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ACS: Ensuring the integrity of the profession and the quality of patient care
With a new administration and Congress in place, as well as many exciting internal changes, the American College of Surgeons (ACS) is looking forward to an exciting year ahead.
Quality improvement
Making certain that surgeons have the tools they need to measure and evaluate their performance is a key mission of the College. To this end, we have initiated the database integration system, which will bring together under a single platform the ACS National Surgical Quality Improvement Program (ACS NSQIP®), National Cancer Database, National Trauma Data Bank, and Surgeon Specific Registry (SSRTM). This project, which is being implemented incrementally, will make it easier for surgeons to meet American Board of Surgery (ABS) Maintenance of Certification requirements and Medicare payment mandates.
Furthermore, the College intends to publish an ACS quality manual this year. This comprehensive guidebook will outline strategies and resources needed to ensure the delivery of optimal surgical care.
Advocacy
The Medicare Access and CHIP Reauthorization Act (MACRA), enacted in 2015, repealed the flawed sustainable growth rate (SGR) methodology that was used for many years to calculate Medicare physician reimbursement. Replacing the SGR is the Quality Payment Program (QPP), which advances a longstanding policy goal of basing payment on value rather than on volume.
Surgeons can participate in the QPP through one of two pathways—the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APMs). MIPS is the default QPP pathway most physicians will use initially. The College has taken a number of steps to ensure that surgeons are able to comply with MIPS’ reporting requirements and performance measures. For example, we have created an online Resource Center (https://www.facs.org/advocacy/qpp) for surgeons seeking information about the QPP. In addition, we are working with health policy experts at Brandeis University, Waltham, MA, and Brigham and Women’s Hospital, Boston, to propose surgical APMs.
We anticipate that the new presidential administration and Republican-controlled Congress will leave QPP untouched—at least for a while. However, we also speculate that they will attempt to repeal at least some provisions in the Affordable Care Act (ACA). The ACS intends to play an active role in what is certain to be a highly charged debate—just as we did when the ACA was under consideration. As we enter this discussion, we will advocate for the policies that we believe will have the greatest benefit toward ensuring that all surgical patients have access to necessary services. We will not be swayed by politics but rather, will promote our enduring principles for health care reform: quality improvement and patient safety, patient access to surgical care, reduction of health care costs, and medical liability reform.
Education
Surgical education and training have been at the heart of the College’s mission since the organization’s inception. We believe the ACS’ education and training programs are the cornerstones of excellence, transform possibilities into realities, and instill the joy of lifelong learning.
Of particular concern in recent years have been reports that a significant percentage of general surgeon residency graduates leave training feeling insecure about their ability to perform advanced procedures and to manage a practice. In response, the College launched the Transition to Practice in General Surgery program, which provides opportunities for recently graduated residents to engage in a period of mentored practice.
In addition, the College has been working with other stakeholders, including the ABS, the Accreditation Council for Graduate Medical Education, the Association of Program Directors in Surgery, and the Residency Review Committee for Surgery, to develop a road map to secure the future of general surgery. Concepts discussed in these meetings include the following:
- Medical student boot camps
- Further training after five years of general surgery residency
- Modification to duty-hour requirements
- Competency-based education and skills assessment
- Guidelines for self-assessment during residency
- A faculty development requirement
- Career-long record keeping, starting in medical school
Today’s residents are tomorrow’s surgeons. Given the aging population that will be seeking their services, it is imperative that the House of Surgery take responsibility for ensuring that graduates of general surgery training programs have the full range of skills and the confidence necessary to care for these vulnerable patients.
Member services and communication
Our Member Services area continues to develop programs that are designed to encourage surgeon engagement and well-being.
The 2017 Leadership & Advocacy Summit, May 6-9 in Washington, DC, will address such topics as team building, managing critical situations, burnout, common mistakes in leadership, and domestic volunteerism. During the advocacy portion of the meeting, members will have opportunities to flex their leadership muscle and advocate on their patients’ behalf.
The College recognizes that surgeons need to be mentally, emotionally, and physically healthy to provide optimal care to their patients. With this thought in mind, the ACS invites all active, dues-paying members to use the Physician Well-Being Index. This validated screening tool provides an opportunity for surgeons to better understand their overall well-being and identify areas of risk compared to physicians across the nation. Access to local and national resources will also be targeted to surgeons based on their results. Access the ACS Surgeon Well-Being page to learn more about the tool.
Furthermore, the College has continued to make its communications vehicles more interactive and user-friendly. The ACS Communities are thriving, allowing members to share their common concerns and interests in a protected environment. We also are working to have all of our major publications, including the Bulletin and the Journal of the American College of Surgeons, moved to fully digital platforms.
I am proud of the strides the College is making and look forward to an exciting and productive year. As always, please let us know how we can better serve you and your patients.
Dr. Hoyt is the Executive Director of the American College of Surgeons.
With a new administration and Congress in place, as well as many exciting internal changes, the American College of Surgeons (ACS) is looking forward to an exciting year ahead.
Quality improvement
Making certain that surgeons have the tools they need to measure and evaluate their performance is a key mission of the College. To this end, we have initiated the database integration system, which will bring together under a single platform the ACS National Surgical Quality Improvement Program (ACS NSQIP®), National Cancer Database, National Trauma Data Bank, and Surgeon Specific Registry (SSRTM). This project, which is being implemented incrementally, will make it easier for surgeons to meet American Board of Surgery (ABS) Maintenance of Certification requirements and Medicare payment mandates.
Furthermore, the College intends to publish an ACS quality manual this year. This comprehensive guidebook will outline strategies and resources needed to ensure the delivery of optimal surgical care.
Advocacy
The Medicare Access and CHIP Reauthorization Act (MACRA), enacted in 2015, repealed the flawed sustainable growth rate (SGR) methodology that was used for many years to calculate Medicare physician reimbursement. Replacing the SGR is the Quality Payment Program (QPP), which advances a longstanding policy goal of basing payment on value rather than on volume.
Surgeons can participate in the QPP through one of two pathways—the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APMs). MIPS is the default QPP pathway most physicians will use initially. The College has taken a number of steps to ensure that surgeons are able to comply with MIPS’ reporting requirements and performance measures. For example, we have created an online Resource Center (https://www.facs.org/advocacy/qpp) for surgeons seeking information about the QPP. In addition, we are working with health policy experts at Brandeis University, Waltham, MA, and Brigham and Women’s Hospital, Boston, to propose surgical APMs.
We anticipate that the new presidential administration and Republican-controlled Congress will leave QPP untouched—at least for a while. However, we also speculate that they will attempt to repeal at least some provisions in the Affordable Care Act (ACA). The ACS intends to play an active role in what is certain to be a highly charged debate—just as we did when the ACA was under consideration. As we enter this discussion, we will advocate for the policies that we believe will have the greatest benefit toward ensuring that all surgical patients have access to necessary services. We will not be swayed by politics but rather, will promote our enduring principles for health care reform: quality improvement and patient safety, patient access to surgical care, reduction of health care costs, and medical liability reform.
Education
Surgical education and training have been at the heart of the College’s mission since the organization’s inception. We believe the ACS’ education and training programs are the cornerstones of excellence, transform possibilities into realities, and instill the joy of lifelong learning.
Of particular concern in recent years have been reports that a significant percentage of general surgeon residency graduates leave training feeling insecure about their ability to perform advanced procedures and to manage a practice. In response, the College launched the Transition to Practice in General Surgery program, which provides opportunities for recently graduated residents to engage in a period of mentored practice.
In addition, the College has been working with other stakeholders, including the ABS, the Accreditation Council for Graduate Medical Education, the Association of Program Directors in Surgery, and the Residency Review Committee for Surgery, to develop a road map to secure the future of general surgery. Concepts discussed in these meetings include the following:
- Medical student boot camps
- Further training after five years of general surgery residency
- Modification to duty-hour requirements
- Competency-based education and skills assessment
- Guidelines for self-assessment during residency
- A faculty development requirement
- Career-long record keeping, starting in medical school
Today’s residents are tomorrow’s surgeons. Given the aging population that will be seeking their services, it is imperative that the House of Surgery take responsibility for ensuring that graduates of general surgery training programs have the full range of skills and the confidence necessary to care for these vulnerable patients.
Member services and communication
Our Member Services area continues to develop programs that are designed to encourage surgeon engagement and well-being.
The 2017 Leadership & Advocacy Summit, May 6-9 in Washington, DC, will address such topics as team building, managing critical situations, burnout, common mistakes in leadership, and domestic volunteerism. During the advocacy portion of the meeting, members will have opportunities to flex their leadership muscle and advocate on their patients’ behalf.
The College recognizes that surgeons need to be mentally, emotionally, and physically healthy to provide optimal care to their patients. With this thought in mind, the ACS invites all active, dues-paying members to use the Physician Well-Being Index. This validated screening tool provides an opportunity for surgeons to better understand their overall well-being and identify areas of risk compared to physicians across the nation. Access to local and national resources will also be targeted to surgeons based on their results. Access the ACS Surgeon Well-Being page to learn more about the tool.
Furthermore, the College has continued to make its communications vehicles more interactive and user-friendly. The ACS Communities are thriving, allowing members to share their common concerns and interests in a protected environment. We also are working to have all of our major publications, including the Bulletin and the Journal of the American College of Surgeons, moved to fully digital platforms.
I am proud of the strides the College is making and look forward to an exciting and productive year. As always, please let us know how we can better serve you and your patients.
Dr. Hoyt is the Executive Director of the American College of Surgeons.
With a new administration and Congress in place, as well as many exciting internal changes, the American College of Surgeons (ACS) is looking forward to an exciting year ahead.
Quality improvement
Making certain that surgeons have the tools they need to measure and evaluate their performance is a key mission of the College. To this end, we have initiated the database integration system, which will bring together under a single platform the ACS National Surgical Quality Improvement Program (ACS NSQIP®), National Cancer Database, National Trauma Data Bank, and Surgeon Specific Registry (SSRTM). This project, which is being implemented incrementally, will make it easier for surgeons to meet American Board of Surgery (ABS) Maintenance of Certification requirements and Medicare payment mandates.
Furthermore, the College intends to publish an ACS quality manual this year. This comprehensive guidebook will outline strategies and resources needed to ensure the delivery of optimal surgical care.
Advocacy
The Medicare Access and CHIP Reauthorization Act (MACRA), enacted in 2015, repealed the flawed sustainable growth rate (SGR) methodology that was used for many years to calculate Medicare physician reimbursement. Replacing the SGR is the Quality Payment Program (QPP), which advances a longstanding policy goal of basing payment on value rather than on volume.
Surgeons can participate in the QPP through one of two pathways—the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APMs). MIPS is the default QPP pathway most physicians will use initially. The College has taken a number of steps to ensure that surgeons are able to comply with MIPS’ reporting requirements and performance measures. For example, we have created an online Resource Center (https://www.facs.org/advocacy/qpp) for surgeons seeking information about the QPP. In addition, we are working with health policy experts at Brandeis University, Waltham, MA, and Brigham and Women’s Hospital, Boston, to propose surgical APMs.
We anticipate that the new presidential administration and Republican-controlled Congress will leave QPP untouched—at least for a while. However, we also speculate that they will attempt to repeal at least some provisions in the Affordable Care Act (ACA). The ACS intends to play an active role in what is certain to be a highly charged debate—just as we did when the ACA was under consideration. As we enter this discussion, we will advocate for the policies that we believe will have the greatest benefit toward ensuring that all surgical patients have access to necessary services. We will not be swayed by politics but rather, will promote our enduring principles for health care reform: quality improvement and patient safety, patient access to surgical care, reduction of health care costs, and medical liability reform.
Education
Surgical education and training have been at the heart of the College’s mission since the organization’s inception. We believe the ACS’ education and training programs are the cornerstones of excellence, transform possibilities into realities, and instill the joy of lifelong learning.
Of particular concern in recent years have been reports that a significant percentage of general surgeon residency graduates leave training feeling insecure about their ability to perform advanced procedures and to manage a practice. In response, the College launched the Transition to Practice in General Surgery program, which provides opportunities for recently graduated residents to engage in a period of mentored practice.
In addition, the College has been working with other stakeholders, including the ABS, the Accreditation Council for Graduate Medical Education, the Association of Program Directors in Surgery, and the Residency Review Committee for Surgery, to develop a road map to secure the future of general surgery. Concepts discussed in these meetings include the following:
- Medical student boot camps
- Further training after five years of general surgery residency
- Modification to duty-hour requirements
- Competency-based education and skills assessment
- Guidelines for self-assessment during residency
- A faculty development requirement
- Career-long record keeping, starting in medical school
Today’s residents are tomorrow’s surgeons. Given the aging population that will be seeking their services, it is imperative that the House of Surgery take responsibility for ensuring that graduates of general surgery training programs have the full range of skills and the confidence necessary to care for these vulnerable patients.
Member services and communication
Our Member Services area continues to develop programs that are designed to encourage surgeon engagement and well-being.
The 2017 Leadership & Advocacy Summit, May 6-9 in Washington, DC, will address such topics as team building, managing critical situations, burnout, common mistakes in leadership, and domestic volunteerism. During the advocacy portion of the meeting, members will have opportunities to flex their leadership muscle and advocate on their patients’ behalf.
The College recognizes that surgeons need to be mentally, emotionally, and physically healthy to provide optimal care to their patients. With this thought in mind, the ACS invites all active, dues-paying members to use the Physician Well-Being Index. This validated screening tool provides an opportunity for surgeons to better understand their overall well-being and identify areas of risk compared to physicians across the nation. Access to local and national resources will also be targeted to surgeons based on their results. Access the ACS Surgeon Well-Being page to learn more about the tool.
