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We are “Fix It” People
• Provide full spectrum care, develop long-term relationships, and make a difference in our patients’ lives; the goals are practical, dilemmas are intellectually stimulating, the procedures include multiple techniques, are anatomically based, aesthetically pleasing, and technically challenging, with many opportunities for innovation.
Major Trends Affecting Vascular Care
Peter A. Schneider, MDKaiser Foundation Hospital
Honolulu, Hawaii
PNEC, 2018
Microsoft CEO Steve Ballmer, 2007
Eventually, we will have one of these.
Jamie OrlikoffOrlikoff and Associates 2018
H ealthcare m ega-m ergers dom inate 2017By A lex Kacik | D ecem ber 26, 2017
H orizontal, vertical, regional, national, large- and sm all-scale— 2017 m arked a year of m ergers.
They ranged in a ll shapes and sizes, from the national hospita l system expansions charted by C atholic H ealth In itia tives and D ignity H ealth to the vertical com bination of reta il pharm acy giant C VS H ealth and insurer Aetna. And they all had one th ing in com m on: try ing to achieve scale and turn it in to a
financia l and com petitive advantage.
F ive m ega-m ergers w ere announced over an eight-day span in early D ecem ber, starting w ith C VS H ealth 's p lanned purchase of Aetna on D ec. 3.
The next day, Advocate H ealth C are and Aurora H ealth C are announced a m erger that w ould create a $10.7 b illion cross-state system , continuing the trend of providers realigning into regional hubs that g ive them significant m arket share. Advocateproposed m erger w ith N orthShore U niversity
H ealthSystem couldn't overcom e antitrust concerns regarding its redundant service areas. So D ow ners G rove, Ill.-based Advocate turned to the largest health system in W isconsin in a proposed deal that does not involve any m arket overlap. O n D ec. 6, the U nitedH ealth G roup agreed to buy dia lysis
provider D aV ita 's m edical unit for $4.9 b illion to expand the national insurer's outpatient care services. D aV ita M edical G roup's physic ian netw ork provides care to approxim ately 1.7 m illion patients annually across s ix states in 35 urgent-care centers and six outpatient surgery centers.
The fo llow ing day, C atholic H ealth In itia tives and D ignity H ealth form alized a deal that w ould have— at the tim e— created the largest not-for-profit hospita l system . The new health system w ould include 139 hospita ls w ith operations in 28 states w ith no overlap in hospita l service areas, s im ilar to the Advocate-
Aurora deal, and com bined revenue of $28.4 b illion, eclipsing Ascension's $22.6 b illion. The m arriage w ould test a new ly popular co-C EO m odel that delegates certa in ro les betw een Lloyd D ean and Kevin Lofton.
N ot to be outdone, on D ec. 10 plans em erged of an Ascension H ealth-Providence S t. Joseph H ealth m erger, w hich w ould create the largest hospita l system , as first reported by the W all S treet Journal. It w ould g ive the com bined not-for-profit entity 191 hospita ls in 27 states and annual revenue of $44.8 b illion, ahead of H C A 's $41.5 b illion. P rovidence S t. Joseph's experience w ith taking on risk through its insurance arm w ould benefit Ascension, said M iki
Kapoor, president of Tea Leaves H ealth, a consulting and softw are com pany.
"W e are seeing the payers becom e providers," he said. "They are beginning to ow n m ore of the risk and get c loser to the patient. These deals are happening because they are finally putting the consum er at the center of healthcare.” N egotiating better rates w ill help offset their losses from taking on m ore M edicaid benefic iaries as the population ages. But th is is a tactic that can also ra ise prices for consum ers.
The healthcare industry saw the start of another shockw ave in 2017 as Am azon tiptoed into the healthcare supply chain. The e-com m erce behem oth, w hich has used its logistical prow ess and scale to upend m any m arkets, has quietly established a grow ing presence in the m edical supply sector. It has
a lso received w holesale d istribution licenses from several state pharm aceutical boards. The m oves have led som e com panies to forge m ore m ergers and acquis itions.those assets and m ust develop re lationships w ith others in the com m unity."
