ACS Surgery News

MACRA will not be as hard on small and solo practices as it first appeared when draft implementing regulations were published, according to Andy Slavitt, administrator of the Centers for Medicare & Medicaid Services.

Mr. Slavitt testified May 11 before the House Ways & Means Health Subcommittee to address legislators’ concerns about how the government intends to implement the Medicare Access and CHIP Reauthorization Act of 2015.

Rep. Sam Johnson (R-Tex.) expressed concern that the draft regulations published April 27 project “the greatest negative impact on payments to practices with nine or fewer doctors and the least harm to large systems with 100 or more docs.”

The calculations in the draft regulation were based on data from 2014, a year in which few small and solo practices reported quality data.

“In 2015 and subsequent years, the reporting went up,” Mr. Slavitt testified. “So at best, this table would be very, very conservative. ... Reporting is going to be far easier going forward.”

Mr. Slavitt said that the CMS will do all it can to help ensure that small and solo practices have every opportunity to participate in the both the Merit-Based Incentive Payment System (MIPS) and in advanced alternative payment models.

“The question of making sure that small groups and solo practitioners can be successful is of utmost importance. Our data show that physicians who are in small and solo practices ... do just as well as physicians that are in practices that are larger than that,” he said, adding that technical assistance specific to solo and small practices is being developed to help them transition to these value-based payment models.

Other federal officials have been spreading the same message to physicians. Speaking May 7 at the annual meeting of the American College of Physicians, Dr. Thomas A. Mason, chief medical officer in the Office of the National Coordinator for Health Information Technology, pointed out that the MACRA legislation put aside $20 million a year for 5 years beginning in 2016 to help solo and small practices transition to MIPS and APMs.

“It is specifically to help with the shift and transforming practices to measuring quality and improving quality performance,” he said in an interview. “The MACRA statute specifically calls out what the dollars need to be used for and the two points are for assisting MIPS-eligible professionals and improving their MIPS composite score as well as the transition to advanced alternative payment models.”

The U.S. Department of Health & Human Services already has begun soliciting contractors to support small and solo practices, he added.

“Direct technical assistance through this program will target eligible clinicians in individual or small group practices of 15 or fewer, focusing on those practicing in historically under resourced areas,” according to a request for proposals. “Technical assistance is defined as provider outreach and education, practice readiness, practice facilitation, health information technology (HIT) optimization, practice workflow redesign, change management, strategic planning, assisting clinicians in fully transitioning to Alternative Payment Models, and enabling partnerships.”

The federal health IT office plans to provide more information on the availability of transition assistance soon, Dr. Mason said.

[email protected]

MACRA will not be as hard on small and solo practices as it first appeared when draft implementing regulations were published, according to Andy Slavitt, administrator of the Centers for Medicare & Medicaid Services.

Mr. Slavitt testified May 11 before the House Ways & Means Health Subcommittee to address legislators’ concerns about how the government intends to implement the Medicare Access and CHIP Reauthorization Act of 2015.

Rep. Sam Johnson (R-Tex.) expressed concern that the draft regulations published April 27 project “the greatest negative impact on payments to practices with nine or fewer doctors and the least harm to large systems with 100 or more docs.”

The calculations in the draft regulation were based on data from 2014, a year in which few small and solo practices reported quality data.

“In 2015 and subsequent years, the reporting went up,” Mr. Slavitt testified. “So at best, this table would be very, very conservative. ... Reporting is going to be far easier going forward.”

Mr. Slavitt said that the CMS will do all it can to help ensure that small and solo practices have every opportunity to participate in the both the Merit-Based Incentive Payment System (MIPS) and in advanced alternative payment models.

“The question of making sure that small groups and solo practitioners can be successful is of utmost importance. Our data show that physicians who are in small and solo practices ... do just as well as physicians that are in practices that are larger than that,” he said, adding that technical assistance specific to solo and small practices is being developed to help them transition to these value-based payment models.

Other federal officials have been spreading the same message to physicians. Speaking May 7 at the annual meeting of the American College of Physicians, Dr. Thomas A. Mason, chief medical officer in the Office of the National Coordinator for Health Information Technology, pointed out that the MACRA legislation put aside $20 million a year for 5 years beginning in 2016 to help solo and small practices transition to MIPS and APMs.

“It is specifically to help with the shift and transforming practices to measuring quality and improving quality performance,” he said in an interview. “The MACRA statute specifically calls out what the dollars need to be used for and the two points are for assisting MIPS-eligible professionals and improving their MIPS composite score as well as the transition to advanced alternative payment models.”

The U.S. Department of Health & Human Services already has begun soliciting contractors to support small and solo practices, he added.

“Direct technical assistance through this program will target eligible clinicians in individual or small group practices of 15 or fewer, focusing on those practicing in historically under resourced areas,” according to a request for proposals. “Technical assistance is defined as provider outreach and education, practice readiness, practice facilitation, health information technology (HIT) optimization, practice workflow redesign, change management, strategic planning, assisting clinicians in fully transitioning to Alternative Payment Models, and enabling partnerships.”

The federal health IT office plans to provide more information on the availability of transition assistance soon, Dr. Mason said.

[email protected]

MACRA will not be as hard on small and solo practices as it first appeared when draft implementing regulations were published, according to Andy Slavitt, administrator of the Centers for Medicare & Medicaid Services.

Mr. Slavitt testified May 11 before the House Ways & Means Health Subcommittee to address legislators’ concerns about how the government intends to implement the Medicare Access and CHIP Reauthorization Act of 2015.

Rep. Sam Johnson (R-Tex.) expressed concern that the draft regulations published April 27 project “the greatest negative impact on payments to practices with nine or fewer doctors and the least harm to large systems with 100 or more docs.”

The calculations in the draft regulation were based on data from 2014, a year in which few small and solo practices reported quality data.

“In 2015 and subsequent years, the reporting went up,” Mr. Slavitt testified. “So at best, this table would be very, very conservative. ... Reporting is going to be far easier going forward.”

Mr. Slavitt said that the CMS will do all it can to help ensure that small and solo practices have every opportunity to participate in the both the Merit-Based Incentive Payment System (MIPS) and in advanced alternative payment models.

“The question of making sure that small groups and solo practitioners can be successful is of utmost importance. Our data show that physicians who are in small and solo practices ... do just as well as physicians that are in practices that are larger than that,” he said, adding that technical assistance specific to solo and small practices is being developed to help them transition to these value-based payment models.

Other federal officials have been spreading the same message to physicians. Speaking May 7 at the annual meeting of the American College of Physicians, Dr. Thomas A. Mason, chief medical officer in the Office of the National Coordinator for Health Information Technology, pointed out that the MACRA legislation put aside $20 million a year for 5 years beginning in 2016 to help solo and small practices transition to MIPS and APMs.

“It is specifically to help with the shift and transforming practices to measuring quality and improving quality performance,” he said in an interview. “The MACRA statute specifically calls out what the dollars need to be used for and the two points are for assisting MIPS-eligible professionals and improving their MIPS composite score as well as the transition to advanced alternative payment models.”

The U.S. Department of Health & Human Services already has begun soliciting contractors to support small and solo practices, he added.

“Direct technical assistance through this program will target eligible clinicians in individual or small group practices of 15 or fewer, focusing on those practicing in historically under resourced areas,” according to a request for proposals. “Technical assistance is defined as provider outreach and education, practice readiness, practice facilitation, health information technology (HIT) optimization, practice workflow redesign, change management, strategic planning, assisting clinicians in fully transitioning to Alternative Payment Models, and enabling partnerships.”

The federal health IT office plans to provide more information on the availability of transition assistance soon, Dr. Mason said.

[email protected]

The digital May issue of ACS Surgery News is available online. Use the mobile app to download or view as a pdf.

The growing problem with reproducibility and sloppy use of statistical tools in biomedical research is the topic of this month’s feature. Even lab mice can be the sources of misleading research results. Dr. Peter Angelos reflects on what all this can mean for surgical research.

Don’t miss Dr. Tyler Hughes’s lighthearted look at a fictional surgeon of the future, Dr. ‘Bones’ McCoy, and how some of Dr. McCoy’s challenges are all too familiar to today’s surgeons.

This issue has news from on-site coverage of the annual meetings of the American Association of Endocrine Surgeons, the American Surgical Association, and the Central Surgical Association.

The digital May issue of ACS Surgery News is available online. Use the mobile app to download or view as a pdf.

The growing problem with reproducibility and sloppy use of statistical tools in biomedical research is the topic of this month’s feature. Even lab mice can be the sources of misleading research results. Dr. Peter Angelos reflects on what all this can mean for surgical research.

Don’t miss Dr. Tyler Hughes’s lighthearted look at a fictional surgeon of the future, Dr. ‘Bones’ McCoy, and how some of Dr. McCoy’s challenges are all too familiar to today’s surgeons.

This issue has news from on-site coverage of the annual meetings of the American Association of Endocrine Surgeons, the American Surgical Association, and the Central Surgical Association.

The digital May issue of ACS Surgery News is available online. Use the mobile app to download or view as a pdf.

The growing problem with reproducibility and sloppy use of statistical tools in biomedical research is the topic of this month’s feature. Even lab mice can be the sources of misleading research results. Dr. Peter Angelos reflects on what all this can mean for surgical research.

Don’t miss Dr. Tyler Hughes’s lighthearted look at a fictional surgeon of the future, Dr. ‘Bones’ McCoy, and how some of Dr. McCoy’s challenges are all too familiar to today’s surgeons.

This issue has news from on-site coverage of the annual meetings of the American Association of Endocrine Surgeons, the American Surgical Association, and the Central Surgical Association.

LOS ANGELES – The detection rate of significant polyps was highest for the first postoperative surveillance colonoscopies performed at 1 year following curative resection for colorectal cancer, results from a single-center study demonstrated.

