Presidential Address: Bigger and better

34^th Annual Vascular Scientific Sessions: Washington, DC, USA September 9, 2023

Good morning to the Society for Vascular Medicine (SVM)! It is my pleasure to welcome you to the 2023 Vascular Scientific Sessions (VSS), our 34^th annual scientific meeting. We are bigger and better today than we were a year ago, and there are many people who helped make that happen. First and foremost, I’d like to thank 2023 VSS Program Chair Ido Weinberg, Program Co-Chair Elizabeth Ratchford, the Program Committee, and the entire Veritas meeting planning team, including Matt Helms, Sandy Addison, Jennifer Fitzgerald, Jennifer Manthei, Ryan O’Sullivan, Donna Kelly, and Sue O’Sullivan.

I’d also like to recognize the SVM Executive Committee and Board of Trustees (Past-President, Raghu Kolluri for his many years of service and invaluable contributions; President-Elect, Ido Weinberg; Secretary, Elizabeth Ratchford; Treasurer, Esther Kim; Trustees-at-Large: Daniella Kadian-Dodov, Yogen Kanthi, Scott Kinlay, Eric Secesmsky, Aditya Sharma, and Mitch Weinberg), and Vascular Medicine journal Editor-in-Chief and ex officio board member Heather Gornik. Although there are too many of you to recognize here by name, we would be lost without our leader and member volunteers who serve on our committees and task forces and do the heavy lifting that ensures our Society continues to flourish. Thank you all!

SVM is in a good place. Under the leadership of Elizabeth Ratchford, our membership has grown year-over-year, and now stands at over 700 members from 47 US states and 19 countries, our largest membership ever. Financially, SVM is on solid ground as well. Under the stewardship of our Treasurer, Esther Kim, our reserves are at an all-time high and we currently have 16 months of cash on hand, a first for our Society.

As I complete my Presidential term and reflect on my time in office, I am perhaps most proud of how we have grown as a community; we are bigger and better. Two years ago, when we overhauled our approach to volunteerism and began sending out an annual call for volunteers, you answered that call. Today, we have 220 members serving on and leading 18 SVM committees and task forces and another 40+ who have volunteered to represent SVM in externally facing roles vis a vis other cardiovascular organizations and initiatives.

Every day, our community connects through social media, educating and sharing experiences on platforms such as Twitter (now X) with our handle, @SVM_Tweets. We are connecting more often through our internal Doc Matter channel, ‘SVM Pulse.’ And, of course, we connect using more traditional means like text, email, phone calls, and in person throughout the year at events like VSS, the SVM Fellows Course, and the SVM APPs Course.

But bigger and better is not enough. Connecting with each other is not enough. As a vascular community, we have collective responsibilities, like advocating on behalf of and serving the ever-expanding population of patients with vascular disease. They need us now more than ever. To that end, I would like to share two recent anecdotes.

In July, the New York Times ran an article entitled ‘They Lost Their Legs. Doctors and Health Care Giants Profited.’ ¹ The story, about a patient’s journey with chronic limb-threatening ischemia (CLTI), is heartbreaking. In the article, a woman ultimately undergoes multiple lower-extremity revascularization procedures at the hands of an interventional cardiologist, but despite these, loses a limb. As clinicians critically reading this piece, it is not possible for us to discern what was reported accurately and what was not, nor is it possible to determine whether there were aspects of this patient’s care that were or were not appropriate. We don’t know whether her amputation was caused by her procedures or was an inevitable outcome despite them. Nevertheless, I have no doubt that after reading this piece, uninitiated readers will leave with a sense of mistrust if not fear of vascular providers. Recognizing this risk, our Society, along with the American College of Cardiology (ACC), American Heart Association (AHA), Association of Black Cardiologists (ABC), Society for Cardiovascular Angiography & Interventions (SCAI), Society for Vascular Surgery (SVS), and Society of Interventional Radiology (SIR), responded by endorsing a ‘Multi-Society Message on Peripheral Artery Disease: A Significant Public Health Issue that Remains Underrecognized, Undertreated, and Underserved.’ ² It is notable that these cardiovascular organizations came together as a community, but not before one vascular organization stated publicly that only their specialists render comprehensive vascular care. ³ Given the shortage of providers available to serve the enormous population affected by vascular disease, self-serving statements such as these are ultimately harmful to our patients. We are stronger and more effective when we speak with a single voice and when that voice is about our patients rather than our own interests. In short, we must be bigger and better than that.

In August, Propublica and The Philadelphia Inquirer copublished a story entitled ‘Unstoppable: This doctor has been investigated at every level of government. How is he still practicing?’ ⁴ In it, the author describes an interventional radiologist who was investigated, and in some cases disciplined, by state medical boards, the Food and Drug Administration (FDA), and the Department of Justice (DOJ) for performing unnecessary diagnostic and therapeutic medical procedures. The author erroneously states, ‘One area that has become perilous for patients is vascular medicine.’ ⁴ Everyone in this room understands the difference between vascular medicine and vascular intervention, but do our patients? The message we need to be sending as a community is that we need MORE not LESS vascular medicine. This audience knows all too well that vascular disease is underrecognized by providers and patients alike and disproportionately affects those with limited access to health care, often along racial and socioeconomic lines. Consequently, vascular disease is underdiagnosed and undertreated in the US and around the world, and the number of affected patients and avoidable outcomes continues to grow. As an example, Black patients in the US are less likely to be diagnosed and more likely to be referred directly for amputation without an antecedent attempt at revascularization when they develop CLTI. Proceeding directly to amputation takes an enormous toll on these patients, on their families and support systems, and on society. Patients must endure suffering, poor quality of life, and loss of function. They may require enormous amounts of time and resources from their families and other social support systems. Communities lose functional, working citizens who may have otherwise made even greater contributions to society.