Imagine when Amazon knows more about your health than you do!
The American Medical Association reported in its 2012 Practice Benchmark Survey that a slight majority (53 percent) of physicians owned their practices, down from 61 percent in 2007/2008; 42 percent of physicians were employees, and 5 percent were independent contractors.1 The percentage of physicians who identified as practice owners varied widely across specialties.
SuperstitionWitchcraftHearsay
Germ theorySanitationResearchTreatmentTwo-thirds of the people in world history
who have reached the age of 65 are alive right now.Dr. Robyn I. Stone, Leading Age
65 and over age group will grow 28% in next decade.10,000 baby boomers turn 65 every day, this will continue for next 12 years.25% of Medicare recipients have five or more chronic conditions, see an average of 13 physicians a year and fill 50 prescriptions per year.
Characteristics of Medicare Recipients
Kaiser Family Foundation 2017
In 1960, 5 workers supported every person over the age of 65.
In 2025, 2 workers will support every person over the age of 65.
The switch to value-based reimbursement turned the traditional model of healthcare reimbursement on
its head, causing providers to change the way they bill for care. Instead of being paid by the number of
visits and tests they order (fee-for-service), providers’ payments are now based on the value of care they
deliver (value-based care). And while the industry waits for the final policy from the federal government,
one thing is certain—the trend for value-based care models will continue.
Much of this change is long overdue and quite exciting because it’s driving improvements to the delivery
of care by mandating better care at a lower cost. But for providers and health systems that can’t achieve
the required scores, the financial penalties and lower reimbursements create a significant financial
burden.
Shifting Revenue Mix: The Rise of Medicare and Medicaid
The first hospital challenge, shifting revenue mix, is demonstrated in the graph below. The percentage of
commercial payers will continue to shrink, while payer types with lower reimbursement rates will increase.
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Executive Report
Copyright © 2017 Health Catalyst 1
performance measurement. For the last few years, Medicare has required hospitals to track their 30-day
readmissions rates for heart attack, heart failure, and pneumonia patients. Medicare is adding three
additional populations to this requirement. Many private payers require that health systems track this
measure for populations covered in their contracts. Health systems must also track 90-day readmission
rates. This 30-day readmissions example is further complicated by the myriad of potential quality
measures and patient populations, demonstrating how complex this process can become.
Challenge #3: Optimizing Margins as Revenue Drops
The transition from FFS to value-based reimbursement will take years—and it will hurt in the short run.
Meeting value-based goals requires hospitals to reduce utilization among their populations, therefore
reducing their procedure volume and revenue. The following simple graph illustrates this trend:
Figure 2: Notice how’s there’s no specific unit of time to mark the transition from fee-for-service
to value-based reimbursement. Nobody knows yet how long this process will take.
No specific units of time have been included in this graph because we don’t know how long this process
will take. But we do know there will be a transition period, during which time to total revenue will likely
Copyright © 2017 Health Catalyst 9
Volume-basedto Value-based
How will we dealwith these challenges?
Way bigger than the open versus endo discussion
Healthcare Systems and Services Practice
Enabling healthcare consumerism Jenny Cordina, Rohit Kumar, and Erin Olson
6McKinsey & Company Healthcare Systems and Services Practice
to use them.15 At present, many consumers
are disappointed by the digital healthcare tools
available to them. For example, less than
one-third of our CHI survey respondents said
they were highly satisfied with the digital tools
offered by their primary care providers—the
lowest satisfaction rating reported for any
aspect of care (other aspects included quality
of care, length of wait time, coordination with
other physicians, and time with physician).
apps were available in the iTunes app store;
thus, building awareness of a specific app is
a crucial first step in getting consumers to use
it. (The difficulty in building awareness helps
explain why only 12% of the apps accounted
for 90% of the downloads.14) However, aware-
ness, although necessary, is not sufficient for
adoption. Consumers are looking for value and
ease—if digital tools do not deliver value and
are not easy to use, consumers won’t continue
Healthcare Consumerism — 2017
Exhibit 4 of 4
Do you currently have a preferred…?
