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VIDEO: What was the most interesting thing you learned at the meeting?
SAN ANTONIO – Our reporter Michele Sullivan asked selected attendees at the San Antonio Breast Cancer Symposium to identify the most interesting or practice-changing study presented at the meeting. The answer was the same across the board - the Suppression of Ovarian Function Trial (SOFT), which showed that selective ovarian suppression reduces disease recurrence in women with early breast cancer.
In our video interview clinicians respond to the implications of the data in their practice.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN ANTONIO – Our reporter Michele Sullivan asked selected attendees at the San Antonio Breast Cancer Symposium to identify the most interesting or practice-changing study presented at the meeting. The answer was the same across the board - the Suppression of Ovarian Function Trial (SOFT), which showed that selective ovarian suppression reduces disease recurrence in women with early breast cancer.
In our video interview clinicians respond to the implications of the data in their practice.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN ANTONIO – Our reporter Michele Sullivan asked selected attendees at the San Antonio Breast Cancer Symposium to identify the most interesting or practice-changing study presented at the meeting. The answer was the same across the board - the Suppression of Ovarian Function Trial (SOFT), which showed that selective ovarian suppression reduces disease recurrence in women with early breast cancer.
In our video interview clinicians respond to the implications of the data in their practice.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT SABCS 2014
Congress leaves SGR, Medicaid parity, ICD-10 undone
The year is ending on a sour note for physicians, as Congress is recessing without addressing the Medicare Sustainable Growth Rate formula or acting on a number of other doctors’ priorities.
Congress did not extend a pay increase for primary care physicians who serve Medicaid recipients, nor did it delay the implementation of the ICD-10 code set nor enact any legislative solutions to help physicians better grapple with meaningful use of health information technology.
Physicians held out hope until the closing days of the 113th Congress, as legislators battled over what would be put into a massive spending bill that was needed to keep the government in operation beyond Dec. 11. That $1.1 trillion bill was approved by the House just before the government was to run out of money, and by the Senate two days later.
Physicians were not able to point out much that was positive in either the spending bill or the 2014 legislative session.
“We’ve had a Congress that’s just been much more interested in fighting with each other than with constructing meaningful legislation,” Dr. R. Mack Harrell, president of the American Association of Clinical Endocrinologists, said in an interview. “For physicians that means we’re stuck with an SGR system that everyone agrees is just not good for health care and not good for patients.”
Many physician groups said that the failure to repeal the SGR was their biggest disappointment.
“We were cautiously optimistic that this seventeeth year of trying to repeal the SGR might have been the successful one,” Dr. Patrick T. O’Gara, president of the American College of Cardiology, said in an interview. He said that the sticking point seemed to be that “there was no politically viable way to pay for it.”
American College of Physicians President Dr. David A. Fleming noted in a statement that finding the money had hung up what otherwise was huge progress: a bill that members of the House and Senate, Republicans and Democrats had put together, and that ultimately passed the House.
The current SGR patch expires Mar. 31, 2015, giving physicians little time to convince a new Congress of the merits of replacing the formula.
Noting that there is about 37 days between when the new Congress begins in January and when a 21% pay cut goes into effect in April, American Medical Association President Robert M. Wah, said in an interview, “We’re already really up against the end of the current patch.”
Even so, physician groups say that they’ll try to start where they left off – with the bill that had gained such widespread support 2014. “We fully expect that this bill will be considered by the new 114th Congress next year, and we will redouble our efforts to get Congress to act upon it before the current patch expires on March 31,” Dr. Fleming said in the statement.
Dr. O’Gara said that the ACC would take a pragmatic approach. “It would likely not be successful to mount a campaign to repeal it between January and March.”
Dr. Robert Wergin, president of the American Academy of Family Physicians, said that having a framework that already exists – and that was supported by most physicians – should help get the ball rolling more quickly in 2015.
The AAFP and other primary care physicians were also disappointed that the Medicaid pay parity provision – which puts reimbursement on par with Medicare for primary care services – was not extended. Dr. Wergin said going back to Medicaid pay rates amounts to essentially a 41% cut.
In a recent report, the Urban Institute estimated that fees increased an average 73% and that the federal government had spent an estimated $5.6 billion on the pay bump by June 2014. The institute said it’s not entirely clear whether the increase in fees has led to more access, or to an easing of pressures on physician practices. And it’s not clear how many states might choose to continue the program without federal help. According to a Kaiser Family Foundation survey published in late October, 15 states said they will continue a pay raise in 2015; 24 states said they would not, and 12 states were undecided.
Many physicians were also disappointed that legislators did not find a way to further delay ICD-10, which is scheduled to go into effect Oct. 1, 2015. Prospects for a delay next year seem slimmer now that two key House Republicans -- Rep. Fred Upton (R-Mich.) and Rep. Pete Sessions (R-Tex.) have said they won’t consider a delay. But, they said, in a joint statement, they also are willing to help physicians and others meet the deadline, and make sure that everything goes smoothly.
ICD-10 “is an important milestone in the future of health care technologies, and it is essential that we understand the state of preparedness at CMS,” they said.
The year is ending on a sour note for physicians, as Congress is recessing without addressing the Medicare Sustainable Growth Rate formula or acting on a number of other doctors’ priorities.
Congress did not extend a pay increase for primary care physicians who serve Medicaid recipients, nor did it delay the implementation of the ICD-10 code set nor enact any legislative solutions to help physicians better grapple with meaningful use of health information technology.
Physicians held out hope until the closing days of the 113th Congress, as legislators battled over what would be put into a massive spending bill that was needed to keep the government in operation beyond Dec. 11. That $1.1 trillion bill was approved by the House just before the government was to run out of money, and by the Senate two days later.
Physicians were not able to point out much that was positive in either the spending bill or the 2014 legislative session.
“We’ve had a Congress that’s just been much more interested in fighting with each other than with constructing meaningful legislation,” Dr. R. Mack Harrell, president of the American Association of Clinical Endocrinologists, said in an interview. “For physicians that means we’re stuck with an SGR system that everyone agrees is just not good for health care and not good for patients.”
Many physician groups said that the failure to repeal the SGR was their biggest disappointment.
“We were cautiously optimistic that this seventeeth year of trying to repeal the SGR might have been the successful one,” Dr. Patrick T. O’Gara, president of the American College of Cardiology, said in an interview. He said that the sticking point seemed to be that “there was no politically viable way to pay for it.”
American College of Physicians President Dr. David A. Fleming noted in a statement that finding the money had hung up what otherwise was huge progress: a bill that members of the House and Senate, Republicans and Democrats had put together, and that ultimately passed the House.
The current SGR patch expires Mar. 31, 2015, giving physicians little time to convince a new Congress of the merits of replacing the formula.
Noting that there is about 37 days between when the new Congress begins in January and when a 21% pay cut goes into effect in April, American Medical Association President Robert M. Wah, said in an interview, “We’re already really up against the end of the current patch.”
Even so, physician groups say that they’ll try to start where they left off – with the bill that had gained such widespread support 2014. “We fully expect that this bill will be considered by the new 114th Congress next year, and we will redouble our efforts to get Congress to act upon it before the current patch expires on March 31,” Dr. Fleming said in the statement.
Dr. O’Gara said that the ACC would take a pragmatic approach. “It would likely not be successful to mount a campaign to repeal it between January and March.”
Dr. Robert Wergin, president of the American Academy of Family Physicians, said that having a framework that already exists – and that was supported by most physicians – should help get the ball rolling more quickly in 2015.
The AAFP and other primary care physicians were also disappointed that the Medicaid pay parity provision – which puts reimbursement on par with Medicare for primary care services – was not extended. Dr. Wergin said going back to Medicaid pay rates amounts to essentially a 41% cut.
In a recent report, the Urban Institute estimated that fees increased an average 73% and that the federal government had spent an estimated $5.6 billion on the pay bump by June 2014. The institute said it’s not entirely clear whether the increase in fees has led to more access, or to an easing of pressures on physician practices. And it’s not clear how many states might choose to continue the program without federal help. According to a Kaiser Family Foundation survey published in late October, 15 states said they will continue a pay raise in 2015; 24 states said they would not, and 12 states were undecided.
Many physicians were also disappointed that legislators did not find a way to further delay ICD-10, which is scheduled to go into effect Oct. 1, 2015. Prospects for a delay next year seem slimmer now that two key House Republicans -- Rep. Fred Upton (R-Mich.) and Rep. Pete Sessions (R-Tex.) have said they won’t consider a delay. But, they said, in a joint statement, they also are willing to help physicians and others meet the deadline, and make sure that everything goes smoothly.
ICD-10 “is an important milestone in the future of health care technologies, and it is essential that we understand the state of preparedness at CMS,” they said.
The year is ending on a sour note for physicians, as Congress is recessing without addressing the Medicare Sustainable Growth Rate formula or acting on a number of other doctors’ priorities.
Congress did not extend a pay increase for primary care physicians who serve Medicaid recipients, nor did it delay the implementation of the ICD-10 code set nor enact any legislative solutions to help physicians better grapple with meaningful use of health information technology.
Physicians held out hope until the closing days of the 113th Congress, as legislators battled over what would be put into a massive spending bill that was needed to keep the government in operation beyond Dec. 11. That $1.1 trillion bill was approved by the House just before the government was to run out of money, and by the Senate two days later.
Physicians were not able to point out much that was positive in either the spending bill or the 2014 legislative session.
“We’ve had a Congress that’s just been much more interested in fighting with each other than with constructing meaningful legislation,” Dr. R. Mack Harrell, president of the American Association of Clinical Endocrinologists, said in an interview. “For physicians that means we’re stuck with an SGR system that everyone agrees is just not good for health care and not good for patients.”
Many physician groups said that the failure to repeal the SGR was their biggest disappointment.
“We were cautiously optimistic that this seventeeth year of trying to repeal the SGR might have been the successful one,” Dr. Patrick T. O’Gara, president of the American College of Cardiology, said in an interview. He said that the sticking point seemed to be that “there was no politically viable way to pay for it.”
American College of Physicians President Dr. David A. Fleming noted in a statement that finding the money had hung up what otherwise was huge progress: a bill that members of the House and Senate, Republicans and Democrats had put together, and that ultimately passed the House.
The current SGR patch expires Mar. 31, 2015, giving physicians little time to convince a new Congress of the merits of replacing the formula.
Noting that there is about 37 days between when the new Congress begins in January and when a 21% pay cut goes into effect in April, American Medical Association President Robert M. Wah, said in an interview, “We’re already really up against the end of the current patch.”
Even so, physician groups say that they’ll try to start where they left off – with the bill that had gained such widespread support 2014. “We fully expect that this bill will be considered by the new 114th Congress next year, and we will redouble our efforts to get Congress to act upon it before the current patch expires on March 31,” Dr. Fleming said in the statement.
Dr. O’Gara said that the ACC would take a pragmatic approach. “It would likely not be successful to mount a campaign to repeal it between January and March.”
Dr. Robert Wergin, president of the American Academy of Family Physicians, said that having a framework that already exists – and that was supported by most physicians – should help get the ball rolling more quickly in 2015.
The AAFP and other primary care physicians were also disappointed that the Medicaid pay parity provision – which puts reimbursement on par with Medicare for primary care services – was not extended. Dr. Wergin said going back to Medicaid pay rates amounts to essentially a 41% cut.