Furthermore, the College has continued to make its communications vehicles more interactive and user-friendly. The ACS Communities are thriving, allowing members to share their common concerns and interests in a protected environment. We also are working to have all of our major publications, including the Bulletin and the Journal of the American College of Surgeons, moved to fully digital platforms.
I am proud of the strides the College is making and look forward to an exciting and productive year. As always, please let us know how we can better serve you and your patients.
Dr. Hoyt is the Executive Director of the American College of Surgeons.
ACS NSQIP conference gets new name, expanded focus
To provide a more comprehensive look at the American College of Surgeons (ACS) quality improvement efforts, the College has announced that the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Annual Conference will now be the 2017 ACS Quality and Safety Conference. The meeting will take place July 21-24 at the New York Hilton Midtown, NY.
The annual ACS NSQIP conference has grown rapidly in recent years – the 2016 conference in San Diego, CA, drew nearly 1,500 surgeon champions, surgical clinical reviewers (SCRs), and other quality improvement professionals. The ACS Quality and Safety Conference will build on that success, featuring leaders in surgery as speakers and various presentations focused on ACS NSQIP, while offering expanded content on the following ACS Quality Programs:
• ACS NSQIP Pediatric
• Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
• Children’s Surgery Verification™ Quality Improvement Program
• Surgeon Specific Registry
Achieving quality
The theme of the expanded conference, Achieving Quality: Present and Future, will serve as the basis of the meeting’s proceedings. To achieve the goal of improving quality, presenters and organizers are striving to accomplish the following objectives:
Provide a forum to share the most up-to-date knowledge pertaining to local, national, and international quality improvement initiatives in surgery.
Present methods used to analyze clinical registry data and demonstrate practical ways to use the data.
Assist hospitals in analyzing, managing, and interpreting data by providing education on proven methods that will empower hospitals to make a positive impact on patient care.
Enhance the learning experience by offering breakout sessions that educate attendees on topic areas of interest to them, with consideration of their level of experience in ACS quality improvement programs.
Conference highlights
In addition to talks from surgical leaders, the 2017 ACS Quality and Safety Conference will offer other notable events.
Keynote speaker Blake Haxton, a member of the 2016 U.S. Paralympic Team in rowing, will share his unique insight with attendees. Mr. Haxton contracted necrotizing fasciitis in March 2009, in his senior year of high school. The infection led to heart, lung, kidney, and liver failure, as well as the loss of both legs; however, after an intensive rehabilitation regimen, he was able to attend and graduate from college and law school.
Another conference highlight will be abstract competitions in four categories: Medical Student and Surgical Resident Abstract Competition, SCR Abstract Competition, Clinical Abstract Competition, and Abstract Poster Competition.
Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care, which oversees all ACS Quality Programs, is enthusiastic about the newly expanded ACS Quality and Safety Conference. “We are excited to have multiple quality programs of the American College of Surgeons coming together for this conference so that we can all learn how to get better, become more efficient, and provide high-value care in all types of settings,” Dr. Ko said. “This is the first time we’ve put together a conference like this, which we hope will be the first of many.”
More information about the 2017 ACS Quality and Safety Conference can be found at facs.org/quality-programs/quality-safety-conference.
To provide a more comprehensive look at the American College of Surgeons (ACS) quality improvement efforts, the College has announced that the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Annual Conference will now be the 2017 ACS Quality and Safety Conference. The meeting will take place July 21-24 at the New York Hilton Midtown, NY.
The annual ACS NSQIP conference has grown rapidly in recent years – the 2016 conference in San Diego, CA, drew nearly 1,500 surgeon champions, surgical clinical reviewers (SCRs), and other quality improvement professionals. The ACS Quality and Safety Conference will build on that success, featuring leaders in surgery as speakers and various presentations focused on ACS NSQIP, while offering expanded content on the following ACS Quality Programs:
• ACS NSQIP Pediatric
• Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
• Children’s Surgery Verification™ Quality Improvement Program
• Surgeon Specific Registry
Achieving quality
The theme of the expanded conference, Achieving Quality: Present and Future, will serve as the basis of the meeting’s proceedings. To achieve the goal of improving quality, presenters and organizers are striving to accomplish the following objectives:
Provide a forum to share the most up-to-date knowledge pertaining to local, national, and international quality improvement initiatives in surgery.
Present methods used to analyze clinical registry data and demonstrate practical ways to use the data.
Assist hospitals in analyzing, managing, and interpreting data by providing education on proven methods that will empower hospitals to make a positive impact on patient care.
Enhance the learning experience by offering breakout sessions that educate attendees on topic areas of interest to them, with consideration of their level of experience in ACS quality improvement programs.
Conference highlights
In addition to talks from surgical leaders, the 2017 ACS Quality and Safety Conference will offer other notable events.
Keynote speaker Blake Haxton, a member of the 2016 U.S. Paralympic Team in rowing, will share his unique insight with attendees. Mr. Haxton contracted necrotizing fasciitis in March 2009, in his senior year of high school. The infection led to heart, lung, kidney, and liver failure, as well as the loss of both legs; however, after an intensive rehabilitation regimen, he was able to attend and graduate from college and law school.
Another conference highlight will be abstract competitions in four categories: Medical Student and Surgical Resident Abstract Competition, SCR Abstract Competition, Clinical Abstract Competition, and Abstract Poster Competition.
Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care, which oversees all ACS Quality Programs, is enthusiastic about the newly expanded ACS Quality and Safety Conference. “We are excited to have multiple quality programs of the American College of Surgeons coming together for this conference so that we can all learn how to get better, become more efficient, and provide high-value care in all types of settings,” Dr. Ko said. “This is the first time we’ve put together a conference like this, which we hope will be the first of many.”
More information about the 2017 ACS Quality and Safety Conference can be found at facs.org/quality-programs/quality-safety-conference.
To provide a more comprehensive look at the American College of Surgeons (ACS) quality improvement efforts, the College has announced that the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Annual Conference will now be the 2017 ACS Quality and Safety Conference. The meeting will take place July 21-24 at the New York Hilton Midtown, NY.
The annual ACS NSQIP conference has grown rapidly in recent years – the 2016 conference in San Diego, CA, drew nearly 1,500 surgeon champions, surgical clinical reviewers (SCRs), and other quality improvement professionals. The ACS Quality and Safety Conference will build on that success, featuring leaders in surgery as speakers and various presentations focused on ACS NSQIP, while offering expanded content on the following ACS Quality Programs:
• ACS NSQIP Pediatric
• Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
• Children’s Surgery Verification™ Quality Improvement Program
• Surgeon Specific Registry
Achieving quality
The theme of the expanded conference, Achieving Quality: Present and Future, will serve as the basis of the meeting’s proceedings. To achieve the goal of improving quality, presenters and organizers are striving to accomplish the following objectives:
Provide a forum to share the most up-to-date knowledge pertaining to local, national, and international quality improvement initiatives in surgery.
Present methods used to analyze clinical registry data and demonstrate practical ways to use the data.
Assist hospitals in analyzing, managing, and interpreting data by providing education on proven methods that will empower hospitals to make a positive impact on patient care.
Enhance the learning experience by offering breakout sessions that educate attendees on topic areas of interest to them, with consideration of their level of experience in ACS quality improvement programs.
Conference highlights
In addition to talks from surgical leaders, the 2017 ACS Quality and Safety Conference will offer other notable events.
Keynote speaker Blake Haxton, a member of the 2016 U.S. Paralympic Team in rowing, will share his unique insight with attendees. Mr. Haxton contracted necrotizing fasciitis in March 2009, in his senior year of high school. The infection led to heart, lung, kidney, and liver failure, as well as the loss of both legs; however, after an intensive rehabilitation regimen, he was able to attend and graduate from college and law school.
Another conference highlight will be abstract competitions in four categories: Medical Student and Surgical Resident Abstract Competition, SCR Abstract Competition, Clinical Abstract Competition, and Abstract Poster Competition.
Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care, which oversees all ACS Quality Programs, is enthusiastic about the newly expanded ACS Quality and Safety Conference. “We are excited to have multiple quality programs of the American College of Surgeons coming together for this conference so that we can all learn how to get better, become more efficient, and provide high-value care in all types of settings,” Dr. Ko said. “This is the first time we’ve put together a conference like this, which we hope will be the first of many.”
More information about the 2017 ACS Quality and Safety Conference can be found at facs.org/quality-programs/quality-safety-conference.
Post-election health policy takes center stage at AMA HOD meeting
The American Medical Association (AMA) Interim House of Delegates (HOD) meeting took place November 12–15, 2016, in Orlando, FL. A total of 530 state medical society and specialty society delegates, including the six members of the American College of Surgeons’ (ACS) delegation, debated the policy implications of 32 reports and 101 resolutions. Occurring within a week of the national elections, a central focus of the meeting was the uncertainty about the future of the Affordable Care Act (ACA). On the other hand, the Stop the Bleed® program received an enthusiastic reception.
ACS delegation sponsors Stop the Bleed skills course
AMA meetings provide an opportunity for the ACS delegates to share College initiatives with physician leaders from a breadth of geographic locations, specialties, and career stages. In this spirit, ACS delegates, all of whom are Stop the Bleed instructors, along with Leonard J. Weireter, MD, FACS, Vice-Chair, ACS Committee on Trauma, presented the skills course to 125 practicing physicians, residents, and medical student delegates. Through four half-hour sessions, participants refreshed their hands-on skills in bleeding control and became advocates for bringing the course back to their communities. Course success was recognized before the entire HOD.
Surgical Caucus focuses on mass casualty readiness
The Surgical Caucus sponsored a one-hour educational session, The Hartford Consensus: Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events. Dr. Weireter shared an overview of the Hartford Consensus recommendations for effective response to active shooter and mass casualty events and highlighted the value of the Stop the Bleed course in improving survival of casualties from these events.
Orlando trauma surgeon Michael Cheatham, MD, FACS, gave a synopsis of the Orlando Regional Medical Center response to the Pulse nightclub shooting in June 2016. In addition to conducting relevant readiness drills, he emphasized the importance of including casualty family assistance and post-event hospital staff counseling in mass casualty plans.
At this meeting, the AMA endorsed recommendations from a 2015 call to action by eight health professional organizations and the American Bar Association to reduce the public health consequences of firearm-related injury.
U.S. elections put health care system in spotlight
Five resolutions covering a spectrum of opinions about AMA engagement in ACA reform were discussed. The five proposals were consolidated into one adopted resolution, which calls for the AMA, in collaboration with state and specialty medical societies, to actively discuss the future of health care reform with the new presidential administration and Congress. AMA executive vice-president James Madera, MD, sent a letter to congressional leaders on January 3 emphasizing the AMA’s interest in proposals that “make coverage more affordable, provide greater choice, and increase the number of those insured.”
The ACS delegation focused on the ACS Health Care Reform General Principles, which promote a systems-based approach to health care quality and safety, patient access to surgical care, reduction of health care costs, and medical liability reform.
Maintenance of Certification
General disaffection with Maintenance of Certification (MOC) requirements persists in multiple specialties, with particular concerns related to its use in credentialing and privileging decisions. The HOD adopted a policy that directs the AMA to increase efforts to ensure that MOC does not become a requirement for insurance panel participation, state medical licensure, and medical staff membership (initial and ongoing).
Medical student and resident training
Delegates agreed with a need for formal leadership training during medical school. The AMA now advocates for the creation of leadership programs that emphasize experiential learning of skills necessary to lead inter-professional teams. Delegates also recognized the importance of having training program policies that support residents who are breastfeeding. As a result, the AMA will now work with appropriate professional regulatory organizations to put policies for protected times and locations for breastfeeding into program requirements.
Surgeon management of patients with perioperative pain
A resolution intended to reduce perioperative opioid consumption was introduced, calling for hospitals to adopt practices for perioperative pain management, which include services dedicated to acute pain management. This proposal generated a great deal of concern among surgical and anesthesiology delegates. The HOD appreciated that surgeons are trained to manage the perioperative pain of their patients and may consult for additional services as needed. Thus, existing AMA efforts to promote appropriate clinical use of opioid analgesics were reaffirmed in lieu of the resolution.
Next meeting
The next meeting of the AMA HOD is scheduled for June 10–14 in Chicago. This meeting will be the first since the inauguration of President Donald Trump, and the ACS delegates anticipate that national health care policy will again dominate the discussion. ACS members with suggestions for potential resolutions should forward them to Jon Sutton at [email protected].
ACS Delegation at the AMA HOD
• John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Ocala, FL
• Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH
• Jacob Moalem, MD, FACS (also Young Physicians Section delegate), general surgery, Rochester, NY
• Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Vice-Chair, ACS Board of Regents
• Naveen F. Sangji, MD, general surgery resident, Boston, MA
• Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; Chair, AMA Council on Medical Education
Dr. Armstrong is a member of the American College of Surgeons (ACS) Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).
Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy, Washington, DC.
The American Medical Association (AMA) Interim House of Delegates (HOD) meeting took place November 12–15, 2016, in Orlando, FL. A total of 530 state medical society and specialty society delegates, including the six members of the American College of Surgeons’ (ACS) delegation, debated the policy implications of 32 reports and 101 resolutions. Occurring within a week of the national elections, a central focus of the meeting was the uncertainty about the future of the Affordable Care Act (ACA). On the other hand, the Stop the Bleed® program received an enthusiastic reception.
ACS delegation sponsors Stop the Bleed skills course
AMA meetings provide an opportunity for the ACS delegates to share College initiatives with physician leaders from a breadth of geographic locations, specialties, and career stages. In this spirit, ACS delegates, all of whom are Stop the Bleed instructors, along with Leonard J. Weireter, MD, FACS, Vice-Chair, ACS Committee on Trauma, presented the skills course to 125 practicing physicians, residents, and medical student delegates. Through four half-hour sessions, participants refreshed their hands-on skills in bleeding control and became advocates for bringing the course back to their communities. Course success was recognized before the entire HOD.