% of respondents1
EXHIBIT 4 Many consumers have few, if any, preferred healthcare partners
1 Numbers shown do not always sum to 100 because of rounding.
Source: 2016 McKinsey Consumer Health Insights Survey
Yes, I have one I use for all care
Yes, I have one I use for occasional care
Yes, I have one I use for some care
No, I don't have one
Pharmacy
Health insurance company
Adult primary care provider (PCP)
Hospital/health system
Laboratory
Specialist
Children’s hospital
Urgent care center
Health clinic in a pharmacy
Health clinic in a retail store
Pediatrician
63
4258
57
49
47
39
17 7 4532
26
22
11
7 7 5 81
8 6 75
15 8 55
10 6 57
14 6 42
10 5 38
17 7 28
10 4 29
13 7 17
Overtreatment Is Common, Doctors Say - The New York Times
https://www.nytimes.com/2017/09/06/well/live/health-care-overtreatment-doctor-survey.html[4/2/2018 4:13:35 PM]
WELL | LIVE
Overtreatment Is Common, Doctors SayBy NICHOLAS BAKALAR SEPT. 6, 2017
41
Most physicians in the United States believe that overtreatment is harmful,wasteful and common.
Researchers surveyed 2,106 physicians in various specialties regarding theirbeliefs about unnecessary medical care. On average, the doctors believedthat 20.6 percent of all medical care was unnecessary, including 22 percentof prescriptions, 24.9 percent of tests and 11.1 percent of procedures. Thestudy is in PLOS One.
Nearly 85 percent said the reason for overtreatment was fear of malpracticesuits, but that fear is probably exaggerated, the authors say. Only 2 to 3percent of patients pursue litigation, and paid claims have declined sharply
checkmark-Q1-sale-export4 Get The Times from $9 99 a month$15.99 SEE MY OPTIONS Log in
Gr3
Overtreatment Is Common, Doctors Say - The New York Times
https://www.nytimes.com/2017/09/06/well/live/health-care-overtreatment-doctor-survey.html[4/2/2018 4:13:35 PM]
RELATED COVERAGE
DOCTORS
Helping Patients Make the Right DecisionsSEPT. 15, 2016
THE NEW OLD AGE
Some Older Patients Are Treated Not Wisely,but Too Much NOV. 6, 2015
THE AGENDA
Overtreatment Is Taking a Harmful TollAUG. 27, 2012
More in Well »
in recent decades.
Nearly 60 percent of doctors said patients demand unnecessary treatment.A smaller number thought that limited access to medical records led to theproblem.
More than 70 percent of doctors conceded that physicians are more likely toperform unnecessary procedures when they profit from them, while only 9.2percent said that their own financial security was a factor.
“This study is essentially the voice of physicians about the problem,” said thesenior author, Dr. Martin A. Makary, a professor of surgery at JohnsHopkins. “We’re told that there are too many operations done for narrowedblood vessels in the legs. Spine surgeons say that a quarter of all spinesurgery may not be necessary. Half of stents placed may be unnecessary.These are significant opportunities to improve quality and lower costs.”
41COMMENTS
A version of this article appears in print on September 12, 2017, on Page D4 of the New York edition with theheadline: Doctors: Overtreatment Weighed. Order Reprints | Today's Paper | Subscribe
New York Times Sept 6, 2017
O
Medicare Payments Surge for Stents to Unblock Blood Vessels in Limbs - The New York Times
https://www.nytimes.com/2015/01/30/business/medicare-payments-surge-for-stents-to-unblock-blood-vessels-in-limbs.html[4/2/2018 4:22:18 PM]
BUSINESS DAY
Medicare Payments Surge for Stents toUnblock Blood Vessels in LimbsBy JULIE CRESWELL and REED ABELSON JAN. 29, 2015
330
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Gr3
Procedures done in officeLoose guidelinesDecreasing coronary volumeCompetition between specialtiesMedicare billing outliers
Mixed up arterial andvenous proceduresIgnored the rise of CLI
New York Times, January 29, 2015
The Major Killers: Cancer and Heart Disease
C D C : D iabetes R eport C ard 2012
More Diabetics and Renal Failure
N ational Institute of D iabetes and D igestive and K idney D iseases (N ID D K)
Buddy Wires
Disease and treatment moving into distal vascular beds.
