- Email: [email protected]
Vascular surgery: A specialty in transformation with a bright future
PRESIDENTIAL ADDRESS From the Society for Vascular Surgery
Vascular surgery: A specialty in transformation with a bright future Gregorio A. Sicard, MD, St Louis, Mo
I am honored to stand before you as the 59th president of the Society for Vascular Surgery (SVS). It has been a privilege to serve as your president during a time marked by great change and significant progress, both in our field and for our society. Vascular surgery in the year 2005 is at a crossroads. Trends in demographics, workforce, technology, public opinion, and public policy will lead to more accountability and to greater autonomy at the same time. Vascular surgeons, like all physicians, will be increasingly accountable to patients, payers, and policy makers. But we will also enjoy a new level of autonomy to control our destiny as a specialty and to direct the educational paths of the generations who follow us. A new chapter in the history of vascular surgery is about to be written. DEMOGRAPHIC TRENDS AND WORKFORCE CHALLENGES First, let us consider demographics. As a nation, we are growing older. The leading edge of the Baby Boomers, including some in this room, will turn 60 next year. In 2003, one in every eight Americans was over the age of 65.1 By 2030, one in every five of us will qualify for Medicare. Meanwhile, a growing number of Americans of all ages are being diagnosed with diabetes— one every 25 seconds. That translates to more than 1.3 million adults diagnosed in 2003. From 1997 through 2003, the number of new cases of diagnosed diabetes increased by 52%.2 Results from the National Health and Nutrition Examination Survey showed a 14.5% prevalence of peripheral arterial disease in From the Department of Surgery, Division of General Surgery and Section of Vascular Surgery, Washington University School of Medicine. Competition of interest: none. Presented at the Fifty-ninth Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, Jun 16-19, 2005. Reprint requests: Gregorio A. Sicard, MD, FACS, Vice Chairman and Professor, Department of Surgery and Chief, Division of General Surgery and Section of Vascular Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Box 8109, Saint Louis, MO 63110 (e-mail: [email protected]). J Vasc Surg 2005;42:811-5 0741-5214/$30.00 Copyright © 2005 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2005.07.003
patients 70 years or older.3 Every year, about 82,000 diabetic patients have leg, foot, or toe amputations. More than 80% of those amputations are preventable—and every day, vascular surgeons are working to prevent them. The aging population and the diabetes epidemic portend tremendous growth in the need for vascular surgeons—a need that we will find increasingly difficult to meet, unless we make significant changes now. To meet demand projections for the year 2030, we should be graduating 160 vascular surgery residents every year.4 The actual number of graduates falls far short of the need. In 2005, 121 candidates took the vascular surgery certifying examination.5 The numbers are not expected to be very different in 2006. This shortfall in manpower is both chronic and cumulative. Recruiting more medical students and residents to our field is a matter of the highest priority. In recognition of that need, SVS, under the leadership of Dr Julie Freischlag and the Education Council, has awarded scholarships to 63 general surgery residents and 23 medical students, enabling them to attend the Vascular Annual Meeting. Filling the pipeline has been at the top of the SVS agenda for several years. My esteemed predecessor, Dr Richard Green, spoke to this issue from this podium in Anaheim, California last year. He described the number of unfilled positions in the vascular match as an ominous trend.6 In 2003, Dr Tony Sidawy addressed this topic in his capacity as president of the Eastern Vascular Society.7 This year, I am pleased to report, we have reason for optimism. The road to a career in vascular surgery has just become a direct route. In March 2005, the American Board of Medical Specialties approved a primary certificate in vascular surgery, effectively eliminating the requirement for residents to obtain board certification in general surgery before beginning their vascular surgery training. That requirement had been in effect since 1982. The American Board of Surgery describes the primary certificate as a “landmark decision that will alter the landscape of surgical training and certification in the United States.”8 Many of us experienced the months leading up to the approval of the primary certificate as a difficult time. Some of our colleagues voiced concerns that the primary certifi811
812 Sicard
cate was not the best long-term strategy, that it would hinder our movement toward independence and autonomy. Opinions were expressed in strong terms on both sides of this issue. As we seek ways to make common cause, to come together as a community with a shared goal, we would do well to remember the words of the great statesman Thomas Jefferson at his first inaugural address in 1801: “Every difference of opinion is not a difference of principle. We have called by different names brethren of the same principle. We are all republicans, we are all federalists.” Jefferson’s words resonate with us today. Reasonable minds may differ on tactics although our ultimate goals are the same. We must move forward knowing that the forces that unite us are stronger than those that would divide us. The need to provide for our professional progeny is a powerful uniting force. The more flexible and in-depth educational tracks made possible by the primary certificate will serve as a catalyst for growth in the number of vascular surgery trainees. By reducing the time spent in general surgery rotations, the primary certificate will result in a shortened training period for junior residents or medical students who choose vascular surgery early on. It will bring more freedom of career choice to medical students and residents, who will be able to make the vascular surgery choice at various stages of training– during medical school, after several years of initial surgical training, or after completion of full general surgery training. And precious curriculum hours will become available for training in open and endovascular techniques as well as in areas such as nonoperative prevention, diagnosis, and management of vascular disease. The new training models made possible by the primary certificate include a 6-year track (“3 ⫹ 3”) for residents who match in initial surgical training, and a 5-year integrated track for trainees who match during medical school. The Association for Program Directors in Vascular Surgery (APDVS), under the leadership of Dr Jim Seeger, is currently working to define the curricula necessary for both of the new models. Our thanks go to the APDVS for the work they have done to bring us to this point and for the ongoing work involved in this major curriculum redevelopment. THE IMPACT OF ENDOVASCULAR TECHNOLOGIES In addition to contending with the workforce challenges that arise from demographic trends, we must also address the impact of changing surgical technologies— specifically, the impact of endovascular surgery. Carotid endarterectomy (CEA) is still the most frequently performed surgical procedure to prevent stroke in this country. In recent years, carotid artery angioplasty and stenting have emerged as an alternative to CEA. In March of this year, the Centers for Medicare and Medicaid Services expanded Medicare coverage beyond trial settings for carotid angioplasty and carotid artery stenting in symptomatic patients at high risk for endarterectomy.
