Cardiac Stents [1] Are We Stenting too Much ?

“At a time when the health care industry faces much ambiguity through reform, one certainty is apparent: Resources will be more constrained as we face a shortage of physicians, an influx of chronic condition patients, and declining reimbursements.”stent-2

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Editor’s Note:

I had an interesting discussion with our chief cardiac surgeon the other day, it is a topic that seems to present itself over and over again regardless of institution.  It is the question of surgical vs cardiac cath lab intervention- and what it really boils down to is volume and how it is controlled.

Having worked as a perfusionist and placing people on bypass at 30 institutions Hawaii and Canada included, this issue remains unresolved since my tenure in the profession began in 1990.

The cardiologists are truly the gate keepers of the cardiac surgery population.  The referral system in medicine can either be described as symbiotic, host-parasite, or purely parasitic, depending on what your relationship is with your referring peers on any given day.  Some days collaboration waxes, and others it weans, and we end up seeing what we always see, feast or famine.  Moments of calm and quiet in the operating room (where there are always the inevitable “Chicken Littles” screaming that we are doomed and our program is destined for eternal obscurity), and sooner than later- getting hit by a cardiac storm and sucking it up doing the 3-4 hearts per day, per perfusionist thing.

There are an array of ethical and moral issues we play around with everyday in the OR in regards to patient distribution and selection.  Certainly in the early stages of setting up a TAVR program, when the only pationts that you are seeing for endovascular aortic valve replacement are nonagenarians, on their last legs, and very very sick.  Watching a couple of those die isn’t pleasant, and since it is in the middle of the evolution of becoming a a legitimate TAVR program, begs a comparison to experimentation and dog labs.  That discussion should be tabled on another day and is beyond my credentials to criticize, but it is not beyond my personal moral and ethical makeup to question.

So today we begin with part 1 of a series of posts dedicated to enlightening all of us with some basic facts and figures of research into just exactly how our numbers become “our numbers”.

Please leave comments in the comments section- they are very welcome 🙂

Frank

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A Closer Look at CV Productivity and Procedure Yield

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At a time when the health care industry faces much ambiguity through reform, one certainty is apparent: Resources will be more constrained as we face a shortage of physicians, an influx of chronic condition patients, and declining reimbursements. Careful planning will be critical; yet, the data needed for such preparations are often elusive.

To provide greater visibility and inform strategic planning efforts, the Roundtable has tackled key questions surrounding typical productivity and procedure yield for the CV service line. Though the exact calculations may vary by region, the following analysis provides baseline data.

Q: What is the approximate annual utilization rate for key cardiovascular services in the United States?

CR: Per 100,000 U.S. population, approximately:

  • 83 CABG surgeries
  • 37 valve surgeries
  • 300 PCI
  • 62 ICD system implants
  • 67 pacemaker system implants
  • 33 EP ablations
  • 0.83 heart transplants
  • 0.67 LVAD implants

Q: What is the supply of cardiovascular specialists per 100,000 population in the United States?

CR: Per 100,000 U.S. population, approximately:

  • 5.5 general (medical) cardiologists
  • 1.8 interventional cardiologists
  • 1.4 cardiothoracic surgeons
  • 0.6 electrophysiologists

Q: What is the typical visit productivity of a cardiologist?

CR: As reported by MGMA (2008), the following benchmarks reflect mean values per FTE cardiologist per year:

  • 18,683 total RVUs
  • 8,183 work RVUs
  • 1,343 patients
  • 4,901 encounters

Q: What is the expected downstream yield for common related cardiac procedures?

CR:The approximate ratios are:

  • 2.2:1 for diagnostic cath to PCI (including concomitant diagnostic cath and PCI)
  • 8:1 for diagnostic cath to CABG (including concomitant diagnostic cath and PCI)
  • 3.5:1 for PCI to CABG

Q: What is the annual downstream volume potential from one cardiologist?

CR: The following data derive from the volume of procedures performed in the United States and the number of cardiologists in practice. This modeling assumes homogenous utilization patterns across markets (i.e., each cardiologist is equally productive).

Also, it is important to note that not all of these services occur as a direct result of a medical cardiologist’s work. For instance, interventional cardiologists also produce downstream business (i.e., medical cardiologists are not the sole source of patient volumes). Similarly, primary care physicians may serve as the originating physician for referrals that ultimately lead to cardiac procedures.

Approximate annual downstream volumes (and associated site of service) are as follows:

  • 10-14 CABG surgeries (100% inpatient)
  • 5-7 valve surgeries (100% inpatient)
  • 40-50 interventional caths (PCI) (approximately 85% inpatient, 15% outpatient)
  • 10-12 ICD system implants (approximately 75% inpatient, 25% outpatient)
  • 12-15 pacemaker implants (approximately 60% inpatient, 40% outpatient)
  • 3-7 lead replacements (replacement and insertion combined; approximately 70% inpatient, 30% outpatient)
  • 5-7 EP ablations (approximately 60% inpatient, 40% outpatient)
  • 300-400 cardiac nuclear exams (approximately 50-60% will be office-based)
  • 600-900 echo exams (approximately 50% will be office based)

Q: What considerations should be accounted for in translating these data for a specific region?

CR: The above data are approximations, and actual procedure yield may vary by region. Note that physician supply, for example, is not evenly distributed across the nation. Specific caveats to consider when using these data include:

  • Demand for cardiovascular services is highly varied region by region. This variance is somewhat tied to availability of cardiologists, but some variability seems to persist even in regions with essentially identical supply of cardiologists per population.
  • The need for cardiologists is in part a function of the supply/practice patterns of other physician types. For instance, in a market with many PCPs/internists, it is possible that fewer cardiologists are needed, assuming these generalists take on a disproportionate share of management responsibility for cardiac patients.
  • The demographic of the market in question is important. Age, overall health profile, insured rate, and so on all come into play when assessing the need for cardiologists.
  • Productivity and practice patterns of cardiac subspecialists will influence physician demand.
  • The definition of each specialist may influence these statistics. Reports of the number of active cardiologists differ, in part because of how distinct specialties are counted (board certified or eligible/fellowship trained, purely non-invasive or those who do diagnostic caths and no PCI, etc.).

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