Exhibit 12. Lower Extremity Amputations as a Result of Diabetes, 2011
3.3
5.0 5.1
6.7 7.1 7.1
8.7 10.0
13.5
17.1 18.4
19.2
0
5
10
15
20
25
SWE AUS UK NZ FR SWIZ NOR CAN NETH US GER DEN
Amputations per 100,000 population
* Data from 2010 for the Netherlands, Switzerland, and the U.S.; and 2009 for Denmark. Source: OECD Health Data 2015.
Vascular Disease Reflects Socioeconomic Status
Figure 1. Prevalence of PAD by poverty-income ratio (PIR) category. PIR is a ratio of self-reported household income relative to a family’s poverty threshold A PIR value < 1.0 indicates family income below the poverty threshold. PIR was categorized as < 1.0, 1.0–1.99, 2.0–2.99, 3.0–3.99, 4.0–4.99, and ≥5.0.
Pande and Creager Page 11
Circ Cardiovasc Qual Outcomes. Author manuscript; available in PMC 2015 July 01.
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Figure 2. Prevalence of PAD according to highest attained education level.
Pande and Creager Page 12
Circ Cardiovasc Qual Outcomes. Author manuscript; available in PMC 2015 July 01.
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Pande et al. Circ Cardiovasc Qual Outcomes 2014;7:532
Diabetes: Global Epidemic
Global Sherpa: Globalization, Sustainable Development and Social Impact in World Rankings, Countries and Cities
2007-US 8-10%2025-US 10-14%
25GL OBAL BURDEN OF DIABE T ES
(ages 20–69) attributable to high blood glucose increased for both sexes across all WHO regions, except among women in the WHO European Region (Figure 3). The increase in the proportion of deaths attributable to high blood glucose was highest in the WHO Western Pacific Region, where the total number of deaths attributable to high blood glucose during this period also increased from 490 000 to 944 000.
1.2 PREVALENCE OF DIABETES AND ASSOCIATED RISK FACTORS
WHO estimates that, globally, 422 million adults aged over 18 years were l iv ing with diabetes in 2014 (more details on methodology can be found in Annex B and reference 4). The largest numbers of people with diabetes were estimated for the WHO South-East Asia and Western
TABLE 2. ESTIMATED PREVALENCE AND NUMBER OF PEOPLE WITH DIABETES (ADULTS 18+ YEARS)
Pacific Regions (see Table 2), accounting for approximately half the diabetes cases in the world.
The number of people with diabetes (defined in surveys as those having a fasting plasma glucose value of greater than or equal to 7.0 mmol/L or on medication for diabetes/raised blood glucose) has steadily risen over the past few decades, due to population growth, the increase in the average age of the population, and the rise in prevalence of diabetes at each age. Worldwide, the number of people with d iabetes has subs tant ia l ly increased between 1980 and 2014, rising from 108 million to current numbers that are around four times higher (see Table 2). Forty per cent of this increase is estimated to result from population growth and ageing, 28% from a rise in age-specific prevalences, and 32% from the interaction of the two (4).
In 2014
422 million adults had diabetes
a. Totals include non-Member States.
WHO Region
Prevalence (%) Number (millions)
1980 2014 1980 2014
African Region 3.1% 7.1% 4 25
Region of the Americas 5% 8.3% 18 62
Eastern Mediterranean Region 5.9% 13.7% 6 43
European Region 5.3% 7.3% 33 64
South-East Asia Region 4.1% 8.6% 17 96
Western Pacific Region 4.4% 8.4% 29 131
Total a 4.7% 8.5% 108 422
Source: (4).World Health OrganizationDiabetes Report 2016
Vascular Disease-Now an International Problem
Vascular Disease in Mummies
Allam et al. JACC: Cardiovasc Imaging 2011;4:315
The estimated mean age at death of these 44mummies was 39.3 ! 11.8 years. The mean age atdeath of this subset of mummies did not differ bysex (mean age 40.9 ! 10.4 years for men vs. meanage 38.2 ! 12.5 years for women, p " 0.45).Predictors of atherosclerosis. Definite or probableatherosclerosis was seen in 20 (45%) of the 44mummies in whom cardiovascular tissue was pres-ent. Twelve of these 20 mummies had definiteatherosclerosis and 8 had probable atherosclerosis.