Surgical Caucus focuses on mass casualty readiness
The Surgical Caucus sponsored a one-hour educational session, The Hartford Consensus: Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events. Dr. Weireter shared an overview of the Hartford Consensus recommendations for effective response to active shooter and mass casualty events and highlighted the value of the Stop the Bleed course in improving survival of casualties from these events.
Orlando trauma surgeon Michael Cheatham, MD, FACS, gave a synopsis of the Orlando Regional Medical Center response to the Pulse nightclub shooting in June 2016. In addition to conducting relevant readiness drills, he emphasized the importance of including casualty family assistance and post-event hospital staff counseling in mass casualty plans.
At this meeting, the AMA endorsed recommendations from a 2015 call to action by eight health professional organizations and the American Bar Association to reduce the public health consequences of firearm-related injury.
U.S. elections put health care system in spotlight
Five resolutions covering a spectrum of opinions about AMA engagement in ACA reform were discussed. The five proposals were consolidated into one adopted resolution, which calls for the AMA, in collaboration with state and specialty medical societies, to actively discuss the future of health care reform with the new presidential administration and Congress. AMA executive vice-president James Madera, MD, sent a letter to congressional leaders on January 3 emphasizing the AMA’s interest in proposals that “make coverage more affordable, provide greater choice, and increase the number of those insured.”
The ACS delegation focused on the ACS Health Care Reform General Principles, which promote a systems-based approach to health care quality and safety, patient access to surgical care, reduction of health care costs, and medical liability reform.
Maintenance of Certification
General disaffection with Maintenance of Certification (MOC) requirements persists in multiple specialties, with particular concerns related to its use in credentialing and privileging decisions. The HOD adopted a policy that directs the AMA to increase efforts to ensure that MOC does not become a requirement for insurance panel participation, state medical licensure, and medical staff membership (initial and ongoing).
Medical student and resident training
Delegates agreed with a need for formal leadership training during medical school. The AMA now advocates for the creation of leadership programs that emphasize experiential learning of skills necessary to lead inter-professional teams. Delegates also recognized the importance of having training program policies that support residents who are breastfeeding. As a result, the AMA will now work with appropriate professional regulatory organizations to put policies for protected times and locations for breastfeeding into program requirements.
Surgeon management of patients with perioperative pain
A resolution intended to reduce perioperative opioid consumption was introduced, calling for hospitals to adopt practices for perioperative pain management, which include services dedicated to acute pain management. This proposal generated a great deal of concern among surgical and anesthesiology delegates. The HOD appreciated that surgeons are trained to manage the perioperative pain of their patients and may consult for additional services as needed. Thus, existing AMA efforts to promote appropriate clinical use of opioid analgesics were reaffirmed in lieu of the resolution.
Next meeting
The next meeting of the AMA HOD is scheduled for June 10–14 in Chicago. This meeting will be the first since the inauguration of President Donald Trump, and the ACS delegates anticipate that national health care policy will again dominate the discussion. ACS members with suggestions for potential resolutions should forward them to Jon Sutton at [email protected].
ACS Delegation at the AMA HOD
• John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Ocala, FL
• Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH
• Jacob Moalem, MD, FACS (also Young Physicians Section delegate), general surgery, Rochester, NY
• Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Vice-Chair, ACS Board of Regents
• Naveen F. Sangji, MD, general surgery resident, Boston, MA
• Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; Chair, AMA Council on Medical Education
Dr. Armstrong is a member of the American College of Surgeons (ACS) Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).
Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy, Washington, DC.
The American Medical Association (AMA) Interim House of Delegates (HOD) meeting took place November 12–15, 2016, in Orlando, FL. A total of 530 state medical society and specialty society delegates, including the six members of the American College of Surgeons’ (ACS) delegation, debated the policy implications of 32 reports and 101 resolutions. Occurring within a week of the national elections, a central focus of the meeting was the uncertainty about the future of the Affordable Care Act (ACA). On the other hand, the Stop the Bleed® program received an enthusiastic reception.
ACS delegation sponsors Stop the Bleed skills course
AMA meetings provide an opportunity for the ACS delegates to share College initiatives with physician leaders from a breadth of geographic locations, specialties, and career stages. In this spirit, ACS delegates, all of whom are Stop the Bleed instructors, along with Leonard J. Weireter, MD, FACS, Vice-Chair, ACS Committee on Trauma, presented the skills course to 125 practicing physicians, residents, and medical student delegates. Through four half-hour sessions, participants refreshed their hands-on skills in bleeding control and became advocates for bringing the course back to their communities. Course success was recognized before the entire HOD.
Surgical Caucus focuses on mass casualty readiness
The Surgical Caucus sponsored a one-hour educational session, The Hartford Consensus: Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events. Dr. Weireter shared an overview of the Hartford Consensus recommendations for effective response to active shooter and mass casualty events and highlighted the value of the Stop the Bleed course in improving survival of casualties from these events.
Orlando trauma surgeon Michael Cheatham, MD, FACS, gave a synopsis of the Orlando Regional Medical Center response to the Pulse nightclub shooting in June 2016. In addition to conducting relevant readiness drills, he emphasized the importance of including casualty family assistance and post-event hospital staff counseling in mass casualty plans.
At this meeting, the AMA endorsed recommendations from a 2015 call to action by eight health professional organizations and the American Bar Association to reduce the public health consequences of firearm-related injury.
U.S. elections put health care system in spotlight
Five resolutions covering a spectrum of opinions about AMA engagement in ACA reform were discussed. The five proposals were consolidated into one adopted resolution, which calls for the AMA, in collaboration with state and specialty medical societies, to actively discuss the future of health care reform with the new presidential administration and Congress. AMA executive vice-president James Madera, MD, sent a letter to congressional leaders on January 3 emphasizing the AMA’s interest in proposals that “make coverage more affordable, provide greater choice, and increase the number of those insured.”
The ACS delegation focused on the ACS Health Care Reform General Principles, which promote a systems-based approach to health care quality and safety, patient access to surgical care, reduction of health care costs, and medical liability reform.
Maintenance of Certification
General disaffection with Maintenance of Certification (MOC) requirements persists in multiple specialties, with particular concerns related to its use in credentialing and privileging decisions. The HOD adopted a policy that directs the AMA to increase efforts to ensure that MOC does not become a requirement for insurance panel participation, state medical licensure, and medical staff membership (initial and ongoing).
Medical student and resident training
Delegates agreed with a need for formal leadership training during medical school. The AMA now advocates for the creation of leadership programs that emphasize experiential learning of skills necessary to lead inter-professional teams. Delegates also recognized the importance of having training program policies that support residents who are breastfeeding. As a result, the AMA will now work with appropriate professional regulatory organizations to put policies for protected times and locations for breastfeeding into program requirements.
Surgeon management of patients with perioperative pain
A resolution intended to reduce perioperative opioid consumption was introduced, calling for hospitals to adopt practices for perioperative pain management, which include services dedicated to acute pain management. This proposal generated a great deal of concern among surgical and anesthesiology delegates. The HOD appreciated that surgeons are trained to manage the perioperative pain of their patients and may consult for additional services as needed. Thus, existing AMA efforts to promote appropriate clinical use of opioid analgesics were reaffirmed in lieu of the resolution.
Next meeting
The next meeting of the AMA HOD is scheduled for June 10–14 in Chicago. This meeting will be the first since the inauguration of President Donald Trump, and the ACS delegates anticipate that national health care policy will again dominate the discussion. ACS members with suggestions for potential resolutions should forward them to Jon Sutton at [email protected].
ACS Delegation at the AMA HOD
• John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Ocala, FL
• Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH
• Jacob Moalem, MD, FACS (also Young Physicians Section delegate), general surgery, Rochester, NY
• Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Vice-Chair, ACS Board of Regents
• Naveen F. Sangji, MD, general surgery resident, Boston, MA
• Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; Chair, AMA Council on Medical Education
Dr. Armstrong is a member of the American College of Surgeons (ACS) Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).
Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy, Washington, DC.
Music in the OR
I am sure that even though Theodor Billroth and Johannes Brahms were close friends, Billroth never listened to music in his operating room. I’m pretty sure because the Victrola was invented around 1906 and the first commercial radio broadcast was in 1920. So unless Billroth hired a Viennese string quartet to play in his amphitheater, it is likely the operating room was a pretty quiet place.
Radios were the size of a small refrigerator into the 1940s when Bell Laboratories’ invention of the transistor technology permitted small units to play tinny music through speakers about 2 inches across. So, I would guess that Alfred Blalock didn’t listen to Elvis Presley or Buddy Holly during his pioneering days at Hopkins.
By the late 1960s high-quality, recorded music was available on 8-track tapes invented by the Lear Jet Corporation. Music at that point was literally available everywhere and the OR became a theater once more for some surgeons. Cassette tapes followed, and Johnny Paycheck echoed in the heart room where I trained in Dallas – usually at high volume. When Apple changed the world with the iPod in 2001 and then the Internet streaming services emerged, it became possible to take out a gall bladder accompanied by Vladimir Horowitz or Madonna. And it happens routinely.
As I write this, I am listening to a jazz streaming station. Music is one of the most important elements of my life. Yet, my operating room has had music on only one occasion since I became an attending surgeon. I love music too much for it to be in my OR. It not only relaxes me, which may not be entirely a good thing in surgery, but it engages my intellect, taking up needed CPU time which might be useful in avoiding catastrophe for the patient before me.
Not long ago this subject was the focus of a discussion thread on the ACS Communities. Many reported that they never listen to music in the OR, others said it was essential to their performance, and still others took a middle ground. Everyone said the music shouldn’t be loud; however, I can recall visiting a number of operating rooms in which loud was the standard volume setting. Most respondents spoke in terms of what they needed and like. Several felt that as captain of the SS Operating Room they had the final say of whether, what, and when music would be played.
I noted in the conversation justification, defensiveness, authoritarianism mixed with personal insight that is so characteristic of many surgeons. Of course, there isn’t a “right” answer here any more than there is in a number of OR traditions. The evidence is all over the place except when it comes to volume. There, it is clear that loud music causes or exacerbates communications errors due to inability of the OR team to hear one another or distraction of the team from their primary task.
Music affects everyone in the OR. It represents one of many operating room components that hold the potential of both betterment of care or endangerment of the patient. To say that music in the OR is wrong is like saying propellers on aircraft are somehow wrong. Among the most serious injuries at general aviation airports is individuals walking into a spinning propeller; however, without the propeller the plane can’t fly and deliver its benefits enjoyed at large. The problem isn’t that propellers are evil. It is that they are invisible to the victim who ignores their dangers.
My point is that music is an example of the need for us to be aware of the primary and secondary effects of even the small things we do in the OR because innocuous as they seem, they have potential dangers. The Council on Surgical and Perioperative Care of which the ACS is a member, has more data and resources on their homepage (cspsteam.org) for those interested in the subject on distractions in the OR.
So, what I’ve learned through listening to the music of my colleagues opinions is that when it comes to music, we need to be aware of the spinning propeller of noise pollution in the OR. Many invisible dangers inhabit the OR. Take a moment and listen for them.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
I am sure that even though Theodor Billroth and Johannes Brahms were close friends, Billroth never listened to music in his operating room. I’m pretty sure because the Victrola was invented around 1906 and the first commercial radio broadcast was in 1920. So unless Billroth hired a Viennese string quartet to play in his amphitheater, it is likely the operating room was a pretty quiet place.
Radios were the size of a small refrigerator into the 1940s when Bell Laboratories’ invention of the transistor technology permitted small units to play tinny music through speakers about 2 inches across. So, I would guess that Alfred Blalock didn’t listen to Elvis Presley or Buddy Holly during his pioneering days at Hopkins.
By the late 1960s high-quality, recorded music was available on 8-track tapes invented by the Lear Jet Corporation. Music at that point was literally available everywhere and the OR became a theater once more for some surgeons. Cassette tapes followed, and Johnny Paycheck echoed in the heart room where I trained in Dallas – usually at high volume. When Apple changed the world with the iPod in 2001 and then the Internet streaming services emerged, it became possible to take out a gall bladder accompanied by Vladimir Horowitz or Madonna. And it happens routinely.
As I write this, I am listening to a jazz streaming station. Music is one of the most important elements of my life. Yet, my operating room has had music on only one occasion since I became an attending surgeon. I love music too much for it to be in my OR. It not only relaxes me, which may not be entirely a good thing in surgery, but it engages my intellect, taking up needed CPU time which might be useful in avoiding catastrophe for the patient before me.
Not long ago this subject was the focus of a discussion thread on the ACS Communities. Many reported that they never listen to music in the OR, others said it was essential to their performance, and still others took a middle ground. Everyone said the music shouldn’t be loud; however, I can recall visiting a number of operating rooms in which loud was the standard volume setting. Most respondents spoke in terms of what they needed and like. Several felt that as captain of the SS Operating Room they had the final say of whether, what, and when music would be played.
I noted in the conversation justification, defensiveness, authoritarianism mixed with personal insight that is so characteristic of many surgeons. Of course, there isn’t a “right” answer here any more than there is in a number of OR traditions. The evidence is all over the place except when it comes to volume. There, it is clear that loud music causes or exacerbates communications errors due to inability of the OR team to hear one another or distraction of the team from their primary task.
Music affects everyone in the OR. It represents one of many operating room components that hold the potential of both betterment of care or endangerment of the patient. To say that music in the OR is wrong is like saying propellers on aircraft are somehow wrong. Among the most serious injuries at general aviation airports is individuals walking into a spinning propeller; however, without the propeller the plane can’t fly and deliver its benefits enjoyed at large. The problem isn’t that propellers are evil. It is that they are invisible to the victim who ignores their dangers.