JOURNAL OF VASCULAR SURGERY October 2005
Treatment for abdominal aortic aneurysm is also undergoing a major shift, perhaps the most significant in its history. In recently published findings, the United Kingdom’s EndoVascular Aneurysm Repair (EVAR) Trial, led by Dr Roger Greenhalgh9 and the Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial, led by Dr Jan Blankensteijn,10 reported that endovascular treatment of abdominal aortic aneurysm is associated with lower rates of 30-day mortality compared with open repair. The DREAM team has recently published the results of their mid-term follow-up, and at 1 and 2 years, they found that the initial 30-day survival advantage of endovascular aneurysm repair over open surgery is no longer evident, apparently due to an excess of nonaneurysm-related cardiovascular mortality.11 In a session to be presented later at this meeting, Dr Roger Greenhalgh will present the 1-year results of the United Kingdom randomized trial.12 In a study presented earlier at this meeting, Dillavou, Muluk, and Makaroun13 discussed the effects of the introduction of endovascular aneurysm repair in the United States. Their conclusions: endovascular aneurysm repair is replacing open surgery without an overall increase in case volume. The proportion of patients treated with endovascular repair increased from about 6% in 2000 to 41% in 2003. At the same time, they found that operative mortality was lower for patients who underwent endovascular repair, replicating the initial United Kingdom and Dutch randomized studies on perioperative mortality. Moreover, patients treated with endovascular repair were discharged from the hospital sooner and were more likely to go home rather than to skilled nursing facilities. There is little doubt that endovascular technologies will fundamentally change the vascular surgery landscape and that we must be prepared to navigate this new terrain. The impact of endovascular technologies on patient outcomes and practice patterns will be lasting and far-reaching. We must provide educational support for endovascular procedures to both practicing and aspiring vascular surgeons. SVS research, under the guidance of Drs Richard Cambria and Craig Kent, has documented that only 31% of 774 practicing vascular surgeons who responded to a survey, received endovascular training in their fellowships (Society for Vascular Surgery Endovascular Training Opportunities Project, unpublished data, Chicago, Ill, 2005). About 60% have taken postfellowship training in endovascular procedures, the majority consisting of 1- to 5-day training programs such as the carotid arteriography and stenting courses initiated by the SVS in December 2004 and repeated in April 2005. The SVS Endovascular Committee, under the leadership of Drs Kim Hodgson and Peter Schneider, is planning to hold additional carotid, aneurysm and peripheral intervention courses in 2005. The Endovascular Training Opportunities Committee is in the process of developing an online endovascular training opportunities clearinghouse to provide information about minifellowships and industry-organized short courses throughout the country.
JOURNAL OF VASCULAR SURGERY Volume 42, Number 4
Sicard 813
GROWING CONSUMER AWARENESS OF VASCULAR SURGERY
PUBLIC POLICY CHANGES THAT SUPPORT VASCULAR SURGERY
The availability of “kinder, gentler” less-invasive endovascular procedures has raised public awareness of vascular surgery. I am happy to report that the era of vascular surgery as the best-kept secret in American medicine is coming to an end. People are starting to know who we are. Consumers, a group that is all-inclusive and not limited to patients, are starting to realize that “it’s not just about their coronary arteries anymore.” This change is happening at the community level, as more hospitals promote vascular wellness and conduct free vascular screenings. Our own American Vascular Association (AVA) has screened more people than ever this year, coordinating the efforts of more than 175 screening centers throughout the country that participated in Vascular Health Month in May 2005. This culminated in the single largest vascular screening the AVA has ever conducted, in which nearly 300 individuals were screened at the Hyatt Regency Chicago on June 14. On behalf of all society members and the SVS board, our thanks go to the 30-plus individuals, including SVS members who volunteered for this screening and to Dr Bill Flinn and screening program administrator Michele Lentz, who have worked very hard to put programs like these together. AVA screening program results consistently show that about 10% of individuals who are screened are referred to their physicians for additional vascular diagnostic testing. All individuals screened are encouraged to take their Vascular Report Card results to their primary care physicians. And all leave with a better understanding of the signs and symptoms of vascular disease. Not only is vascular disease awareness increasing in communities throughout the country, it is increasing in the virtual community as well. We are now reaching thousands of consumers through the patient education section of our Website, VascularWeb. This year, through a partnership with content development specialists at NorthPoint Domain, we have added 35 topics related to vascular conditions, tests, and treatments. Traffic began increasing almost immediately, thanks to citations by major Internet search engines and megasites such as Medline Plus, the online patient health resource provided by the National Library of Medicine and the National Institutes of Health. Since the relaunch of the redesigned VascularWeb in 2004, the number of people using the site has increased steadily and is now at about 3000 per day. Much of this increase is because VascularWeb has become a leading patient education resource for vascular disease. With an estimated 95 million American adults now searching for health information online,14 VascularWeb goes a long way toward increasing awareness and understanding of vascular disease. We appreciate the dedication and diligence of Dr Wayne Johnston and Karen Thomas, who have overseen the development of the patient information section and the relaunch of the entire Website.
