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The Mayo Vascular Center Experience
Cardiovascular Surgery, Vol. 6, No. 4, pp. 333–336, 1998 1998 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd All rights reserved. Printed in Great Britain 0967–2109/98 $19.00 + 0.00
PII: S0967-2109(98)00060-X
The Mayo Vascular Center Experience J. W. Hallett, T. W. Rooke and M. Koch The Mayo Gonda Vascular Center, Rochester, Minnesota, USA American medicine is trending toward an increasing number of specialty care centers. Cancer centers, transplant centers, and sports medicine centers are only a few common examples. Vascular centers are relatively new entities that are forming for obvious reasons. As the general population ages, peripheral vascular disease has become more prevalent. Several types of medical, surgical, and radiological specialists are involved in the diagnosis and treatment of such patients. Creating multispecialty vascular centers is one method to focus expert care on the patient, to alleviate some of the turf battles between specialties, and to contain burgeoning Medicare costs. 1998 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved
Impetus for change At the Mayo Clinic, the concept of an integrated vascular center originated in 1987. During the previous five decades, Mayo had established a national reputation as a referral center with vascular medical and surgical experts. In fact, one of the earliest textbooks in vascular diseases came from physicians such as Doctors Allen, Barker, and Hines at Mayo, and their work was followed a generation later by Doctors Fairburn, Juergens, and Spittell. Although they specialized in vascular diseases, their practices were incorporated in the cardiovascular division, and no specific vascular center existed. Eventually, the development of various non-invasive technologies for vascular diagnosis encouraged a change in practice organization. When the first laboratories were formed, several different clinical departments became involved in non-invasive vascular diagnosis. For example, the vascular medicine laboratory focused on arterial and venous testing that relied primarily on functional assessments. Most of these examinations were performed with continuous wave Dopplers, pulse volume recordings, transcutaneous oximetry and various types of plethysmogra-
phy. In another clinic location, radiology lead to the development and introduction of duplex ultrasonography. In still another area, neurology focused their evaluation of cerebrovascular disease on ocular pneumoplethysmography and transcranial Doppler analysis. Another section of neurology performed autonomic testing for various types of sympathetic conditions such as reflex sympathetic dystrophy. The vascular surgeons, neurosurgeons and various medical vascular practitioners cared for their outpatients in separate areas of the Mayo Clinic. In many ways, this dispersion of non-invasive diagnostic technology created inconveniences for both the patient and physician staff. For example, a patient with an asymptomatic carotid bruit might go to one laboratory for ocular pneumoplethysmography and to another location for a carotid ultrasound. In addition, physicians and surgeons from various departments could not interact directly since they were dispersed in a relatively large clinic campus. Another dilemma arose when a patient was seen in one area of the clinic by a physician who needed a non-invasive diagnostic test from a laboratory in another location. Leaders in clinical practice at the Mayo Clinic began to realize the benefits of establishing an integrated and centralized vascular center.
Correspondence to: John W. Hallett, Jr, MD, Division of Vascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
CARDIOVASCULAR SURGERY
AUGUST 1998 VOL 6 NO 4
333
The Mayo Vascular Center Experience: J. W. Hallett et al.
Organizing process Organizing a multispecialty vascular center is problematic. Difficult issues include finding space, agreeing on governance and management, and creating a cost/revenue structure for the center. Since the Mayo Clinic was already a multispecialty practice of medicine, these problems were more easily solved. The Clinical Practice Committee appointed representatives from the following specialties to organize the new Vascular Center: cardiovascular medicine, vascular surgery, radiology, neurology and neurosurgery. The founding members were selected because of past interest and expertise in vascular disease and because of genuine interest in creating a workable multispecialty vascular center. In developing a strategic vision for the new Mayo Vascular Center, the founding members agreed upon the following tenets. First, the center would provide a ‘one-stop’ location for the patient encounter. Once the patient was in the center, he or she could move easily between various laboratories and physician offices. Likewise, physicians from various specialties could walk down the hall and quickly seek consultation from one another. Second, staff privileges in the center would be open to multiple subspecialties. As the center developed, the founding specialties opened the opportunities to any Mayo physician or surgeon who had a dedicated interest in some aspect of vascular disease. For example, endocrinologists, and physical medicine and rehabilitation physicians became active members of the team for the vascular center’s Wound Care Clinic.
