Years of Advancement: 1990-1998

Note: The 25th Anniversary Retrospection series was been based on the "History of the Society of Cardiovascular Radiology," compiled and written by Dr. Andrew Crummy. This document ended with 1988.

The following installment to the Society's history is newly drafted, and although it will serve as the written history for SCVIR, it is a work in progress. Comments from members are welcome. The decade of the 1990s has been a period of tremendous achievement for the Society, and SCVIR's success has directly contributed to the rapid advancement of interventional radiology as a specialty.

Society infrastructure was a major focus during the early part of the decade. Amendments to Society bylaws restructured the Executive Committee and expanded it to a nine member Executive Council. Two new categories of membership, associate and inactive, were created. Society Fellows voted to revise the Fellowship election process, changing it from an annual vote to a process that enabled members to apply for Fellowship status throughout the year. The election process evolved into a 30-day comment period, and the limit of 150 Fellows was removed. "Fellowship became something that members could strive for as the old two-tiered society elitism began to disappear," says past president Ernest Ring, M.D.

SCVIR continued to expand under its management contract. Membership increased to 1,476. The newly formed Cardiovascular and Interventional Radiology Research and Education Foundation (CIRREF) received funding to develop a series of seven interactive educational videodiscs. CIRREF also sponsored a multi-institutional intra-arterial contrast registry. SCVIR began to develop standards of practice and quality guidelines and became more active in the political arena with the formation of the Interventional Radiology Political Action Committee (IRPAC). Development also began on an interventional radiology quality assurance software program, which ultimately became the SCVIR HI-IQ System, so named to indicate "High in Quality." The Society hosted an international summit meeting during the annual meeting involving leaders from European and Asian interventional radiology societies. SCVIR elected to continue operating the interventional radiology fellowship match program, begun the previous year. One of the most significant accomplishments of the year was the debut of the first issue of the Society's official quarterly journal, the Journal of Vascular and Interventional Radiology. Dr. Gary Becker, who was instrumental in ensuring the journal's debut and ultimate success, served as editor.

The focus of the meeting changed from a refresher course to a plenary format. Scientific sessions were added to the annual meeting and an annual young investigator award was instituted. More than 2,100 attended the meeting in Miami Beach, FL, a 41.5 percent increase. "The growth of the Society and corresponding growth of the annual meeting is staggering, but I don't think it hit me until I arrived in Miami for the 1990 Annual Meeting. I was a little overwhelmed by the size of it all and the sheer numbers we'd be accommodating," said Dr. Arina van Breda, 1990 annual meeting program chair, following the close of the meeting.

A new era of subspecialization began, and 1991 was a year marked by significant achievements in accreditation/training and physician payment for interventional services. On the training and accreditation front, a group of SCVIR volunteers worked tirelessly with the American Board of Radiology to achieve formal recognition of our subspecialty. "Achieving subspecialty accreditation was vital. When the process began, the SCVIR Education Division knew it had to act quickly," states Gary Becker, MD. "Both cardiology and vascular surgery were posing significant turf problems to interventionalists around the nation, and we didn't even have a recognized discipline of medicine to which we could point as our foundation or justification."

The goal was achieved when the ACGME approved accreditation of subspecialty training programs in vascular and interventional radiology. This was the first part of the two-part process of formal subspecialty recognition with the second part being the granting of Certificates of Added Qualification to practitioners. "Prior to SCVIR's application only once had a subspecialty discipline received approval from ACGME on the accreditation of training programs in the absence of an ongoing program of testing and subspecialty certification by the respective member board of the ABMS," explains Gary Becker, MD.

Similar success was achieved in physician payment with the initiation by HCFA of the Medicare Fee Schedule, which used the so-called Resource Based Relative Value Scale (RBRVS) to allow more equitable reimbursement to all physician groups. The new system had a particularly large impact on our specialty because of the inadequacy of proper CPT codes to describe the work involved in interventional radiology procedures. Following vigorous work by SCVIR and a long process that included legal redress, the AMA CPT Panel allowed a total revision of interventional radiology coding with deletion of all complete procedure coding in 1992. In a decision that had a major financial impact on their practices, interventional radiologists were thereby allowed to code procedures by using a combination of surgical procedure codes plus Supervision & Interpretation codes.

Following the revision of interventional radiology coding, SCVIR, under HCFA supervision, then participated in the critical development of resource based relative values for interventional radiology, which ultimately determined appropriate payment for those services. Key to this success were Gary Dorfman, M.D., and Barry Katzen, M.D., whose vision and remarkable efforts yielded fair values for the services that interventionalists provided to patients.

"The SCVIR leadership on behalf of the entire membership is vigorously pursuing several courses of action to redress the inequities in the proposed RVS System as it applies to our specialty. We have and will continue to work closely with the ACR, have already made strong representations to HCFA, and if necessary, will take legal action to obtain equitable reimbursement to ensure the survival of interventional radiology." --Gary Dorfman, M.D., and Barry Katzen, M.D., on behalf of the entire Executive Committee - excerpted from SCVIR News; January 1989.

