Vascular Specialist, September 2020

16–17 #MEDBIKINI Letter to the editor Gaining a voice—and delivering a message

Featured in this issue:

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20192020 408 positions to be filled, held by 277 unique members across 29 councils and committees

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GUEST EDITORIAL LOOK WITHIN DURING TURBULENT TIMES

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Vol.16 No.9 SEPTEMBER 2020

20202021 451 positions to be filled, held by 630 unique members across 30 councils and committees

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COMMITTEES PRESIDENT DALMAN DETAILS CHANGES

COMMUNITY SERVICES VASCULAR SURGEON TRIO RECOGNIZED WITH AWARDS

They are the sort of cuts the Society for Vascular Surgery (SVS) says will have a massive impact on vascular surgery practices for years to come. The recently released Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule (PFS) Proposed Rule decreases vascular surgeon work relative value unit (W RVU) and practice expense RVU (PE RVU) by 2 and 5%, respectively, resulting in an estimated reduction of 7% in the total payment for the services vascular surgeons provide.

SPECIAL REPORT

S Action plan: How to help halt sharp cuts to Medicare

BY MARGARET C. TRACCI, MD, AND MATTHEW J. SIDEMAN, MD

VS MEMBERS MAY HAVE noticed a recent flurry of attention around the proposed cuts, changes currently scheduled to take effect Jan. 1, 2021.

The stakes are high, demanding we unpack in some detail what these cuts mean to surgeons in practice and what you can do to help support our community in order to work to prevent this looming catastrophe.

On Aug. 3, CMS released the 2021 Medicare PFS Proposed Rule which lays out a series of changes that in aggregate will result in the predicted 7% cut in reimbursement for vascular services administered to Medicare patients.

What will this look like on Jan. 1?

The conversion factor (CF), or dollar amount per work RVU, will drop nearly 11%—by $3.83—from this year’s CF of $36.09 to $32.26. Pause for a moment to reflect on the fact that this is less in actual, non-inflation adjusted dollars than we were paid back in 1998. In fact, had 1998 payment levels kept up with inflation over the past 27 years, the CF for 2021

should be $57 per RVU, representing an inflation-adjusted loss of more than 43%. This amounts to an acute collapse layered on top of a long-term devaluation of physician services that has gone on—essentially unchecked— for 27 years.

How did this happen? The failure to adjust reimbursement to keep pace with inflation is a long-term problem but changes to Evaluation and Management (E/M) coding and reimbursement are driving the sharp drop for 2021. This began with a CMS proposed initiative for 2019 to collapse the new and established outpatient office visit levels into one code each, with add-on codes for complexity. The goal was to reduce documentation burden on physicians and simplify the coding system. This proposal was universally rejected by the house of medicine. The American Medical Association (AMA) then embarked on an enormous undertaking to rewrite the code set for outpatient office visits. The new code set keeps the level structure essentially intact but removes the requirement for history See page 4–5

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GUEST EDITORIAL

Look within yourself during turbulent times

BY BHAGWAN SATIANI, MD

THERE ARE MANY STRATEGIES PEOPLE HAVE for surviving turbulent times.

At times like these, I am often asked for advice by younger vascular surgeons, trainees or colleagues.

Typically, I respond with a question: Are you following your personal mission statement?

Most often I get a quizzical look in response.

I ask: Do you have a personal mission statement?

Usually the response is “no.”

Should we all have a personal mission statement?

Yes, of course. But permit me to interject a metaphor here before explaining the importance of personal mission statements, particularly in turbulent times.

We are all familiar with organizational mission statements. These can be short or long; conventional or progressive; complex or simple; concrete or abstract. Some are easy to forget, while others truly stand out.

Like a good logo, practical organizational mission statements are recognized not only by members of the organization, but by individuals outside the organization as well. See if you can identify which organizations these mission statements represent.

“We fulfill our dreams through the experience of motorcycling.”

“Spread ideas.”

“To connect the world’s professionals to make them more productive and successful.”

“To organize the world’s information and make it universally accessible and useful.”

These of course are the mission statements of Harley Davidson, TED, LinkedIn and Google.

We need to write personal mission statements for the same reason organizations do. They help guide us in turbulent times. They help us to prioritize our work, our efforts and our lives. They define us and help us to plot a course for how we want to be known to ourselves and be known by others. Unlike organizational mission

VASCULAR SPECIALIST Medical Editor Malachi Sheahan III, MD Associate Medical Editors Bernadette Aulivola, MD, O. William Brown, MD, Elliot L. Chaikof, MD, PhD, Carlo Dall’Olmo, MD, Alan M. Dietzek, MD, RPVI, FACS, Professor Hans-Henning Eckstein, MD, John F. Eidt, MD, Robert Fitridge, MD, Dennis R. Gable, MD, Linda Harris, MD, Krishna Jain, MD, Larry Kraiss, MD, Joann Lohr, MD, James McKinsey, MD, Joseph Mills, MD, Erica L. Mitchell, MD, MEd, FACS, Leila Mureebe, MD, Frank Pomposelli, MD, David Rigberg, MD, Clifford Sales, MD, Bhagwan Satiani, MD, Larry Scher, MD, Marc Schermerhorn, MD, Murray L. Shames, MD, Niten Singh, MD, Frank J. Veith, MD, Robert Eugene Zierler, MD Resident/Fellow Editor Laura Drudi, MD Executive Director SVS Kenneth M. Slaw, PhD Director of Membership, Marketing and Communications Angela Taylor Managing Editor SVS Beth Bales

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statements, which may be quite public, personal mission statements can remain just that—personal.

I bring this up now, because in times of turmoil we rely on tools such as personal mission statements to remain on track or to stay the course. We rely on our personal missions to help us remain true to ourselves and those around us. Are we treating people with dignity and fairness, caring for our loved ones, and are we tolerant of people who hold differing views?

We also can use our personal mission statements to evaluate our performance, judge whether we are faithful to our beliefs, or whether we need to adjust our path.

Reflection is the key to professional and personal growth, and the bottom-line is having your own personal mission statement makes reflection easier.

Whether you choose a personal mission or vision statement is a matter of personal choice. Do whatever feels right to you. Remember, you can be as personal as you like since most of us will rarely broadcast our personal mission statements to the rest of the world the way organizations broadcast theirs.

How do you start? Think about those foundational values you have carried throughout life. These values may be rooted in family, religion, education, inspirational reading, etc. These are core values which define you or define how you want to be known or remembered. It’s OK to ask others who know you best for feedback or help.

Once you identify these foundational values, jot them down. Some people use post-its and leave them where they see them every day. But then edit them often, until you feel they represent you in a holistic way. From this exercise will come a personal mission statement, one that represents your true north.

Can you change your mission statement? Sure, your mission statement may evolve. But if well designed and well thought out, it’s not likely to change very often. My personal mission statement was written over 20 years ago, at a time when I was forced to alter my career path.

Since that time, it has sustained me and I have not found

a reason to change it. I reflect upon my personal mission statement whenever my core beliefs are challenged, or when I have to make difficult decisions.

I have certainly not succeeded in being loyal to my statement 100% of the time. But the written word does prod my conscience Bhagwan Satiani when I am challenged or tempted to deviate from it. My personal mission statement does not follow a purist model. It is somewhat long and multifaceted, but it seems to cover most aspects of my life.

Rarely have I shared my personal mission statement with others. But if it will help you to develop yours, why not? Just do me a favor: Please don’t post it to social media!

“To remember my Creator at all times and know that I will have to answer for all my actions and deeds in this life.

To recognize that my potential for personal growth is infinite.

To lead my life so my family can remember me as an honest human being, who was trustworthy in marriage, who cared for them deeply, and left a legacy of love and core values to be passed on.

I will value loyalty, treat friends and co-workers with dignity, be tolerant, and strive to remain humble.

To be a model of professional integrity and have my patients say that I cared.

To try and maintain a sense of humor, know that perpetual happiness in life was not guaranteed at birth, and remember that the bad days shall pass.”

The hardest part about developing a personal mission statement is getting started. So… Just Do ItTM. It is not too late.

P.S. My personal mission statement mentions nothing about following the rules of golf.

Bhagwan Satiani is professor of clinical surgery in the division of vascular surgery, the department of surgery, in the Ohio State College of Medicine at Ohio State University in Columbus.

He is an associate medical editor of Vascular Specialist.

Published by BIBA Publishing, which is a subsidiary of BIBA Medical Ltd.

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SEPTEMBER 2020

LOWER-EXTREMITY CARE

‘Rapid reduction’ in amputations follows opening of multidisciplinary limb preservation service

BY BRYAN KAY

A multidisciplinary limb preservation service under the leadership of vascular surgery in a level one trauma center was associated with an immediate and rapid decline in the number of amputations performed for all indications, including trauma, acute limb ischemia (ALI), chronic limb-threatening ischemia (CLTI) and revision—supporting their implementation in spite of the resources they might demand.

THOSE WERE THE MAIN FINDINGS of a research team from the division of vascular surgery at University of Washington (UW) in Seattle after a retrospective review of all amputations performed at UW Medicine’s Harborview Medical Center over a 10-year period.

The results were recently published in the Annals of Vascular Surgery.

The investigators aimed to characterize trends of major amputations performed for all indications at a level one trauma

center. Multidisciplinary services have been shown by multiple groups to be a cost-effective approach to improving limb salvage and wound healing rates in patients with CLTI and diabetic foot ulcers but their impact on amputations performed for non-vascular causes remains unknown, noted first-named author Jake Hemingway, a vascular surgery resident at UW, et al.