Space requirements In establishing any vascular center, space is one of the most critical requirements. When the Mayo Vascular Center was established in the late 1980s, hospital beds were being reduced because of shorter hospital stays. The Vascular Center Organizing Committee pursued the opportunity to utilize one of the vacated hospital units at the Rochester Methodist Hospital, which is on the downtown campus of the Mayo Clinic. Initially, this 15,000-square-foot area seemed generous. Nonetheless, rapid growth was anticipated in the vascular center, and this prediction was ultimately proved correct. The configuration of the previous hospital area created a central reception desk and lobby for patients but maintained distinct areas for the major subspecialty groups. In the initial configuration, the center contained approximately 12 patient examination rooms with a similar number of diagnostic rooms for testing equipment. Ten additional rooms were utilized for test interpretation, physician activities and secretarial support. A small conference room and library with 334
adjacent office space for residents and fellows was also incorporated.
The governance Coordinating the activities of a vascular center depends on the type and style of both clinical and administrative governance. To prevent dominance by any single subspecialty, the Mayo Vascular Center Executive Committee consists of five codirectors from the five primary specialties that founded the center. Initially, each co-director rotated as the chair of the committee on a yearly basis. Currently, the director rotates for 3 years to allow continuity in developing new programs and in organizing annual plans and budgets. As new programs develop (e.g. a thrombophilia clinic), additional consulting staff are appointed to the Executive Committee. A non-physician administrator is assigned to the vascular center. Non-physician laboratory technologists are also active representatives on the Executive Committee. Each subspecialty provides secretarial support for their particular activities. Although the co-directors interact in daily practice, the entire Executive Committee and its supporting members meet monthly to discuss programs, problems and productivity. The co-directors and administrator meet weekly to discuss both daily and strategic operational activities that need more frequent attention. Establishing cost centers for activities and tracking productivity are essential in the evolution of any clinical center. Subspecialties have had the option of placing their cost center under the management of the Vascular Center administration or accounting their activities and revenues to their original departments. Over time, all activities are evolving toward a single cost center.
Patient access Access of both patients and physicians to the Mayo Vascular Center may arise from several directions. Flexibility is a key to access, and has been essential in providing expeditious care in a high-growth clinical environment. For example, a patient can be referred directly to the Vascular Center by a non-Mayo physician for consultation on a specific problem. Depending on the nature of the problem, the patient is directed toward the appropriate subspecialist for initial evaluation. Second, a patient can call the Mayo Clinic and request direct referral to the Vascular Center. Third, a patient can be referred by any Mayo Clinic physician to the Vascular Center for specific diagnostic tests. Following such tests, the patient returns to the primary Mayo physician. If tests suggest that a physician consultation in the VasCARDIOVASCULAR SURGERY
AUGUST 1998 VOL 6 NO 4
The Mayo Vascular Center Experience: J. W. Hallett et al.
Figure 1 Number of patients seen in Mayo Vascular Center per year.
cular Center would be beneficial to the patient, the referring physician is informed immediately.
pressure indices) has shown a modest growth of approximately 6%. Productivity is estimated by relative resource units per patient-care consultant per work day. The relative resource unit (RRU) is similar to the relative value unit (RVU) described by the Health Care Financing Administration (HCFA). Essentially, the Mayo RRU is the RVU minus malpractice expenses. Productivity has shown a steady increase from approximately 50 RRU per patient-care consultant per workday in 1993 to nearly 60 RRUs by 1996 (Figure 3). For the entire Vascular Center, relative resource units have increased from slightly over 50,000 in 1993 to over 80,000 in 1996. The cost per Mayo relative resource unit has been maintained in the $38–40 range.