Yet another significant accomplishment was achieving a seat in the AMA House of Delegates. "With only a six week running start, SCVIR engineered an unbelievable lobbying effort during the short time available and essentially did what couldn't be done, said 1990 Council Chair Arina van Breda, M.D. "None of this would have been possible without the phenomenal efforts of Drs. John Fulco and Robert Vogelzang."

Members showed their support for SCVIR's efforts when they voted to approve the Society's first dues increase during the Members' Business Meeting, which doubled the price of dues to support the Society's rapidly growing activities and to build a special reserve for extraordinary expenses, such as the efforts regarding RBRVS. This enabled members to continue to receive JVIR and attend the meeting at no fee. As the Society's achievements continued to increase, SCVIR also elected not to renew its management contract with ACR and established an independent office in Fairfax, VA, on August 1. This was the same year the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) established its own permanent office in Zurich. In addition, the SCVIR Executive Council expanded to 12 members. The Executive Council voted to suspend the Interventional Radiology Fellowship Match Program because a substantial majority of training programs and potential trainees were not participating. Members were instead asked to abide by a May 1 selection date for interventional radiology fellows. CIRREF assisted in supporting data collection for a transluminal angioplasty registry.

Interventional radiology was truly beginning to achieve recognition as a viable specialty. The American Board of Radiology announced it would consider offering Certificates of Added Qualifications (CAQs) in vascular and interventional radiology beginning in 1994. HCFA developed a Medicare specialty designation for interventional radiology, and "interventional radiology" was defined in defined in Dorland's Illustrated Medical Dictionary for the first time. Additionally, the National Library of Medicine selected JVIR to be included in Index Medicus.

Bylaws changes were approved to open the member-in-training category to third and fourth year radiology residents and assessed minor dues. Canadian members were allowed to choose between active and corresponding member status. Amendments to the inactive member category revised it to include those retired strictly from the practice of interventional radiology and not just from the practice of medicine. The time length for eligibility was reduced from ten to five years.

SCVIR developed angioplasty standards of practice and interventional radiology patient information brochures. Vascular stents and TIPS dominated the annual meeting program. Dr. Sven-Ivar Seldinger was honored with the SCVIR Pioneer in Interventional Radiology Award. This prestigious honor has only been awarded once. The Society redefined its mission and goals during a strategic planning process. The Miami based JVIR editorial office was destroyed during hurricane Andrew. SCVIR held numerous coding workshops to educate members on the new coding system. The Society also served as a resource to the FDA on risk issues related to fluoroscopy.

Momentous changes rocked the US health care system. SCVIR members faced a national shifting away from subspecialty medicine to primary care. "Specialists become politically incorrect," says Past President Gordon McLean, M.D. The Society advocated for quality patient care throughout the process. Dr. McLean presented interventional radiology's concerns with health care reform during testimony before the Congressional Subcommittee on Health of the Ways and Means Committee.

Society membership rose to 2,120. SCVIR opened the member-in-training category to first and second year radiology residents. The SCVIR office and staff expanded. Guidelines for diagnostic arteriography in adults were drafted. A medical student career brochure for interventional radiology was developed. SCVIR produced case log books. SCVIR also joined the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) and the Coalition on Smoking OR Health. The Society intensified its active promotion of admitting privileges for interventional radiologists. The annual scientific meeting had grown to a size that warranted moving from a hotel setting to a convention center. There were 2,746 attendees in New Orleans, LA, for the 18th annual meeting.

Fifty percent of vascular and interventional radiology fellowships were accredited by this time. The American Board of Medical Specialties officially approved vascular and interventional radiology CAQs, and an ABR Vascular and Interventional CAQ Committee was assembled for the purpose of creating the first oral examination on videodisc. The Committee included Drs. Gary Becker, William Casarella, Gary Dorfman, Helen Redman, Daniel Picus, and Arina Van Breda. The first phase of the SCVIR HI-IQ System, the quality assurance database, was successfully completed and released.

SCVIR joined with the National Cancer Institute and the National Aeronautics and Space Administration to organize a workshop on Technology Transfer in Image-Guided Therapy. The Society produced quality improvement guidelines for adult percutaneous abscess and fluid drainage and jointly authored a document on guidelines for development and use of transluminally placed endovascular prosthetic (stented) grafts in the arterial system with the Society for Vascular Surgery and the International Society for Cardiovascular Surgery. The Society produced a Vascular and Interventional Radiology Curriculum. The Society developed and adopted an Ethics statement.

On behalf of the Society, Dr. Arina van Breda testified before the FDA's Drug Abuse Advisory Committee during hearings to determine whether nicotine in cigarettes should be regulated as a drug. The OIG issued subpoenas to more than 100 hospitals requesting a complete listing of all procedures involving devices that were not approved by the FDA for marketing, including the use of approved devices for non-approved purposes and/or involving non FDA approved procedures.

