1. Integrating Multiple Specialties into Professional Training and Practice: A Vascular Surgeon’s Perspective
John J. Ricotta MD FACS
Harold Hawfield Chair of Surgery
Washington Hospital Center

2. John J. Ricotta, MD DISCLOSURES
I have no real or apparent conflicts of interest to report.

3. Vascular Disease: A Distinct Specialty
90 M Hypertensives / 23 M Diabetics
133,000 amputations annually
750,000 strokes annually
2.5% males over 50 have AAA
5% US adult population with “PAD”
10-30% adults have venous disease 4% of >65 have CVI with Ulcers

4. Vascular Disease: Poorly Taught, Poorly Practiced
Dx and Mgmt of Vascular Diseases not a major focus of Core Residencies
Most patients with PVD do not have recommended medical treatment Antiplatelet agents Statins ACE’s & ARB’s Smoking cessation
Prevention / Rehab Programs are lacking

5. Vascular Disease: Too Many Interventions?
> 80% of > 170,000 annual carotid interventions are for asymptomatic disease
Impact of SFA intervention on life and limb is marginal
No demonstrated benefit of intervention for AAA<5.5 cm, TAA <6 cm.
Minimal benefit of Renal PTA

6. Vascular Disease: Need to Refocus
Procedure / Intervention oriented
Identify and treat asymptomatic or moderately symptomatic disease
Prevention and Medical Management need improvement
WHAT WILL HAPPEN IF (WHEN) THE INCENTIVES CHANGE?

7. Vascular Disease: The Future?
Disease rather than procedure oriented
Reward comprehensive management rather than episodes of care
“VASCULAR HOME”
Outcome driven
Risk Adjusted
Independently Audited

8. The Future Vascular Practitioner: A Vascular Surgeon’s Perspective
Broad Knowledge of Vascular Disease
Expertise in Vascular Imaging
Evidence based
Subspecialization – Intervention and Non Intervention
Capable of Open and Endoluminal Interventions – reduce selection bias
Regionalization for High end interventions?

9. Unified Model of Training

10. “Funnel” Model of Training

11. Current and Future Training Models in Vascular Surgery
“5 + 2” – 2 years Vascular after 5 years GS
“0 +5” – 24 months “Core” plus 36 months Vascular
60 months of clinical training
36 months dedicated to Vascular Care
“0+7” – 24 months Core, 36 months Vascular , 24 months Thoracic

12. Essentials of a Common Training Pathway: Vascular Perspective
5 years of clinical training
3 years Vascular Training Interventionalists train in Open and Endovascular Techniques. Non Interventionalists focus on VM, VL, Venous Disease
Certification through multiple Boards?

13. Integrating Specialties into Current Practice
Much more difficult in current climate
Different indications for intervention
Lack of Common Outcome Reporting
“Cherry picking” cases
Lack of Financial Integration
Money and Ego

14. Guidelines for Integration
Common Practice Standards evidence based when possible different approaches require entry into a common database
Transparent Outcomes Reporting
Independent Audit
Common Quality Review
Commitment to comprehensive patient care – individual or practice group

15. Goals of Vascular Practice Integration:
Disease rather than procedure oriented
Provide comprehensive management rather than episodes of care
“VASCULAR HOME”
Outcome driven
Risk Adjusted
Independently Audited