In a recent report, the Urban Institute estimated that fees increased an average 73% and that the federal government had spent an estimated $5.6 billion on the pay bump by June 2014. The institute said it’s not entirely clear whether the increase in fees has led to more access, or to an easing of pressures on physician practices. And it’s not clear how many states might choose to continue the program without federal help. According to a Kaiser Family Foundation survey published in late October, 15 states said they will continue a pay raise in 2015; 24 states said they would not, and 12 states were undecided.
Many physicians were also disappointed that legislators did not find a way to further delay ICD-10, which is scheduled to go into effect Oct. 1, 2015. Prospects for a delay next year seem slimmer now that two key House Republicans -- Rep. Fred Upton (R-Mich.) and Rep. Pete Sessions (R-Tex.) have said they won’t consider a delay. But, they said, in a joint statement, they also are willing to help physicians and others meet the deadline, and make sure that everything goes smoothly.
ICD-10 “is an important milestone in the future of health care technologies, and it is essential that we understand the state of preparedness at CMS,” they said.
Physicians shun Stage 2 of meaningful use
Of the 269,000 physicians and health care providers who successfully attested to Stage 1 of meaningful use, just 3,655 have successfully attested to Stage 2 and are ready to receive the incentive payment from Medicare. The Stage 2 deadline is Feb. 28.
For hospitals, the number is similarly weak: just 164 of 4,245 who successfully met the Stage 1 benchmarks have met those for Stage 2.
The totals – accurate as of the end of October – were reported Dec. 9 at a meeting of the Health IT Policy Committee, an advisory committee to the Office of the National Coordinator for Health Information Technology.
The low numbers reflect “the difficulty physicians are having in meeting the meaningful use program’s strict requirements and underlines the need for more flexibility and a shorter reporting period,” said Dr. Steven Stack, president-elect of the American Medical Association in a statement.
However, Dr. Steven Waldren, director of the Alliance for eHealth Innovation at the American Academy of Family Physicians, did not see a reason to panic yet.
“I think it’s probably fair to be nervous, but I still think we have a couple of months to actually see what happens,” Dr. Waldren said in an interview.
Dr. Waldren said several issues could affect physicians’ reporting time frames, including actually meeting Stage 2 criteria, coupled with difficulties that have been documented around implementing 2014-certified electronic health records.
“I think because of the heavy lifting, the numbers are going to be down from what we would think they should be based on this regular progression through the program,” he said.
“But I also think that we won’t know exactly what the magnitude of that decrease will be until after the February time frame.”
Of the 269,000 physicians and health care providers who successfully attested to Stage 1 of meaningful use, just 3,655 have successfully attested to Stage 2 and are ready to receive the incentive payment from Medicare. The Stage 2 deadline is Feb. 28.
For hospitals, the number is similarly weak: just 164 of 4,245 who successfully met the Stage 1 benchmarks have met those for Stage 2.
The totals – accurate as of the end of October – were reported Dec. 9 at a meeting of the Health IT Policy Committee, an advisory committee to the Office of the National Coordinator for Health Information Technology.
The low numbers reflect “the difficulty physicians are having in meeting the meaningful use program’s strict requirements and underlines the need for more flexibility and a shorter reporting period,” said Dr. Steven Stack, president-elect of the American Medical Association in a statement.
However, Dr. Steven Waldren, director of the Alliance for eHealth Innovation at the American Academy of Family Physicians, did not see a reason to panic yet.
“I think it’s probably fair to be nervous, but I still think we have a couple of months to actually see what happens,” Dr. Waldren said in an interview.
Dr. Waldren said several issues could affect physicians’ reporting time frames, including actually meeting Stage 2 criteria, coupled with difficulties that have been documented around implementing 2014-certified electronic health records.
“I think because of the heavy lifting, the numbers are going to be down from what we would think they should be based on this regular progression through the program,” he said.
“But I also think that we won’t know exactly what the magnitude of that decrease will be until after the February time frame.”
Of the 269,000 physicians and health care providers who successfully attested to Stage 1 of meaningful use, just 3,655 have successfully attested to Stage 2 and are ready to receive the incentive payment from Medicare. The Stage 2 deadline is Feb. 28.
For hospitals, the number is similarly weak: just 164 of 4,245 who successfully met the Stage 1 benchmarks have met those for Stage 2.
The totals – accurate as of the end of October – were reported Dec. 9 at a meeting of the Health IT Policy Committee, an advisory committee to the Office of the National Coordinator for Health Information Technology.
The low numbers reflect “the difficulty physicians are having in meeting the meaningful use program’s strict requirements and underlines the need for more flexibility and a shorter reporting period,” said Dr. Steven Stack, president-elect of the American Medical Association in a statement.
However, Dr. Steven Waldren, director of the Alliance for eHealth Innovation at the American Academy of Family Physicians, did not see a reason to panic yet.
“I think it’s probably fair to be nervous, but I still think we have a couple of months to actually see what happens,” Dr. Waldren said in an interview.
Dr. Waldren said several issues could affect physicians’ reporting time frames, including actually meeting Stage 2 criteria, coupled with difficulties that have been documented around implementing 2014-certified electronic health records.
“I think because of the heavy lifting, the numbers are going to be down from what we would think they should be based on this regular progression through the program,” he said.
“But I also think that we won’t know exactly what the magnitude of that decrease will be until after the February time frame.”
VIDEO: Multidisciplinary panel addresses role of anesthesia, analgesics in patient outcomes
SAN ANTONIO – A panel that included a breast surgeon, a medical oncologist, and a patient advocate met at the San Antonio Breast Cancer Symposium to discuss emerging research on the link between anesthesia and cancer recurrence. The issue was first raised following publication of a retrospective study in 2006, which showed a 40% reduction in recurrence in women given a type of regional anesthesia, with general anesthesia, rather than general anesthesia and postoperative morphine anesthesia during primary breast cancer surgery.
Dr. William J. Gradishar, Betsy Bramsen Professor of Breast Oncology at Northwestern University, Chicago, moderated the discussion with Dr. Juan Cata, assistant professor in the department of anesthesiology and perioperative medicine at the University of Texas MD Anderson Cancer Center, Dr. Susan Love, breast surgeon, and president and medical director of the Dr. Susan Love Research Foundation, and Musa Mayer, author and patient advocate.
The panel addressed the impact of surgery alone, anesthesia during surgery, and perioperative analgesics on patients’ immune functioning and ultimately disease outcomes. The state of the evidence in breast cancer and other tumor types, and an ongoing prospective trial with breast cancer patients, were also discussed.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @nikolaideslaura
SAN ANTONIO – A panel that included a breast surgeon, a medical oncologist, and a patient advocate met at the San Antonio Breast Cancer Symposium to discuss emerging research on the link between anesthesia and cancer recurrence. The issue was first raised following publication of a retrospective study in 2006, which showed a 40% reduction in recurrence in women given a type of regional anesthesia, with general anesthesia, rather than general anesthesia and postoperative morphine anesthesia during primary breast cancer surgery.
Dr. William J. Gradishar, Betsy Bramsen Professor of Breast Oncology at Northwestern University, Chicago, moderated the discussion with Dr. Juan Cata, assistant professor in the department of anesthesiology and perioperative medicine at the University of Texas MD Anderson Cancer Center, Dr. Susan Love, breast surgeon, and president and medical director of the Dr. Susan Love Research Foundation, and Musa Mayer, author and patient advocate.
The panel addressed the impact of surgery alone, anesthesia during surgery, and perioperative analgesics on patients’ immune functioning and ultimately disease outcomes. The state of the evidence in breast cancer and other tumor types, and an ongoing prospective trial with breast cancer patients, were also discussed.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @nikolaideslaura
SAN ANTONIO – A panel that included a breast surgeon, a medical oncologist, and a patient advocate met at the San Antonio Breast Cancer Symposium to discuss emerging research on the link between anesthesia and cancer recurrence. The issue was first raised following publication of a retrospective study in 2006, which showed a 40% reduction in recurrence in women given a type of regional anesthesia, with general anesthesia, rather than general anesthesia and postoperative morphine anesthesia during primary breast cancer surgery.
Dr. William J. Gradishar, Betsy Bramsen Professor of Breast Oncology at Northwestern University, Chicago, moderated the discussion with Dr. Juan Cata, assistant professor in the department of anesthesiology and perioperative medicine at the University of Texas MD Anderson Cancer Center, Dr. Susan Love, breast surgeon, and president and medical director of the Dr. Susan Love Research Foundation, and Musa Mayer, author and patient advocate.
The panel addressed the impact of surgery alone, anesthesia during surgery, and perioperative analgesics on patients’ immune functioning and ultimately disease outcomes. The state of the evidence in breast cancer and other tumor types, and an ongoing prospective trial with breast cancer patients, were also discussed.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @nikolaideslaura
AT SABCS 2014
Experts debate venous sinus stenting for intracranial hypertension
SCOTTSDALE, ARIZ. – Venous sinus stenting remains a controversial treatment for headache associated with benign intracranial hypertension. Opponents highlight potentially serious adverse effects and a lack of rigorous studies on the procedure, while supporters describe it as safe and effective. Experts recently debated the procedure at a symposium sponsored by the American Headache Society.
Which came first?
Stenting is based on the rationale that lowering venous sinus pressure might lower intracranial pressure, said Dr. Deborah Friedman, a neuro-ophthalmologist at the University of Texas Southwestern Medical Center in Dallas.
“Other surgical techniques create a fistula the body wants to close,” she said. “Stenting may provide a permanent solution.”
The crux of the debate on stenting is whether venous sinus stenosis is a cause or outcome of benign intracranial hypertension (BIH), said Dr. Felipe Albuquerque, an endovascular neurosurgeon at the Barrow Neurological Institute in Phoenix. The fact that 90% of affected patients have venous sinus stenosis on MRI suggests stenosis is a valid etiology the condition, he said.
But Dr. Friedman disagreed. In a retrospective study of 51 patients with BIH and transverse sinus stenosis, 71% had more than 50% stenosis, but the degree and location of stenosis did not predict clinical outcome. The analysis also found no link between cerebrospinal fluid pressure and the location, degree, or residual area of stenosis. Nonetheless, the procedure may be useful in patients who have persistent transverse sinus stenosis after undergoing a shunt procedure, she said.
The cons of stenting
“Stenting carries a high risk of morbidity and mortality, compared with currently used treatments, and should only be used as a last resort in patients who are losing vision,” Dr. Friedman asserted. Most patients do well, but others suffer serious complications, including life-threatening anaphylaxis, subdural hematomas, subarachnoid hemorrhage, and brain herniation, she said.
In contrast, optic nerve sheath fenestration for BIH has no associated fatalities, according to Dr. Friedman. And in a National Inpatient Sample database analysis of 1,224 shunts, mortality was only 0.9% for ventriculoperitoneal shunt and 0.3% for lumbar-peritoneal shunt. No deaths were recorded for shunts performed for BIH or pseudotumor cerebri, she added.
The literature on venous sinus stenting “is a mess,” Dr. Friedman continued. “All data are from retrospective case series, and the diagnosis of idiopathic intracranial hypertension is questionable in some cases,” she said. “The indication for stenting is not well defined.”
