Development of a Multispecialty Practice and Operation of Multispecialty Cardiovascular Centers

Introduction

A service line strategy has long been used by medical centers to counter inefficiency in provision of multidisciplinary care, improve quality, and capitalize on high-frequency diseases with well-reimbursed treatments. Common examples are neuroscience, cancer, and wound care services. The concept of a vascular service line has existed since World War II, and organized cardiovascular (CV) centers have existed in civilian hospitals since the 1980s.

However, service line strategies involving multiple specialties can be a challenge in academic medical centers (AMCs), where departmental silos can splinter the care of a single patient. For example, vascular disease can be managed by vascular surgery, vascular medicine, interventional radiology, and cardiology. These difficulties may also arise in community hospitals, where turf battles between private groups may exist.

Currently, the multispecialty CV center remains a priority of health system leaders, but the forces shaping their evolution are changing rapidly in the contemporary healthcare environment. Successful multispecialty CV centers are adapting, whereas others are losing market share. Vascular diseases in particular represent a strategic priority for CV centers because of the projected growth in demand for services, disruptive technology, prevailing poor care coordination, and a lack of integration with cardiac disorders. In this chapter, we review early examples of multispecialty CV centers and the impact of changes in market forces, consider development and operational aspects, appraise trends within existing CV centers, and look to the future.

Early Examples Of Multispecialty Cardiovascular Centers

An early concept of a vascular center was described by Elkin and DeBakey in 1943:

The problem of supplying competent specialized care by experienced personnel for large numbers of casualties with vascular injuries was resolved in World War II by the establishment in the Zone of Interior of vascular centers to which surgeons experienced in vascular surgery were attached and in which other surgeons could be trained. To these centers were sent patients with vascular injuries and diseases. The establishment of these centers made it possible to carry out the necessary treatment of such patients with an economy of equipment, personnel, and effort which would have been impossible had the patients been scattered through a large number of hospitals. It also permitted the observation of patients with vascular injury and disease in numbers far beyond those of any similar previous experience. Careful and detailed records were kept and analysis of data derived therefrom permitted deductions and conclusions which could not be gained from the small series of cases previously observed by surgeons in civilian practice.

Even in the midst of war, these surgeons had the foresight to recognize and address the challenges and opportunities facing a service line strategy, all the while paying equal attention to the clinical care, teaching, and research missions. The War Department set up the first vascular center at Ashford General Hospital in West Virginia. It was, indeed, a true multispecialty CV center consisting of a surgeon, assistant surgeon, two medical officers, a cardiologist, a physiotherapist, and an officer to supervise reconditioning after treatment had concluded.

Modern CV centers do not have to deal with the volumes of military injuries that Ashford General Hospital did but instead must navigate an increasingly complex environment with a shifting regulatory landscape, decreasing reimbursement, demands for transparency and quality measures, and interspecialty competition. However, CV centers are well suited for multispecialty collaboration. Emphasis on one organ system, high volumes and visibility, and a major source of revenue for health systems, have led to initiatives to undertake new care models with reimbursement tied to varying incentives through novel strategies, such as Medicare demonstration projects. With increasing employment of all CV specialties by health systems, the task of getting multiple specialties to agree on protocols and quality metrics has become possible. Modern vascular centers that employed CV specialists arose in the 1980s and include the Mayo Vascular Center.

The birth of the Mayo Vascular Center in 1987 arose from the recognition that because multiple clinical departments were involved in the diagnosis and treatment of most vascular diseases, diagnostic testing suites and physician clinics became physically and administratively distinct and spread across the campus. As the Mayo Vascular Center developed a national referral base, these separations introduced significant inefficiency. The strategic vision of the founders of the Center prioritized a “one-stop” patient experience and openness to any interested specialties. This represented an early recognition of patient satisfaction as a quality metric, as well as the potential for competition between specialties in the vascular space.

Initially, large private health systems were unable to duplicate the Mayo experience, which is unique both geographically as well as organizationally, following a foundation model for physician–hospital alignment. However, as the fee-for-service model evolved into the health maintenance organization (HMO) era in the 1980s and 1990s, then to the present value-based payment (VBP) system in which cost containment and value are emphasized, academic, private, and foundational model CV centers have found success, and their strategic visions have dramatically changed and increased in complexity.

