risk.

NEW YORK – A clever strategy to evaluate long term outcomes in patients undergoing endovascular abdominal aortic aneurysm repair identified a 20% rate of reintervention, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation by Philip P. Goodney, MD.

In this video interview with Dr. Goodney, an associate professor of vascular surgery at Geisel School of Medicine at Dartmouth, Hanover, N.H., he explains how Medicare data were employed to track patients long term, even when they had moved to other hospital systems.

The main message from the long-term follow-up is that there is a persistent risk of recurrence and need for reintervention, according to Dr. Goodney. The hypothesis was that there would be an early risk of failure, followed by a diminishing need for reintervention over time, but this was not what was observed.Rather, the findings suggest that the rate of reinterventions was relatively steady over the course of follow-up, suggesting that patients should be informed of a persistent risk. However, Dr. Goodney reports that age was not a predictor of reintervention, so that older patients were at no greater risk.

NEW YORK – A clever strategy to evaluate long term outcomes in patients undergoing endovascular abdominal aortic aneurysm repair identified a 20% rate of reintervention, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation by Philip P. Goodney, MD.

In this video interview with Dr. Goodney, an associate professor of vascular surgery at Geisel School of Medicine at Dartmouth, Hanover, N.H., he explains how Medicare data were employed to track patients long term, even when they had moved to other hospital systems.

The main message from the long-term follow-up is that there is a persistent risk of recurrence and need for reintervention, according to Dr. Goodney. The hypothesis was that there would be an early risk of failure, followed by a diminishing need for reintervention over time, but this was not what was observed.Rather, the findings suggest that the rate of reinterventions was relatively steady over the course of follow-up, suggesting that patients should be informed of a persistent risk. However, Dr. Goodney reports that age was not a predictor of reintervention, so that older patients were at no greater risk.

NEW YORK – With a median follow-up of almost 4 years in more than 200 patients, the snorkel/chimney technique of endovascular repair of complex abdominal aortic aneurysms continues to generate very good results, according data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

In a video interview with Jason T. Lee, MD, professor of vascular surgery, Stanford (Calif.) University, who presented the long-term results, he explains why these findings are important.

After several single-center studies associated the snorkel/chimney technique with good rates of patency and durability, the PERICLES Registry was created almost 10 years ago to test whether these data could be reproduced in the real world.The data presented by Dr. Lee involved outcomes in 244 patients who were followed for at least 2.5 years. The median follow-up is 47 months.

The results overall confirm that this is a viable technique, according to Dr. Lee who noted very little diminution of patency rates in this long-term cohort relative to the previously published follow-up of 17.1 months.

He acknowledged that the snorkel/chimney repair is not free of potential complications, particularly gutter endovascular leaks, but he recounted that at least some resolve over time. Moreover, he suggests that several strategies are being pursued that appear promising for avoiding this risk.

Most importantly, the registry, which captured the experience at 13 centers in the United States and Europe, shows outcomes that are similar to those reported at centers where the techniques were developed and championed.

NEW YORK – With a median follow-up of almost 4 years in more than 200 patients, the snorkel/chimney technique of endovascular repair of complex abdominal aortic aneurysms continues to generate very good results, according data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

In a video interview with Jason T. Lee, MD, professor of vascular surgery, Stanford (Calif.) University, who presented the long-term results, he explains why these findings are important.

After several single-center studies associated the snorkel/chimney technique with good rates of patency and durability, the PERICLES Registry was created almost 10 years ago to test whether these data could be reproduced in the real world.The data presented by Dr. Lee involved outcomes in 244 patients who were followed for at least 2.5 years. The median follow-up is 47 months.

The results overall confirm that this is a viable technique, according to Dr. Lee who noted very little diminution of patency rates in this long-term cohort relative to the previously published follow-up of 17.1 months.

He acknowledged that the snorkel/chimney repair is not free of potential complications, particularly gutter endovascular leaks, but he recounted that at least some resolve over time. Moreover, he suggests that several strategies are being pursued that appear promising for avoiding this risk.

Most importantly, the registry, which captured the experience at 13 centers in the United States and Europe, shows outcomes that are similar to those reported at centers where the techniques were developed and championed.

NEW YORK – With a median follow-up of almost 4 years in more than 200 patients, the snorkel/chimney technique of endovascular repair of complex abdominal aortic aneurysms continues to generate very good results, according data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

In a video interview with Jason T. Lee, MD, professor of vascular surgery, Stanford (Calif.) University, who presented the long-term results, he explains why these findings are important.

After several single-center studies associated the snorkel/chimney technique with good rates of patency and durability, the PERICLES Registry was created almost 10 years ago to test whether these data could be reproduced in the real world.The data presented by Dr. Lee involved outcomes in 244 patients who were followed for at least 2.5 years. The median follow-up is 47 months.

The results overall confirm that this is a viable technique, according to Dr. Lee who noted very little diminution of patency rates in this long-term cohort relative to the previously published follow-up of 17.1 months.

He acknowledged that the snorkel/chimney repair is not free of potential complications, particularly gutter endovascular leaks, but he recounted that at least some resolve over time. Moreover, he suggests that several strategies are being pursued that appear promising for avoiding this risk.

Most importantly, the registry, which captured the experience at 13 centers in the United States and Europe, shows outcomes that are similar to those reported at centers where the techniques were developed and championed.

NEW YORK – Artificial intelligence is currently linked to specific problem solving and is not some form of Terminator model capable of handling multiple tasks with autonomy. In other words, each time you hear the term “AI,” it is a computer solving a specific problem or task using algorithms “and not ‘thinking’ like you and me,” said Ido Weinberg, MD, assistant professor, Harvard Medical School, Boston.

AI is present in daily life – everything from cellphones to the Alexa voice interface on a smart speaker. That AI system, however, is amassing data, learning about you, and using that data intelligently, Dr. Weinberg said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

AI in health care make sense, he said, because the health sector is a vast consumer market with potential for financial gain. Repetition, which is common in the health sector, is one of the foundations required for using AI and robotics. If a task can be repeated, then it means a machine can do it, said Dr. Weinberg.

The spread of AI and robotics one day may improve health care accessibility in remote areas where physicians with the appropriate training may not be available.

AI is already at work in the health care industry. “Pulmonary nodule detection can be done better with machines than by people, pathological identification and scanning of various slides can be done better by a machine than by a humans,” he said.

Artificial intelligence also can be designed to detect emotion by assessing various cues in phrasing, key words, and tone. These AI functions already are being used by sales reps on the phone to defuse and control interactions with customers and complainants. AI also can be implemented in interactions with people, which is an important part of dealing with patients, Dr. Weinberg said. Drug discovery is a key area where AI is flourishing, as well.

Luckily, in terms of physicians keeping their jobs, there are barriers to the use of AI to replace clinicians, Dr. Weinberg pointed out. Health care is not a monolith, and every specialty is different, meaning AI would have to be tailored to each task and specialty for each unique field. Quick proliferation of AI across the board is unlikely, especially when the varying roles of nurses and physician assistants are included.