The Harborview multidisciplinary service, which also involves orthopedic surgery, plastic surgery, rehabilitation medicine,

PORTRAIT study: Disproportionately more women are affected by depression when pursuing specialty PAD care

BY BRYAN KAY

A DISPROPORTIONATELY HIGHER PERCENTAGE of women are affected by depressive symptoms when they seek specialty care for new or worsening peripheral arterial disease (PAD) symptoms, with rates almost twice that observed in men, according to a new study published in the Journal of the American Heart Association (JAHA).

Qurat‐ul‐ain Jelani, MD, of the Vascular Medicine Outcomes Program at Yale University School of Medicine in New Haven, Connecticut, et al had hypothesized that women with PAD have a higher burden of depressive symptoms compared with men, both at baseline and in the year following a new or worsening diagnosis, and that depressive symptoms would be associated with worse health status outcomes over time.

Though depressive symptoms are known to be associated with a more dramatic annual decline in functional performance, reduced walking distance and less quality‐of‐life benefit after revascularization, it is unclear to what extent depressive symptoms may be associated with a worse health status recovery profile in patients with PAD, and whether women are affected differently than men, the authors assert.

Known as the PORTRAIT (Patient‐centered outcomes related to treatment practices in peripheral artery disease: Investigating trajectories) registry—which was partially SEPTEMBER 2020

podiatry, prosthetics, wound care and infectious disease, was opened in 2014.

Amputations from between January 2009 and December 2018 were studied. Patients were divided into two cohorts: the pre(2009–2013) and post-service eras (2014– 2018). The results demonstrated that of the 609 major amputations performed, 490 took place prior to the multidisciplinary limb preservation service’s creation, with just 119 coming afterward—representing a 76% reduction. An increasing number was observed each year prior to the service.

Below-the-knee amputation was the most common in both cohorts, but a much higher proportion pre-service were at the through-knee level compared with the postservice era (27% vs. 7%). Practice patterns showed a single surgeon performed more than 50% of all amputations during the study period but when this practitioner— an orthopedic surgeon—was excluded the data showed the maintenance of a 63.5% reduction in the number of major amputations following the coming of the multidisciplinary limb preservation service. Similarly, most amputations were performed by orthopedic surgery during the study period (68% pre- vs. 71% post-service), largely owing to the single surgeon, the researchers point out. Upon this individual’s elimination, vascular surgery emerges as the specialty most

commonly performing amputations.

Previous research has shown an association between a multidisciplinary service and improved limb salvage and wound healing, but their impact on amputations for indications like trauma or ALI is unknown, they write. Hemingway et al say their study is the first review to probe the affect on amputations within a level one trauma center setting, and showed steep falls for all indications.

Notably, there was a drastic reduction in the number carried out for trauma (95%) after the service went into operation.

“The utilization of aggressive endovascular and open revascularization techniques, along with podiatric surgery involvement, has led to a decrease in major amputations,” they write. “In addition, vascular surgeons in our institution are more likely to perform definitive major amputations when appropriate...”

The investigators conclude that a multidisciplinary limb preservation service’s value extends beyond vascular disease alone. “The drastic reductions seen in the number of amputations performed for a variety of indications, including trauma and diabetic foot infections, further validates the use of [such a service].”

SOURCE: DOI.ORG/10.1016/J. AVSG.2020.08.001

funded through a Patient‐Centered Outcomes Research not differ by sex. Depressive symptoms explained 19% of Institute (PCORI) award and an unrestricted grant by the association between sex differences in one‐year PAQ Gore—the investigation took the form of a prospective, summary scores, the authors noted. observational study designed to address gaps in knowledge “Having a depressed mood has potentially major about the quality of care and health status outcomes of implications for the success of patients’ PAD rehabilitation patients with PAD. process and their PAD functioning over time,” they write.

Some 1,243 patients with new or worsening PAD “Depressive symptoms marked a suboptimal PAD recovery symptoms were enrolled in the study between June pathway, with differences as large as 16 to 21 points 2011 and December 2015, and were derived on the PAQ summary scale one year following from 16 vascular specialty clinics—10 active PAD treatment, differences that are in the United States, five in the almost twice the minimally clinically Netherlands and one in Australia.

PAD and depression: important difference, as defined from Depressive symptoms were 1,243 patients; 16 vascular the patients’ perspective.” assessed at baseline and three specialty clinics—10 in The researchers noted limitations months using the eight‐item the United States, 5 in to their investigation, including the Patient Health Questionnaire the Netherlands and 1 in fact the cohort studied included (PHQ-8). A score ≥10 indicates Australia. More women patients seen at vascular specialty clinically-relevant depressive than men (21.1% vs. clinics—therefore, they comment, symptoms.

12.9%; p<0.001) presented potentially unrepresentative of the Meanwhile, disease‐specific and with severe depressive general PAD population who may generic health status were measured symptoms not have access to specialty clinics. by the Peripheral Artery Questionnaire Concluding, they cite a set of (PAQ) and EQ‐5D Visual Analogue findings that indicate the burden Scale at baseline and three, six and 12 of depressive symptoms in PAD months. as being substantial, with affected The mean age of the patients patients, particularly women, having was 67.6 years, with 38% of them a “distinctly worse PAD‐specific women (n=470). A total of 199 health status” after specialty care. patients (16.0%) had moderate– The authors say there is a need to severe depressive (PHQ‐8 ≥10) explore mechanisms of this increased symptoms on presentation. More vulnerability in women. women than men (21.1% vs. 12.9%; They add: “Depressive symptoms p<0.001) presented with severe in older, chronic disease populations, depressive symptoms. In the adjusted such as PAD, should be a continuous model, patients with depressive focus of its multidisciplinary symptoms had worse health status treatment so as to ensure quality at each time point (all p<0.0001).

PAD care and optimize outcomes.”

Results were similar for EQ‐5D scores. The magnitude in one‐year SOURCE: DOI.ORG/10.1161/ change in health status scores did JAHA.119.014583

21.1 VS 12.9 %

%

vascularspecialistonline.com • 3

CMS

Action plan: How to help halt sharp cuts to Medicare Continued from page 1

and physical “bullets” to determine visit level. The outpatient office visit level is now determined simply by time or medical decision making (MDM).

CONSEQUENCES The original CMS proposal for consolidation of codes maintained total expenditures and was projected to have relatively little impact on vascular surgery payments. The AMA’s RVU Update Committee (the RUC) then proposed large increases in RVUs for the revised E/M code set that emerged from the AMA CPT panel. The unspoken consequence, however, is that under budget neutrality requirements, those increases must be offset by decreases elsewhere—in this case, through reducing the CF. Those decreases will severely impact surgical procedures as well as radiology, pathology and other services not associated with E/M services.

The precise impact on individual vascular surgery practices may vary significantly based on the volume of E/M services provided, case mix and site of service.

For those who hope that reduced payment for surgical services may be a mere oversight, another aspect of the rule underscores the concern that regulators continue to believe Medicare is actually overpaying for surgical services.

Despite strong feedback from the surgical community when the outline of this policy was first introduced a year ago, CMS has elected not to include the increased value for E/M services in the valuation of services that surgeons provide within the 10- and 90-day global periods associated with an operation. In fact, the agency volunteered—when including the increase in payment for maternity care—the opinion that “unlike the 10- and 90-day global surgical service codes … we have never expressed concerns as to the 4 • Vascular Specialist

accuracy of the values of the maternity packages.” They note the agency’s prior attempt to reduce payment for the global periods by “unbundling” these services, and reference ongoing activity to investigate whether surgeons are actually providing the postoperative care we are paid for in this period.

TAKING ACTION So, what can vascular surgeons do to oppose these cuts, stand up for the value of the care we provide, and ensure that we have the resources to continue to do

Margaret C. Tracci

Matthew J. Sideman

so? The SVS will provide a strong, detailed response to each of the policy points in this proposed rule by the deadline of Oct. 3, 2020. In addition, the SVS has launched its own advocacy effort, marshaling policy and advocacy staff and SVS members to reach out to CMS and Congress on your behalf. In an unprecedented partnership, the SVS has also joined the Surgical Care Coalition, a group formed in response to this challenge that is making a substantial investment to support policy polling, research, and a forceful advocacy campaign to educate surgeons, policymakers, and legislators about the urgency of this matter. Please also take a moment to visit the Surgical Care Coalition’s website, which is located at www.surgicalcare.org.

However, it is clear that this year’s situation requires the full strength of our membership to avert a severe blow on Jan. 1 through advocating for Congressional intervention. In this case, the “ask” is that Congress act to waive the requirement for budget neutrality, which would avert cuts to surgical services while continuing to support the desired increases in payment for E/M services, primary care,

telemedicine and others. How can you support this effort? There are a number of important immediate steps that you and your partners can take.

Had 1998 payment levels kept up with inflation over the past 27 years, the CF for 2021 should be $57 per RVU, representing an inflation-adjusted loss of more than 43%

CONGRESS Let your Congressional delegation know what you think on behalf of your patients, practice and profession. The SVS’s easyto-use Voter Voice platform allows you to quickly identify your legislators and utilize pre-drafted email letters to reach out. Take the time to personalize these with a description of the longitudinal care you provide a medically complex, often socioeconomically challenged population, or how the cuts would impact your practice’s ability to maintain access.

