At the recent International Congress meeting in Phoenix, AZ, Dr Edward B Diethrich discussed the ever-changing role of endovascular therapy and how the specialities involved must adapt their training protocols to match the endovascular evolution taking place.
"The players and stage upon which we are performing are dramatically changing," he began. "We all recognise that the origins of endovascular development were difficult and the tools used were crude. The stage on which those early pioneers performed was a particularly unpleasant one...However, it introduced the basic concept of working within the blood vessel and it is this idea that has led to numerous advancements and change."
Despite such a positive evolution in endovascular medicine, Diethrich warned that there are still critical issues that need to be resolved, especially what he termed, "the metamorphosis of the specialties". He argued that as the roles of the players involved change the economic
benefits decline. Diethrich said that nowhere was the more pronounced than in the training and perceptions of the next-generation of endovascular specialists. "The perception of the stage is blurred, as are the pathways of the future."
He said that when endovascular therapies were first mooted, vascular surgeons considered it a 'crazy' notion and cardiologists were only interested in developing their own agenda. However, according to Diethrich, cardiology has now taken an aggressive role in endovascular therapies. He cited the example of the EuroPCR and Transcatheter Cardiovascular Therapeutics conferences, which have both increased their focus on peripheral and carotid treatments, so much so that the former, he hypothesised, may need to change its name.
Diethrich said that the future of cardiothoracic and vascular surgery was at risk as the number of applicants was falling year on year. He cited figures that demonstrated that cardiothoracic and vascular fellowships had, in his own words, "become less attractive". For example, with the advent of drug-eluting stents, the reimbursement for coronary artery bypass surgery, "the economic driver for cardiothoracic surgeons over the past two decades," has fallen by $3,000 over the past 17 years. During the same period, the customer price index has risen by 70%. "Obviously, things are going in the wrong direction." Given the rate for two out-patient procedures in a vein clinic is $4,200, Diethrich said, "is it any surprise that those seeking training in vein centres are cardiothoracic surgeons?"
This means that young students looking for a career path have a confused idea regarding their future. "Do they know what we do? Where we are going in the future? Are they going to be vascular specialists or enter vascular endosurgery?" Future training is the key to answering these questions. However, he lamented the lack of emphasis on a training paradigm for the future. A future, he said, that was "now" and he asked, "Should the training be multi-disciplinary to deliver vascular surgery?"
European experience
The European experience of vascular surgeons and interventional radiologists teaming up has worked well, Diethrich observed, "But my feeling is that it would not work in the US, because there are economic incentives at risk." He added that the data currently available indicates that the evolution of peripheral intervention will proceed along classical lines.
The facts are damning. In 1996, 3,400 peripheral interventions were performed: 25% by interventional cardiologists, 65% by interventional radiologists and 10% by vascular surgeons. In 2005, there were 750,000 peripheral intervention procedures: 55% performed by interventional cardiologists, 30% by interventional radiologists and 15% by vascular surgeons (numbers do not reflect aortic endografting repair or carotid stenting). Diethrich argued, "If this trend continues, interventional radiology with have a lessening role except in some centres of vascular excellence. Cardiology will continue to conquer the peripheral vascular bed (iliacs, renals, etc) and vascular surgery will experience a decline in some areas, but dominate abdominal and thoracic endografting.
"As regards the carotid artery, perhaps there is more uncertainty here than any other place. It is all about money! Centers for Medicaid and Medicare Services has assured us there is limited reimbursement for carotid artery stenting. It is also clear that carotid stenting is just the beginning of designation therapy, with reimbursement linked to certification and outcome analysis. It is clear that the players and the stage are morphing in each issue - and in the wrong direction," Diethrich concluded.
|
