Opportunity Knocks: Starting a Peripheral Artery Disease Program

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 - Decision

One decision some cardiology groups may wrangle with is whether or not to launch a peripheral artery disease (PAD) program. Local geography, community needs and physician interest all play a role in the decision, but the overall demographic and clinical trends point to a sound case for launching a PAD program—provided certain conditions are met.

The increasing prevalence of obesity and diabetes in the U.S., coupled with the general aging of the population, means the denominator of potential patients with PAD is increasing. Plus, the use of antilipidemic drugs and more extensive use of antiplatelet agents and antihypertensive medications means patients with these PAD-predisposing conditions are living longer and also are manifesting PAD problems that impact quality of life and daily activities.

And the trend is projected to continue. “PAD and cardiovascular disease will continue to be a problem for at the next 30 years,” predicts Sanjay Misra, MD, of the Mayo Clinic Gonda Vascular Center in Rochester, Minn.

People living with peripheral artery disease (thousands) worldwide

 20002010Rate of change (2000-2010)
25-29 years13,06814,41910-34%
30-34 years14,27215,1035-82%
35-39 years14,73317,11916-19%
40-44 years15,20918,64522-59%
45-49 years15,93619,20520-51%
50-54 years14,80819,60332-37%
55-59 years13,64120,11847-49%
60-64 years14,41618,02925-06%
65-69 years13,70415,67014-35%
70-74 years12,54715,06320-05%
75-79 years9,76812,38226-75%
80-84 years6,1239,11848-92%
85-89 years3,6585,11539-84%
90 years1,7172,47444-09%
Total163,600202,06223-51%

Estimated number of people living with peripheral artery disease and worldwide in the years 2000 and 2010, and the rate of change from 2000 to 2010

Source: 2013 Lancet;382:1329-1340.

Studies have connected the dots between the growing patient population and procedure volume. The utilization of endovascular lower extremity revascularization, a common PAD intervention, nearly tripled among Medicare beneficiaries between 1996 and 2006 (J Vasc Interv Radiol 2012; 23:3-9).

As practices assess whether or not to move ahead with a PAD program, they need to consider multiple factors. These include physician interest and commitment, infrastructure, practice configuration, education, training and marketing. They also need to evaluate the evolving issues in reimbursement and comparative effectiveness.

Ready or not?

No one single specialty owns PAD. Board-certified physicians in a number of specialties—interventional cardiology, interventional radiology, vascular surgery, vascular medicine—manage patients with PAD.

Regardless of the specialty or location of the practice, experienced clinicians who care for these patients agree on one prerequisite for starting a program. Providers must be interested and committed to taking care of patients with PAD. “You can’t just dabble in PAD,” says James Benenati, MD, medical director of the Peripheral Vascular Laboratory at Baptist Cardiac and Vascular Institute in Miami. “It has to be a full-time commitment.”

Physicians who care for patients with PAD need to understand the anatomy and pathophysiology of the disease as well as noninvasive therapies like exercise or drug therapies and image-guided and surgical interventions. Foundational expertise should be acquired during internship, residency and fellowship training rather than a weekend course.

Physicians who understand the patient population and are willing to evaluate and care for them both in an acute setting and longitudinally may be the best-equipped to meet patient needs and achieve the economic goals of the practice. “There has to be some level of subspecialization,” continues Benenati. Technology, devices and medications are rapidly evolving, which requires a commitment to ongoing training.

In addition, volume comes into play. A practice may find that its volume cannot support six physicians performing stenting, but the same volume could support three physicians and also help them grow skills and expertise and build efficiencies, which can translate into improved patient care.

In addition to clinical interest, infrastructure is a must. “You need a certain amount of infrastructure—a clinic space to see and evaluate patients, an on-site vascular laboratory or lab access at a local hospital and the ability to perform interventional procedures, if indicated,” says Bret Wiechmann, MD, a vascular and interventional radiologist with Vascular & Interventional Physicians in Gainesville, Fla.

The vascular lab is a key component of the business as it is critical for the initial diagnostic evaluation of the patient, but also important for patient follow-up. It not only allows the practice to serve patients from beginning to end, and also is a major revenue generator.