Recognition of the impact of vascular disease is happening at the public policy level as well. This year marked the release of new US Preventive Services Task Force recommendations on screening for abdominal aortic aneurysms.15 The task force’s previous recommendations, issued in 1996, did not find evidence to support screening in any population. The new task force report supports screening for men older than 65 years with a history of smoking. We are very pleased about the progress this represents: the new recommendations capture an estimated 70% of the men in this age group. The Preventive Services Task Force recommendations are widely viewed as the gold standard for good quality scientific evidence of effectiveness. Furthermore, the task force recommendations serve as the basis for benefits and coverage policies by many commercial insurers and third-party payers. But the society will not stop here in its efforts to broaden coverage for aneurysm screening. Discussions between the National Aneurysm Alliance and the Agency for Healthcare Research and Quality on this issue are ongoing. Meanwhile, the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act (HR 827/S.390), which was introduced in February 2005 by bipartisan sponsors, would provide an ultrasound screening benefit for at-risk Medicare beneficiaries, including men and women with a positive family history for aneurysms as well as those with established medical risk factors. This legislation is supported by the National Aneurysm Alliance, a broad coalition founded by the SVS that includes medical professional organizations, foundations, patient advocates, and medical technology manufacturers. Our sincere thanks go to Dr Bob Zwolak, who is leading the National Aneurysm Alliance effort to make this happen. OUTCOMES ASSESSMENT IN VASCULAR SURGERY The new higher profile for vascular surgery comes at a time when every sector of American medicine is under the microscope. Patient safety, quality improvement, and outcomes reporting are at the top of everyone’s agenda. Norman Hertzer predicted this trend back in 1994 during his tenure as president of the society. The title of his presidential address said it all: Outcomes Assessment in Vascular Surgery–Results Mean Everything. Dr Hertzer went on to say: If we can distance ourselves for a moment from the daily confusion regarding healthcare and how to finance it, the present debate about quality and cost offers an unmistakable opportunity for us to make vascular surgery better than it ever has been. We just have to get back to the fundamentals. What do we really stand for as surgeons? I think we stand for results. Hospitals should know their own results, and surgeons must be among the first, not the last, to insist on it. For nearly 50 years, [our society] has conducted a proud and principled search for excel-
814 Sicard
lence in vascular surgery. These are uncertain times, but we cannot stop now.16
The trend toward outcomes reporting is being driven by increasing public demands for accountability and the move toward “pay for performance” (P4P) among other factors. The Centers for Medicare and Medicaid Services (CMS) is working toward implementation of P4P in all health-care settings. The first P4P demonstration project for physician groups became operational in April of this year. Meanwhile, nearly 300 hospitals are participating in a CMS demonstration project involving 34 quality measures related to five clinical conditions. These hospitals receive financial incentives for high quality, while institutionspecific performance data are reported on CMS Website. And this is just the beginning. After years of development on many fronts, there is finally a risk-adjusted, outcomes-based program to measure and improve the quality of surgical care—the National Surgical Quality Improvement Program (NSQIP)—sponsored by the American College of Surgeons. NSQIP uses a prospective, peer-controlled, validated database to quantify 30-day, risk-adjusted surgical outcomes, allowing for valid comparison of outcomes among all hospitals in the program. When NSQIP was launched more than 20 years ago, risk-adjusted surgical outcomes and national averages did not exist. In response to Veterans Affairs (VA) institutions coming under intense public scrutiny over the quality of their surgical care, a 1986 congressional law was passed mandating that the VA report its surgical outcomes every year. NSQIP was launched in January 1994 as a program that analyzes surgical data in VA institutions using risk-adjusted methodology to facilitate reporting of their outcomes on an annual basis. Subsequently, from 1991 to 2001, the VA saw a 27% decline in postoperative mortality, a 45% drop in postoperative morbidity, a decline in the median postoperative length of stay from 9 days to 4 days, and improvements in patient satisfaction.17 During the early VA years, NSQIP developed and validated risk-adjustment models, using stepwise forward logistical regression to identify the preoperative risk factors that were predictive of outcomes. The concept is simple: it is based on observed vs expected (O/E) ratios of surgical outcomes. NSQIP suggests thinking of the O/E ratio as a par on a golf course—the score that is expected. An O/E ratio of less than 1 means better-than-expected performance; a ratio of more than 1 indicates an excess of adverse events. The ratios show that risk adjustment has a profound effect in determining a hospital’s true performance. Recognizing the success of the VA-NSQIP program, the American College of Surgeons (ACS) adopted its methodology to collect and analyze data in nonfederal institutions in what was termed the AC-NSQIP. In 1999, a pilot study that included only general surgery and vascular surgery was launched to determine the feasibility of implementing NSQIP outside of the VA. Would the riskadjustment model used in the VA system hold true for the more heterogeneous private sector? After 1 year, the results
