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Study pinpoints link between ERAS and acute kidney injury
JACKSONVILLE, FLA. – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data to monitor and improve their outcomes.
The rate of acute kidney injury (AKI) before ERAS was 7.1% ,compared with 13.6% after ERAS (P less than .01). After researchers adjusted for significant covariates, “ERAS patients were 2.3 times more likely to develop postoperative acute kidney injury,” Mr. Wiener said (P less than .01). That led the researchers to conclude that the ERAS protocol was independently associated with AKI following colorectal surgery. Average hospital stays for the ERAS group were less than half of those for the non-ERAS group, Wiener said: 3 days for the former vs. 7 days for the latter (P less than .01).
He noted that when UAB implemented ERAS for colorectal surgery, it also adopted the PDSA – Plan, Do, Study, Act – a cyclical quality improvement tool. “So we had done the study,” he said. “How do we act?”
Further investigation revealed the surgeons were using a stacked dosing of ketorolac with one dose at the end of the case and the next dose with initiation of the postoperative order set. “We eliminated the last intraoperative ketorolac dose to avoid the stacked dosing,” Wiener said. “Furthermore, we educated our residents to use ERAS as a guideline, but to always remember to treat the patient individually first.”
After that change, the subsequent semiannual ACS NSQIP report showed that UAB’s outcomes had improved. “We were able to go from the 10th decile for kidney failure after colorectal surgery to the first decile,” Wiener said.
“Moving forward, we will continue to monitor protocol outcomes in our ERAS patients and customize a pathway based on individual preoperative risk,” he said. That includes identifying optimal perioperative IV fluid management and refining multimodal pain management.
Mr. Wiener and coauthors had no financial relationships to disclose.
SOURCE: Wiener JG et al. Abstract 76.03
JACKSONVILLE, FLA. – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data to monitor and improve their outcomes.
The rate of acute kidney injury (AKI) before ERAS was 7.1% ,compared with 13.6% after ERAS (P less than .01). After researchers adjusted for significant covariates, “ERAS patients were 2.3 times more likely to develop postoperative acute kidney injury,” Mr. Wiener said (P less than .01). That led the researchers to conclude that the ERAS protocol was independently associated with AKI following colorectal surgery. Average hospital stays for the ERAS group were less than half of those for the non-ERAS group, Wiener said: 3 days for the former vs. 7 days for the latter (P less than .01).
He noted that when UAB implemented ERAS for colorectal surgery, it also adopted the PDSA – Plan, Do, Study, Act – a cyclical quality improvement tool. “So we had done the study,” he said. “How do we act?”
Further investigation revealed the surgeons were using a stacked dosing of ketorolac with one dose at the end of the case and the next dose with initiation of the postoperative order set. “We eliminated the last intraoperative ketorolac dose to avoid the stacked dosing,” Wiener said. “Furthermore, we educated our residents to use ERAS as a guideline, but to always remember to treat the patient individually first.”
After that change, the subsequent semiannual ACS NSQIP report showed that UAB’s outcomes had improved. “We were able to go from the 10th decile for kidney failure after colorectal surgery to the first decile,” Wiener said.
“Moving forward, we will continue to monitor protocol outcomes in our ERAS patients and customize a pathway based on individual preoperative risk,” he said. That includes identifying optimal perioperative IV fluid management and refining multimodal pain management.
Mr. Wiener and coauthors had no financial relationships to disclose.
SOURCE: Wiener JG et al. Abstract 76.03
JACKSONVILLE, FLA. – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data to monitor and improve their outcomes.
The rate of acute kidney injury (AKI) before ERAS was 7.1% ,compared with 13.6% after ERAS (P less than .01). After researchers adjusted for significant covariates, “ERAS patients were 2.3 times more likely to develop postoperative acute kidney injury,” Mr. Wiener said (P less than .01). That led the researchers to conclude that the ERAS protocol was independently associated with AKI following colorectal surgery. Average hospital stays for the ERAS group were less than half of those for the non-ERAS group, Wiener said: 3 days for the former vs. 7 days for the latter (P less than .01).
He noted that when UAB implemented ERAS for colorectal surgery, it also adopted the PDSA – Plan, Do, Study, Act – a cyclical quality improvement tool. “So we had done the study,” he said. “How do we act?”
Further investigation revealed the surgeons were using a stacked dosing of ketorolac with one dose at the end of the case and the next dose with initiation of the postoperative order set. “We eliminated the last intraoperative ketorolac dose to avoid the stacked dosing,” Wiener said. “Furthermore, we educated our residents to use ERAS as a guideline, but to always remember to treat the patient individually first.”
After that change, the subsequent semiannual ACS NSQIP report showed that UAB’s outcomes had improved. “We were able to go from the 10th decile for kidney failure after colorectal surgery to the first decile,” Wiener said.
“Moving forward, we will continue to monitor protocol outcomes in our ERAS patients and customize a pathway based on individual preoperative risk,” he said. That includes identifying optimal perioperative IV fluid management and refining multimodal pain management.
Mr. Wiener and coauthors had no financial relationships to disclose.
SOURCE: Wiener JG et al. Abstract 76.03
REPORTING FROM THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Implementation of the ERAS protocol for colorectal surgery was independently associated with acute kidney injury.
Major finding: After elective colorectal surgery, 13.6% of those in the ERAS protocol had acute kidney failure vs. 7.1 % of those who had surgery preprotocol (P less than .01).
Study details: Single-institution retrospective study of a prospectively maintained database containing 480 patients in the pre-ERAS group and 572 in the ERAS group.
Disclosures: The investigators reported having no financial disclosures.
Source: Wiener JG et al. Abstract 76.03.
VIDEO: Stroke benefits from stem cells maintained for 2 years
LOS ANGELES – , Gary K. Steinberg, MD, said at the International Stroke Conference, sponsored by the American Heart Association.
Seeing sustained benefit out to 2 years was “quite surprising. We thought we’d lose the benefit,” Dr. Steinberg said in a video interview.
The findings “change our notion of what happens after a stroke. The damaged circuits can be resurrected,” said Dr. Steinberg, professor and chair of neurosurgery at Stanford (Calif.) University.
He reported long-term follow-up data for 18 chronic stroke patients who had received transplantation of allogeneic bone marrow–derived stem cells. The study’s primary efficacy endpoint, at 6 months after treatment, showed clinically meaningful improvements in several measures of stroke disability and function in 13 of the 18 patients (72%), including a rise of at least 10 points in the Fugl-Meyer total motor function score.
His new report on 2-year follow-up showed that these 6-month improvements continued. The average increase in Fugl-Meyer score over baseline was about 18 points at 6, 12, and 24 months of follow-up.
Based on the promise shown in this pilot study, Dr. Steinberg and his associates are running a randomized study with 156 patients. Enrollment recently completed, and the results should be available during the second half of 2019, Dr. Steinberg said.
SanBio funded the study. Dr. Steinberg has been a consultant or advisor to Qool Therapeutics, Peter Lazic US, and NeuroSave.
SOURCE: Steinberg K et al. International Stroke Conference 2018, Abstract LB14.
LOS ANGELES – , Gary K. Steinberg, MD, said at the International Stroke Conference, sponsored by the American Heart Association.
Seeing sustained benefit out to 2 years was “quite surprising. We thought we’d lose the benefit,” Dr. Steinberg said in a video interview.
The findings “change our notion of what happens after a stroke. The damaged circuits can be resurrected,” said Dr. Steinberg, professor and chair of neurosurgery at Stanford (Calif.) University.
He reported long-term follow-up data for 18 chronic stroke patients who had received transplantation of allogeneic bone marrow–derived stem cells. The study’s primary efficacy endpoint, at 6 months after treatment, showed clinically meaningful improvements in several measures of stroke disability and function in 13 of the 18 patients (72%), including a rise of at least 10 points in the Fugl-Meyer total motor function score.
His new report on 2-year follow-up showed that these 6-month improvements continued. The average increase in Fugl-Meyer score over baseline was about 18 points at 6, 12, and 24 months of follow-up.
Based on the promise shown in this pilot study, Dr. Steinberg and his associates are running a randomized study with 156 patients. Enrollment recently completed, and the results should be available during the second half of 2019, Dr. Steinberg said.
SanBio funded the study. Dr. Steinberg has been a consultant or advisor to Qool Therapeutics, Peter Lazic US, and NeuroSave.
SOURCE: Steinberg K et al. International Stroke Conference 2018, Abstract LB14.
LOS ANGELES – , Gary K. Steinberg, MD, said at the International Stroke Conference, sponsored by the American Heart Association.
Seeing sustained benefit out to 2 years was “quite surprising. We thought we’d lose the benefit,” Dr. Steinberg said in a video interview.
The findings “change our notion of what happens after a stroke. The damaged circuits can be resurrected,” said Dr. Steinberg, professor and chair of neurosurgery at Stanford (Calif.) University.
He reported long-term follow-up data for 18 chronic stroke patients who had received transplantation of allogeneic bone marrow–derived stem cells. The study’s primary efficacy endpoint, at 6 months after treatment, showed clinically meaningful improvements in several measures of stroke disability and function in 13 of the 18 patients (72%), including a rise of at least 10 points in the Fugl-Meyer total motor function score.
His new report on 2-year follow-up showed that these 6-month improvements continued. The average increase in Fugl-Meyer score over baseline was about 18 points at 6, 12, and 24 months of follow-up.