Although robots in science fiction stories and films often are capable of multitasking a variety of needs, robots at present are much more limited in real life. In surgical situations, for example, they can perform specifically tailored tasks but cannot extend beyond those defined parameters as a real surgeon can, according to Dr. Weinberg, and this lack of flexibility is a severe limitation on the expansion of AI into health care.

Despite these limitations, Dr. Weinberg urged attendees to consider how AI can be used to facilitate their work.

“Believe in the roadblocks, but be a fast adopter – an early adopter – and understand where AI can currently augment you and make you better and more productive,” he said. “And keep doing procedures; AI and robotics currently have a problem with most of those,” Dr. Weinberg concluded.

Dr. Weinberg reported no conflicts relevant to his talk.

mlesney@mdedge.com

NEW YORK – Artificial intelligence is currently linked to specific problem solving and is not some form of Terminator model capable of handling multiple tasks with autonomy. In other words, each time you hear the term “AI,” it is a computer solving a specific problem or task using algorithms “and not ‘thinking’ like you and me,” said Ido Weinberg, MD, assistant professor, Harvard Medical School, Boston.

AI is present in daily life – everything from cellphones to the Alexa voice interface on a smart speaker. That AI system, however, is amassing data, learning about you, and using that data intelligently, Dr. Weinberg said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

AI in health care make sense, he said, because the health sector is a vast consumer market with potential for financial gain. Repetition, which is common in the health sector, is one of the foundations required for using AI and robotics. If a task can be repeated, then it means a machine can do it, said Dr. Weinberg.

The spread of AI and robotics one day may improve health care accessibility in remote areas where physicians with the appropriate training may not be available.

AI is already at work in the health care industry. “Pulmonary nodule detection can be done better with machines than by people, pathological identification and scanning of various slides can be done better by a machine than by a humans,” he said.

Artificial intelligence also can be designed to detect emotion by assessing various cues in phrasing, key words, and tone. These AI functions already are being used by sales reps on the phone to defuse and control interactions with customers and complainants. AI also can be implemented in interactions with people, which is an important part of dealing with patients, Dr. Weinberg said. Drug discovery is a key area where AI is flourishing, as well.

Luckily, in terms of physicians keeping their jobs, there are barriers to the use of AI to replace clinicians, Dr. Weinberg pointed out. Health care is not a monolith, and every specialty is different, meaning AI would have to be tailored to each task and specialty for each unique field. Quick proliferation of AI across the board is unlikely, especially when the varying roles of nurses and physician assistants are included.

Although robots in science fiction stories and films often are capable of multitasking a variety of needs, robots at present are much more limited in real life. In surgical situations, for example, they can perform specifically tailored tasks but cannot extend beyond those defined parameters as a real surgeon can, according to Dr. Weinberg, and this lack of flexibility is a severe limitation on the expansion of AI into health care.

Despite these limitations, Dr. Weinberg urged attendees to consider how AI can be used to facilitate their work.

“Believe in the roadblocks, but be a fast adopter – an early adopter – and understand where AI can currently augment you and make you better and more productive,” he said. “And keep doing procedures; AI and robotics currently have a problem with most of those,” Dr. Weinberg concluded.

Dr. Weinberg reported no conflicts relevant to his talk.

mlesney@mdedge.com

NEW YORK – Artificial intelligence is currently linked to specific problem solving and is not some form of Terminator model capable of handling multiple tasks with autonomy. In other words, each time you hear the term “AI,” it is a computer solving a specific problem or task using algorithms “and not ‘thinking’ like you and me,” said Ido Weinberg, MD, assistant professor, Harvard Medical School, Boston.

AI is present in daily life – everything from cellphones to the Alexa voice interface on a smart speaker. That AI system, however, is amassing data, learning about you, and using that data intelligently, Dr. Weinberg said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

AI in health care make sense, he said, because the health sector is a vast consumer market with potential for financial gain. Repetition, which is common in the health sector, is one of the foundations required for using AI and robotics. If a task can be repeated, then it means a machine can do it, said Dr. Weinberg.

The spread of AI and robotics one day may improve health care accessibility in remote areas where physicians with the appropriate training may not be available.

AI is already at work in the health care industry. “Pulmonary nodule detection can be done better with machines than by people, pathological identification and scanning of various slides can be done better by a machine than by a humans,” he said.

Artificial intelligence also can be designed to detect emotion by assessing various cues in phrasing, key words, and tone. These AI functions already are being used by sales reps on the phone to defuse and control interactions with customers and complainants. AI also can be implemented in interactions with people, which is an important part of dealing with patients, Dr. Weinberg said. Drug discovery is a key area where AI is flourishing, as well.

Luckily, in terms of physicians keeping their jobs, there are barriers to the use of AI to replace clinicians, Dr. Weinberg pointed out. Health care is not a monolith, and every specialty is different, meaning AI would have to be tailored to each task and specialty for each unique field. Quick proliferation of AI across the board is unlikely, especially when the varying roles of nurses and physician assistants are included.

Although robots in science fiction stories and films often are capable of multitasking a variety of needs, robots at present are much more limited in real life. In surgical situations, for example, they can perform specifically tailored tasks but cannot extend beyond those defined parameters as a real surgeon can, according to Dr. Weinberg, and this lack of flexibility is a severe limitation on the expansion of AI into health care.

Despite these limitations, Dr. Weinberg urged attendees to consider how AI can be used to facilitate their work.

“Believe in the roadblocks, but be a fast adopter – an early adopter – and understand where AI can currently augment you and make you better and more productive,” he said. “And keep doing procedures; AI and robotics currently have a problem with most of those,” Dr. Weinberg concluded.

Dr. Weinberg reported no conflicts relevant to his talk.

mlesney@mdedge.com

NEW YORK – Registry data can be used to craft guidance for determining the appropriateness of procedures at vein centers, based on data presented by Thomas W. Wakefield, MD at the 2018 Veith Symposium.

The Vascular Quality Initiative Varicose Vein Registry (VQI-VVR), initiated in 2014 by the Society for Vascular Surgery in conjunction with the American Venous Forum, captures procedures that are performed in vein centers, office-based practices, and ambulatory or inpatient settings. The VVR looks at ablation and phlebectomy techniques and captures data including patient demographics, history, procedure data, plus early and late office-based and patient-reported follow-up in order to benchmark and improve outcomes and develop best practices and to help meet vein center certification requirements. The VVR includes 39 centers and more than 23,000 procedures.

Dr. Wakefield, who heads the VVR, used this registry as a means to illustrate how VQIs could be used to establish whether “the expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing.” This can be considered to be “appropriateness, which is part of ethical treatment.” Dr. Wakefield is the Stanley Professor of Vascular Surgery at the University of Michigan and section head, vascular surgery, University of Michigan Cardiovascular Center, Ann Arbor.