Use Voter Voice’s legislator identification function to find your own representatives and request in-person or (more likely this year, and more easily worked into a surgeon’s schedule) virtual visits with your senators or representatives. SVS staff will gladly provide preparation, supporting material, or virtual support for these meetings and can also help you arrange them. Work to become an advisor to your legislator and his or her staff on matters that impact vascular surgery.

Volunteer to work with SVS and Surgical Care Coalition staff to write and place letters and op-ed articles in your local paper or other key, highprofile publications that will reach critical legislators and policymakers.

Become an SVS Ambassador and help us raise the profile of this campaign on platforms from Twitter and Instagram to Facebook, SVSConnect and LinkedIn. Give to the SVS Political Action Committee (PAC), which supports events and other meetings with legislators.

This year has brought unprecedented challenges. Please help the SVS work to prevent an additional blow in 2021. Take the time to do one or more of the things listed above and encourage your partners and colleagues to do the same.

Margaret C. Tracci is chair of the SVS Government Relations Committee.

Matthew J. Sideman is chair of SVS Policy and Advocacy Council

SEPTEMBER 2020

MATTHEW COFFRON/AMERICAN COLLEGE OF SURGEONS

SPECIAL REPORT

Join the fight: The useful job of lobbying members of Congress

BY THE SVS GOVERNMENT RELATIONS COMMITTEE

Society for Vascular Surgery (SVS) members can help in the fight against announced reimbursement reductions included in the calendar year 2021 Medicare Physician Fee Schedule (PFS). One of the best ways is by lobbying your local member of Congress.

M

embers may simply send pre-written emails, found on the SVS advocacy page, to their members of Congress. Of course, surgeons can also compose their own messages.

As anticipated, the conversion factor in the proposed fee schedule, released Aug. 3, includes reductions for vascular surgery. These cuts are a result of a budget neutrality adjustment that accounts for increases in relative value units (RVUs) for certain services, as required by federal law. In this case, these are new and established patient office visit codes for Evaluation and Management (E/M) services.

Under the proposed rule, the Centers for Medicare and Medicaid Services (CMS) would set the PFS conversion factor for 2021 at $32.26—a reduction of $3.83, or almost 11%—from 2020’s conversion factor of $36.09. The statutory physician payment update for 2021 is 0% as provided under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

The drastic 11% reduction in the conversion factor is necessitated by proposed additional spending of $10.2 billion. The American Medical Association (AMA) RUC’s recommendations to increase the value of E/M office visits account for only half of this additional spending and half of the reduction. The remaining spending increases and resulting conversion factor reduction is attributed

Medicare reimbursement fails to adequately cover cost of care after open bypass surgery among most CLTI patients

BY BRYAN KAY

For most patients with critical limb-threatening ischemia (CLTI), Medicare reimbursement for lower extremity bypass surgery does not adequately account for case complexity in the compensation of vascular surgeons, a study published in the September issue of the Journal of Vascular Surgery finds.

THE RESEARCH WAS CARRIED OUT by senior author Richard J. Powell, MD, the section chief of vascular surgery at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues.

SEPTEMBER 2020

to the CMS proposal to increase valuation for several services, including end-stage renal disease, initial preventive physical exam and annual wellness visits, and emergency department visits and increased utilization assumptions about the new E/M office visit primary care add-on code.

CMS did not propose changes to the valuation of 10- and 90-day global surgical packages to reflect

SVS is urging Congress to enact legislation waiving Medicare's budget neutrality requirements for the E/M code adjustments and incorporating the E/M office visit increases into global surgical packages to mitigate the projected payment cuts.

They argued in favor of a re-evaluation of Medicare’s diagnosis- and Current Procedural Terminology (CPT)-based reimbursement categories.

In a retrospective examination of infrainguinal bypass procedures performed at Dartmouth-Hitchcock Medical Center from 2011 to 2017, 68 patients with hemodynamically confirmed CLTI were analyzed.

Patients were identified by assignment to a diagnosis-related group based on the level of complexity—other vascular procedure with major complication/comorbidity, with complication/comorbidity, and without complication/comorbidity.

Additional clinical data were incorporated from the Vascular Quality Initiative (VQI) clinical registry, the researchers explained. For non-Medicare patients, reimbursement was indexed to Medicare rates. Contribution margins (reimbursement minus cost) from technical and professional services were analyzed for each patient and summarized by diagnosis.

The mean age of the cohort was 66.1 years, with 69% male, 49% diabetic, 44% current smokers and 4% on dialysis. In general, total infrainguinal bypass cost was adequately compensated for patients assigned only the most complex diagnosis (median: $2,490; interquartile range [IQR]: -$1,621 to $10,080).

But in the majority of patients with less complex diagnoses—with complication/

changes made to values for the office E/M visit codes.

The cumulative effect of these proposals is a projected 7% overall reduction to vascular and general surgeons’ Medicare payments for 2021.

In the area of telehealth, the proposed rule expands the list of telehealth services that will remain permanent beyond the COVID-19 public health emergency (PHE) and keeps additional services—including certain emergency department visits—on the Medicare telehealth list until the end of the calendar year in which the PHE ends.

CMS also reviewed the valuation of several codes used by vascular surgeons. For example, CMS disagreed with the RUC recommendations and proposed lower work RVUs for toe amputation (CPT codes 28820 and 28825).

CMS agreed with the RUC recommended work RVUs for venography (CPT codes 75820 and 75822).

CMS proposed changes to the Merit-based Incentive Payment System (MIPS), including postponing implementation of the Value Pathways participation option to allow for additional stakeholder feedback while proposing a new MIPS pathway for participants in alternative payment models. CMS also proposed lowering the weight of the Quality Category performance score from 45 to 40% of the MIPS final score, and increasing the weight of the Cost Performance Category from 15% of the MIPS final score to 20%. CMS would also increase the number of MIPS points needed to avoid a payment penalty.

SVS is urging Congress to enact legislation waiving Medicare’s budget neutrality requirements for the E/M code adjustments and incorporating the E/M office visit increases into global surgical packages to mitigate the projected payment cuts.

SVS members are urged to visit the SVS advocacy page at vsweb.org/VoterVoice and send a pre-written email on this issue to your representatives in Congress. The Society will provide comments on the proposed rule prior to the Oct. 5 deadline.

comorbidity (median: -$3,100; IQR: cost for all three groups. “This finding -$8,499 to $109) and without complication may not be surprising, given recent comorbidity (median: -$4,902; IQR: -$9,259 studies showing that vascular surgeon to $1,059)—reimbursement did not cover reimbursement has decreased significantly the cost of care, the investigators explain. in the last decade,” the authors continue.

Both technical costs and professional costs “This finding is strongly indicative of the varied significantly with the complexity need for a reevaluation of the professional of diagnosis. Total reimbursement for component of Medicare reimbursement inpatient hospitalizations is composed for lower extremity bypass for patients of the professional reimbursement for with CLTI. It is unclear what impact this the vascular surgeon performing the negative financial picture has had procedure and the technical on the decreasing use of lower reimbursement for the extremity bypass in Medicare Bypass compensation hospitalization costs. beneficiaries to treat (median) “Although patients with CLTI.” Major complication: reimbursement from They concede a number $2,490; technical services increased of limitations to the Complication: alongside increasing study. An intrinsic one, -$3,100; complexity of diagnosis, the researchers admit, No complication: there was insignificant is their characterization -$4,902 variation in professional of lower extremity bypass reimbursement as [diagnosis] reimbursement at a single complexity increased,” the authors academic, tertiary care center. Another write. “On multivariable modeling, longer was the decision to index reimbursement length of stay (-$2,547 per additional day) for non-Medicare patients to Medicare and preoperative dialysis (-$5,555) were rates, they add. In conclusion, the authors significantly associated with negative write: “Professional service payments do margins.” not cover professional service costs for The investigators noted another key the majority of CLTI surgical procedures finding: Professional contribution margins performed at our tertiary medical center, were negative for all three diagnosis and this discrepancy was especially groups. By way of contrast, technical applicable for the least complex cases.” reimbursement and cost increased alongside diagnosis complexity, and SOURCE: DOI.ORG/10.1016/J. technical reimbursement exceeded the JVS.2020.01.062 vascularspecialistonline.com • 5

GOVERNANCE

SVS Appointments Committee confidential

BY RONALD L. DALMAN, MD

The success of the Society for Vascular Surgery (SVS) in its many missions is driven by the passion and commitment of its members.

Each year, the Appointments Committee seeks to fill committee and council positions with member volunteers who have demonstrated interest and ability in specific topics relevant to the work of the Society. All member categories are eligible to apply.

The overall appointments process spans the first six months of the calendar year. SVS Governance Office staff, liaisons from each council and committee, and the Appointments Committee itself— which is comprised of the president, president-elect and vice president, and chaired by the president-elect—all contribute to the process.

20192020

UP

2020 SVS appointments by the numbers

408 positions to be filled, held by 277 unique members across 29 councils and committees

DOWN MEMBERS ARE ENCOURAGED to apply via a web application page specifically developed for the SVS. Each volunteer is required to provide a statement of interest and disclose potential conflicts of commitment with their applications. Only completed applications are considered for appointment. The actual work of the Appointments Committee encompasses approximately 10 hours of teleconferences and file reviews, including the evaluations of existing members from council and committee leadership, and appointing new leadership based on term expiration or member request for removal.