Based on the promise shown in this pilot study, Dr. Steinberg and his associates are running a randomized study with 156 patients. Enrollment recently completed, and the results should be available during the second half of 2019, Dr. Steinberg said.
SanBio funded the study. Dr. Steinberg has been a consultant or advisor to Qool Therapeutics, Peter Lazic US, and NeuroSave.
SOURCE: Steinberg K et al. International Stroke Conference 2018, Abstract LB14.
REPORTING FROM ISC 2018
Key clinical point: The stroke benefits from cell transplantation continued during 2-year follow-up.
Major finding: Among 18 treated patients, 13 (72%) had a sustained, clinically meaningful rise in their total motor function score.
Study details: Review of 18 patients who received intracranial cell transplantations at two U.S. sites.
Disclosures: SanBio funded the study. Dr. Steinberg has been a consultant or adviser to Qool Therapeutics, Peter Lazic US, and NeuroSave.
Source: Steinberg K et al. International Stroke Conference 2018, Abstract LB14.
Application Deadline Extended for ACS and MacLean Center Fellowships in Surgical Ethics
The American College of Surgeons (ACS) Division of Education is offering fellowships in surgical ethics with the MacLean Center for Clinical Medical Ethics, University of Chicago, IL. The MacLean Center will prepare two surgeons for careers that combine clinical surgery with scholarly studies in surgical ethics, beginning with a five-week, full-time course in Chicago in July and August 2018. From September 2018 to June 2019, fellowship recipients will meet weekly for a structured ethics curriculum. In addition, fellows will participate in an ethics consultation service and complete a research project.
For additional information about this fellowship, contact Patrice Gabler Blair, MPH, Associate Director, ACS Division of Education, at [email protected]. Application materials are now due March 15.
The American College of Surgeons (ACS) Division of Education is offering fellowships in surgical ethics with the MacLean Center for Clinical Medical Ethics, University of Chicago, IL. The MacLean Center will prepare two surgeons for careers that combine clinical surgery with scholarly studies in surgical ethics, beginning with a five-week, full-time course in Chicago in July and August 2018. From September 2018 to June 2019, fellowship recipients will meet weekly for a structured ethics curriculum. In addition, fellows will participate in an ethics consultation service and complete a research project.
For additional information about this fellowship, contact Patrice Gabler Blair, MPH, Associate Director, ACS Division of Education, at [email protected]. Application materials are now due March 15.
The American College of Surgeons (ACS) Division of Education is offering fellowships in surgical ethics with the MacLean Center for Clinical Medical Ethics, University of Chicago, IL. The MacLean Center will prepare two surgeons for careers that combine clinical surgery with scholarly studies in surgical ethics, beginning with a five-week, full-time course in Chicago in July and August 2018. From September 2018 to June 2019, fellowship recipients will meet weekly for a structured ethics curriculum. In addition, fellows will participate in an ethics consultation service and complete a research project.
For additional information about this fellowship, contact Patrice Gabler Blair, MPH, Associate Director, ACS Division of Education, at [email protected]. Application materials are now due March 15.
Register for 2018 ACS Residents as Teachers and Leaders Course
Registration is open for the 12th annual Residents as Teachers and Leaders Course hosted by the American College of Surgeons (ACS) Division of Education. The 2018 program, April 13−15 at the ACS headquarters in Chicago, IL, is designed specifically for surgery residents and will address the essential nonclinical skills—teaching and leading—that are required for success as surgeons and members of the health care team.
The course faculty, all experts in resident education, will provide an interactive learning environment. Residents will learn to lead a team more effectively, resolve conflict, be better teachers, give constructive feedback, and apply these skills during and after residency. The number of participants is limited to allow ample interaction with faculty and to facilitate networking. This course is targeted at mid- to senior-level residents, but all are welcome to attend.
Registration information and a brochure are available on the course web page at www.facs.org/education/division-of-education/courses/residents-as-teachers; the advance registration discount ends March 16. Note that last year’s course was oversubscribed, so register soon if you are interested in attending. Contact Kim Echert at [email protected] or at 312-202-5488 with any questions.
Registration is open for the 12th annual Residents as Teachers and Leaders Course hosted by the American College of Surgeons (ACS) Division of Education. The 2018 program, April 13−15 at the ACS headquarters in Chicago, IL, is designed specifically for surgery residents and will address the essential nonclinical skills—teaching and leading—that are required for success as surgeons and members of the health care team.
The course faculty, all experts in resident education, will provide an interactive learning environment. Residents will learn to lead a team more effectively, resolve conflict, be better teachers, give constructive feedback, and apply these skills during and after residency. The number of participants is limited to allow ample interaction with faculty and to facilitate networking. This course is targeted at mid- to senior-level residents, but all are welcome to attend.
Registration information and a brochure are available on the course web page at www.facs.org/education/division-of-education/courses/residents-as-teachers; the advance registration discount ends March 16. Note that last year’s course was oversubscribed, so register soon if you are interested in attending. Contact Kim Echert at [email protected] or at 312-202-5488 with any questions.
Registration is open for the 12th annual Residents as Teachers and Leaders Course hosted by the American College of Surgeons (ACS) Division of Education. The 2018 program, April 13−15 at the ACS headquarters in Chicago, IL, is designed specifically for surgery residents and will address the essential nonclinical skills—teaching and leading—that are required for success as surgeons and members of the health care team.
The course faculty, all experts in resident education, will provide an interactive learning environment. Residents will learn to lead a team more effectively, resolve conflict, be better teachers, give constructive feedback, and apply these skills during and after residency. The number of participants is limited to allow ample interaction with faculty and to facilitate networking. This course is targeted at mid- to senior-level residents, but all are welcome to attend.
Registration information and a brochure are available on the course web page at www.facs.org/education/division-of-education/courses/residents-as-teachers; the advance registration discount ends March 16. Note that last year’s course was oversubscribed, so register soon if you are interested in attending. Contact Kim Echert at [email protected] or at 312-202-5488 with any questions.
Morbid, super obesity raises laparoscopic VHR risk
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
REPORTING FROM THE ANNUAL ACADEMIC SURGICAL CONGRESS
Key clinical point: Laparoscopic ventral hernia repair is associated with a significantly increased risk of complications in the morbidly and super obese.
Major finding: Individuals with a body mass index in the overweight range (BMI 25 to 29.99 kg/m2) had a complication rate of 3% vs. 6.9% for those with BMI greater than or equal to 50 kg/m2.
Story details: A retrospective analysis of 57,957 patients in the NSQIP database who had laparoscopic ventral hernia repair between 2005 and 2015.
Disclosures: Dr. Swendiman and coauthors reported having no financial disclosures.
Source: Academic Surgical Congress. Abstract 50.02.
Unscheduled visits for pain after hernia surgery common, costly
And although these calls and visits are costly in health care resources, many patients do not receive an actionable diagnosis, according to a study published in The American Journal of Surgery.
Colin G. DeLong, MD, and his colleagues reviewed health records of patients who underwent an open procedure for complex ventral hernia repair (cVHR) at Penn State Milton S. Hershey Medical Center in Hershey, Penn., between January 2013 and August 2015 using the American College of Surgeons National Surgery Quality Improvement Project (NSQIP) data available at the institution. They identified a cohort of 177 patients, 79% of whom were reviewed for pain issues at 1 year.
The study focused on postoperative pain during the first year following open cVHR. The investigators looked at how patients registered postoperative discomfort, risk factors that predicted greater utilization of the health system for pain-related complaints, and how often complaints of chronic pain resulted in an actionable diagnosis.
All postop encounters in the year after surgery were documented, including the sequence of events in response to pain complaints. In addition, the investigators recorded “instances in which a diagnosis resulted from such actions and whether the diagnosis was actionable, meaning it led to a specific intervention that was expected to alleviate the pain.”
Of the 177 patients, 91 patients made an unsolicited call, clinic visit, or ED visit for pain issues. For 38 patients in this group, action was taken (additional prescription, imaging ordered, ED workup recommended or undertaken). For the other 53, no action was taken. From each group, some cases resolved because of further intervention, and some cases resolved without further action. Mesh use and preoperative pain scores were predictors of postop pain, but not age, ethnicity, sex, or other comorbidities. But 38 (21%) patients continued to have pain that was not resolved at 1 year, 32 of which had no actionable diagnosis.
The study was retrospective and limited by inclusion of visits and calls only to the surgical services and not to other medical services or physicians. Pain complaints were subjective and levels of severity were not recorded.
The investigators concluded that estimates of the number of patients who have chronic pain after cVHR do not capture the level of health care resource utilization for this problem. Patients experiencing postop pain make unscheduled calls or visits to the clinic or ED, and many do so repeatedly without receiving an actionable diagnosis. “A cost analysis specific to treating postoperative pain for 1 year would provide a better understanding of the magnitude of the problem. Subjective complaints of pain in the year following cVHR are frequent and represent a hidden driver of resource utilization which must be better understood to achieve optimal, cost effective care.”
The authors declared no conflicts of interest.
SOURCE: DeLong CG et al. Am J Surg. 2018. doi: 10.1016/j.amjsurg.2018.01.030.
And although these calls and visits are costly in health care resources, many patients do not receive an actionable diagnosis, according to a study published in The American Journal of Surgery.