Data from the VQI registry (of which the VVR is a component) are now being used to generate appropriateness reports, said Dr. Wakefield.

The VQI represents a large comprehensive database of long-term data to define appropriate care. In addition, the VQI infrastructure is already geared to producing these reports both at a center and at a surgeon level. One disadvantage of the VVR registry, however, is low participation – only the 39 centers – and that it doesn’t capture cosmetic procedures and lesser (C1) disease. Further, it’s “likely the VQI participants are the ‘good actors,’ ” he added.

Targets for appropriateness include the proportion of patients undergoing ablation C2 or C4 disease or greater, the mean number of ablations per patient, the mean number of ablations per limb, and the proportion of perforated ablations for greater than C4 disease. Plotting out the data for these procedures at the center level can be assessed against current thinking on best practices in the various areas. For example, “the mean number of ablations per patient has been suggested at 1.8 to be about the right number,” and he used the graph of the center performance in this area to show that most of the centers were below this objective.

In an even more appropriate example of how this kind of data could be used to determine appropriateness, Dr. Wakefield described how perforated ablations should be performed for greater than C4 disease, but not for C2 disease. He described how, according to the actual data in the registry, there have been 870 total perforated treatments recorded, 38% for C2 disease, and of these 332 procedures, almost half of these were performed at one center only, with two other centers reporting 30 such procedures. “So clearly there are three centers that are doing perforated ablations for patients that are outside the guidelines,” Dr. Wakefield pointed out.

In future, payer demand is likely to demand that each treating physician provide evidence of the appropriateness of procedures performed, as well as appropriate patient selection and adherence to best practices, and good outcomes, which is part of what a society-based registry such as the VVR can provide.

“I believe the VQI-VVR is well-positioned to meet these needs. And if we ask the question ‘can VQI be used as a benchmark for setting ethical standards,’ I think it can certainly be used to help set appropriate standards, and since appropriateness is one part of ethical standards, I believe it has a role,” he concluded.

Dr. Wakefield reported that he had no disclosures.

mlesney@mdedge.com

NEW YORK – Registry data can be used to craft guidance for determining the appropriateness of procedures at vein centers, based on data presented by Thomas W. Wakefield, MD at the 2018 Veith Symposium.

The Vascular Quality Initiative Varicose Vein Registry (VQI-VVR), initiated in 2014 by the Society for Vascular Surgery in conjunction with the American Venous Forum, captures procedures that are performed in vein centers, office-based practices, and ambulatory or inpatient settings. The VVR looks at ablation and phlebectomy techniques and captures data including patient demographics, history, procedure data, plus early and late office-based and patient-reported follow-up in order to benchmark and improve outcomes and develop best practices and to help meet vein center certification requirements. The VVR includes 39 centers and more than 23,000 procedures.

Dr. Wakefield, who heads the VVR, used this registry as a means to illustrate how VQIs could be used to establish whether “the expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing.” This can be considered to be “appropriateness, which is part of ethical treatment.” Dr. Wakefield is the Stanley Professor of Vascular Surgery at the University of Michigan and section head, vascular surgery, University of Michigan Cardiovascular Center, Ann Arbor.

Data from the VQI registry (of which the VVR is a component) are now being used to generate appropriateness reports, said Dr. Wakefield.

The VQI represents a large comprehensive database of long-term data to define appropriate care. In addition, the VQI infrastructure is already geared to producing these reports both at a center and at a surgeon level. One disadvantage of the VVR registry, however, is low participation – only the 39 centers – and that it doesn’t capture cosmetic procedures and lesser (C1) disease. Further, it’s “likely the VQI participants are the ‘good actors,’ ” he added.

Targets for appropriateness include the proportion of patients undergoing ablation C2 or C4 disease or greater, the mean number of ablations per patient, the mean number of ablations per limb, and the proportion of perforated ablations for greater than C4 disease. Plotting out the data for these procedures at the center level can be assessed against current thinking on best practices in the various areas. For example, “the mean number of ablations per patient has been suggested at 1.8 to be about the right number,” and he used the graph of the center performance in this area to show that most of the centers were below this objective.

In an even more appropriate example of how this kind of data could be used to determine appropriateness, Dr. Wakefield described how perforated ablations should be performed for greater than C4 disease, but not for C2 disease. He described how, according to the actual data in the registry, there have been 870 total perforated treatments recorded, 38% for C2 disease, and of these 332 procedures, almost half of these were performed at one center only, with two other centers reporting 30 such procedures. “So clearly there are three centers that are doing perforated ablations for patients that are outside the guidelines,” Dr. Wakefield pointed out.

In future, payer demand is likely to demand that each treating physician provide evidence of the appropriateness of procedures performed, as well as appropriate patient selection and adherence to best practices, and good outcomes, which is part of what a society-based registry such as the VVR can provide.

“I believe the VQI-VVR is well-positioned to meet these needs. And if we ask the question ‘can VQI be used as a benchmark for setting ethical standards,’ I think it can certainly be used to help set appropriate standards, and since appropriateness is one part of ethical standards, I believe it has a role,” he concluded.

Dr. Wakefield reported that he had no disclosures.

mlesney@mdedge.com

NEW YORK – Registry data can be used to craft guidance for determining the appropriateness of procedures at vein centers, based on data presented by Thomas W. Wakefield, MD at the 2018 Veith Symposium.

The Vascular Quality Initiative Varicose Vein Registry (VQI-VVR), initiated in 2014 by the Society for Vascular Surgery in conjunction with the American Venous Forum, captures procedures that are performed in vein centers, office-based practices, and ambulatory or inpatient settings. The VVR looks at ablation and phlebectomy techniques and captures data including patient demographics, history, procedure data, plus early and late office-based and patient-reported follow-up in order to benchmark and improve outcomes and develop best practices and to help meet vein center certification requirements. The VVR includes 39 centers and more than 23,000 procedures.

Dr. Wakefield, who heads the VVR, used this registry as a means to illustrate how VQIs could be used to establish whether “the expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing.” This can be considered to be “appropriateness, which is part of ethical treatment.” Dr. Wakefield is the Stanley Professor of Vascular Surgery at the University of Michigan and section head, vascular surgery, University of Michigan Cardiovascular Center, Ann Arbor.

Data from the VQI registry (of which the VVR is a component) are now being used to generate appropriateness reports, said Dr. Wakefield.

The VQI represents a large comprehensive database of long-term data to define appropriate care. In addition, the VQI infrastructure is already geared to producing these reports both at a center and at a surgeon level. One disadvantage of the VVR registry, however, is low participation – only the 39 centers – and that it doesn’t capture cosmetic procedures and lesser (C1) disease. Further, it’s “likely the VQI participants are the ‘good actors,’ ” he added.