Studies on the safety and efficacy of stenting have lacked a common primary outcome variable and may reflect reporting bias, Dr. Friedman said. Studies have been heterogeneous with regard to disease duration and the presence or absence of papilledema, visual status, previous treatments, and definitions of treatment failure, she added. No randomized, controlled trials have been carried out with sham stenting to assess the possibility of placebo effect, she noted.
“I think stenting may have utility in patients who have failed conventional therapy and have had another procedure that did not work. I think it very likely that there is a strong placebo effect in this group,” Dr. Friedman said.
“It’s not like our existing procedures are wonderful,” she added. “I wish we had something better to offer our patients.”
The pros
Venous sinus stenting “is usually effective in ameliorating both subjective headache and objective papilledema symptoms,” Dr. Albuquerque said. “One could argue that both ventriculoperitoneal shunt and lumbar-peritoneal shunt, the most commonly performed surgical interventions for benign intracranial hypertension, are substantially more invasive than stenting is and associated with far more severe complications.”
Dr. Albuquerque described a prospective study he conducted with his associates on 15 patients with BIH who underwent venous sinus stenting. In all, 80% of patients said their headaches improved, and 60% reported at least a 50% decrease in headache pain. Rates of patency and technical success were 100%, and no patients had permanent complications from the procedure, although one patient developed acute retroperitoneal hematoma, he said.
Dr. Albuquerque also reported his long-term follow-up of 27 patients who underwent venous sinus stenting to treat pseudotumors. All patients had more than 50% stenosis confirmed by retrograde venogram and a transstenotic pressure gradient that was greater than 12 mm Hg. Fully 70% of patients improved symptomatically, but five underwent a shunt procedure after they failed to improve. Patients experienced no permanent complications, although one required a stent for femoral artery pseudoaneurysm. Angiographies performed an average of 23 months later showed that all stents remained patent, although four patients had mild (less than 25%) stenosis. Five patients had narrowing of the sinus proximal to the stent.
Patients need dual antiplatelet therapy after venous sinus stenting, and the rate of chronic patency after the procedure is unknown, Dr. Albuquerque noted. Patients can develop scalp pain over the stented segment, he added.
“I think if you limit this procedure to a very select group of patients, I think its efficacy is tremendous,” Dr. Albuquerque concluded.
Dr. Albuquerque declared no conflicts of interest. Dr. Friedman reported serving on the speakers bureau of Allergan, receiving research grants from the National Eye Institute, Merck & Co., and ElectroCore, and having served as an expert witness (for the plaintiff and defense) on idiopathic intracranial hypertension.
SCOTTSDALE, ARIZ. – Venous sinus stenting remains a controversial treatment for headache associated with benign intracranial hypertension. Opponents highlight potentially serious adverse effects and a lack of rigorous studies on the procedure, while supporters describe it as safe and effective. Experts recently debated the procedure at a symposium sponsored by the American Headache Society.
Which came first?
Stenting is based on the rationale that lowering venous sinus pressure might lower intracranial pressure, said Dr. Deborah Friedman, a neuro-ophthalmologist at the University of Texas Southwestern Medical Center in Dallas.
“Other surgical techniques create a fistula the body wants to close,” she said. “Stenting may provide a permanent solution.”
The crux of the debate on stenting is whether venous sinus stenosis is a cause or outcome of benign intracranial hypertension (BIH), said Dr. Felipe Albuquerque, an endovascular neurosurgeon at the Barrow Neurological Institute in Phoenix. The fact that 90% of affected patients have venous sinus stenosis on MRI suggests stenosis is a valid etiology the condition, he said.
But Dr. Friedman disagreed. In a retrospective study of 51 patients with BIH and transverse sinus stenosis, 71% had more than 50% stenosis, but the degree and location of stenosis did not predict clinical outcome. The analysis also found no link between cerebrospinal fluid pressure and the location, degree, or residual area of stenosis. Nonetheless, the procedure may be useful in patients who have persistent transverse sinus stenosis after undergoing a shunt procedure, she said.
The cons of stenting
“Stenting carries a high risk of morbidity and mortality, compared with currently used treatments, and should only be used as a last resort in patients who are losing vision,” Dr. Friedman asserted. Most patients do well, but others suffer serious complications, including life-threatening anaphylaxis, subdural hematomas, subarachnoid hemorrhage, and brain herniation, she said.
In contrast, optic nerve sheath fenestration for BIH has no associated fatalities, according to Dr. Friedman. And in a National Inpatient Sample database analysis of 1,224 shunts, mortality was only 0.9% for ventriculoperitoneal shunt and 0.3% for lumbar-peritoneal shunt. No deaths were recorded for shunts performed for BIH or pseudotumor cerebri, she added.
The literature on venous sinus stenting “is a mess,” Dr. Friedman continued. “All data are from retrospective case series, and the diagnosis of idiopathic intracranial hypertension is questionable in some cases,” she said. “The indication for stenting is not well defined.”
Studies on the safety and efficacy of stenting have lacked a common primary outcome variable and may reflect reporting bias, Dr. Friedman said. Studies have been heterogeneous with regard to disease duration and the presence or absence of papilledema, visual status, previous treatments, and definitions of treatment failure, she added. No randomized, controlled trials have been carried out with sham stenting to assess the possibility of placebo effect, she noted.
“I think stenting may have utility in patients who have failed conventional therapy and have had another procedure that did not work. I think it very likely that there is a strong placebo effect in this group,” Dr. Friedman said.
“It’s not like our existing procedures are wonderful,” she added. “I wish we had something better to offer our patients.”
The pros
Venous sinus stenting “is usually effective in ameliorating both subjective headache and objective papilledema symptoms,” Dr. Albuquerque said. “One could argue that both ventriculoperitoneal shunt and lumbar-peritoneal shunt, the most commonly performed surgical interventions for benign intracranial hypertension, are substantially more invasive than stenting is and associated with far more severe complications.”
Dr. Albuquerque described a prospective study he conducted with his associates on 15 patients with BIH who underwent venous sinus stenting. In all, 80% of patients said their headaches improved, and 60% reported at least a 50% decrease in headache pain. Rates of patency and technical success were 100%, and no patients had permanent complications from the procedure, although one patient developed acute retroperitoneal hematoma, he said.
Dr. Albuquerque also reported his long-term follow-up of 27 patients who underwent venous sinus stenting to treat pseudotumors. All patients had more than 50% stenosis confirmed by retrograde venogram and a transstenotic pressure gradient that was greater than 12 mm Hg. Fully 70% of patients improved symptomatically, but five underwent a shunt procedure after they failed to improve. Patients experienced no permanent complications, although one required a stent for femoral artery pseudoaneurysm. Angiographies performed an average of 23 months later showed that all stents remained patent, although four patients had mild (less than 25%) stenosis. Five patients had narrowing of the sinus proximal to the stent.
Patients need dual antiplatelet therapy after venous sinus stenting, and the rate of chronic patency after the procedure is unknown, Dr. Albuquerque noted. Patients can develop scalp pain over the stented segment, he added.
“I think if you limit this procedure to a very select group of patients, I think its efficacy is tremendous,” Dr. Albuquerque concluded.
Dr. Albuquerque declared no conflicts of interest. Dr. Friedman reported serving on the speakers bureau of Allergan, receiving research grants from the National Eye Institute, Merck & Co., and ElectroCore, and having served as an expert witness (for the plaintiff and defense) on idiopathic intracranial hypertension.
SCOTTSDALE, ARIZ. – Venous sinus stenting remains a controversial treatment for headache associated with benign intracranial hypertension. Opponents highlight potentially serious adverse effects and a lack of rigorous studies on the procedure, while supporters describe it as safe and effective. Experts recently debated the procedure at a symposium sponsored by the American Headache Society.
Which came first?
Stenting is based on the rationale that lowering venous sinus pressure might lower intracranial pressure, said Dr. Deborah Friedman, a neuro-ophthalmologist at the University of Texas Southwestern Medical Center in Dallas.
“Other surgical techniques create a fistula the body wants to close,” she said. “Stenting may provide a permanent solution.”
The crux of the debate on stenting is whether venous sinus stenosis is a cause or outcome of benign intracranial hypertension (BIH), said Dr. Felipe Albuquerque, an endovascular neurosurgeon at the Barrow Neurological Institute in Phoenix. The fact that 90% of affected patients have venous sinus stenosis on MRI suggests stenosis is a valid etiology the condition, he said.
But Dr. Friedman disagreed. In a retrospective study of 51 patients with BIH and transverse sinus stenosis, 71% had more than 50% stenosis, but the degree and location of stenosis did not predict clinical outcome. The analysis also found no link between cerebrospinal fluid pressure and the location, degree, or residual area of stenosis. Nonetheless, the procedure may be useful in patients who have persistent transverse sinus stenosis after undergoing a shunt procedure, she said.
The cons of stenting
“Stenting carries a high risk of morbidity and mortality, compared with currently used treatments, and should only be used as a last resort in patients who are losing vision,” Dr. Friedman asserted. Most patients do well, but others suffer serious complications, including life-threatening anaphylaxis, subdural hematomas, subarachnoid hemorrhage, and brain herniation, she said.
In contrast, optic nerve sheath fenestration for BIH has no associated fatalities, according to Dr. Friedman. And in a National Inpatient Sample database analysis of 1,224 shunts, mortality was only 0.9% for ventriculoperitoneal shunt and 0.3% for lumbar-peritoneal shunt. No deaths were recorded for shunts performed for BIH or pseudotumor cerebri, she added.
The literature on venous sinus stenting “is a mess,” Dr. Friedman continued. “All data are from retrospective case series, and the diagnosis of idiopathic intracranial hypertension is questionable in some cases,” she said. “The indication for stenting is not well defined.”
Studies on the safety and efficacy of stenting have lacked a common primary outcome variable and may reflect reporting bias, Dr. Friedman said. Studies have been heterogeneous with regard to disease duration and the presence or absence of papilledema, visual status, previous treatments, and definitions of treatment failure, she added. No randomized, controlled trials have been carried out with sham stenting to assess the possibility of placebo effect, she noted.
“I think stenting may have utility in patients who have failed conventional therapy and have had another procedure that did not work. I think it very likely that there is a strong placebo effect in this group,” Dr. Friedman said.
“It’s not like our existing procedures are wonderful,” she added. “I wish we had something better to offer our patients.”
The pros
Venous sinus stenting “is usually effective in ameliorating both subjective headache and objective papilledema symptoms,” Dr. Albuquerque said. “One could argue that both ventriculoperitoneal shunt and lumbar-peritoneal shunt, the most commonly performed surgical interventions for benign intracranial hypertension, are substantially more invasive than stenting is and associated with far more severe complications.”
Dr. Albuquerque described a prospective study he conducted with his associates on 15 patients with BIH who underwent venous sinus stenting. In all, 80% of patients said their headaches improved, and 60% reported at least a 50% decrease in headache pain. Rates of patency and technical success were 100%, and no patients had permanent complications from the procedure, although one patient developed acute retroperitoneal hematoma, he said.
Dr. Albuquerque also reported his long-term follow-up of 27 patients who underwent venous sinus stenting to treat pseudotumors. All patients had more than 50% stenosis confirmed by retrograde venogram and a transstenotic pressure gradient that was greater than 12 mm Hg. Fully 70% of patients improved symptomatically, but five underwent a shunt procedure after they failed to improve. Patients experienced no permanent complications, although one required a stent for femoral artery pseudoaneurysm. Angiographies performed an average of 23 months later showed that all stents remained patent, although four patients had mild (less than 25%) stenosis. Five patients had narrowing of the sinus proximal to the stent.