Forces Shaping The Evolution Of Contemporary Multidisciplinary Cardiovascular Centers

The United States spends more than any other country on healthcare, and US healthcare expenditures are expected to exceed 20% of the gross domestic product. Inefficiencies in US healthcare are widely viewed as opportunities to contain costs, particularly in the government-sponsored Medicare and Medicaid programs. Regulators and the public are increasing focus on value, transparency, and definitions of quality. Total demand for CV services is increasing rapidly as the population ages, while a specialty physician shortage looms. ^, What started out as a marketing tactic aimed at increasing market share has now evolved into a holistic focus on quality, efficiency, transparency, patient satisfaction, and cost, almost all driven by changing reimbursement systems. Health systems still continue to fight for market share to compensate for diminishing revenue. This is the difficult environment in which the contemporary multidisciplinary CV center must succeed. Hospital systems and physicians alike should weigh the advantages and disadvantages before undertaking the process of CV center formation ( Table 197.1 ).

Changes in Demographics and Care Delivery

The number of board-certified vascular surgeons in the United States has remained relatively stable, and in 2010 there were, by one estimate, fewer than 3000. This number is projected to grow linearly over the next decades to approximately 3500 in 2040. Simultaneously, the general population will continue to expand rapidly, and the elderly population even more quickly over the coming years. Vascular surgeons are one of the smaller physician workforces, yet they take care of a disease process that is one of the leading causes of death in the United States. A vascular surgeon shortage looms, and this has and will continue to shape the makeup of the vascular provider pool and the modes of delivery of vascular care. Because vascular care is also provided by cardiologists, interventional radiologists, and vascular medicine specialists, a multidisciplinary CV center makes an ideal organization in which to provide comprehensive services to patients with a common pathology ( Table 197.2 ).

TABLE 197.2

Essential Components of a Multidisciplinary Cardiovascular (CV) Center

1. Medical/surgical specialties: a. Vascular and endovascular surgery b. Cardiothoracic surgery c. Cardiology: interventional and noninvasive d. Radiology: interventional and noninterventional e. Vascular medicine f. Anesthesiology g. Podiatry h. Neurology/neuroradiology i. Endocrinology (including lipid metabolism) j. Wound care specialist 2. Vascular nursing 3. Noninvasive vascular laboratory 4. Noninvasive cardiac laboratory 5. Rehabilitation: cardiac and vascular diseases 6. Prevention and wellness screening programs 7. Research 8. Education

Although still relatively rare before the age of 50 years, by age 80 the prevalence of peripheral arterial disease (PAD) rises to 20%. By 2030, 180,000,000 people are estimated to have at least one risk factor for PAD. Thus, as the elderly population continues to expand faster than younger segments, the prevalence of PAD will continue to increase sharply, and the number of PAD procedures will increase accordingly ( Fig. 197.1 ). Furthermore, the elderly are living longer, requiring treatment over longer periods of time, and are accumulating more comorbidities that affect PAD risk and treatment outcomes.

Despite these demographic changes, management of these aging and increasingly complex patients is moving increasingly into the outpatient arena. The rate of inpatient PAD interventions declined from 209.7 to 151.6 per 100,000 Medicare beneficiaries between 2006 and 2011, whereas the rate of outpatient interventions increased from 184.7 to 228.5. With the shift to outpatient care, significant increases in office-based procedures are also occurring (see Ch. 198 , Development and Successful Operation of an Outpatient Vascular Center).

Paradoxically, medical innovation has largely focused on inpatient treatments. Costs for inpatient care continue to rise and make up the majority of Medicare expenditures for PAD ; this highlights the disconnect between increasing outpatient volumes and a focus on inpatient care. Given the push by multiple stakeholders, it is likely that financial incentives for outpatient care, preventive medicine, and population health management will drive the design of multispecialty CV centers in the future. For example, the safety, patient satisfaction, and financial viability of endovascular procedures performed in the outpatient setting has already been established (See Ch. 198 , Development and Successful Operation of an Outpatient Vascular Center).