The workflow proceeds council by council, reviewing the committees within respective councils, affirming term expirations of members, and appointing new members from the list of existing members and volunteers. During this process, the size of each respective committee is weighed 6 • Vascular Specialist

their annual committee assignments, the goal of the Appointments Committee is to create—to the greatest extent possible— capable, diverse and representative work groups to meet the overall needs of the SVS. In addition to the candidate’s statement of interest, the evaluation process is informed by liaison and chair evaluations regarding the performance and participation of existing committee members who desire to continue in their assignments. A full term of membership is generally considered to be three years for most positions, with the expectation that members are evaluated for re-appointment annually based on performance metrics. All evaluation information is kept confidential within the Appointments Committee process.

Once the initial appointments are completed, the Appointments Committee reviews all at a higher level to ensure that no single member is burdened with too many (no more than three councils and/ or committees each), and that committee composition reflects SVS diversity, equity and inclusion goals.

Once this final review is complete, appointment notification, term expiration, and non-appointed member letters are completed and sent. In a typical year, these activities conclude in early June to allow

Timeline

20202021 451 positions to be filled, held by 630 unique members across 30 councils and committees

against their respective responsibilities, function and workflow.

As a rule, members are appointed only to committees for which they have specifically volunteered. Following a reorganization process completed a few years ago, council chairs and vice chairs are chosen from the leadership of their constituent committees rather than the membership at large. In selecting committee members, the Appointments Committee takes into consideration multiple variables including domain expertise, relevancy of the candidate statement to the work of the specified committee, practice type, geographic location, career stage, ethnicity, gender, and existing commitments to other SVS initiatives and work groups. For assistance in this latter assessment, the SVS keeps a master file of member volunteers and their current and prior SVS activities. In making

DECEMBER Staff preparation for council and committee evaluation time. Staff update of council and committee charges as well as the scope of work for the upcoming year (June– May) JANUARY–MID-FEBRUARY Committee chair evaluation of current members. Council chair evaluation of constituent committee chairs MID-FEBRUARY–END OF MARCH Call for volunteers from the membership body. Statement of interest. Demographics and practice information. And conflict of commitment disclosure MID-APRIL–EARLY MAY Appointments Committee meetings (virtual, in the form of conference calls). New or reappointment of chairs. New or re-appointment of vice-chairs (vicechairs typically ascend to the chair, pending evaluation). In addition, new or re-appointment of the committee members EARLY JUNE Appointment letters sent out during the week of June 6, 2020 EARLY JULY End of term as well as nonappointed e-mails delivered the week of July 6, 2020

new committee members to join their new committees at the Vascular Annual Meeting (VAM). The 2020 timeline was extended somewhat due to disruptions related to COVID-19.

Improvements undertaken in the last four years include requiring more specific interest statements from candidate volunteers, leveraging chair and staff evaluations to judge performance and the fit of existing appointments, and enhanced attention to SVS diversity and inclusion metrics in the appointments process.

Work is ongoing to more completely characterize the demographic makeup of existing committees to facilitate meeting diversity and inclusivity goals. That, in combination with requesting more detail from new applicants, will best serve the overall interests of the SVS in future Appointments Committee activities.

Given that the number of volunteers exceeds that of available positions, interested applicants should pay specific attention to how their candidate statement addresses their strengths vis-à-vis the perceived needs of desired committees.

Similarly, to improve the impact of their statements, applicants may want to reach out to specific staff liaisons or chairs to gain additional insight into the work of desired committees. Re-applications in future years are not biased by prior

The title of this summary notwithstanding, the work of the Appointments Committee should not be cloaked in secrecy application status, so interested applicants should continue to apply in future years to a variety of positions to gain insight into the process as their interests and expertise develop. Elsa Hall, SVS staff liaison for the Appointments Committee, is available throughout the year to answer inquiries regarding opportunities, process and deadlines at ehall@vascularsociety.org.

The SVS is grateful to its hundreds of member volunteers who enable the work of the Society. The title of this summary notwithstanding, the work of the Appointments Committee should not be cloaked in secrecy. Our goal is to make the process as transparent, inclusive and equitable as possible. Great progress has been made towards these goals, but there still is much more to do. On behalf of the 2020 Appointments Committee and its staff liaisons, we thank you for your continued participation in—and support of—the annual appointments process.

Ronald L. Dalman is SVS president.

SEPTEMBER 2020

VA SYSTEM

VA delivers high quality services for veterans

BY GALE TANG, MD, AND JASON JOHANNING, MD

Vascular surgery in the Veterans Health Administration has always been a robust service, developing into a mature specialty around the time of the Vietnam conflict.

Over the years, many have called into question the quality of care within the Veterans Affairs (VA) system, even while multiple studies have recognized equivalent or better care than in the general community. And this is despite the high level of chronic conditions experienced by our veteran population.1,2 This review highlights the history of high-quality vascular surgery services delivered for common procedures in the VA system.

Peripheral arterial disease We can assess the veteran with regards to comorbidities, medical management and outcomes compared to the community. In a comprehensive review of the epidemiology of peripheral arterial disease (PAD) in the VA, Willey et al found that compared with other non-VA studies, VA PAD patients were older (mean age: 70 years), predominantly white (68%), and male (98%), which reflects

8 • Vascular Specialist

the general demographics of the veteran population.3 In the studied VA cohort, 1.3% developed chronic limbthreatening ischemia (CLTI) at one year, increasing to 2.5% at a median follow-up of 3.8 years. This is markedly higher than Medicare patients, for which the mean annual incidence of CLTI was 0.35%.4 For medical therapy, overall statin use was present in 60.8% of patients, with a high-intensity statin rate of 34.9% within the VA setting, comparing favorably to the National Health and Nutrition Examination Survey with a rate of 30.5%.

Revascularization The overall rate of revascularization in the VA was low at less than 3%, while community studies suggest an exponential increase in the use of endovascular revascularization, especially endovascular stenting.5 This raises concerns about underutilization of this therapy in the VA setting; but despite the low rate of revascularization in this cohort, the overall amputation rate was 1.1%. Comparing community amputation rates is difficult due to methodology issues regarding major vs. minor amputations.

Carotid revascularization Perhaps the most studied surgical procedure in the medical literature, carotid revascularization lends itself to direct outcomes that can ensure quality vascular surgical care. Giants in our field authored “Efficacy of carotid endarterectomy [CEA] for asymptomatic carotid stenosis.

The Veterans Affairs Cooperative Study Group” to provide a solid footing for recent studies documenting clinical equipoise with the private sector.6 Recent studies have demonstrated that both short- and long-term outcomes for carotid revascularization, primarily carotid endarterectomy, is equal to if not better than Medicare patients undergoing similar procedures.7,8

Abdominal aortic aneurysms In contrast to CEA, the treatment of abdominal aortic aneurysms (AAAs) and performance of randomized trials do not occur with routine vigor. Performance of open vs. endovascular clinical trials have only occurred in public healthcare systems, both in the U.K. and the U.S. Just look at the results of the EVAR 1 (United Kingdom endovascular aneurysm repair 1) and DREAM (Dutch randomized endovascular aneurysm management) trials to assess quality of AAA repair in the VA. In the EVAR 1 trial, the 30-day operative mortality was 1.8% in the endovascular and 4.3% in the open repair groups. In the DREAM trial, the operative mortality rate was 4.6% in the open repair group and 1.2% for endovascular repair.9,10 With results similar to the other trials, operative mortality was lower with endovascular repair at 30 days compared to open repair but the mortality rate of veterans was markedly less in the endovascular group at 0.5%. A 3% reduction in open mortality was noted compared with other trials.11 The OVER (Open versus endovascular repair) trial is an example of research and clinical outcomes for veterans with AAAs to acknowledge the quality present within the VA system. The VA vascular surgery community can be proud of the outcomes achieved in a challenging population. Direct comparison to the community in clinical trials and real-world data suggest veterans receive care that meets or exceeds community standards (see footnotes at vsweb.org/TBD).

Gale Tang is chair of the SVS VA Vascular Surgeons Committee.

Jason Johanning is a former committee member.

SEPTEMBER 2020

VASCULAR ACCESS

Artery-to-vein AVF technique leads to longer patency, lower rates of reintervention

BY BRYAN KAY

A NEW STUDY CARRIED OUT ON patients and rats shows that artery-to-vein configuration of arteriovenous fistulae (AVF) improves hemodynamics and decreases hyperplasia in rats, and leads to longer-term patency with reduced reintervention rates in patients.

The findings—made by Hualong Bai, MD, Alan Dardik, MD, and colleagues at the vascular biology and therapeutics program and the department of surgery at Yale School of Medicine, Connecticut— were published as the cover research article in the latest issue of Science Translational Medicine. The research team hailed their findings as supporting the use of arteryto-vein-configured AVFs for durable hemodialysis access.

Some 60% of conventional AVFs, or vein-to-artery, fail to mature, with just 50% remaining patent at one year, they note.

Previously, the researchers had shown improved maturation and patency in a 53-patient pilot study of the radial artery deviation and reimplantation (RADAR) technique that uses an artery-to-vein configuration.

The new study involved a single institution cohort study on the patient side, with a retrospective review of a prospectively maintained clinical database.

Furthermore, a bilateral carotid arteryinternal jugular vein AVF model was developed to assess both artery-to-vein and vein-to-artery configurations in a single rat.