“There’s no consensus on when to perform the first surveillance colonoscopy post curative resection for colorectal cancer,” lead study author Dr. Noura Alhassan said at the annual meeting of the American Society of Colon and Rectal Surgeons. For example, the American Society of Colon and Rectal Surgeons and National Carcinoma Comprehensive Network guidelines recommend a colonoscopy at 1 year, while the Canadian Association of Gastroenterology recommends surveillance at 3 years postoperatively.

Doug Brunk/Frontline Medical News

In an effort to determine the optimal timing of the first surveillance colonoscopy following curative colorectal carcinoma resection, Dr. Alhassan and her associates retrospectively reviewed the charts of all patients who underwent colorectal resection from 2007 to 2012 at Jewish General Hospital, a tertiary care center affiliated with McGill University, Montreal. The study included patients who had a complete preoperative colonoscopy, those who had a complete postoperative colonoscopy performed by one of the Jewish General Hospital colorectal surgeons, and those who had colorectal cancer resection with curative intent. Excluded from the study were patients with stage IV colorectal cancer, those with a prior history of colorectal cancer, those who underwent total abdominal colectomies or proctocolectomies, those who underwent local excision, and those with familial cancer syndromes and inflammatory bowel disease.

Dr. Alhassan, a fourth-year resident in the division of general surgery at McGill University, said that the researchers classified the colonoscopic findings as normal, nonsignificant polyps, significant polyps, and recurrence. Significant polyps consisted of adenomas 1 cm or greater in size, villous or tubulovillous adenoma, adenoma with high-grade dysplasia, three or more adenomas, or sessile serrated polyps at least 1 cm in size or with dysplasia. Of the 857 colorectal resections performed during the study period, 181 met inclusion criteria. The tumor stage was evenly distributed among study participants and 57% of the resections were colon operations, while the remaining 43% were proctectomies.

The preoperative colonoscopy was done by one of the Jewish General Hospital gastroenterologists 43% of the time, by one of the Jewish General Hospital colorectal surgeons 41% of the time, and by an outside hospital 16% of the time. The median time to postoperative colonoscopy was 421 days (1.1 years). Specifically, 25.90% of patients underwent their first surveillance colonoscopy in the first postoperative year, 48.10% in the second year, 14.40% in the third year, 8.5% in the fourth year, and 2.7% in the fifth year.

Dr. Alhassan reported that the all-polyp detection rate was 30.1%; 21.3% were detected in postoperative year 1, 33.3% in year 2, and 34.6% in year 3.

The overall significant polyp detection rate was 10.5%, but the detection rate was 12.8% in postoperative year 1, 8% in postoperative year 2, and 7.7% in postoperative year 3. There were two anastomotic recurrences: one in year 1 (2.1%) and one in year 3 (3.8%).

On univariate analysis, factors associated with significant polyp detection were male gender, poor bowel preparation on preoperative colonoscopy, and concomitant use of metformin, while having stage III disease was associated with a lower significant polyp detection rate.

On multivariate analysis only male gender was associated with a higher significant polyp detection rate, while stage III disease was associated with a lower significant polyp detection rate.

“Significant polyp detection rate of 12.8% at postoperative year 1 justifies surveillance colonoscopy at 1 year post curative colon cancer resection,” Dr. Alhassan concluded. She reported having no financial disclosures.

[email protected]

LOS ANGELES – The detection rate of significant polyps was highest for the first postoperative surveillance colonoscopies performed at 1 year following curative resection for colorectal cancer, results from a single-center study demonstrated.

“There’s no consensus on when to perform the first surveillance colonoscopy post curative resection for colorectal cancer,” lead study author Dr. Noura Alhassan said at the annual meeting of the American Society of Colon and Rectal Surgeons. For example, the American Society of Colon and Rectal Surgeons and National Carcinoma Comprehensive Network guidelines recommend a colonoscopy at 1 year, while the Canadian Association of Gastroenterology recommends surveillance at 3 years postoperatively.

Doug Brunk/Frontline Medical News

In an effort to determine the optimal timing of the first surveillance colonoscopy following curative colorectal carcinoma resection, Dr. Alhassan and her associates retrospectively reviewed the charts of all patients who underwent colorectal resection from 2007 to 2012 at Jewish General Hospital, a tertiary care center affiliated with McGill University, Montreal. The study included patients who had a complete preoperative colonoscopy, those who had a complete postoperative colonoscopy performed by one of the Jewish General Hospital colorectal surgeons, and those who had colorectal cancer resection with curative intent. Excluded from the study were patients with stage IV colorectal cancer, those with a prior history of colorectal cancer, those who underwent total abdominal colectomies or proctocolectomies, those who underwent local excision, and those with familial cancer syndromes and inflammatory bowel disease.

Dr. Alhassan, a fourth-year resident in the division of general surgery at McGill University, said that the researchers classified the colonoscopic findings as normal, nonsignificant polyps, significant polyps, and recurrence. Significant polyps consisted of adenomas 1 cm or greater in size, villous or tubulovillous adenoma, adenoma with high-grade dysplasia, three or more adenomas, or sessile serrated polyps at least 1 cm in size or with dysplasia. Of the 857 colorectal resections performed during the study period, 181 met inclusion criteria. The tumor stage was evenly distributed among study participants and 57% of the resections were colon operations, while the remaining 43% were proctectomies.

The preoperative colonoscopy was done by one of the Jewish General Hospital gastroenterologists 43% of the time, by one of the Jewish General Hospital colorectal surgeons 41% of the time, and by an outside hospital 16% of the time. The median time to postoperative colonoscopy was 421 days (1.1 years). Specifically, 25.90% of patients underwent their first surveillance colonoscopy in the first postoperative year, 48.10% in the second year, 14.40% in the third year, 8.5% in the fourth year, and 2.7% in the fifth year.

Dr. Alhassan reported that the all-polyp detection rate was 30.1%; 21.3% were detected in postoperative year 1, 33.3% in year 2, and 34.6% in year 3.

The overall significant polyp detection rate was 10.5%, but the detection rate was 12.8% in postoperative year 1, 8% in postoperative year 2, and 7.7% in postoperative year 3. There were two anastomotic recurrences: one in year 1 (2.1%) and one in year 3 (3.8%).

On univariate analysis, factors associated with significant polyp detection were male gender, poor bowel preparation on preoperative colonoscopy, and concomitant use of metformin, while having stage III disease was associated with a lower significant polyp detection rate.

On multivariate analysis only male gender was associated with a higher significant polyp detection rate, while stage III disease was associated with a lower significant polyp detection rate.

“Significant polyp detection rate of 12.8% at postoperative year 1 justifies surveillance colonoscopy at 1 year post curative colon cancer resection,” Dr. Alhassan concluded. She reported having no financial disclosures.

[email protected]

LOS ANGELES – The detection rate of significant polyps was highest for the first postoperative surveillance colonoscopies performed at 1 year following curative resection for colorectal cancer, results from a single-center study demonstrated.

“There’s no consensus on when to perform the first surveillance colonoscopy post curative resection for colorectal cancer,” lead study author Dr. Noura Alhassan said at the annual meeting of the American Society of Colon and Rectal Surgeons. For example, the American Society of Colon and Rectal Surgeons and National Carcinoma Comprehensive Network guidelines recommend a colonoscopy at 1 year, while the Canadian Association of Gastroenterology recommends surveillance at 3 years postoperatively.

Doug Brunk/Frontline Medical News

In an effort to determine the optimal timing of the first surveillance colonoscopy following curative colorectal carcinoma resection, Dr. Alhassan and her associates retrospectively reviewed the charts of all patients who underwent colorectal resection from 2007 to 2012 at Jewish General Hospital, a tertiary care center affiliated with McGill University, Montreal. The study included patients who had a complete preoperative colonoscopy, those who had a complete postoperative colonoscopy performed by one of the Jewish General Hospital colorectal surgeons, and those who had colorectal cancer resection with curative intent. Excluded from the study were patients with stage IV colorectal cancer, those with a prior history of colorectal cancer, those who underwent total abdominal colectomies or proctocolectomies, those who underwent local excision, and those with familial cancer syndromes and inflammatory bowel disease.

Dr. Alhassan, a fourth-year resident in the division of general surgery at McGill University, said that the researchers classified the colonoscopic findings as normal, nonsignificant polyps, significant polyps, and recurrence. Significant polyps consisted of adenomas 1 cm or greater in size, villous or tubulovillous adenoma, adenoma with high-grade dysplasia, three or more adenomas, or sessile serrated polyps at least 1 cm in size or with dysplasia. Of the 857 colorectal resections performed during the study period, 181 met inclusion criteria. The tumor stage was evenly distributed among study participants and 57% of the resections were colon operations, while the remaining 43% were proctectomies.

The preoperative colonoscopy was done by one of the Jewish General Hospital gastroenterologists 43% of the time, by one of the Jewish General Hospital colorectal surgeons 41% of the time, and by an outside hospital 16% of the time. The median time to postoperative colonoscopy was 421 days (1.1 years). Specifically, 25.90% of patients underwent their first surveillance colonoscopy in the first postoperative year, 48.10% in the second year, 14.40% in the third year, 8.5% in the fourth year, and 2.7% in the fifth year.

Dr. Alhassan reported that the all-polyp detection rate was 30.1%; 21.3% were detected in postoperative year 1, 33.3% in year 2, and 34.6% in year 3.

The overall significant polyp detection rate was 10.5%, but the detection rate was 12.8% in postoperative year 1, 8% in postoperative year 2, and 7.7% in postoperative year 3. There were two anastomotic recurrences: one in year 1 (2.1%) and one in year 3 (3.8%).

On univariate analysis, factors associated with significant polyp detection were male gender, poor bowel preparation on preoperative colonoscopy, and concomitant use of metformin, while having stage III disease was associated with a lower significant polyp detection rate.

On multivariate analysis only male gender was associated with a higher significant polyp detection rate, while stage III disease was associated with a lower significant polyp detection rate.

“Significant polyp detection rate of 12.8% at postoperative year 1 justifies surveillance colonoscopy at 1 year post curative colon cancer resection,” Dr. Alhassan concluded. She reported having no financial disclosures.

