I suppose that turf battles have existed for as long as people have had areas of subspecialization. Family physicians performing urgent care. General Surgeons performing colonoscopy. The care of blood vessels, specifically the minimally invasive treatment of vascular disease seems to have created a turf battle like no other.
Interventional Radiologists, Interventional Cardiologists and Vascular Surgeons all lay claim to this turf. All make credible arguments that range from being the first historically to perform the technical procedures and therefore likely the most qualified. ie IR. The argument of being the most qualified by virtue of expertise in treating the "most important" blood vessel in the human body. that is the heart and Int. Cardiology. After all, everyone knows that all other blood vessels are kid's stuff. And lastly, the argument that we are the specialty most familiar with the "overall disease process" having been the guardians of this arena for so long. ie Vasc Surg.
Now enter the latest entrant to the field. Interventional Nephrologist. A relatively new area of specialization dedicated to maintenance of dialysis access. The types of procedures include percutaneous angioplasty, stenting of arteriovenous access, percutaneous declots, tunneled dialysis catheter placement and PD cath placement.
It seems that the genesis of this new specialty is multifactorial. A perceived lack of dedicated care for maintenance of dialysis access in certain settings. This probably stems from the fact that there is no specialty which has full accepted dialysis access as their given area of dedication. For examply, although I perform a broad spectrum of dialysis access procedures including surgical creation and percutaneous management, I didnt learn open procedures during my vascular fellowship training. I actually learned most of it during general surgery training. My catheter skill are extrapolated from my advanced arterial intervention skill of Vascular Surgery.
Second, is a desire by general nephrologists to create althernative revenue streams. And the third is the theoretical desire to provide comprehensive, overall care of their own patients. Irregardless, many nephrologists are moving full speed ahead to open independent, free standing access centers.
The benefit is that they have a ready made internal referral base. The question becomes one of conflict of interest with regard to self referral and it would appear that cardiologist have set precedent with the model of a general specialist referring to a technical specialist all within the same group and with some financial incentive to perform a greater number of procedures. These issues notwithstanding, this is a field which will certainly expand. The question is how lucrative will it actually turn out to be for nephrologists. At some point, it becomes a matter of sticking to the model which is well known, the dialysis medical director business model vs the new access center model. The ability to generate revenue in the access center was very easy five years ago with the advent of the model. However, now much less of a "slam dunk"
At The University of Pennsylvania HealthCare System, we have a unique relationship between the Interventional Radiologist, nephrologists and vascular surgeons. We work collaboratively to maintain, create and manage dialysis access.
Ill continue to elaborate on this topic over upcoming blogs. Ill also have a guest commentator on some intersting dialysis access topics.
It's here. Bard Medical has finally received FDA clearance to release The Flair Endovascular covered stent graft for management of dialysis access. The device, which comes in a flared configuration as well as a tube configuration has demonstrated impressive results in randomized prospective trial compared to percutaneous angioplasty.