In the human portion of the study, 201 patients who had RADAR performed between October 2014 and April 2017 were compared with 73 patients who received control (vein-to-artery) AVF between May 2013 and September 2014. In a pooled cohort that included both female and male patients, AVF performed with RADAR had significantly higher rates of maturation at six weeks (p=0.002) and three months (p=0.001) compared to control AVF, with more RADAR remaining in use for hemodialysis at the end of follow-up (p<0.0001), the investigators revealed.

The cumulative reintervention rate in the juxta-anastomotic segment was significantly lower in patients with RADAR compared to controls (cumulative reintervention rate: 12.6% vs. 42.6% at 12

Reintervention rate significantly lower in patients with RADAR compared to controls (cumulative reintervention rate: 12.6% vs. 42.6% at one year and 17.3% vs.

49.1% at three years)

months and 17.3% vs. 49.1% at 36 months, p<0.000001). Both primary and secondary patencies were significantly increased at 12 and 36 months in patients treated with RADAR compared to controls (primary patency: 72.2% vs. 48.1% at 12 months and 62.1% vs. 37.6% at 36 months, p=0.000065; secondary patency: 98.4% vs. 72.1% at 12 months and 94.9% vs. 66.8% at 36 months, p<0.0000001).

Patients with RADAR required significantly fewer reinterventions (30.1 vs. 39.9 per 100 person-years, p=0.03). Reintervention for venous juxta-anastomotic stenosis was 1.6 per 100 person-years with RADAR

Six-month IN.PACT AV Access results show superiority of DCB angioplasty

BY JOCELYN HUDSON

Recently published six-month results of the IN.PACT AV Access study show that drugcoated balloon (DCB) angioplasty is superior to standard angioplasty for the treatment of stenotic lesions in dysfunctional hemodialysis arteriovenous fistulae (AVF). Furthermore, it was found to be non-inferior with respect to access circuit-related serious adverse events within 30 days.

T

hese results were published Aug. 19 in the New England Journal of Medicine (NEJM). Robert Lookstein, MD, of Mount Sinai Health System, New York, and colleagues note that long-term outcomes for standard percutaneous transluminal angioplasty (PTA)—the current recommended treatment for dysfunctional hemodialysis fistulae—are poor. DCBs delivering the antirestonotic agent paclitaxel may improve outcomes, they write.

In this prospective, single-blinded, 1:1 randomized trial, the investigators enrolled 330 participants across 29 sites in the U.S., Japan and New Zealand. Patients with new or restenotic lesions in native upper-extremity AVFs were eligible for participation. After successful high-pressure PTA, participants were randomly assigned to receive treatment with either the IN.PACT AV drug-coated balloon (Medtronic) or a standard balloon.

Lookstein and colleagues detail that the primary effectiveness endpoint was target-lesion primary patency, defined as freedom from clinically-driven target revascularization or access-circuit thrombosis during the six months after the index procedure. They assessed the primary safety endpoint—serious adverse events involving the arteriovenous access circuit within 30 days—in a noninferiority analysis (margin of noninferiority 7.5 percentage points).

SEPTEMBER 2020

“We now have Level 1 evidence of a simple technology that is proven to be safe and effective at improving outcomes for patients with endstage renal disease [ESRD] on hemodialysis”— Robert Lookstein

compared to 17.1 (p<0.0001), whereas the RADAR group required more arterial reinterventions (p=0.02). “These long-term clinical results confirm the results of our pilot study and demonstrate that RADAR is associated with less juxta-anastomotic stenosis and improved rates of maturation and long-term patency in human patients,” the authors write. They added: “These findings collectively demonstrate that RADAR is a durable surgical option for patients requiring radial-cephalic AVF for hemodialysis access.”

SOURCE: DOI:10.1126/ SCITRANSLMED.AAX7613

Lookstein et al write that a total of 330 participants underwent randomization, with 170 assigned to receive treatment with a DCB and 160 with a standard balloon.

The authors report that, during the six months after the index procedure, target-lesion primary patency was maintained more often in participants who had been treated with a DCB than in those who had been treated with a standard balloon (82.2% [125/152] vs. 59.5% [88/148]; difference in risk, 22.8 percentage points; 95% confidence interval [CI] 12.8–32.8; p<0.001).

In addition, they found that DCBs were non-inferior to standard balloons with respect to the primary safety endpoint (4.2% [7/166] and 4.4% [7/158], respectively; difference in risk, -0.2 percentage points, 95% CI -5.5–5; p=0.002 for noninferiority). Lookstein et al detail that there has been a wide adoption of continuous hemodialysis through autologous AVF. However, this has been associated with a high incidence of dysfunction caused by vascular stenosis within the fistula circuit, leading to inadequate hemodialysis.

Lookstein and colleagues acknowledge some limitations.

For example, they note that the DCB has a different appearance than a standard balloon, which made a double-blind trial design “unfeasible.” In addition, the investigators recognize that further studies will be required to evaluate the safety and effectiveness of DCBs for the treatment of central vein obstruction, in-stent restenosis, or arteriovenous graft stenosis, as they investigated only lesions in AVF. “We now have Level 1 evidence of a simple technology that is proven to be safe and effective at improving outcomes for patients with end-stage renal disease [ESRD] on hemodialysis,” Lookstein commented. “This is the first U.S. Food and Drug Administration [FDA]-approved paclitaxel-based device since the controversy last year, which is a testament not only to the incredible results seen in this trial, but also the significant needs of this population.”

SOURCE: DOI:10.1056/NEJMOA1914617 vascularspecialistonline.com • 9

COMMUNITY PRACTICE

Local matters: Three community service honorees in profile

BY BETH BALES

The Society for Vascular Surgery (SVS) has honored three members in community practice for their leadership of patients and their local communities, as well as exemplary professional practice and leadership.

standards of the profession. It is due to the extraordinary and selfless efforts of individuals like Dr. Jain vascular surgery has thrived at a community level.”

Russell Samson Samson may seem familiar to members from his photo appearing in Vascular Specialist monthly from 2013 to 2018, when he served as medical editor.

In private practice in Russell Sarasota, Florida, he has Samson served as chief of surgery at several area hospitals. He is also a clinical professor of vascular surgery at Florida State University Medical School.

His academic achievements include authoring many textbook chapters and

RECIPIENTS OF THE EXCELLENCE in Community Service Award, in only its second year, must have a minimum of 20 years as a practicing vascular surgeon, five years of SVS membership and an impact on vascular care or community health.

This year’s awardees are Krishna Jain, MD, Russell Samson, MD, and William Shutze, MD.

William Shutze

12 • Vascular Specialist

OVIDIU DUGULAN

Krishna Jain Jain started his career in an academic vascular surgery practice. But the desire to serve locally drew him to community practice, instead. He set up shop in Kalamazoo, Michigan, where he served patients for more than 30 years. He founded Advanced Vascular Surgery, a private group that eventually grew to support five full-time vascular surgeons, and also is founding director of Paragon Health, a multi-specialty physician group.

Love of community shaped his life and career, developing a vascular program in Kalamazoo and helping create a network of rural satellite clinics, as well as a mobile vascular lab that took care to patients’ homes.

He contributed to the beginnings of the city’s IndoAmerican Cultural Center and, when SVS was Krishna working toward Jain an international presence, Jain actively supported the effort by engaging the Vascular Society of India.

He is founding president of the South Asian American Vascular Society. And throughout his years of busy community practice, he nonetheless remained active in research.

A surgeon who has always embraced the future, he introduced endovascular therapy and outpatient treatment centers to Kalamazoo and was part of a steering committee to create the SVS’s Section on Outpatient & Office Vascular Care. He is a founding member of the Outpatient Endovascular and Interventional Society

aimed at doing the right thing better for each patient.” Samson also has been an educator, imparting knowledge to colleagues, students and the public via media presentations. Teaching others how to build a successful, principled practice is his passion. Vascular surgeons who have attended his lectures and courses and, in turn, their patients, are the beneficiaries of his lessons in integrity and quality.

There can be no greater impact on the health of a community than when that community receives care from a community practice where high-quality service is rendered with empathy. This pursuit of excellence has been Samson’s trademark—delivered for an entire career.

“I have been blessed to find many pathways to serve my community and my specialty as a community-based vascular surgeon, and I hope that in some small way my efforts have made a positive contribution”—William Shutze and edited the recently published book, “Office-Based Endovascular Centers.”

“He is one of the leading proponents of the outpatient vascular lab interventions focusing on improving outcomes for patients,” a colleague said.

Though he retired from active practice four years ago, he continues to mentor medical, college and high school students, influencing the next generation.

“Dr. Jain built a vascular surgery program par excellence, [and] provided outstanding physician leadership within the community of Kalamazoo,” said Jain’s colleague. “As a practicing vascular surgeon, he maintained exceptional personal integrity and the highest

being an assistant editor for the sixth edition of “Rutherford’s Vascular Surgery and Endovascular Therapy.” He also developed the Jobst UlcerCare® therapy for venous ulcerations and the Atrium® Vascular reporting package and database.

Samson has been a prolific writer, having authored 100 peer-reviewed articles on improving ways to deliver patient care “from wound care centers to critical writings about achieving the highest and best outcomes in every vascular procedure,” a colleague wrote.