JOURNAL OF VASCULAR SURGERY October 2005
were conclusive: the NSQIP system worked. Based on the success of that study, the Agency for Healthcare Research and Quality approved funding for an application by ACS to expand the pilot program to 14 additional medical centers, including the institution where I work in St Louis. In 2002, the Institute of Medicine named NSQIP “the best in the nation” for measuring and reporting surgical quality and outcomes. The SVS and the AVA have begun discussions with ACS about modifying existing NSQIP protocols to permit collection of data on long-term outcomes of CAS compared with CEA. A program is anticipated for rollout in late 2005 or early 2006. We look forward to the implementation of the NSQIP program in vascular surgery. At the same time, we realize that the CMS mandate for CAS facilities to collect outcomes data means that vascular surgeons must have an outcomes data collection now, not next year. To meet this need, I have appointed an AVA/SVS Outcomes Steering Committee that will help guide us as we move forward in this arena. Our first major initiative is the AVA/SVS Vascular Registry, which will permit easy, straightforward collection of both carotid endarterectomy and stent procedure data. In addition to meeting CMS regulations for payment of CAS, this Web-based registry will provide individual surgeons with confidential benchmarking reports and will give hospitals a downloadable database of all carotid procedures performed at their institutions. All SVS members are encouraged to take advantage of the opportunity to participate in the first carotid registry in the market. Wide participation by vascular surgeons in these outcomes initiatives will allow regulatory agencies, researchers, practitioners, and industry to gain insight into the most appropriate indications and patient populations for carotid interventions. The success of the AVA/SVS Registry is important in establishing outcomes mechanisms that should be expanded to other anatomic sectors. Like it or not, we are practicing vascular surgery during a time when innovation is leading to transformation. You have probably heard a saying that is often attributed to the ancient Chinese: “May you live in interesting times.” Although it is usually described as a curse, it may also be viewed as a blessing. Vascular surgery is an exciting specialty with a bright future, despite all the challenges we face today—indeed, partly because of them. We must accept public accountability and embrace professional autonomy, always mindful of the privileges and responsibilities inherent in both. And we must move forward as one community with a single voice and a shared vision for the benefit of our fellow vascular surgeons, and above all, for the benefit of our patients. I thank all of you for your support. It has been an honor and privilege to serve as your president. I will never forget this extraordinary experience. The author would like to thank Karen Thomas and Debi Swap for assistance in the preparation and review of this manuscript.
JOURNAL OF VASCULAR SURGERY Volume 42, Number 4
Sicard 815
REFERENCES 1. US Census Bureau, Decennial Census and Projections. 2. National Center for Chronic Disease Prevention and Health Promotion, National Diabetes Surveillance System. Annual number (in thousands) of new cases of diagnosed diabetes among adults aged 18-79 years, United States, 1997-2003. Available at www.cdc.gov (accessed May 15, 2005). 3. Selvin E. Prevalence of and risk factors for peripheral arterial disease in the United States. Circulation 2004;110:738-43. 4. Stanley JC. Personal communication quoted in Presidential address. Generations apart— bridging the generational divide in vascular surgery by Sidawy, AN. J Vasc Surg 2003;38:1147-53. 5. Association of Program Directors in Vascular Surgery. June 2004 minutes. Available at www.vascularweb.org. Accessed May 15, 2005. 6. Green, RM. Presidential address: a live dog is better than a dead lion. J Vasc Surg 2004;40:583-8 7. Sidawy AN. Presidential address: generations apart— bridging the generational divide in vascular surgery. J Vasc Surg 2003:38:1147-53. 8. Press release: ABS receives approval for primary certificate in vascular surgery. American Board of Surgery, March 17, 2005, Available at http://home.absurgery.org/default.jsp?newsvsprimarycert (accessed May 15, 2005). 9. Greenhalgh, R. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1): 30-day operative mortality results: randomized controlled trial. Lancet 2004;364:843-8. 10. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeck MR, Balm R, et al; Dutch Randomized Endovascular Aneurysm Manage-
11.
12.
13.
14.
15.
16. 17.
ment (DREAM) Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351:1607-18. De Jong S, Prinssen M, van der Ham A, van Sterkenburg S, Hence JM, Buskens E, et al. One-year survival rates in the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial: Is endovascular repair still better? Presented at the Fifty-ninth Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, Jun 17, 2005. Greenhalgh R. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomized controlled trial. Lancet 2005;365:2179-86. Dillavou E, Muluk S, Makaroun M. Improving aneurysm-related outcomes: nationwide benefits of endovascular repair. Presented at the Fifty-ninth Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, Jun 17, 2005. Pew Internet & American Life Project. Health Information Online. May 17, 2005. Available at http://www.pewinternet.org (accessed May 25, 2005). US Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Available at http://www.ahrq. gov/clinic/uspstf05/aaascr/aaars.htm (accessed May 15, 2005). Hertzer NR. Presidential address. Outcome assessment in vascular surgery: results mean everything. J Vasc Surg 1995;21:1-6. American College of Surgeons National Surgical Quality Improvement Program. Using surgical outcomes to improve care and lower costs. Available at https://acsnsqip.org (accessed May 15, 2005).
