Jeannetta G. Sanders, FACHE, president and CEO, Horizon Health Group, Rockville, Maryland

ORGANIZATIONAL INFORMATION

Two organizations are the subject of this article: a community general hospital and a four-person private practice surgery group working at the hospital. The hospital, a private not-for-profit institution established in 1921, is a 300-bed Joint Commission-accredited hospital. It is governed by a board of directors composed of both community laypersons and physicians. The surgical group comprises three general and vascular surgeons and one general surgeon. Established in 1974, the group performs 80 percent of the vascular surgery in its market and a large percentage of the general surgery. It is owned by two senior partners and governed by a board of directors composed of the two owners and the CEO. Both the hospital and the physician group are in a suburban location with a population of approximately 400,000.

BRIEF STATEMENT OF THE PROBLEM

Minimally invasive and endovascular surgical techniques have been developed to diagnose and treat vascular disease. Several specialties are involved in using these techniques. Implementation of an endovascular program within the hospital required new alliances among executives, radiologists, cardiologists, and the vascular surgeons. An integrated program was necessary to maximize the clinical and financial success for all parties.

DESCRIPTION OF THE PROBLEM

Endovascular Treatment
To better understand this problem a brief background of the evolution of endovascular techniques is helpful. Endovascular refers to the diagnosis and treatment of vascular disease via percutaneous or minimally invasive access to blood vessels. This innovation obviates the need for open surgery and is similar in impact to the laparoscopic treatment of abdominal disease, in which very small incisions are made into the patient's abdomen through which trocars or ports are placed for the removal of a diseased organ.

The skills necessary for a physician to perform endovascular procedures incorporate vascular surgical techniques and the use of guidewires, balloons, and catheters inserted through a puncture wound to reach the diseased vessel, and all procedures are done under x-ray guidance. Traditionally, percutaneous procedures in this community were performed in radiology suites by interventional radiologists, in cardiac catheterization laboratories by cardiologists, or in the operating room by vascular surgeons.

Cardiologists started using the techniques they learned in cardiac catheterization laboratories to treat peripheral vascular lesions. Radiologists developed newer methods of treating vascular disease as more sophisticated balloons and stents were developed. The vascular surgeons saw their patient volume diminish and learned endovascular methods, extended endovascular techniques to open surgical procedures, and wanted procedure time available in the angiography suites.

Turf battles and competition made these changes a significant problem for hospital executives and the physicians involved. These problems have been experienced nationally and are often addressed in physicians' specialty-specific meetings. Ideally the three specialties would develop uniform criteria for procedure performance and follow through using similar equipment and supplies in the least-expensive site.

Problems Within the Hospital

The hospital's program development was complicated by the difficulty of developing credentialing criteria among disparate groups of specialists. As endovascular techniques evolved, there was an overlap in the clinical capabilities of the different specialties to perform procedures not traditionally under their domain. Furthermore, the hospital CEO recognized that the political problems that endovascular programs have introduced nationally now existed in his hospital.

General and vascular surgeons and invasive cardiologists perform endovascular procedures in the normal course of their clinical care of patients. For general and vascular surgeons this includes the insertion of inferior vena cava filters, dialysis grafts, and other clinical interventions. Invasive cardiologists perform cardiac angioplasty and cardiac imaging via the use of guidewires and other radiologic techniques. These endovascular procedures involve the use of radiologic imaging equipment, which can prompt clinical competition.

The hospital had recruited a cardiologist to develop a cardiac catheterization laboratory in spite of an absence of cardiac surgery within the hospital. His clinical interest went beyond cardiac intervention. Although he had not previously performed peripheral vascular interventions, he planned to do so.

The vascular surgery group had been affiliated with the hospital for 25 years. Its accomplishments included establishment of a breast diagnostic facility, a freestanding outpatient laboratory, and a vascular testing facility. Additionally, the senior surgical partner had first introduced laparoscopic surgical techniques into the community at this hospital. Most significantly, the senior surgeon had spent extensive time studying and incorporating endovascular methods into his set of surgical skills.