The 20 mummies with definite or probableatherosclerosis were older (mean age 45.1 ! 9.2
years) than the mummies with CV tissue but noatherosclerosis (mean age 34.5 ! 11.8 years, p #0.002) (Fig. 1). With each year of advancing age,the probability of having atherosclerosis increasedby 9.6% (p " 0.006).
The frequency of atherosclerosis did not differbetween sexes. Of the 20 with atherosclerosis, 11(55%) were male and 9 (45%) were female (p " 0.38).
In mummies with definite or probable athero-sclerosis, the average number of vascular beds in-volved was 2.2 ! 1.3. Mummies with atheroscle-rotic involvement of !3 beds were significantlymore likely to be !40 years of age in comparisonwith those having involvement of 1 or 2 beds (p "0.02). In fact, all mummies with involvement of !3beds were !40 years old.
Atherosclerosis was most common in the aorta, itwas observed in 14 of 44 (32%), followed by theperipheral vessels in 13 of 44 (30%), carotids in 8 of 44(18%), iliacs in 6 of 44 (14%), and coronaries in 3 of44 (7%). An example of a mummy with atherosclero-sis in each vascular bed is a princess who lived duringthe Second Intermediate Period (1580 to 1550 BCE)and died in her early 40s (Mummy #35) (Figs. 2 and 3A,Online Videos 1 and 2). An image from a CT scan ofthe abdominal aorta from a modern patient is shownfor comparison (Fig. 3B). Figure 4 shows severeatherosclerotic calcifications in the arteries of theupper leg in a male scribe who lived during the 18thDynasty. Online Video 3 represents a female mummyrecently excavated from Fayuom of an unknownhistoric period who died in her late 40s, also withatherosclerosis of multiple vascular territories. Of note,
Figure 1. Age at Death of Mummies With and Without Atherosclerosis
Median age at death (line) !25th percentile (shaded box) and range(brackets) of the mummies with vascular tissue but no atherosclerosis andmummies with probable or definite atherosclerosis. The mummies with ath-erosclerosis were significantly older (p # 0.002).
Figure 2. Atherosclerosis in the Common Iliac Arteries
Computed tomography maximum intensity projection showing heavy calcifications (arrows) in the common iliac arteries on (A) axial and (B)coronal projections in the mummy of a princess who lived during the Second Intermediate Period (Mummy #35). Also see Online Video 1.
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 4 , N O . 4 , 2 0 1 1
A P R I L 2 0 1 1 : 3 1 5 – 2 7
Allam et al.
Atherosclerosis in Ancient Egyptian Mummies
320
D I S C U S S I O N
We used noninvasive CT scanning in a mannersimilar to its use in contemporary humans (16) tosearch for calcified atherosclerotic plaque in theremains of 52 ancient Egyptians. Of the 44 mum-mies in whom we could identify vascular tissue,45% had vascular calcification. While the number ofsubjects we were able to examine is small in com-parison with modern epidemiologic studies, ourdata are consistent with the conclusion that athero-sclerosis was common in ancient Egypt.
We saw evidence of calcification in the aorta,peripheral vessels, carotids, iliacs, and coronaryarteries. Incomplete preservation of the mummiesand embalming techniques that differed in theremoval of vessels or organs resulted in our inabilityto image all vascular beds in each mummy. Theaorta, iliac, and peripheral arteries were generallybetter preserved and available than the coronariesand carotids. It is apparent, however, that vascularcalcification affected arteries in many regions of thebody in ancient Egyptians, just as it does in con-temporary humans. Similar to findings in contem-
Figure 5. Atherosclerosis in the Popliteal and Tibial Arteries
Axial computed tomography images of the left leg distal to the knee showing (A) calcifications in the popliteal artery (arrow), and (B) ina slightly distal position, showing calcifications in the peroneal artery and the anterior tibial artery (arrows) in the mummy of a womanwho lived during the Ptolemaic Period (Mummy #22).