Colin G. DeLong, MD, and his colleagues reviewed health records of patients who underwent an open procedure for complex ventral hernia repair (cVHR) at Penn State Milton S. Hershey Medical Center in Hershey, Penn., between January 2013 and August 2015 using the American College of Surgeons National Surgery Quality Improvement Project (NSQIP) data available at the institution. They identified a cohort of 177 patients, 79% of whom were reviewed for pain issues at 1 year.
The study focused on postoperative pain during the first year following open cVHR. The investigators looked at how patients registered postoperative discomfort, risk factors that predicted greater utilization of the health system for pain-related complaints, and how often complaints of chronic pain resulted in an actionable diagnosis.
All postop encounters in the year after surgery were documented, including the sequence of events in response to pain complaints. In addition, the investigators recorded “instances in which a diagnosis resulted from such actions and whether the diagnosis was actionable, meaning it led to a specific intervention that was expected to alleviate the pain.”
Of the 177 patients, 91 patients made an unsolicited call, clinic visit, or ED visit for pain issues. For 38 patients in this group, action was taken (additional prescription, imaging ordered, ED workup recommended or undertaken). For the other 53, no action was taken. From each group, some cases resolved because of further intervention, and some cases resolved without further action. Mesh use and preoperative pain scores were predictors of postop pain, but not age, ethnicity, sex, or other comorbidities. But 38 (21%) patients continued to have pain that was not resolved at 1 year, 32 of which had no actionable diagnosis.
The study was retrospective and limited by inclusion of visits and calls only to the surgical services and not to other medical services or physicians. Pain complaints were subjective and levels of severity were not recorded.
The investigators concluded that estimates of the number of patients who have chronic pain after cVHR do not capture the level of health care resource utilization for this problem. Patients experiencing postop pain make unscheduled calls or visits to the clinic or ED, and many do so repeatedly without receiving an actionable diagnosis. “A cost analysis specific to treating postoperative pain for 1 year would provide a better understanding of the magnitude of the problem. Subjective complaints of pain in the year following cVHR are frequent and represent a hidden driver of resource utilization which must be better understood to achieve optimal, cost effective care.”
The authors declared no conflicts of interest.
SOURCE: DeLong CG et al. Am J Surg. 2018. doi: 10.1016/j.amjsurg.2018.01.030.
And although these calls and visits are costly in health care resources, many patients do not receive an actionable diagnosis, according to a study published in The American Journal of Surgery.
Colin G. DeLong, MD, and his colleagues reviewed health records of patients who underwent an open procedure for complex ventral hernia repair (cVHR) at Penn State Milton S. Hershey Medical Center in Hershey, Penn., between January 2013 and August 2015 using the American College of Surgeons National Surgery Quality Improvement Project (NSQIP) data available at the institution. They identified a cohort of 177 patients, 79% of whom were reviewed for pain issues at 1 year.
The study focused on postoperative pain during the first year following open cVHR. The investigators looked at how patients registered postoperative discomfort, risk factors that predicted greater utilization of the health system for pain-related complaints, and how often complaints of chronic pain resulted in an actionable diagnosis.
All postop encounters in the year after surgery were documented, including the sequence of events in response to pain complaints. In addition, the investigators recorded “instances in which a diagnosis resulted from such actions and whether the diagnosis was actionable, meaning it led to a specific intervention that was expected to alleviate the pain.”
Of the 177 patients, 91 patients made an unsolicited call, clinic visit, or ED visit for pain issues. For 38 patients in this group, action was taken (additional prescription, imaging ordered, ED workup recommended or undertaken). For the other 53, no action was taken. From each group, some cases resolved because of further intervention, and some cases resolved without further action. Mesh use and preoperative pain scores were predictors of postop pain, but not age, ethnicity, sex, or other comorbidities. But 38 (21%) patients continued to have pain that was not resolved at 1 year, 32 of which had no actionable diagnosis.
The study was retrospective and limited by inclusion of visits and calls only to the surgical services and not to other medical services or physicians. Pain complaints were subjective and levels of severity were not recorded.
The investigators concluded that estimates of the number of patients who have chronic pain after cVHR do not capture the level of health care resource utilization for this problem. Patients experiencing postop pain make unscheduled calls or visits to the clinic or ED, and many do so repeatedly without receiving an actionable diagnosis. “A cost analysis specific to treating postoperative pain for 1 year would provide a better understanding of the magnitude of the problem. Subjective complaints of pain in the year following cVHR are frequent and represent a hidden driver of resource utilization which must be better understood to achieve optimal, cost effective care.”
The authors declared no conflicts of interest.
SOURCE: DeLong CG et al. Am J Surg. 2018. doi: 10.1016/j.amjsurg.2018.01.030.
FROM THE AMERICAN JOURNAL OF SURGERY
Key clinical point: Chronic pain has a significant effect on resource utilization following complex ventral hernia repair.
Major finding: Of patients who made unscheduled calls or visits to the clinic or ED for postop pain, 21% did not receive an actionable diagnosis.
Study details: Records from the ACS NSQIP of 177 patients undergoing cVHR were reviewed for postop pain visits and follow-up.
Disclosures: The authors declared no conflicts of interest.
Source: DeLong CG et al. Am J Surg. 2018. doi: 10.1016/j.amjsurg.2018.01.030.
From the ACS President: The joy and privilege of a surgical career
As a Fellow of the American College of Surgeons (ACS), only you can recall the personal sacrifices you have made to attain the skills and knowledge necessary to enjoy the privilege of being a surgeon – years of missed time with family and friends, sleepless nights, and endless formative hours of deep experiential learning in the hospital. Someone else could have been there instead; you could have made a different career choice. But, no – surgery chose you, and you dove in. Thank you, thank you.
I hope you never lose sight of the lives you touched during those “lost” times – injured people, previously unknown neighbors with deadly diseases, or simply patients needing a little “repair.” People with a surgical disease are experiencing a rare life event: an operation. Never forget that each of those individuals, each patient, came to you – you personally – to help them.
Challenges
Regrettably, however, at times the cherished bond between a surgeon and a patient can get lost in our busy, burdened lives. It can get lost in physical fatigue, regulatory hoops, frustrations of the electronic health record, contract negotiations, challenging reimbursement policies, and on and on.
Add to that list other challenges that will surely arise in the course of your career: You will face various forms of threatened obsolescence in knowledge, skills, and technology. You will age. You will suffer personal tragedy and loss. You will become ill. That you may stumble when facing such challenges is not a sign of weakness. It is life.
I believe there is a bit of light ahead as our health care industry begins to recognize that this thing we call burnout is not a personal failing, but rather a function of our flawed work environments – and a significant threat not only to the surgeon, but also to patient safety, quality of care, and institutional financial stability. An active voice and actions in these essential domains of our work environment are mission critical for our College, as are efforts that are pursued on many fronts by Fellows and professionals in the Division of Advocacy and Health Policy in Washington, DC, and the Divisions of Research and Optimal Patient Care, Education, and Member Services in Chicago, IL. Fostering an environment to optimally support the care of the surgical patient – and surgeons – is core business in all we do in the ACS.
Let’s tackle a few other challenges. First, consider your personal and society’s investment in surgical training. Getting you to this skilled and knowledgeable point reflects an investment of more than $1 million dollars in costs of medical school and graduate medical education, and inestimable time and effort.
Second, the dire anticipated shortage of surgeons of many disciplines – general surgeons, orthopedists, urologists – appears to be real. If we are to keep our surgical pipeline full, we need to offer careers that are attractive to men and women equally. The U.S. general surgery pathway has entering classes of 40% women; however, other high-demand disciplines, such as neurosurgery, orthopedics, and cardiothoracic surgery, have not yet attracted women to their ranks in sufficient numbers, despite the fact that 50% of our medical school graduates are women. We need to examine the pathways to those surgical disciplines to ensure that gender- and ethnicity-based barriers are receding. Efforts are underway to address these challenges by the leadership in these disciplines that our College can help with.
Although much has changed for women in surgery in recent years, there are still differences in the lives of many female surgeons compared to their male colleagues. They remain at risk for pay inequity, being in aggregate compensated 10-17% less than their male colleagues for equal work. Despite a mature gender pipeline in some surgical specialties, women are still less likely to rise to leadership roles in their group practices, hospital structures, professional organizations, and academic institutions. The ACS can serve as a professional home to develop strategies to highlight and remedy these imbalances.
Parenting, to engage as fully and successfully as one may wish, is a challenge for many who choose our careers, regardless of gender. However, for most female surgeons beginning a family, the first step often comes with pregnancy and infant care, conditions that we have yet to embrace and support as a societal good rather than an individual’s gauntlet to run. Given our long and arduous educational pathways, these women often find themselves starting a family, be it by pregnancy or adoption, at the same moment they are beginning their busy early years of practice. Policies and practices to support surgeons who choose parenthood in the workforce are sorely needed and will, in fact, benefit all in the long run.
Our College, with guidance from the Women in Surgery Committee and the Association of Women Surgeons, has advanced that goal, issuing a statement that acknowledges the need for appropriate pregnancy and parental leave and that clearly articulates that the choice to become a parent in no way diminishes a surgeon’s commitment to career. The next steps will be building the institutional, financial, and community infrastructure to foster success in both career and parenting for all.
Retooling reimagined
Let’s ponder another challenge: the need to add to your repertoire a new, potentially transformative skill. How do we safely retool?
Twenty years ago, in the flawed early adoption of laparoscopic surgery, the ACS Committee on Emerging Surgical Technology Education articulated the principles of new skill acquisition: didactic learning, coupled with simulation-based training, and then proctored early experience, leading to independent practice and assessment of outcomes.