[email protected]

CHICAGO – Preadmission and postdischarge factors were important predictors of postoperative readmission in a large cohort of surgical patients, but the hospital course had little incremental impact on either readmissions or postdischarge complications in the cohort, according to a retrospective study of Veterans Affairs data.

The findings suggest that efforts to reduce postoperative readmissions should focus on enhanced postdischarge surveillance and early intervention, Dr. Melanie S. Morris of the University of Alabama at Birmingham reported at the annual meeting of the American Surgical Association.

Dr. Morris

To assess the relative contributions of patient factors, operative characteristics, and postoperative hospital course on readmissions, she and her colleagues evaluated 243,956 general, vascular, and orthopedic surgery patients in 121 VA hospitals. The overall readmission rate among the cohort was 11.1%, and for general, vascular, and orthopedic surgeries, the rates were 12.9%, 15.4%, and 7.6%, respectively; the average postoperative length of stay was 6.9 days, and 6.1% of patients experienced a predischarge complication.

Almost all readmissions occurred within 2 weeks of discharge, and for general surgery patients, most occurred within 1 week. The readmission rate for vascular surgery patients remained high beyond the 2-week mark.

An examination of the reasons for readmission showed that wound complications were the most common reason for readmission, and this was particularly true for vascular surgery patients, in whom 44% of readmissions were for wound complications, Dr. Morris said.

Gastrointestinal complications including ileus and obstruction were also common, accounting for nearly 28% of readmissions among general surgery patients, she said.

Importantly, when including preoperative data (such as demographics, comorbidities, social and behavioral factors, labs and vital signs, and planned procedure type), the variability in readmissions could only be explained 8.6% of the time, she said.

“Adding in operative data, such as procedure complexity and intraoperative blood transfusions, as well as postoperative course, added very little to our predictive ability. Including both of those groups, we could only explain 10% of the variation in readmission,” she said.

Including postdischarge data such as complications and emergency department utilization in the model increased predictive ability to 18%.

R² and C-statistics comparing the sequentially built model showed that demographics and comorbidities contributed the most to predicting readmission risk, Dr. Morris said.

Modeling based on readmission reason and specialty improved predictive ability. For example, almost 12% of readmissions for wound complications among vascular surgery patients were predictable.

“Our best predictive ability was for orthopedic patients who were readmitted with pneumonia. We were able to predict that 14% of the time,” she said.

The findings were derived by merging VA Surgical Quality Improvement Program data from inpatient operations performed between 2007 and 2014 and involving at least a 2-day postoperative hospital stay, with clinical data including laboratory findings, vitals, prior health care utilization, and postoperative complications.

“We then grouped our variables of interest into the following categories: preoperative, operative, postoperative but predischarge, and postdischarge,” she explained, noting that logistic models predicting 30-day readmission were constructed by sequentially adding groups into the model. Models were compared by way of adjusted R² and C-statistics.

Assuming postoperative readmissions are preventable suggests that they are linked to the quality of care during the index hospitalization. The current findings demonstrate the challenges in predicting readmissions, and are important given that hospitals with higher-than-expected readmission rates for certain diagnoses and procedures are fined by the Centers for Medicare & Medicaid Services; 54% of hospitals were fined in 2015, she said.

“Readmission is difficult to predict at the time of discharge despite exhaustive statistical modeling with very granular clinical patient-level detail. Preoperative patient factors and postdischarge complications contribute the most to predictive models. Efforts to decrease readmissions should focus on modifiable patient-level factors, transitions of care, and minimizing postoperative complications,” she concluded.

Dr. Morris reported having no disclosures.

The complete manuscript of this presentation is anticipated to be published in Annals of Surgery pending editorial review.

[email protected]

CHICAGO – Preadmission and postdischarge factors were important predictors of postoperative readmission in a large cohort of surgical patients, but the hospital course had little incremental impact on either readmissions or postdischarge complications in the cohort, according to a retrospective study of Veterans Affairs data.

The findings suggest that efforts to reduce postoperative readmissions should focus on enhanced postdischarge surveillance and early intervention, Dr. Melanie S. Morris of the University of Alabama at Birmingham reported at the annual meeting of the American Surgical Association.

Dr. Morris

To assess the relative contributions of patient factors, operative characteristics, and postoperative hospital course on readmissions, she and her colleagues evaluated 243,956 general, vascular, and orthopedic surgery patients in 121 VA hospitals. The overall readmission rate among the cohort was 11.1%, and for general, vascular, and orthopedic surgeries, the rates were 12.9%, 15.4%, and 7.6%, respectively; the average postoperative length of stay was 6.9 days, and 6.1% of patients experienced a predischarge complication.

Almost all readmissions occurred within 2 weeks of discharge, and for general surgery patients, most occurred within 1 week. The readmission rate for vascular surgery patients remained high beyond the 2-week mark.

An examination of the reasons for readmission showed that wound complications were the most common reason for readmission, and this was particularly true for vascular surgery patients, in whom 44% of readmissions were for wound complications, Dr. Morris said.

Gastrointestinal complications including ileus and obstruction were also common, accounting for nearly 28% of readmissions among general surgery patients, she said.

Importantly, when including preoperative data (such as demographics, comorbidities, social and behavioral factors, labs and vital signs, and planned procedure type), the variability in readmissions could only be explained 8.6% of the time, she said.

“Adding in operative data, such as procedure complexity and intraoperative blood transfusions, as well as postoperative course, added very little to our predictive ability. Including both of those groups, we could only explain 10% of the variation in readmission,” she said.

Including postdischarge data such as complications and emergency department utilization in the model increased predictive ability to 18%.

R² and C-statistics comparing the sequentially built model showed that demographics and comorbidities contributed the most to predicting readmission risk, Dr. Morris said.

Modeling based on readmission reason and specialty improved predictive ability. For example, almost 12% of readmissions for wound complications among vascular surgery patients were predictable.

“Our best predictive ability was for orthopedic patients who were readmitted with pneumonia. We were able to predict that 14% of the time,” she said.

The findings were derived by merging VA Surgical Quality Improvement Program data from inpatient operations performed between 2007 and 2014 and involving at least a 2-day postoperative hospital stay, with clinical data including laboratory findings, vitals, prior health care utilization, and postoperative complications.

“We then grouped our variables of interest into the following categories: preoperative, operative, postoperative but predischarge, and postdischarge,” she explained, noting that logistic models predicting 30-day readmission were constructed by sequentially adding groups into the model. Models were compared by way of adjusted R² and C-statistics.

Assuming postoperative readmissions are preventable suggests that they are linked to the quality of care during the index hospitalization. The current findings demonstrate the challenges in predicting readmissions, and are important given that hospitals with higher-than-expected readmission rates for certain diagnoses and procedures are fined by the Centers for Medicare & Medicaid Services; 54% of hospitals were fined in 2015, she said.

“Readmission is difficult to predict at the time of discharge despite exhaustive statistical modeling with very granular clinical patient-level detail. Preoperative patient factors and postdischarge complications contribute the most to predictive models. Efforts to decrease readmissions should focus on modifiable patient-level factors, transitions of care, and minimizing postoperative complications,” she concluded.

Dr. Morris reported having no disclosures.

The complete manuscript of this presentation is anticipated to be published in Annals of Surgery pending editorial review.

[email protected]

CHICAGO – Preadmission and postdischarge factors were important predictors of postoperative readmission in a large cohort of surgical patients, but the hospital course had little incremental impact on either readmissions or postdischarge complications in the cohort, according to a retrospective study of Veterans Affairs data.

The findings suggest that efforts to reduce postoperative readmissions should focus on enhanced postdischarge surveillance and early intervention, Dr. Melanie S. Morris of the University of Alabama at Birmingham reported at the annual meeting of the American Surgical Association.

Dr. Morris

To assess the relative contributions of patient factors, operative characteristics, and postoperative hospital course on readmissions, she and her colleagues evaluated 243,956 general, vascular, and orthopedic surgery patients in 121 VA hospitals. The overall readmission rate among the cohort was 11.1%, and for general, vascular, and orthopedic surgeries, the rates were 12.9%, 15.4%, and 7.6%, respectively; the average postoperative length of stay was 6.9 days, and 6.1% of patients experienced a predischarge complication.

Almost all readmissions occurred within 2 weeks of discharge, and for general surgery patients, most occurred within 1 week. The readmission rate for vascular surgery patients remained high beyond the 2-week mark.

An examination of the reasons for readmission showed that wound complications were the most common reason for readmission, and this was particularly true for vascular surgery patients, in whom 44% of readmissions were for wound complications, Dr. Morris said.

Gastrointestinal complications including ileus and obstruction were also common, accounting for nearly 28% of readmissions among general surgery patients, she said.

Importantly, when including preoperative data (such as demographics, comorbidities, social and behavioral factors, labs and vital signs, and planned procedure type), the variability in readmissions could only be explained 8.6% of the time, she said.

“Adding in operative data, such as procedure complexity and intraoperative blood transfusions, as well as postoperative course, added very little to our predictive ability. Including both of those groups, we could only explain 10% of the variation in readmission,” she said.

Including postdischarge data such as complications and emergency department utilization in the model increased predictive ability to 18%.

R² and C-statistics comparing the sequentially built model showed that demographics and comorbidities contributed the most to predicting readmission risk, Dr. Morris said.

Modeling based on readmission reason and specialty improved predictive ability. For example, almost 12% of readmissions for wound complications among vascular surgery patients were predictable.

“Our best predictive ability was for orthopedic patients who were readmitted with pneumonia. We were able to predict that 14% of the time,” she said.

The findings were derived by merging VA Surgical Quality Improvement Program data from inpatient operations performed between 2007 and 2014 and involving at least a 2-day postoperative hospital stay, with clinical data including laboratory findings, vitals, prior health care utilization, and postoperative complications.

“We then grouped our variables of interest into the following categories: preoperative, operative, postoperative but predischarge, and postdischarge,” she explained, noting that logistic models predicting 30-day readmission were constructed by sequentially adding groups into the model. Models were compared by way of adjusted R² and C-statistics.

