Establishment of a Varicose Vein Center in a Tertiary Vascular Surgery Practice: Urban Versus Rural Differences
Article Outline
We examined changes in practice patterns after the establishment of a varicose vein center (VVC) within two tertiary university vascular surgery practices and compared differences between urban (U) and rural (R) sites. Practice patterns for the treatment of VVs were compared 3 years before (period 1) and 3 years after (period 2) the formation of a U-VVC and an R-VVC in 2001, Both VVCs were part of similar-sized tertiary vascular surgery practices. Evaluation was specific to VVs, reticular veins, and telangiectasias. Prior to U-VVC, there were 338 office visits, six office procedures, and 114 hospital procedures. After U-VVC, there were 624, 120, and 312, respectively. Prior to R-VVC, there were 85 office visits, five office procedures, and 69 hospital procedures. After R-VVC, there were 528,163, and 303, respectively. In period 1 for U-VVC and R-VVC, VVC relative value unit (RVU) generation as a percent of total practice RVUs was 1.0% and 0.7%, respectively. In period 2 for U-VVC and R-VVC, VVC RVU generation as a percent of total practice RVUs was 2.6% and 2.5%, respectively. In an effort to provide more coordinated treatment for patients with VVs, establishing a VVC within a tertiary academic vascular surgery practice can lead to rapid expansion of clinical volume by increased office visits, office procedures, and hospital procedures. Clinical demand for evaluation and treatment of VVs showed little variation between R-VVC and U-VVC.
INTRODUCTION
The treatment of varicose veins (VVs) has undergone a dramatic evolution over the past 10 years. Many new treatment modalities can now be potentially offered to 40 million afflicted Americans.1, 2, 3, 4 Unclear in the delivery of care for VVs is the amount of public awareness of these new modalities and whether demand for VV treatment varies from one geographic location to another.
The formation of independent centers solely devoted to the treatment of VVs is becoming more common. While these centers are presumed to be successful in maintaining a busy practice, the outcome of forming a varicose vein center (VVC) within an already well-established comprehensive vascular surgery practice is unknown. Herein, we report the experience of an urban and a rural VVC as a distinct part of two comprehensive academic vascular practices.
METHODS
A 6-year review (1998–2004) of treatments for VVs was performed at two tertiary university vascular surgery practices. The Division of Vascular Surgery at Vanderbilt University (Nashville, TN; population ∼1.1 million) serves primarily an urban area (U). The Division of Vascular Surgery at Southern Illinois University School of Medicine (Springfield, IL; population ∼110,000) serves primarily a rural area (R). Both centers, independent of one another, formed a specialty VVC in January 2001. Hence, for purposes of comparison, period 1 was designated as 1998–2000 and period 2 as 2001–2004. Each period encompassed 36 months.
During period 1 for each center, new and return patients with VVs were referred accordingly to each vascular surgeon's general clinic. During period 2, new and return patients with VVs were directed to the VVC held once a week. The number of surgeons rotating at any one time during period 2 varied from two to four at each center. For both practices and periods, VVs were defined by evaluation and treatment for telangiectasias, reticular veins, and VVs.
Number of treatments for VVs in each period were determined by querying the billing database of each institution using the 2005 Current Procedural Terminology codes. Treatment codes were further grouped into those considered office procedures and those considered hospital procedures. Briefly, office procedures included laser sclero-therapy, injection sclerotherapy (3% liquid sodium tetradecyl sulfate), and limited stab phlebectomy. Hospital procedures included great saphenous vein ablation, stripping, or ligation with or without stab phlebectomy. Patients needing extensive stab phlebectomy (>10 incisions) in the hospital operating room were also included in this group. Other parameters compared between time periods included number of office visits for VVs and number of relative value units (RVUs). The study protocol was approved by the institutional review boards of both centers.
RESULTS
Prior to U-VVC, 338 office visits occurred in period 1. After U-VVC, 624 office visits occurred in period 2, representing a 184% increase from period 1 to 2. Prior to R-VVC, 85 office visits occurred in period 1. After R-VVC, 528 office visits occurred in period 2, representing a 621% increase from period 1 to 2. Prior to U-VVC, six office procedures were performed. After U-VVC, 120 office procedures were performed in period 2, representing a 2,000% increase from period 1 to 2. Prior to R-VVC, five office procedures were performed. After R-VVC, 163 office procedures were performed, representing a 3,200% increase from period 1 to 2. Prior to U-VVC, 114 hospital procedures were performed. After U-VVC, 312 hospital procedures were performed in period 2, representing a 273% increase from period 1 to 2. Prior to R-VVC, 69 hospital procedures were performed. After R-VVC, 303 hospital procedures were performed, representing a 439% increase from period 1 to 2.