My point is that music is an example of the need for us to be aware of the primary and secondary effects of even the small things we do in the OR because innocuous as they seem, they have potential dangers. The Council on Surgical and Perioperative Care of which the ACS is a member, has more data and resources on their homepage (cspsteam.org) for those interested in the subject on distractions in the OR.
So, what I’ve learned through listening to the music of my colleagues opinions is that when it comes to music, we need to be aware of the spinning propeller of noise pollution in the OR. Many invisible dangers inhabit the OR. Take a moment and listen for them.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
I am sure that even though Theodor Billroth and Johannes Brahms were close friends, Billroth never listened to music in his operating room. I’m pretty sure because the Victrola was invented around 1906 and the first commercial radio broadcast was in 1920. So unless Billroth hired a Viennese string quartet to play in his amphitheater, it is likely the operating room was a pretty quiet place.
Radios were the size of a small refrigerator into the 1940s when Bell Laboratories’ invention of the transistor technology permitted small units to play tinny music through speakers about 2 inches across. So, I would guess that Alfred Blalock didn’t listen to Elvis Presley or Buddy Holly during his pioneering days at Hopkins.
By the late 1960s high-quality, recorded music was available on 8-track tapes invented by the Lear Jet Corporation. Music at that point was literally available everywhere and the OR became a theater once more for some surgeons. Cassette tapes followed, and Johnny Paycheck echoed in the heart room where I trained in Dallas – usually at high volume. When Apple changed the world with the iPod in 2001 and then the Internet streaming services emerged, it became possible to take out a gall bladder accompanied by Vladimir Horowitz or Madonna. And it happens routinely.
As I write this, I am listening to a jazz streaming station. Music is one of the most important elements of my life. Yet, my operating room has had music on only one occasion since I became an attending surgeon. I love music too much for it to be in my OR. It not only relaxes me, which may not be entirely a good thing in surgery, but it engages my intellect, taking up needed CPU time which might be useful in avoiding catastrophe for the patient before me.
Not long ago this subject was the focus of a discussion thread on the ACS Communities. Many reported that they never listen to music in the OR, others said it was essential to their performance, and still others took a middle ground. Everyone said the music shouldn’t be loud; however, I can recall visiting a number of operating rooms in which loud was the standard volume setting. Most respondents spoke in terms of what they needed and like. Several felt that as captain of the SS Operating Room they had the final say of whether, what, and when music would be played.
I noted in the conversation justification, defensiveness, authoritarianism mixed with personal insight that is so characteristic of many surgeons. Of course, there isn’t a “right” answer here any more than there is in a number of OR traditions. The evidence is all over the place except when it comes to volume. There, it is clear that loud music causes or exacerbates communications errors due to inability of the OR team to hear one another or distraction of the team from their primary task.
Music affects everyone in the OR. It represents one of many operating room components that hold the potential of both betterment of care or endangerment of the patient. To say that music in the OR is wrong is like saying propellers on aircraft are somehow wrong. Among the most serious injuries at general aviation airports is individuals walking into a spinning propeller; however, without the propeller the plane can’t fly and deliver its benefits enjoyed at large. The problem isn’t that propellers are evil. It is that they are invisible to the victim who ignores their dangers.
My point is that music is an example of the need for us to be aware of the primary and secondary effects of even the small things we do in the OR because innocuous as they seem, they have potential dangers. The Council on Surgical and Perioperative Care of which the ACS is a member, has more data and resources on their homepage (cspsteam.org) for those interested in the subject on distractions in the OR.
So, what I’ve learned through listening to the music of my colleagues opinions is that when it comes to music, we need to be aware of the spinning propeller of noise pollution in the OR. Many invisible dangers inhabit the OR. Take a moment and listen for them.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
MACRA: Not going away any time soon
MACRA is now a fact of life.
Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.
1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?
A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.
Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.
From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.
So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.
Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.
Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.
2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?
The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.
Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.
Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.
3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?
There is a relatively straightforward process, which revolves around a series of questions and individual decisions.
First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.
If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.
However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.
If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.
For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit facs.org/qpp where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.
4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?
If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:
A) The required base score measures for your EHR (now known as Advancing Care Information) OR
B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR
C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims
One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.
Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.
Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.
It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.
5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?
That question is perhaps best addressed in the form of a comparison between 2016 and 2017.
In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.
In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.
However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.
6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?
The ACS one-stop shop is the Quality Payment Program Resource Center found at www.facs.org/qpp.
Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the facs.org/qpp webpage.
Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.
The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.
We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.
I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.
Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.
Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.
MACRA is now a fact of life.
Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.
1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?
A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.
Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.
From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.
So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.
Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.
Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.
2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?
The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.
Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.
Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.
3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?
There is a relatively straightforward process, which revolves around a series of questions and individual decisions.
First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.
If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.
However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.
If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.
For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit facs.org/qpp where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.
4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?
If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:
A) The required base score measures for your EHR (now known as Advancing Care Information) OR
B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR
C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims
One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.
Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.
Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.
It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.
5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?
That question is perhaps best addressed in the form of a comparison between 2016 and 2017.
In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.
In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.
However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.
6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?
The ACS one-stop shop is the Quality Payment Program Resource Center found at www.facs.org/qpp.
Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the facs.org/qpp webpage.
Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.
The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.
We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.
I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.
Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.
Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.
MACRA is now a fact of life.
Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.
1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?
A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.
Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.
From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.
So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.
Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.
Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.
2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?
The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.
Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.
Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.
3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?
There is a relatively straightforward process, which revolves around a series of questions and individual decisions.
First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.
If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.
However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.
If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.
For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit facs.org/qpp where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.
4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?
If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:
A) The required base score measures for your EHR (now known as Advancing Care Information) OR
B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR
C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims
One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.
Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.
Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.
It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.
5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?
That question is perhaps best addressed in the form of a comparison between 2016 and 2017.
In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.
In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.
However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.
6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?
The ACS one-stop shop is the Quality Payment Program Resource Center found at www.facs.org/qpp.
Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the facs.org/qpp webpage.
Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.
The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.
We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.
I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.
Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.
Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.
VIDEO: Subclinical leaflet thrombosis frequent after TAVR, SAVR
WASHINGTON – Subclinical leaflet thrombosis, as evidenced by reduced leaflet motion and corresponding hypoattenuating lesions on high-resolution CT, occurs frequently in bioprosthetic aortic valves implanted either by the transcatheter route or surgically, according to a report presented at the annual meeting of the American College of Cardiology and simultaneously published March 19 in the Lancet.
In an observational cohort study involving 890 patients enrolled in two single-center registries, reduced leaflet motion signaling the presence of thrombosis was detected in 106 patients (12%) by four-dimensional, volume-rendered CT. The thrombosis was hemodynamically silent and undetected by transthoracic echocardiograms done in a large subgroup of the study participants. Mean aortic valve gradients were numerically higher in affected patients, but still fell within the normal range in most of them, said Raj R. Makkar, MD, of Cedars-Sinai Heart Institute, Los Angeles.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Dr. Makkar and his associates studied this issue by analyzing data in the RESOLVE (Assessment of Transcatheter and Surgical Aortic Bioprosthetic Valve Thrombosis and its Treatment with Anticoagulation) registry at Cedars-Sinai and the SAVORY (Subclinical Aortic Valve Biosprosthesis Thrombosis Assessed with Four-Dimensional CT) registry at the Rigshospitalet Heart Center in Copenhagen. Their study focused on enrolled patients who underwent either TAVR (626 patients) or SAVR (264 patients) and then had high-resolution CT scans done at various times after implantation. All the CT scans were analyzed in blinded fashion, and the study participants were followed for a mean of 540 days.
The prevalence of subclinical leaflet thrombosis was significantly higher in TAVR valves (13%) than in SAVR valves (4%). The severity of the thrombosis also was significantly higher in TAVR valves, when measured by the extent of leaflet motion restriction (71.0% vs. 56.9%).
One possible reason for this discrepancy is that traumatic injury to the pericardial leaflets, which theoretically could predispose to thrombus formation, may be more likely to occur during crimping and deployment of balloon-expandable and self-expanding stent valves in TAVR. Another possibility is that resection of the calcified native aortic valves during SAVR might improve flow dynamics after valve replacement, compared with leaving native aortic valve cusps in situ during TAVR. A third possibility is that inadvertent incomplete expansion or overexpansion of transcatheter valves might alter mechanical stress on the leaflets, predisposing them to thrombus formation, compared with the uniform expansion of valves placed surgically, the investigator said.
“Nevertheless, these findings should be interpreted in the context of findings from multiple randomized controlled trials showing similar mortality and stroke rates, better hemodynamics, and equivalent durability of transcatheter aortic valves at 5 years, compared with surgical valves,” he noted.
Patients taking novel oral anticoagulants (NOACs) or warfarin for anticoagulation before valve replacement were less likely to develop subclinical leaflet thrombosis than patients not taking those anticoagulants. And the thrombosis appeared to resolve in all patients treated with NOACs or warfarin for 30 days after it was found on CT, but it persisted or progressed in those not treated with anticoagulation. Thus, “anticoagulation with NOACs or warfarin was effective in prevention and treatment of reduced leaflet motion, but dual-antiplatelet therapy, which is the standard of care, was not,” the investigators said (Lancet 2017 Mar 19. doi: 10.1016/S0140-6736(17)30757-2.
“Our study challenges the American College of Cardiology and American Heart Association and European Society of Cardiology and European Association for Cardio-Thoracic Surgery guidelines, which recommend dual-antiplatelet therapy after TAVR and do not recommend routine anticoagulation after TAVR,” he noted.
However, routine anticoagulation for all TAVR and SAVR patients, or even for all who develop leaflet thrombosis, cannot be recommended on the basis of results from a single observational study. The benefit of anticoagulation may not offset the risk of bleeding in this predominantly elderly population with multiple comorbidities, he said.
There were no significant differences between patients who developed subclinical leaflet thrombosis and those who did not regarding rates of death, MI, or stroke. However, “reduced leaflet wall motion was significantly associated with increased rates of all TIAs [transient ischemic attacks], nonprocedural TIAs, and post-CT TIAs.” Dr. Makkar said.
Based on his new findings, Dr. Makkar suggested that clinicians keep possible leaflet thrombosis on a replaced aortic valve in mind if they see clinical evidence for it, such as an increase in the valve’s pressure gradient or development of a TIA or stroke.* These events should trigger further investigation of the valve with CT angiography, and if thrombosis is then confirmed, the patient should receive treatment with an anticoagulant, although the appropriate duration of anticoagulant treatment remains unclear, he said in a video interview. Dr. Makkar also said that trials are needed to determine whether routine CT angiography assessment or routine prophylactic treatment with an anticoagulant is warranted because the antiplatelet therapy that patients currently receive after aortic valve replacement seems unable to prevent leaflet thrombosis.
Since this was an observational study based on data from nonrandomized registries, the findings cannot prove causality but only an association between leaflet thrombosis and TIA. They must be substantiated in further studies, including “the current Food and Drug Administration–mandated imaging substudies in randomized clinical trials.”
Dr. Makkar has received consultant fees and/or honoraria from Abbott Vascular, Medtronic, Cordis, and Entourage Medical, and research grants from Edwards Lifesciences and St. Jude Medical.
Mitchel L. Zoler contributed to this report.
Correction, 3/20/17: An earlier version of this article misstated the clinical evidence for possible leaflet thrombosis on a replaced aortic valve.
The study by Dr. Makkar and his coinvestigators provides important new information to guide future research, but changing clinical practice or guidelines on the basis of this information would be premature.
In particular, whether to recommend anticoagulation therapy to TAVR and SAVR patients is unknown, given the risks of chronic anticoagulation. We do not yet know whether such a recommendation should be guided by CT or echocardiographic imaging, and, if so, at what intervals? We don’t yet know the optimal duration of anticoagulation treatment, or whether NOAC’s are as good as or better than warfarin in this setting. And we don’t yet know whether the risk of bleeding is offset by a reduction in stroke or any other meaningful clinical sequelae.
Jeroen J. Bax, MD, is in the department of cardiology at Leiden (the Netherlands) University Medical Center. Gregg W. Stone, MD, is at Columbia University Medical Center and the Cardiovascular Research Foundation, both in New York. Dr. Bax’s institution has received unrestricted research grants from Biotronik, Medtronic, Boston Scientific, and Edwards LifeScience; Dr. Stone reported ties to numerous industry sources. Dr. Bax and Dr. Stone made these remarks in an editorial accompanying the Lancet report (Lancet 2017 Mar 19. doi: 10.1016/S0140-6736(17)30757-2).
The study by Dr. Makkar and his coinvestigators provides important new information to guide future research, but changing clinical practice or guidelines on the basis of this information would be premature.
In particular, whether to recommend anticoagulation therapy to TAVR and SAVR patients is unknown, given the risks of chronic anticoagulation. We do not yet know whether such a recommendation should be guided by CT or echocardiographic imaging, and, if so, at what intervals? We don’t yet know the optimal duration of anticoagulation treatment, or whether NOAC’s are as good as or better than warfarin in this setting. And we don’t yet know whether the risk of bleeding is offset by a reduction in stroke or any other meaningful clinical sequelae.
Jeroen J. Bax, MD, is in the department of cardiology at Leiden (the Netherlands) University Medical Center. Gregg W. Stone, MD, is at Columbia University Medical Center and the Cardiovascular Research Foundation, both in New York. Dr. Bax’s institution has received unrestricted research grants from Biotronik, Medtronic, Boston Scientific, and Edwards LifeScience; Dr. Stone reported ties to numerous industry sources. Dr. Bax and Dr. Stone made these remarks in an editorial accompanying the Lancet report (Lancet 2017 Mar 19. doi: 10.1016/S0140-6736(17)30757-2).