The radiologists were concerned that a multispecialty endovascular program could usurp their usual clinical domain. The hospital CEO also expressed concern that opening access to endovascular procedures for other specialists could result in a loss of the cardiac catheterization business.

Endovascular procedures within this community hospital were performed in a fragmented, specialty-specific manner. However, the hospital recognized the emerging importance of an endovascular program. In 1997, the senior partner of the surgical group approached the hospital CEO with a proposal for the development of an integrated approach to the performance of endovascular procedures. His plan outlined criteria for the radiologists, cardiologists, and vascular surgeons to perform these endovascular procedures in all appropriate procedure suites. The CEO was reluctant to accept this challenge for the political reasons outlined above and tabled the program's development at that time.

Need for Compromise
1998 was an appropriate time to reintroduce this concept based on the clinical acceptance and imminent Food and Drug Administration (FDA) approval of endovascular devices to repair abdominal aortic aneurysms. As CEO of the general and vascular group, I was responsible for working with the senior partner of our organization and the CEO of the hospital to develop this endovascular program.

The treatment of abdominal aortic aneurysms has not changed for 50 years. The repair involves major surgery, which results in a 97 percent success rate when performed electively. It is, however, a traumatic surgery that entails significant hospital resources and lengthy patient recuperation.

In 1991, Dr. Juan Parodi, an Argentinean, introduced an endovascular graft that was inserted through a small incision in the groin to repair abdominal aortic aneurysms. American corporations began the aggressive development and FDA-approved clinical trials of endovascular abdominal aortic aneurysm repair devices. Further development produced clinical outcomes comparable to the open method but with drastically reduced hospital length of stay, cost, and patient recuperation time.

To be prepared for endovascular techniques such as abdominal aortic aneurysm repair, the hospital clearly had to develop an endovascular program or face clinical obsolescence and a decline in revenue. As in the 1980s with laparoscopy, endovascular abdominal aortic aneurysm repair has a great potential impact on patient treatment and subsequent hospital and physician reimbursement.

ADMINISTRATIVE DECISIONS

As CEO of the surgical group, I was responsible for ensuring the financial success of the organization. I was confident that we would be clinically and financially best served if we could implement an endovascular program. As a former hospital executive, I understood the multifaceted nature of the hospital CEO's political and financial concerns. I met with the board of directors of my organization and recommended that the hospital CEO be approached again with a concrete proposal for development of an endovascular program. The proposal included the following components:

• The approach would limit the hospital CEO's political exposure.
• The senior vascular surgeon would present the plan to the hospital CEO. This would emphasize the clinical nature of the program and was in harmony with the leadership role this physician plays in the medical community.
• The program included creation of an endovascular committee, development of hospital credentialing criteria for performance of endovascular procedures in all appropriate procedure suites throughout the hospital, and establishment of an abdominal aortic aneurysm repair team.
• The key feature of the proposal was the ability to treat abdominal aortic aneurysms with an endovascular approach within the hospital.
• The senior surgeon worked with the interventional radiologists to learn to perform arteriograms and other guidewire procedures in both the radiology and operating room suites. He accomplished this by inviting the chief interventional radiologist to be a participant in the design of an abdominal aortic aneurysm repair program. The surgeon demonstrated to the radiologist that the imminent FDA approval of endovascular abdominal aortic aneurysm repair devices would necessitate a collaborative approach to avoid losing market share to other hospitals that had endovascular abdominal aortic aneurysm repair capabilities.
• The senior vascular surgeon attended the clinical training programs he knew would be necessary to allow the hospital program to be functioning on final FDA approval of the grafts.
• An analysis of the efforts of the four other local hospitals relative to endovascular program development was conducted; little organized effort to establish an endovascular program was occurring. This presented a window of opportunity to develop a program in conjunction with the community general hospital.

