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The Strategic Role of Vascular Surgery in Improving Patient Outcomes and Strengthening Health System Performance
00:18:40
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- [00:00]
A
Hi, everyone. This is Brian Zimman with Becker's Healthcare. Thank you so much for tuning into the Beckers Healthcare podcast. Today we're going to talk about the strategic role of vascular surgery in improving patient outcomes and strengthening health system performance. Joining me for Today's discussion is Dr. William Shoots, a vascular surgeon at Texas Vascular Associates in Dallas and Plano, Texas, and former executive board member of the Society for vascular surgery. And Dr. Robert Molner, a a vascular surgeon and chief of surgery at McLaren Flint in Flint, Michigan, an executive board at large member of the Society for vascular surgery. Dr. Schutz and Dr. Molner, thank you so much for being here today.
- [00:40]
B
It's great to be here. Thank you for having us.
- [00:43]
A
Excellent. So let's get into it. Let's start with a bigger introduction than what I just gave each of you. I'm going to tap on each of you to share just a bit more about yourself, your professional background and the work you're doing today. Dr. Molner, let's begin with you.
- [00:59]
C
Well, thanks again. It's great to be here. I've been in private practice with the Michigan Vascular center in Flint, Michigan for 28 years. So this is where I landed right out of my fellowship at Vanderbilt. Been here ever since and it's been a great opportunity. We're sort of one of the largest and oldest groups in the country. Started in 1963, so the group's been around a while and provided services to the hospitals. I've been in, engaged with clinical research. I've had education of vascular fellows and surgical residents and medical students. So it's been a good run for me and hopefully we can have a great discussion here today because I think vascular surgery has a lot to offer.
- [01:37]
A
Yeah. Excited to get into it today and kudos to you for landing and finding a home right out, right out of the gate. So well done, Dr. Molnar. Dr. Shoots, go ahead. Same question to you.
- [01:48]
B
Well, I'm going to sound like the Texas clone of Dr. Molnar. I'm in private community practice and in the Dallas metropolitan area and it was my first job out of fellowship and I've been here for 35 years. Our group has grown pretty big, too, just as Michigan Vaster has. We currently have 21 surgeons and we're expanding to 24 surgeons this year. We cover six counties and over 20 different hospitals, providing all facets of vascular care. Similar to Dr. Molnar, I've been involved in a resident medical student and fellowship teaching as well as been active in both vendor sponsored research and unsponsored research as well. I'm former secretary of the Society of Vascular Surgery and a former executive board member, had the privilege of serving along with Dr. Molnar, a current board member, for many, many years. And I'm president elect of Texas Surgical Society, our local surgical society here in Texas. I am proud to say that I'm currently the task force chair for a combined Society of Vascular Surgery, American College of Surgeons Quality Program, which is the Vascular Verification Program. And I've been very active in getting this program developed, launched and now out the door for subscriptions.
- [03:04]
A
Excellent. Well, it's a pleasure to have you both on. Let's get into it and let's begin here. Sort of really wanted to Dr. Schutz, maybe we'll start with you really think about the role of vascular surgeons within healthcare systems, the broader healthcare system. What role role do vascular surgeons play, especially in the context of what we're talking about, you know, improving patient outcomes, strengthening overall performance. Dr. Schutz, let's begin with you on this.
- [03:31]
B
You know, Brian, that's a great place to start because there's a lot of misunderstanding of actually what vascular surgeons do and where we do fit, you know, both in the hospital and outside of the hospital. You know, vascular surgeons take care of all aspects of vascular disease, arterial, venous and we not only take care of patients using stents and balloons, but we're also able to offer surgical treatments as well when that is necessary. And we take care of different kinds of patients, the patients that come in with an acute urgent situation, as well as patients that have chronic diseases that need managed and monitoring as well. But there's more to it than that. Our presence is essential for other service lines within the hospital to work and function at a high level. Think about it. Blood vessels run through all parts of our body. Blood vessels are everywhere. And if those blood vessels get injured or have a problem, you're going to have to have a vascular surgeon there to take care of it. And think about what service lines we support. It's emergency medicine, orthopedics, trauma, spine, neurosurgery, cardiac surgery, neurology, oncology. And I could keep going on, but those are the ones that are most in need of vascular services for highly complex or for acute emergent conditions. And when a hospital doesn't have a highly functional, well developed vascular service line, then they're not able to take care of complex patients. And that means that patients are being transferred out of hospitals. And when those patients are transferred out, because there's not adequate vascular care to support these other service lines or to support to take care of vascular emergencies. And two things go out the door. One is revenue for the hospital and the second thing is reputation.
- [05:23]
A
Some really, really strong points and I think a good framework for us to think through this. And forgive the obvious metaphor, but sounds like vascular surgeons are really running much like blood cells all throughout the organization. You're touching so many different service lines and special. Dr. Molner, with that setup in mind, can you talk a little bit about or expand upon how vascular service lines enable growth across other major service lines? I think Dr. Su sort of alluded to some of that there, but specifically in regards to growth, can you expand on that, Dr. Moeller?