The study by Dr. Makkar and his coinvestigators provides important new information to guide future research, but changing clinical practice or guidelines on the basis of this information would be premature.
In particular, whether to recommend anticoagulation therapy to TAVR and SAVR patients is unknown, given the risks of chronic anticoagulation. We do not yet know whether such a recommendation should be guided by CT or echocardiographic imaging, and, if so, at what intervals? We don’t yet know the optimal duration of anticoagulation treatment, or whether NOAC’s are as good as or better than warfarin in this setting. And we don’t yet know whether the risk of bleeding is offset by a reduction in stroke or any other meaningful clinical sequelae.
Jeroen J. Bax, MD, is in the department of cardiology at Leiden (the Netherlands) University Medical Center. Gregg W. Stone, MD, is at Columbia University Medical Center and the Cardiovascular Research Foundation, both in New York. Dr. Bax’s institution has received unrestricted research grants from Biotronik, Medtronic, Boston Scientific, and Edwards LifeScience; Dr. Stone reported ties to numerous industry sources. Dr. Bax and Dr. Stone made these remarks in an editorial accompanying the Lancet report (Lancet 2017 Mar 19. doi: 10.1016/S0140-6736(17)30757-2).
WASHINGTON – Subclinical leaflet thrombosis, as evidenced by reduced leaflet motion and corresponding hypoattenuating lesions on high-resolution CT, occurs frequently in bioprosthetic aortic valves implanted either by the transcatheter route or surgically, according to a report presented at the annual meeting of the American College of Cardiology and simultaneously published March 19 in the Lancet.
In an observational cohort study involving 890 patients enrolled in two single-center registries, reduced leaflet motion signaling the presence of thrombosis was detected in 106 patients (12%) by four-dimensional, volume-rendered CT. The thrombosis was hemodynamically silent and undetected by transthoracic echocardiograms done in a large subgroup of the study participants. Mean aortic valve gradients were numerically higher in affected patients, but still fell within the normal range in most of them, said Raj R. Makkar, MD, of Cedars-Sinai Heart Institute, Los Angeles.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Dr. Makkar and his associates studied this issue by analyzing data in the RESOLVE (Assessment of Transcatheter and Surgical Aortic Bioprosthetic Valve Thrombosis and its Treatment with Anticoagulation) registry at Cedars-Sinai and the SAVORY (Subclinical Aortic Valve Biosprosthesis Thrombosis Assessed with Four-Dimensional CT) registry at the Rigshospitalet Heart Center in Copenhagen. Their study focused on enrolled patients who underwent either TAVR (626 patients) or SAVR (264 patients) and then had high-resolution CT scans done at various times after implantation. All the CT scans were analyzed in blinded fashion, and the study participants were followed for a mean of 540 days.
The prevalence of subclinical leaflet thrombosis was significantly higher in TAVR valves (13%) than in SAVR valves (4%). The severity of the thrombosis also was significantly higher in TAVR valves, when measured by the extent of leaflet motion restriction (71.0% vs. 56.9%).
One possible reason for this discrepancy is that traumatic injury to the pericardial leaflets, which theoretically could predispose to thrombus formation, may be more likely to occur during crimping and deployment of balloon-expandable and self-expanding stent valves in TAVR. Another possibility is that resection of the calcified native aortic valves during SAVR might improve flow dynamics after valve replacement, compared with leaving native aortic valve cusps in situ during TAVR. A third possibility is that inadvertent incomplete expansion or overexpansion of transcatheter valves might alter mechanical stress on the leaflets, predisposing them to thrombus formation, compared with the uniform expansion of valves placed surgically, the investigator said.
“Nevertheless, these findings should be interpreted in the context of findings from multiple randomized controlled trials showing similar mortality and stroke rates, better hemodynamics, and equivalent durability of transcatheter aortic valves at 5 years, compared with surgical valves,” he noted.
Patients taking novel oral anticoagulants (NOACs) or warfarin for anticoagulation before valve replacement were less likely to develop subclinical leaflet thrombosis than patients not taking those anticoagulants. And the thrombosis appeared to resolve in all patients treated with NOACs or warfarin for 30 days after it was found on CT, but it persisted or progressed in those not treated with anticoagulation. Thus, “anticoagulation with NOACs or warfarin was effective in prevention and treatment of reduced leaflet motion, but dual-antiplatelet therapy, which is the standard of care, was not,” the investigators said (Lancet 2017 Mar 19. doi: 10.1016/S0140-6736(17)30757-2.
“Our study challenges the American College of Cardiology and American Heart Association and European Society of Cardiology and European Association for Cardio-Thoracic Surgery guidelines, which recommend dual-antiplatelet therapy after TAVR and do not recommend routine anticoagulation after TAVR,” he noted.
However, routine anticoagulation for all TAVR and SAVR patients, or even for all who develop leaflet thrombosis, cannot be recommended on the basis of results from a single observational study. The benefit of anticoagulation may not offset the risk of bleeding in this predominantly elderly population with multiple comorbidities, he said.
There were no significant differences between patients who developed subclinical leaflet thrombosis and those who did not regarding rates of death, MI, or stroke. However, “reduced leaflet wall motion was significantly associated with increased rates of all TIAs [transient ischemic attacks], nonprocedural TIAs, and post-CT TIAs.” Dr. Makkar said.
Based on his new findings, Dr. Makkar suggested that clinicians keep possible leaflet thrombosis on a replaced aortic valve in mind if they see clinical evidence for it, such as an increase in the valve’s pressure gradient or development of a TIA or stroke.* These events should trigger further investigation of the valve with CT angiography, and if thrombosis is then confirmed, the patient should receive treatment with an anticoagulant, although the appropriate duration of anticoagulant treatment remains unclear, he said in a video interview. Dr. Makkar also said that trials are needed to determine whether routine CT angiography assessment or routine prophylactic treatment with an anticoagulant is warranted because the antiplatelet therapy that patients currently receive after aortic valve replacement seems unable to prevent leaflet thrombosis.
Since this was an observational study based on data from nonrandomized registries, the findings cannot prove causality but only an association between leaflet thrombosis and TIA. They must be substantiated in further studies, including “the current Food and Drug Administration–mandated imaging substudies in randomized clinical trials.”
Dr. Makkar has received consultant fees and/or honoraria from Abbott Vascular, Medtronic, Cordis, and Entourage Medical, and research grants from Edwards Lifesciences and St. Jude Medical.
Mitchel L. Zoler contributed to this report.
Correction, 3/20/17: An earlier version of this article misstated the clinical evidence for possible leaflet thrombosis on a replaced aortic valve.
WASHINGTON – Subclinical leaflet thrombosis, as evidenced by reduced leaflet motion and corresponding hypoattenuating lesions on high-resolution CT, occurs frequently in bioprosthetic aortic valves implanted either by the transcatheter route or surgically, according to a report presented at the annual meeting of the American College of Cardiology and simultaneously published March 19 in the Lancet.
In an observational cohort study involving 890 patients enrolled in two single-center registries, reduced leaflet motion signaling the presence of thrombosis was detected in 106 patients (12%) by four-dimensional, volume-rendered CT. The thrombosis was hemodynamically silent and undetected by transthoracic echocardiograms done in a large subgroup of the study participants. Mean aortic valve gradients were numerically higher in affected patients, but still fell within the normal range in most of them, said Raj R. Makkar, MD, of Cedars-Sinai Heart Institute, Los Angeles.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Dr. Makkar and his associates studied this issue by analyzing data in the RESOLVE (Assessment of Transcatheter and Surgical Aortic Bioprosthetic Valve Thrombosis and its Treatment with Anticoagulation) registry at Cedars-Sinai and the SAVORY (Subclinical Aortic Valve Biosprosthesis Thrombosis Assessed with Four-Dimensional CT) registry at the Rigshospitalet Heart Center in Copenhagen. Their study focused on enrolled patients who underwent either TAVR (626 patients) or SAVR (264 patients) and then had high-resolution CT scans done at various times after implantation. All the CT scans were analyzed in blinded fashion, and the study participants were followed for a mean of 540 days.
The prevalence of subclinical leaflet thrombosis was significantly higher in TAVR valves (13%) than in SAVR valves (4%). The severity of the thrombosis also was significantly higher in TAVR valves, when measured by the extent of leaflet motion restriction (71.0% vs. 56.9%).
One possible reason for this discrepancy is that traumatic injury to the pericardial leaflets, which theoretically could predispose to thrombus formation, may be more likely to occur during crimping and deployment of balloon-expandable and self-expanding stent valves in TAVR. Another possibility is that resection of the calcified native aortic valves during SAVR might improve flow dynamics after valve replacement, compared with leaving native aortic valve cusps in situ during TAVR. A third possibility is that inadvertent incomplete expansion or overexpansion of transcatheter valves might alter mechanical stress on the leaflets, predisposing them to thrombus formation, compared with the uniform expansion of valves placed surgically, the investigator said.
“Nevertheless, these findings should be interpreted in the context of findings from multiple randomized controlled trials showing similar mortality and stroke rates, better hemodynamics, and equivalent durability of transcatheter aortic valves at 5 years, compared with surgical valves,” he noted.
Patients taking novel oral anticoagulants (NOACs) or warfarin for anticoagulation before valve replacement were less likely to develop subclinical leaflet thrombosis than patients not taking those anticoagulants. And the thrombosis appeared to resolve in all patients treated with NOACs or warfarin for 30 days after it was found on CT, but it persisted or progressed in those not treated with anticoagulation. Thus, “anticoagulation with NOACs or warfarin was effective in prevention and treatment of reduced leaflet motion, but dual-antiplatelet therapy, which is the standard of care, was not,” the investigators said (Lancet 2017 Mar 19. doi: 10.1016/S0140-6736(17)30757-2.
“Our study challenges the American College of Cardiology and American Heart Association and European Society of Cardiology and European Association for Cardio-Thoracic Surgery guidelines, which recommend dual-antiplatelet therapy after TAVR and do not recommend routine anticoagulation after TAVR,” he noted.
However, routine anticoagulation for all TAVR and SAVR patients, or even for all who develop leaflet thrombosis, cannot be recommended on the basis of results from a single observational study. The benefit of anticoagulation may not offset the risk of bleeding in this predominantly elderly population with multiple comorbidities, he said.
There were no significant differences between patients who developed subclinical leaflet thrombosis and those who did not regarding rates of death, MI, or stroke. However, “reduced leaflet wall motion was significantly associated with increased rates of all TIAs [transient ischemic attacks], nonprocedural TIAs, and post-CT TIAs.” Dr. Makkar said.
Based on his new findings, Dr. Makkar suggested that clinicians keep possible leaflet thrombosis on a replaced aortic valve in mind if they see clinical evidence for it, such as an increase in the valve’s pressure gradient or development of a TIA or stroke.* These events should trigger further investigation of the valve with CT angiography, and if thrombosis is then confirmed, the patient should receive treatment with an anticoagulant, although the appropriate duration of anticoagulant treatment remains unclear, he said in a video interview. Dr. Makkar also said that trials are needed to determine whether routine CT angiography assessment or routine prophylactic treatment with an anticoagulant is warranted because the antiplatelet therapy that patients currently receive after aortic valve replacement seems unable to prevent leaflet thrombosis.
Since this was an observational study based on data from nonrandomized registries, the findings cannot prove causality but only an association between leaflet thrombosis and TIA. They must be substantiated in further studies, including “the current Food and Drug Administration–mandated imaging substudies in randomized clinical trials.”
Dr. Makkar has received consultant fees and/or honoraria from Abbott Vascular, Medtronic, Cordis, and Entourage Medical, and research grants from Edwards Lifesciences and St. Jude Medical.
Mitchel L. Zoler contributed to this report.
Correction, 3/20/17: An earlier version of this article misstated the clinical evidence for possible leaflet thrombosis on a replaced aortic valve.
AT ACC 17
Key clinical point: Subclinical leaflet thrombosis occurs frequently in bioprosthetic aortic valves implanted either by the transcatheter route or surgically.
Major finding: Reduced leaflet motion signaling the presence of thrombosis was detected in 106 patients (12%).
Data source: An observational cohort study involving 890 patients enrolled in two registries who underwent high-resolution CT to detect leaflet thrombosis after either TAVR or SAVR.
Disclosures: The RESOLVE study was funded by Cedars-Sinai Heart Institute and the SAVORY study was funded by Rigshospitalet. Dr. Makkar has received consultant fees and/or honoraria from Abbott Vascular, Medtronic, Cordis, and Entourage Medical, and research grants from Edwards Lifesciences and St. Jude Medical.
Cardiovascular disease most common cause of death in CRC survivors
SEATTLE – Improvements in diagnosis and treatment have lengthened the survival time of patients with colorectal cancer, but the majority of deaths from CRC occur within the first 5 years.
According to new findings presented at the annual Society of Surgical Oncology Cancer Symposium, CRC as a cause of death is surpassed by cardiovascular disease (CVD) and second primary cancers as time goes on.
Dr. Lewis explained that CRC as a cause of death begins to plateau over time and other causes become more important.
“As time goes on, colorectal cancer becomes less prominent, and by year 8, cardiovascular death surpasses it. By year 10, colorectal cancer is surpassed by second cancers and neurologic diseases.”
Information about long-term health problems in long-term colorectal cancer survivors is limited. To address this, Dr. Lewis and his colleagues sought to understand the trends and causes of death over time.
They analyzed causes of death in CRC patients who have survived 5 years and longer using the California Cancer Registry (2000-2011) that is linked to inpatient records. From this database, 139,743 patients with CRC were identified, with 97,604 (69.8%) having been treated for disease originating from the colon and 42,139 (30.2%) from the rectum.