“This speaks to the exceptional quality of care that he pursued and rendered for the patients in his community. It was extensive, and it was geared to quality, integrity and compassion—all

Shutze has spent his entire nearly 30year career in the same community in the Dallas area. He has contributed in countless ways to vascular surgery via membership, mentorship, education and research—locally and at the state and national levels. He has a long list of local accomplishments in the Lone Star State, including currently serving as president of the Texas Vascular and Endovascular Society, and membership in the Texas Surgery Society. Within the latter, he has worked to elevate the profile of vascular surgery through regular scientific presentations at biannual meetings on vascular topics.

He finds service to state and regional societies important William as he has the Shutze opportunity to enjoy camaraderie with and learn from fellow vascular surgeons at the grassroots level. He supports the SVS quality initiatives through service to the Southern Vascular Outcomes Network and the VQI national research advisory committee.

He has mentored students at all levels, including residents and fellows, medical students and even university and high school students. He helped develop and launch the SVS Mentor Match program.

Apart from vascular surgery, Shutze is proud to serve his church, Highland Park United Methodist Church. Within the SVS, among others he has chaired the Community Practice Committee and been a member of the Strategic Board of Directors.

“I have been blessed to find many pathways to serve my community and my specialty as a community-based vascular surgeon, and I hope that in some small way my efforts have made a positive contribution,” he said. “It’s been very rewarding to be a vascular surgeon in community practice.”

SEPTEMBER 2020

NEWS FROM SVS

SVS ONLINE 2020 meeting returns in series of recordings

BY BETH BALES

Time marches on. Time heals all wounds.

If I could turn back time.

A

ll of these may be true—but in the case of the SVS ONLINE virtual meeting, people can turn back time, in a fashion. Registrants certainly can go back in time to see what they missed during SVS ONLINE: “New Advances and Discoveries in Vascular Surgery,” held virtually in June and July.

Registration is required; those who did so during or before the meeting do not need to register again to view the content. Separate registrations are required for the Society for Vascular Nursing’s annual conference sessions and the Vascular Quality Initiative’s virtual meeting. Visit vsweb.org/RegisterONLINE. Participants may view, listen and/or download post-live and pre-recorded lectures, known as “enduring content,” at their own convenience, and also may claim educational

credits in many cases. Materials include educational presentations; scientific sessions featuring the latest research; special forums such as the E. Stanley Crawford Critical Issues Forum, the Presidential Welcome, the Roy Greenberg Distinguished Lecture, the International Lecture, a special session on assuring quality in vascular care, VESS programming, international programming and the ONLINE wrap-up; four presentations for general surgery residents and medical students (not available for credits); and the VQI’s virtual meeting.

Industry played a vital role in the virtual meeting, as it does with the SVS live Vascular Annual Meeting. A second section in the left navigation panel links to industry sponsors, recordings of live industry and OnDemand presentations.

To access all materials, log in at vsweb.org/ Planner2020. Use the left-hand panel to navigate to sessions of choice.

Participants can claim Continuing Medical Education and Maintenance of Certification credits for sessions that offer them. Industry sessions and presentations are not eligible for credits.

Credit claimed for sessions attended during the live event may not be claimed a second time.

Additional information is available at the top of the navigation tab. For more, email education@ vascularsociety.org. Claiming credits will be available until Oct. 31.

Registration Fees: SVS ONLINE Society for Vascular Surgery Member (includes Active, Distinguished Fellow, Graduated Candidates, Honorary, International, Associate) $75 SVS Candidate Member-in-Training (includes Medical Students, General Surgery Residents and Vascular Residents and Fellows) $0 SVS Affiliate Member (includes PAs, Nurses, Nurse Practitioners, Technologists and SVN Active members) $75 Non-Member Physicians and Researchers $200 Non-Member General Surgery Resident/Student/SVN Associate and Student* $100

Keep the money you deserve

* Fees will be assigned automatically based on your membership status.

Be sure that your dues are current in order to obtain the member pricing.

Non-member medical students and general surgery residents may qualify for the SVS Candidate-in-Training $0 registration rate by applying for complimentary membership with the SVS. Visit vsweb.org/SVSDues to pay dues. This process must be completed prior to the start of registration in order to qualify.

In memoriam (1930–2020)

BY BETH BALES

Coding for aneurysm repair, for catheterization, for lowerextremity amputation. Information on modifiers, not to mention reimbursement appeals.

AND DON’T FORGET NEW guidelines for Evaluation and Management (E/M) codes that take effect Jan. 1 next year. Attendees of this year’s virtual SVS Coding and Reimbursement Workshop—Sept. 24 and 25, with an optional E/M workshop on Sept. 24—will learn all they need to know about how to navigate proper coding for vascular surgery, including not only changes but also how to code to maximize reimbursement. And who wants to leave money on the table, particularly with upcoming changes in the Medicare Physician Fee Schedule (PFS) that will reduce reimbursement for vascular surgery services by an estimated 7%?

SEPTEMBER 2020

“This course is members’ opportunity to hear about accurate coding and the kind of coding that will optimize their revenue,” said Teri Romano, BSN, one of the course faculty members.

The main workshop (all times Central Daylight Time) will be held from 10 a.m. to 2 p.m. and 2:30 to 6:45 p.m. on Friday, Sept. 25, and from 10 a.m. to 2:15 p.m. Saturday, Sept. 26. The optional workshop will be from 10 a.m. to 2 p.m. on Thursday, Sept. 24.

Costs are $620 for SVS members, $670 for non-members and $175 for trainees.

Fees for the optional workshop are $70, $85 and $35, respectively.

Visit vsweb.org/Coding2020Coding2020.

Howard Denbo, MD, May 24, 2020, of San Francisco, who served as a combat medic in the Korean War (1950–53) and trained under pioneers Michael DeBakey, MD, Denton Cooley, MD, and Walter “Sam” Henley, MD, the latter of whom remained a close friend, passed away May 24. He started his practice in San Francisco in 1965, serving a number of local hospitals.

He was 90.

SVS Foundation makes structural changes to board make-up

BY BETH BALES

THE SVS FOUNDATION BOARD OF DIRECTORS has altered its infrastructure, including expanding the board and adding seats specifically for public members and changing the term of the Foundation chair to a three-year instead of a one-year term. Expanding the board provides for broader representation while the three-year term for the chair provides continuity, said Michel S. Makaroun, MD, whose term as chair ended in June.

In addition, the immediate past president of the SVS will no longer succeed to the chair position, but will serve on the Foundation board. In announcing these changes at the first SVS Annual Business Meeting on June 15, Makaroun named Peter Lawrence, MD, who chaired the Foundation in 2015–16, as the new chair.

New public members are “friends of the SVS” Marty Sylvain and James Neupert.

Other infrastructure changes include the creation of three-year terms for board members, with the exception of staggered terms for the first cycle to provide continuity; the development of criteria for evaluation of current and future programs; and amended bylaws to enact the changes. Members of the SVS Foundation Development Committee are Peter Nelson, MD (chair), Thomas Forbes, MD (vice chair), Lawrence, Nilesh Bala, MD, Lisa Bennett, MD, Peter Brant-Zawadzki, MD, Rocco Ciocca, MD, Lisa Bennett, MD, Chanda Vemuri, MD, and Mohamed Zayed, MD. The other members of the Foundation Board of Directors are SVS treasurer Keith Calligaro, MD; Edith Tzeng, MD, chair of the Research Council; SVS president Ronald L. Dalman, MD; president-elect Ali AbuRahma, MD; immediate past president Kim Hodgson, MD; and SVS members William Shutze, MD, Richard Lynn, MD, Matthew Eagleton, MD, and Joseph Hart; as well as non-SVS members Nasim Hedayati, MD, Sylvain and Neupert.

PAD month, new app, membership dues

BY BETH BALES

SEPTEMBER IS PAD AWARENESS MONTH, and the Society for Vascular Surgery (SVS) has plenty of resources for its members.

And just now getting started is a pilot program for an SVS app for surgeons to use with their PAD patients undergoing Supervised Exercise Therapy (SET), a firstline therapy, carried out in hospitals and clinics with physicians “immediately available,” said SVS member Oliver Aalami, MD. The app—which must be prescribed by physicians—is launching with 50 patients from across the United States, with a national launch planned for the last quarter of this year. Users will receive health education, exercise assessment, goal-setting and coaching. Read more about the app, introduced during the SVS virtual meeting this summer, at vsweb.org/SVSSET. Meanwhile, invoices for 2021 dues will be emailed to all SVS members on or about Oct. 1. Payment is due by Dec. 31 to maintain SVS membership and benefits.

vascularspecialistonline.com • 13

INTERVIEW

Dalman ponders challenges in year ahead

BY BETH BALES

New SVS president Ronald L. Dalman, MD, has several initiatives he’d like to see move forward during the year of his presidency.

THESE INCLUDE A NUMBER OF AREAS MEMBERS have found challenging. “We put together the Crawford Forum [E. Stanley Critical Issues Forum] to address these issues: valuation, branding, wellness and how they fit together. And we got lots of positive feedback,” he said.

He wants to add equity, diversity and inclusion, ongoing important topics, as well as appropriate reimbursement and appropriate outcomes.

“Unfortunately, some of our members, our colleagues, face disadvantages because of their gender, or their race, or other factors,” he said. These factors have taken on new importance in the wake of the death of George Floyd, followed by demonstrations and protests around the country, as well as the recent controversy over an article about professionalism and social media published in the Journal of Vascular Surgery (JVS).