The vascular and interventional radiology Certificates of Added Qualification became a reality, and 400 examinees sat for the first CAQ exam. SCVIR debuted Phase II of the SCVIR HI-IQ System -- Inventory Management, and the future benefits of the system were clear. "We must undertake the monumental effort to demonstrate the cost effectiveness and long-term outcomes of the services we render to our patients," said Gary Dorfman. "Fortunately participation in this effort will be possible as part of your everyday practice. Through the efforts of the Electronic Database Committee, the HI-IQ System has become a reality." Tremendous time and effort were given to the development of this system by Drs. Kenneth Rholl, Terence Matalon, and Bayne Selby.

Training became an important focus. SCVIR developed and submitted a plan for training interventional radiologists to the American Board of Radiology and the Residency Review Committee of the ACGME that would allow for two years of clinical training, two years of imaging, and two years of interventional radiology. "One of our long-range strategies is to train interventional radiologists with the clinical skills necessary to assume more control over patient care," stated Michael Pentecost, M.D. "This program will serve as the 'interventional track' in radiology residency."

SCVIR met the membership's growing need to develop and market their practices by producing a marketing manual. The Society marked the 20th anniversary of its annual postgraduate course. The annual young investigator award was named after Dr. Gary J. Becker to honor him as founding editor of JVIR. SCVIR received ACCME accreditation to sponsor CME. The SCVIR Office expanded space and staff. SCVIR also became accessible throughout the world when it launched a web site. HCFA changes to payment policy regarding payment for multiple surgical procedures improved physician payment for interventional radiologists.

With a growing history of innovations, SCVIR took the lead to ensure that interventional radiologists continued to be leaders in the development of new devices and techniques. CIRREF launched Interventional America 2000 (IA2000), a campaign to raise $5 million to fund cardiovascular and interventional radiology research. The campaign kicked off with $3.3 million dollars in pledges.

The Society instituted a Gold Medal Award and awarded the first medals to Drs. Cesare Gianturco and Kurt Amplatz. "The Society needs heroes," said Dr. Ernest Ring. Scientific posters were instituted during the annual meeting as well as a virtual reality workshop. More than 4,000 attended the meeting. The Society honored its founding members during the annual Fellows' Dinner.

SCVIR held the first annual Morbidity & Mortality Conference. The Society also began developing more extensive ties with health care related organizations and actively supported patient access to specialty care and legislation to ensure biomaterials availability. HCFA outlined supervision rules for physicians teaching residents and fellows. HCFA also set forth rules to eliminate the use of incorrect codes and developed an extensive set of guidelines and computer edits that automatically disallowed the use of certain codes with other codes, know as the Rebundling and later the Correct Coding Initiative. SCVIR actively participated in commenting on both HCFA rules. After three exams, 859 interventional radiologists had successfully achieved their vascular and interventional radiology CAQ. SCVIR published quality improvement guidelines for image-guided percutaneous biopsy in adults. The Society also held its third strategic planning meeting.

SCVIR entered into an agreement with Fairfax Partners to create ConexSys, a company dedicated to the continued development of the SCVIR HI-IQ System. Bylaws changes opened the membership deleting the requirement that members spend 50 percent practice time in cardiovascular and interventional radiology. Use of FSCVIR by Fellows was encouraged for the first time.

ACCME Awards Full Accreditation to SCVIR for four years as a sponsor of continuing medical education for physicians. The SCVIR Case Club was launched on the home page. Attention was focused on acute stroke treatment. IA2000 reached $3,559,000 in pledges after one year. CIRREF created a new vision and mission statement during a strategic planning meeting and awarded the Foundation's first research grants. The SCVIR Technology Assessment Committee drafted and published General Principles for Evaluation of New Interventional Technologis and Devices and Reporting Standards for Clinical Evaluation of New Peripheral Arterial Revascularization Devices.

SCVIR, under the direction of Dr. Curt Bakal, developed a scientific consensus based method of developing quality improvement guidelines and published a record number of guidelines and reporting standards. Among these were reporting standards for Transjugular Intrahepatic Portosystemic Shunts (TIPS) and guidelines for percutaneous transhepatic cholangiography and biliary drainage, HIV and other bloodborne pathogens, venous access, and percutaneous transcatheter embolization. SCVIR also developed a clinical trials workshop with FDA and the Food and Drug Law Institute (FDLI) and established an SCVIR/FDA Device Forum through the efforts of Patricia Cole, PhD, MD. Increased communication and relations with vascular surgery and neuroradiology were a focus.

"As we reflect on SCVIR's Silver Anniversary milestone, it has been a remarkable 25 years. With membership surpassing 3,000 and a wealth of growing activities, SCVIR and interventional radiology face a bright future," stated Dr. Robert Vogelzang, president. "The first 25 years of our specialty and our Society have been truly amazing. We made medical advances that pioneered a new field and benefited millions of patients. At the same time, we established a firm practice and economic basis for the continued health of our specialty. I predict the next chapter for SCVIR and interventional radiology will be The Years of Leadership as we assimilate many of the changes we have made and help establish interventional radiologists as the premier practitioners of the methods and techniques we invented."

Published in: SCVIR News - January/February 1998