Creating and Maintaining a Successful Service Line in an Academic Medical Center at the Dawn of Value-Based Care: Lessons Learned From the Heart and Vascular Service Line at UMass Memorial Health Care.

The service line (SL) model has been proven to help shift health care toward value-based services, which is characterized by coordinated, multidisciplinary, high-quality, and cost-effective care. However, academic medical centers struggle with how to effectively set up SL structures that overcome the organizational and cultural challenges associated with simultaneously delivering the highest-value care for the patient and advancing the academic mission. In this article, the authors examine the evolution of UMass Memorial Health Care's heart and vascular service line (HVSL) from 2006 to 2011 and describe the impact on its success of multiple strategic decisions. These include key academic physician leadership recruitments and engagement via a matrixed governance and management model; development of multidisciplinary teams; empowerment of SL leadership through direct accountability and authority over programs and budgets; joint educational and training programs; incentives for academic achievement; and co-localization of faculty, personnel, and facilities. The authors also explore the barriers to success, including the need to overcome historical departmental-based silos, cultural and training differences among disciplines, confusion engendered by a matrixed reporting structure, and faculty's unfamiliarity with the financial and organizational skills required to operate a successful SL. Also described here is the impact that successful implementation of the SL has on creating high-quality services, increased profitability, and contribution to the financial stability and academic achievement of the academic medical center.

An increasing demand for integrated vascular residency training far outweighs the limited supply of positions.

OBJECTIVE: The integrated vascular surgery residency training paradigm ("0 + 5") was first approved by the Accreditation Council for Graduate Medical Education (ACGME) in 2006, with the first residents beginning in 2007. We sought to evaluate the demand for these new positions and to better understand applicant pool demographics. METHOD: The Association of American Medical Colleges (AAMC) was petitioned for data on applicants to traditional vascular surgery fellowship and integrated vascular residency training programs (years 2006-2009). In addition, 111 applications received at a single academic institution for the year 2009 were reviewed in depth. RESULT: The number of traditional vascular fellowship applicants and the corresponding number of positions remained stable. In contrast, the number of integrated vascular resident applicants increased dramatically, with 152 applicants seeking to match into 19 available positions in 2009. For the year 2009, 88% of integrated vascular residency applicants did not match, while 16% of traditional fellowship positions went unfilled. The most notable difference between integrated residency and traditional fellowship applicants is the number of foreign medical graduates (68.7% vs. 26.7% in 2008, P < .001). Of the 111 integrated applicants applying for our single position (73% of entire 2009 applicant pool), the majority of applicants were residing in the United States (88.3%) and a sizable proportion (25.2%) had completed at least one full year of either surgical training or surgical research at an institution in the Unites States. Objective measures of academic success included mean United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores of 89.1 and 89.5, respectively. The mean number of peer-reviewed journal publications at the time of application was 2.8. CONCLUSION: The number of integrated vascular surgery residency applicants far outweighs the number of available positions. Growing interest in more efficient and comprehensive vascular surgery training will continue to augment demand. As educators, vascular surgeons should seize this opportunity and aggressively expand the number of available integrated residency training positions.

Complications related to dapsone use for Pneumocystis jirovecii pneumonia prophylaxis in solid organ transplant recipients.

Dapsone, used for prevention of Pneumocystis jirovecii infections, has been reported to cause hemolytic anemia and methemoglobinemia; its tolerability in solid organ transplant recipients is not well described. We investigated dapsone-related adverse events in patients undergoing solid organ transplantation from 1999 to 2004. Transplant providers identified patients for the investigators who then reviewed the patients' hospital and outpatient records. Sixteen solid organ transplant recipients fit case definitions for dapsone-related hemolytic anemia (n = 11) or methemoglobinemia (n = 5). Median time from event to dapsone discontinuation was 15 days; all patients improved after drug discontinuation. G6PD enzyme activity was normal in all patients whose test results were available. Dapsone may be associated with hemolytic anemia or methemoglobinemia, even with normal G6PD levels. These events are often not promptly recognized, and drug discontinuation is delayed. Dapsone-related hemolytic anemia or methemoglobinemia should be considered in solid organ transplant recipients with unexplained anemia or hypoxia.

Appendicitis among liver transplant recipients.

Appendicitis among liver transplant recipients has not been described in the current literature. We report 8 recipients who experienced appendicitis three weeks to 181 months after liver transplantation (LT). Initial presenting findings differed from the nonimmunosuppressed population in that a majority of the patients did not have leukocytosis (>10,000 cells/mm3). Four patients experienced perforation, three of whom presented three days after the development of abdominal pain. All patients recovered after surgery without untoward sequela.