Targets for appropriateness include the proportion of patients undergoing ablation C2 or C4 disease or greater, the mean number of ablations per patient, the mean number of ablations per limb, and the proportion of perforated ablations for greater than C4 disease. Plotting out the data for these procedures at the center level can be assessed against current thinking on best practices in the various areas. For example, “the mean number of ablations per patient has been suggested at 1.8 to be about the right number,” and he used the graph of the center performance in this area to show that most of the centers were below this objective.

In an even more appropriate example of how this kind of data could be used to determine appropriateness, Dr. Wakefield described how perforated ablations should be performed for greater than C4 disease, but not for C2 disease. He described how, according to the actual data in the registry, there have been 870 total perforated treatments recorded, 38% for C2 disease, and of these 332 procedures, almost half of these were performed at one center only, with two other centers reporting 30 such procedures. “So clearly there are three centers that are doing perforated ablations for patients that are outside the guidelines,” Dr. Wakefield pointed out.

In future, payer demand is likely to demand that each treating physician provide evidence of the appropriateness of procedures performed, as well as appropriate patient selection and adherence to best practices, and good outcomes, which is part of what a society-based registry such as the VVR can provide.

“I believe the VQI-VVR is well-positioned to meet these needs. And if we ask the question ‘can VQI be used as a benchmark for setting ethical standards,’ I think it can certainly be used to help set appropriate standards, and since appropriateness is one part of ethical standards, I believe it has a role,” he concluded.

Dr. Wakefield reported that he had no disclosures.

mlesney@mdedge.com

NEW YORK – “A physician falls overboard on a large cruise ship and passengers gather at the guard rail. The first passenger at the guardrail shakes his finger down at the drowning physician and says, ‘You need to learn how to swim!’ Another passenger says, ‘No, man, throw him a life preserver.’ ... Finally, a passenger says, ‘We need better guard rails.’ ”

That’s the analogy Cynthia K. Shortell, MD used to kick off her presentation on physician burnout and the need for resilience at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

“Which of these is right? Well, of course, the answer is they all are,” said Dr. Shortell, who is a professor of surgery at Duke University Durham, N.C. But certainly, only the life preserver answer was appropriate at that time for the drowning physician, she added.

Continuing the analogy, Dr. Shortell pointed out that surely there is a man overboard, with 1 in 20 surgeons reporting suicidal ideation. That rate jumps threefold if the surgeon has had a recent medical error. In addition, vascular surgeons in particular are within the top tier of specialties at risk for burnout.

“We do need better guardrails,” she said, and described the need to actively engage with the health care system to help solve these issues, including those involving electronic medical records and operating room inefficiency and use. In addition, there is a great need for additional services that are provided to other high-end professionals, including food, concierge service, gym access, and other services that help with tasks of daily life when physicians need to spend most of their time at the hospital.

But, in the end, Dr. Shortell said, “We do need to learn to swim. Ultimately, we do need to take a role in having responsibility to solve this problem on our own. We need to change the way we think about our work, and the way we think about our health, and the way our culture values working hard instead of working hard at living.”

Dr. Shortell also highlighted the need to deal with musculoskeletal issues arising from the way that surgeons operate. This, along with good leadership, are key factors in preventing and remediating burnout.

Dr. Shortell had no disclosures relevant to her talk.
 

mlesney@mdedge.com

NEW YORK – “A physician falls overboard on a large cruise ship and passengers gather at the guard rail. The first passenger at the guardrail shakes his finger down at the drowning physician and says, ‘You need to learn how to swim!’ Another passenger says, ‘No, man, throw him a life preserver.’ ... Finally, a passenger says, ‘We need better guard rails.’ ”

That’s the analogy Cynthia K. Shortell, MD used to kick off her presentation on physician burnout and the need for resilience at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

“Which of these is right? Well, of course, the answer is they all are,” said Dr. Shortell, who is a professor of surgery at Duke University Durham, N.C. But certainly, only the life preserver answer was appropriate at that time for the drowning physician, she added.

Continuing the analogy, Dr. Shortell pointed out that surely there is a man overboard, with 1 in 20 surgeons reporting suicidal ideation. That rate jumps threefold if the surgeon has had a recent medical error. In addition, vascular surgeons in particular are within the top tier of specialties at risk for burnout.

“We do need better guardrails,” she said, and described the need to actively engage with the health care system to help solve these issues, including those involving electronic medical records and operating room inefficiency and use. In addition, there is a great need for additional services that are provided to other high-end professionals, including food, concierge service, gym access, and other services that help with tasks of daily life when physicians need to spend most of their time at the hospital.

But, in the end, Dr. Shortell said, “We do need to learn to swim. Ultimately, we do need to take a role in having responsibility to solve this problem on our own. We need to change the way we think about our work, and the way we think about our health, and the way our culture values working hard instead of working hard at living.”

Dr. Shortell also highlighted the need to deal with musculoskeletal issues arising from the way that surgeons operate. This, along with good leadership, are key factors in preventing and remediating burnout.

Dr. Shortell had no disclosures relevant to her talk.
 

mlesney@mdedge.com

NEW YORK – “A physician falls overboard on a large cruise ship and passengers gather at the guard rail. The first passenger at the guardrail shakes his finger down at the drowning physician and says, ‘You need to learn how to swim!’ Another passenger says, ‘No, man, throw him a life preserver.’ ... Finally, a passenger says, ‘We need better guard rails.’ ”

That’s the analogy Cynthia K. Shortell, MD used to kick off her presentation on physician burnout and the need for resilience at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

“Which of these is right? Well, of course, the answer is they all are,” said Dr. Shortell, who is a professor of surgery at Duke University Durham, N.C. But certainly, only the life preserver answer was appropriate at that time for the drowning physician, she added.

Continuing the analogy, Dr. Shortell pointed out that surely there is a man overboard, with 1 in 20 surgeons reporting suicidal ideation. That rate jumps threefold if the surgeon has had a recent medical error. In addition, vascular surgeons in particular are within the top tier of specialties at risk for burnout.

“We do need better guardrails,” she said, and described the need to actively engage with the health care system to help solve these issues, including those involving electronic medical records and operating room inefficiency and use. In addition, there is a great need for additional services that are provided to other high-end professionals, including food, concierge service, gym access, and other services that help with tasks of daily life when physicians need to spend most of their time at the hospital.

But, in the end, Dr. Shortell said, “We do need to learn to swim. Ultimately, we do need to take a role in having responsibility to solve this problem on our own. We need to change the way we think about our work, and the way we think about our health, and the way our culture values working hard instead of working hard at living.”

Dr. Shortell also highlighted the need to deal with musculoskeletal issues arising from the way that surgeons operate. This, along with good leadership, are key factors in preventing and remediating burnout.

Dr. Shortell had no disclosures relevant to her talk.
 

mlesney@mdedge.com

NEW YORK – The Vascular Quality Initiative (VQI) is designed to improve the quality, safety, and effectiveness of vascular health care, but also reduce costs through the collection and exchange of information, according to Larry W. Kraiss, MD, professor of surgery, University of Utah, Salt Lake City.