- [05:56]
C
Certainly. And agree completely with Bill's assessment? Certainly. A strong vascular surgery service line is critical to any hospital's efforts to increase its market share, especially of complex and high margin cases. Hospital executives know all too well that financial margins are kind of slim and to provide the needed community care, you have to really maximize gain from your winners. And this is what vascular surgery service lines enable us to do. If there is a strongly supported vascular surgery service line, it can really align with the mission of the institution and enable growth across all their major service lines. For example, specifically, again, if you wanted to increase your operative spine program, both orthopedic and neurosurgical spine surgeons really rely on vascular surgeons to obtain their exposure for these procedures. For hospitals to provide complex cardiology and cardiothoracic procedures, vascular surgeons are needed to address the inevitable ischemic extremities or life threatening bleeding complications that are associated with these interventions. So vascular surgery service line really is the infrastructure that allows for some of these most profitable service lines. And Bill named a few trauma is a big one. If you get a gunshot wound in the palpito artery, they're going to need a vascular surgeon. If you have a strong cardiology or cardiac program, you need vascular surgery to be available and to help plan for these cases and take care of the inevitable iatrogenic issues that occur with them. Same with orthopedics or stroke centers. So to accept more complex and challenging cases, which again, as Bill alluded to, really significantly increases the case mix index and thus hospital margins, you need a well rounded and supported vascular surgery service line. As a matter of fact, a recent study by Johnson in 2019 demonstrated that the ACE Mix Index for cases with vascular surgery involvement was 5.4 versus 2.1 for cases that did not have vascular surgery involvement. And for all of these service lines, early and planned vascular surgery involvement provides better outcomes at lower costs than unplanned or emergent consultations do.
- [08:17]
A
Excellent. Well, I think we've established sort of the importance from an operational and clinical perspective of having a strong vascular service line. But I also, and we've touched on this a bit, but curious if we can paint the picture a little bit more clearly in terms of what this looks like when vascular coverage isn't strong. Again, like some of that, Dr. Molnar, the stats that you mentioned and some of the previous comments sort of get to this a bit. And there's some here that's probably intuitive, but I would love for listeners if we can sort of paint a very specific picture of what it looks like when coverage isn't strong. And Dr. Shoots, maybe you can, you can start us there. And then conversely, what does it look like when this goes well? How does intervention improve outcomes like length of stay and readmission? So a two parter there for you, Dr. Shoots.
- [09:03]
B
Okay, thank you very much. First of all, I think it's important to point out that when vascular coverage is weak or fragmented, health systems are paying for this in ways that really don't show up on a financial report, but they add up quickly. I think the most immediate problem is what happens when an unplanned vascular complication occurs and there's not a vascular surgeon with the right skills available there. Well, there was a recent very robust systemic review of 27 studies that was published and this had thousands of patients, thousands of patients. In this study, it demonstrated that when a vascular surgeon is called in during a case rather than planned in advance, the blood loss is dramatically higher, more than double in some series over 2000 ML compared to 1000 ML operative times increase significantly, complication rates go up. And when complication rates goes up, everything else goes up with them. What does that mean? It means like length of stay, ICU utilization, readmissions and mortality. So you can see how all of this could be unrecognized hits to the bottom line that is a direct consequence of not having robust vascular care available. But it's not just the emergency conditions that are leading, lead to problems and poor, poor outcomes and a hit on the bottom line as well. When vascular surgeons are involved in case planning with other disciplines in advance, we see much, much better results. For instance, vascular complications can be avoided before they happen. And when that happens, there's no complication. So preoperative collaboration has been shown to directly be associated with shorter operating times, less blood loss, better post operative Outcomes in multiple areas in regards to, like, hemorrhage, loss of blood flow, or what we call ischemia. And then even in oncologic surgery where there's a lower rate of positive margins in cases where vascular surgeons have been involved. So operationally that means shorter hospital stays, fewer patients who need to be stepped up to the ICU, fewer 30 day readmissions, which can trigger penalties, and fewer cases that turn from routine and catastrophic. And all that has a direct operational cost attached to it. Now, when vascular surgeons are collaborating with our peers in whatever the realm is, whether it's trauma, whether it's a structural heart, like with ecmo, whether with our oncologic surgeons or urologic surgeons, and we have a very complex, challenging case, and we come together as a team to work through that case, and we get that patient through the case skillfully, safely, without complications. It's just a glorious event to take something that's so high risk and so complex and have a good outcome. And the fact that you can develop these multidisciplinary teams with vascular involvement, you're able to increase your casement index. It's been shown that these complex cases with vascular surgeons evolved, have a significantly higher case mix index. It's like 5.6 versus 2.1 for the routine cases that vascular surgeons aren't involved. So again, it's a multiplier and allows the hospital and its other service lines to do more complex cases right there without sending them out.