Assuming postoperative readmissions are preventable suggests that they are linked to the quality of care during the index hospitalization. The current findings demonstrate the challenges in predicting readmissions, and are important given that hospitals with higher-than-expected readmission rates for certain diagnoses and procedures are fined by the Centers for Medicare & Medicaid Services; 54% of hospitals were fined in 2015, she said.

“Readmission is difficult to predict at the time of discharge despite exhaustive statistical modeling with very granular clinical patient-level detail. Preoperative patient factors and postdischarge complications contribute the most to predictive models. Efforts to decrease readmissions should focus on modifiable patient-level factors, transitions of care, and minimizing postoperative complications,” she concluded.

Dr. Morris reported having no disclosures.

The complete manuscript of this presentation is anticipated to be published in Annals of Surgery pending editorial review.

[email protected]

LOS ANGELES – Overall 5-year survival rates for anal cancer in the United States have steadily improved since the 1970s, but the incidence of disease continues to rise. In addition, African Americans with anal cancer have significantly and disproportionally lower 5-year survival rates, compared with whites.

Those are key findings from an analysis of Surveillance, Epidemiology and End Results (SEER) data that primary study author Dr. Marco Ferrara presented at the annual meeting of the American Society of Colon and Rectal Surgeons.

“Disparities in health-related outcomes for diseases such as cancer are unfortunately commonly observed,” Dr. Ferrara’s mentor and the senior study author Dr. Daniel I. Chu said in an interview in advance of the meeting. “African Americans in particular have higher cancer-specific death rates, higher rates of advanced cancer on initial diagnosis, and less frequent use of cancer screening tests. While our understanding of disparities continues to progress for the more common cancers (lung, breast, prostate, colorectal), comparatively fewer data are available for anal cancer. This gap in knowledge is important because anal cancer incidence has actually been increasing in the U.S. population over the past decades. While effective treatment is available, we asked if disparities exist in anal cancer.”

To find out, the researchers used the national SEER database to identify all patients with cancer of the anus, anal canal, and anorectum from 1973 to 1999 (Period 1; a total of 6,755 cases) and 2000 to 2012 (Period 2; a total of 18,027 cases) and stratified them by race. They determined the incidence, staging, and treatment provided for each group and used 2000 Census data to calculate the age-adjusted annual incidence of anal cancer. The primary outcome was 5-year survival.

More than half of patients (61%) were female, 86% were white, 10% were African American, and the remaining 4% were from other ethnic groups. Dr. Ferrara, who is a fourth-year surgery resident at Baptist Health System in Birmingham, Ala., reported that between Periods 1 and 2, the overall incidence of anal cancer increased from 1.1 to 1.8 cases per 100,000 individuals. The overall incidence was higher among African Americans, compared with whites (1.6 vs. 1.3 cases per 100,000 individuals, respectively). The incidence among African-American males was slightly higher, at 1.9 cases per 100,000 individuals.

The researchers found that nearly half of patients (48%) presented with localized disease, while 31% had regional disease. Between Periods 1 and 2 the proportion of patients who received any treatment for anal cancer increased from 63% to 74%. The use of radiation therapy increased from 61% to 72%, while the use of local excisions and abdominoperineal resections decreased from 60% to 45%. Overall, African Americans were more likely than whites to not undergo recommended surgery (9.8% vs. 8.7%, respectively) or to refuse recommended surgery (1.8% vs. 1.1%; P less than .05 for both associations).

Overall 5-year survival for anal cancer improved from 63% in Period 1 to 70% in Period 2 (P less than .05). However, African Americans had significantly lower 5-year survival rates, compared with whites in both time periods (53% vs. 64% in Period 1, and 62% vs. 71% in Period 2; P less than .05 for both associations).

“Health disparities exist in anal cancer with African Americans faring worse than Caucasian patients,” said Dr. Chu, who is a gastrointestinal surgeon at the University of Alabama at Birmingham. “While the etiologies for these disparities are unclear, anal cancer is a very treatable disease when caught early, regardless of race. Screening should be done for those at higher risk, such as patients with a family history of anal cancer, HIV, or HPV [human papillomavirus]. Ultimately, more research is needed to understand the factors driving these disparities at the patient, provider, and health care system level.”

He acknowledged certain limitations of the study, including its retrospective nature, the inability to assess the potential impact of education status and other social factors, and the generalizability of its findings, since SEER is limited to major cancer hospitals.

The researchers reported having no financial disclosures.

[email protected]

LOS ANGELES – Overall 5-year survival rates for anal cancer in the United States have steadily improved since the 1970s, but the incidence of disease continues to rise. In addition, African Americans with anal cancer have significantly and disproportionally lower 5-year survival rates, compared with whites.

Those are key findings from an analysis of Surveillance, Epidemiology and End Results (SEER) data that primary study author Dr. Marco Ferrara presented at the annual meeting of the American Society of Colon and Rectal Surgeons.

“Disparities in health-related outcomes for diseases such as cancer are unfortunately commonly observed,” Dr. Ferrara’s mentor and the senior study author Dr. Daniel I. Chu said in an interview in advance of the meeting. “African Americans in particular have higher cancer-specific death rates, higher rates of advanced cancer on initial diagnosis, and less frequent use of cancer screening tests. While our understanding of disparities continues to progress for the more common cancers (lung, breast, prostate, colorectal), comparatively fewer data are available for anal cancer. This gap in knowledge is important because anal cancer incidence has actually been increasing in the U.S. population over the past decades. While effective treatment is available, we asked if disparities exist in anal cancer.”

To find out, the researchers used the national SEER database to identify all patients with cancer of the anus, anal canal, and anorectum from 1973 to 1999 (Period 1; a total of 6,755 cases) and 2000 to 2012 (Period 2; a total of 18,027 cases) and stratified them by race. They determined the incidence, staging, and treatment provided for each group and used 2000 Census data to calculate the age-adjusted annual incidence of anal cancer. The primary outcome was 5-year survival.

More than half of patients (61%) were female, 86% were white, 10% were African American, and the remaining 4% were from other ethnic groups. Dr. Ferrara, who is a fourth-year surgery resident at Baptist Health System in Birmingham, Ala., reported that between Periods 1 and 2, the overall incidence of anal cancer increased from 1.1 to 1.8 cases per 100,000 individuals. The overall incidence was higher among African Americans, compared with whites (1.6 vs. 1.3 cases per 100,000 individuals, respectively). The incidence among African-American males was slightly higher, at 1.9 cases per 100,000 individuals.

The researchers found that nearly half of patients (48%) presented with localized disease, while 31% had regional disease. Between Periods 1 and 2 the proportion of patients who received any treatment for anal cancer increased from 63% to 74%. The use of radiation therapy increased from 61% to 72%, while the use of local excisions and abdominoperineal resections decreased from 60% to 45%. Overall, African Americans were more likely than whites to not undergo recommended surgery (9.8% vs. 8.7%, respectively) or to refuse recommended surgery (1.8% vs. 1.1%; P less than .05 for both associations).

Overall 5-year survival for anal cancer improved from 63% in Period 1 to 70% in Period 2 (P less than .05). However, African Americans had significantly lower 5-year survival rates, compared with whites in both time periods (53% vs. 64% in Period 1, and 62% vs. 71% in Period 2; P less than .05 for both associations).

“Health disparities exist in anal cancer with African Americans faring worse than Caucasian patients,” said Dr. Chu, who is a gastrointestinal surgeon at the University of Alabama at Birmingham. “While the etiologies for these disparities are unclear, anal cancer is a very treatable disease when caught early, regardless of race. Screening should be done for those at higher risk, such as patients with a family history of anal cancer, HIV, or HPV [human papillomavirus]. Ultimately, more research is needed to understand the factors driving these disparities at the patient, provider, and health care system level.”

He acknowledged certain limitations of the study, including its retrospective nature, the inability to assess the potential impact of education status and other social factors, and the generalizability of its findings, since SEER is limited to major cancer hospitals.

The researchers reported having no financial disclosures.

[email protected]

LOS ANGELES – Overall 5-year survival rates for anal cancer in the United States have steadily improved since the 1970s, but the incidence of disease continues to rise. In addition, African Americans with anal cancer have significantly and disproportionally lower 5-year survival rates, compared with whites.

Those are key findings from an analysis of Surveillance, Epidemiology and End Results (SEER) data that primary study author Dr. Marco Ferrara presented at the annual meeting of the American Society of Colon and Rectal Surgeons.

“Disparities in health-related outcomes for diseases such as cancer are unfortunately commonly observed,” Dr. Ferrara’s mentor and the senior study author Dr. Daniel I. Chu said in an interview in advance of the meeting. “African Americans in particular have higher cancer-specific death rates, higher rates of advanced cancer on initial diagnosis, and less frequent use of cancer screening tests. While our understanding of disparities continues to progress for the more common cancers (lung, breast, prostate, colorectal), comparatively fewer data are available for anal cancer. This gap in knowledge is important because anal cancer incidence has actually been increasing in the U.S. population over the past decades. While effective treatment is available, we asked if disparities exist in anal cancer.”

To find out, the researchers used the national SEER database to identify all patients with cancer of the anus, anal canal, and anorectum from 1973 to 1999 (Period 1; a total of 6,755 cases) and 2000 to 2012 (Period 2; a total of 18,027 cases) and stratified them by race. They determined the incidence, staging, and treatment provided for each group and used 2000 Census data to calculate the age-adjusted annual incidence of anal cancer. The primary outcome was 5-year survival.

More than half of patients (61%) were female, 86% were white, 10% were African American, and the remaining 4% were from other ethnic groups. Dr. Ferrara, who is a fourth-year surgery resident at Baptist Health System in Birmingham, Ala., reported that between Periods 1 and 2, the overall incidence of anal cancer increased from 1.1 to 1.8 cases per 100,000 individuals. The overall incidence was higher among African Americans, compared with whites (1.6 vs. 1.3 cases per 100,000 individuals, respectively). The incidence among African-American males was slightly higher, at 1.9 cases per 100,000 individuals.