Patients need dual antiplatelet therapy after venous sinus stenting, and the rate of chronic patency after the procedure is unknown, Dr. Albuquerque noted. Patients can develop scalp pain over the stented segment, he added.
“I think if you limit this procedure to a very select group of patients, I think its efficacy is tremendous,” Dr. Albuquerque concluded.
Dr. Albuquerque declared no conflicts of interest. Dr. Friedman reported serving on the speakers bureau of Allergan, receiving research grants from the National Eye Institute, Merck & Co., and ElectroCore, and having served as an expert witness (for the plaintiff and defense) on idiopathic intracranial hypertension.
EXPERT ANALYSIS AT THE SCOTTSDALE HEADACHE SYMPOSIUM
Reduced sedation during ventilation lowered ventilator-associated events
PHILADELPHIA – A nurse- and respiratory therapist–led opt-out protocol for coordinated daily spontaneous awakening trials and spontaneous breathing trials was associated with significant reductions in hospital length of stay and ventilator-associated events in a multicenter quality improvement collaborative nested within a prospective study of ventilator-associated events.
The protocol led to significant increases – after adjustment for age, sex, Sequential Organ Failure Assessment score, reason for intubation, comorbidity score, and unit ID – in spontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), and in the percentage of SBTs performed without sedation among 3,425 episodes and 22,991days of mechanical ventilation in the collaborative units, Dr. Deverick Anderson of Duke University Medical Center, Durham, N.C., reported at an annual scientific meeting on infectious diseases.
The SAT performance rate increased from 30% to 70% during the course of the study, and the SBT performance rate also increased, though more modestly, from about 55% to nearly 70%. The performance rate of SBTs performed with sedatives off – an intervention that improves the ability to be extubated – increased from nearly 55% to more than 95%.
The mean duration of mechanical ventilation decreased by 2.4 days, mean ICU stay decreased by 3 days, and mean hospital length of stay decreased by 6.3 days, Dr. Anderson said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Further, ventilator-associated conditions and infection-related ventilator-associated complications significantly decreased (odds ratio, 0.63 and 0.35, respectively). However, there was no decrease in possible or probable pneumonia (OR, 0.51).
Self-extubations increased (OR, 2.1, but there was no change in reintubations within 24 hours (OR, 0.96), Dr. Anderson said
“When we put all of this together, we were able to show a decrease in our rates of VAEs [ventilator-associated events] per 100 episodes. Over the course of the entire study, we calculated a 37% decrease in the risk of VAEs,” Dr. Anderson said.
However, the number of VAEs per 1,000 days didn’t change, because both the denominator and the numerator changed with the intervention. This finding raises questions about determining the right denominator to use. Based on the findings, it appears that ventilator episodes, rather than ventilator days, might be the best denominators, he said.
The study was conducted at 12 adult intensive care units at seven hospitals participating in the Centers for Disease Control and Prevention’s Prevention Epicenters Wake Up and Breathe Collaborative between November 2011 and May 2013. The collaborative was designed to prevent VAEs by decreasing patients’ sedative and ventilator exposures.
The collaborative was developed after early 2013 when the CDC replaced its ventilator-associated pneumonia (VAP) definitions with VAE definitions, expanding surveillance to VAEs in an effort to improve the objectivity of the definitions, to improve the ease of performing surveillance, and to try to improve the ability to make interhospital comparisons, Dr. Anderson explained, adding that VAEs include VAP, but also include pulmonary edema, atelectasis, and acute respiratory distress syndrome.
Thus, interventions aimed simply at reducing VAP may not change the rate of VAEs, he said.
Patients with VAEs stay on ventilators longer, stay in the ICU longer, are exposed to more antibiotic, and have two- to threefold increased rates of mortality, compared with those on ventilators but without VAEs, but little is known about preventing VAEs.
A larger study suggested that about a third of cases might be preventable, but no intervention has been tested and found to have an effect on the rate of VAEs. The Wake Up and Breathe Collaborative was tasked with answering the question of whether VAEs are preventable, and the investigators thought the best opportunity for prevention was to decrease the amount of sedation that ventilated patients received, Dr. Anderson said.
“More specifically – to decrease sedation through daily SATs and SBTs,” he added.
The opt-out protocol called for SATs and SBTs in all ventilated patients unless they met specific safety criteria or a physician wrote a specific opt-out order.
Though limited by the quasi-experimental open label study design, the findings are consistent with those from prior studies of such protocols.
“We felt that our multicenter prospective collaborative study was a success. … putting it all together, we conclude that VAEs are preventable when we improve compliance with evidence-based practice for our ventilated patients,” he said.Dr. Anderson reported receiving royalties from UpToDate and receiving research support from the CDC and the National Institutes of Health/National Institute of Allergy and Infectious Diseases.
 |
| Dr. Vera DePalo |
Dr. Vera DePalo, FCCP, comments: The results of this collaborative underscore an important point in patient-focused care, namely that participation of the patient in his or her own care is often able to accelerate a patient's recovery.
It seems that with a protocol for coordinated daily spontaneous awakening trials, patients were more likely to be able to have success with a spontaneous breathing trial. A more awake state enables the patient to have a stronger cough, do a better job of clearing secretions, and take deeper breaths.
In this study, these interventions resulted in a reduction in mechanical ventilator days, a reduction in ICU days, and a decrease in mean hospital length of stay. The partnership between patient, physician and care team has enhanced the care delivery and improved health in many chronic conditions. With the current focus on population health, engaging patients in improving their health will be a win for all. As care providers, we should continue to look for every opportunity to engage our patients to participate actively in their health care.
Dr. DePalo is CMO, Chief of Medicine, for Signature Healthcare Brockton Hospital in Brockton, MA.
|
| Dr. Vera DePalo |
Dr. Vera DePalo, FCCP, comments: The results of this collaborative underscore an important point in patient-focused care, namely that participation of the patient in his or her own care is often able to accelerate a patient's recovery.
It seems that with a protocol for coordinated daily spontaneous awakening trials, patients were more likely to be able to have success with a spontaneous breathing trial. A more awake state enables the patient to have a stronger cough, do a better job of clearing secretions, and take deeper breaths.
In this study, these interventions resulted in a reduction in mechanical ventilator days, a reduction in ICU days, and a decrease in mean hospital length of stay. The partnership between patient, physician and care team has enhanced the care delivery and improved health in many chronic conditions. With the current focus on population health, engaging patients in improving their health will be a win for all. As care providers, we should continue to look for every opportunity to engage our patients to participate actively in their health care.
Dr. DePalo is CMO, Chief of Medicine, for Signature Healthcare Brockton Hospital in Brockton, MA.
|
| Dr. Vera DePalo |
Dr. Vera DePalo, FCCP, comments: The results of this collaborative underscore an important point in patient-focused care, namely that participation of the patient in his or her own care is often able to accelerate a patient's recovery.
It seems that with a protocol for coordinated daily spontaneous awakening trials, patients were more likely to be able to have success with a spontaneous breathing trial. A more awake state enables the patient to have a stronger cough, do a better job of clearing secretions, and take deeper breaths.
In this study, these interventions resulted in a reduction in mechanical ventilator days, a reduction in ICU days, and a decrease in mean hospital length of stay. The partnership between patient, physician and care team has enhanced the care delivery and improved health in many chronic conditions. With the current focus on population health, engaging patients in improving their health will be a win for all. As care providers, we should continue to look for every opportunity to engage our patients to participate actively in their health care.
Dr. DePalo is CMO, Chief of Medicine, for Signature Healthcare Brockton Hospital in Brockton, MA.
PHILADELPHIA – A nurse- and respiratory therapist–led opt-out protocol for coordinated daily spontaneous awakening trials and spontaneous breathing trials was associated with significant reductions in hospital length of stay and ventilator-associated events in a multicenter quality improvement collaborative nested within a prospective study of ventilator-associated events.
The protocol led to significant increases – after adjustment for age, sex, Sequential Organ Failure Assessment score, reason for intubation, comorbidity score, and unit ID – in spontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), and in the percentage of SBTs performed without sedation among 3,425 episodes and 22,991days of mechanical ventilation in the collaborative units, Dr. Deverick Anderson of Duke University Medical Center, Durham, N.C., reported at an annual scientific meeting on infectious diseases.
The SAT performance rate increased from 30% to 70% during the course of the study, and the SBT performance rate also increased, though more modestly, from about 55% to nearly 70%. The performance rate of SBTs performed with sedatives off – an intervention that improves the ability to be extubated – increased from nearly 55% to more than 95%.
The mean duration of mechanical ventilation decreased by 2.4 days, mean ICU stay decreased by 3 days, and mean hospital length of stay decreased by 6.3 days, Dr. Anderson said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Further, ventilator-associated conditions and infection-related ventilator-associated complications significantly decreased (odds ratio, 0.63 and 0.35, respectively). However, there was no decrease in possible or probable pneumonia (OR, 0.51).
Self-extubations increased (OR, 2.1, but there was no change in reintubations within 24 hours (OR, 0.96), Dr. Anderson said
“When we put all of this together, we were able to show a decrease in our rates of VAEs [ventilator-associated events] per 100 episodes. Over the course of the entire study, we calculated a 37% decrease in the risk of VAEs,” Dr. Anderson said.
However, the number of VAEs per 1,000 days didn’t change, because both the denominator and the numerator changed with the intervention. This finding raises questions about determining the right denominator to use. Based on the findings, it appears that ventilator episodes, rather than ventilator days, might be the best denominators, he said.
The study was conducted at 12 adult intensive care units at seven hospitals participating in the Centers for Disease Control and Prevention’s Prevention Epicenters Wake Up and Breathe Collaborative between November 2011 and May 2013. The collaborative was designed to prevent VAEs by decreasing patients’ sedative and ventilator exposures.
The collaborative was developed after early 2013 when the CDC replaced its ventilator-associated pneumonia (VAP) definitions with VAE definitions, expanding surveillance to VAEs in an effort to improve the objectivity of the definitions, to improve the ease of performing surveillance, and to try to improve the ability to make interhospital comparisons, Dr. Anderson explained, adding that VAEs include VAP, but also include pulmonary edema, atelectasis, and acute respiratory distress syndrome.
Thus, interventions aimed simply at reducing VAP may not change the rate of VAEs, he said.
Patients with VAEs stay on ventilators longer, stay in the ICU longer, are exposed to more antibiotic, and have two- to threefold increased rates of mortality, compared with those on ventilators but without VAEs, but little is known about preventing VAEs.
A larger study suggested that about a third of cases might be preventable, but no intervention has been tested and found to have an effect on the rate of VAEs. The Wake Up and Breathe Collaborative was tasked with answering the question of whether VAEs are preventable, and the investigators thought the best opportunity for prevention was to decrease the amount of sedation that ventilated patients received, Dr. Anderson said.
“More specifically – to decrease sedation through daily SATs and SBTs,” he added.
The opt-out protocol called for SATs and SBTs in all ventilated patients unless they met specific safety criteria or a physician wrote a specific opt-out order.
Though limited by the quasi-experimental open label study design, the findings are consistent with those from prior studies of such protocols.
