‘Good outcomes not good enough’


A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.

Dr. Kim J. Hodgson
Nationwide Photographers / Kim J. Hodgson

Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”

He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.

He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.

“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”

Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.

She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.

Dr. Kim Hodgson (podium) kicks off the E. Stanley Crawford Critical Issues Forum Thursday at VAM. Also participating, from left, are Drs. Fred Weaver, Anton Sidawy, Arlene Seid and Larry Kraiss.Nationwide Photographers

Dr. Kim Hodgson (podium) kicks off the E. Stanley Crawford Critical Issues Forum at VAM. Also participating, from left, are Drs. Fred Weaver, Anton Sidawy, Arlene Seid, and Larry Kraiss.

As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.

She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.

Anton Sidawy, MD, MPH, FACS, professor and chair of the Department of Surgery at the George Washington University Medical Center, discussed how SVS is working with the American College of Surgeons to develop certification for vascular surgery centers. He addressed the need for organizations such as SVS to take the initiative in defining quality and value for the field, in no small part because payment models are shifting from the rewarding of volume to the rewarding of value.

Defining value may come from many sources: government, private insurers, and the public. Unless SVS has a strong voice in defining value, it may find itself not pleased with the results, according to Dr. Sidawy.

Then Fred A. Weaver, MD, chair of the SVS Patient Safety Organization and professor of surgery and chief of the vascular surgery division at Keck School of Medicine of University of Southern California, described the current state of the Vascular Quality Initiative. This is an SVS database whose 12 registries have gathered demographic, clinical, procedural and outcomes data from more than 500,000 vascular procedures performed in North America in 18 regional quality groups.

Currently, the VQI is comprised of 571 centers in the United States and Canada, with one in Singapore. Of particular importance, the makeup of the practitioners involved in the VQI is very diverse in specialty training, with only 41% of the membership being vascular surgeons.

In the near future, three more VQI registries are coming, according to Dr. Weaver: An ultrasound registry (in concert with the Society of Vascular Ultrasound); Venous Stenting; and Vascular Medicine (in concert with the American Heart Association).

Dr. Weaver emphasized how tracking outcomes is crucial for both vascular surgeons and certified vascular surgery centers to assess and improve their performance and how the VQI is critical to these endeavors.

Finally, Larry Kraiss, MD, chair of the SVS Quality Council and professor and chief of the vascular surgery division at the University of Utah, presented the goals of the new SVS council and described how the council is expanding the quality mission to include appropriate use criteria in addition to the long-standing clinical practice guidelines the SVS produces.

Dr. Kraiss elaborated on how Appropriate Use Criteria (AUC) perform a substantially different role than that of Clinical Practice Guidelines (CPG).

Since 2006, SVS has developed 13 active guidelines, with more on the way. Guidelines provide positive yes/no statements with regard to treatment decision-making. However, many patients fall outside the guidelines, often due to comorbidities or other confounding factors, and appropriate use criteria are vital in these cases to evaluate where on a spectrum the patient fits for making a decision with regard to performing an operation or the use of a device.

Appropriate use criteria can be developed through the use of risk assessment to determine where on the spectrum of safety and effectiveness a particular patient falls with regard to a particular procedure or device. A major role of the new SVS Quality Council is to develop appropriate use criteria using outcome tools such as VQI and to provide recommendations as to how individuals and institutions could improve their performance by taking into account risk factors and assess infrastructural needs.

“The SVS board has authorized development of AUC in particular areas,” said Dr. Kraiss. “This process with be closely tied with updating the CPG. The first commissioned AUC will be to address intermittent claudication. But I invite the membership to participate in this process, especially on the panels, which can have up to 17 members, and we envision AUC coming out in carotid intervention, AAA management, and venous disease,” he added.


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