Subsequently, the College took the visionary step of establishing the ACS Accredited Education Institutes (AEI) program to develop a network of centers that would leverage emerging simulation technologies to enhance surgical training. The 96 national and international AEIs now serve as both educational and research centers to teach technical and nontechnical skills to surgeons and other health care professionals. At Houston Methodist Hospital, for example, we have built MITIE (Methodist Institute for Technology Innovation and Education), a comprehensive center with a focus on retooling surgeons in practice. We have hosted more than 13,000 surgeons in practice for retooling hands-on courses, along with more than 30,000 other health care professionals.
To ensure our surgical workforce stays at the top of their performance over a 40-year career, our College has convened a group of stakeholders, including payers, consumers, liability carriers, surgical technology industries, hospital executives, and, of course, surgeons, to define the infrastructure – facilities, faculty, curricula, assessment tools, and finances – needed to incorporate retooling and retraining into our health care system. Work to do.
Shape your future
The retooling reimagined initiative is but one example of how we can shape our professional futures. Remember, the ACS was founded nearly 105 years ago by surgeons who sought to improve the care of the surgical patient. Since then, individual surgeons, banding together within our College, have created some of the most effective systems in the world to improve surgical care – including the formation of the Committee on Trauma and the Commission on Cancer, which have led initiatives that have vastly improved care for their respective patient populations.
The ACS National Surgical Quality Improvement Program, born of the vision of Shukri Khuri, MD, FACS, who, when tasked with resolving a perceived problem in surgical care in the Veterans Affairs Health Care System, launched a research study to measure quality. Soon thereafter, he led an army of surgeons to improve surgical care in their own hospitals, founding a nationwide movement that now flourishes in thousands of hospitals as the world’s most effective surgical quality measurement and improvement system.
We can go on and on. A surgeon identifies a gap and with a good idea, and coupled to abundant College focus and the engagement of our Fellows, a valuable new program is launched. These initiatives were not delivered from on high. They were created by regular surgeons, like you and me, who saw gaps in their professional worlds and took steps to effect meaningful change.
Caring for each other
I have one more request: I want you to be aware of your colleagues. I want you to watch them for signs of stress and disturbances in their forces. And if you see something, ask a supportive question or offer needed assistance. Be aware of help that is available in your institution; know how to move a concern up the chain with sensitivity, but also with efficacy, coupled with compassionate concern for your colleague.
These are not easy discussions and may prove fruitless, but they are worth the effort to try, for we surgeons are a high-risk group for depression, substance abuse, and suicide – and for failing to seek assistance. This situation must change, but doing so will require that we destigmatize these conditions in ourselves and our colleagues, and destigmatize seeking assistance.
But, for now, on a joyful or a challenging day in your surgical life, I hope you are proud of your Fellowship in the ACS and your FACS initials that signify your commitment to the values of our profession. I hope you will draw endless support and friendship from those around you and that you will contribute more than you receive. And I hope that you will forever treasure your opportunity to practice as a surgeon, an exceptional joy and privilege.
Dr. Bass is the John F. and Carolyn Bookout Presidential Endowed Chair, professor of surgery and chair, department of surgery, Houston Methodist Hospital, TX, and the President of the American College of Surgeons (ACS).
As a Fellow of the American College of Surgeons (ACS), only you can recall the personal sacrifices you have made to attain the skills and knowledge necessary to enjoy the privilege of being a surgeon – years of missed time with family and friends, sleepless nights, and endless formative hours of deep experiential learning in the hospital. Someone else could have been there instead; you could have made a different career choice. But, no – surgery chose you, and you dove in. Thank you, thank you.
I hope you never lose sight of the lives you touched during those “lost” times – injured people, previously unknown neighbors with deadly diseases, or simply patients needing a little “repair.” People with a surgical disease are experiencing a rare life event: an operation. Never forget that each of those individuals, each patient, came to you – you personally – to help them.
Challenges
Regrettably, however, at times the cherished bond between a surgeon and a patient can get lost in our busy, burdened lives. It can get lost in physical fatigue, regulatory hoops, frustrations of the electronic health record, contract negotiations, challenging reimbursement policies, and on and on.
Add to that list other challenges that will surely arise in the course of your career: You will face various forms of threatened obsolescence in knowledge, skills, and technology. You will age. You will suffer personal tragedy and loss. You will become ill. That you may stumble when facing such challenges is not a sign of weakness. It is life.
I believe there is a bit of light ahead as our health care industry begins to recognize that this thing we call burnout is not a personal failing, but rather a function of our flawed work environments – and a significant threat not only to the surgeon, but also to patient safety, quality of care, and institutional financial stability. An active voice and actions in these essential domains of our work environment are mission critical for our College, as are efforts that are pursued on many fronts by Fellows and professionals in the Division of Advocacy and Health Policy in Washington, DC, and the Divisions of Research and Optimal Patient Care, Education, and Member Services in Chicago, IL. Fostering an environment to optimally support the care of the surgical patient – and surgeons – is core business in all we do in the ACS.
Let’s tackle a few other challenges. First, consider your personal and society’s investment in surgical training. Getting you to this skilled and knowledgeable point reflects an investment of more than $1 million dollars in costs of medical school and graduate medical education, and inestimable time and effort.
Second, the dire anticipated shortage of surgeons of many disciplines – general surgeons, orthopedists, urologists – appears to be real. If we are to keep our surgical pipeline full, we need to offer careers that are attractive to men and women equally. The U.S. general surgery pathway has entering classes of 40% women; however, other high-demand disciplines, such as neurosurgery, orthopedics, and cardiothoracic surgery, have not yet attracted women to their ranks in sufficient numbers, despite the fact that 50% of our medical school graduates are women. We need to examine the pathways to those surgical disciplines to ensure that gender- and ethnicity-based barriers are receding. Efforts are underway to address these challenges by the leadership in these disciplines that our College can help with.
Although much has changed for women in surgery in recent years, there are still differences in the lives of many female surgeons compared to their male colleagues. They remain at risk for pay inequity, being in aggregate compensated 10-17% less than their male colleagues for equal work. Despite a mature gender pipeline in some surgical specialties, women are still less likely to rise to leadership roles in their group practices, hospital structures, professional organizations, and academic institutions. The ACS can serve as a professional home to develop strategies to highlight and remedy these imbalances.
Parenting, to engage as fully and successfully as one may wish, is a challenge for many who choose our careers, regardless of gender. However, for most female surgeons beginning a family, the first step often comes with pregnancy and infant care, conditions that we have yet to embrace and support as a societal good rather than an individual’s gauntlet to run. Given our long and arduous educational pathways, these women often find themselves starting a family, be it by pregnancy or adoption, at the same moment they are beginning their busy early years of practice. Policies and practices to support surgeons who choose parenthood in the workforce are sorely needed and will, in fact, benefit all in the long run.
Our College, with guidance from the Women in Surgery Committee and the Association of Women Surgeons, has advanced that goal, issuing a statement that acknowledges the need for appropriate pregnancy and parental leave and that clearly articulates that the choice to become a parent in no way diminishes a surgeon’s commitment to career. The next steps will be building the institutional, financial, and community infrastructure to foster success in both career and parenting for all.
Retooling reimagined
Let’s ponder another challenge: the need to add to your repertoire a new, potentially transformative skill. How do we safely retool?
Twenty years ago, in the flawed early adoption of laparoscopic surgery, the ACS Committee on Emerging Surgical Technology Education articulated the principles of new skill acquisition: didactic learning, coupled with simulation-based training, and then proctored early experience, leading to independent practice and assessment of outcomes.
Subsequently, the College took the visionary step of establishing the ACS Accredited Education Institutes (AEI) program to develop a network of centers that would leverage emerging simulation technologies to enhance surgical training. The 96 national and international AEIs now serve as both educational and research centers to teach technical and nontechnical skills to surgeons and other health care professionals. At Houston Methodist Hospital, for example, we have built MITIE (Methodist Institute for Technology Innovation and Education), a comprehensive center with a focus on retooling surgeons in practice. We have hosted more than 13,000 surgeons in practice for retooling hands-on courses, along with more than 30,000 other health care professionals.
To ensure our surgical workforce stays at the top of their performance over a 40-year career, our College has convened a group of stakeholders, including payers, consumers, liability carriers, surgical technology industries, hospital executives, and, of course, surgeons, to define the infrastructure – facilities, faculty, curricula, assessment tools, and finances – needed to incorporate retooling and retraining into our health care system. Work to do.
Shape your future
The retooling reimagined initiative is but one example of how we can shape our professional futures. Remember, the ACS was founded nearly 105 years ago by surgeons who sought to improve the care of the surgical patient. Since then, individual surgeons, banding together within our College, have created some of the most effective systems in the world to improve surgical care – including the formation of the Committee on Trauma and the Commission on Cancer, which have led initiatives that have vastly improved care for their respective patient populations.
The ACS National Surgical Quality Improvement Program, born of the vision of Shukri Khuri, MD, FACS, who, when tasked with resolving a perceived problem in surgical care in the Veterans Affairs Health Care System, launched a research study to measure quality. Soon thereafter, he led an army of surgeons to improve surgical care in their own hospitals, founding a nationwide movement that now flourishes in thousands of hospitals as the world’s most effective surgical quality measurement and improvement system.