“We felt that our multicenter prospective collaborative study was a success. … putting it all together, we conclude that VAEs are preventable when we improve compliance with evidence-based practice for our ventilated patients,” he said.Dr. Anderson reported receiving royalties from UpToDate and receiving research support from the CDC and the National Institutes of Health/National Institute of Allergy and Infectious Diseases.
PHILADELPHIA – A nurse- and respiratory therapist–led opt-out protocol for coordinated daily spontaneous awakening trials and spontaneous breathing trials was associated with significant reductions in hospital length of stay and ventilator-associated events in a multicenter quality improvement collaborative nested within a prospective study of ventilator-associated events.
The protocol led to significant increases – after adjustment for age, sex, Sequential Organ Failure Assessment score, reason for intubation, comorbidity score, and unit ID – in spontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), and in the percentage of SBTs performed without sedation among 3,425 episodes and 22,991days of mechanical ventilation in the collaborative units, Dr. Deverick Anderson of Duke University Medical Center, Durham, N.C., reported at an annual scientific meeting on infectious diseases.
The SAT performance rate increased from 30% to 70% during the course of the study, and the SBT performance rate also increased, though more modestly, from about 55% to nearly 70%. The performance rate of SBTs performed with sedatives off – an intervention that improves the ability to be extubated – increased from nearly 55% to more than 95%.
The mean duration of mechanical ventilation decreased by 2.4 days, mean ICU stay decreased by 3 days, and mean hospital length of stay decreased by 6.3 days, Dr. Anderson said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Further, ventilator-associated conditions and infection-related ventilator-associated complications significantly decreased (odds ratio, 0.63 and 0.35, respectively). However, there was no decrease in possible or probable pneumonia (OR, 0.51).
Self-extubations increased (OR, 2.1, but there was no change in reintubations within 24 hours (OR, 0.96), Dr. Anderson said
“When we put all of this together, we were able to show a decrease in our rates of VAEs [ventilator-associated events] per 100 episodes. Over the course of the entire study, we calculated a 37% decrease in the risk of VAEs,” Dr. Anderson said.
However, the number of VAEs per 1,000 days didn’t change, because both the denominator and the numerator changed with the intervention. This finding raises questions about determining the right denominator to use. Based on the findings, it appears that ventilator episodes, rather than ventilator days, might be the best denominators, he said.
The study was conducted at 12 adult intensive care units at seven hospitals participating in the Centers for Disease Control and Prevention’s Prevention Epicenters Wake Up and Breathe Collaborative between November 2011 and May 2013. The collaborative was designed to prevent VAEs by decreasing patients’ sedative and ventilator exposures.
The collaborative was developed after early 2013 when the CDC replaced its ventilator-associated pneumonia (VAP) definitions with VAE definitions, expanding surveillance to VAEs in an effort to improve the objectivity of the definitions, to improve the ease of performing surveillance, and to try to improve the ability to make interhospital comparisons, Dr. Anderson explained, adding that VAEs include VAP, but also include pulmonary edema, atelectasis, and acute respiratory distress syndrome.
Thus, interventions aimed simply at reducing VAP may not change the rate of VAEs, he said.
Patients with VAEs stay on ventilators longer, stay in the ICU longer, are exposed to more antibiotic, and have two- to threefold increased rates of mortality, compared with those on ventilators but without VAEs, but little is known about preventing VAEs.
A larger study suggested that about a third of cases might be preventable, but no intervention has been tested and found to have an effect on the rate of VAEs. The Wake Up and Breathe Collaborative was tasked with answering the question of whether VAEs are preventable, and the investigators thought the best opportunity for prevention was to decrease the amount of sedation that ventilated patients received, Dr. Anderson said.
“More specifically – to decrease sedation through daily SATs and SBTs,” he added.
The opt-out protocol called for SATs and SBTs in all ventilated patients unless they met specific safety criteria or a physician wrote a specific opt-out order.
Though limited by the quasi-experimental open label study design, the findings are consistent with those from prior studies of such protocols.
“We felt that our multicenter prospective collaborative study was a success. … putting it all together, we conclude that VAEs are preventable when we improve compliance with evidence-based practice for our ventilated patients,” he said.Dr. Anderson reported receiving royalties from UpToDate and receiving research support from the CDC and the National Institutes of Health/National Institute of Allergy and Infectious Diseases.
Key clinical point: Reducing ventilated patients’ sedation time through a nurse- and respiratory therapist–led opt-out protocol reduces the risk of ventilator-associated events.
Major finding: Protocol implementation was associated with a 37% decrease in VAE risk.
Data source: A multicenter quasi-experimental open-label study of 3,425 mechanical ventilation episodes.
Disclosures: Dr. Anderson reported receiving royalties from UpToDate, Online, and receiving research support from the CDC and the NIH/NIAID.
Race and gender may predict VAP risk
AUSTIN, TEX. – Race, gender, and care setting appear to predict ventilator-associated pneumonia, according to an analysis of data from the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample.
The strongest predictor of ventilator-associated pneumonia (VAP) was mechanical ventilation for more than 96 hours (odds ratio, 13.64) in an analysis of 13,082 patients who developed the condition. The study subjects were among the 905,000 patients who required mechanical ventilation between 2008 and 2011 and who were available for analysis. The study was controlled for known VAP risk factors, including age, chronic lung disease, altered level of consciousness, acute respiratory distress syndrome, nasogastric tube, aspiration, comorbid conditions, chest surgery, hospital characteristics, and insurance status, Dr. Kathan Mehta of the University of Pittsburgh Medical Center, reported at the annual meeting of the American College of Chest Physicians.
Black patients, men, and those who were treated at a teaching hospital were also at significantly increased risk for VAP (OR, 1.23, 1.33, and 1.64, respectively), Dr. Mehta said.
VAP is an important cause of morbidity and mortality in hospitalized patients requiring mechanical ventilation. A number of risk factors have been associated with high incidence of VAP, but the role of epidemiologic factors in VAP development has been largely unknown, he said.
The current findings – from the one of the largest available comprehensive hospital discharge datasets on mechanical ventilation – have implications for preventing VAP and for improving the diagnosis and treatment of VAP. The at-risk population may benefit from higher suspicion for VAP for early diagnosis and treatment, and from aggressive measures to prevent VAP,” he said. Dr. Mehta reported having no disclosures.
AUSTIN, TEX. – Race, gender, and care setting appear to predict ventilator-associated pneumonia, according to an analysis of data from the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample.
The strongest predictor of ventilator-associated pneumonia (VAP) was mechanical ventilation for more than 96 hours (odds ratio, 13.64) in an analysis of 13,082 patients who developed the condition. The study subjects were among the 905,000 patients who required mechanical ventilation between 2008 and 2011 and who were available for analysis. The study was controlled for known VAP risk factors, including age, chronic lung disease, altered level of consciousness, acute respiratory distress syndrome, nasogastric tube, aspiration, comorbid conditions, chest surgery, hospital characteristics, and insurance status, Dr. Kathan Mehta of the University of Pittsburgh Medical Center, reported at the annual meeting of the American College of Chest Physicians.
Black patients, men, and those who were treated at a teaching hospital were also at significantly increased risk for VAP (OR, 1.23, 1.33, and 1.64, respectively), Dr. Mehta said.
VAP is an important cause of morbidity and mortality in hospitalized patients requiring mechanical ventilation. A number of risk factors have been associated with high incidence of VAP, but the role of epidemiologic factors in VAP development has been largely unknown, he said.
The current findings – from the one of the largest available comprehensive hospital discharge datasets on mechanical ventilation – have implications for preventing VAP and for improving the diagnosis and treatment of VAP. The at-risk population may benefit from higher suspicion for VAP for early diagnosis and treatment, and from aggressive measures to prevent VAP,” he said. Dr. Mehta reported having no disclosures.
AUSTIN, TEX. – Race, gender, and care setting appear to predict ventilator-associated pneumonia, according to an analysis of data from the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample.
The strongest predictor of ventilator-associated pneumonia (VAP) was mechanical ventilation for more than 96 hours (odds ratio, 13.64) in an analysis of 13,082 patients who developed the condition. The study subjects were among the 905,000 patients who required mechanical ventilation between 2008 and 2011 and who were available for analysis. The study was controlled for known VAP risk factors, including age, chronic lung disease, altered level of consciousness, acute respiratory distress syndrome, nasogastric tube, aspiration, comorbid conditions, chest surgery, hospital characteristics, and insurance status, Dr. Kathan Mehta of the University of Pittsburgh Medical Center, reported at the annual meeting of the American College of Chest Physicians.
Black patients, men, and those who were treated at a teaching hospital were also at significantly increased risk for VAP (OR, 1.23, 1.33, and 1.64, respectively), Dr. Mehta said.
VAP is an important cause of morbidity and mortality in hospitalized patients requiring mechanical ventilation. A number of risk factors have been associated with high incidence of VAP, but the role of epidemiologic factors in VAP development has been largely unknown, he said.
The current findings – from the one of the largest available comprehensive hospital discharge datasets on mechanical ventilation – have implications for preventing VAP and for improving the diagnosis and treatment of VAP. The at-risk population may benefit from higher suspicion for VAP for early diagnosis and treatment, and from aggressive measures to prevent VAP,” he said. Dr. Mehta reported having no disclosures.
AT CHEST 2014
Key clinical point: Epidemiologic factors linked to increased risk of ventilator-associated pneumonia should increase clinical suspicion of VAP.
Major finding: Black race, male gender, and teaching hospital setting predicted VAP (odds ratios, 1.23, 1.33, and 1.64, respectively).
Data source: An analysis of data from 905,000 patients in the Nationwide Inpatient Sample.
Disclosures: Dr. Mehta reported having no disclosures.
From the Washington Office
Congress has returned for the lame duck session of the 113th Congress. As has been the case for as many years as many of your D.C. staff can remember, the repeal of the flawed Sustainable Growth Rate is a primary focus of our legislative efforts during this brief time that Congress has remaining before the end of the year.
As many will recall, in February 2014, Congress came to a bipartisan, bicameral agreement for repeal of the SGR formula and overhaul of the Medicare physician payment system. The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015 – the SGR Repeal Act) was the product of a yearlong collaborative effort between Congress and key stakeholders, including the American College of Surgeons. In fact, ACS was the only physician group to testify before all three congressional committees of jurisdiction (House Ways and Means, House Energy and Commerce, and Senate Finance) during the process culminating in the legislation.
Congress was subsequently unable to agree on offsets to pay for the cost of the SGR Repeal Act. This is extremely unfortunate and, in sum, represents a classic example of partisanship trumping good policy. This is particularly significant when one considers the exemplary bipartisan and bicameral efforts that culminated in the legislation and the fact that the $170 billion cost of the 17 temporary “patches” Congress has utilized over the past 11 years far surpasses the estimated cost of the current agreed-upon policy.
In September, representatives from five major physician organizations, including ACS, made visits to offices of congressional leaders specifically to urge action on S. 2000/H.R. 4015 during the lame duck session. Subsequently, letters urging action on the SGR Repeal Act have been sent to House leaders by the Pennsylvania congressional delegation; the House Doctors’ Caucus; and 114 additional members who signed a bipartisan letter circulated by Rep. Reid Ribble (R-Wis.) and Rep. Kurt Schrader (D-Ore.). When the signatures on these three letters are combined with those from similar correspondence circulated by Rep. Bill Flores (R-Tex.) and Rep. Dan Maffei (D-N.Y.) and sent to House leaders in November 2013, a total of 287 of the 435 members of the House of Representatives have indicated their support for passage of H.R. 4015.