Developing new programs
In January 1991, the Mayo Vascular Center commenced operation. Subsequently, growth has been significant, and several parameters deserve emphasis. Within a year of opening, about 1000 patients were being seen each month, and more than 1500 laboratory procedures were performed each month. Between 1993 and 1996, total patient volumes increased from 10,037 to 20,713 per year (Figure 1). Several clinical areas demonstrated rapid growth (Figure 2). In 1993, a specific vascular center activity for wound care was established. Expansion in wound care activity has risen dramatically from approximately 5000 patients in the first year to 10,000 patients by the third year of operation. The second area of greatest growth has been vascular ultrasound where total patient volumes have risen from 4500 in 1993 to approximately 7500 in 1996. Traditional non-invasive vascular lab tests (e.g. ankle brachial
The Mayo Vascular Center continues to respond with new programs that meet patient needs. First among our new programs was the establishment of a Wound Care clinic in 1993. In a unique cooperation with Physical Medicine and Rehabilitation, a Lymphedema Clinic has also been made available to patients. Recently, a Thrombophilia Center has been started for the outpatient management of anticoagulation. The Mayo Foundation continues to develop a regional Mayo Health System. This network affiliates the Rochester Mayo Clinic main campus with multiple clinics and hospitals within a 150- to 200mile radius. To extend the expertise of the Rochester Mayo Clinic staff to these regional clinics and hospitals, several Outreach Programs have been established. For example, cardiologists with a mobile echocardiology laboratory visit several communities on a regular basis. Currently, the Mayo Vascular Center is organizing a similar outreach program to facilitate care of vascular patients.
Figure 2 The two areas of greatest growth have been wound care and vascular ultrasound.
Figure 3 Productivity measured by relative resource units (RRU) per patient-care consultant (PCC) per workday has increased steadily.
A successful beginning
CARDIOVASCULAR SURGERY
AUGUST 1998 VOL 6 NO 4
335
The Mayo Vascular Center Experience: J. W. Hallett et al.
Adapting to future needs Although one can debate the future care of the vascular patient, several facts are clear. Because the number of Americans over the age of 65 is increasing, the prevalence of cardiovascular diseases will also increase. Second, non-invasive technologies have established safe and accurate methods to delineate most vascular problems in the outpatient setting. A variety of patient needs (e.g. venous ulcers) can also be managed in the Vascular Center. Third,
336
a variety of subspecialists have evolved in the past two decades as experts in the care of various aspects of vascular disease. These experts come from a variety of medical, radiologic and surgical disciplines. Finally, we have the bias that the best method to care for these patients is an integrated multispecialty vascular center. The Mayo Clinic Vascular Center represents one example of how such a multispecialty vascular center can be organized and managed successfully. Paper accepted 26 March 1998
CARDIOVASCULAR SURGERY
AUGUST 1998 VOL 6 NO 4
PII: S0967-2109(98)00060-X
The Mayo Vascular Center Experience J. W. Hallett, T. W. Rooke and M. Koch The Mayo Gonda Vascular Center, Rochester, Minnesota, USA American medicine is trending toward an increasing number of specialty care centers. Cancer centers, transplant centers, and sports medicine centers are only a few common examples. Vascular centers are relatively new entities that are forming for obvious reasons. As the general population ages, peripheral vascular disease has become more prevalent. Several types of medical, surgical, and radiological specialists are involved in the diagnosis and treatment of such patients. Creating multispecialty vascular centers is one method to focus expert care on the patient, to alleviate some of the turf battles between specialties, and to contain burgeoning Medicare costs. 1998 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved
Impetus for change At the Mayo Clinic, the concept of an integrated vascular center originated in 1987. During the previous five decades, Mayo had established a national reputation as a referral center with vascular medical and surgical experts. In fact, one of the earliest textbooks in vascular diseases came from physicians such as Doctors Allen, Barker, and Hines at Mayo, and their work was followed a generation later by Doctors Fairburn, Juergens, and Spittell. Although they specialized in vascular diseases, their practices were incorporated in the cardiovascular division, and no specific vascular center existed. Eventually, the development of various non-invasive technologies for vascular diagnosis encouraged a change in practice organization. When the first laboratories were formed, several different clinical departments became involved in non-invasive vascular diagnosis. For example, the vascular medicine laboratory focused on arterial and venous testing that relied primarily on functional assessments. Most of these examinations were performed with continuous wave Dopplers, pulse volume recordings, transcutaneous oximetry and various types of plethysmogra-
phy. In another clinic location, radiology lead to the development and introduction of duplex ultrasonography. In still another area, neurology focused their evaluation of cerebrovascular disease on ocular pneumoplethysmography and transcranial Doppler analysis. Another section of neurology performed autonomic testing for various types of sympathetic conditions such as reflex sympathetic dystrophy. The vascular surgeons, neurosurgeons and various medical vascular practitioners cared for their outpatients in separate areas of the Mayo Clinic. In many ways, this dispersion of non-invasive diagnostic technology created inconveniences for both the patient and physician staff. For example, a patient with an asymptomatic carotid bruit might go to one laboratory for ocular pneumoplethysmography and to another location for a carotid ultrasound. In addition, physicians and surgeons from various departments could not interact directly since they were dispersed in a relatively large clinic campus. Another dilemma arose when a patient was seen in one area of the clinic by a physician who needed a non-invasive diagnostic test from a laboratory in another location. Leaders in clinical practice at the Mayo Clinic began to realize the benefits of establishing an integrated and centralized vascular center.
