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Revenue-Driving Cardio Subspecialties Thriving

Joe Cantlupe, for HealthLeaders Media, August 8, 2013

J.A. Mustapha, MD, director of Metro Health's endovascular intervention, heads the hospital's vascular amputation prevention program. His specialty is performing artery and vein catheterizations designed to open vessels and improve circulation. In the process, the hospital has developed a technique to treat vascular systems successfully and in many cases avoid amputations. The treatment approach uses an ultrasound-guided interventional device through the foot and an ultrasound transducer that helps identify blood flow that traditional angiography misses. Often, medication can address this condition to prevent amputations.

When the endovascular intervention program began five years ago, the Metro Health System saved at least 88% to 92% of limbs that had been recommended for amputation. It now saves even more—96% to 98%, says Mustapha. Limb preservation care is part of Metro Health's overall work in peripheral arterial disease, an area in which patient volumes have increased dramatically at the hospital. Over the past five years, the volume of cases has increased from 67 to 827, he says.

"We are asking for more operating rooms and staff, and we are booked," he says. "We are improving care and making money for the hospital."

The hospital uses a diagnostic technique that "basically goes down around the foot area and puts a small catheter in there to take pictures. We mastered the method of clearing the vessels, have a plan of attack to follow and we stick with it," says Mustapha, adding that "it's amazing we are saving 96% of the limbs; we would have been happy saving 50%."

Physicians have referred cases to the hospital after they believed there was no other option than amputation, Mustapha says. Too often, these doctors lack superior techniques to properly evaluate areas of the leg or feet that may be impacted, he explains.  

At Metro's amputation prevention program, all referred patients scheduled for amputation are seen within 24 hours. If there is no contraindication, patients will then undergo peripheral angiography within 48 hours.  

Primary care physicians often rely on "conventional angiograms that do not detect blood flow below the knee," Mustapha explains. As a result, "these physicians see a brick wall and believe there is nothing else to do [other than amputation]." Some physicians make a singular decision and do not make referrals for second opinions and amputations are performed. "It's a sad thing," Mustapha says.

An important key to building a successful peripheral vascular disease program is partnering with and educating the referring physicians, who include primary care providers and podiatrists, Mustapha says. Hospital peripheral interventionists visit physician offices in the field to educate primary care doctors on peripheral vascular disease screening.

Metro Health's PVD program includes collaborations with other specialists, including those involved in interventional radiology, cardiology, vascular surgery, and wound healing. Patients are instructed about healthful practices, including the need to quit smoking, follow a reasonable diet, and exercise.  

The hospital's program began after Mustapha counseled a 52-year-old patient with severe PAD in her leg. Mustapha made the connection that a device commonly used to clear clogged arteries leading to the heart could be adapted for PAD. "It opened the door to what we are doing. This created a cascade of events that have been successful beyond what we thought possible," Mustapha says. "Patients are so grateful when we are saving a limb. Ironically, when we save their lives, they aren't as expressive."

Success key No. 2: Congenital heart disease

For years, children were the primary focus of congenital heart care. But many youth afflicted with congenital heart disease are now living past 18 years, which translates into an increased need for treating them as adult patients. However, only 10% are seeking appropriate care from adult congenital cardiologists, according to the Adult Congenital Heart Association. More than 1 million adults in the United States live with congenital heart disease.

"Probably the majority of these adult congenital patients who are seeking cardiology care are in pediatric care still," says Joseph Kay, MD, program director of the University of Colorado Hospital adult congenital heart disease program. "So a pediatric cardiologist who followed them throughout their lives is still managing them, through adulthood in the U.S. But it's not the ideal scenario."

UCH is finding a niche market by improving care for adults and children, says Kay.

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