The researchers found that nearly half of patients (48%) presented with localized disease, while 31% had regional disease. Between Periods 1 and 2 the proportion of patients who received any treatment for anal cancer increased from 63% to 74%. The use of radiation therapy increased from 61% to 72%, while the use of local excisions and abdominoperineal resections decreased from 60% to 45%. Overall, African Americans were more likely than whites to not undergo recommended surgery (9.8% vs. 8.7%, respectively) or to refuse recommended surgery (1.8% vs. 1.1%; P less than .05 for both associations).

Overall 5-year survival for anal cancer improved from 63% in Period 1 to 70% in Period 2 (P less than .05). However, African Americans had significantly lower 5-year survival rates, compared with whites in both time periods (53% vs. 64% in Period 1, and 62% vs. 71% in Period 2; P less than .05 for both associations).

“Health disparities exist in anal cancer with African Americans faring worse than Caucasian patients,” said Dr. Chu, who is a gastrointestinal surgeon at the University of Alabama at Birmingham. “While the etiologies for these disparities are unclear, anal cancer is a very treatable disease when caught early, regardless of race. Screening should be done for those at higher risk, such as patients with a family history of anal cancer, HIV, or HPV [human papillomavirus]. Ultimately, more research is needed to understand the factors driving these disparities at the patient, provider, and health care system level.”

He acknowledged certain limitations of the study, including its retrospective nature, the inability to assess the potential impact of education status and other social factors, and the generalizability of its findings, since SEER is limited to major cancer hospitals.

The researchers reported having no financial disclosures.

[email protected]

CHICAGO – A novel plasma microRNA assay and prediction model appears to successfully differentiate colorectal neoplasia from other neoplasms and from controls.

The assay includes seven microRNAs that were selected, based on P value, area under the curve (AUC), fold change, and biological plausibility, from among 380 microRNAs screened using microfluidic array technology from a “training” cohort of 60 patients. The training cohort included groups of patients, 10 each, with colorectal cancer, advanced adenoma, breast cancer, pancreatic cancer, and lung cancer – cancers chosen because they frequently develop at similar ages as colon cancer – and 10 controls.

Dr. Carter

A panel of seven “uniquely dysregulated” microRNAs specific for colorectal neoplasia was evaluated using single assays in a “test” cohort of 120 patients. A mathematical model was developed to predict sample identity in a 150-patient blinded “validation” cohort using repeat-subsampling validation of the testing dataset with 1,000 iterations each to assess model detection accuracy, Dr. Jane V. Carter of the University of Louisville (Ky.) explained at the annual meeting of the American Surgical Association.

The area under the curve for test cohort comparisons with the assay was 0.91, 0.79, and 0.98 for comparison No. 1 (comparing any neoplasia vs. controls), comparison No. 2 (comparing colorectal neoplasia with other cancers) and comparison No. 3 (comparing colorectal cancer with colorectal adenomas) respectively, Dr. Carter reported.

“Our prediction model identified blinded sample identity with 69%-77% accuracy in comparison No. 1, 66%-76% accuracy in comparison No. 2, and 86%-90% accuracy in comparison No. 3,” she said, noting that the sensitivity and specificity of the assay compare very well with current clinical standards.

©Gio_tto/Thinkstock.com

Colorectal neoplasms frequently develop in individuals at ages when other common cancers also occur. Current screening methods, including endoscopic and imaging studies and fecal testing have poor patient compliance. Fecal and blood tests lack sensitivity and specificity for the detection of adenomas, limiting their use as screening methods, she said.

But this novel assay, which builds on the earlier work identifying miR-21 as a potential marker for colorectal cancer, provides a useful tool for identifying colorectal neoplasms, she said.

Efforts are underway to confirm the findings in a larger study population. If the findings are confirmed, the assay may have other potential uses such as monitoring therapy by comparing microRNA expression before and after treatment, and also for predicting response to treatment such as following preoperative neoadjuvant chemoradiation, Dr. Carter suggested.

The current findings have significant implications for the development of a noninvasive, reliable, and reproducible screening test for detection of colorectal neoplasia.

“If we can improve early-stage detection, we can improve survival,” she said.

Dr. Carter reported having no relevant disclosures.

The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.

[email protected]

CHICAGO – A novel plasma microRNA assay and prediction model appears to successfully differentiate colorectal neoplasia from other neoplasms and from controls.

The assay includes seven microRNAs that were selected, based on P value, area under the curve (AUC), fold change, and biological plausibility, from among 380 microRNAs screened using microfluidic array technology from a “training” cohort of 60 patients. The training cohort included groups of patients, 10 each, with colorectal cancer, advanced adenoma, breast cancer, pancreatic cancer, and lung cancer – cancers chosen because they frequently develop at similar ages as colon cancer – and 10 controls.

Dr. Carter

A panel of seven “uniquely dysregulated” microRNAs specific for colorectal neoplasia was evaluated using single assays in a “test” cohort of 120 patients. A mathematical model was developed to predict sample identity in a 150-patient blinded “validation” cohort using repeat-subsampling validation of the testing dataset with 1,000 iterations each to assess model detection accuracy, Dr. Jane V. Carter of the University of Louisville (Ky.) explained at the annual meeting of the American Surgical Association.

The area under the curve for test cohort comparisons with the assay was 0.91, 0.79, and 0.98 for comparison No. 1 (comparing any neoplasia vs. controls), comparison No. 2 (comparing colorectal neoplasia with other cancers) and comparison No. 3 (comparing colorectal cancer with colorectal adenomas) respectively, Dr. Carter reported.

“Our prediction model identified blinded sample identity with 69%-77% accuracy in comparison No. 1, 66%-76% accuracy in comparison No. 2, and 86%-90% accuracy in comparison No. 3,” she said, noting that the sensitivity and specificity of the assay compare very well with current clinical standards.

©Gio_tto/Thinkstock.com

Colorectal neoplasms frequently develop in individuals at ages when other common cancers also occur. Current screening methods, including endoscopic and imaging studies and fecal testing have poor patient compliance. Fecal and blood tests lack sensitivity and specificity for the detection of adenomas, limiting their use as screening methods, she said.

But this novel assay, which builds on the earlier work identifying miR-21 as a potential marker for colorectal cancer, provides a useful tool for identifying colorectal neoplasms, she said.

Efforts are underway to confirm the findings in a larger study population. If the findings are confirmed, the assay may have other potential uses such as monitoring therapy by comparing microRNA expression before and after treatment, and also for predicting response to treatment such as following preoperative neoadjuvant chemoradiation, Dr. Carter suggested.

The current findings have significant implications for the development of a noninvasive, reliable, and reproducible screening test for detection of colorectal neoplasia.

“If we can improve early-stage detection, we can improve survival,” she said.

Dr. Carter reported having no relevant disclosures.

The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.

[email protected]

CHICAGO – A novel plasma microRNA assay and prediction model appears to successfully differentiate colorectal neoplasia from other neoplasms and from controls.

The assay includes seven microRNAs that were selected, based on P value, area under the curve (AUC), fold change, and biological plausibility, from among 380 microRNAs screened using microfluidic array technology from a “training” cohort of 60 patients. The training cohort included groups of patients, 10 each, with colorectal cancer, advanced adenoma, breast cancer, pancreatic cancer, and lung cancer – cancers chosen because they frequently develop at similar ages as colon cancer – and 10 controls.

Dr. Carter

A panel of seven “uniquely dysregulated” microRNAs specific for colorectal neoplasia was evaluated using single assays in a “test” cohort of 120 patients. A mathematical model was developed to predict sample identity in a 150-patient blinded “validation” cohort using repeat-subsampling validation of the testing dataset with 1,000 iterations each to assess model detection accuracy, Dr. Jane V. Carter of the University of Louisville (Ky.) explained at the annual meeting of the American Surgical Association.

The area under the curve for test cohort comparisons with the assay was 0.91, 0.79, and 0.98 for comparison No. 1 (comparing any neoplasia vs. controls), comparison No. 2 (comparing colorectal neoplasia with other cancers) and comparison No. 3 (comparing colorectal cancer with colorectal adenomas) respectively, Dr. Carter reported.

“Our prediction model identified blinded sample identity with 69%-77% accuracy in comparison No. 1, 66%-76% accuracy in comparison No. 2, and 86%-90% accuracy in comparison No. 3,” she said, noting that the sensitivity and specificity of the assay compare very well with current clinical standards.

©Gio_tto/Thinkstock.com

Colorectal neoplasms frequently develop in individuals at ages when other common cancers also occur. Current screening methods, including endoscopic and imaging studies and fecal testing have poor patient compliance. Fecal and blood tests lack sensitivity and specificity for the detection of adenomas, limiting their use as screening methods, she said.

But this novel assay, which builds on the earlier work identifying miR-21 as a potential marker for colorectal cancer, provides a useful tool for identifying colorectal neoplasms, she said.

Efforts are underway to confirm the findings in a larger study population. If the findings are confirmed, the assay may have other potential uses such as monitoring therapy by comparing microRNA expression before and after treatment, and also for predicting response to treatment such as following preoperative neoadjuvant chemoradiation, Dr. Carter suggested.

The current findings have significant implications for the development of a noninvasive, reliable, and reproducible screening test for detection of colorectal neoplasia.

“If we can improve early-stage detection, we can improve survival,” she said.

Dr. Carter reported having no relevant disclosures.

The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.

[email protected]

One of the great honors of my professional career was being nominated to the presidency of the Society of Gynecologic Surgeons and being given the opportunity to deliver the presidential address at the Society’s 42nd annual scientific meeting in Palm Springs, Calif.

One of the core principles of the SGS mission statement is supporting excellence in gynecologic surgery and, to that end, the main focus of my term was to address the decline in vaginal hysterectomy rates. What follows is an excerpt from my speech explaining the rationale for vaginal hysterectomy (VH) and steps the SGS is taking to reverse the decline.