Figure 6. Atherosclerosis in the Carotid Arteries
Computed tomography maximum intensity projection sagittal view (A) showing heavy calcifications in the region of the left carotidartery at the carotid bulb (arrow), and (B) axial view showing heavy calcifications in the region of both the right and left carotid bulbs(arrows) in the mummy of man who lived during the 18th Dynasty (Hatiay, Mummy #23).
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 4 , N O . 4 , 2 0 1 1
A P R I L 2 0 1 1 : 3 1 5 – 2 7
Allam et al.
Atherosclerosis in Ancient Egyptian Mummies
322
20 of 52 mummies from Ancient Egypt. Circa 1500-2000 BC
Lord Kelvin, President of the Royal Society, 1883
Advanced Imaging
100 years later
Anatomical Digitization of the Patient
20 years after that
Radiation Exposure
• Generational issue for practitioners• Self-experimentation• Increased cancer risk?• New tools• Guided therapy-combination of advanced
imaging and interactive computer guided treatment.
Occupational radiation exposure linked to left-sided brain tumorsRoguin A. Am J Cardiol. 2013;doi:10.1016/j.amjcard.2012.12.060.
Med Gadget 6/5/12
Hansen Medical’s Magellan Robotic System for Vascular Interventions Gets FDA NodThe FDA has given Hansen Medical (Mountain View, CA) the green light to bring the Magellan Robotic System domestically for peripheral vascular interventional procedures-510(k).It received European approval about a year ago and is already being used by clinicians.
Guided Therapy: Linking Device Development and Usage with Advanced Imaging
1 billion transistors in the I-phone.I am using catheters, guided by 2-D fluoroscopy.The same as I was at the beginning of my career.
Open Surgery
• We are “fix it” people.• Open surgery will mostly go away in next
20 years.• Trajectory of the last 20.• Where next:
– Femoral, most diffuse disease (TASC F),endo failures, hybrid procedures, emergencies
• Particular challenge for vascular surgeons– Our identity
Fig. 4.Percentage of physicians’ operative case loads that was open cases vs endovascularprocedures for 2010–2011.
Matthews et al. Page 13
J Vasc Surg. Author manuscript; available in PMC 2013 December 16.
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Matthews et al. J Vasc Surg 2013;57:10
Trends in a changing vascular practice environment formembers of the Society for Vascular Surgery
Mika A. B. Matthews, MDa, Bhagwan Satiani, MD, MBA, FACSa,b, and Joann M. Lohr, MDc
aDepartment of Surgery, The Ohio State University College of Medicine, ColumbusbThe Ohio State Heart and Vascular Center, The Ohio State University College of Medicine,ColumbuscLohr Surgical Specialists, Cincinnati
Abstract
Objective—To survey the Society for Vascular Surgery (SVS) membership with regard topractice trends related to work effort, employment status, practice ownership, endovascular cases,and anticipated changes in practice in the near future.
Methods—A survey questionnaire was developed to gather information about memberdemographics and practice, hours worked, full-time (FT) or part-time status, employment status,practice ownership, competition for referrals, proportion of endovascular vs open procedures, andanticipated changes in practice in the next 3 years. We used SurveyMonkey and distributed thesurvey to all active vascular surgeon (VS) members of the SVS.
Results—The response rate was 207 of 2230 (10.7%). Two thirds were in private practice, and21% were in solo practice. Twenty-four percent were employed by hospitals/health systems.Those VS under the age of 50 years were more likely to exclusively practice vascular surgerycompared with VS over the age of 50 years (P = .0003). Sixty-eight of the physicians (32.7%)were between 50 and 59 years old, 186 (90.3%) were men, 192 (92.8%) worked FT (>36 hours ofpatient care per week), and almost two thirds worked >60 hours per week. Those in physician-owned practices worked >40 hours of patient care per week more often than did FT employed VS(P = .012). Younger VS (age <50 years) more frequently reported >50% of their workload beingendovascular compared with older VS (age ≥50 years; P < .001). Eighty percent of FT VS plannedto continue their current practice over the next 3 years. Of the 43.6% indicating loss of referrals,82% pointed to cardiologists as the competition.