The median age of the patients at the time of presentation was 68 years; at 5 years after diagnosis, 70 years; and at 10 years, 74 years. The 5-year overall survival was 59.1%, and it was during that 5 years that 95% of cancer-specific deaths occurred.
During the first 5 years, the major cause of death was CRC, accounting for nearly two-thirds of the mortality (n = 38,992, 65.4%). This was followed by cardiovascular disease (n = 7,140, 12.0%), second primary cancer (n = 3,775, 6.3%), neurologic disease (n = 2,329, 3.9%), and pulmonary disease (n = 2,307, 3.9%).
The most common second primary malignancies affecting CRC survivors were lung and hematologic cancers, followed by pancreatic and liver cancers.
Overall, in long-term survivors, cardiovascular disease was the major cause of death (n = 2,163, 24.0%) although nearly as many deaths were due to CRC (2,094, 23.2%). This was followed by neurologic disease (n = 1,174, 13.0%), secondary primary cancer (n = 1,146, 12.7%), and pulmonary disease (n = 765, 8.5%).
There was no funding source disclosed in the abstract. Dr. Lewis had no disclosures.
SEATTLE – Improvements in diagnosis and treatment have lengthened the survival time of patients with colorectal cancer, but the majority of deaths from CRC occur within the first 5 years.
According to new findings presented at the annual Society of Surgical Oncology Cancer Symposium, CRC as a cause of death is surpassed by cardiovascular disease (CVD) and second primary cancers as time goes on.
Dr. Lewis explained that CRC as a cause of death begins to plateau over time and other causes become more important.
“As time goes on, colorectal cancer becomes less prominent, and by year 8, cardiovascular death surpasses it. By year 10, colorectal cancer is surpassed by second cancers and neurologic diseases.”
Information about long-term health problems in long-term colorectal cancer survivors is limited. To address this, Dr. Lewis and his colleagues sought to understand the trends and causes of death over time.
They analyzed causes of death in CRC patients who have survived 5 years and longer using the California Cancer Registry (2000-2011) that is linked to inpatient records. From this database, 139,743 patients with CRC were identified, with 97,604 (69.8%) having been treated for disease originating from the colon and 42,139 (30.2%) from the rectum.
The median age of the patients at the time of presentation was 68 years; at 5 years after diagnosis, 70 years; and at 10 years, 74 years. The 5-year overall survival was 59.1%, and it was during that 5 years that 95% of cancer-specific deaths occurred.
During the first 5 years, the major cause of death was CRC, accounting for nearly two-thirds of the mortality (n = 38,992, 65.4%). This was followed by cardiovascular disease (n = 7,140, 12.0%), second primary cancer (n = 3,775, 6.3%), neurologic disease (n = 2,329, 3.9%), and pulmonary disease (n = 2,307, 3.9%).
The most common second primary malignancies affecting CRC survivors were lung and hematologic cancers, followed by pancreatic and liver cancers.
Overall, in long-term survivors, cardiovascular disease was the major cause of death (n = 2,163, 24.0%) although nearly as many deaths were due to CRC (2,094, 23.2%). This was followed by neurologic disease (n = 1,174, 13.0%), secondary primary cancer (n = 1,146, 12.7%), and pulmonary disease (n = 765, 8.5%).
There was no funding source disclosed in the abstract. Dr. Lewis had no disclosures.
SEATTLE – Improvements in diagnosis and treatment have lengthened the survival time of patients with colorectal cancer, but the majority of deaths from CRC occur within the first 5 years.
According to new findings presented at the annual Society of Surgical Oncology Cancer Symposium, CRC as a cause of death is surpassed by cardiovascular disease (CVD) and second primary cancers as time goes on.
Dr. Lewis explained that CRC as a cause of death begins to plateau over time and other causes become more important.
“As time goes on, colorectal cancer becomes less prominent, and by year 8, cardiovascular death surpasses it. By year 10, colorectal cancer is surpassed by second cancers and neurologic diseases.”
Information about long-term health problems in long-term colorectal cancer survivors is limited. To address this, Dr. Lewis and his colleagues sought to understand the trends and causes of death over time.
They analyzed causes of death in CRC patients who have survived 5 years and longer using the California Cancer Registry (2000-2011) that is linked to inpatient records. From this database, 139,743 patients with CRC were identified, with 97,604 (69.8%) having been treated for disease originating from the colon and 42,139 (30.2%) from the rectum.
The median age of the patients at the time of presentation was 68 years; at 5 years after diagnosis, 70 years; and at 10 years, 74 years. The 5-year overall survival was 59.1%, and it was during that 5 years that 95% of cancer-specific deaths occurred.
During the first 5 years, the major cause of death was CRC, accounting for nearly two-thirds of the mortality (n = 38,992, 65.4%). This was followed by cardiovascular disease (n = 7,140, 12.0%), second primary cancer (n = 3,775, 6.3%), neurologic disease (n = 2,329, 3.9%), and pulmonary disease (n = 2,307, 3.9%).
The most common second primary malignancies affecting CRC survivors were lung and hematologic cancers, followed by pancreatic and liver cancers.
Overall, in long-term survivors, cardiovascular disease was the major cause of death (n = 2,163, 24.0%) although nearly as many deaths were due to CRC (2,094, 23.2%). This was followed by neurologic disease (n = 1,174, 13.0%), secondary primary cancer (n = 1,146, 12.7%), and pulmonary disease (n = 765, 8.5%).
There was no funding source disclosed in the abstract. Dr. Lewis had no disclosures.
AT SSO 2017
Key clinical point: Long-term colorectal cancer survivors generally will die from other causes.
Major finding: By year 8, cardiovascular disease surpasses colorectal cancer in survivors, as the leading cause of death.
Data source: Large cancer registry with almost 140,000 colorectal cancer patients.
Disclosures: There was no funding source disclosed in the abstract. Dr. Lewis had no disclosures.
Racial differences in skin cancer risk after organ transplantation
Nonwhite organ transplant recipients (OTRs) are more likely to present with inflammatory or infectious conditions after transplantation, while white organ recipients more commonly present with malignant disease, new research suggests.
While the high incidence of skin cancers has been well described in patients who undergo solid organ transplants, little is known about the risk factors, incidence, locations, and types of skin disease that occur in nonwhite OTRs, wrote Christina Lee Chung, MD, from Drexel University, Philadelphia, and her coauthors in JAMA Dermatology.
In a retrospective review, the investigators examined the medical records of 412 organ transplant recipients treated at an academic referral center during 2011-2016, of whom 154 were white, 35 were Asian, 33 were Hispanic, and 190 were black (JAMA Dermatology. 2017 Mar 8. doi: 10.1001/jamadermatol.2017.0045).
Among the white patients, malignant or premalignant disease was the most common diagnostic category (67.8%), followed by inflammatory (20.7%) and infectious processes (11.6%). However, among nonwhite organ transplant recipients, inflammatory processes were present in 48.8% of patients, infectious processes in 37.5% and the remaining 13.7% presented with malignant or premalignant lesions.
Black and Hispanic patients were more likely to present with inflammatory or infectious disease; only 8.6% presented with malignant conditions and 16% presented with premalignant disease.
Among the Asian patient population, one-third presented with malignant or premalignant, one-third presented with infectious, and one-third presented with inflammatory conditions.
“Although early detection and treatment of cancer is vital, nonwhite OTRs would also benefit from addressing nonmalignant processes that are exacerbated by immunosuppression,” the authors wrote.
Overall, 389 skin cancers were diagnosed, with squamous cell carcinoma in situ (SCC) the most common type of skin cancer diagnosed in each racial or ethnic group. The mean time between transplant and first skin cancer lesion was 12.67 years in black patients, 6.5 years in Hispanic patients, 6.13 years among white patients, and 3.75 years in Asian patients.
The vast majority of skin cancers (95.1%) were found in white patients. While the majority of lesions in white and Asian patients were found in sun-exposed areas, the few skin cancers seen in black patients were more likely to be found in sun-protected areas, particularly the genitals.
Four of the six genital SCCs tested positive for high-risk human papillomavirus strains – in one Asian patient and three black patients – while the two SCCs found on lower extremities in Hispanic patients tested negative for HPV.
Researchers also looked at skin cancer awareness among the organ transplant recipients using data from initial visit questionnaires. They found that more than 17 of the 22 (77.3%) white organ transplant recipients surveyed were aware their skin cancer risk was increased, compared with 30 of the 44 (68.2%) nonwhite patients.
Similarly, 72.7% of white patients surveyed were aware that sunscreen decreased the risk of cancer, compared with 59.1% of nonwhite patients; 27.3% of white patients reported using a daily sunscreen, compared with 13.6% of nonwhite patients.
“Based on our findings, we suggest that optimal posttransplant dermatologic care be determined based on the race or ethnicity of the patients; however, regardless of skin type or race or ethnicity, a baseline full-skin assessment should be performed in all patients,” the authors wrote.
They proposed that skin cancer follow-up screenings should be given to Asian and Hispanic patients immediately after transplant, but that black organ transplant recipients could delay yearly screenings.
However, they said routine skin checks should begin earlier after transplantation for all nonwhite transplant recipients with a history of, or clinically evident HPV infection.
No conflicts of interest were declared.
Nonwhite organ transplant recipients (OTRs) are more likely to present with inflammatory or infectious conditions after transplantation, while white organ recipients more commonly present with malignant disease, new research suggests.
While the high incidence of skin cancers has been well described in patients who undergo solid organ transplants, little is known about the risk factors, incidence, locations, and types of skin disease that occur in nonwhite OTRs, wrote Christina Lee Chung, MD, from Drexel University, Philadelphia, and her coauthors in JAMA Dermatology.
In a retrospective review, the investigators examined the medical records of 412 organ transplant recipients treated at an academic referral center during 2011-2016, of whom 154 were white, 35 were Asian, 33 were Hispanic, and 190 were black (JAMA Dermatology. 2017 Mar 8. doi: 10.1001/jamadermatol.2017.0045).
Among the white patients, malignant or premalignant disease was the most common diagnostic category (67.8%), followed by inflammatory (20.7%) and infectious processes (11.6%). However, among nonwhite organ transplant recipients, inflammatory processes were present in 48.8% of patients, infectious processes in 37.5% and the remaining 13.7% presented with malignant or premalignant lesions.
Black and Hispanic patients were more likely to present with inflammatory or infectious disease; only 8.6% presented with malignant conditions and 16% presented with premalignant disease.
Among the Asian patient population, one-third presented with malignant or premalignant, one-third presented with infectious, and one-third presented with inflammatory conditions.
“Although early detection and treatment of cancer is vital, nonwhite OTRs would also benefit from addressing nonmalignant processes that are exacerbated by immunosuppression,” the authors wrote.
Overall, 389 skin cancers were diagnosed, with squamous cell carcinoma in situ (SCC) the most common type of skin cancer diagnosed in each racial or ethnic group. The mean time between transplant and first skin cancer lesion was 12.67 years in black patients, 6.5 years in Hispanic patients, 6.13 years among white patients, and 3.75 years in Asian patients.
The vast majority of skin cancers (95.1%) were found in white patients. While the majority of lesions in white and Asian patients were found in sun-exposed areas, the few skin cancers seen in black patients were more likely to be found in sun-protected areas, particularly the genitals.
Four of the six genital SCCs tested positive for high-risk human papillomavirus strains – in one Asian patient and three black patients – while the two SCCs found on lower extremities in Hispanic patients tested negative for HPV.
Researchers also looked at skin cancer awareness among the organ transplant recipients using data from initial visit questionnaires. They found that more than 17 of the 22 (77.3%) white organ transplant recipients surveyed were aware their skin cancer risk was increased, compared with 30 of the 44 (68.2%) nonwhite patients.
Similarly, 72.7% of white patients surveyed were aware that sunscreen decreased the risk of cancer, compared with 59.1% of nonwhite patients; 27.3% of white patients reported using a daily sunscreen, compared with 13.6% of nonwhite patients.
“Based on our findings, we suggest that optimal posttransplant dermatologic care be determined based on the race or ethnicity of the patients; however, regardless of skin type or race or ethnicity, a baseline full-skin assessment should be performed in all patients,” the authors wrote.
They proposed that skin cancer follow-up screenings should be given to Asian and Hispanic patients immediately after transplant, but that black organ transplant recipients could delay yearly screenings.
However, they said routine skin checks should begin earlier after transplantation for all nonwhite transplant recipients with a history of, or clinically evident HPV infection.
No conflicts of interest were declared.
Nonwhite organ transplant recipients (OTRs) are more likely to present with inflammatory or infectious conditions after transplantation, while white organ recipients more commonly present with malignant disease, new research suggests.
While the high incidence of skin cancers has been well described in patients who undergo solid organ transplants, little is known about the risk factors, incidence, locations, and types of skin disease that occur in nonwhite OTRs, wrote Christina Lee Chung, MD, from Drexel University, Philadelphia, and her coauthors in JAMA Dermatology.
In a retrospective review, the investigators examined the medical records of 412 organ transplant recipients treated at an academic referral center during 2011-2016, of whom 154 were white, 35 were Asian, 33 were Hispanic, and 190 were black (JAMA Dermatology. 2017 Mar 8. doi: 10.1001/jamadermatol.2017.0045).
Among the white patients, malignant or premalignant disease was the most common diagnostic category (67.8%), followed by inflammatory (20.7%) and infectious processes (11.6%). However, among nonwhite organ transplant recipients, inflammatory processes were present in 48.8% of patients, infectious processes in 37.5% and the remaining 13.7% presented with malignant or premalignant lesions.
Black and Hispanic patients were more likely to present with inflammatory or infectious disease; only 8.6% presented with malignant conditions and 16% presented with premalignant disease.