I find the allegations raised in these two articles to be extremely concerning; I am sure that you do as well. If the accusations are true, then the harm caused to these patients and their loved ones is inexcusable. But I would argue that this is not how we want to monitor nor improve quality in the vascular space. Quality assurance and improvement should not be assessed by the lay media as neither the reporters nor the readers (even when they are content experts like us) have access to the medical record to discern the facts. That said, we cannot simply argue against lay adjudication of quality concerns. As a community, we must be bigger and better than that; we must provide a solution. In short, we must police ourselves.

The problem with these two articles is that they undermine the public’s trust in vascular health care and its providers, the overwhelming majority of whom are well-intentioned and render excellent care to this vulnerable patient population. We need to redouble our efforts and encourage more appropriate and effective diagnosis and treatment. Of course, we must do so while addressing the elephant in the room, an issue at the other end of the care spectrum – procedural overuse.

Although it is essential to assess the appropriateness of care, questions like these are more appropriately answered by well-informed, independent departmental or hospital quality committees, or by professional medical organizations comprised of content experts who can analyze quality registry data available through our cardiovascular professional organizations and reconcile these against multispecialty appropriate use documents, clinical guidelines, performance standards, and established best practices. Collectively, we have done the work to develop tools for assessing and assuring quality, but we need to ensure that these tools are widely available and objectively applied.

I am incredibly proud of the great quality work that SVM has done in the vascular arena. Throughout our history, SVM has worked alongside partner cardiovascular organizations to create scientific statements, including appropriate use and clinical guideline documents covering arterial and venous imaging, operator training and competency, and the medical, interventional, and surgical treatment of various disease states.^5–9 Likewise, I believe we are fortunate to have access to quality registries around vascular disease states and procedures, like the Vascular Quality Initiative (VQI), VIRTEX SIR Registry, and the Outpatient Endovascular and Interventional Society (OEIS) Registry; these registries incorporate process and outcome metrics that are benchmarked across US institutions, many of which are risk-adjusted to account for patient differences.

Our challenge is that we must do more than simply create these quality tools. We must adopt them as a community, at every hospital, in every lab and operating room, and in every clinic where we care for patients. We must apply similar quality standards across specialties and create collaborative, nonpunitive environments where care can be discussed constructively and where all boats rise with the tide. And when care is rendered outside the walls of hospitals, in office-based labs or ambulatory surgical centers, and when we are owners of such facilities, we must act as good citizens and participate in these quality efforts, even when not required to do so by an external body. Though the cost of registry participation and, even more so, the cost of registry data abstraction may be viewed as a major barrier to widespread implementation, I would argue that it should be considered a cost of doing business for every entity and person with ownership in a medical facility. There are some vascular procedures like TCAR (transcarotid artery revascularization), where payment is not possible without registry participation, but other examples are few and far between, and such requirements may ease over time. For most vascular procedures, registry participation is NOT required, even though it is in our patients’ collective best interests.

So how can we ensure community-wide participation in quality improvement efforts? Would participation in any initiative suffice? I am not certain. In some registry efforts, clinicians adjudicate their own outcomes, and it is impossible under circumstances like these to eliminate bias from our assessments. Other cardiovascular organizations have implemented voluntary random case reviews (or audits) where one institution randomly samples a small number of cases and submits them anonymously for external peer review by clinicians at another institution. We do this in my home state of Michigan as part of the BMC2 (Blue Cross Blue Shield of Michigan) PCI quality consortium. The challenge with this solution is that it is voluntary, so not all institutions participate, and patients usually are not aware of institutional participation in such efforts, so it rarely becomes a care differentiator. In my opinion, what we need above and beyond guidelines, appropriate use statements, and registries is universal participation in random case reviews, by all institutions and all providers. Importantly, we need verification of participation in these quality initiatives by an objective third party organization, like a vascular professional society. If, as good citizens, we not only submit randomly selected encounters but volunteer to review those submitted by others, an initiative like this could be very successful, and the resources needed to support it would be relatively small. The alternative is litigation of quality concerns in the lay press, fearful patients, care avoidance, and continued growth of the epidemic that is vascular disease. I submit to you that we CAN do better, and we MUST do better. It is our responsibility as a vascular community and as a vascular professional society.

It has been an honor and a privilege to have served as your President. Thank you.

Herbert D. Aronow, MD, MPH, FSVM Henry Ford Health, Detroit, MI, USA Michigan State University, East Lansing, MI, USA President, Society for Vascular Medicine