Conclusions—The current workforce is predominately male and works FT; one-third isbetween the ages of 50 and 59 years. Younger VS (age <50 years) are more likely to exclusivelypractice VS and have a higher caseload of endovascular procedures. Those in physician-ownedpractices are more likely to put in >40 hours of patient care per week than are FT employed VS.Longitudinal surveys of SVS members are imperative to help tailor educational, training, andpractice management offerings, guide governmental activities, advocate for issues important tomembers, improve branding initiatives, and sponsor workforce analyses.
Reprint requests: Dr Bhagwan Satiani, 701 Prior Hall, 376 W. 10th Ave, Columbus, OH 43210 ([email protected]).Presented at the Fortieth Annual Symposium of the Society for Clinical Vascular Surgery, Las Vegas, Nev, March 17, 2012.The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewersto decline review of any manuscript for which they may have a conflict of interest.Additional material for this article may be found online at www.jvascsurg.org.
NIH Public AccessAuthor ManuscriptJ Vasc Surg. Author manuscript; available in PMC 2013 December 16.
Published in final edited form as:J Vasc Surg. 2013 February ; 57(2): . doi:10.1016/j.jvs.2012.09.064.
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70% of those surveyed performed endovascular in ½ to ¾ of their cases.Another 22% performed endovascular in ¾ to all of their cases.
Occlusive Disease-Era of Drug DeliveryPharmacology is natural next step
• Mechanical solutions have plateaued.• Next leap will be through drug delivery.
IN.PACT SFA
Primary'Patency''Kaplan/Meier'
Free from
Primary Patency
Event (%)
100 90 80 70 60 50 40 30 20 10 0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 Months from Randomization Date
PTA
DCB
Survival %
Time Lutonix D C B Standard PTA P-value
365 days 73.5% 56.8% 0.001
Proportions-based difference was 65.2% for DCB vs. 52.6% for standard PTA � 12.6% difference
Tepe et al. Circ 2015;131:495
Rosenfield et al. NEJM 2015;373:145
Levant
50.4% @ day 410
73.7% @ day 410
DCB 82.3% @ day 365
PTA 70.9% @ day 365
Lyden, TCT 2016
Illumenate
12 Month Patency RCTs of DCB vs PTA
-Limus drugsNano-encapsulationTibialsDialysisCalcified arteriesPost-atherectomyRe-birth of DES
Just the beginning!!
Nanoparticle Polymer Free Sirolimus Coated Balloon Delivery Catheter
Large Vessel-Total Relining for Aneurysm DiseaseDevelopment of Branches
Ascending aorta, spinal cord and endoleaks (and cost) remain unsolved.
Remote Monitoring
• 2018-CMS reimburses for remote monitoring• Injectable oxygen sensor• A watch that monitors heart rate and rhythm
(https://mhealthintelligence.com/)
Topic
Topic
REMOTE MONITORING NEWS
Top 10 Remote Patient MonitoringCompanies for HospitalsThe top remote patient monitoring platforms by vendors offer hospitals advancedchronic disease management features and capabilities.
Source: Thinkstock
Imaging a bypass graft or stent that has a remote sensor.Monitored like on-star or a home burglar alarm.
How to Transfer Existing Technologies to Medicine?
Top 10 R em ote Patient M onitoring C om panies for H ospitalsThe top rem ote patient m onitoring p latform s by vendors offer hospita ls advanced chronic d isease m anagem ent features and capabilities.Thom as B eaton
July 07, 2017 - To enhance care delivery and im prove patient outcom es for conditions that need constant surveillance, hospita ls are increasing their use of rem ote patient m onitoring solutions.Integrated rem ote m onitoring solutions w ith m essaging and alert system s can let providers know w hen patients are in stable or critica l conditions w ithout the need for hospita l room . R em ote m onitoring can im prove the m anagem ent of chronic d iseases by m easuring critica l risk indicators such as g lucose, b lood pressure, etc. These devices can also provide patient-generated health data (PG H D ) to physic ians and keep patients inform ed on their health goals.