Correspondence to: John W. Hallett, Jr, MD, Division of Vascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
CARDIOVASCULAR SURGERY
AUGUST 1998 VOL 6 NO 4
333
The Mayo Vascular Center Experience: J. W. Hallett et al.
Organizing process Organizing a multispecialty vascular center is problematic. Difficult issues include finding space, agreeing on governance and management, and creating a cost/revenue structure for the center. Since the Mayo Clinic was already a multispecialty practice of medicine, these problems were more easily solved. The Clinical Practice Committee appointed representatives from the following specialties to organize the new Vascular Center: cardiovascular medicine, vascular surgery, radiology, neurology and neurosurgery. The founding members were selected because of past interest and expertise in vascular disease and because of genuine interest in creating a workable multispecialty vascular center. In developing a strategic vision for the new Mayo Vascular Center, the founding members agreed upon the following tenets. First, the center would provide a ‘one-stop’ location for the patient encounter. Once the patient was in the center, he or she could move easily between various laboratories and physician offices. Likewise, physicians from various specialties could walk down the hall and quickly seek consultation from one another. Second, staff privileges in the center would be open to multiple subspecialties. As the center developed, the founding specialties opened the opportunities to any Mayo physician or surgeon who had a dedicated interest in some aspect of vascular disease. For example, endocrinologists, and physical medicine and rehabilitation physicians became active members of the team for the vascular center’s Wound Care Clinic.
Space requirements In establishing any vascular center, space is one of the most critical requirements. When the Mayo Vascular Center was established in the late 1980s, hospital beds were being reduced because of shorter hospital stays. The Vascular Center Organizing Committee pursued the opportunity to utilize one of the vacated hospital units at the Rochester Methodist Hospital, which is on the downtown campus of the Mayo Clinic. Initially, this 15,000-square-foot area seemed generous. Nonetheless, rapid growth was anticipated in the vascular center, and this prediction was ultimately proved correct. The configuration of the previous hospital area created a central reception desk and lobby for patients but maintained distinct areas for the major subspecialty groups. In the initial configuration, the center contained approximately 12 patient examination rooms with a similar number of diagnostic rooms for testing equipment. Ten additional rooms were utilized for test interpretation, physician activities and secretarial support. A small conference room and library with 334
adjacent office space for residents and fellows was also incorporated.
The governance Coordinating the activities of a vascular center depends on the type and style of both clinical and administrative governance. To prevent dominance by any single subspecialty, the Mayo Vascular Center Executive Committee consists of five codirectors from the five primary specialties that founded the center. Initially, each co-director rotated as the chair of the committee on a yearly basis. Currently, the director rotates for 3 years to allow continuity in developing new programs and in organizing annual plans and budgets. As new programs develop (e.g. a thrombophilia clinic), additional consulting staff are appointed to the Executive Committee. A non-physician administrator is assigned to the vascular center. Non-physician laboratory technologists are also active representatives on the Executive Committee. Each subspecialty provides secretarial support for their particular activities. Although the co-directors interact in daily practice, the entire Executive Committee and its supporting members meet monthly to discuss programs, problems and productivity. The co-directors and administrator meet weekly to discuss both daily and strategic operational activities that need more frequent attention. Establishing cost centers for activities and tracking productivity are essential in the evolution of any clinical center. Subspecialties have had the option of placing their cost center under the management of the Vascular Center administration or accounting their activities and revenues to their original departments. Over time, all activities are evolving toward a single cost center.