Fellows received an e-mail earlier in October requesting that they contact their individual member of Congress to urge action on the SGR Repeal Act. The message is simple: The physician community has united around a sound bicameral and bipartisan payment reform policy that will permanently repeal the flawed SGR formula and make sound reforms to modernize Medicare physician payment. It is now Congress’ job to develop bipartisan, bicameral offsets and pass the legislation. For Fellows who have not taken the opportunity to act, they can still do so by logging on to www.surgeonsvoice.org and following the links for “Take Action Now.”
There is certainly a compelling argument that action during this lame duck session represents a real opportunity to permanently address and resolve the SGR. All seem to agree that we are long past the time to address this chronic, festering issue. Lame duck sessions also present opportunities for legislators who will not be returning to proceed without the considerations of short-term political consequences. For those returning for the 114th Congress, an opportunity to address a recurrent problem, clean it off the plate, and start fresh with the new Congress in January is also very appealing. Finally, one can also argue, as was done by a prominent member of the House Doctors’ Caucus, that the lame duck session presents an opportunity to more palatably return to bipartisan cooperation on the issue – a sort of “Butch Cassidy and the Sundance Kid Theory” of jumping off the cliff together.
Without action, the latest short-term patch is scheduled to expire on March 31, 2015. At that time, another patch, the 18th, would be necessary to preclude the cuts to Medicare physician payment that all, even Medicare’s Board of Trustees, agree Congress is likely never to allow to take place for fear of the political repercussions following such cuts from seniors and the physician community. Short-term patches obviously do not solve the problem. It is reasonable to predict that any short-term patch put in place in March would be set to expire around the time of the next debt limit debate, currently predicted to be just before the August recess in the summer. That one would be the 19th. Thus, to quote a famous American philosopher and poet, “The road goes on forever and the party never ends.”
In closing, I urge all Fellows to contact the offices of their representatives and senators – whether by phone, e-mail, logging on to www.surgeonsvoice.org, or paying a personal visit to their local district office – and seize the opportunity to support favorable action on the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015) during the lame duck session.
Until next month …
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
Congress has returned for the lame duck session of the 113th Congress. As has been the case for as many years as many of your D.C. staff can remember, the repeal of the flawed Sustainable Growth Rate is a primary focus of our legislative efforts during this brief time that Congress has remaining before the end of the year.
As many will recall, in February 2014, Congress came to a bipartisan, bicameral agreement for repeal of the SGR formula and overhaul of the Medicare physician payment system. The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015 – the SGR Repeal Act) was the product of a yearlong collaborative effort between Congress and key stakeholders, including the American College of Surgeons. In fact, ACS was the only physician group to testify before all three congressional committees of jurisdiction (House Ways and Means, House Energy and Commerce, and Senate Finance) during the process culminating in the legislation.
Congress was subsequently unable to agree on offsets to pay for the cost of the SGR Repeal Act. This is extremely unfortunate and, in sum, represents a classic example of partisanship trumping good policy. This is particularly significant when one considers the exemplary bipartisan and bicameral efforts that culminated in the legislation and the fact that the $170 billion cost of the 17 temporary “patches” Congress has utilized over the past 11 years far surpasses the estimated cost of the current agreed-upon policy.
In September, representatives from five major physician organizations, including ACS, made visits to offices of congressional leaders specifically to urge action on S. 2000/H.R. 4015 during the lame duck session. Subsequently, letters urging action on the SGR Repeal Act have been sent to House leaders by the Pennsylvania congressional delegation; the House Doctors’ Caucus; and 114 additional members who signed a bipartisan letter circulated by Rep. Reid Ribble (R-Wis.) and Rep. Kurt Schrader (D-Ore.). When the signatures on these three letters are combined with those from similar correspondence circulated by Rep. Bill Flores (R-Tex.) and Rep. Dan Maffei (D-N.Y.) and sent to House leaders in November 2013, a total of 287 of the 435 members of the House of Representatives have indicated their support for passage of H.R. 4015.
Fellows received an e-mail earlier in October requesting that they contact their individual member of Congress to urge action on the SGR Repeal Act. The message is simple: The physician community has united around a sound bicameral and bipartisan payment reform policy that will permanently repeal the flawed SGR formula and make sound reforms to modernize Medicare physician payment. It is now Congress’ job to develop bipartisan, bicameral offsets and pass the legislation. For Fellows who have not taken the opportunity to act, they can still do so by logging on to www.surgeonsvoice.org and following the links for “Take Action Now.”
There is certainly a compelling argument that action during this lame duck session represents a real opportunity to permanently address and resolve the SGR. All seem to agree that we are long past the time to address this chronic, festering issue. Lame duck sessions also present opportunities for legislators who will not be returning to proceed without the considerations of short-term political consequences. For those returning for the 114th Congress, an opportunity to address a recurrent problem, clean it off the plate, and start fresh with the new Congress in January is also very appealing. Finally, one can also argue, as was done by a prominent member of the House Doctors’ Caucus, that the lame duck session presents an opportunity to more palatably return to bipartisan cooperation on the issue – a sort of “Butch Cassidy and the Sundance Kid Theory” of jumping off the cliff together.
Without action, the latest short-term patch is scheduled to expire on March 31, 2015. At that time, another patch, the 18th, would be necessary to preclude the cuts to Medicare physician payment that all, even Medicare’s Board of Trustees, agree Congress is likely never to allow to take place for fear of the political repercussions following such cuts from seniors and the physician community. Short-term patches obviously do not solve the problem. It is reasonable to predict that any short-term patch put in place in March would be set to expire around the time of the next debt limit debate, currently predicted to be just before the August recess in the summer. That one would be the 19th. Thus, to quote a famous American philosopher and poet, “The road goes on forever and the party never ends.”
In closing, I urge all Fellows to contact the offices of their representatives and senators – whether by phone, e-mail, logging on to www.surgeonsvoice.org, or paying a personal visit to their local district office – and seize the opportunity to support favorable action on the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015) during the lame duck session.
Until next month …
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
Congress has returned for the lame duck session of the 113th Congress. As has been the case for as many years as many of your D.C. staff can remember, the repeal of the flawed Sustainable Growth Rate is a primary focus of our legislative efforts during this brief time that Congress has remaining before the end of the year.
As many will recall, in February 2014, Congress came to a bipartisan, bicameral agreement for repeal of the SGR formula and overhaul of the Medicare physician payment system. The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015 – the SGR Repeal Act) was the product of a yearlong collaborative effort between Congress and key stakeholders, including the American College of Surgeons. In fact, ACS was the only physician group to testify before all three congressional committees of jurisdiction (House Ways and Means, House Energy and Commerce, and Senate Finance) during the process culminating in the legislation.
Congress was subsequently unable to agree on offsets to pay for the cost of the SGR Repeal Act. This is extremely unfortunate and, in sum, represents a classic example of partisanship trumping good policy. This is particularly significant when one considers the exemplary bipartisan and bicameral efforts that culminated in the legislation and the fact that the $170 billion cost of the 17 temporary “patches” Congress has utilized over the past 11 years far surpasses the estimated cost of the current agreed-upon policy.
In September, representatives from five major physician organizations, including ACS, made visits to offices of congressional leaders specifically to urge action on S. 2000/H.R. 4015 during the lame duck session. Subsequently, letters urging action on the SGR Repeal Act have been sent to House leaders by the Pennsylvania congressional delegation; the House Doctors’ Caucus; and 114 additional members who signed a bipartisan letter circulated by Rep. Reid Ribble (R-Wis.) and Rep. Kurt Schrader (D-Ore.). When the signatures on these three letters are combined with those from similar correspondence circulated by Rep. Bill Flores (R-Tex.) and Rep. Dan Maffei (D-N.Y.) and sent to House leaders in November 2013, a total of 287 of the 435 members of the House of Representatives have indicated their support for passage of H.R. 4015.
Fellows received an e-mail earlier in October requesting that they contact their individual member of Congress to urge action on the SGR Repeal Act. The message is simple: The physician community has united around a sound bicameral and bipartisan payment reform policy that will permanently repeal the flawed SGR formula and make sound reforms to modernize Medicare physician payment. It is now Congress’ job to develop bipartisan, bicameral offsets and pass the legislation. For Fellows who have not taken the opportunity to act, they can still do so by logging on to www.surgeonsvoice.org and following the links for “Take Action Now.”
There is certainly a compelling argument that action during this lame duck session represents a real opportunity to permanently address and resolve the SGR. All seem to agree that we are long past the time to address this chronic, festering issue. Lame duck sessions also present opportunities for legislators who will not be returning to proceed without the considerations of short-term political consequences. For those returning for the 114th Congress, an opportunity to address a recurrent problem, clean it off the plate, and start fresh with the new Congress in January is also very appealing. Finally, one can also argue, as was done by a prominent member of the House Doctors’ Caucus, that the lame duck session presents an opportunity to more palatably return to bipartisan cooperation on the issue – a sort of “Butch Cassidy and the Sundance Kid Theory” of jumping off the cliff together.
Without action, the latest short-term patch is scheduled to expire on March 31, 2015. At that time, another patch, the 18th, would be necessary to preclude the cuts to Medicare physician payment that all, even Medicare’s Board of Trustees, agree Congress is likely never to allow to take place for fear of the political repercussions following such cuts from seniors and the physician community. Short-term patches obviously do not solve the problem. It is reasonable to predict that any short-term patch put in place in March would be set to expire around the time of the next debt limit debate, currently predicted to be just before the August recess in the summer. That one would be the 19th. Thus, to quote a famous American philosopher and poet, “The road goes on forever and the party never ends.”
In closing, I urge all Fellows to contact the offices of their representatives and senators – whether by phone, e-mail, logging on to www.surgeonsvoice.org, or paying a personal visit to their local district office – and seize the opportunity to support favorable action on the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015) during the lame duck session.
Until next month …
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
From the Washington Office
This month, I would like to call Fellows’ attention to some pending changes in the quality measures landscape, which can impact Medicare payment. By the time this issue goes to press, all Fellows should have received e-mail from ACS leadership referencing the document, “How to Avoid Medicare Penalties” available at . This document highlights the penalties Fellows might face if they do not participate in the various Medicare quality incentive programs. It also summarizes an excellent article in the September issue of the ACS Bulletin (Vol. 99, No. 9, pp. 28-32), “The benefits of PQRS participation and what the College is doing on your behalf,” by Charles D. Mabry, MD, FACS, Chair, ACS Health Policy Advisory Council (HPAC) and Sana Z. Gokak, MPH, a member of the Quality Affairs team here in the Washington office.
As most are acutely aware, the last few years have seen a change in the quantity and types of data collected by the Centers for Medicare & Medicaid Services (CMS). As part of this change, a shift has been made from the collection of administrative data toward collection of clinical data. Medicare payment has begun to shift from pay for reporting with the Physician Quality Reporting System (PQRS) program to pay for performance with the Value-Based Payment Modifier (VM).