Among the Asian patient population, one-third presented with malignant or premalignant, one-third presented with infectious, and one-third presented with inflammatory conditions.
“Although early detection and treatment of cancer is vital, nonwhite OTRs would also benefit from addressing nonmalignant processes that are exacerbated by immunosuppression,” the authors wrote.
Overall, 389 skin cancers were diagnosed, with squamous cell carcinoma in situ (SCC) the most common type of skin cancer diagnosed in each racial or ethnic group. The mean time between transplant and first skin cancer lesion was 12.67 years in black patients, 6.5 years in Hispanic patients, 6.13 years among white patients, and 3.75 years in Asian patients.
The vast majority of skin cancers (95.1%) were found in white patients. While the majority of lesions in white and Asian patients were found in sun-exposed areas, the few skin cancers seen in black patients were more likely to be found in sun-protected areas, particularly the genitals.
Four of the six genital SCCs tested positive for high-risk human papillomavirus strains – in one Asian patient and three black patients – while the two SCCs found on lower extremities in Hispanic patients tested negative for HPV.
Researchers also looked at skin cancer awareness among the organ transplant recipients using data from initial visit questionnaires. They found that more than 17 of the 22 (77.3%) white organ transplant recipients surveyed were aware their skin cancer risk was increased, compared with 30 of the 44 (68.2%) nonwhite patients.
Similarly, 72.7% of white patients surveyed were aware that sunscreen decreased the risk of cancer, compared with 59.1% of nonwhite patients; 27.3% of white patients reported using a daily sunscreen, compared with 13.6% of nonwhite patients.
“Based on our findings, we suggest that optimal posttransplant dermatologic care be determined based on the race or ethnicity of the patients; however, regardless of skin type or race or ethnicity, a baseline full-skin assessment should be performed in all patients,” the authors wrote.
They proposed that skin cancer follow-up screenings should be given to Asian and Hispanic patients immediately after transplant, but that black organ transplant recipients could delay yearly screenings.
However, they said routine skin checks should begin earlier after transplantation for all nonwhite transplant recipients with a history of, or clinically evident HPV infection.
No conflicts of interest were declared.
FROM JAMA DERMATOLOGY
Key clinical point: Nonwhite organ transplant recipients are more likely than are white recipients to present with inflammatory or infectious conditions than with skin cancer after transplantation.
Major finding: Malignant or premalignant disease was seen in 67.8% of white organ transplant recipients but just 13.7% of nonwhite recipients.
Data source: A retrospective review of medical records from 412 organ transplant recipients.
Disclosures: No conflicts of interest were declared.
Antiviral medication successful for treating HCV in hepatocellular carcinoma
Direct-acting antiviral (DAA) medication was successful in treating hepatitis C in 74.5% of patients with hepatocellular carcinoma, and 93.4% of patients with HCC who underwent liver transplants, according to a study funded by Veterans Affairs.
In order to study the effectiveness of DAAs in this setting, Lauren A. Beste, MD, and her colleagues studied a cohort of 17,487 veterans; 624 patients reported having HCC, including 142 with HCC and liver transplantation (J Hepatol. 2017. doi. org/10.1016/j.jhep.2017.02.027).
Effects of the DAAs were also studied based on the genotype of patients’ HCV. According to analysis, patients with the genotype 1 HCV virus were most susceptible to the medication, with sustained virologic response (SVR) rates calculated at 79.1% for patients with HCC, 96.4% for HCC and transplant, and 93.1% for non-HCC.
For patients with genotype 2 virus, the SVR rate was 68.9% for those with HCC, and 86.5% for patients without HCC; for genotype 3, the rate of SVR was 68.9% and 86.5% for patients with and without HCC, respectively; and for genotype 4, the SVR rate was 50% and 90.2% for patients with and without HCC, respectively.
Unlike the genotype 1 population, which had 111 patients with HCC and liver transplantation, genotypes 2, 3, and 4 had only 4, 18, and 0 patients, respectively.
Dr. Beste and her colleagues attribute this to how common genotype 1 is, which made up 11,761 of 11,871 patients (99%) with known genotypes treated with either of the two medications.
An LDV/SOF-based regimen was given to more of those with genotype 1 who had HCC (88.1%) or HCC and liver transplantation (99.1%) than to those without HCC.
When comparing fibrosis and cirrhosis (FIB-4) scores among patients with an LDV/SOF-based and PrOD p/m ribavirin regimens, patients given PrOD regimens were less likely to have a higher FIB-4 score (47.7% vs. 73.1%), thrombocytopenia (23.1% vs. 40.2%), or elevated bilirubin (21.6% vs. 35.9%).
Patients with genotype 4 showed similar results in favor of PrOD treatment and genotype 2 patients only received LDV/SOF-based treatment; however genotype 3 showed the most positive results with LDV/SOF-based regimens, reporting a 100% success rate for the seven patients treated in the specific sample.
Overall, treatment was less successful for patients with HCC, compared with those without or who underwent transplantation. While Dr. Beste and her colleagues could not definitively explain this, the researchers suggested that it might be from the HCC itself. “The association between HCC and treatment failure persisted after adjustment for cirrhosis, markers of liver dysfunction, and genotype,” said Dr. Beste. “Therefore, these factors cannot explain the lower SVR in patients with HCC, and lead us to suspect that HCC itself could be causally linked to antiviral treatment failure.”
The researcher’s presented the hypothesis that “altered hepatic immune processes may predispose both to HCC and to poorer antiviral treatment outcomes.”
While the study was strengthened by the size and scope of the cohort, researchers were limited by a lack of data, including SVR data for 11.6% of HCC patients and 6.3% of HCC patients with transplantations. Researchers were also unable to attain HCC treatment data for nearly 24% of nontransplanted cases. Finally, the sample size was “overwhelmingly” male, which may give the study “limited generalizability to women.”
[email protected]
On Twitter @EAZweets
Direct-acting antiviral (DAA) medication was successful in treating hepatitis C in 74.5% of patients with hepatocellular carcinoma, and 93.4% of patients with HCC who underwent liver transplants, according to a study funded by Veterans Affairs.
In order to study the effectiveness of DAAs in this setting, Lauren A. Beste, MD, and her colleagues studied a cohort of 17,487 veterans; 624 patients reported having HCC, including 142 with HCC and liver transplantation (J Hepatol. 2017. doi. org/10.1016/j.jhep.2017.02.027).
Effects of the DAAs were also studied based on the genotype of patients’ HCV. According to analysis, patients with the genotype 1 HCV virus were most susceptible to the medication, with sustained virologic response (SVR) rates calculated at 79.1% for patients with HCC, 96.4% for HCC and transplant, and 93.1% for non-HCC.
For patients with genotype 2 virus, the SVR rate was 68.9% for those with HCC, and 86.5% for patients without HCC; for genotype 3, the rate of SVR was 68.9% and 86.5% for patients with and without HCC, respectively; and for genotype 4, the SVR rate was 50% and 90.2% for patients with and without HCC, respectively.
Unlike the genotype 1 population, which had 111 patients with HCC and liver transplantation, genotypes 2, 3, and 4 had only 4, 18, and 0 patients, respectively.
Dr. Beste and her colleagues attribute this to how common genotype 1 is, which made up 11,761 of 11,871 patients (99%) with known genotypes treated with either of the two medications.
An LDV/SOF-based regimen was given to more of those with genotype 1 who had HCC (88.1%) or HCC and liver transplantation (99.1%) than to those without HCC.
When comparing fibrosis and cirrhosis (FIB-4) scores among patients with an LDV/SOF-based and PrOD p/m ribavirin regimens, patients given PrOD regimens were less likely to have a higher FIB-4 score (47.7% vs. 73.1%), thrombocytopenia (23.1% vs. 40.2%), or elevated bilirubin (21.6% vs. 35.9%).
Patients with genotype 4 showed similar results in favor of PrOD treatment and genotype 2 patients only received LDV/SOF-based treatment; however genotype 3 showed the most positive results with LDV/SOF-based regimens, reporting a 100% success rate for the seven patients treated in the specific sample.
Overall, treatment was less successful for patients with HCC, compared with those without or who underwent transplantation. While Dr. Beste and her colleagues could not definitively explain this, the researchers suggested that it might be from the HCC itself. “The association between HCC and treatment failure persisted after adjustment for cirrhosis, markers of liver dysfunction, and genotype,” said Dr. Beste. “Therefore, these factors cannot explain the lower SVR in patients with HCC, and lead us to suspect that HCC itself could be causally linked to antiviral treatment failure.”
The researcher’s presented the hypothesis that “altered hepatic immune processes may predispose both to HCC and to poorer antiviral treatment outcomes.”
While the study was strengthened by the size and scope of the cohort, researchers were limited by a lack of data, including SVR data for 11.6% of HCC patients and 6.3% of HCC patients with transplantations. Researchers were also unable to attain HCC treatment data for nearly 24% of nontransplanted cases. Finally, the sample size was “overwhelmingly” male, which may give the study “limited generalizability to women.”
[email protected]
On Twitter @EAZweets
Direct-acting antiviral (DAA) medication was successful in treating hepatitis C in 74.5% of patients with hepatocellular carcinoma, and 93.4% of patients with HCC who underwent liver transplants, according to a study funded by Veterans Affairs.
In order to study the effectiveness of DAAs in this setting, Lauren A. Beste, MD, and her colleagues studied a cohort of 17,487 veterans; 624 patients reported having HCC, including 142 with HCC and liver transplantation (J Hepatol. 2017. doi. org/10.1016/j.jhep.2017.02.027).
Effects of the DAAs were also studied based on the genotype of patients’ HCV. According to analysis, patients with the genotype 1 HCV virus were most susceptible to the medication, with sustained virologic response (SVR) rates calculated at 79.1% for patients with HCC, 96.4% for HCC and transplant, and 93.1% for non-HCC.
For patients with genotype 2 virus, the SVR rate was 68.9% for those with HCC, and 86.5% for patients without HCC; for genotype 3, the rate of SVR was 68.9% and 86.5% for patients with and without HCC, respectively; and for genotype 4, the SVR rate was 50% and 90.2% for patients with and without HCC, respectively.
Unlike the genotype 1 population, which had 111 patients with HCC and liver transplantation, genotypes 2, 3, and 4 had only 4, 18, and 0 patients, respectively.
Dr. Beste and her colleagues attribute this to how common genotype 1 is, which made up 11,761 of 11,871 patients (99%) with known genotypes treated with either of the two medications.
An LDV/SOF-based regimen was given to more of those with genotype 1 who had HCC (88.1%) or HCC and liver transplantation (99.1%) than to those without HCC.
When comparing fibrosis and cirrhosis (FIB-4) scores among patients with an LDV/SOF-based and PrOD p/m ribavirin regimens, patients given PrOD regimens were less likely to have a higher FIB-4 score (47.7% vs. 73.1%), thrombocytopenia (23.1% vs. 40.2%), or elevated bilirubin (21.6% vs. 35.9%).
Patients with genotype 4 showed similar results in favor of PrOD treatment and genotype 2 patients only received LDV/SOF-based treatment; however genotype 3 showed the most positive results with LDV/SOF-based regimens, reporting a 100% success rate for the seven patients treated in the specific sample.
Overall, treatment was less successful for patients with HCC, compared with those without or who underwent transplantation. While Dr. Beste and her colleagues could not definitively explain this, the researchers suggested that it might be from the HCC itself. “The association between HCC and treatment failure persisted after adjustment for cirrhosis, markers of liver dysfunction, and genotype,” said Dr. Beste. “Therefore, these factors cannot explain the lower SVR in patients with HCC, and lead us to suspect that HCC itself could be causally linked to antiviral treatment failure.”
The researcher’s presented the hypothesis that “altered hepatic immune processes may predispose both to HCC and to poorer antiviral treatment outcomes.”
While the study was strengthened by the size and scope of the cohort, researchers were limited by a lack of data, including SVR data for 11.6% of HCC patients and 6.3% of HCC patients with transplantations. Researchers were also unable to attain HCC treatment data for nearly 24% of nontransplanted cases. Finally, the sample size was “overwhelmingly” male, which may give the study “limited generalizability to women.”
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FROM JOURNAL OF HEPATOLOGY
Key clinical point:
Major finding: Of the 17,487 patients given HCV treatment, sustained virologic response was found in 91.9% of patients without HCC, 74.5% with HCC, and 93.4% of patients with HCC and liver transplantation.
Data source: 17,487 patient records from 2014-2015 obtained through the Veterans Affairs Corporate Data Warehouse. Tests were approved by the VA Puget Sound Institutional Review Board.
Disclosures: The study was funded in part by Clinical Science Research and Development, Office of Research and Development, Veterans Affairs. Researchers reported no conflicts of interest.
Can better operations improve CABG in women?
Worse outcomes after cardiovascular arterial bypass grafting (CABG) in women have been attributed to a number of clinical and nonclinical factors: older age, delayed diagnosis and treatment, more comorbidities, smaller body size, underuse of arterial grafts, and referral bias. However, a team of Cleveland Clinic researchers reported that women were less likely than men to have bilateral–internal thoracic artery (ITA) grafting and complete revascularization, both of which are linked to better long-term survival.
“Women had less favorable preoperative characteristics than men but received fewer bilateral-ITA grafts and less all-arterial grafting as part of their revascularization strategy,” Tamer Attia, MD, MSc, and his coauthors said in the study published in the Journal of Thoracic and Cardiovascular Surgery. They also found that women were more likely to die in the hospital after CABG and had lower risk-adjusted long-term survival than men (2017 March;153:571-9).
Survival was lowest in women who were not completely revascularized and had no ITA grafting, while survival was highest in men who were completely revascularized and had bilateral grafting, Dr. Attia and coauthors said.