Patient access Access of both patients and physicians to the Mayo Vascular Center may arise from several directions. Flexibility is a key to access, and has been essential in providing expeditious care in a high-growth clinical environment. For example, a patient can be referred directly to the Vascular Center by a non-Mayo physician for consultation on a specific problem. Depending on the nature of the problem, the patient is directed toward the appropriate subspecialist for initial evaluation. Second, a patient can call the Mayo Clinic and request direct referral to the Vascular Center. Third, a patient can be referred by any Mayo Clinic physician to the Vascular Center for specific diagnostic tests. Following such tests, the patient returns to the primary Mayo physician. If tests suggest that a physician consultation in the VasCARDIOVASCULAR SURGERY
AUGUST 1998 VOL 6 NO 4
The Mayo Vascular Center Experience: J. W. Hallett et al.
Figure 1 Number of patients seen in Mayo Vascular Center per year.
cular Center would be beneficial to the patient, the referring physician is informed immediately.
pressure indices) has shown a modest growth of approximately 6%. Productivity is estimated by relative resource units per patient-care consultant per work day. The relative resource unit (RRU) is similar to the relative value unit (RVU) described by the Health Care Financing Administration (HCFA). Essentially, the Mayo RRU is the RVU minus malpractice expenses. Productivity has shown a steady increase from approximately 50 RRU per patient-care consultant per workday in 1993 to nearly 60 RRUs by 1996 (Figure 3). For the entire Vascular Center, relative resource units have increased from slightly over 50,000 in 1993 to over 80,000 in 1996. The cost per Mayo relative resource unit has been maintained in the $38–40 range.
Developing new programs
In January 1991, the Mayo Vascular Center commenced operation. Subsequently, growth has been significant, and several parameters deserve emphasis. Within a year of opening, about 1000 patients were being seen each month, and more than 1500 laboratory procedures were performed each month. Between 1993 and 1996, total patient volumes increased from 10,037 to 20,713 per year (Figure 1). Several clinical areas demonstrated rapid growth (Figure 2). In 1993, a specific vascular center activity for wound care was established. Expansion in wound care activity has risen dramatically from approximately 5000 patients in the first year to 10,000 patients by the third year of operation. The second area of greatest growth has been vascular ultrasound where total patient volumes have risen from 4500 in 1993 to approximately 7500 in 1996. Traditional non-invasive vascular lab tests (e.g. ankle brachial
The Mayo Vascular Center continues to respond with new programs that meet patient needs. First among our new programs was the establishment of a Wound Care clinic in 1993. In a unique cooperation with Physical Medicine and Rehabilitation, a Lymphedema Clinic has also been made available to patients. Recently, a Thrombophilia Center has been started for the outpatient management of anticoagulation. The Mayo Foundation continues to develop a regional Mayo Health System. This network affiliates the Rochester Mayo Clinic main campus with multiple clinics and hospitals within a 150- to 200mile radius. To extend the expertise of the Rochester Mayo Clinic staff to these regional clinics and hospitals, several Outreach Programs have been established. For example, cardiologists with a mobile echocardiology laboratory visit several communities on a regular basis. Currently, the Mayo Vascular Center is organizing a similar outreach program to facilitate care of vascular patients.
Figure 2 The two areas of greatest growth have been wound care and vascular ultrasound.
Figure 3 Productivity measured by relative resource units (RRU) per patient-care consultant (PCC) per workday has increased steadily.
A successful beginning
CARDIOVASCULAR SURGERY
AUGUST 1998 VOL 6 NO 4
335
The Mayo Vascular Center Experience: J. W. Hallett et al.
Adapting to future needs Although one can debate the future care of the vascular patient, several facts are clear. Because the number of Americans over the age of 65 is increasing, the prevalence of cardiovascular diseases will also increase. Second, non-invasive technologies have established safe and accurate methods to delineate most vascular problems in the outpatient setting. A variety of patient needs (e.g. venous ulcers) can also be managed in the Vascular Center. Third,
336
a variety of subspecialists have evolved in the past two decades as experts in the care of various aspects of vascular disease. These experts come from a variety of medical, radiologic and surgical disciplines. Finally, we have the bias that the best method to care for these patients is an integrated multispecialty vascular center. The Mayo Clinic Vascular Center represents one example of how such a multispecialty vascular center can be organized and managed successfully. Paper accepted 26 March 1998
CARDIOVASCULAR SURGERY
AUGUST 1998 VOL 6 NO 4