The VQI consists of three major components: a federally accredited patient safety organization (PSO), a registry, and a distributed network of quality groups, which can also serve as a platform for internal quality improvement efforts.

Even though registries are considered less reliable than the venerated randomized clinical trial models are, registries have some unique advantages, according to Dr. Kraiss, who spoke at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. Randomized clinical trials (RCTs) are very expensive to conduct and are criticized for potentially not being generalizable because of their rigidly defined inclusion/exclusion criteria. Despite inherent problems with registry data, especially bias, there are now statistical methods to help account for the biases. Registry-controlled trials are going to be important to answer many questions that cannot be answered by RCTs. Such trials can be too costly or actually unethical to randomize under certain circumstances. Registries, however, provide real-world patient populations in greater numbers than RCTs can manage, including access to rare events that would otherwise not be detected.

The VQI holds an important place in this second tier and is an important source of information for clinical care.

The VQI has grown steadily since its inception, and there are more than 500 centers now participating, including 6 international centers, and 18 regional groups, according to Dr. Kraiss. There are more than 530,000 procedures contained within the VQI’s 12 registries, with more than half of them involving peripheral vascular interventions and carotid endarterectomies. “But there [are] a healthy number of cases in all of the other registries, which provide a very rich resource and evidence base,” he added.

The VQI is becoming very important in the regulatory framework, with the Food and Drug Administration embracing “real-world evidence” as a way to justify some of its decisions, and the VQI has been involved in this process. The VQI has coordinated several post-market surveillance programs, the two most important being in the areas of thoracic endovascular aortic repair (TEVAR) and transcarotid artery revascularization (TCAR), said Dr. Kraiss.

One of the important values of the VQI is the ability to examine benchmarks and to compare performance across centers. For example, looking at aortic abdominal aneurysm (AAA) repair data, the results showed that a number of centers were not following established Society for Vascular Society guidelines and that there were a substantial number of AAAs reported in the VQI that were treated when they were below the threshold for intervention and should have received routine observation only.

So, ultimately two of the greatest values of the VQI are the ability to use it as a means of local quality improvement, and to provide an avenue for important clinical research, Dr. Kraiss concluded.

Dr. Kraiss reported that they had no disclosures.

mlesney@mdedge.com

NEW YORK – The Vascular Quality Initiative (VQI) is designed to improve the quality, safety, and effectiveness of vascular health care, but also reduce costs through the collection and exchange of information, according to Larry W. Kraiss, MD, professor of surgery, University of Utah, Salt Lake City.

The VQI consists of three major components: a federally accredited patient safety organization (PSO), a registry, and a distributed network of quality groups, which can also serve as a platform for internal quality improvement efforts.

Even though registries are considered less reliable than the venerated randomized clinical trial models are, registries have some unique advantages, according to Dr. Kraiss, who spoke at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. Randomized clinical trials (RCTs) are very expensive to conduct and are criticized for potentially not being generalizable because of their rigidly defined inclusion/exclusion criteria. Despite inherent problems with registry data, especially bias, there are now statistical methods to help account for the biases. Registry-controlled trials are going to be important to answer many questions that cannot be answered by RCTs. Such trials can be too costly or actually unethical to randomize under certain circumstances. Registries, however, provide real-world patient populations in greater numbers than RCTs can manage, including access to rare events that would otherwise not be detected.

The VQI holds an important place in this second tier and is an important source of information for clinical care.

The VQI has grown steadily since its inception, and there are more than 500 centers now participating, including 6 international centers, and 18 regional groups, according to Dr. Kraiss. There are more than 530,000 procedures contained within the VQI’s 12 registries, with more than half of them involving peripheral vascular interventions and carotid endarterectomies. “But there [are] a healthy number of cases in all of the other registries, which provide a very rich resource and evidence base,” he added.

The VQI is becoming very important in the regulatory framework, with the Food and Drug Administration embracing “real-world evidence” as a way to justify some of its decisions, and the VQI has been involved in this process. The VQI has coordinated several post-market surveillance programs, the two most important being in the areas of thoracic endovascular aortic repair (TEVAR) and transcarotid artery revascularization (TCAR), said Dr. Kraiss.

One of the important values of the VQI is the ability to examine benchmarks and to compare performance across centers. For example, looking at aortic abdominal aneurysm (AAA) repair data, the results showed that a number of centers were not following established Society for Vascular Society guidelines and that there were a substantial number of AAAs reported in the VQI that were treated when they were below the threshold for intervention and should have received routine observation only.

So, ultimately two of the greatest values of the VQI are the ability to use it as a means of local quality improvement, and to provide an avenue for important clinical research, Dr. Kraiss concluded.

Dr. Kraiss reported that they had no disclosures.

mlesney@mdedge.com

NEW YORK – The Vascular Quality Initiative (VQI) is designed to improve the quality, safety, and effectiveness of vascular health care, but also reduce costs through the collection and exchange of information, according to Larry W. Kraiss, MD, professor of surgery, University of Utah, Salt Lake City.

The VQI consists of three major components: a federally accredited patient safety organization (PSO), a registry, and a distributed network of quality groups, which can also serve as a platform for internal quality improvement efforts.

Even though registries are considered less reliable than the venerated randomized clinical trial models are, registries have some unique advantages, according to Dr. Kraiss, who spoke at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. Randomized clinical trials (RCTs) are very expensive to conduct and are criticized for potentially not being generalizable because of their rigidly defined inclusion/exclusion criteria. Despite inherent problems with registry data, especially bias, there are now statistical methods to help account for the biases. Registry-controlled trials are going to be important to answer many questions that cannot be answered by RCTs. Such trials can be too costly or actually unethical to randomize under certain circumstances. Registries, however, provide real-world patient populations in greater numbers than RCTs can manage, including access to rare events that would otherwise not be detected.

The VQI holds an important place in this second tier and is an important source of information for clinical care.

The VQI has grown steadily since its inception, and there are more than 500 centers now participating, including 6 international centers, and 18 regional groups, according to Dr. Kraiss. There are more than 530,000 procedures contained within the VQI’s 12 registries, with more than half of them involving peripheral vascular interventions and carotid endarterectomies. “But there [are] a healthy number of cases in all of the other registries, which provide a very rich resource and evidence base,” he added.

The VQI is becoming very important in the regulatory framework, with the Food and Drug Administration embracing “real-world evidence” as a way to justify some of its decisions, and the VQI has been involved in this process. The VQI has coordinated several post-market surveillance programs, the two most important being in the areas of thoracic endovascular aortic repair (TEVAR) and transcarotid artery revascularization (TCAR), said Dr. Kraiss.

One of the important values of the VQI is the ability to examine benchmarks and to compare performance across centers. For example, looking at aortic abdominal aneurysm (AAA) repair data, the results showed that a number of centers were not following established Society for Vascular Society guidelines and that there were a substantial number of AAAs reported in the VQI that were treated when they were below the threshold for intervention and should have received routine observation only.