Prior to U-VVC, a mean of 4.7 hospital operations/month were performed. After U-VVC, a mean of 8.6 hospital operations/month were performed, representing a 183% increase from period 1 to 2. Prior to R-VVC, a mean of 2.8 hospital operations/ month were performed. After R-VVC, a mean of 8.4 hospital operations/month were performed, representing a 442% increase from period 1 to 2. Table I outlines office visits, office procedures, and hospital procedures. Fig. 1, Fig. 2, Fig. 3 illustrate changes in office visits, office procedures, and hospital procedures, respectively, between the two periods for U-VVC and R-VVC.
Table I. Numbers of office visits, office procedures, hospital procedures, and RVUs before (period 1) and after (period 2) formation of the U-VVC and the R-VVC
| Period 1 | Period 2 | % Change | ||
|---|---|---|---|---|
| Office VV visits | ||||
| U-VVC | 338 | 624 | 184 | |
| R-VVC | 85 | 528 | 621 | |
| Office procedures | ||||
| U-VVC | 6 | 120 | 2,000 | |
| R-VVC | 5 | 163 | 3,200 | |
| Hospital procedures | ||||
| U-VVC | 114 | 312 | 273 | |
| R-VVC | 69 | 303 | 439 | |
| VV RVUs | ||||
| U-VVC | 582 | 1,800 | 209 | |
| R-VVC | 345 | 1,496 | 333 | |
| RVU % totala | ||||
| U-VVC | 1.0% | 2.5% | ||
| R-VVC | 0.7% | 2.6% | ||
a RVUs from VVC as a percent of total RVUs for each tertiary academic vascular surgery practice. |
Fig. 1.
Number of office visits before and after the formation of an urban (U-) and a rural (R-) VVC.
Fig. 2.
Number of office procedures before and after the formation of an urban (U-) and a rural (R-) VVC.
Fig. 3.
Number of hospital procedures before and after the formation of an urban (U-) and a rural (R-) VVC.
RVUs for U-VVC and R-VVC in periods 1 and 2 are shown in Table I. VV RVU generation as a percent of total vascular practice RVU generation increased from 1.0% before U-VVC to 2.5% after U-VVC. VV RVU generation as a percent of total vascular practice RVU generation increased from 0.7% before R-VVC to 2.6% after R-VVC.
DISCUSSION
After forming a distinct VVC as a unique part of an urban and rural tertiary university vascular surgery practice, a dramatic increase in office visits, office procedures, hospital procedures, and RVUs was observed for the treatment of VVs. The two vascular surgery practices were similar in the number of practicing surgeons during the two 3-year periods. Interestingly, the outcome measurements after formation of an R-VVC either nearly equaled or surpassed those of the U-VVC. This was especially evident in treating VVs with office procedures, the large majority of which were for cosmetic purposes. One reason for this may relate to the presumption that there are more centers able to provide cosmetic treatment in Nashville compared to Springfield. Nevertheless, a dramatic increase at the U-VVC was observed as well, despite the differences in proportion to each population.
The explanation for this dramatic increase in the treatment of VVs at urban and rural sites may be multifold. Both the U-VVC and R-VVC promoted their centers with formal notification of primary care physicians within their practice and informing the public through newspapers, newsletters, bulletins, public educational symposia, and free vein screening. A second reason may relate to the fact that telangiectasia, reticular veins, and VVs are ubiquitous, afflicting up to 20% of Americans. Capitalizing on these two previous reasons may lead to improved ease of access for patients with an additional day of clinic time specifically dedicated to the VVC and, possibly, a more satisfying patient experience because of consistent and focused care. These factors may have led to further increases in patients referring family and friends for evaluation and treatment. In contrast, growth of this part of the practice for each tertiary academic center was not due to a dramatic increase in numbers of faculty during the second time period.