Unfortunately, what is happening in today’s practice environment is declining use of vaginal hysterectomy, with concomitant increases in endoscopic hysterectomy, mostly with the use of robotic assistance. Being the president of a society previously known as the Vaginal Surgeons Society, it would not be surprising to hear that I have been accused of being “anti-robot.”

Nothing could be further from the truth.

When we talk about the surgical treatment of patients with endometrial and cervical cancer, I do not need a randomized clinical trial to know that not making a laparotomy incision is probably a good thing when you’re treating these patients. There are benefits to using robotic techniques in this subpopulation; it is cost effective due to the reduced morbidity and straight stick laparoscopy for these patients is difficult to perform; therefore it’s not been as widely published or performed. I believe that robotic hysterectomy for these disorders should be the standard of care. In this regard, I am pro robot (Gynecologic Oncol. 2015;138[2]:457-71).

On the other hand, I also don’t need a randomized trial (even though randomized trials exist) to know that if you have a choice to make, or not make, extra incisions during surgery, it’s better to not make the extra incisions.

It’s certainly not rocket science to know that a Zeppelin or Heaney clamp is orders of magnitude cheaper than equipment required to perform an endoscopic hysterectomy – $22.25 USD for instrument and $3.19 USD to process per case (Am J Obstet Gynecol. 2016;214[4]:S461-2]).

Level I evidence demonstrates that when compared to other minimally invasive hysterectomy techniques, vaginal hysterectomy is cheaper, the convalescence is stable or reduced, and the complication rates are lower (Cochrane Database Syst Rev. 2015 Aug. 12;8:CD003677).

Moreover, if you don’t place a port, you can’t get a port site complication (these complications are rare, but potentially serious when they occur). You can’t perforate the common iliac vein. You can’t put a Veress needle through the small bowel. You can’t get a Richter’s hernia. And finally, while you can get cuff dehiscence with vaginal hysterectomy, I’ve never seen it, and this is a real issue with the endoscopic approaches (Cochrane Database Syst Rev. 2012 Feb. 15;2:CD006583 ).

This isn’t just my opinion. Every major surgical society has recommended vaginal hysterectomy when technically feasible.

Of course, “technical feasibility” is the kicker and it’s important to ask what this means.

First, we have to look at what I call the hysterectomy continuum. There are the young, sexually-active women with uterovaginal procidentia where an endoscopic approach for sacral colpopexy might be considered. Then you have patients who are vaginally parous, have a mobile uterus less than 12 weeks in size, and have a basic gynecologic condition such as dysfunctional uterine bleeding, cervical intraepithelial neoplasia, or painful menses (this is about 40%-50% of patients when I reviewed internal North Valley Permanente Group data in 2012); these patients are certainly excellent candidates for vaginal hysterectomy. Then there are patients with 30-week-size fibroid uterus, three prior C-sections, and known stage 4 endometriosis (where an open or robotic approach would be justified).

Second, we have to address the contradictory data presented in the literature regarding vaginal hysterectomy rates. On one hand, we have data from large case series and randomized, controlled trials which demonstrate that it’s feasible to perform a high percentage of vaginal hysterectomies (Obstet Gynecol. 2004;103[6]:1321-5and Arch Gynecol Obstet. 2014;290[3]:485-91). On the other hand, 40 years of population data show the opposite (Obstet Gynecol. 2009;114[5]:1041-8).

In the pre-endoscopic era, 80% and 20% of hysterectomies were performed via the abdominal and vaginal routes, respectively. During the laparoscopic era, 64%, 22%, and 14% of hysterectomies were performed via the abdominal, vaginal, and laparoscopic routes, respectively. And during the current robotic era, it is now 32%, 16%, 28%, and 25% performed via the abdominal, vaginal, laparoscopic, and robotic routes, respectively.

During this 40-year time frame, despite data and recommendations that support vaginal hysterectomy, there has never been an obvious incentive to perform this procedure (e.g. to my knowledge, no one has ever been paid more to do a vaginal hysterectomy, or been prominently featured on a hospital’s website regarding his or her ability to perform an “incision-less” hysterectomy (Am J Obstet Gynecol. 2012;207[3]:174.e1-174.e7). Why weren’t and why aren’t we outraged about this? I have always been under the impression that cheaper and safer is better!

The first thing I hear to explain this – mostly from robotic surgeons and from the robotic surgery device sales representatives – is that the decline in the proportion of vaginal hysterectomies is irrelevant in that it has taken the robot to meaningfully reduce open hysterectomy rates. The other argument I hear – mostly from the laparoscopic surgeons – is that vaginal hysterectomy rates have not changed because most gynecologists cannot and will never be able to perform the procedure. So, what is the point of even discussing solutions?

I disagree with the laparoscopic and robotic surgeons. We should be outraged and do something to effect change. Vaginal hysterectomy offers better value (for surgeons who aren’t thinking about value right now, I suggest that you start. Value-based reimbursement is coming soon) and we know that a high percentage of vaginal hysterectomies are feasible in general gynecologic populations. Surgeons who perform vaginal hysterectomy are not magicians or better surgeons, just differently trained. We have to recognize that many, or even most, patients are candidates for vaginal hysterectomy.

Finally, when we look at robotics for benign disease, we spend more money than on other minimally invasive hysterectomy techniques but we don’t get better outcomes (J Minim Invasive Gynecol. 2010;17[6]:730-8and Eur J Obstet Gynecol Reprod Biol. 150[1]:92-6). Yet surgeons currently use robotics for 25% or more of benign hysterectomies.

What are we thinking and how can we afford to continue this?

We need to counsel our patients (and ourselves) that a total hysterectomy requires an incision in the vagina, and there can be a need for additional abdominal incisions of varying size and number. Fully informed consent must include a discussion of all types of hysterectomy including both patient and surgeon factors associated with the recommended route. Ultimately, the route of hysterectomy should be based on the patient and not the surgeon (Obstet Gynecol. 2014;124[3]:585-8).

It is easy to say, and supported by the evidence, that we should do more vaginal hysterectomies. It is also easy to note that the rate of vaginal hysterectomy has been stable to declining over the last 4 decades and that there are significant issues with residency training in gynecologic surgery (serious issues, but beyond the scope of this editorial).

So, what are we at SGS doing to support increased rates of vaginal hysterectomy? Every December we sponsor a postgraduate course on vaginal hysterectomy techniques. This is an excellent learning opportunity. (Visit www.sgsonline.org for more information regarding dates and costs). We’re starting partnerships with the American College of Obstetricians and Gynecologists (ACOG), the Foundation for Exxcellence in Women’s Health and others, to begin a “train the trainer” program to teach junior faculty how to do and teach vaginal hysterectomy. We’ve developed CREOG (Council on Resident Education in Obstetrics and Gynecology) modules to educate residents about the procedure, and we are in the process of communicating with residency and fellowship program directors about what else we can do to assist them with vaginal hysterectomy teaching. Other goals are to work with ACOG to develop quality metrics for hysterectomy and to develop physician-focused alternative payment models that recognize the value of vaginal hysterectomy.

I believe that in this country we should train for, incentivize, and insist upon a vaginal hysterectomy rate of at least 40% (this albeit arbitrary percentage is based upon the majority of vaginally parous women with uteri less than 12 weeks in size and a minority of the more difficult patients getting a vaginal hysterectomy). And before you say “it’s never been 40%,” please consider the famous quotation by Dr. William Mayo: “The best interest of the patient is the only interest to be considered.” Clearly, the best interest of the patient, if she is a candidate, is to have a vaginal hysterectomy. Our mission at SGS is to facilitate surgical education to make more patients candidates for vaginal hysterectomy so that we can achieve the 40% goal.

Dr. Walter is director of urogynecology and pelvic pain at The Permanente Medical Group, Roseville, Calif. He is also the immediate past president of the Society of Gynecologic Surgeons. He reported having no financial disclosures.

One of the great honors of my professional career was being nominated to the presidency of the Society of Gynecologic Surgeons and being given the opportunity to deliver the presidential address at the Society’s 42nd annual scientific meeting in Palm Springs, Calif.

One of the core principles of the SGS mission statement is supporting excellence in gynecologic surgery and, to that end, the main focus of my term was to address the decline in vaginal hysterectomy rates. What follows is an excerpt from my speech explaining the rationale for vaginal hysterectomy (VH) and steps the SGS is taking to reverse the decline.

Unfortunately, what is happening in today’s practice environment is declining use of vaginal hysterectomy, with concomitant increases in endoscopic hysterectomy, mostly with the use of robotic assistance. Being the president of a society previously known as the Vaginal Surgeons Society, it would not be surprising to hear that I have been accused of being “anti-robot.”

Nothing could be further from the truth.

When we talk about the surgical treatment of patients with endometrial and cervical cancer, I do not need a randomized clinical trial to know that not making a laparotomy incision is probably a good thing when you’re treating these patients. There are benefits to using robotic techniques in this subpopulation; it is cost effective due to the reduced morbidity and straight stick laparoscopy for these patients is difficult to perform; therefore it’s not been as widely published or performed. I believe that robotic hysterectomy for these disorders should be the standard of care. In this regard, I am pro robot (Gynecologic Oncol. 2015;138[2]:457-71).

On the other hand, I also don’t need a randomized trial (even though randomized trials exist) to know that if you have a choice to make, or not make, extra incisions during surgery, it’s better to not make the extra incisions.

It’s certainly not rocket science to know that a Zeppelin or Heaney clamp is orders of magnitude cheaper than equipment required to perform an endoscopic hysterectomy – $22.25 USD for instrument and $3.19 USD to process per case (Am J Obstet Gynecol. 2016;214[4]:S461-2]).

Level I evidence demonstrates that when compared to other minimally invasive hysterectomy techniques, vaginal hysterectomy is cheaper, the convalescence is stable or reduced, and the complication rates are lower (Cochrane Database Syst Rev. 2015 Aug. 12;8:CD003677).

Moreover, if you don’t place a port, you can’t get a port site complication (these complications are rare, but potentially serious when they occur). You can’t perforate the common iliac vein. You can’t put a Veress needle through the small bowel. You can’t get a Richter’s hernia. And finally, while you can get cuff dehiscence with vaginal hysterectomy, I’ve never seen it, and this is a real issue with the endoscopic approaches (Cochrane Database Syst Rev. 2012 Feb. 15;2:CD006583 ).