We can go on and on. A surgeon identifies a gap and with a good idea, and coupled to abundant College focus and the engagement of our Fellows, a valuable new program is launched. These initiatives were not delivered from on high. They were created by regular surgeons, like you and me, who saw gaps in their professional worlds and took steps to effect meaningful change.
Caring for each other
I have one more request: I want you to be aware of your colleagues. I want you to watch them for signs of stress and disturbances in their forces. And if you see something, ask a supportive question or offer needed assistance. Be aware of help that is available in your institution; know how to move a concern up the chain with sensitivity, but also with efficacy, coupled with compassionate concern for your colleague.
These are not easy discussions and may prove fruitless, but they are worth the effort to try, for we surgeons are a high-risk group for depression, substance abuse, and suicide – and for failing to seek assistance. This situation must change, but doing so will require that we destigmatize these conditions in ourselves and our colleagues, and destigmatize seeking assistance.
But, for now, on a joyful or a challenging day in your surgical life, I hope you are proud of your Fellowship in the ACS and your FACS initials that signify your commitment to the values of our profession. I hope you will draw endless support and friendship from those around you and that you will contribute more than you receive. And I hope that you will forever treasure your opportunity to practice as a surgeon, an exceptional joy and privilege.
Dr. Bass is the John F. and Carolyn Bookout Presidential Endowed Chair, professor of surgery and chair, department of surgery, Houston Methodist Hospital, TX, and the President of the American College of Surgeons (ACS).
As a Fellow of the American College of Surgeons (ACS), only you can recall the personal sacrifices you have made to attain the skills and knowledge necessary to enjoy the privilege of being a surgeon – years of missed time with family and friends, sleepless nights, and endless formative hours of deep experiential learning in the hospital. Someone else could have been there instead; you could have made a different career choice. But, no – surgery chose you, and you dove in. Thank you, thank you.
I hope you never lose sight of the lives you touched during those “lost” times – injured people, previously unknown neighbors with deadly diseases, or simply patients needing a little “repair.” People with a surgical disease are experiencing a rare life event: an operation. Never forget that each of those individuals, each patient, came to you – you personally – to help them.
Challenges
Regrettably, however, at times the cherished bond between a surgeon and a patient can get lost in our busy, burdened lives. It can get lost in physical fatigue, regulatory hoops, frustrations of the electronic health record, contract negotiations, challenging reimbursement policies, and on and on.
Add to that list other challenges that will surely arise in the course of your career: You will face various forms of threatened obsolescence in knowledge, skills, and technology. You will age. You will suffer personal tragedy and loss. You will become ill. That you may stumble when facing such challenges is not a sign of weakness. It is life.
I believe there is a bit of light ahead as our health care industry begins to recognize that this thing we call burnout is not a personal failing, but rather a function of our flawed work environments – and a significant threat not only to the surgeon, but also to patient safety, quality of care, and institutional financial stability. An active voice and actions in these essential domains of our work environment are mission critical for our College, as are efforts that are pursued on many fronts by Fellows and professionals in the Division of Advocacy and Health Policy in Washington, DC, and the Divisions of Research and Optimal Patient Care, Education, and Member Services in Chicago, IL. Fostering an environment to optimally support the care of the surgical patient – and surgeons – is core business in all we do in the ACS.
Let’s tackle a few other challenges. First, consider your personal and society’s investment in surgical training. Getting you to this skilled and knowledgeable point reflects an investment of more than $1 million dollars in costs of medical school and graduate medical education, and inestimable time and effort.
Second, the dire anticipated shortage of surgeons of many disciplines – general surgeons, orthopedists, urologists – appears to be real. If we are to keep our surgical pipeline full, we need to offer careers that are attractive to men and women equally. The U.S. general surgery pathway has entering classes of 40% women; however, other high-demand disciplines, such as neurosurgery, orthopedics, and cardiothoracic surgery, have not yet attracted women to their ranks in sufficient numbers, despite the fact that 50% of our medical school graduates are women. We need to examine the pathways to those surgical disciplines to ensure that gender- and ethnicity-based barriers are receding. Efforts are underway to address these challenges by the leadership in these disciplines that our College can help with.
Although much has changed for women in surgery in recent years, there are still differences in the lives of many female surgeons compared to their male colleagues. They remain at risk for pay inequity, being in aggregate compensated 10-17% less than their male colleagues for equal work. Despite a mature gender pipeline in some surgical specialties, women are still less likely to rise to leadership roles in their group practices, hospital structures, professional organizations, and academic institutions. The ACS can serve as a professional home to develop strategies to highlight and remedy these imbalances.
Parenting, to engage as fully and successfully as one may wish, is a challenge for many who choose our careers, regardless of gender. However, for most female surgeons beginning a family, the first step often comes with pregnancy and infant care, conditions that we have yet to embrace and support as a societal good rather than an individual’s gauntlet to run. Given our long and arduous educational pathways, these women often find themselves starting a family, be it by pregnancy or adoption, at the same moment they are beginning their busy early years of practice. Policies and practices to support surgeons who choose parenthood in the workforce are sorely needed and will, in fact, benefit all in the long run.
Our College, with guidance from the Women in Surgery Committee and the Association of Women Surgeons, has advanced that goal, issuing a statement that acknowledges the need for appropriate pregnancy and parental leave and that clearly articulates that the choice to become a parent in no way diminishes a surgeon’s commitment to career. The next steps will be building the institutional, financial, and community infrastructure to foster success in both career and parenting for all.
Retooling reimagined
Let’s ponder another challenge: the need to add to your repertoire a new, potentially transformative skill. How do we safely retool?
Twenty years ago, in the flawed early adoption of laparoscopic surgery, the ACS Committee on Emerging Surgical Technology Education articulated the principles of new skill acquisition: didactic learning, coupled with simulation-based training, and then proctored early experience, leading to independent practice and assessment of outcomes.
Subsequently, the College took the visionary step of establishing the ACS Accredited Education Institutes (AEI) program to develop a network of centers that would leverage emerging simulation technologies to enhance surgical training. The 96 national and international AEIs now serve as both educational and research centers to teach technical and nontechnical skills to surgeons and other health care professionals. At Houston Methodist Hospital, for example, we have built MITIE (Methodist Institute for Technology Innovation and Education), a comprehensive center with a focus on retooling surgeons in practice. We have hosted more than 13,000 surgeons in practice for retooling hands-on courses, along with more than 30,000 other health care professionals.
To ensure our surgical workforce stays at the top of their performance over a 40-year career, our College has convened a group of stakeholders, including payers, consumers, liability carriers, surgical technology industries, hospital executives, and, of course, surgeons, to define the infrastructure – facilities, faculty, curricula, assessment tools, and finances – needed to incorporate retooling and retraining into our health care system. Work to do.
Shape your future
The retooling reimagined initiative is but one example of how we can shape our professional futures. Remember, the ACS was founded nearly 105 years ago by surgeons who sought to improve the care of the surgical patient. Since then, individual surgeons, banding together within our College, have created some of the most effective systems in the world to improve surgical care – including the formation of the Committee on Trauma and the Commission on Cancer, which have led initiatives that have vastly improved care for their respective patient populations.
The ACS National Surgical Quality Improvement Program, born of the vision of Shukri Khuri, MD, FACS, who, when tasked with resolving a perceived problem in surgical care in the Veterans Affairs Health Care System, launched a research study to measure quality. Soon thereafter, he led an army of surgeons to improve surgical care in their own hospitals, founding a nationwide movement that now flourishes in thousands of hospitals as the world’s most effective surgical quality measurement and improvement system.
We can go on and on. A surgeon identifies a gap and with a good idea, and coupled to abundant College focus and the engagement of our Fellows, a valuable new program is launched. These initiatives were not delivered from on high. They were created by regular surgeons, like you and me, who saw gaps in their professional worlds and took steps to effect meaningful change.
Caring for each other
I have one more request: I want you to be aware of your colleagues. I want you to watch them for signs of stress and disturbances in their forces. And if you see something, ask a supportive question or offer needed assistance. Be aware of help that is available in your institution; know how to move a concern up the chain with sensitivity, but also with efficacy, coupled with compassionate concern for your colleague.
These are not easy discussions and may prove fruitless, but they are worth the effort to try, for we surgeons are a high-risk group for depression, substance abuse, and suicide – and for failing to seek assistance. This situation must change, but doing so will require that we destigmatize these conditions in ourselves and our colleagues, and destigmatize seeking assistance.
But, for now, on a joyful or a challenging day in your surgical life, I hope you are proud of your Fellowship in the ACS and your FACS initials that signify your commitment to the values of our profession. I hope you will draw endless support and friendship from those around you and that you will contribute more than you receive. And I hope that you will forever treasure your opportunity to practice as a surgeon, an exceptional joy and privilege.
Dr. Bass is the John F. and Carolyn Bookout Presidential Endowed Chair, professor of surgery and chair, department of surgery, Houston Methodist Hospital, TX, and the President of the American College of Surgeons (ACS).
From the Editors: An unexpected call to action
In the waning weeks of 2017, still another disaster was added to the long list of natural and man-made tragedies of the year: the derailment of an Amtrak train near Tacoma, Washington. Although the cause of this event has not yet been determined and will not be for at least several months, we do know that safety equipment that has been recommended for years had not been installed in the train. I can only hope that this accident reminds our governmental leaders and institutional officials of the costs in lives and injury of ignoring deteriorating infrastructure and neglecting known safety measures.