A year ago, then president Kim Hodgson created the SVS Diversity, Equity and Inclusion Task Force to study the issue, Dalman noted; it sent its formal report and

14 • Vascular Specialist

recommendations to the SVS Executive Board in July for review and board recommendations. “The article confirmed the persistence of implicit bias and other structural and generational blind spots and insensitivities in both the SVS and the larger society around us,” said Dalman. “We can and will do better for our membership in this critical domain.”

He also noted that circumstances can precipitate a change in direction. “Most presidents have some idea at the beginning of the year what they want to focus on,” said Dalman.” For example, Michel Makaroun, MD, made the upcoming workforce shortage a primary focus.

Several years ago, then-president Peter Lawrence, MD, had a focus—and then the New York Times published a story on the gross overutilization of services. “He pivoted to deal with that,” said Dalman. “That became his topic and focus.”

“The [JVS] article confirmed the persistence of implicit bias and other structural and generational blind spots and insensitivities in both the SVS and the larger society around us”— Ronald L. Dalman

He knows he and the SVS will need to continue to deal with the ongoing COVID-19 pandemic and its effects on the healthcare system and SVS members. The proposed Physician Fee Schedule from the Centers for Medicare and Medical Services (CMS) and other proposed CMS rules promise to affect vascular surgeons deeply and adversely, with a 7% reimbursement reduction coming down the line. It is, he said, a time of extraordinary pressure for the healthcare system, and he and SVS leaders will be working to find the best ways to support our members in a time of great uncertainty.

“Maybe we can, as an organization, provide more to help members achieve everything they hope for in their careers,” said Dalman, who has been an SVS member since 1998. When assuming the presidency on June 20 during the second Annual Business Meeting, he asked members to offer feedback and suggestions, a stance he repeats.

“I encourage everyone to reach out to me if they have ideas on how to do our jobs better.”

Ronald L. Dalman

SEPTEMBER 2020

AORTIC VIENNA

8â&#x20AC;&#x201C;11 SEPTEMBER 2020 We would like to invite all specialists treating patients with aortic disease to attend the inaugural CX Aortic Vienna meeting, which will be livestreamed 8â&#x20AC;&#x201C;11 September 2020 to an international, online audience, and will include registrant participation, interaction, and polling.

Registration open www.cxaortic.com

LETTER TO THE EDITOR

'Women must not only have a seat at the table, but be heard, respected and have a seat at the head of the table' Dear editor:

S

ubmitted with little fanfare to the Society for Clinical Vascular Surgery (SCVS) in July of 2019 and accepted later that year in October, an article entitled “Prevalence of unprofessional social media content among young vascular surgeons” was

16 • Vascular Specialist

published in the Journal of Vascular Surgery. Just one year later, the article proved to be true: that we are indeed judged by social media, just not in the way the study intended. A firestorm erupted and social media, namely Twitter and Facebook, judged the

article and launched backlash campaigns against the research, the journal, and the authors, including trending hashtags for #Medbikini and #professionalism.

The article’s intent was to determine the extent of unprofessional social media on recently graduated vascular surgeon accounts. One problem with trying to create a scientifically, unbiased article was the creation of false (“neutral”) social media accounts used to search through the postings of selected young surgeons. While, the intent was with merit, the second problem was that of how the criteria of unprofessional behavior was decided: the opinion of the authors.

With female surgeons by the dozens posting pictures of themselves in their bikinis, a tipping point that has long been overdue was defined. Additionally, female and male physicians from all fields also posted in support of their vascular surgery colleagues and out of a recognition that this is not just a vascular surgery problem; it reaches far in medicine, and especially surgery.

From perspective as a female vascular surgeon, #Medbikini trending on Twitter was and is not how I imagined the tipping point would fall. And with it, we must ensure that the message does not get buried. Perhaps the raw grit of prior generations of women surgeons has slowly paved the road for those of the modern social media generation to allow a voice to be heard.

But the tipping point in numbers and fearlessness was undeniable for anyone watching as the Twitter feeds grew.

Previous generations of female surgeons would not have been able to respond in this manner. The numbers would not have allowed for it to happen.

Numbers are power. The amount of backlash from recently graduated and early practice surgeons, along with those with careers that have long been established, reveals the systemic sexism within the surgical community that most of us have experienced personally in the profession, and have long known to exist, albeit in a more subtle manner. The social media firestorm was anything but subtle. This issue in vascular surgery and medicine has now been exposed worldwide.

The real issue at hand is not the attire that was deemed appropriate or inappropriate, that should or should not be posted on social media vis à vis female or male surgeons, but the amount of mentorship and leadership female surgeons still have yet to achieve. Academically and technically, the vascular surgery arena has made tremendous progress. We are able to open arteries to the toes and create highly specialized repairs to many arteries throughout the body so that blood flow can be restored. The recent advances in the technical aspects of vascular surgery have been met with success. Women have been witness to this but have remained poorly represented on editorial boards, as head of surgery departments, as chairpersons on professional societal committees, as having significant mentors—or simply by our low numbers as partners

SEPTEMBER 2020

within practice. The numbers of females entering vascular surgery and the impetus of the new generation, however, has reached the tipping point, making this impossible to accept and continue with the status quo of watching and remaining silent. Women must not only have a seat at the table, they must be heard, respected and have a seat at the head of the table.

An article published in the February 2020 issue of the Journal of Vascular Surgery reported the dismal number of women within the profession, but stated that they were growing in number (from 2007 to 2016). In the article, showing integrated residency is associated with an increase in women among vascular surgery trainees, the authors stated that “the number of female vascular trainees increased from 27 out of 221 to 164 out of 501.”

This increase was reportedly the single biggest among female physicians in any one field over the nine-year study period. The biggest overall factor for this was the integrated residency program of five years versus a fellowship track that took seven. This

Previous generations of female surgeons would not have been able to respond in this manner. The numbers would not have allowed for it to happen.

Numbers are power surgical subspecialty, however, remains one of the most disproportionately male.

In the not so distant past, female surgeons were even fewer in number.

As a vascular surgery fellow who graduated in 2009, I can recall that, most of the time, I was the sole female surgeon. I was the only female in the room amid a roomful of suits at a conference. I was the only female fellow

Through the looking glass: Addressing bias in surgery

(trainee) to present their scientific work. I was also the only female in a room of board members for a vascular surgery professional society. Being the only woman silences that woman’s voice. The old adage of “If a tree falls in the woods who hears it?” would best describe the female vascular surgeon a decade ago. The social media firestorm provided insight that the numbers of female surgeons are growing, gaining a voice they are unafraid to use.

We should not dismiss the article completely. While it was full of bias as demonstrated by the firestorm, the intended message is not without merit. Creating an objective standard to what is appropriate on social media is challenging. Ironically, the study itself proved that social media itself will be judge and jury. In a prior generation, the sole woman wearing a bikini would likely have been scorned, or even lost what professional credibility had been gained. But, today, the tipping point is real, and the number of female surgeons in medicine, unifying into one voice, have a message that cannot be lost. That voice, this article, is not about

the bikini; it is about our relevance and abilities to perform as surgeons to the highest level and still be women.

Alissa Brotman O’Neill, DO is a vascular surgeon based in New Jersey.

This letter was co-signed by the following vascular surgeons: Sherry Cavanagh, MD; Kira Long, MD; Leigh Ann O’Banion, MD; Laurel Hastings, MD; Bernadette Aulivola, MD; Ruth Bush, MD; Anna Gasparyan, MD; Angela Echeverria, MD; Sarah Rajaee, MD; Kai Hata, MD; Megan March, MD; Yana Etkin, MD; Kathryn E Bowser, MD; Javariah Asghar, MD; Jessica Williams, MD; Longon Guidry, MD; Neeta Karani, MD; Olamide Alabi, MD; Dejah Judelson, MD; Shipra Arya, MD; Julie Gilkeson, MD; Misty Humphries, MD; Pallavi ManvarSingh, MD; Neelima Katragunta, MD; Ageliki G Vouyouka, MD; Joanelle Lugo, MD; Laura Marie Drudi, MD; Elizabeth Blazick, MD; Christine Lotto, MD; Mimmie Kwong, MD; Nida Ahmed, MD; Danielle Dombrowski, MD; Alyson L. Waterman, MD; Sarah E. Deery, MD; and Trisha L. Roy, MD.

we are ultimately brainwashed into feeling like it is a consequence of our poor performance.

It’s a trap. We ask for more opportunities and advocate for ourselves, and we are labeled as aggressive. It happens everyday.