Submitted Jun 30, 2005; accepted Jul 1, 2005.
Vascular surgery: A specialty in transformation with a bright future Gregorio A. Sicard, MD, St Louis, Mo
I am honored to stand before you as the 59th president of the Society for Vascular Surgery (SVS). It has been a privilege to serve as your president during a time marked by great change and significant progress, both in our field and for our society. Vascular surgery in the year 2005 is at a crossroads. Trends in demographics, workforce, technology, public opinion, and public policy will lead to more accountability and to greater autonomy at the same time. Vascular surgeons, like all physicians, will be increasingly accountable to patients, payers, and policy makers. But we will also enjoy a new level of autonomy to control our destiny as a specialty and to direct the educational paths of the generations who follow us. A new chapter in the history of vascular surgery is about to be written. DEMOGRAPHIC TRENDS AND WORKFORCE CHALLENGES First, let us consider demographics. As a nation, we are growing older. The leading edge of the Baby Boomers, including some in this room, will turn 60 next year. In 2003, one in every eight Americans was over the age of 65.1 By 2030, one in every five of us will qualify for Medicare. Meanwhile, a growing number of Americans of all ages are being diagnosed with diabetes— one every 25 seconds. That translates to more than 1.3 million adults diagnosed in 2003. From 1997 through 2003, the number of new cases of diagnosed diabetes increased by 52%.2 Results from the National Health and Nutrition Examination Survey showed a 14.5% prevalence of peripheral arterial disease in From the Department of Surgery, Division of General Surgery and Section of Vascular Surgery, Washington University School of Medicine. Competition of interest: none. Presented at the Fifty-ninth Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, Jun 16-19, 2005. Reprint requests: Gregorio A. Sicard, MD, FACS, Vice Chairman and Professor, Department of Surgery and Chief, Division of General Surgery and Section of Vascular Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Box 8109, Saint Louis, MO 63110 (e-mail: [email protected]). J Vasc Surg 2005;42:811-5 0741-5214/$30.00 Copyright © 2005 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2005.07.003
patients 70 years or older.3 Every year, about 82,000 diabetic patients have leg, foot, or toe amputations. More than 80% of those amputations are preventable—and every day, vascular surgeons are working to prevent them. The aging population and the diabetes epidemic portend tremendous growth in the need for vascular surgeons—a need that we will find increasingly difficult to meet, unless we make significant changes now. To meet demand projections for the year 2030, we should be graduating 160 vascular surgery residents every year.4 The actual number of graduates falls far short of the need. In 2005, 121 candidates took the vascular surgery certifying examination.5 The numbers are not expected to be very different in 2006. This shortfall in manpower is both chronic and cumulative. Recruiting more medical students and residents to our field is a matter of the highest priority. In recognition of that need, SVS, under the leadership of Dr Julie Freischlag and the Education Council, has awarded scholarships to 63 general surgery residents and 23 medical students, enabling them to attend the Vascular Annual Meeting. Filling the pipeline has been at the top of the SVS agenda for several years. My esteemed predecessor, Dr Richard Green, spoke to this issue from this podium in Anaheim, California last year. He described the number of unfilled positions in the vascular match as an ominous trend.6 In 2003, Dr Tony Sidawy addressed this topic in his capacity as president of the Eastern Vascular Society.7 This year, I am pleased to report, we have reason for optimism. The road to a career in vascular surgery has just become a direct route. In March 2005, the American Board of Medical Specialties approved a primary certificate in vascular surgery, effectively eliminating the requirement for residents to obtain board certification in general surgery before beginning their vascular surgery training. That requirement had been in effect since 1982. The American Board of Surgery describes the primary certificate as a “landmark decision that will alter the landscape of surgical training and certification in the United States.”8 Many of us experienced the months leading up to the approval of the primary certificate as a difficult time. Some of our colleagues voiced concerns that the primary certifi811
812 Sicard
cate was not the best long-term strategy, that it would hinder our movement toward independence and autonomy. Opinions were expressed in strong terms on both sides of this issue. As we seek ways to make common cause, to come together as a community with a shared goal, we would do well to remember the words of the great statesman Thomas Jefferson at his first inaugural address in 1801: “Every difference of opinion is not a difference of principle. We have called by different names brethren of the same principle. We are all republicans, we are all federalists.” Jefferson’s words resonate with us today. Reasonable minds may differ on tactics although our ultimate goals are the same. We must move forward knowing that the forces that unite us are stronger than those that would divide us. The need to provide for our professional progeny is a powerful uniting force. The more flexible and in-depth educational tracks made possible by the primary certificate will serve as a catalyst for growth in the number of vascular surgery trainees. By reducing the time spent in general surgery rotations, the primary certificate will result in a shortened training period for junior residents or medical students who choose vascular surgery early on. It will bring more freedom of career choice to medical students and residents, who will be able to make the vascular surgery choice at various stages of training– during medical school, after several years of initial surgical training, or after completion of full general surgery training. And precious curriculum hours will become available for training in open and endovascular techniques as well as in areas such as nonoperative prevention, diagnosis, and management of vascular disease. The new training models made possible by the primary certificate include a 6-year track (“3 ⫹ 3”) for residents who match in initial surgical training, and a 5-year integrated track for trainees who match during medical school. The Association for Program Directors in Vascular Surgery (APDVS), under the leadership of Dr Jim Seeger, is currently working to define the curricula necessary for both of the new models. Our thanks go to the APDVS for the work they have done to bring us to this point and for the ongoing work involved in this major curriculum redevelopment. THE IMPACT OF ENDOVASCULAR TECHNOLOGIES In addition to contending with the workforce challenges that arise from demographic trends, we must also address the impact of changing surgical technologies— specifically, the impact of endovascular surgery. Carotid endarterectomy (CEA) is still the most frequently performed surgical procedure to prevent stroke in this country. In recent years, carotid artery angioplasty and stenting have emerged as an alternative to CEA. In March of this year, the Centers for Medicare and Medicaid Services expanded Medicare coverage beyond trial settings for carotid angioplasty and carotid artery stenting in symptomatic patients at high risk for endarterectomy.