An eyewitness and participant in the response to the accident was the Oregon Health & Science University Chair of Neurological Surgery, Nathan Selden, MD, PhD, FACS, who was driving north on Interstate 5 that morning with his 18-year-old son. I spoke recently with Dr. Selden to obtain his first-hand impressions of the experience.
They came upon the scene of the derailment shortly after it had occurred. He recognized immediately the horrifying potential for serious injuries and fatalities. First responders were already arriving on the scene and Dr. Selden offered his services to assist the injured. The first responders eagerly accepted his offer, and he spent the next two hours working with another MD and one RN from nearby Joint Base Lewis-McChord and a large number of EMTs and firefighters mobilized from nearby communities. The team of emergency workers removed almost 80 victims from precariously dangling train cars, provided first aid and basic trauma care, and triaged the victims to the most appropriate next site for treatment. Dr. Selden was most impressed by the courage of the firefighters who climbed into two train cars hanging off the highway overpass. He commented, “They were awesome, working in incredibly risky conditions.”
A pediatric neurosurgeon in his daily work, Dr. Selden is not in the habit of performing the duties that he did that day, but he used his expertise in trauma to assess the victims’ injuries, listing their problems on tags hung around their necks and advising the scene commander about what kind of specialist each patient would likely need. The commander could then direct ambulances to the most appropriate nearby facility for definitive care.
Although most of the hastily assembled emergency response team were strangers to one another, Dr. Selden remarked that “they all worked together efficiently” at a scene that he described as “orderly, purposeful chaos” to stop bleeding, bandage cuts, splint fractures, apply cervical collars, place the injured on backboards, and reassure and calm the victims, who were understandably scared and in shock. Dr. Selden modestly downplayed his role at the scene, and praised the EMTs, firefighters, and police for their leadership and professionalism in organizing and coordinating everyone efficiently and expertly. His comments about the experience focused on the effective way that the caregivers at the scene did their jobs and emphasized how long the road to healing will be for many of the injured. These victims will be in need of support and healing long after the public’s attention has moved on from the drama of that remarkably devastating event. For many of them and their families, he soberly noted, “their lives will be changed forever.” His comments reflect his deep understanding of the implications of the victims’ injuries, many of which involved his area of expertise, neurosurgical trauma.
Few of us will be called on during our careers to step out of our comfort zone to provide emergency care in a situation as far from our normal daily environment as this one was. But if we are, we would do well to follow the lead exemplified by Dr. Selden: call on the basic skills that we as surgeons all possess, work collaboratively with those trained to be first responders and rescuers, and acknowledge the profound and long-lasting effect such a calamity has on all of those who experience it.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
In the waning weeks of 2017, still another disaster was added to the long list of natural and man-made tragedies of the year: the derailment of an Amtrak train near Tacoma, Washington. Although the cause of this event has not yet been determined and will not be for at least several months, we do know that safety equipment that has been recommended for years had not been installed in the train. I can only hope that this accident reminds our governmental leaders and institutional officials of the costs in lives and injury of ignoring deteriorating infrastructure and neglecting known safety measures.
An eyewitness and participant in the response to the accident was the Oregon Health & Science University Chair of Neurological Surgery, Nathan Selden, MD, PhD, FACS, who was driving north on Interstate 5 that morning with his 18-year-old son. I spoke recently with Dr. Selden to obtain his first-hand impressions of the experience.
They came upon the scene of the derailment shortly after it had occurred. He recognized immediately the horrifying potential for serious injuries and fatalities. First responders were already arriving on the scene and Dr. Selden offered his services to assist the injured. The first responders eagerly accepted his offer, and he spent the next two hours working with another MD and one RN from nearby Joint Base Lewis-McChord and a large number of EMTs and firefighters mobilized from nearby communities. The team of emergency workers removed almost 80 victims from precariously dangling train cars, provided first aid and basic trauma care, and triaged the victims to the most appropriate next site for treatment. Dr. Selden was most impressed by the courage of the firefighters who climbed into two train cars hanging off the highway overpass. He commented, “They were awesome, working in incredibly risky conditions.”
A pediatric neurosurgeon in his daily work, Dr. Selden is not in the habit of performing the duties that he did that day, but he used his expertise in trauma to assess the victims’ injuries, listing their problems on tags hung around their necks and advising the scene commander about what kind of specialist each patient would likely need. The commander could then direct ambulances to the most appropriate nearby facility for definitive care.
Although most of the hastily assembled emergency response team were strangers to one another, Dr. Selden remarked that “they all worked together efficiently” at a scene that he described as “orderly, purposeful chaos” to stop bleeding, bandage cuts, splint fractures, apply cervical collars, place the injured on backboards, and reassure and calm the victims, who were understandably scared and in shock. Dr. Selden modestly downplayed his role at the scene, and praised the EMTs, firefighters, and police for their leadership and professionalism in organizing and coordinating everyone efficiently and expertly. His comments about the experience focused on the effective way that the caregivers at the scene did their jobs and emphasized how long the road to healing will be for many of the injured. These victims will be in need of support and healing long after the public’s attention has moved on from the drama of that remarkably devastating event. For many of them and their families, he soberly noted, “their lives will be changed forever.” His comments reflect his deep understanding of the implications of the victims’ injuries, many of which involved his area of expertise, neurosurgical trauma.
Few of us will be called on during our careers to step out of our comfort zone to provide emergency care in a situation as far from our normal daily environment as this one was. But if we are, we would do well to follow the lead exemplified by Dr. Selden: call on the basic skills that we as surgeons all possess, work collaboratively with those trained to be first responders and rescuers, and acknowledge the profound and long-lasting effect such a calamity has on all of those who experience it.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
In the waning weeks of 2017, still another disaster was added to the long list of natural and man-made tragedies of the year: the derailment of an Amtrak train near Tacoma, Washington. Although the cause of this event has not yet been determined and will not be for at least several months, we do know that safety equipment that has been recommended for years had not been installed in the train. I can only hope that this accident reminds our governmental leaders and institutional officials of the costs in lives and injury of ignoring deteriorating infrastructure and neglecting known safety measures.
An eyewitness and participant in the response to the accident was the Oregon Health & Science University Chair of Neurological Surgery, Nathan Selden, MD, PhD, FACS, who was driving north on Interstate 5 that morning with his 18-year-old son. I spoke recently with Dr. Selden to obtain his first-hand impressions of the experience.
They came upon the scene of the derailment shortly after it had occurred. He recognized immediately the horrifying potential for serious injuries and fatalities. First responders were already arriving on the scene and Dr. Selden offered his services to assist the injured. The first responders eagerly accepted his offer, and he spent the next two hours working with another MD and one RN from nearby Joint Base Lewis-McChord and a large number of EMTs and firefighters mobilized from nearby communities. The team of emergency workers removed almost 80 victims from precariously dangling train cars, provided first aid and basic trauma care, and triaged the victims to the most appropriate next site for treatment. Dr. Selden was most impressed by the courage of the firefighters who climbed into two train cars hanging off the highway overpass. He commented, “They were awesome, working in incredibly risky conditions.”
A pediatric neurosurgeon in his daily work, Dr. Selden is not in the habit of performing the duties that he did that day, but he used his expertise in trauma to assess the victims’ injuries, listing their problems on tags hung around their necks and advising the scene commander about what kind of specialist each patient would likely need. The commander could then direct ambulances to the most appropriate nearby facility for definitive care.
Although most of the hastily assembled emergency response team were strangers to one another, Dr. Selden remarked that “they all worked together efficiently” at a scene that he described as “orderly, purposeful chaos” to stop bleeding, bandage cuts, splint fractures, apply cervical collars, place the injured on backboards, and reassure and calm the victims, who were understandably scared and in shock. Dr. Selden modestly downplayed his role at the scene, and praised the EMTs, firefighters, and police for their leadership and professionalism in organizing and coordinating everyone efficiently and expertly. His comments about the experience focused on the effective way that the caregivers at the scene did their jobs and emphasized how long the road to healing will be for many of the injured. These victims will be in need of support and healing long after the public’s attention has moved on from the drama of that remarkably devastating event. For many of them and their families, he soberly noted, “their lives will be changed forever.” His comments reflect his deep understanding of the implications of the victims’ injuries, many of which involved his area of expertise, neurosurgical trauma.
Few of us will be called on during our careers to step out of our comfort zone to provide emergency care in a situation as far from our normal daily environment as this one was. But if we are, we would do well to follow the lead exemplified by Dr. Selden: call on the basic skills that we as surgeons all possess, work collaboratively with those trained to be first responders and rescuers, and acknowledge the profound and long-lasting effect such a calamity has on all of those who experience it.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
From the Washington Office: MIPS 2018 … Determining your status, making your plan
Surgeons’ practice situations vary. Therefore, for various reasons, surgeons may not be required to participate in MIPS, or they may not be eligible to do so. For 2018, the Centers for Medicare & Medicaid Services (CMS) estimates that approximately 40 percent of eligible clinicians will be required to submit data under MIPS. Furthermore, many providers (particularly those who are employed or are in large group practices) will have data submitted on their behalf by their groups, institutions, or employers. It is thus imperative that surgeons determine whether they are exempt from participating in the MIPS program. If not exempt, they should then determine if their practice situation necessitates that they report their own individual MIPS data for 2018 or, alternatively, if data will be reported for their groups, institutions, or employers.
