Office Based Endovascular center Lessons Learnt

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Presentation transcript:

Office Based Endovascular center Lessons Learnt Krishna Jain MD South Florida Society for Vascular Surgery 10/26/13 Office Based Endovascular center Lessons Learnt

Government policy In 2005 deficit reduction act payment was approved for percutaneous vascular procedures when performed in office CMS starting paying for the procedures Other insurance companies followed soon after

Changing Paradigm Endovascular procedures are effective Patients prefer endovascular approach Recovery time is shortened Can be cost effective Trend towards endovascular first

Benefits Own your dialysis access so that you can keep it functional for the longest period of time Perform other invasive procedures Increase your revenue Control your schedule Improve your life style Increase productivity Improve patient care Able to recruit

Current status Life line vascular access (72) Fresenius (54) Nephrologists 65 18 Vascular surgeons 6 8 General surgeon 1 Intervention radiologists 27 Hospital based 1 Other centers (100) miscellaneous

Procedures Procedure Aortogram Fistulogram/Angioplasty/Coiling Aortogram/Runoff Microphlebectomy Aortogram/Angioplasty EVLT Aortogram/Angioplasty/Stent EVLT/Microphlebectomy Aortogram/Runoff/Angioplasty Tunneled Catheter Insertion Aortogram/Runoff/Angioplasty/Stent Tunneled Catheter Removal Atherectomy Tunneled Catheter Exchange Fistulogram Venogram Fistulogram/Angioplasty Venogram/Angioplasty Fistulogram/Angioplasty/Stent Inferior Vena Cava Filter Insertion Fistulogram/Thrombectomy Inferior Vena Cava Filter Removal Fistulogram/Thrombectomy/Angioplasty Power Port Insertion and removal Fistulogram/Thrombectomy/Angioplasty/Stent Carotid angiogram Fistulogram/Coiling Renal angiogram and angioplasty

Total Procedures 5/22/2007-12/31/2012 Procedure Type Number Procedures per Type Percentage Total Procedures Fistulogram 2719 42% Catheter 1477 23% Venous 1019 16% Arteriogram 939 15% PowerPort 184 3% Venogram 63 <1% IVC 57 Total 6,458

Complications by Procedure Type Procedures Complications % Complications/Procedures Venous 1019 22 2.2% Arteriogram with no interventions 571 4 1% Arteriogram with intervention 368 10 2.7 Fistulogram 2719 13 0.5% Catheters 1477 0.3% Inferior Vena Cava Filter 57 1 2%

Lessons learnt You can do more than you think Do not push the envelop Follow Medicare guidelines and avoid audits Cost containment is mandatory Follow protocols

Lessons learnt Mentor new associates Communication between the team members is essential Use conscious sedation judiciously Be prepared to handle all emergencies Know your data

Cost containment Join Buying group Employee cost Sharing facility Inventory

Contraindications for Procedure in Office Weight over 400 pounds Poor pain tolerance ASA 4 Severe dye allergy Previous bad experience for patient 4% of dialysis patients are not suitable for office procedures

Complication Comparison Type Procedures Complications Complication Rate National Rates ARTERIAL 833 14 1.15% 1.9% - 2.9% DIALYSIS 2379 11 0.39% 0.80% - 2.0% EVLT 824 17 1.00% 2.0% - 15% MICRO 121 2 0% CATHETERS 1465 0.31 0.89% - 1.39% IVC 41 1 25% Overall Complication Rate 5,663 47 0.61%

Building

Future Greater than 75% of endovascular procedures will be performed in office based access/ endovascular centers unless government decides to change the current regulations and financial structure in a drastic way