JOURNAL OF VASCULAR SURGERY October 2005
Treatment for abdominal aortic aneurysm is also undergoing a major shift, perhaps the most significant in its history. In recently published findings, the United Kingdom’s EndoVascular Aneurysm Repair (EVAR) Trial, led by Dr Roger Greenhalgh9 and the Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial, led by Dr Jan Blankensteijn,10 reported that endovascular treatment of abdominal aortic aneurysm is associated with lower rates of 30-day mortality compared with open repair. The DREAM team has recently published the results of their mid-term follow-up, and at 1 and 2 years, they found that the initial 30-day survival advantage of endovascular aneurysm repair over open surgery is no longer evident, apparently due to an excess of nonaneurysm-related cardiovascular mortality.11 In a session to be presented later at this meeting, Dr Roger Greenhalgh will present the 1-year results of the United Kingdom randomized trial.12 In a study presented earlier at this meeting, Dillavou, Muluk, and Makaroun13 discussed the effects of the introduction of endovascular aneurysm repair in the United States. Their conclusions: endovascular aneurysm repair is replacing open surgery without an overall increase in case volume. The proportion of patients treated with endovascular repair increased from about 6% in 2000 to 41% in 2003. At the same time, they found that operative mortality was lower for patients who underwent endovascular repair, replicating the initial United Kingdom and Dutch randomized studies on perioperative mortality. Moreover, patients treated with endovascular repair were discharged from the hospital sooner and were more likely to go home rather than to skilled nursing facilities. There is little doubt that endovascular technologies will fundamentally change the vascular surgery landscape and that we must be prepared to navigate this new terrain. The impact of endovascular technologies on patient outcomes and practice patterns will be lasting and far-reaching. We must provide educational support for endovascular procedures to both practicing and aspiring vascular surgeons. SVS research, under the guidance of Drs Richard Cambria and Craig Kent, has documented that only 31% of 774 practicing vascular surgeons who responded to a survey, received endovascular training in their fellowships (Society for Vascular Surgery Endovascular Training Opportunities Project, unpublished data, Chicago, Ill, 2005). About 60% have taken postfellowship training in endovascular procedures, the majority consisting of 1- to 5-day training programs such as the carotid arteriography and stenting courses initiated by the SVS in December 2004 and repeated in April 2005. The SVS Endovascular Committee, under the leadership of Drs Kim Hodgson and Peter Schneider, is planning to hold additional carotid, aneurysm and peripheral intervention courses in 2005. The Endovascular Training Opportunities Committee is in the process of developing an online endovascular training opportunities clearinghouse to provide information about minifellowships and industry-organized short courses throughout the country.
JOURNAL OF VASCULAR SURGERY Volume 42, Number 4
Sicard 813
GROWING CONSUMER AWARENESS OF VASCULAR SURGERY
PUBLIC POLICY CHANGES THAT SUPPORT VASCULAR SURGERY
The availability of “kinder, gentler” less-invasive endovascular procedures has raised public awareness of vascular surgery. I am happy to report that the era of vascular surgery as the best-kept secret in American medicine is coming to an end. People are starting to know who we are. Consumers, a group that is all-inclusive and not limited to patients, are starting to realize that “it’s not just about their coronary arteries anymore.” This change is happening at the community level, as more hospitals promote vascular wellness and conduct free vascular screenings. Our own American Vascular Association (AVA) has screened more people than ever this year, coordinating the efforts of more than 175 screening centers throughout the country that participated in Vascular Health Month in May 2005. This culminated in the single largest vascular screening the AVA has ever conducted, in which nearly 300 individuals were screened at the Hyatt Regency Chicago on June 14. On behalf of all society members and the SVS board, our thanks go to the 30-plus individuals, including SVS members who volunteered for this screening and to Dr Bill Flinn and screening program administrator Michele Lentz, who have worked very hard to put programs like these together. AVA screening program results consistently show that about 10% of individuals who are screened are referred to their physicians for additional vascular diagnostic testing. All individuals screened are encouraged to take their Vascular Report Card results to their primary care physicians. And all leave with a better understanding of the signs and symptoms of vascular disease. Not only is vascular disease awareness increasing in communities throughout the country, it is increasing in the virtual community as well. We are now reaching thousands of consumers through the patient education section of our Website, VascularWeb. This year, through a partnership with content development specialists at NorthPoint Domain, we have added 35 topics related to vascular conditions, tests, and treatments. Traffic began increasing almost immediately, thanks to citations by major Internet search engines and megasites such as Medline Plus, the online patient health resource provided by the National Library of Medicine and the National Institutes of Health. Since the relaunch of the redesigned VascularWeb in 2004, the number of people using the site has increased steadily and is now at about 3000 per day. Much of this increase is because VascularWeb has become a leading patient education resource for vascular disease. With an estimated 95 million American adults now searching for health information online,14 VascularWeb goes a long way toward increasing awareness and understanding of vascular disease. We appreciate the dedication and diligence of Dr Wayne Johnston and Karen Thomas, who have overseen the development of the patient information section and the relaunch of the entire Website.