One size does not fit all

One challenge of launching a PAD program is deciding which of the wide array of practice models fits the local community. A single physician might practice as a solo interventional cardiologist or interventional radiologist; in a multiple specialty group comprised of vascular surgeons, interventional cardiologists and interventional radiologists; or in a comprehensive vascular center that includes podiatrists and wound care specialists. Most configurations work with some degree of success, but what works in one market may not work in another, says Wiechmann.

As in real estate, the words that determine the optimal configuration are location, location, location. Can the local market volume in a community of 10,000 support a larger multispecialty group? More importantly, can physicians navigate the traditional turf wars that can haunt multispecialty practices?

“The advantage of a single-specialty group is that it’s a neat package," explains Wiechmann. "The culture is the same. Sometimes, physicians of other specialties can be possessive of their turf, which is difficult to manage.”

However, practices that can curb group politics, and are located in areas with the volume to support a larger multispecialty group, may be ideally equipped to serve patients with PAD.

Take, for example, the Mayo Clinic, which operates one of the longest-standing vascular centers in the U.S. The practice, which is comprised of vascular surgeons, interventional cardiologists, interventional radiologists, vascular medicine specialists, podiatrists and wound care specialists, has been taking care of patients with PAD for 30 years.

Physicians work side-by-side and share facilities, including exam rooms, imaging systems and vascular labs. “We’re able to consult each other rather quickly,” says Misra. Such curbside consults can be valuable. “Our patients don’t present with a single indication, like femoral occlusion. They come in with multiple problems, including coronary and carotid disease.”

In this type of configuration, practitioners can bring their specific expertise and skill set to the table to tailor therapy for each patient at a personalized level, says Alan Matsumoto, MD, chairman of the University of Virginia Department of Radiology in Charlottesville. Cardiologists and vascular medicine specialists offer training in cardiovascular disease and medical management of hypertension, while interventional radiologists have imaging expertise and understand how to create and read studies of the blood vessels. Rapid and complementary access to multiple specialists’ input can better serve patients with multiple complex conditions.

Benenati agrees. “It’s hard to have a true center of excellence without multispecialty collaboration.” Still, touting collaboration and practicing it are different activities.

Baptist Cardiac promotes collaboration in multiple ways. This includes credentialing as well as joint morbidity and mortality committees where every physician’s work is reviewed by members of other specialties, which minimizes favoritism and the sense that one group’s work is better or more valuable than the other.

The practice eliminated economic incentives that instigate turf wars by forming common professional associations. Physicians share revenue on multispecialty reading panels and some noninvasive procedures. “There’s a lot more synergy and opportunity for growth when people work together and pool resources,” explains Benenati.

Although current conditions support multiple practice configurations, trends indicate that multispecialty groups may be poised to thrive. “We’re starting to see increasing trends toward integration and sharing expertise,” says Misra, who adds that in the next 10 years, the push to link outcomes and quality metrics to reimbursement could nudge the market toward a more comprehensive, whole-patient approach.

Setting the stage for success

Establishing a local reputation as the go-to practice for carotid intervention or critical limb ischemia is critical to the success of any practice. As with the practice configuration, there is no right answer, but some strategies tend to be more successful than others.

The basics include awareness of local referral patterns and an assessment of which services already are provided in the community. Then the provider needs a plan to stand out in the market.

“One of the things we did early on to differentiate ourselves was to get involved in clinical trials. It provides access to the latest and greatest technology and puts you on the forefront of the next device or potential therapy,” offers Wiechmann.

Marketing techniques like referral dinners have met with limited success, according to Wiechmann, while direct-to-physician office visits have delivered more bang for the buck. He attributes the incremental success with direct office visits to the captive one-on-one audience, while referral dinners represent yet another after-hours commitment competing for physicians’ time. An online presence also is essential as more patients turn to the web for research.

The overall clinical and demographic data are clear and point to a burgeoning market for PAD care. A solid evaluation of the local market and assessment of clinical commitment and skillsets can inform the decision about whether or not to launch a PAD program. Other essentials to consider are practice configuration and marketing strategies.