This isn’t just my opinion. Every major surgical society has recommended vaginal hysterectomy when technically feasible.

Of course, “technical feasibility” is the kicker and it’s important to ask what this means.

First, we have to look at what I call the hysterectomy continuum. There are the young, sexually-active women with uterovaginal procidentia where an endoscopic approach for sacral colpopexy might be considered. Then you have patients who are vaginally parous, have a mobile uterus less than 12 weeks in size, and have a basic gynecologic condition such as dysfunctional uterine bleeding, cervical intraepithelial neoplasia, or painful menses (this is about 40%-50% of patients when I reviewed internal North Valley Permanente Group data in 2012); these patients are certainly excellent candidates for vaginal hysterectomy. Then there are patients with 30-week-size fibroid uterus, three prior C-sections, and known stage 4 endometriosis (where an open or robotic approach would be justified).

Second, we have to address the contradictory data presented in the literature regarding vaginal hysterectomy rates. On one hand, we have data from large case series and randomized, controlled trials which demonstrate that it’s feasible to perform a high percentage of vaginal hysterectomies (Obstet Gynecol. 2004;103[6]:1321-5and Arch Gynecol Obstet. 2014;290[3]:485-91). On the other hand, 40 years of population data show the opposite (Obstet Gynecol. 2009;114[5]:1041-8).

In the pre-endoscopic era, 80% and 20% of hysterectomies were performed via the abdominal and vaginal routes, respectively. During the laparoscopic era, 64%, 22%, and 14% of hysterectomies were performed via the abdominal, vaginal, and laparoscopic routes, respectively. And during the current robotic era, it is now 32%, 16%, 28%, and 25% performed via the abdominal, vaginal, laparoscopic, and robotic routes, respectively.

During this 40-year time frame, despite data and recommendations that support vaginal hysterectomy, there has never been an obvious incentive to perform this procedure (e.g. to my knowledge, no one has ever been paid more to do a vaginal hysterectomy, or been prominently featured on a hospital’s website regarding his or her ability to perform an “incision-less” hysterectomy (Am J Obstet Gynecol. 2012;207[3]:174.e1-174.e7). Why weren’t and why aren’t we outraged about this? I have always been under the impression that cheaper and safer is better!

The first thing I hear to explain this – mostly from robotic surgeons and from the robotic surgery device sales representatives – is that the decline in the proportion of vaginal hysterectomies is irrelevant in that it has taken the robot to meaningfully reduce open hysterectomy rates. The other argument I hear – mostly from the laparoscopic surgeons – is that vaginal hysterectomy rates have not changed because most gynecologists cannot and will never be able to perform the procedure. So, what is the point of even discussing solutions?

I disagree with the laparoscopic and robotic surgeons. We should be outraged and do something to effect change. Vaginal hysterectomy offers better value (for surgeons who aren’t thinking about value right now, I suggest that you start. Value-based reimbursement is coming soon) and we know that a high percentage of vaginal hysterectomies are feasible in general gynecologic populations. Surgeons who perform vaginal hysterectomy are not magicians or better surgeons, just differently trained. We have to recognize that many, or even most, patients are candidates for vaginal hysterectomy.

Finally, when we look at robotics for benign disease, we spend more money than on other minimally invasive hysterectomy techniques but we don’t get better outcomes (J Minim Invasive Gynecol. 2010;17[6]:730-8and Eur J Obstet Gynecol Reprod Biol. 150[1]:92-6). Yet surgeons currently use robotics for 25% or more of benign hysterectomies.

What are we thinking and how can we afford to continue this?

We need to counsel our patients (and ourselves) that a total hysterectomy requires an incision in the vagina, and there can be a need for additional abdominal incisions of varying size and number. Fully informed consent must include a discussion of all types of hysterectomy including both patient and surgeon factors associated with the recommended route. Ultimately, the route of hysterectomy should be based on the patient and not the surgeon (Obstet Gynecol. 2014;124[3]:585-8).

It is easy to say, and supported by the evidence, that we should do more vaginal hysterectomies. It is also easy to note that the rate of vaginal hysterectomy has been stable to declining over the last 4 decades and that there are significant issues with residency training in gynecologic surgery (serious issues, but beyond the scope of this editorial).

So, what are we at SGS doing to support increased rates of vaginal hysterectomy? Every December we sponsor a postgraduate course on vaginal hysterectomy techniques. This is an excellent learning opportunity. (Visit www.sgsonline.org for more information regarding dates and costs). We’re starting partnerships with the American College of Obstetricians and Gynecologists (ACOG), the Foundation for Exxcellence in Women’s Health and others, to begin a “train the trainer” program to teach junior faculty how to do and teach vaginal hysterectomy. We’ve developed CREOG (Council on Resident Education in Obstetrics and Gynecology) modules to educate residents about the procedure, and we are in the process of communicating with residency and fellowship program directors about what else we can do to assist them with vaginal hysterectomy teaching. Other goals are to work with ACOG to develop quality metrics for hysterectomy and to develop physician-focused alternative payment models that recognize the value of vaginal hysterectomy.

I believe that in this country we should train for, incentivize, and insist upon a vaginal hysterectomy rate of at least 40% (this albeit arbitrary percentage is based upon the majority of vaginally parous women with uteri less than 12 weeks in size and a minority of the more difficult patients getting a vaginal hysterectomy). And before you say “it’s never been 40%,” please consider the famous quotation by Dr. William Mayo: “The best interest of the patient is the only interest to be considered.” Clearly, the best interest of the patient, if she is a candidate, is to have a vaginal hysterectomy. Our mission at SGS is to facilitate surgical education to make more patients candidates for vaginal hysterectomy so that we can achieve the 40% goal.

Dr. Walter is director of urogynecology and pelvic pain at The Permanente Medical Group, Roseville, Calif. He is also the immediate past president of the Society of Gynecologic Surgeons. He reported having no financial disclosures.

One of the great honors of my professional career was being nominated to the presidency of the Society of Gynecologic Surgeons and being given the opportunity to deliver the presidential address at the Society’s 42nd annual scientific meeting in Palm Springs, Calif.

One of the core principles of the SGS mission statement is supporting excellence in gynecologic surgery and, to that end, the main focus of my term was to address the decline in vaginal hysterectomy rates. What follows is an excerpt from my speech explaining the rationale for vaginal hysterectomy (VH) and steps the SGS is taking to reverse the decline.

Unfortunately, what is happening in today’s practice environment is declining use of vaginal hysterectomy, with concomitant increases in endoscopic hysterectomy, mostly with the use of robotic assistance. Being the president of a society previously known as the Vaginal Surgeons Society, it would not be surprising to hear that I have been accused of being “anti-robot.”

Nothing could be further from the truth.

When we talk about the surgical treatment of patients with endometrial and cervical cancer, I do not need a randomized clinical trial to know that not making a laparotomy incision is probably a good thing when you’re treating these patients. There are benefits to using robotic techniques in this subpopulation; it is cost effective due to the reduced morbidity and straight stick laparoscopy for these patients is difficult to perform; therefore it’s not been as widely published or performed. I believe that robotic hysterectomy for these disorders should be the standard of care. In this regard, I am pro robot (Gynecologic Oncol. 2015;138[2]:457-71).

On the other hand, I also don’t need a randomized trial (even though randomized trials exist) to know that if you have a choice to make, or not make, extra incisions during surgery, it’s better to not make the extra incisions.

It’s certainly not rocket science to know that a Zeppelin or Heaney clamp is orders of magnitude cheaper than equipment required to perform an endoscopic hysterectomy – $22.25 USD for instrument and $3.19 USD to process per case (Am J Obstet Gynecol. 2016;214[4]:S461-2]).

Level I evidence demonstrates that when compared to other minimally invasive hysterectomy techniques, vaginal hysterectomy is cheaper, the convalescence is stable or reduced, and the complication rates are lower (Cochrane Database Syst Rev. 2015 Aug. 12;8:CD003677).

Moreover, if you don’t place a port, you can’t get a port site complication (these complications are rare, but potentially serious when they occur). You can’t perforate the common iliac vein. You can’t put a Veress needle through the small bowel. You can’t get a Richter’s hernia. And finally, while you can get cuff dehiscence with vaginal hysterectomy, I’ve never seen it, and this is a real issue with the endoscopic approaches (Cochrane Database Syst Rev. 2012 Feb. 15;2:CD006583 ).

This isn’t just my opinion. Every major surgical society has recommended vaginal hysterectomy when technically feasible.

Of course, “technical feasibility” is the kicker and it’s important to ask what this means.

First, we have to look at what I call the hysterectomy continuum. There are the young, sexually-active women with uterovaginal procidentia where an endoscopic approach for sacral colpopexy might be considered. Then you have patients who are vaginally parous, have a mobile uterus less than 12 weeks in size, and have a basic gynecologic condition such as dysfunctional uterine bleeding, cervical intraepithelial neoplasia, or painful menses (this is about 40%-50% of patients when I reviewed internal North Valley Permanente Group data in 2012); these patients are certainly excellent candidates for vaginal hysterectomy. Then there are patients with 30-week-size fibroid uterus, three prior C-sections, and known stage 4 endometriosis (where an open or robotic approach would be justified).

Second, we have to address the contradictory data presented in the literature regarding vaginal hysterectomy rates. On one hand, we have data from large case series and randomized, controlled trials which demonstrate that it’s feasible to perform a high percentage of vaginal hysterectomies (Obstet Gynecol. 2004;103[6]:1321-5and Arch Gynecol Obstet. 2014;290[3]:485-91). On the other hand, 40 years of population data show the opposite (Obstet Gynecol. 2009;114[5]:1041-8).