Recognition of the impact of vascular disease is happening at the public policy level as well. This year marked the release of new US Preventive Services Task Force recommendations on screening for abdominal aortic aneurysms.15 The task force’s previous recommendations, issued in 1996, did not find evidence to support screening in any population. The new task force report supports screening for men older than 65 years with a history of smoking. We are very pleased about the progress this represents: the new recommendations capture an estimated 70% of the men in this age group. The Preventive Services Task Force recommendations are widely viewed as the gold standard for good quality scientific evidence of effectiveness. Furthermore, the task force recommendations serve as the basis for benefits and coverage policies by many commercial insurers and third-party payers. But the society will not stop here in its efforts to broaden coverage for aneurysm screening. Discussions between the National Aneurysm Alliance and the Agency for Healthcare Research and Quality on this issue are ongoing. Meanwhile, the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act (HR 827/S.390), which was introduced in February 2005 by bipartisan sponsors, would provide an ultrasound screening benefit for at-risk Medicare beneficiaries, including men and women with a positive family history for aneurysms as well as those with established medical risk factors. This legislation is supported by the National Aneurysm Alliance, a broad coalition founded by the SVS that includes medical professional organizations, foundations, patient advocates, and medical technology manufacturers. Our sincere thanks go to Dr Bob Zwolak, who is leading the National Aneurysm Alliance effort to make this happen. OUTCOMES ASSESSMENT IN VASCULAR SURGERY The new higher profile for vascular surgery comes at a time when every sector of American medicine is under the microscope. Patient safety, quality improvement, and outcomes reporting are at the top of everyone’s agenda. Norman Hertzer predicted this trend back in 1994 during his tenure as president of the society. The title of his presidential address said it all: Outcomes Assessment in Vascular Surgery–Results Mean Everything. Dr Hertzer went on to say: If we can distance ourselves for a moment from the daily confusion regarding healthcare and how to finance it, the present debate about quality and cost offers an unmistakable opportunity for us to make vascular surgery better than it ever has been. We just have to get back to the fundamentals. What do we really stand for as surgeons? I think we stand for results. Hospitals should know their own results, and surgeons must be among the first, not the last, to insist on it. For nearly 50 years, [our society] has conducted a proud and principled search for excel-
814 Sicard
lence in vascular surgery. These are uncertain times, but we cannot stop now.16
The trend toward outcomes reporting is being driven by increasing public demands for accountability and the move toward “pay for performance” (P4P) among other factors. The Centers for Medicare and Medicaid Services (CMS) is working toward implementation of P4P in all health-care settings. The first P4P demonstration project for physician groups became operational in April of this year. Meanwhile, nearly 300 hospitals are participating in a CMS demonstration project involving 34 quality measures related to five clinical conditions. These hospitals receive financial incentives for high quality, while institutionspecific performance data are reported on CMS Website. And this is just the beginning. After years of development on many fronts, there is finally a risk-adjusted, outcomes-based program to measure and improve the quality of surgical care—the National Surgical Quality Improvement Program (NSQIP)—sponsored by the American College of Surgeons. NSQIP uses a prospective, peer-controlled, validated database to quantify 30-day, risk-adjusted surgical outcomes, allowing for valid comparison of outcomes among all hospitals in the program. When NSQIP was launched more than 20 years ago, risk-adjusted surgical outcomes and national averages did not exist. In response to Veterans Affairs (VA) institutions coming under intense public scrutiny over the quality of their surgical care, a 1986 congressional law was passed mandating that the VA report its surgical outcomes every year. NSQIP was launched in January 1994 as a program that analyzes surgical data in VA institutions using risk-adjusted methodology to facilitate reporting of their outcomes on an annual basis. Subsequently, from 1991 to 2001, the VA saw a 27% decline in postoperative mortality, a 45% drop in postoperative morbidity, a decline in the median postoperative length of stay from 9 days to 4 days, and improvements in patient satisfaction.17 During the early VA years, NSQIP developed and validated risk-adjustment models, using stepwise forward logistical regression to identify the preoperative risk factors that were predictive of outcomes. The concept is simple: it is based on observed vs expected (O/E) ratios of surgical outcomes. NSQIP suggests thinking of the O/E ratio as a par on a golf course—the score that is expected. An O/E ratio of less than 1 means better-than-expected performance; a ratio of more than 1 indicates an excess of adverse events. The ratios show that risk adjustment has a profound effect in determining a hospital’s true performance. Recognizing the success of the VA-NSQIP program, the American College of Surgeons (ACS) adopted its methodology to collect and analyze data in nonfederal institutions in what was termed the AC-NSQIP. In 1999, a pilot study that included only general surgery and vascular surgery was launched to determine the feasibility of implementing NSQIP outside of the VA. Would the riskadjustment model used in the VA system hold true for the more heterogeneous private sector? After 1 year, the results
JOURNAL OF VASCULAR SURGERY October 2005