The current calendar year of 2014 is the last year in which physicians may earn PQRS and Electronic Health Record (EHR) Incentive Program bonus payments based on their participation in CMS programs. Based on their record from 2014 of either successful participation or nonparticipation in the PQRS, VM, and EHR programs, surgeons’ Medicare payment could be impacted by up to a –6% in 2016. Whether or not providers participate in PQRS will also be indicated on the PHYSICIAN COMPARE website. The deadline for submission of data to CMS for 2014 is Jan. 31, 2015.
Physicians and other providers must submit data to the PQRS program in order to have such indicated on the PHYSICIAN COMPARE website. In addition, the data submitted through PQRS will be utilized in future years to increase or decrease fee-for-service (FFS) payments based on the VM. The VM payment adjustment will begin in 2015, but the data utilized for the 2015 adjustment will be based on 2013 performance. Payment adjustment will apply to all physicians by 2017, based on their 2015 data. For most Medicare incentive programs, penalties will apply to the physician’s Medicare payments 2 years after their performance in the programs.
Providing data to PQRS is thus the key and may be submitted by physician group practices via the Group Practice Reporting Option (GPRO) or individually via claims, EHRs, or Qualified Registries, or Qualified Clinical Data Registries (QCDR). The ACS has two registries available to assist Fellows to be successful participants in the submission of data for the PQRS program. These are the Surgeon Specific Registry (SSR) Qualified Registry and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) QCDR.
Many surgeons are familiar with the SSR as the ACS Case Log system whereby data was collected for the American Board of Surgery Maintenance of Certification program. Through this online program, surgeons can report on either the Perioperative Measures Group or the General Surgery Measures Group. To be successful for 2014, and thus avoid a penalty applied to payment in 2016, reports on 20 majority Medicare patients for either of the two measures groups seen during calendar year 2014 should be submitted to the SSR by Jan, 31, 2015. The SSR will submit the PQRS data to CMS.
The SSR is available at no cost to ACS members. For those not familiar with the Case Log, they may register for same at https://www.facs.org/quality-programs/ssr. Surgeons must consent to and sign up for PQRS reporting through the SSR if they want their data submitted to CMS.
In sum, it is frequently said that the only constant is change. Though the administrative requirements are much different than they were in the past, the ACS is working hard to make resources available to assist members in being successful in the ever-changing health care environment. The following ACS staff members are available to answer questions and assist members in participating in the 2014 PQRS program, EHR Incentive Program, the VM and to facilitate enrollment in the SSR and MBSAQIP:
• General PQRS, EHR, and VM questions: Sana Gokak, ACS Division of Advocacy and Health Policy, 202/337-2701 or [email protected].
• Information on the SSR: Bianca Reyes, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
• Information on MBSAQIP: Rasa Krapikas, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
Until next month …
This month, I would like to call Fellows’ attention to some pending changes in the quality measures landscape, which can impact Medicare payment. By the time this issue goes to press, all Fellows should have received e-mail from ACS leadership referencing the document, “How to Avoid Medicare Penalties” available at . This document highlights the penalties Fellows might face if they do not participate in the various Medicare quality incentive programs. It also summarizes an excellent article in the September issue of the ACS Bulletin (Vol. 99, No. 9, pp. 28-32), “The benefits of PQRS participation and what the College is doing on your behalf,” by Charles D. Mabry, MD, FACS, Chair, ACS Health Policy Advisory Council (HPAC) and Sana Z. Gokak, MPH, a member of the Quality Affairs team here in the Washington office.
As most are acutely aware, the last few years have seen a change in the quantity and types of data collected by the Centers for Medicare & Medicaid Services (CMS). As part of this change, a shift has been made from the collection of administrative data toward collection of clinical data. Medicare payment has begun to shift from pay for reporting with the Physician Quality Reporting System (PQRS) program to pay for performance with the Value-Based Payment Modifier (VM).
The current calendar year of 2014 is the last year in which physicians may earn PQRS and Electronic Health Record (EHR) Incentive Program bonus payments based on their participation in CMS programs. Based on their record from 2014 of either successful participation or nonparticipation in the PQRS, VM, and EHR programs, surgeons’ Medicare payment could be impacted by up to a –6% in 2016. Whether or not providers participate in PQRS will also be indicated on the PHYSICIAN COMPARE website. The deadline for submission of data to CMS for 2014 is Jan. 31, 2015.
Physicians and other providers must submit data to the PQRS program in order to have such indicated on the PHYSICIAN COMPARE website. In addition, the data submitted through PQRS will be utilized in future years to increase or decrease fee-for-service (FFS) payments based on the VM. The VM payment adjustment will begin in 2015, but the data utilized for the 2015 adjustment will be based on 2013 performance. Payment adjustment will apply to all physicians by 2017, based on their 2015 data. For most Medicare incentive programs, penalties will apply to the physician’s Medicare payments 2 years after their performance in the programs.
Providing data to PQRS is thus the key and may be submitted by physician group practices via the Group Practice Reporting Option (GPRO) or individually via claims, EHRs, or Qualified Registries, or Qualified Clinical Data Registries (QCDR). The ACS has two registries available to assist Fellows to be successful participants in the submission of data for the PQRS program. These are the Surgeon Specific Registry (SSR) Qualified Registry and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) QCDR.
Many surgeons are familiar with the SSR as the ACS Case Log system whereby data was collected for the American Board of Surgery Maintenance of Certification program. Through this online program, surgeons can report on either the Perioperative Measures Group or the General Surgery Measures Group. To be successful for 2014, and thus avoid a penalty applied to payment in 2016, reports on 20 majority Medicare patients for either of the two measures groups seen during calendar year 2014 should be submitted to the SSR by Jan, 31, 2015. The SSR will submit the PQRS data to CMS.
The SSR is available at no cost to ACS members. For those not familiar with the Case Log, they may register for same at https://www.facs.org/quality-programs/ssr. Surgeons must consent to and sign up for PQRS reporting through the SSR if they want their data submitted to CMS.
In sum, it is frequently said that the only constant is change. Though the administrative requirements are much different than they were in the past, the ACS is working hard to make resources available to assist members in being successful in the ever-changing health care environment. The following ACS staff members are available to answer questions and assist members in participating in the 2014 PQRS program, EHR Incentive Program, the VM and to facilitate enrollment in the SSR and MBSAQIP:
• General PQRS, EHR, and VM questions: Sana Gokak, ACS Division of Advocacy and Health Policy, 202/337-2701 or [email protected].
• Information on the SSR: Bianca Reyes, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
• Information on MBSAQIP: Rasa Krapikas, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
Until next month …
This month, I would like to call Fellows’ attention to some pending changes in the quality measures landscape, which can impact Medicare payment. By the time this issue goes to press, all Fellows should have received e-mail from ACS leadership referencing the document, “How to Avoid Medicare Penalties” available at . This document highlights the penalties Fellows might face if they do not participate in the various Medicare quality incentive programs. It also summarizes an excellent article in the September issue of the ACS Bulletin (Vol. 99, No. 9, pp. 28-32), “The benefits of PQRS participation and what the College is doing on your behalf,” by Charles D. Mabry, MD, FACS, Chair, ACS Health Policy Advisory Council (HPAC) and Sana Z. Gokak, MPH, a member of the Quality Affairs team here in the Washington office.
As most are acutely aware, the last few years have seen a change in the quantity and types of data collected by the Centers for Medicare & Medicaid Services (CMS). As part of this change, a shift has been made from the collection of administrative data toward collection of clinical data. Medicare payment has begun to shift from pay for reporting with the Physician Quality Reporting System (PQRS) program to pay for performance with the Value-Based Payment Modifier (VM).
The current calendar year of 2014 is the last year in which physicians may earn PQRS and Electronic Health Record (EHR) Incentive Program bonus payments based on their participation in CMS programs. Based on their record from 2014 of either successful participation or nonparticipation in the PQRS, VM, and EHR programs, surgeons’ Medicare payment could be impacted by up to a –6% in 2016. Whether or not providers participate in PQRS will also be indicated on the PHYSICIAN COMPARE website. The deadline for submission of data to CMS for 2014 is Jan. 31, 2015.
Physicians and other providers must submit data to the PQRS program in order to have such indicated on the PHYSICIAN COMPARE website. In addition, the data submitted through PQRS will be utilized in future years to increase or decrease fee-for-service (FFS) payments based on the VM. The VM payment adjustment will begin in 2015, but the data utilized for the 2015 adjustment will be based on 2013 performance. Payment adjustment will apply to all physicians by 2017, based on their 2015 data. For most Medicare incentive programs, penalties will apply to the physician’s Medicare payments 2 years after their performance in the programs.
Providing data to PQRS is thus the key and may be submitted by physician group practices via the Group Practice Reporting Option (GPRO) or individually via claims, EHRs, or Qualified Registries, or Qualified Clinical Data Registries (QCDR). The ACS has two registries available to assist Fellows to be successful participants in the submission of data for the PQRS program. These are the Surgeon Specific Registry (SSR) Qualified Registry and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) QCDR.
Many surgeons are familiar with the SSR as the ACS Case Log system whereby data was collected for the American Board of Surgery Maintenance of Certification program. Through this online program, surgeons can report on either the Perioperative Measures Group or the General Surgery Measures Group. To be successful for 2014, and thus avoid a penalty applied to payment in 2016, reports on 20 majority Medicare patients for either of the two measures groups seen during calendar year 2014 should be submitted to the SSR by Jan, 31, 2015. The SSR will submit the PQRS data to CMS.
The SSR is available at no cost to ACS members. For those not familiar with the Case Log, they may register for same at https://www.facs.org/quality-programs/ssr. Surgeons must consent to and sign up for PQRS reporting through the SSR if they want their data submitted to CMS.
In sum, it is frequently said that the only constant is change. Though the administrative requirements are much different than they were in the past, the ACS is working hard to make resources available to assist members in being successful in the ever-changing health care environment. The following ACS staff members are available to answer questions and assist members in participating in the 2014 PQRS program, EHR Incentive Program, the VM and to facilitate enrollment in the SSR and MBSAQIP:
• General PQRS, EHR, and VM questions: Sana Gokak, ACS Division of Advocacy and Health Policy, 202/337-2701 or [email protected].
• Information on the SSR: Bianca Reyes, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
• Information on MBSAQIP: Rasa Krapikas, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
Until next month …
From the Washington Office: Who we are and what we do
Senior staff of the Division of Advocacy and Health Policy was recently approached and asked to consider contributing a monthly column for ACS Surgery News. Unanimously, we agreed that it was imperative to do so and with this inaugural column, we embark on such an endeavor.
As many Fellows may be unfamiliar with the College’s Washington, DC, office and the Division of Advocacy and Health Policy, we thought it might be instructive with our first contribution to provide an overview of the office. However, being mindful of the proximity to the November elections, I will also refer Fellows to Election 2014: Issue-based considerations from a surgeon’s perspective in the Sept. 30th edition of the ACS Advocate for a quick refresher on some of the cogent issues expected to impact surgeons and their patients in the 114th Congress.
The ACS offices in Washington, DC, are located at 20 F St., NW, on the “Senate side” of Capitol Hill. The Division of Advocacy and Health Policy consists of 20 staff members working in the following areas: Legislative and Political Affairs, Quality Affairs, and Regulatory Affairs and State Affairs.