So, ultimately two of the greatest values of the VQI are the ability to use it as a means of local quality improvement, and to provide an avenue for important clinical research, Dr. Kraiss concluded.

Dr. Kraiss reported that they had no disclosures.

mlesney@mdedge.com

NEW YORK – In March 2005, the Accreditation Council for Graduate Medical Education approved the primary certificate in vascular surgery, and the first integrated vascular surgery residencies (0+5) were approved shortly thereafter. By 2015, there was more than a 900% increase in both the number of programs and positions, which were offered for matriculation in July 2016, according to Murray L. Shames, MD, professor of surgery and radiology at the University of South Florida, Tampa, and chief of the division of vascular surgery at Tampa General Hospital.

In 2009, Dr. Shames and his colleagues first looked at the issue to try to better understand the applicant pool, and they found that there was a 900% increase in demand for the 0+5 residency positions, compared with the traditional 5+2 vascular fellowships, and that there was a 0+5 applicant-to-position ratio of 8:1 that year. “Despite initial concerns regarding the shortened training, studies have demonstrated equivalent case volumes and job opportunities for integrated vascular residents and vascular fellows,” Dr. Shames stated at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

His current presentation was an update of that assessment done for the 2015 data, as integrated vascular surgery residents have begun to enter the workforce. They looked at the current supply and demand for 0+5 training programs (as well as the traditional 5+2 programs), and the quality and attributes of the 0+5 residency applicants. They obtained data for applicants for both types of programs: 2008-2015 for 0+2 and 2007-2016 for 5+2) and comparable match data were queried for 2008-2016. They looked at the number of programs, the number of positions, the total number of applicants, sex of the applicants, applications/program and applications/position, and the U.S. versus international applicant ratios.

They found that the number of integrated programs increased from 4 to 48, with an increase from 4 to 56 positions, during the study period, said Dr. Shames. Demand for integrated vascular residencies has increased nearly 300%, from 112 applicants in 2008 to 434 in 2015. The total number of U.S. medical school graduate applicants to these programs has increased from 40 in 2008 to 2,030 in 2015, with the increase in program applicants driven primarily by these U.S. medical school graduates; the number of international applicants per program decrease over this time period from 57 to 37. The percentage of women applicants has steadily increased, from 16% to 27%, and currently women constitute 41% of all integrated vascular surgery residents.

“Overall, the supply for integrated vascular surgery residency positions continues to be outnumbered by the number of applicants, with increasing applicant to position ratios at 7.8:1 in 2015, while the total number for vascular surgery fellowships has remained stable at about 1:1,” Dr. Shames concluded.

Dr. Shames reported having no relevant disclosures for his presentation.

mlesney@mdedge.com

NEW YORK – In March 2005, the Accreditation Council for Graduate Medical Education approved the primary certificate in vascular surgery, and the first integrated vascular surgery residencies (0+5) were approved shortly thereafter. By 2015, there was more than a 900% increase in both the number of programs and positions, which were offered for matriculation in July 2016, according to Murray L. Shames, MD, professor of surgery and radiology at the University of South Florida, Tampa, and chief of the division of vascular surgery at Tampa General Hospital.

In 2009, Dr. Shames and his colleagues first looked at the issue to try to better understand the applicant pool, and they found that there was a 900% increase in demand for the 0+5 residency positions, compared with the traditional 5+2 vascular fellowships, and that there was a 0+5 applicant-to-position ratio of 8:1 that year. “Despite initial concerns regarding the shortened training, studies have demonstrated equivalent case volumes and job opportunities for integrated vascular residents and vascular fellows,” Dr. Shames stated at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

His current presentation was an update of that assessment done for the 2015 data, as integrated vascular surgery residents have begun to enter the workforce. They looked at the current supply and demand for 0+5 training programs (as well as the traditional 5+2 programs), and the quality and attributes of the 0+5 residency applicants. They obtained data for applicants for both types of programs: 2008-2015 for 0+2 and 2007-2016 for 5+2) and comparable match data were queried for 2008-2016. They looked at the number of programs, the number of positions, the total number of applicants, sex of the applicants, applications/program and applications/position, and the U.S. versus international applicant ratios.

They found that the number of integrated programs increased from 4 to 48, with an increase from 4 to 56 positions, during the study period, said Dr. Shames. Demand for integrated vascular residencies has increased nearly 300%, from 112 applicants in 2008 to 434 in 2015. The total number of U.S. medical school graduate applicants to these programs has increased from 40 in 2008 to 2,030 in 2015, with the increase in program applicants driven primarily by these U.S. medical school graduates; the number of international applicants per program decrease over this time period from 57 to 37. The percentage of women applicants has steadily increased, from 16% to 27%, and currently women constitute 41% of all integrated vascular surgery residents.

“Overall, the supply for integrated vascular surgery residency positions continues to be outnumbered by the number of applicants, with increasing applicant to position ratios at 7.8:1 in 2015, while the total number for vascular surgery fellowships has remained stable at about 1:1,” Dr. Shames concluded.

Dr. Shames reported having no relevant disclosures for his presentation.

mlesney@mdedge.com

NEW YORK – In March 2005, the Accreditation Council for Graduate Medical Education approved the primary certificate in vascular surgery, and the first integrated vascular surgery residencies (0+5) were approved shortly thereafter. By 2015, there was more than a 900% increase in both the number of programs and positions, which were offered for matriculation in July 2016, according to Murray L. Shames, MD, professor of surgery and radiology at the University of South Florida, Tampa, and chief of the division of vascular surgery at Tampa General Hospital.

In 2009, Dr. Shames and his colleagues first looked at the issue to try to better understand the applicant pool, and they found that there was a 900% increase in demand for the 0+5 residency positions, compared with the traditional 5+2 vascular fellowships, and that there was a 0+5 applicant-to-position ratio of 8:1 that year. “Despite initial concerns regarding the shortened training, studies have demonstrated equivalent case volumes and job opportunities for integrated vascular residents and vascular fellows,” Dr. Shames stated at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

His current presentation was an update of that assessment done for the 2015 data, as integrated vascular surgery residents have begun to enter the workforce. They looked at the current supply and demand for 0+5 training programs (as well as the traditional 5+2 programs), and the quality and attributes of the 0+5 residency applicants. They obtained data for applicants for both types of programs: 2008-2015 for 0+2 and 2007-2016 for 5+2) and comparable match data were queried for 2008-2016. They looked at the number of programs, the number of positions, the total number of applicants, sex of the applicants, applications/program and applications/position, and the U.S. versus international applicant ratios.