If you are a Qualifying Participant (QP) in an Advanced Alternative Payment Model (APM), you are exempt from reporting MIPS data. If you are unsure of your status as such a participant, you can use you NPI number to determine your status at data.cms.gov/qplookup. QPs are not only exempt from reporting MIPS data, but could receive a 5 percent bonus in 2020 for participation in 2018.
For 2018, CMS increased the low-volume threshold. The low-volume threshold is now set at less than or equal to $90,000 in Medicare Part B allowable charges or 200 or fewer Medicare Part B patients seen during the period selected by CMS. Because this threshold represents an increase compared to 2017, it will result in even more providers being exempted from participating in MIPS. It should be noted that failure to meet either of these thresholds, $90,000 in allowable charges or 200 Medicare Part B patients, is sufficient to exclude one from reporting MIPS data in 2018. As was the case in 2017, we anticipate that CMS will notify those providers who are exempt based on the low-volume threshold within the first or second quarter of 2018. Alternatively, surgeons may use their NPI to check their status relative to MIPS reporting at qpp.cms.gov/participation-lookup.
To determine whether MIPS applies to your practice circumstances, you can use the following simple steps:
1) Are you a participant in a qualified advanced alternative payment model (A-APM)? If you are unsure, you can use your National Provider Identifier (NPI) number to look up your status at data.cms.gov/qplookup. If you are a qualified participant in an A-APM, you are not only exempt from reporting MIPS data, but you could also receive a 5 percent bonus in 2020 for your participation in 2018.
2) Are you exempt from participating in MIPS based on the low-volume threshold? As mentioned above, for 2018, the increase in the low-volume threshold is expected to exclude a significant number of providers. To determine if you are exempt based on the low-volume threshold, use your NPI number at qpp.cms.gov/participation-lookup.
3) Are your MIPS data reported for you by your institution, your employer, or your group? If your data are being reported for you then you need take no further action. You should contact your institution, employer, or group to confirm that data are being reported for you.
If MIPS applies to your practice, you need to make a choice between:
1) Submitting the minimum data necessary to avoid a penalty, and accept a freeze in your payments in 2020 for the 2018 performance period.
or
2) Submitting data in an effort to compete for a positive update.
If you prefer to submit the minimum amount of data necessary to avoid a penalty, your best option is to complete the requirements for the Improvement Activities (IA) component of MIPS. By achieving full credit in this category of MIPS, you will acquire enough points (15) to reach the performance threshold in your MIPS final score to avoid a 5 percent penalty in your Medicare payments in 2020 based on your performance and participation in 2018.
Within the IA category, each activity is assigned either a high (20 points) or medium (10 points) weight. To receive full credit in the IA component, most surgeons must select and attest to having completed between two and four activities for a total of 40 points in the IA category. For small practices or rural practices to achieve full credit, only one high-value or two medium-value activities are required. CMS defines small practices as those consisting of 15 or fewer eligible clinicians. The Centers for Medicare and Medicaid Services defines rural practices as those where more than 75 percent of the NPIs billing under the individual MIPS eligible clinician or group’s Tax Identification Number (TIN) are designated in a ZIP code as a rural area or Health Professional Shortage Area (HPSA), based on the most recent Health Resources and Services Administration Area Health Resource File data set.
Those who fulfill these requirements will receive the maximum score and full credit in the IA category toward their MIPS Final Score (15 points). Because the performance threshold for 2018 is set at 15 points, those who wish to avoid a payment penalty can acquire the required number of points to avoid a penalty for their performance in 2018 by simply fulfilling the IA requirements.
Attestation to having completed the Improvement Activities can be accomplished via a qualified registry, qualified clinical data registry (QCDR), an electronic health record (EHR), or the QPP Data Submission System (accessible at qpp.cms.gov/login). The American College of Surgeons (ACS) has two QCDRs, the Surgeon Specific Registry (SSR) and the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) Data Registry. Both can be used to attest to completing the IAs.
If you plan to compete for a positive update in 2020 based on your performance in 2018, you should ideally report on the Quality, Advancing Care Information (ACI), and Improvement Activities categories of MIPS. If this is your intent, we recommend you obtain a copy of our new 2018 MACRA manual, visit facs.org/qpp, and make your plan for 2018.
Regardless of your choice, ACS staff in the DC office and the SSR are here to help and can be reached at 202-337-2701 (DC) or 312-202-5408 (SSR).
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.
Surgeons’ practice situations vary. Therefore, for various reasons, surgeons may not be required to participate in MIPS, or they may not be eligible to do so. For 2018, the Centers for Medicare & Medicaid Services (CMS) estimates that approximately 40 percent of eligible clinicians will be required to submit data under MIPS. Furthermore, many providers (particularly those who are employed or are in large group practices) will have data submitted on their behalf by their groups, institutions, or employers. It is thus imperative that surgeons determine whether they are exempt from participating in the MIPS program. If not exempt, they should then determine if their practice situation necessitates that they report their own individual MIPS data for 2018 or, alternatively, if data will be reported for their groups, institutions, or employers.
If you are a Qualifying Participant (QP) in an Advanced Alternative Payment Model (APM), you are exempt from reporting MIPS data. If you are unsure of your status as such a participant, you can use you NPI number to determine your status at data.cms.gov/qplookup. QPs are not only exempt from reporting MIPS data, but could receive a 5 percent bonus in 2020 for participation in 2018.
For 2018, CMS increased the low-volume threshold. The low-volume threshold is now set at less than or equal to $90,000 in Medicare Part B allowable charges or 200 or fewer Medicare Part B patients seen during the period selected by CMS. Because this threshold represents an increase compared to 2017, it will result in even more providers being exempted from participating in MIPS. It should be noted that failure to meet either of these thresholds, $90,000 in allowable charges or 200 Medicare Part B patients, is sufficient to exclude one from reporting MIPS data in 2018. As was the case in 2017, we anticipate that CMS will notify those providers who are exempt based on the low-volume threshold within the first or second quarter of 2018. Alternatively, surgeons may use their NPI to check their status relative to MIPS reporting at qpp.cms.gov/participation-lookup.
To determine whether MIPS applies to your practice circumstances, you can use the following simple steps:
1) Are you a participant in a qualified advanced alternative payment model (A-APM)? If you are unsure, you can use your National Provider Identifier (NPI) number to look up your status at data.cms.gov/qplookup. If you are a qualified participant in an A-APM, you are not only exempt from reporting MIPS data, but you could also receive a 5 percent bonus in 2020 for your participation in 2018.
2) Are you exempt from participating in MIPS based on the low-volume threshold? As mentioned above, for 2018, the increase in the low-volume threshold is expected to exclude a significant number of providers. To determine if you are exempt based on the low-volume threshold, use your NPI number at qpp.cms.gov/participation-lookup.
3) Are your MIPS data reported for you by your institution, your employer, or your group? If your data are being reported for you then you need take no further action. You should contact your institution, employer, or group to confirm that data are being reported for you.
If MIPS applies to your practice, you need to make a choice between:
1) Submitting the minimum data necessary to avoid a penalty, and accept a freeze in your payments in 2020 for the 2018 performance period.
or
2) Submitting data in an effort to compete for a positive update.
If you prefer to submit the minimum amount of data necessary to avoid a penalty, your best option is to complete the requirements for the Improvement Activities (IA) component of MIPS. By achieving full credit in this category of MIPS, you will acquire enough points (15) to reach the performance threshold in your MIPS final score to avoid a 5 percent penalty in your Medicare payments in 2020 based on your performance and participation in 2018.
Within the IA category, each activity is assigned either a high (20 points) or medium (10 points) weight. To receive full credit in the IA component, most surgeons must select and attest to having completed between two and four activities for a total of 40 points in the IA category. For small practices or rural practices to achieve full credit, only one high-value or two medium-value activities are required. CMS defines small practices as those consisting of 15 or fewer eligible clinicians. The Centers for Medicare and Medicaid Services defines rural practices as those where more than 75 percent of the NPIs billing under the individual MIPS eligible clinician or group’s Tax Identification Number (TIN) are designated in a ZIP code as a rural area or Health Professional Shortage Area (HPSA), based on the most recent Health Resources and Services Administration Area Health Resource File data set.
Those who fulfill these requirements will receive the maximum score and full credit in the IA category toward their MIPS Final Score (15 points). Because the performance threshold for 2018 is set at 15 points, those who wish to avoid a payment penalty can acquire the required number of points to avoid a penalty for their performance in 2018 by simply fulfilling the IA requirements.
Attestation to having completed the Improvement Activities can be accomplished via a qualified registry, qualified clinical data registry (QCDR), an electronic health record (EHR), or the QPP Data Submission System (accessible at qpp.cms.gov/login). The American College of Surgeons (ACS) has two QCDRs, the Surgeon Specific Registry (SSR) and the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) Data Registry. Both can be used to attest to completing the IAs.
If you plan to compete for a positive update in 2020 based on your performance in 2018, you should ideally report on the Quality, Advancing Care Information (ACI), and Improvement Activities categories of MIPS. If this is your intent, we recommend you obtain a copy of our new 2018 MACRA manual, visit facs.org/qpp, and make your plan for 2018.
Regardless of your choice, ACS staff in the DC office and the SSR are here to help and can be reached at 202-337-2701 (DC) or 312-202-5408 (SSR).
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.
