Halt Interventional Radiology Turf Wars

This article appears in the August 2012 issue of HealthLeaders magazine.

It sounds like a conflict of epic proportions when you talk to some healthcare leaders. As David Levin, MD, former chairman of the department of radiology for the 969-bed Thomas Jefferson University Hospital in Philadelphia puts it, "There are turf wars, and there's been a big turf war between interventional radiologists and vascular surgeons."

Levin is referring to a longstanding healthcare issue: the disputes between interventional radiologists and other physician groups that center on which medical professionals should do certain procedures. Today, more health systems see the value in working to overcome the conflicts and finding ways to thrive in models where radiologists collaborate with physicians from different service lines.

Interventional radiologists' main focus is minimally invasive techniques that can produce improved outcomes, reduced infection rates, faster recovery time, and shortened hospital stays. But, as more cardiologists and vascular surgeons use interventional techniques—and as interventional radiologists move into the other physicians' territory—doctors and hospital officials see an increased need to manage a delicate balance of these relationships.

Hospitals are intently working to improve collaboration among physician groups. Experts say that team approaches are crucial for improved outcomes and more efficiencies of care. To that end, hospitals are ensuring that radiologists and other physician groups consult with one another and are working on programs that rotate their reading of x-rays and work with CT scans.

Interventional radiologists saw themselves years ago as among the first minimally invasive specialists; they were using their expertise in angioplasty and catheter-delivered stents to treat peripheral arterial disease. Soon, cardio and vascular surgeons increased their use of interventional techniques, which set the stage for territorial disputes.

"Historically, interventional radiologists have been doing catheter-based interventional procedures literally since 1963, when the first angioplasties were done," says Timothy Murphy, MD, medical director of the Vascular Disease Research Center at the 719-bed Rhode Island Hospital in Providence. "Surgeons for years denigrated the interventional procedures and wanted to operate on people. But then they had an epiphany, decided that surgery wasn't so great and they wanted to adopt interventional radiology procedures."

But the reverse was also true: Other specialties saw interventional radiologists infringing on their work.

"I think at one point in time interventional radiologists encroached on other people's turf," says Eric Russell, MD, FACR, a neuroradiologist and chair of the department of radiology for the 894-staffed-bed Northwestern Memorial Hospital in Chicago. "I don't see it as a unidirectional issue. We are trying to find a middle ground once conflicts have potential to rise, and try an approach that is good for the patient. It's hard when you are doing business, but ultimately that is what we have to focus on."

In recent years, interventional radiologists have expanded into new areas such as nonsurgical ablation of tumors to kill the cancer without harm; carotid artery angioplasty and stenting to prevent strokes; and treating liver tumors with intra-arterial yttrium-90 radioembolization, or tiny beads of radiation, to improve outcomes.

Some hospitals, such as the 960-bed Emory University Hospital in Atlanta, have launched cooperative vascular programs, involving vascular surgeons, interventional radiologists, and interventional cardiologists. Radiologists rotate in programs with other specialists and work in vascular clinics while consulting with other cardiovascular specialists, according to Kevin Kim, MD, director of interventional radiology and image-guided medicine and associate professor of radiology obstetrics and gynecology, hematology, and medical oncology and surgery at the Winship Cancer Institute of Emory University.

"Interventional radiology covers a wide spectrum of disease, from peripheral vascular to spine disease to cancer therapies, you name it," says Kim. "Our field is a young field, but it has advanced substantially in light of imaging technology advances and is making image-guided interventional therapies less invasive and more efficient and cost effective.

"I cannot say there is no turf war even in our system, but when it comes to liver cancer, for instance, all the specialists come together with their own expertise and evaluate the patient. The patient comes in and everybody literally sits together. The patient gets the benefit of opinions, and the expertise of the multiple specialties in the same visit," Kim adds. "We work hand in hand in collaboration," which also means sharing in reimbursement.

Interventional radiologists grapple with one overriding issue: their relatively low profile to the public. "A major obstacle is that people aren't familiar with interventional radiology as a name. It has low recognition compared to something like cardiology, which is a chronic problem for interventional radiology as a whole. We just have to get the message out there that we have a lot to offer patents," says Dan Brown, MD, director of interventional radiology at Thomas Jefferson
University Hospital.

Interventional radiology—a recognized medical specialty by the American Board of Medical Specialties, which certifies these specialists—also has trouble commanding respect within the larger physician community. Murphy expresses concern that other physicians besides radiologists have been able to obtain interventional privileges without proper training. "The problem is the board of examination process," he says. "There should be a higher bar to get privileges, not a lower one."

Success key No.1: Team concepts

Russell, the chairman of the department of radiology for Northwestern Memorial Hospital, years ago began to look around the landscape of interventional radiology at his hospital and saw it was changing immensely. For one thing, vascular surgeons were performing procedures that interventional radiologists had handled for many years. "You lose control of the situation to some degree; that is a common theme," he says.