They found that the number of integrated programs increased from 4 to 48, with an increase from 4 to 56 positions, during the study period, said Dr. Shames. Demand for integrated vascular residencies has increased nearly 300%, from 112 applicants in 2008 to 434 in 2015. The total number of U.S. medical school graduate applicants to these programs has increased from 40 in 2008 to 2,030 in 2015, with the increase in program applicants driven primarily by these U.S. medical school graduates; the number of international applicants per program decrease over this time period from 57 to 37. The percentage of women applicants has steadily increased, from 16% to 27%, and currently women constitute 41% of all integrated vascular surgery residents.

“Overall, the supply for integrated vascular surgery residency positions continues to be outnumbered by the number of applicants, with increasing applicant to position ratios at 7.8:1 in 2015, while the total number for vascular surgery fellowships has remained stable at about 1:1,” Dr. Shames concluded.

Dr. Shames reported having no relevant disclosures for his presentation.

mlesney@mdedge.com

NEW YORK – Increasing the number of 0+5 integrated vascular surgery residency programs would help to alleviate a projected shortage of vascular surgeons, according to William D. Jordan, Jr., MD, professor of surgery, Emory University, Atlanta.*

“Ultimately the question is whether the workforce pipeline is large enough,” Dr. Jordan said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. “When you consider that there are little more than 600 vascular trainees right now, and almost 600 planned retirements over the next 5 years, the answer to the question is no. Our workforce pipeline is not big enough.”

Dr. Jordan pointed out that, in addition, if one considers the current geographic distribution of vascular surgeons across the country, and go with the new standard that 1.4 surgeons are needed per 100,000 population, there is not a single state in the country that matches up to that goal. “So we are clearly going to have a shortage,” he commented. The only way to fill that shortage is to produce more vascular surgeons. But how does the change to a 0+5 residency program model impact that need?

In a survey conducted by the Association of Program Directors in Vascular Surgery in 2016, regarding challenges as perceived by the trainees, the top two concerns expressed were regarding competing specialties and physician burnout. Statistics bear out the concern regarding competing specialties, for example, there is an increase of 85% in interventional cardiology trainees being produced and a nearly 50% increase in interventional radiology trainees. However, in vascular, it is only 18%. With regard to the goals of those vascular trainees, 90% indicated that they wanted to be attached to some academic or teaching environment. “They don’t want to be the lone wolf out there,” Dr. Jordan said, and this is from concerns regarding workload, mentorship, and camaraderie, as well as regulatory and administrative obligations that are steadily increasing and can be handled more easily in a large institution. This will not fill the need for vascular surgeons in community hospitals, creating a shortage of distribution as well as actual numbers.

One key problem with current training is the fact that the new form of student comes with almost no real surgical skills and there is a dearth of vascular surgery cases available to fully accommodate many of them throughout their training career. This is a problem exacerbated by some residency review committees, which are loathe to give vascular surgery cases to new trainees.

Integrated vascular surgery residency programs have grown and there is a substantially greater interest in them, receiving even more applicants than orthopedics or neurosurgery. U.S. interest exceeds the number of 0+5 positions available. One way to deal with the projected 31% deficit in vascular surgeons by 2025 would thus be to increase the number of these training positions. The financial accommodations to do this would be large, but perhaps the creation of an independent vascular surgery specialty board would facilitate dealing with that issue, he concluded.

Dr. Jordan reported no disclosures relevant to his talk.

mlesney@mdedge.com

Correction, 11/19/18: An earlier version of this article misidentified the speaker in the session. The speaker was William D. Jordan, Jr., MD.

NEW YORK – Increasing the number of 0+5 integrated vascular surgery residency programs would help to alleviate a projected shortage of vascular surgeons, according to William D. Jordan, Jr., MD, professor of surgery, Emory University, Atlanta.*

“Ultimately the question is whether the workforce pipeline is large enough,” Dr. Jordan said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. “When you consider that there are little more than 600 vascular trainees right now, and almost 600 planned retirements over the next 5 years, the answer to the question is no. Our workforce pipeline is not big enough.”

Dr. Jordan pointed out that, in addition, if one considers the current geographic distribution of vascular surgeons across the country, and go with the new standard that 1.4 surgeons are needed per 100,000 population, there is not a single state in the country that matches up to that goal. “So we are clearly going to have a shortage,” he commented. The only way to fill that shortage is to produce more vascular surgeons. But how does the change to a 0+5 residency program model impact that need?

In a survey conducted by the Association of Program Directors in Vascular Surgery in 2016, regarding challenges as perceived by the trainees, the top two concerns expressed were regarding competing specialties and physician burnout. Statistics bear out the concern regarding competing specialties, for example, there is an increase of 85% in interventional cardiology trainees being produced and a nearly 50% increase in interventional radiology trainees. However, in vascular, it is only 18%. With regard to the goals of those vascular trainees, 90% indicated that they wanted to be attached to some academic or teaching environment. “They don’t want to be the lone wolf out there,” Dr. Jordan said, and this is from concerns regarding workload, mentorship, and camaraderie, as well as regulatory and administrative obligations that are steadily increasing and can be handled more easily in a large institution. This will not fill the need for vascular surgeons in community hospitals, creating a shortage of distribution as well as actual numbers.

One key problem with current training is the fact that the new form of student comes with almost no real surgical skills and there is a dearth of vascular surgery cases available to fully accommodate many of them throughout their training career. This is a problem exacerbated by some residency review committees, which are loathe to give vascular surgery cases to new trainees.

Integrated vascular surgery residency programs have grown and there is a substantially greater interest in them, receiving even more applicants than orthopedics or neurosurgery. U.S. interest exceeds the number of 0+5 positions available. One way to deal with the projected 31% deficit in vascular surgeons by 2025 would thus be to increase the number of these training positions. The financial accommodations to do this would be large, but perhaps the creation of an independent vascular surgery specialty board would facilitate dealing with that issue, he concluded.

Dr. Jordan reported no disclosures relevant to his talk.

mlesney@mdedge.com

Correction, 11/19/18: An earlier version of this article misidentified the speaker in the session. The speaker was William D. Jordan, Jr., MD.

NEW YORK – Increasing the number of 0+5 integrated vascular surgery residency programs would help to alleviate a projected shortage of vascular surgeons, according to William D. Jordan, Jr., MD, professor of surgery, Emory University, Atlanta.*

“Ultimately the question is whether the workforce pipeline is large enough,” Dr. Jordan said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. “When you consider that there are little more than 600 vascular trainees right now, and almost 600 planned retirements over the next 5 years, the answer to the question is no. Our workforce pipeline is not big enough.”

Dr. Jordan pointed out that, in addition, if one considers the current geographic distribution of vascular surgeons across the country, and go with the new standard that 1.4 surgeons are needed per 100,000 population, there is not a single state in the country that matches up to that goal. “So we are clearly going to have a shortage,” he commented. The only way to fill that shortage is to produce more vascular surgeons. But how does the change to a 0+5 residency program model impact that need?