were conclusive: the NSQIP system worked. Based on the success of that study, the Agency for Healthcare Research and Quality approved funding for an application by ACS to expand the pilot program to 14 additional medical centers, including the institution where I work in St Louis. In 2002, the Institute of Medicine named NSQIP “the best in the nation” for measuring and reporting surgical quality and outcomes. The SVS and the AVA have begun discussions with ACS about modifying existing NSQIP protocols to permit collection of data on long-term outcomes of CAS compared with CEA. A program is anticipated for rollout in late 2005 or early 2006. We look forward to the implementation of the NSQIP program in vascular surgery. At the same time, we realize that the CMS mandate for CAS facilities to collect outcomes data means that vascular surgeons must have an outcomes data collection now, not next year. To meet this need, I have appointed an AVA/SVS Outcomes Steering Committee that will help guide us as we move forward in this arena. Our first major initiative is the AVA/SVS Vascular Registry, which will permit easy, straightforward collection of both carotid endarterectomy and stent procedure data. In addition to meeting CMS regulations for payment of CAS, this Web-based registry will provide individual surgeons with confidential benchmarking reports and will give hospitals a downloadable database of all carotid procedures performed at their institutions. All SVS members are encouraged to take advantage of the opportunity to participate in the first carotid registry in the market. Wide participation by vascular surgeons in these outcomes initiatives will allow regulatory agencies, researchers, practitioners, and industry to gain insight into the most appropriate indications and patient populations for carotid interventions. The success of the AVA/SVS Registry is important in establishing outcomes mechanisms that should be expanded to other anatomic sectors. Like it or not, we are practicing vascular surgery during a time when innovation is leading to transformation. You have probably heard a saying that is often attributed to the ancient Chinese: “May you live in interesting times.” Although it is usually described as a curse, it may also be viewed as a blessing. Vascular surgery is an exciting specialty with a bright future, despite all the challenges we face today—indeed, partly because of them. We must accept public accountability and embrace professional autonomy, always mindful of the privileges and responsibilities inherent in both. And we must move forward as one community with a single voice and a shared vision for the benefit of our fellow vascular surgeons, and above all, for the benefit of our patients. I thank all of you for your support. It has been an honor and privilege to serve as your president. I will never forget this extraordinary experience. The author would like to thank Karen Thomas and Debi Swap for assistance in the preparation and review of this manuscript.
JOURNAL OF VASCULAR SURGERY Volume 42, Number 4
Sicard 815
REFERENCES 1. US Census Bureau, Decennial Census and Projections. 2. National Center for Chronic Disease Prevention and Health Promotion, National Diabetes Surveillance System. Annual number (in thousands) of new cases of diagnosed diabetes among adults aged 18-79 years, United States, 1997-2003. Available at www.cdc.gov (accessed May 15, 2005). 3. Selvin E. Prevalence of and risk factors for peripheral arterial disease in the United States. Circulation 2004;110:738-43. 4. Stanley JC. Personal communication quoted in Presidential address. Generations apart— bridging the generational divide in vascular surgery by Sidawy, AN. J Vasc Surg 2003;38:1147-53. 5. Association of Program Directors in Vascular Surgery. June 2004 minutes. Available at www.vascularweb.org. Accessed May 15, 2005. 6. Green, RM. Presidential address: a live dog is better than a dead lion. J Vasc Surg 2004;40:583-8 7. Sidawy AN. Presidential address: generations apart— bridging the generational divide in vascular surgery. J Vasc Surg 2003:38:1147-53. 8. Press release: ABS receives approval for primary certificate in vascular surgery. American Board of Surgery, March 17, 2005, Available at http://home.absurgery.org/default.jsp?newsvsprimarycert (accessed May 15, 2005). 9. Greenhalgh, R. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1): 30-day operative mortality results: randomized controlled trial. Lancet 2004;364:843-8. 10. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeck MR, Balm R, et al; Dutch Randomized Endovascular Aneurysm Manage-
11.
12.
13.
14.
15.
16. 17.
ment (DREAM) Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351:1607-18. De Jong S, Prinssen M, van der Ham A, van Sterkenburg S, Hence JM, Buskens E, et al. One-year survival rates in the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial: Is endovascular repair still better? Presented at the Fifty-ninth Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, Jun 17, 2005. Greenhalgh R. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomized controlled trial. Lancet 2005;365:2179-86. Dillavou E, Muluk S, Makaroun M. Improving aneurysm-related outcomes: nationwide benefits of endovascular repair. Presented at the Fifty-ninth Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, Jun 17, 2005. Pew Internet & American Life Project. Health Information Online. May 17, 2005. Available at http://www.pewinternet.org (accessed May 25, 2005). US Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Available at http://www.ahrq. gov/clinic/uspstf05/aaascr/aaars.htm (accessed May 15, 2005). Hertzer NR. Presidential address. Outcome assessment in vascular surgery: results mean everything. J Vasc Surg 1995;21:1-6. American College of Surgeons National Surgical Quality Improvement Program. Using surgical outcomes to improve care and lower costs. Available at https://acsnsqip.org (accessed May 15, 2005).
Submitted Jun 30, 2005; accepted Jul 1, 2005.