B iotronik, B iotronik H om e M onitoringThe cardiac hom e m onitoring tools offered by B iotronik aim to replace unnecessary doctor’s v is its through early detection of cardiac health risks. D evices are equipped w ith an antenna and extra storage capacity that connects to a patient device called C ardioM essenger. Through C ardioM essenger, c lin ical data (e.g., v ita ls, health inform ation) is collected, encrypted, and sent to a patient’s provider.B oston Scientific, Latitude N XTThe Latitude N XT in-hom e patient m onitoring system allow s a healthcare team to m onitor connected devices in-betw een prim ary care vis its. D evices send data to providers at regularly scheduled tim es from blood pressure m onitors, pacem akers, cardiac m onitors, w eight scales, and other connected health devices.G E H ealthcare, A pex Pro C HApex Pro C H is a te lem etry system offered by G E H ealthcare that a llow s hospita ls and other healthcare organizations to unify their m onitoring system s under a s ingle w ire less netw ork. P roviders can m onitor 438 patients under a coverage area, and allow s access from m ultip le devices.H oneyw ell, G enesis TouchThe G enesis Touch device from H oneyw ell collects b iom etrics from patients to rem otely located providers, and transm its them to a patient m anagem ent dashboard. The device can host v ideo vis its, a llow m ultip le providers access to a patient’s v ita ls, and can be used w ith an optional 2-gigabyte data p lan in lieu of a w ire less netw ork. The G enesis Touch also integrates w ith an oxim eter, b lood pressure m onitor, and precis ion health scale.M edtronic, V ital SyncThrough the V ita l Sync m onitoring p latform from M edtronic, providers can integrate physio logical in form ation from bedside m onitors and w earable devices to a hospita l server. P roviders are able to set c lin ical protocols through m obile apps and devices, v iew patient inform ation rem otely, and receive alerts and updates to a m obile device.N ihon K oden, A w areN ihon Koden’s alarm m anagem ent system allow s hospita ls to draw analytics from their m onitoring param eters, and see detailed inform ation about the types of patients and w hen patients experience health risks. Aw are is intended to assist providers in identify ing w hich alarm s need the m ost attention.Philips H ealthcare, EncorePro 2Providers can use the EncorePro 2 to have all a patient’s data presented in one convenient dashboard w hile autom ating routine s leep and respiratory settings. C hanges in a patient’s health data or condition are autom atically updated on a sm artcard that im m ediate ly updates a provider on any changes. Spacelabs H ealthcare, Xhib itThe Xhib it rem ote m onitoring p latform allow s providers to custom ize m onitoring for specific patient needs through connected m onitors, w earable health devices, and dashboards. W ith instant access to patient data, a provider is able to use a c lin ical suite to m ake data-inform ed decis ions v ia m onitoring-generated vita ls, and determ ine if new care solutions are needed for said patient.A bbott, M erlin .netThe M erlin.net patient care netw ork and the M erlin@ hom e transm itter enhances provider com m unication w ith rem otely m onitored patients through fo llow -ups in care available for hom e-use and during travel. The transm itter uses the care netw ork to transfer health inform ation to a doctor w ithout a v is it can m onitor a device daily betw een vis its. S t. Jude is a lso offering 2017 updates in security to the M erlin.net platform to further protect patient health data.
mHealth Intel
AI, Big Data, Machine Learning• Electronic medical record integrated with
digitally collected data (EHR meets Google (fountain-of-youth project), Facebook, Amazon, IBM-Watson)
• Population management• Assessment of seemingly random patterns• Remote sensors and monitoring: real-time
assessment
Major Trends in Vascular CareConclusion• There is no conclusion; it’s a process.• Day-to-day seems the same; but the
tectonic plates are moving.• Dramatic new opportunities.
We are “Fix It” People
• Provide full spectrum care, develop long-term relationships, and make a difference in our patients’ lives; the goals are practical, dilemmas are intellectually stimulating, the procedures include multiple techniques, are anatomically based, aesthetically pleasing, and technically challenging, with many opportunities for innovation.