While other diseases and demands for evaluation and treatment may vary depending on geographic location,5, 6, 7 this does not seem to be true for people seeking evaluation and treatment for VVs. Considering that the large majority of sclerotherapy in our study was for cosmetic purposes and the severity of VV symptoms can vary markedly among individuals, one might have postulated that people living in rural areas would be less inclined to seek out evaluation and treatment. Clearly, this presumption is incorrect. More importantly, given that the number of evaluations and treatments for VVs were very similar between the R-VVC and U-VVC, the fact that the immediate nearby population of the R-VVC (∼110,000) was much lower than that of the U-VVC (∼1.1 million) made no difference. Although this study has no objective data as to how far people lived from the R-VVC, one might assume that many were willing to travel longer distances to be evaluated and treated for VV problems. The larger referral base population for Southern Illinois University School of Medicine (∼1 million) encompasses hundreds of small farming communities across a large portion of central and southern Illinois.
Positive results other than increasing numbers of VV evaluations and treatments occurred after VVC formation at both tertiary university vascular surgery practices. These included the development and convergence of clinical pathways, the improvement of nursing and ancillary staff training and knowledge, and the expansion and modernization of types of VV treatment. Given the scope of each practice's work in arterial disease and the already created infrastructure for this part of the practice, start-up costs were minimal with regard to creating a VVC. Hospitals purchased equipment for vein ablation, and costs for sclerotherapy were minimal if only injection methods were used.
This study cannot account for surgeon biases within each VVC and between each VVC. The use of laser sclerotherapy represents one example of this bias. In the R-VVC, one surgeon may have believed one form of sclerotherapy was better suited for a particular telangiectasia. Injection sclerotherapy was the only method used for telangiectasias at the U-VVC. Another shortcoming of the study is the lack of patient demographic data. Clearly, epidemiological data such as age, gender, occupation, and ethnicity before and after formation of a VVC would define those groups most responsive to this endeavor. Lastly, there is always the risk that the increase in procedures represents a drive for “easy revenue.” This seems less likely as a reason given that both of these institutions are academic in pursuit. Other nonacademic single standing cosmetic vein centers may be more apt to pursue this type of practice.
The formation of a distinct VVC as a unique part of a tertiary university vascular surgery practice can provide a successful mechanism for increasing the number of evaluations and treatments for VVs. Given that multiple specialties, such as interventional radiology and dermatology, intend to or do treat VVs, the formation of a VVC can provide further security for maintaining this vital part of the vascular surgeon's practice. Although the RVUs from VV procedures continue to be a small fraction of the practice, other indirect benefits, such as defining the specialty with a new group of patients, may lead to other referrals. This is particularly true for women, who generally are responsible for much of the choice of family medical and specialty care.8 Lastly, the data from this report suggest that vascular surgeons contemplating the formation of a distinct VVC should be prepared as a large number of people may inquire about treatment for VVs. If demand outweighs supply, then patient access, quality of care, and patient satisfaction may suffer.
REFERENCES
- . Saphenous ablation: sclerosant or sclerofoam? . Semin Vase Surg . 2005;18:19–24
- . Microfoam ultrasound-guided sclerotherapy treatment for varicose veins in a subgroup with diameters at the junction of 10 mm or greater compared with a subgroup of less than 10 mm . Dermatol Surg . 2004;30:1386–1390
- Foam-sclero-therapy, surgery, sclerotherapy, and combined treatment for varicose veins: a 10-year, prospective, randomized, controlled, trial (VEDICO trial) . Angiology . 2003;54:307–315
- . Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications . J Vase Surg . 2005;42:488–493
- Geographic variation in utilization of cataract surgery . Med Care . 1995;33:90–95
- Determining the need for hip and knee arthroplasty: the role of clinical severity and patients' preferences . Med Care . 2001;39:206–216
- Variation in tertiary prevention and health service utilization among the elderly: the role of urban-rural residence and supplemental insurance . Med Care . 1998;36:965–976
- . Children's health care use: a prospective investigation of factors related to care-seeking . Med Care . 2001;39:990–1001
Presented at the Winter Meeting of the Peripheral Vascular Surgery Society, Park City, UT, January 27, 2006.
PII: S0890-5096(06)61460-X
doi:10.1007/s10016-006-9092-1
© 2006 Annals of Vascular Surgery, Inc. Published by Elsevier Inc All rights reserved.