In a survey conducted by the Association of Program Directors in Vascular Surgery in 2016, regarding challenges as perceived by the trainees, the top two concerns expressed were regarding competing specialties and physician burnout. Statistics bear out the concern regarding competing specialties, for example, there is an increase of 85% in interventional cardiology trainees being produced and a nearly 50% increase in interventional radiology trainees. However, in vascular, it is only 18%. With regard to the goals of those vascular trainees, 90% indicated that they wanted to be attached to some academic or teaching environment. “They don’t want to be the lone wolf out there,” Dr. Jordan said, and this is from concerns regarding workload, mentorship, and camaraderie, as well as regulatory and administrative obligations that are steadily increasing and can be handled more easily in a large institution. This will not fill the need for vascular surgeons in community hospitals, creating a shortage of distribution as well as actual numbers.

One key problem with current training is the fact that the new form of student comes with almost no real surgical skills and there is a dearth of vascular surgery cases available to fully accommodate many of them throughout their training career. This is a problem exacerbated by some residency review committees, which are loathe to give vascular surgery cases to new trainees.

Integrated vascular surgery residency programs have grown and there is a substantially greater interest in them, receiving even more applicants than orthopedics or neurosurgery. U.S. interest exceeds the number of 0+5 positions available. One way to deal with the projected 31% deficit in vascular surgeons by 2025 would thus be to increase the number of these training positions. The financial accommodations to do this would be large, but perhaps the creation of an independent vascular surgery specialty board would facilitate dealing with that issue, he concluded.

Dr. Jordan reported no disclosures relevant to his talk.

mlesney@mdedge.com

Correction, 11/19/18: An earlier version of this article misidentified the speaker in the session. The speaker was William D. Jordan, Jr., MD.

NEW YORK – The presence of a bovine arch predicts higher mortality in patients with a type B aortic dissection (TBAD), according to a study presented by Jan S. Brunkwall, MD, at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

The bovine arch is a congenital interruption in the evolution of the arch, and is a misnomer because it does not actually reflect the arch branching pattern found in cattle. It represents the most common variation of the aortic arch, with a prevalence of 1%-41%, depending on the literature, according to a study published by Dr. Brunkwall, chairman of the department of vascular and endovascular surgery at the University of Cologne (Germany), and his colleagues (Eur J Vasc Endovasc Surg. 2018; 55:385-391).

In order to assess the effect of the bovine arch on survival, Dr. Brunkwall and his colleagues performed a retrospective cohort analysis of patients with TBAD admitted at two centers. CT angiograms (CTAs) of patients referred because of aortic dissection were also reevaluated with regard to the presence of a bovine arch.

A total of 154 patients with TBAD and 168 with type A aortic dissection were assessed, and 110 oncologic patients who had undergone a chest CTA for disease staging during the study period acted as a control group.

There was an overall prevalence of 17.6% for bovine arch variants, with no statistical difference in prevalence between patients with a dissection and those in the control group, or between patients with a type A or type B dissection. However, mortality was 34.5% in patients with TBAD who had a bovine arch versus 16% in patients without a bovine arch. This was a significant difference (P =.04), according to Dr. Brunkwall.

Multivariate analysis showed that the presence of a bovine arch with TBAD was an independent predictor of mortality. “The reason for the high mortality cannot be explained by our data,” said Dr. Brunkwall, “but there has been a suggestion that the shear stress is different and higher in patients with a bovine arch leading to a stiffer aorta and more endothelial damage.”

Dr. Brunkwall reported that he had no disclosures.

mlesney@mdedge.com

NEW YORK – The presence of a bovine arch predicts higher mortality in patients with a type B aortic dissection (TBAD), according to a study presented by Jan S. Brunkwall, MD, at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

The bovine arch is a congenital interruption in the evolution of the arch, and is a misnomer because it does not actually reflect the arch branching pattern found in cattle. It represents the most common variation of the aortic arch, with a prevalence of 1%-41%, depending on the literature, according to a study published by Dr. Brunkwall, chairman of the department of vascular and endovascular surgery at the University of Cologne (Germany), and his colleagues (Eur J Vasc Endovasc Surg. 2018; 55:385-391).

In order to assess the effect of the bovine arch on survival, Dr. Brunkwall and his colleagues performed a retrospective cohort analysis of patients with TBAD admitted at two centers. CT angiograms (CTAs) of patients referred because of aortic dissection were also reevaluated with regard to the presence of a bovine arch.

A total of 154 patients with TBAD and 168 with type A aortic dissection were assessed, and 110 oncologic patients who had undergone a chest CTA for disease staging during the study period acted as a control group.

There was an overall prevalence of 17.6% for bovine arch variants, with no statistical difference in prevalence between patients with a dissection and those in the control group, or between patients with a type A or type B dissection. However, mortality was 34.5% in patients with TBAD who had a bovine arch versus 16% in patients without a bovine arch. This was a significant difference (P =.04), according to Dr. Brunkwall.

Multivariate analysis showed that the presence of a bovine arch with TBAD was an independent predictor of mortality. “The reason for the high mortality cannot be explained by our data,” said Dr. Brunkwall, “but there has been a suggestion that the shear stress is different and higher in patients with a bovine arch leading to a stiffer aorta and more endothelial damage.”

Dr. Brunkwall reported that he had no disclosures.

mlesney@mdedge.com

NEW YORK – The presence of a bovine arch predicts higher mortality in patients with a type B aortic dissection (TBAD), according to a study presented by Jan S. Brunkwall, MD, at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

The bovine arch is a congenital interruption in the evolution of the arch, and is a misnomer because it does not actually reflect the arch branching pattern found in cattle. It represents the most common variation of the aortic arch, with a prevalence of 1%-41%, depending on the literature, according to a study published by Dr. Brunkwall, chairman of the department of vascular and endovascular surgery at the University of Cologne (Germany), and his colleagues (Eur J Vasc Endovasc Surg. 2018; 55:385-391).

In order to assess the effect of the bovine arch on survival, Dr. Brunkwall and his colleagues performed a retrospective cohort analysis of patients with TBAD admitted at two centers. CT angiograms (CTAs) of patients referred because of aortic dissection were also reevaluated with regard to the presence of a bovine arch.

A total of 154 patients with TBAD and 168 with type A aortic dissection were assessed, and 110 oncologic patients who had undergone a chest CTA for disease staging during the study period acted as a control group.

There was an overall prevalence of 17.6% for bovine arch variants, with no statistical difference in prevalence between patients with a dissection and those in the control group, or between patients with a type A or type B dissection. However, mortality was 34.5% in patients with TBAD who had a bovine arch versus 16% in patients without a bovine arch. This was a significant difference (P =.04), according to Dr. Brunkwall.

Multivariate analysis showed that the presence of a bovine arch with TBAD was an independent predictor of mortality. “The reason for the high mortality cannot be explained by our data,” said Dr. Brunkwall, “but there has been a suggestion that the shear stress is different and higher in patients with a bovine arch leading to a stiffer aorta and more endothelial damage.”

Dr. Brunkwall reported that he had no disclosures.

mlesney@mdedge.com