US vets not receiving standard of care in vascular and cardiac surgery

Thousands of United States veterans wait daily to receive standard of care in vascular and cardiac surgery. The face of these medical specialties today is a stark contrast to their existence 25 years ago: What was once a long incision over the belly for repair an aortic aneurysm is now two small punctures in the groin.

What once required cracking the chest open to replace a heart valve, leaves only a tiny scar. These amazing advances in cardiovascular disease are due to one word, endovascular, meaning from within the vessel, and those who’ve put their lives on the line don’t have access to what is now the best care available.

{mosads}Most U.S. hospitals have what’s called a hybrid operating room or have plans to build one in the next five years. This is a specially designed surgery suite with the ability to perform CT scans and moving X-rays during a procedure. Unfortunately, if a veteran were to call their local Veterans Administration hospital, they would find a far different answer: Less than 10 percent of Veterans Affairs (VA) hospitals in this country have a hybrid room. 

Endovascular repair requires moving X-rays and even CT scans intraoperatively, and in the 1990s, mobile X-ray machines, were brought into the operating room for this purpose. However, as this technique quickly expanded to virtually all avenues of vascular disease, higher-level imaging was required. Thus the hybrid suite was born, a modern solution that combines the high definition of X-ray imaging, while performing a sterile invasive vascular operation.

And while university medical centers and the vast majority of large community hospitals adjust their real estate and budget to accommodate hybrid rooms for their insured and out-of-pocket paying patients, the VA system I’m sad to say is, at best, slow to respond even 20 years later.

Frankly, these rooms cost about $1 million dollars to build, but I assure you there are veterans who need complex cardiac or vascular procedures that absolutely require hybrid rooms. How then are these veterans getting those surgeries? Currently, they are sent to a local university. This is option provided by the VA administration allows payment to a non-VA facility, which can provide a necessary service the local VA does not offer. I challenge a single VA hospital to calculate current fee-based costs for the past five years. I suspect this sum would far outreach the actual budget to build their own hybrid operating room, as many VA neurosurgeons, interventional cardiologists, interventional radiologists, and neuro-interventional radiologists are all fee-basing out complex patients to the nearest hybrid room.

But as a practicing academic vascular surgeon, the issue is not money; it is the dedication to provide medical care to America’s veterans, and the complexity of the case doesn’t matter. When Dr. Jason Lee of Stanford University evaluated outcomes of straight-forward aneurysm repair in a hybrid room compared to the traditional X-ray and found a trend toward decreased radiation exposure and complications.

Do not get me wrong, VA hospitals are institutions of excellence, and countless veterans love their VA. VA hospitals are a warm and welcoming family where “welcome to Walmart” is replaced by “Thank you for your service.” Some veterans feel a sense of belonging among their fellow brothers and sisters and enjoy the familiarity of one facility from primary care to podiatry. The thought of driving to a cold, white titanic of a university hospital where they will pay a fortune for parking does not sit well. They have come to expect quality care and are absolutely entitled to just that.

There have been many movements since the calamity of the Vietnam War to embrace our veterans and acknowledge their dedication and sacrifice for their country: the Greenlight campaign, Mission 22, and public awareness for post-traumatic stress disorder. This is the call to provide the same standard of cardiovascular care to the veterans most Americans already enjoy.

Dr. Kristine Orion, a Public Voices Fellow, is an assistant professor of surgery at Yale School of Medicine.