Peripheral Vascular Care: Should You Have a "Vascular Center"? by Barbara Sallo, RN, MBA

The designated Vascular Center can be the main geographic location for admissions and screening functions providing the referral and coordination for additional diagnostic studies and treatment. Additionally, prevention, education and outreach staff can be housed in this area and can support a “cross functioning” staff model. A sample design for a Vascular Center is shown in Exhibit 3.

In addition to the patient entrance and medical staff/exam location there are a number of additional components located in areas throughout the hospital that provide services for the PVD patient:

1.The Noninvasive Lab: ideally located in or close to the Vascular Center, performs a comprehensive range of testing to diagnosis PVD, and should provide same day testing with rapid report turnaround, utilizing a dedicated staff. It is advisable for the Noninvasive Lab to be accredited by Intersocietal Commission for Accreditation of Vascular Lab and/or American College of Radiology Accreditation.

2.Magnetic Resonance Angiography: a diagnostic tool for PVD that has the patient benefit of not requiring contrast use and few procedural side effects. The equipment requires specialized software and personnel education. A new type of contrast (MS-325) to be released next year will offer additional imaging potential.

3.Radiology Suite: provides diagnostic and intervention procedures and advanced imaging quality. It is still considered the “Gold Standard” for diagnostic testing, invasive procedures using both radiation and iodine based contrast. Procedures are performed typically by interventional radiologists.

4.Cardiac Catheterization Lab: typically used for cardiac procedures, however, underutilized labs may provide accommodation of advanced imaging for PV catheter based procedures. Labs with high cardiac volumes may prohibit PVD procedures and non cardiology practitioners are not always made welcome.

5.Operating Room: can be equipped to provide advanced imaging for catheter based minimally invasive procedures, should involve vascular surgeon in imaging choices, fixed equipment may limit the room flexibility, sterile environment offers advantages for PVD procedures, supplies of stents and catheters should be controlled/coordinated with radiology and cath lab

6.Wound Healing Center: PVD is a common diagnosis for patients with non healing wounds. These patients may utilize the services of the wound center resulting in the need for good coordination between the Vascular Center and Wound Center if they not located within the same department.

What are the Staffing Considerations of a Vascular Center?

A number of physician disciplines have experience and involvement with vascular care. Today, we are seeing the emergence of the Vascular Medicine Specialist. This physician often has a background in family practice and/or internal medicine. They can serve as the Medical Director of the Vascular Center. This individual determines the appropriate referral of patients to the most appropriate sub specialist and maintains the continuum of care process with daily rounding on all inpatients. The Vascular Medicine Specialist which is most common at academic medical centers can serve as attending physician for Interventional Radiologists. They also can be responsible for reading and reporting on vascular tests.

While this physician staff model is growing in popularity, historically many different types of physicians have been in charge of patients’ PV care as shown in Exhibit 4.

The nursing and technical staff has had a “home grown” tendency as it has only been of late that the rationale for dedicated, trained and focused staff has taken off. The role and function of the personnel vary from hospital to hospital but some distinct models are developing as shown in Exhibit 5.

What is the Revenue Associated with PVD Care?

If PVD services are provided in existing surgery and interventional radiology suites, no additional capital costs can be expected. The expansion of catheter-based care in the cath lab to include peripheral vascular interventions will give rise to additional expenses. Imaging requirements for the PVD patient may require new equipment purchases but many hospitals have been able to use existing coronary cameras. Specialized supplies are also required. Staff education and training must be expanded to include peripheral procedure techniques and potential PV complications.

Revenue from PVD care provides the opportunity for healthy margins for hospitals. Medicare contribution margins for vascular DRGs compare favorably with cardiac DRG margins. Across all vascular DRGs the average contribution margin (revenue less direct costs) is more than 30 percent (Source: Market Insights, Inc., San Francisco; Cardiovascular Roundtable analysis 1999).

While there are no statistics on the revenue generating figures for interventional radiologists and cardiologists treating PVD, a recent survey provides that information on vascular surgeons. Results from a survey of 1,200 hospital CFOs reveals that vascular surgeons generate an average of $2.2 million in revenue—derived from referrals and associated treatments—for their affiliate hospitals each year as show in Exhibit 6.

Where to Go to from Here?

Cardiovascular care is big business. This year alone, the American Heart Association anticipates that $329 billion will be spent on this patient population. While the PVD portion of the total is significantly smaller than the cardiac portion, the patients are the same. Peripheral vascular care is an essential component of full service cardiovascular care.

There is no question that the number of PVD patients is growing and these patients are underserved today. Hospitals must decide how to best care for this population. One of the first steps is compiling a PVD dedicated business plan that covers:

Market size/opportunity

Competitive environment/issues

Scope of service

Physician specialties/medical coverage

Clinical operations model

Marketing and outreach initiatives

Financial requirements/assumptions

Structure/governance/ownership

Conditions for success

Implementation recommendations and timeline

With the growing trend toward healthcare self-education supported through the press and the Internet, the public is becoming increasingly aware of the potential dangers of untreated vascular disease. Quality of life has taken on new meaning and the older population will continue to seek healthcare resources that will enable them to maintain active lifestyles. Be prepared for the baby boomers to seek out and demand assessment and treatment of peripheral vascular problems.

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BIO:

Barbara Sallo, RN, MBA is the President of Health Care Visions, Ltd. a cardiovascular consulting firm based in Pittsburgh, Pennsylvania. The firm brings extensive knowledge and expertise in this area of clinical care. Health Care Visions, Ltd. has assisted a multitude of hospitals in all phases of cardiovascular programs from market assessments, program assessments and feasibility studies to business planning and implementation.

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