The researchers’ goal was to use extensive risk adjustment to evaluate how differences in revascularization strategies influenced survival of men and women after CABG. They analyzed 57,943 primary, isolated CABG procedures performed at Cleveland Clinic from 1972 to 2011, including 11,009 procedures in women.
The researchers identified differences between sexes in three key areas: revascularization strategies, in-hospital outcomes, and time-related survival.
With regard to revascularization strategies, while men were significantly more likely to have incomplete revascularization than were women, women received significantly fewer arterial grafts (8.4% vs. 9.3% for men). This included fewer bilateral-ITA grafts and radial artery grafts, less use of total arterial revascularization, and greater use of saphenous vein grafts (SVGs) to the left anterior descending artery. Women were also significantly more likely to receive only SVGs for revascularization (32% vs. 30% for men; P less than .0001). Most operations for both women and men were done with cardiopulmonary bypass, but significantly more women had off-pump procedures (5.4% vs. 2.9%).
In the hospital after operations, women were significantly more prone to postoperative deep sternal–wound infections and septicemias, as well as strokes and renal failure, including dialysis-dependent renal failure. Women also had higher rates of new-onset atrial fibrillation (15% vs. 13% in men), and higher rates of mechanical ventilation for more than 24 hours (13% vs. 9.2%). Women spent more time in the ICU and hospital overall, and their in-hospital death rate was more than double that of men (2.7% vs. 1.1%).
Women also had shorter long-term survival, “and this has persisted since the beginning of CABG at Cleveland Clinic,” Dr. Attia and coauthors said. What’s more, the survival gap between women in the study and women in the general population post CABG was wider than that in men. “After we adjusted for patient and revascularization strategy differences, female sex remained an independent risk factor for death overall and both early and late after CABG.”
Incomplete revascularization had greater consequences for women than for men. At 10 years, 58% of women with incomplete revascularization survived, vs. 70% of men. At 20 years, the rates were 25% for women and 35% for men. “Use of ITA grafts was associated with better survival than use of SVGs alone and was best when bilateral-ITA grafting was performed,” Dr. Attia and coauthors said. However, the study determined that bilateral grafting seems less effective in women long-term. “Hence, a patient’s sex deserves special consideration in operative planning.”
Many questions about CABG in women remain: Identifying which female patients would benefit from more meticulous conduit harvesting, from better coronary artery selection, and from bilateral-ITA grafting and which are less susceptible to sternal would infections could increase appropriate use of bilateral-ITA grafting, the researchers noted. “The difference in effectiveness of bilateral-ITA grafting needs to be considered in women at elevated risk for bilateral-ITA harvesting complications.”
Coauthor Ellen Mayer Sabik, MD, is a principal investigator for Abbott Laboratories and is on the scientific advisory board of Medtronic. Dr. Attia and all other coauthors reported having no relevant financial relationships to disclose.
As with other long-term analyses, the answer in this study “is in the shadows as opposed to the spotlight,” George L. Hicks Jr., MD, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153[3]:580-1).
Dr. Hicks of the University of Rochester (N.Y.) noted key limitations of the study: use of all-cause mortality, substandard use of bilateral– or single–internal thoracic artery grafting, little data about postdischarge cholesterol levels, diabetes incidence, or blood pressure, among others. However, “the authors raise the banner for the continued need for increased use of arterial revascularization with the eventual hope that the Arterial Revascularization Trial will reinforce the survival benefits manifested by that strategy,” he said.
Reducing risks and not changing the type of operation will even out the differences in postoperative survival between genders, he indicated. “Furthermore, the extension of similar therapies – for example, [bilateral–internal thoracic artery] or all-arterial grafting and improved long-term risk modification in both men and women – may improve the inequality but not eliminate the differences until we know that both men and women come from the same planet,” he said.
Dr. Hicks reported having no relevant financial relationships to disclose.
As with other long-term analyses, the answer in this study “is in the shadows as opposed to the spotlight,” George L. Hicks Jr., MD, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153[3]:580-1).
Dr. Hicks of the University of Rochester (N.Y.) noted key limitations of the study: use of all-cause mortality, substandard use of bilateral– or single–internal thoracic artery grafting, little data about postdischarge cholesterol levels, diabetes incidence, or blood pressure, among others. However, “the authors raise the banner for the continued need for increased use of arterial revascularization with the eventual hope that the Arterial Revascularization Trial will reinforce the survival benefits manifested by that strategy,” he said.
Reducing risks and not changing the type of operation will even out the differences in postoperative survival between genders, he indicated. “Furthermore, the extension of similar therapies – for example, [bilateral–internal thoracic artery] or all-arterial grafting and improved long-term risk modification in both men and women – may improve the inequality but not eliminate the differences until we know that both men and women come from the same planet,” he said.
Dr. Hicks reported having no relevant financial relationships to disclose.
As with other long-term analyses, the answer in this study “is in the shadows as opposed to the spotlight,” George L. Hicks Jr., MD, said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153[3]:580-1).
Dr. Hicks of the University of Rochester (N.Y.) noted key limitations of the study: use of all-cause mortality, substandard use of bilateral– or single–internal thoracic artery grafting, little data about postdischarge cholesterol levels, diabetes incidence, or blood pressure, among others. However, “the authors raise the banner for the continued need for increased use of arterial revascularization with the eventual hope that the Arterial Revascularization Trial will reinforce the survival benefits manifested by that strategy,” he said.
Reducing risks and not changing the type of operation will even out the differences in postoperative survival between genders, he indicated. “Furthermore, the extension of similar therapies – for example, [bilateral–internal thoracic artery] or all-arterial grafting and improved long-term risk modification in both men and women – may improve the inequality but not eliminate the differences until we know that both men and women come from the same planet,” he said.
Dr. Hicks reported having no relevant financial relationships to disclose.
Worse outcomes after cardiovascular arterial bypass grafting (CABG) in women have been attributed to a number of clinical and nonclinical factors: older age, delayed diagnosis and treatment, more comorbidities, smaller body size, underuse of arterial grafts, and referral bias. However, a team of Cleveland Clinic researchers reported that women were less likely than men to have bilateral–internal thoracic artery (ITA) grafting and complete revascularization, both of which are linked to better long-term survival.
“Women had less favorable preoperative characteristics than men but received fewer bilateral-ITA grafts and less all-arterial grafting as part of their revascularization strategy,” Tamer Attia, MD, MSc, and his coauthors said in the study published in the Journal of Thoracic and Cardiovascular Surgery. They also found that women were more likely to die in the hospital after CABG and had lower risk-adjusted long-term survival than men (2017 March;153:571-9).
Survival was lowest in women who were not completely revascularized and had no ITA grafting, while survival was highest in men who were completely revascularized and had bilateral grafting, Dr. Attia and coauthors said.
The researchers’ goal was to use extensive risk adjustment to evaluate how differences in revascularization strategies influenced survival of men and women after CABG. They analyzed 57,943 primary, isolated CABG procedures performed at Cleveland Clinic from 1972 to 2011, including 11,009 procedures in women.
The researchers identified differences between sexes in three key areas: revascularization strategies, in-hospital outcomes, and time-related survival.
With regard to revascularization strategies, while men were significantly more likely to have incomplete revascularization than were women, women received significantly fewer arterial grafts (8.4% vs. 9.3% for men). This included fewer bilateral-ITA grafts and radial artery grafts, less use of total arterial revascularization, and greater use of saphenous vein grafts (SVGs) to the left anterior descending artery. Women were also significantly more likely to receive only SVGs for revascularization (32% vs. 30% for men; P less than .0001). Most operations for both women and men were done with cardiopulmonary bypass, but significantly more women had off-pump procedures (5.4% vs. 2.9%).
In the hospital after operations, women were significantly more prone to postoperative deep sternal–wound infections and septicemias, as well as strokes and renal failure, including dialysis-dependent renal failure. Women also had higher rates of new-onset atrial fibrillation (15% vs. 13% in men), and higher rates of mechanical ventilation for more than 24 hours (13% vs. 9.2%). Women spent more time in the ICU and hospital overall, and their in-hospital death rate was more than double that of men (2.7% vs. 1.1%).
Women also had shorter long-term survival, “and this has persisted since the beginning of CABG at Cleveland Clinic,” Dr. Attia and coauthors said. What’s more, the survival gap between women in the study and women in the general population post CABG was wider than that in men. “After we adjusted for patient and revascularization strategy differences, female sex remained an independent risk factor for death overall and both early and late after CABG.”
Incomplete revascularization had greater consequences for women than for men. At 10 years, 58% of women with incomplete revascularization survived, vs. 70% of men. At 20 years, the rates were 25% for women and 35% for men. “Use of ITA grafts was associated with better survival than use of SVGs alone and was best when bilateral-ITA grafting was performed,” Dr. Attia and coauthors said. However, the study determined that bilateral grafting seems less effective in women long-term. “Hence, a patient’s sex deserves special consideration in operative planning.”
Many questions about CABG in women remain: Identifying which female patients would benefit from more meticulous conduit harvesting, from better coronary artery selection, and from bilateral-ITA grafting and which are less susceptible to sternal would infections could increase appropriate use of bilateral-ITA grafting, the researchers noted. “The difference in effectiveness of bilateral-ITA grafting needs to be considered in women at elevated risk for bilateral-ITA harvesting complications.”
Coauthor Ellen Mayer Sabik, MD, is a principal investigator for Abbott Laboratories and is on the scientific advisory board of Medtronic. Dr. Attia and all other coauthors reported having no relevant financial relationships to disclose.
Worse outcomes after cardiovascular arterial bypass grafting (CABG) in women have been attributed to a number of clinical and nonclinical factors: older age, delayed diagnosis and treatment, more comorbidities, smaller body size, underuse of arterial grafts, and referral bias. However, a team of Cleveland Clinic researchers reported that women were less likely than men to have bilateral–internal thoracic artery (ITA) grafting and complete revascularization, both of which are linked to better long-term survival.
“Women had less favorable preoperative characteristics than men but received fewer bilateral-ITA grafts and less all-arterial grafting as part of their revascularization strategy,” Tamer Attia, MD, MSc, and his coauthors said in the study published in the Journal of Thoracic and Cardiovascular Surgery. They also found that women were more likely to die in the hospital after CABG and had lower risk-adjusted long-term survival than men (2017 March;153:571-9).
Survival was lowest in women who were not completely revascularized and had no ITA grafting, while survival was highest in men who were completely revascularized and had bilateral grafting, Dr. Attia and coauthors said.
The researchers’ goal was to use extensive risk adjustment to evaluate how differences in revascularization strategies influenced survival of men and women after CABG. They analyzed 57,943 primary, isolated CABG procedures performed at Cleveland Clinic from 1972 to 2011, including 11,009 procedures in women.
The researchers identified differences between sexes in three key areas: revascularization strategies, in-hospital outcomes, and time-related survival.
With regard to revascularization strategies, while men were significantly more likely to have incomplete revascularization than were women, women received significantly fewer arterial grafts (8.4% vs. 9.3% for men). This included fewer bilateral-ITA grafts and radial artery grafts, less use of total arterial revascularization, and greater use of saphenous vein grafts (SVGs) to the left anterior descending artery. Women were also significantly more likely to receive only SVGs for revascularization (32% vs. 30% for men; P less than .0001). Most operations for both women and men were done with cardiopulmonary bypass, but significantly more women had off-pump procedures (5.4% vs. 2.9%).
In the hospital after operations, women were significantly more prone to postoperative deep sternal–wound infections and septicemias, as well as strokes and renal failure, including dialysis-dependent renal failure. Women also had higher rates of new-onset atrial fibrillation (15% vs. 13% in men), and higher rates of mechanical ventilation for more than 24 hours (13% vs. 9.2%). Women spent more time in the ICU and hospital overall, and their in-hospital death rate was more than double that of men (2.7% vs. 1.1%).
Women also had shorter long-term survival, “and this has persisted since the beginning of CABG at Cleveland Clinic,” Dr. Attia and coauthors said. What’s more, the survival gap between women in the study and women in the general population post CABG was wider than that in men. “After we adjusted for patient and revascularization strategy differences, female sex remained an independent risk factor for death overall and both early and late after CABG.”
Incomplete revascularization had greater consequences for women than for men. At 10 years, 58% of women with incomplete revascularization survived, vs. 70% of men. At 20 years, the rates were 25% for women and 35% for men. “Use of ITA grafts was associated with better survival than use of SVGs alone and was best when bilateral-ITA grafting was performed,” Dr. Attia and coauthors said. However, the study determined that bilateral grafting seems less effective in women long-term. “Hence, a patient’s sex deserves special consideration in operative planning.”
Many questions about CABG in women remain: Identifying which female patients would benefit from more meticulous conduit harvesting, from better coronary artery selection, and from bilateral-ITA grafting and which are less susceptible to sternal would infections could increase appropriate use of bilateral-ITA grafting, the researchers noted. “The difference in effectiveness of bilateral-ITA grafting needs to be considered in women at elevated risk for bilateral-ITA harvesting complications.”
Coauthor Ellen Mayer Sabik, MD, is a principal investigator for Abbott Laboratories and is on the scientific advisory board of Medtronic. Dr. Attia and all other coauthors reported having no relevant financial relationships to disclose.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Survival rates after CABG are worse for women than for men.
Major finding: In both men and women, complete revascularization and use of bilateral-ITA grafting achieve better long-term survival than incomplete revascularization and single-ITA grafting.
Data source: Analysis of 57,943 adults who had primary isolated CABG from 1972 to 2011 at Cleveland Clinic.
Disclosure: Coauthor Ellen Mayer Sabik, MD, is a principal investigator for Abbott Laboratories and is on the scientific advisory board of Medtronic. Dr. Attia and all other coauthors reported having no relevant financial disclosures.