The Legislative and Political Affairs section currently consists of a Deputy Director, John Hedstrom, JD; as well as Manager of Political Affairs, Sara Morse; and lobbyists Matt Coffron and Heather Smith. Obviously, their focus is upon working toward the passage of legislation that furthers the College’s objectives of assuring access to quality surgical care. In the course of doing so, ACS staff routinely interface and work with not only individual members of Congress but also with congressional staff representing those individual members as well as the committee staff of the major committees of jurisdiction for our issues: 1) House Committee on Energy and Commerce; 2) House Ways and Means Committee; and 3) Senate Finance Committee. This section supports the College’s Legislative Committee.
ACSPA-SurgeonsPAC and the ACSPA-SurgeonsVoice platform of the Health Policy Advisory Council are managed by this section as well. The access to legislators facilitated by SurgeonsPAC enables us to have an opportunity to frame the argument on the issues affecting surgical patients and the practice of surgery. SurgeonsVoice provides resources for Fellows to develop relationships with their individual senators and representatives such that they too can actively participate in advocacy both at home via in-district meetings and here on Capitol Hill.
Though legislation and its attendant politics frequently garner more attention, it is the sections of Quality Affairs and Regulatory Affairs that concentrate on the effects of that successful legislation that becomes law and thus impacts surgeons and their patients. Staffing these sections are Manager of Regulatory Affairs, Vinita Ollapaly, JD; Manager of Quality Affairs, Jill Sage, MPH; as well as Sana Gokak, MPH; Neha Agrawal and Sarah Kurusz. Specific activities of this section include support of the General Surgery Coding and Reimbursement Committee and the annual ACS response to the Medicare Physician Fee Schedule proposed rule. This year that rule included proposals to eliminate 10- and 90-day global codes and to eliminate an exemption in the Open Payments (“Sunshine Act”) for physicians who serve as speakers at accredited CME programs. These areas of the ACS also assist Fellows in understanding and maintaining compliance with the Physician Quality Reporting System (PQRS). An excellent example of their work product can be found in the September issue of the ACS Bulletin entitled, “The benefits of PQRS participation and what the College is doing on your behalf (p. 28).
The State Affairs section moved to the Washington, DC, office from Chicago just over a year ago. Jon Sutton, who has been with ACS for 16 years, heads up this section and is assisted by Justin Rosen and Tara Leystra, MPH. Current active projects on which Jon and his team are engaged include obtaining coverage for bariatric surgery in the essential benefit packages of the various state exchanges, passage of the Uniform Emergency Volunteer Health Practitioners Act, as well as supporting the legislative and regulatory advocacy efforts of state chapters. The State Affairs section also supports the ACS delegation to the AMA House of Delegates and administers the State Lobby Day grant program.
The Director of the Division of Advocacy and Health Policy is Christian Shalgian, who has been with ACS for more than 16 years. Frank Opelka, MD, FACS (Medical Director for Quality and Health Policy) and I (Medical Director for Advocacy) are extremely pleased to have joined him this past June and look forward to assisting our Fellows and the College with challenges facing healthcare in the near and long-term future. We also look forward to contributing to ACS Surgery News as a means by which to communicate with you about our efforts relative to same.
Until next month …..
Dr. Bailey is a Pediatric Surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
Senior staff of the Division of Advocacy and Health Policy was recently approached and asked to consider contributing a monthly column for ACS Surgery News. Unanimously, we agreed that it was imperative to do so and with this inaugural column, we embark on such an endeavor.
As many Fellows may be unfamiliar with the College’s Washington, DC, office and the Division of Advocacy and Health Policy, we thought it might be instructive with our first contribution to provide an overview of the office. However, being mindful of the proximity to the November elections, I will also refer Fellows to Election 2014: Issue-based considerations from a surgeon’s perspective in the Sept. 30th edition of the ACS Advocate for a quick refresher on some of the cogent issues expected to impact surgeons and their patients in the 114th Congress.
The ACS offices in Washington, DC, are located at 20 F St., NW, on the “Senate side” of Capitol Hill. The Division of Advocacy and Health Policy consists of 20 staff members working in the following areas: Legislative and Political Affairs, Quality Affairs, and Regulatory Affairs and State Affairs.
The Legislative and Political Affairs section currently consists of a Deputy Director, John Hedstrom, JD; as well as Manager of Political Affairs, Sara Morse; and lobbyists Matt Coffron and Heather Smith. Obviously, their focus is upon working toward the passage of legislation that furthers the College’s objectives of assuring access to quality surgical care. In the course of doing so, ACS staff routinely interface and work with not only individual members of Congress but also with congressional staff representing those individual members as well as the committee staff of the major committees of jurisdiction for our issues: 1) House Committee on Energy and Commerce; 2) House Ways and Means Committee; and 3) Senate Finance Committee. This section supports the College’s Legislative Committee.
ACSPA-SurgeonsPAC and the ACSPA-SurgeonsVoice platform of the Health Policy Advisory Council are managed by this section as well. The access to legislators facilitated by SurgeonsPAC enables us to have an opportunity to frame the argument on the issues affecting surgical patients and the practice of surgery. SurgeonsVoice provides resources for Fellows to develop relationships with their individual senators and representatives such that they too can actively participate in advocacy both at home via in-district meetings and here on Capitol Hill.
Though legislation and its attendant politics frequently garner more attention, it is the sections of Quality Affairs and Regulatory Affairs that concentrate on the effects of that successful legislation that becomes law and thus impacts surgeons and their patients. Staffing these sections are Manager of Regulatory Affairs, Vinita Ollapaly, JD; Manager of Quality Affairs, Jill Sage, MPH; as well as Sana Gokak, MPH; Neha Agrawal and Sarah Kurusz. Specific activities of this section include support of the General Surgery Coding and Reimbursement Committee and the annual ACS response to the Medicare Physician Fee Schedule proposed rule. This year that rule included proposals to eliminate 10- and 90-day global codes and to eliminate an exemption in the Open Payments (“Sunshine Act”) for physicians who serve as speakers at accredited CME programs. These areas of the ACS also assist Fellows in understanding and maintaining compliance with the Physician Quality Reporting System (PQRS). An excellent example of their work product can be found in the September issue of the ACS Bulletin entitled, “The benefits of PQRS participation and what the College is doing on your behalf (p. 28).
The State Affairs section moved to the Washington, DC, office from Chicago just over a year ago. Jon Sutton, who has been with ACS for 16 years, heads up this section and is assisted by Justin Rosen and Tara Leystra, MPH. Current active projects on which Jon and his team are engaged include obtaining coverage for bariatric surgery in the essential benefit packages of the various state exchanges, passage of the Uniform Emergency Volunteer Health Practitioners Act, as well as supporting the legislative and regulatory advocacy efforts of state chapters. The State Affairs section also supports the ACS delegation to the AMA House of Delegates and administers the State Lobby Day grant program.
The Director of the Division of Advocacy and Health Policy is Christian Shalgian, who has been with ACS for more than 16 years. Frank Opelka, MD, FACS (Medical Director for Quality and Health Policy) and I (Medical Director for Advocacy) are extremely pleased to have joined him this past June and look forward to assisting our Fellows and the College with challenges facing healthcare in the near and long-term future. We also look forward to contributing to ACS Surgery News as a means by which to communicate with you about our efforts relative to same.
Until next month …..
Dr. Bailey is a Pediatric Surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
Senior staff of the Division of Advocacy and Health Policy was recently approached and asked to consider contributing a monthly column for ACS Surgery News. Unanimously, we agreed that it was imperative to do so and with this inaugural column, we embark on such an endeavor.
As many Fellows may be unfamiliar with the College’s Washington, DC, office and the Division of Advocacy and Health Policy, we thought it might be instructive with our first contribution to provide an overview of the office. However, being mindful of the proximity to the November elections, I will also refer Fellows to Election 2014: Issue-based considerations from a surgeon’s perspective in the Sept. 30th edition of the ACS Advocate for a quick refresher on some of the cogent issues expected to impact surgeons and their patients in the 114th Congress.
The ACS offices in Washington, DC, are located at 20 F St., NW, on the “Senate side” of Capitol Hill. The Division of Advocacy and Health Policy consists of 20 staff members working in the following areas: Legislative and Political Affairs, Quality Affairs, and Regulatory Affairs and State Affairs.
The Legislative and Political Affairs section currently consists of a Deputy Director, John Hedstrom, JD; as well as Manager of Political Affairs, Sara Morse; and lobbyists Matt Coffron and Heather Smith. Obviously, their focus is upon working toward the passage of legislation that furthers the College’s objectives of assuring access to quality surgical care. In the course of doing so, ACS staff routinely interface and work with not only individual members of Congress but also with congressional staff representing those individual members as well as the committee staff of the major committees of jurisdiction for our issues: 1) House Committee on Energy and Commerce; 2) House Ways and Means Committee; and 3) Senate Finance Committee. This section supports the College’s Legislative Committee.
ACSPA-SurgeonsPAC and the ACSPA-SurgeonsVoice platform of the Health Policy Advisory Council are managed by this section as well. The access to legislators facilitated by SurgeonsPAC enables us to have an opportunity to frame the argument on the issues affecting surgical patients and the practice of surgery. SurgeonsVoice provides resources for Fellows to develop relationships with their individual senators and representatives such that they too can actively participate in advocacy both at home via in-district meetings and here on Capitol Hill.
Though legislation and its attendant politics frequently garner more attention, it is the sections of Quality Affairs and Regulatory Affairs that concentrate on the effects of that successful legislation that becomes law and thus impacts surgeons and their patients. Staffing these sections are Manager of Regulatory Affairs, Vinita Ollapaly, JD; Manager of Quality Affairs, Jill Sage, MPH; as well as Sana Gokak, MPH; Neha Agrawal and Sarah Kurusz. Specific activities of this section include support of the General Surgery Coding and Reimbursement Committee and the annual ACS response to the Medicare Physician Fee Schedule proposed rule. This year that rule included proposals to eliminate 10- and 90-day global codes and to eliminate an exemption in the Open Payments (“Sunshine Act”) for physicians who serve as speakers at accredited CME programs. These areas of the ACS also assist Fellows in understanding and maintaining compliance with the Physician Quality Reporting System (PQRS). An excellent example of their work product can be found in the September issue of the ACS Bulletin entitled, “The benefits of PQRS participation and what the College is doing on your behalf (p. 28).
The State Affairs section moved to the Washington, DC, office from Chicago just over a year ago. Jon Sutton, who has been with ACS for 16 years, heads up this section and is assisted by Justin Rosen and Tara Leystra, MPH. Current active projects on which Jon and his team are engaged include obtaining coverage for bariatric surgery in the essential benefit packages of the various state exchanges, passage of the Uniform Emergency Volunteer Health Practitioners Act, as well as supporting the legislative and regulatory advocacy efforts of state chapters. The State Affairs section also supports the ACS delegation to the AMA House of Delegates and administers the State Lobby Day grant program.
The Director of the Division of Advocacy and Health Policy is Christian Shalgian, who has been with ACS for more than 16 years. Frank Opelka, MD, FACS (Medical Director for Quality and Health Policy) and I (Medical Director for Advocacy) are extremely pleased to have joined him this past June and look forward to assisting our Fellows and the College with challenges facing healthcare in the near and long-term future. We also look forward to contributing to ACS Surgery News as a means by which to communicate with you about our efforts relative to same.
Until next month …..
Dr. Bailey is a Pediatric Surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