It was important for the radiologists not just to lose control, but also to initiate cooperation, he says. As a result, Russell began a cooperative program with other specialists that led to improved working relationships among physicians, while delivering more efficient patient care. The hospital started seeing so much improvement in patient outcomes, in fact, that vascular surgery and interventional radiology departments combined resources and shared expenses to form a vein center within the Northwestern Medical Faculty Foundation. The center provides treatment for patients with varicose veins, spider veins, and vein-related pain. Performing minimally invasive procedures is a cornerstone of the program.

"We have had collaboration, so as turf issues developed, that helped to overcome any problems," Russell notes. "We had institutional backing throughout the hospital to keep things balanced. Now we have a shared practice in cardiac-specific imaging, so we've been able to avoid any real conflict." Interventional radiologists are seeing increased volume related to other interventional procedures, primarily interventional oncology, he says. "We also have taken on the responsibility of taking over interventional radiology programs at smaller, local hospitals," he says. It was important, too, for interventional radiologists to become involved in cancer therapies. "That's a key program for us," he adds, noting that interventional radiologists can't simply rely on vascular procedures to generate income. If that was the case, "we would have suffered a drop in overall procedure volume if we didn't have new avenues," he adds.

To continue overcoming turf wars, Russell says it is important that the hospital coordinate an enhanced training opportunity for both interventional radiologists and vascular surgeons. "We worked out a system where vascular surgeon trainees could come down to the interventional radiology team, and our trainees would go up to vascular surgery. Because we have radiologists and vascular surgeons who respect each other, we've been able to accomplish that," he says.

To thwart turf wars, the 570-staffed-bed Harbor-UCLA Medical Center has designated champions for specific aspects of care, either interventional radiologists or other physicians, to coordinate patient care and multidisciplinary surgical programs. "A decision is made upfront about what procedure is best for the patient, with the single person as the point person to determine what is equitable and honest," says Matthew Budoff, MD, director of Harbor UCLA BioMED CT Reading Center. Those champions could be an interventional radiologist or vascular surgeon or cardiologist, for instance, he adds. Various team champions are designated for areas of cancer or cardiac care, for instance. Patients are evaluated on a case-by-case basis, and champions determine whether interventional radiologists or other specialists should lead the procedures.

"When you have a motivated radiologist who wants to do a cardiac CT, he knows he's treading somewhere in the cardiac space, and knows he should reach out to cardiologists. And vice versa. When a cardiologist is in the interventional radiologist's space, he knows he should reach out to an interventional radiologist. I think there's motivation to work together. It's harder and harder for small radiology groups to own their own equipment. We have rotation of reading images. I think there's a motivation to work together. They can refer patients and control the patient flow. It's a win-win situation."

"I see the turf wars going away largely," he says. "I train quite a few cardiologists and radiologists for CT, and both groups are in my office working side by side."

Success key No. 2: Improved patient outcomes

Improvements in the technology used by interventional radiologists are advancing their status as well. For instance, implanting small radioactive beads that cause tumors to die are enhancing programs in the treatment of liver cancer for improved patient outcomes, says Brown of Thomas Jefferson University Hospital, which is stepping up the procedures. As patient outcomes improve, Thomas Jefferson is finding its results are drawing the attention of patients seeking interventional radiology treatment for their own cancer. Over the past four years, there has been a 35% increase in patients being treated by interventional radiology with a sizeable increase in cases for liver cancer at Thomas Jefferson University Hospital, with about 600 seen annually, Brown says. "It has grown so much. It's a huge part of our interventional radiology practice, a large chunk of what we do. It makes the hospital happy and gives us much professional satisfaction. We've had good results and the work has built itself up."

Primary liver cancer forms in the tissues of the liver, and secondary liver cancer spreads to the organ from other parts of the body. This year, an estimated 28,720 new cases are projected, along with 20,550 deaths, according to the National Cancer Institute. Brown says advances in interventional radiology for treatment of liver cancer use a technique that allows for a very high dose of radiation to be delivered without much impact to healthy tissues in the body.

In the Journal of Vascular and Interventional Radiology, the Jefferson team reported on improved results using yttrium-90 radioembolization, a treatment that consists of radioactive microspheres (tiny beads) that are injected through a catheter from the groin to an artery supplying the tumor. The beads cause tumor cells to die.

While radioembolization is not a cure for liver cancer, the treatment has fewer side effects than other cancer treatments and it extends life. Thomas Jefferson researchers found in a study of 81 patients treated for primary or metastic liver tumors that the radioembolization is not only a safe treatment, but 90% of the people in the study who received infusions showed no or few changes in liver function, according to Brown, who was the senior investigator on the study.

Northwestern Memorial Hospital also is performing the procedure, which allows for increased doses of radiation to the tumor while sparing nontargeted adjacent normal tissue. The beads, smaller in diameter than a human hair, are injected into the liver, and irradiate it for 12 days. A key element of the procedure for cancer patients is that it offers them the opportunity to be treated without facing radiation or chemotherapy side effects, such as loss of hair or nausea.