- [12:27]
A
Thank you so much, Dr. Schutz. Dr. Molnar. Yes. Let's move to you get your take here. In terms of the complications that can be prevented here, what else would you add? And I would invite any additional commentary too, around sort of what the good picture looks like when you've got strong vascular coverage, as Dr. Schutz started to sort of paint that picture as well.
- [12:49]
C
Yeah, I've been fortunate to be part of a strong vascular team. And again, it is very number one, it's rewarding to be able to work with our colleagues in such a way. I know for our surgical oncologists, it's great that they will consult us often before a big procedure because they recognize that if they're going to do that Whipple procedure, which is again, a high complex case, high index case, but there might be portal vein involvement with the tumor, and they might need to shave the portal vein or reconstruct the portal vein, it's much better that we're engaged at the front end of that, so that we're either scrubbed with them when, when that part of the case is coming or we're on standby so they know we're not in our up to our elbows and other things going on, that we've sort of set that time aside to be there for them. And as Dr. Shute said, I mean, there's decreased blood loss, there's better outcomes. It's just a well oiled machine. And that's what a hospital administration wants. I mean, they want their service lines to be protected not only from potential complications, but when those complications occur, which I don't care what you're doing or what service line you're in. As Bill said, there's blood vessels all over the body and I'm not sure what the number is. I think it's 60,000 miles of blood vessels within the human body. It's an amazing thing. But if it's the ICU putting in lines, if it's the anesthesiologist putting in a cordis, if it's a general surgeon or an obstetrician gynecologist putting in a trocar, those things are going to happen. That trocar can get into that aorta. And if you don't have a strong team ready to take care of that, you're going to have increased risk to loss of life and limb. And so it is a beautiful thing. The inevitable is going to happen. But if you don't have a strong team in place to take care of those complications, you're going to have bad outcomes. If you don't have any vascular surgeons at all, you're going to have to transfer some of those patients, as Bill had alluded to, which number one, puts them at an increased risk. If you have an ischemic limb and it's not taken care of, you have, you know, hours to get that addressed. And if you have a massive hemorrhage issue, you have minutes. So without a strong team in place that can come and respond and take care of the institution, you know, we're sort of known as the firemen. Things happen, we go and we're the first responders to take care of it. And we're often overlooked and people don't recognize that. But there's not a service line within the hospital that we don't touch and help enable them to do their trade.
- [15:26]
A
Excellent. Well, Dr. Molner, Dr. Shoots truly appreciate you coming on and sort of really helping our listeners understand the value of vascular surgery and the value of having strong vascular surgeon teams. If our listeners, if a hospital executive out there is listening to this. Those listening to this remembers one thing from our conversation today. What would you like that to be? Dr. Molner, let's begin with you.
- [15:50]
C
I think again, strong administrative support for a vascular service line is win, win for. I mean, first off, it's the biggest win comes for the patients because they have better outcomes. Some cases that might not have been taken on or addressed before now can be with again, the assistance of the vascular surgery team. And the vascular surgeons, of course, benefit because they can increase their portfolio of complex cases that are provided. But the hospital really needs that infrastructure. And I think the administration, if they have a great strong vascular service line, congratulations. And if they do have that, I'd encourage them to continue to engage with them and to see how they can advance going further. If they don't, I should suggest you should consider that because I think that's where your growth is going to be. That's where you're going to have growth of complex cases and you're going to have decreased complications and better overall outcomes with increased margins. Excellent.
- [16:53]
A
Thank you so much, Dr. Molnar. Dr. Shoots, what are your final thoughts here?
- [16:56]
B
I agree with everything, Dr. Molnar. Beautifully said. I'd like to let the healthcare executives just think about this for a second. Vascular surgery is not a cost center. It's the infrastructure that makes your highest value service lines possible. As we discussed before, in the way that we support these service lines, there's data that shows that has been published. It shows vascular surgery often generates 6% of a health system system's growth margin, but only uses 3% of the inpatient volume. That's exceptional efficiency. And as Dr. Molnar mentioned, investing in your vascular surgery is a very forward thinking view that will provide great returns to your system and that is going to be even more challenging to systems that wait. There's projected to be a significant shortfall of vascular surgeons in the next 2010-20 years. So if you don't start now, you're going to be way behind when it's time to play catch up with the increasing number of patients that are going to require vascular care.
- [18:11]
A
Yeah, building this strong service line isn't going to get easier in the future, but it better, better start immediately. Well, again, one final thank you to both of you. It was a pleasure having this conversation. Truly appreciate it. I also want to thank our sponsor, Society for Vascular Surgery for helping us put this podcast together. You can tune into more podcasts from Becker's Healthcare by visiting our podcast page at beckershospitalreview. Dot com.