RESULTS

The senior vascular surgeon met with the hospital CEO in early 1999. He presented the program as outlined above, including his collaborative work with the interventional radiologist. The data from the local hospitals were presented, along with the FDA projection of imminent approval of abdominal aortic aneurysm grafts. A tentative outline of the goals of the proposed endovascular committee as well as members of the aortic aneurysm team were reviewed.

The CEO now viewed this program as advantageous. He agreed to commit capital resources to the endovascular program and make it one of the hospital's strategic initiatives. Credentialing criteria were drafted and approved by the hospital's board of directors. The hospital's team of operating room nurses, x-ray technicians, and postoperative nurses was trained by the vascular surgeon.

In September 1999, the FDA approved two devices for clinical use for abdominal aortic aneurysm repair. The senior surgeon trained the interventional radiologists in the insertion of the abdominal aortic aneurysm graft. This training took place in the operating room suite and introduced "nonsurgeons" into the vascular surgery arena at the hospital for the first time.

The first case was performed in March 2000. The patient was operated on with epidural anesthesia and was discharged in 48 hours, a significant reduction from the standard five to seven days required with open repair. This remarkable accomplishment helped rally the three clinical groups to work together. The hospital's endovascular committee now meets monthly and reviews cases performed in all areas of the hospital and by all credentialed physicians (vascular surgeons, cardiologists, and radiologists).

In 2001, the American Medical Association published CPT codes specifically describing endovascular aortic aneurysm repair, and the Health Care Financing Administration recognized these codes for Medicare reimbursement.

The hospital's surgical team is viewed as very accomplished by device manufacturers. The senior surgeon has invited representatives from all developers to attend cases when patients agreed. This has promoted the reputation of the surgical group as well as the hospital as a training organization; the physician group has been targeted by one manufacturer to be the site for national training. The FDA invited the vascular surgeon to speak to its team on abdominal aortic aneurysm grafts. This invitation was unusual, as physician presenters are typically representatives of universities rather than community hospitals and private practice groups.

The surgeon is a guest speaker on endovascular surgery for both lay and professional groups. He was featured in a local newspaper and in the newspaper's online program on vascular disease. The online discussion was the impetus for a patient to travel 900 miles for treatment. This in turn led to further press coverage that positively presented the hospital as well as the surgical group.

The organization has evaluated 75 patients for endovascular repair of their aneurysms; 26 procedures have been performed, converting three to open procedures, with no deaths and all positive clinical outcomes. Patients are now discharged 24 hours following repair, with cases typically performed under local anesthesia and intravenous sedation.

The hospital CEO informed me that reimbursement for endovascular abdominal aortic aneurysm repair has been positive, largely because of the decreased length of stay. The cost of the endovascular graft is approximately $10,000. It is anticipated that over time this will decline, thus providing further financial benefit to the hospital as well as payers and patients.

Because of the cooperation of the surgeons, radiologists, and hospital, cooperative marketing has occurred. The hospital CEO and I arranged two highly successful seminars on abdominal aortic aneurysms and vascular disease for the community. Establishment of the endovascular surgery program required years of clinical and financial planning, but the organization has significantly benefited from the program. Although the other four area hospitals are in various stages of program development, this hospital is the leader and plans to remain in that position.

Sources

The author utilized knowledge and experience in clinical program development for this case presentation. The articles listed in the bibliography were also sources of information specific to endovascular program development and implementation.

Bibliography

Levin, D., et al. 1992. "Training Standards for Physicians Performing Peripheral Angioplasty and Other Percutaneous Peripheral Vascular Interventions." Circulation 86: 1348-50.

Sacks, D. 1999. "Quality First: Credentialing for Peripheral Vascular Procedures." Advance for Administrators in Radiology and Radiation Oncology (February): 44-50.

Silva, M., et al. 1996. "A Program of Operative Angioplasty: Endovascular Intervention and the Vascular Surgeon." Journal of Vascular Surgery 24: 948-49.

White, R., et al. 1999. "Endovascular Interventions Training and Credentialing for Vascular Surgeons." Journal of Vascular Surgery 29: 27-40.