In the pre-endoscopic era, 80% and 20% of hysterectomies were performed via the abdominal and vaginal routes, respectively. During the laparoscopic era, 64%, 22%, and 14% of hysterectomies were performed via the abdominal, vaginal, and laparoscopic routes, respectively. And during the current robotic era, it is now 32%, 16%, 28%, and 25% performed via the abdominal, vaginal, laparoscopic, and robotic routes, respectively.

During this 40-year time frame, despite data and recommendations that support vaginal hysterectomy, there has never been an obvious incentive to perform this procedure (e.g. to my knowledge, no one has ever been paid more to do a vaginal hysterectomy, or been prominently featured on a hospital’s website regarding his or her ability to perform an “incision-less” hysterectomy (Am J Obstet Gynecol. 2012;207[3]:174.e1-174.e7). Why weren’t and why aren’t we outraged about this? I have always been under the impression that cheaper and safer is better!

The first thing I hear to explain this – mostly from robotic surgeons and from the robotic surgery device sales representatives – is that the decline in the proportion of vaginal hysterectomies is irrelevant in that it has taken the robot to meaningfully reduce open hysterectomy rates. The other argument I hear – mostly from the laparoscopic surgeons – is that vaginal hysterectomy rates have not changed because most gynecologists cannot and will never be able to perform the procedure. So, what is the point of even discussing solutions?

I disagree with the laparoscopic and robotic surgeons. We should be outraged and do something to effect change. Vaginal hysterectomy offers better value (for surgeons who aren’t thinking about value right now, I suggest that you start. Value-based reimbursement is coming soon) and we know that a high percentage of vaginal hysterectomies are feasible in general gynecologic populations. Surgeons who perform vaginal hysterectomy are not magicians or better surgeons, just differently trained. We have to recognize that many, or even most, patients are candidates for vaginal hysterectomy.

Finally, when we look at robotics for benign disease, we spend more money than on other minimally invasive hysterectomy techniques but we don’t get better outcomes (J Minim Invasive Gynecol. 2010;17[6]:730-8and Eur J Obstet Gynecol Reprod Biol. 150[1]:92-6). Yet surgeons currently use robotics for 25% or more of benign hysterectomies.

What are we thinking and how can we afford to continue this?

We need to counsel our patients (and ourselves) that a total hysterectomy requires an incision in the vagina, and there can be a need for additional abdominal incisions of varying size and number. Fully informed consent must include a discussion of all types of hysterectomy including both patient and surgeon factors associated with the recommended route. Ultimately, the route of hysterectomy should be based on the patient and not the surgeon (Obstet Gynecol. 2014;124[3]:585-8).

It is easy to say, and supported by the evidence, that we should do more vaginal hysterectomies. It is also easy to note that the rate of vaginal hysterectomy has been stable to declining over the last 4 decades and that there are significant issues with residency training in gynecologic surgery (serious issues, but beyond the scope of this editorial).

So, what are we at SGS doing to support increased rates of vaginal hysterectomy? Every December we sponsor a postgraduate course on vaginal hysterectomy techniques. This is an excellent learning opportunity. (Visit www.sgsonline.org for more information regarding dates and costs). We’re starting partnerships with the American College of Obstetricians and Gynecologists (ACOG), the Foundation for Exxcellence in Women’s Health and others, to begin a “train the trainer” program to teach junior faculty how to do and teach vaginal hysterectomy. We’ve developed CREOG (Council on Resident Education in Obstetrics and Gynecology) modules to educate residents about the procedure, and we are in the process of communicating with residency and fellowship program directors about what else we can do to assist them with vaginal hysterectomy teaching. Other goals are to work with ACOG to develop quality metrics for hysterectomy and to develop physician-focused alternative payment models that recognize the value of vaginal hysterectomy.

I believe that in this country we should train for, incentivize, and insist upon a vaginal hysterectomy rate of at least 40% (this albeit arbitrary percentage is based upon the majority of vaginally parous women with uteri less than 12 weeks in size and a minority of the more difficult patients getting a vaginal hysterectomy). And before you say “it’s never been 40%,” please consider the famous quotation by Dr. William Mayo: “The best interest of the patient is the only interest to be considered.” Clearly, the best interest of the patient, if she is a candidate, is to have a vaginal hysterectomy. Our mission at SGS is to facilitate surgical education to make more patients candidates for vaginal hysterectomy so that we can achieve the 40% goal.

Dr. Walter is director of urogynecology and pelvic pain at The Permanente Medical Group, Roseville, Calif. He is also the immediate past president of the Society of Gynecologic Surgeons. He reported having no financial disclosures.

WASHINGTON – Are you ready for the way you are paid for seeing patients to change, and not just change, but change dramatically?

The value-based care system of reimbursement for primary care physicians under the Medicare Access and CHIP Reauthorization Act (MACRA) is expected to take effect beginning in 2019, but how those payments will be made will be based on measurements of your overall performance in 2017. Will you be ready?

“Times are changing, and we need to change with them,” says Dr. Nitin Damle, the incoming president of the American College of Physicians, and an internist with South County Internal Medicine, Wakefield, R.I.

In this video, part of a series of roundtable discussions with leading health policy analysts and academic primary care physicians and mental health specialists, Dr. Damle and Dr. Lee Beers, the medical director for municipal and regional affairs at Children’s National Health System, Washington, discuss the essential steps physician practices must take in order to survive – and thrive – in a value-based care environment.

These steps include: team-based care, inclusion of mental health services, flexible IT electronic health record systems, quality measures tailored to your practice’s competencies and patient panel, and adequate funding.

Whether you’ve already begun the transition to a value-based system, or have yet to begin, this video will help focus your efforts and expectations of what’s to come.

“Don’t let perfect be the enemy of good. Start with incremental steps so you can get momentum going so that you end up where you want to be,” says Dr. Beers.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Are you ready for the way you are paid for seeing patients to change, and not just change, but change dramatically?

The value-based care system of reimbursement for primary care physicians under the Medicare Access and CHIP Reauthorization Act (MACRA) is expected to take effect beginning in 2019, but how those payments will be made will be based on measurements of your overall performance in 2017. Will you be ready?

“Times are changing, and we need to change with them,” says Dr. Nitin Damle, the incoming president of the American College of Physicians, and an internist with South County Internal Medicine, Wakefield, R.I.

In this video, part of a series of roundtable discussions with leading health policy analysts and academic primary care physicians and mental health specialists, Dr. Damle and Dr. Lee Beers, the medical director for municipal and regional affairs at Children’s National Health System, Washington, discuss the essential steps physician practices must take in order to survive – and thrive – in a value-based care environment.

These steps include: team-based care, inclusion of mental health services, flexible IT electronic health record systems, quality measures tailored to your practice’s competencies and patient panel, and adequate funding.

Whether you’ve already begun the transition to a value-based system, or have yet to begin, this video will help focus your efforts and expectations of what’s to come.

“Don’t let perfect be the enemy of good. Start with incremental steps so you can get momentum going so that you end up where you want to be,” says Dr. Beers.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Are you ready for the way you are paid for seeing patients to change, and not just change, but change dramatically?

The value-based care system of reimbursement for primary care physicians under the Medicare Access and CHIP Reauthorization Act (MACRA) is expected to take effect beginning in 2019, but how those payments will be made will be based on measurements of your overall performance in 2017. Will you be ready?

“Times are changing, and we need to change with them,” says Dr. Nitin Damle, the incoming president of the American College of Physicians, and an internist with South County Internal Medicine, Wakefield, R.I.

In this video, part of a series of roundtable discussions with leading health policy analysts and academic primary care physicians and mental health specialists, Dr. Damle and Dr. Lee Beers, the medical director for municipal and regional affairs at Children’s National Health System, Washington, discuss the essential steps physician practices must take in order to survive – and thrive – in a value-based care environment.

These steps include: team-based care, inclusion of mental health services, flexible IT electronic health record systems, quality measures tailored to your practice’s competencies and patient panel, and adequate funding.

Whether you’ve already begun the transition to a value-based system, or have yet to begin, this video will help focus your efforts and expectations of what’s to come.

“Don’t let perfect be the enemy of good. Start with incremental steps so you can get momentum going so that you end up where you want to be,” says Dr. Beers.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Feel free to continue operating under a fee-for-service system, but according to Neil Kirschner, Ph.D., the senior associate for regulatory and insurer affairs at the American College of Physicians, “It’ll slowly be bled. The updates will be less, and will be linked to quality and efficiency.”

But just what is “value-based care” and why is it now, literally, the law of the land?

In this video interview, Dr. Kirschner explains how and why practice is being transformed and what this means in practical terms, and he lists resources for what you can do to ensure your practice is not left behind.

“I think many doctors still are not seeing the change, or not seeing how quickly it’s coming,” says Dr. Kirschner. “Once it comes, it’s going to hit physicians in the face if they’re not prepared.”

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Feel free to continue operating under a fee-for-service system, but according to Neil Kirschner, Ph.D., the senior associate for regulatory and insurer affairs at the American College of Physicians, “It’ll slowly be bled. The updates will be less, and will be linked to quality and efficiency.”

But just what is “value-based care” and why is it now, literally, the law of the land?

In this video interview, Dr. Kirschner explains how and why practice is being transformed and what this means in practical terms, and he lists resources for what you can do to ensure your practice is not left behind.

“I think many doctors still are not seeing the change, or not seeing how quickly it’s coming,” says Dr. Kirschner. “Once it comes, it’s going to hit physicians in the face if they’re not prepared.”

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Feel free to continue operating under a fee-for-service system, but according to Neil Kirschner, Ph.D., the senior associate for regulatory and insurer affairs at the American College of Physicians, “It’ll slowly be bled. The updates will be less, and will be linked to quality and efficiency.”

But just what is “value-based care” and why is it now, literally, the law of the land?

In this video interview, Dr. Kirschner explains how and why practice is being transformed and what this means in practical terms, and he lists resources for what you can do to ensure your practice is not left behind.

“I think many doctors still are not seeing the change, or not seeing how quickly it’s coming,” says Dr. Kirschner. “Once it comes, it’s going to hit physicians in the face if they’re not prepared.”

[email protected]

On Twitter @whitneymcknight