Success key No 3: Less cost, more safety

For years, peripheral arterial disease, a common circulation problem popularly referred to as "hardening of the arteries," has been a major focus of interventional radiology treatment. PAD is narrowing of the blood vessels in the leg, which limits the supply of oxygen and nutrients to the leg, causing pain and discomfort. It affects 10 million people in the United States and can lead to heart attack or stroke.

The interventional radiologist often can treat PAD using minimally invasive techniques, relying on miniaturized tools, x-rays, and catheters to perform angioplasty or insert stents. Occasionally, open surgery is necessary to remove blockages from arteries or to bypass clogged arteries in procedures performed by vascular surgeons.

Another area where turf wars have developed is in the area of determining whether the PAD techniques of cardiologists and vascular surgeons are equitable to those of interventional radiologists. Murphy, at Rhode Island Hospital, wanted to verify what he thought would be improved outcomes for interventional radiology compared to other specialists.

He did.

In a review of treatments for 14,000 Medicare patients 65 and older, endovascular lower-extremity revascularization procedures were shown to require fewer repeat procedures, less intensive care use, lower costs, and shorter hospital stays when done by interventional radiologists compared to vascular surgeons.

Overall, there were lower costs, too, according to the study Murphy published earlier this year in the Journal of Vascular and Interventional Radiology, in which the outcomes of PAD treatments were reviewed. The average one-year procedure cost by interventional radiologists was about $17,640, which is $1,372 less than the same procedure done by  vascular surgeons. Such savings could translate to $20 million a year, according to Murphy.

Murphy says the study proved the importance of interventional radiology, particularly in PAD, and the likelihood that it should be incorporated into other programs. "When vascular surgeons do the procedures, they are not as invested as interventional radiologists, in my opinion, because if the procedure doesn't work, they have a fallback and can provide an open surgical procedure. Interventional radiologists have no other procedures and get it right the first time," he says.

A decade ago, interventional radiologists were doing a greater percentage of PAD cases than today, because many other specialists are now performing them, Murphy says.  However, the volume of cases "is still large and still growing." He says he did not carry out the study to perpetuate turf wars, but to reinforce the need and importance of interventional radiology in procedures.

Success key No. 4: A new building, new imaging

As soon as the University of Buffalo Medical Center and Kaleida Health teamed up to build the new, 10-story Gates Vascular Institute, which includes the Kaleida Health Gates Stroke Center, the turf wars started deteriorating, says Elad Levy, MD, FACS, FAHA, director of the endovascular stroke service for the Gates Stroke Center.

It began with a new structure, and also with new imaging technology improvements.

Having a new building adjacent to the 610-licensed-bed Buffalo General Hospital made it easier to develop multidisciplinary approaches and overcome turf wars. The building features four floors dedicated to surgical and interventional management of cardiac, vascular, and neurological conditions, as well as interventional labs, CT scanners, and MRIs.

"Doctors are working right next to each other and it forces doctors to work together from different disciplines. We are constantly interacting all day long," Levy says. "Before, you'd be in silos. In the old hospital, the physicians would be on a different floor. We have multidisciplinary work on a daily basis."

Imaging technology improvements also were important to not only bring the team members together, but also for better patient outcomes, according to Levy.

"Cardiologists have been using stents in the heart for a decade before we have begun to use it in the brain," he says. "We were seeing how we could adapt that for a stroke. Out of that has come new stroke technology."

A Kaleida Health Gates Stroke Center study found more than $2 million in annual cost savings with installation of a new CT system that dramatically reduced the time it takes to diagnose stroke symptoms. Patient length of stay also was reduced, through advanced imaging technology, improved training, and multidisciplinary approaches, according to the hospital system. The study had compared inpatient data before and after installation of the imaging technology.

The most advanced CT scans can take in an entire brain in a single pass, producing videos that show the brain's structure, movement, and blood flow, whereas previous CT scans can only capture a portion of the brain. Levy credits the new technology—known as Toshiba Aquilion ONE—with allowing hospital physicians to perform whole brain perfusion and digital angiography more efficiently.

The hospital reported a decreased length of stay from six to five days for a stroke. The hospital also reported a 14.8% improvement among patients discharged to their homes, and a 48% reduction in patients discharged to skilled nursing facilities.

Every day, Levy finds that multidisciplinary teams, working together, are overcoming the turf wars for meaningful returns.

In one incident, "we were doing a brain procedure and the patient was having a heart attack on the table," Levy recalls. "Normally, that would be a disaster, but right next door to us was the interventional cardiologist. He did what he had to do with the patient's heart. There was no lag time. He was 10 feet away. He saved the patient's life."

This article appears in the August 2012 issue of HealthLeaders magazine.