The “culturescape,” or the cultural landscape, is a term coined by the author Vishen Lakhiani in his novel “The Code of the Extraordinary Mind.” He dares readers to redefine their own views to recreate an

BY RITA MANCINI, MS, TRISHA ROY, MD, environment they envision and yearn to AND LAURA MARIE DRUDI, MD be a part of. Translating this to the surgical culturescape, female and male surgeons THE #MEDBIKINI CAMPAIGN SPREAD are redefining the way they want to like wildfire following the publication of move forward, integrating a new vision the journal article in question. Reading of their culturescape and thereby the manuscript seemed like we crossed redefining the cultural landscape for the the threshold of Lewis Carroll’s looking next generation. There is much work to glass into a bizarre, flipped universe be done to transcend this culturescape. of odd definitions of professionalism, The way in which the medical profession unethical study methods, and views female surgeons is nothing but misogynistic and oppressive issues a social construct; it’s been socially facing young surgeons—particularly Rita Mancini Trisha Roy Laura Marie Drudi created, which means it can be socially female surgeons. A storm of female challenged and recreated. We have healthcare professionals took to their social Whether you are a female medical trainee, the power as a society to reject sexist and media platforms and began posting pictures in surgical resident or a female surgeon, chances misogynistic beliefs, and we have the power swimwear and with alcoholic beverages. It was are you have experienced a form of misogyny to choose what holds value and truth. So let’s a collective stand of solidarity, which moved or unfair treatment. Prior to even committing redefine our perspectives. Female surgeons away from a single publication and became to a surgical specialty, we are continuously are not only intelligent and capable but we a cry against the injustices towards women in deterred. We have either been told or heard deserve equality. surgery, medicine and society. from female colleagues exploring surgery The truth is, women can have accomplished We have attained some incredible advances the following: “You're a woman, your efforts careers but we can also be great mothers, in modern medicine owing to our forward should be focused on raising a family… wives, travelers, athletes, artists and, thinking and our commitment to progress. Yet, choose a less demanding specialty.” But ultimately, human beings. Through the looking our attitudes towards women in medicine and has the thought not crossed your mind that glass, we collectively had a chance to look at surgery have clearly not followed suit. Female maybe, just maybe, we can do both? The the backwards world women in medicine and physicians and surgeons face a mountain hardest challenge is honestly the implicit and surgery have been facing for years. But with of challenges rooted in gender inequality explicit ways people tell us that we don’t clarity, vision and a unified voice, we have and discrimination: seen through the lens of belong. Opportunities and autonomy are not decided to break that glass and create a world conscious and unconscious bias. Biases can be at all equivalent to our male colleagues, and we deserve.

SEPTEMBER 2020

intentional (conscious bias); however, they can also be rooted in attitudes and beliefs formed outside our conscious awareness (unconscious bias). The biases towards female doctors are numerous and have serious consequences.

We earn less money for equivalent work, hold fewer leadership positions despite equivalent qualifications, and we also experience harassment, poor treatment, depression and burnouts more frequently, all of which appears to be a consequence of the medical profession’s adverse alpha culture.

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VIRTUALLY VASCULAR

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Boston Massachusetts

Minneapolis Minnesota

September slate of regional vascular meetings goes digital

BY BRYAN KAY

This time last year, the ranks of vascular surgery were gearing up to head for points East, West, Midwest and Northeast as the slew of key regional meetings that take place in the early fall entered their viewfield.

BUT LIKE THE SOCIETY FOR Vascular Surgery (SVS) did by transforming the 2020 Vascular Annual Meeting (VAM) into SVS ONLINE, each of the major regional societies has pivoted to create digital equivalents to host their scientific and educational programming.

The impetus to do so was perhaps captured best by Western Vascular Society (WVS) president Benjamin W. Starnes, MD, in a message to members. “Essential for the successful process of conducting a scientific meeting like ours is the safety and security of our membership,” he wrote. “I personally felt as if it would be reckless and arrogant to proceed with plans for an inperson meeting like we are all accustomed to in September.”

First up among the regional meetings is Midwestern Vascular 2020—which had been set to take place in Minneapolis— from Sept. 9–12. The scientific sessions include a range of talks across the vascular spectrum, including: “Clinical outcomes differ after femoropopliteal artery treatment between individual paclitaxel (PTX)-coated balloons,” to be delivered by Alexander H. King, MD, of the University Hospitals Cleveland Medical Center; “Racial disparities in major amputation rates are associated with more advanced WIfI score at initial presentation amongst blacks,” by Melissa D'Andrea, BA, of Loyola University Medical Center, Maywood, Illinois; and “Televascular consultation is the answer to rural vascular surgery shortage,” which is to be presented 18 • Vascular Specialist

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Santa Monica California

by Amy B. Reed, MD, of the University of Minnesota, Minneapolis.

“Our decision to go virtual was made after discussing all options and surveying the membership, who overwhelmingly supported a virtual scientific meeting,” explained Kellie R. Brown, MD, president of the Midwestern Vascular Surgical Society (MVSS). “The Program Committee has been diligently working to provide an engaging program, and we are happy to announce that the Szilagyi, Guthrie and Pfeifer competitions will still be conducted, and winners will be awarded.”

The New England Society for Vascular Surgery (NESVS) Annual Meeting, originally set to take place in Boston, starts two days after the Midwestern event, running from Sept. 11–12.

Marc Schermerhorn, MD, NESVS president, made clear the society’s intention to ensure new science be delivered as originally scripted, only virtually. He told the membership: “The NESVS Program Committee remains committed to highlighting the high impact scientific work that was accepted for presentation. We had an unprecedented number of very high-quality submissions.

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Charleston South Carolina

All accepted presentations will be presented in an online format that leverages audience participation and discussion. We also look forward to a special session with our Advanced Practice Providers, and will run a Postgraduate Course highlighting technical tips, all with full CME credit.”

Among the new science on the agenda, Salvatore T. Scali, MD, of University of Florida in Gainesville, et al are set to present: “A significant proportion of current United States EVAR practice fails to meet SVS Clinical Practice Guideline recommended AAA diameter treatment thresholds”; Jeffrey Siracuse, MD, of Boston University School of Medicine, et al with: “Contemporary intermittent claudication treatment patterns in the commercially insured non-Medicare population”; and Charles DeCarlo, MD, of Massachusetts General Hospital, Boston, et al on: “Simultaneous treatment of common carotid lesions increases the risk of stroke and death after carotid artery stenting.”

The WVS Annual Meeting follows from Sept 27–29. Scientific sessions include such talks as: “Factors influencing medical student choices in the 2020 integrated

vascular surgery match: Implications for the upcoming 2021 COVID-19 affected match,” by Arash Fereydooni, MD, of Stanford School of Medicine, Stanford, et al; “Economic value of podiatry service in a limb salvage alliance,” by Wei Zhou, MD, of the University of Arizona, Tuscon; and “Early recognition of venous ulcer improves healing rates and resource utilization,” by Misaki Kiguchi, MD, of MedStar Washington Hospital Center, Washington, D.C. Meanwhile, the Eastern Vascular Society (EVS) rearranged its Sept. 24–27 Annual Meeting, set for Charleston, South Carolina, as a series of weekly evening sessions to run from Oct. 7 to Nov. 18. The webinars are anticipated to cover the full vascular surgery range. “These October and November webinars will consist of a weekly 1.5-hour evening session which will be focused on specific topics with a combination of abstracts, invited talks, industry sponsored mini-symposiums and debates and will be moderated by experts in the field with a lively question and answers sessions involving the panelists, speakers and questions from the audience,” said EVS president James F. McKinsey, MD. SEPTEMBER 2020

PANDEMIC

Seattle team secures funding to examine COVID-19 impacts on aortic dissection

BY BRYAN KAY

A team at the University of Washington in Seattle has received a funding award through the Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington Engagement Awards program to convene a collaborative of patients with—and at risk for—aortic dissection.

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ed by Sherene Shalhub, MD, associate professor of surgery in the institution’s division of vascular surgery, the Aortic Dissection Collaborative also includes patients, researchers and healthcare providers as partners in patient-centered outcomes research.

The team aims to improve the management of aortic dissection and increase quality of life for people impacted by the condition. To do so, the collaborative is engaging stakeholders to build a research infrastructure focused on patientcentered outcomes. It will feature research training; support and networking among patients, physicians and researchers with expertise in aortic dissection; research consortia dedicated to aortic dissection; industry stakeholders; and patient advocacy

groups. The main deliverable over the next two years is to create a virtual research network and establish research priorities among the stakeholder group, Shalhub explained. These research priorities will then be used to guide future proposals that reflect patient-centered priorities.

Initial PCORI funding began in August last year, with additional funds awarded in May 2020 to enhance the work of the collaborative. “The new enhancement award provides a critical opportunity to expand our current work to include the impacts of the COVID-19 pandemic on people living with or at risk for aortic dissection, such as people affected with Marfan syndrome, Loeys-Dietz syndrome and Vascular EhlersDanlos syndrome,” said Shalhub.

As COVID-19 took hold across the world, the patient collaborative members expressed concerns over their potential susceptibility to

the novel coronavirus, whether they were at higher risk for adverse outcomes from the virus, and on their ability to access necessary ongoing care related to aortic dissection.

Collaborative participants who represent healthcare providers, research and advocacy confirmed that the lack of evidence about how COVID-19 affects aortic dissection patients represents a critical knowledge gap. This may negatively affect the aortic dissection community if it remains unaddressed, Shalhub said.

Key areas the team will investigate in the coming months include how COVID-19 is affecting access to ongoing care, including outpatient visits and operations; changes in patterns of care-seeking behavior for acute symptoms or complications of

aortic dissection (e.g., whether patients are withholding visits to the emergency department); and how COVID-19 affects the risk of complications among people with or at risk for aortic dissection.

Starting Aug. 3, the Aortic Dissection Collaborative was set to disseminate a COVID-19-specific survey for patients, family members and physicians. This survey is seen as adding to continuing support for another survey designed to capture aortic dissection patient experiences.

“Both surveys will form the basis to understand the concerns and experiences of those living with aortic dissection, and will guide our next steps in research topic identification and prioritization,” added Shalhub.

“The new enhancement award provides a critical opportunity to expand our current work to include the impacts of the COVID-19 pandemic on people living with or at risk for aortic dissection, such as people affected with Marfan syndrome, LoeysDietz syndrome and Vascular Ehlers-Danlos syndrome”— Sherene Shalhub SEPTEMBER 2020

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