Surgeons’ practice situations vary. Therefore, for various reasons, surgeons may not be required to participate in MIPS, or they may not be eligible to do so. For 2018, the Centers for Medicare & Medicaid Services (CMS) estimates that approximately 40 percent of eligible clinicians will be required to submit data under MIPS. Furthermore, many providers (particularly those who are employed or are in large group practices) will have data submitted on their behalf by their groups, institutions, or employers. It is thus imperative that surgeons determine whether they are exempt from participating in the MIPS program. If not exempt, they should then determine if their practice situation necessitates that they report their own individual MIPS data for 2018 or, alternatively, if data will be reported for their groups, institutions, or employers.
If you are a Qualifying Participant (QP) in an Advanced Alternative Payment Model (APM), you are exempt from reporting MIPS data. If you are unsure of your status as such a participant, you can use you NPI number to determine your status at data.cms.gov/qplookup. QPs are not only exempt from reporting MIPS data, but could receive a 5 percent bonus in 2020 for participation in 2018.
For 2018, CMS increased the low-volume threshold. The low-volume threshold is now set at less than or equal to $90,000 in Medicare Part B allowable charges or 200 or fewer Medicare Part B patients seen during the period selected by CMS. Because this threshold represents an increase compared to 2017, it will result in even more providers being exempted from participating in MIPS. It should be noted that failure to meet either of these thresholds, $90,000 in allowable charges or 200 Medicare Part B patients, is sufficient to exclude one from reporting MIPS data in 2018. As was the case in 2017, we anticipate that CMS will notify those providers who are exempt based on the low-volume threshold within the first or second quarter of 2018. Alternatively, surgeons may use their NPI to check their status relative to MIPS reporting at qpp.cms.gov/participation-lookup.
To determine whether MIPS applies to your practice circumstances, you can use the following simple steps:
1) Are you a participant in a qualified advanced alternative payment model (A-APM)? If you are unsure, you can use your National Provider Identifier (NPI) number to look up your status at data.cms.gov/qplookup. If you are a qualified participant in an A-APM, you are not only exempt from reporting MIPS data, but you could also receive a 5 percent bonus in 2020 for your participation in 2018.
2) Are you exempt from participating in MIPS based on the low-volume threshold? As mentioned above, for 2018, the increase in the low-volume threshold is expected to exclude a significant number of providers. To determine if you are exempt based on the low-volume threshold, use your NPI number at qpp.cms.gov/participation-lookup.
3) Are your MIPS data reported for you by your institution, your employer, or your group? If your data are being reported for you then you need take no further action. You should contact your institution, employer, or group to confirm that data are being reported for you.
If MIPS applies to your practice, you need to make a choice between:
1) Submitting the minimum data necessary to avoid a penalty, and accept a freeze in your payments in 2020 for the 2018 performance period.
or
2) Submitting data in an effort to compete for a positive update.
If you prefer to submit the minimum amount of data necessary to avoid a penalty, your best option is to complete the requirements for the Improvement Activities (IA) component of MIPS. By achieving full credit in this category of MIPS, you will acquire enough points (15) to reach the performance threshold in your MIPS final score to avoid a 5 percent penalty in your Medicare payments in 2020 based on your performance and participation in 2018.
Within the IA category, each activity is assigned either a high (20 points) or medium (10 points) weight. To receive full credit in the IA component, most surgeons must select and attest to having completed between two and four activities for a total of 40 points in the IA category. For small practices or rural practices to achieve full credit, only one high-value or two medium-value activities are required. CMS defines small practices as those consisting of 15 or fewer eligible clinicians. The Centers for Medicare and Medicaid Services defines rural practices as those where more than 75 percent of the NPIs billing under the individual MIPS eligible clinician or group’s Tax Identification Number (TIN) are designated in a ZIP code as a rural area or Health Professional Shortage Area (HPSA), based on the most recent Health Resources and Services Administration Area Health Resource File data set.
Those who fulfill these requirements will receive the maximum score and full credit in the IA category toward their MIPS Final Score (15 points). Because the performance threshold for 2018 is set at 15 points, those who wish to avoid a payment penalty can acquire the required number of points to avoid a penalty for their performance in 2018 by simply fulfilling the IA requirements.
Attestation to having completed the Improvement Activities can be accomplished via a qualified registry, qualified clinical data registry (QCDR), an electronic health record (EHR), or the QPP Data Submission System (accessible at qpp.cms.gov/login). The American College of Surgeons (ACS) has two QCDRs, the Surgeon Specific Registry (SSR) and the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) Data Registry. Both can be used to attest to completing the IAs.
If you plan to compete for a positive update in 2020 based on your performance in 2018, you should ideally report on the Quality, Advancing Care Information (ACI), and Improvement Activities categories of MIPS. If this is your intent, we recommend you obtain a copy of our new 2018 MACRA manual, visit facs.org/qpp, and make your plan for 2018.
Regardless of your choice, ACS staff in the DC office and the SSR are here to help and can be reached at 202-337-2701 (DC) or 312-202-5408 (SSR).
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.
Leigh A. Neumayer, MD, MS, FACS, elected Chair of ACS Board of Regents
Leigh A. Neumayer, MD, MS, FACS, Tucson, AZ, is the 2017–2018 Chair of the Board of Regents (B/R) of the American College of Surgeons (ACS). She was elected at the Annual Business Meeting of Members, October 25, 2017, in San Diego, CA.
A general surgeon, Dr. Neumayer is professor and chair, department of surgery, and the Margaret and Fenton Maynard Endowed Chair in Breast Cancer Research, University of Arizona (UA) College of Medicine, Tucson. She also is the interim senior vice-president for UA Health Sciences. Before accepting these positions in Arizona, Dr. Neumayer was professor, department of surgery, University of Utah Health Sciences Center, and the Jon and Karen Huntsman Presidential Professor, University of Utah/Huntsman Cancer Institute, Salt Lake City.
Previous leadership roles
A Fellow of the ACS since 1994 and a member of the B/R since 2009, Dr. Neumayer has served in many leadership roles within the organization. She was Chair of the Committee on Medical Student Education (2001–2003), Vice-Chair of the Surgical Research Committee (2015–2016), a Governor for the ACS Utah Chapter (2002–2008), and Vice-Chair of the Board of Regents (2016–2017). Dr. Neumayer also was Vice-Chair of the Nominating Committee of the Board of Governors (2004–2006) and a Board of Governors Executive Committee Member (2008–2011).
Nationally, Dr. Neumayer has served on the board of directors of the American Board of Surgery (2005–2011) and as the President of the Association of Women Surgeons (1997–1998), the Association for Surgical Education (2001–2002), the Association of Veterans Administration Surgeons (2002–2003), and the Society of Clinical Surgery (2012–2014).
At present, she serves on the editorial boards for the Journal of the American College of Surgeons and Annals of Surgery.
Dr. Neumayer’s most recent work is focused on the diagnosis and treatment of breast cancer via innovative technology and clinical trials. She has led investigations in hernia repair techniques, breast cancer treatment, surgical quality and outcomes, and surgical education techniques. Dr. Neumayer has mentored students, residents, and colleagues in these and other pursuits.
Dr. Neumayer studied biomedical engineering at Colorado State University, Fort Collins, before getting her medical degree from Baylor College of Medicine, Houston, TX. She trained in general surgery at the University of California, San Francisco, and at the University of Arizona, Tuscon. Dr. Neumayer then studied clinical research design and statistical analysis at the University of Michigan, Ann Arbor.
Dr. Schwartz elected Vice-Chair
A Fellow of the College since 1982, Dr. Schwartz has been a Regent since 2009 and has served on many ACS Committees. He was Chair of the Advisory Council Chairs (2004–2008), the Advisory Council for Pediatric Surgery (2004–2008), and the Health Policy and Advocacy Group (2014–2017). At present, he is Chair of the Comprehensive Communications Committee and a Member of the Surgical History Group Executive Committee.
Leigh A. Neumayer, MD, MS, FACS, Tucson, AZ, is the 2017–2018 Chair of the Board of Regents (B/R) of the American College of Surgeons (ACS). She was elected at the Annual Business Meeting of Members, October 25, 2017, in San Diego, CA.
A general surgeon, Dr. Neumayer is professor and chair, department of surgery, and the Margaret and Fenton Maynard Endowed Chair in Breast Cancer Research, University of Arizona (UA) College of Medicine, Tucson. She also is the interim senior vice-president for UA Health Sciences. Before accepting these positions in Arizona, Dr. Neumayer was professor, department of surgery, University of Utah Health Sciences Center, and the Jon and Karen Huntsman Presidential Professor, University of Utah/Huntsman Cancer Institute, Salt Lake City.
Previous leadership roles
A Fellow of the ACS since 1994 and a member of the B/R since 2009, Dr. Neumayer has served in many leadership roles within the organization. She was Chair of the Committee on Medical Student Education (2001–2003), Vice-Chair of the Surgical Research Committee (2015–2016), a Governor for the ACS Utah Chapter (2002–2008), and Vice-Chair of the Board of Regents (2016–2017). Dr. Neumayer also was Vice-Chair of the Nominating Committee of the Board of Governors (2004–2006) and a Board of Governors Executive Committee Member (2008–2011).
Nationally, Dr. Neumayer has served on the board of directors of the American Board of Surgery (2005–2011) and as the President of the Association of Women Surgeons (1997–1998), the Association for Surgical Education (2001–2002), the Association of Veterans Administration Surgeons (2002–2003), and the Society of Clinical Surgery (2012–2014).
At present, she serves on the editorial boards for the Journal of the American College of Surgeons and Annals of Surgery.
Dr. Neumayer’s most recent work is focused on the diagnosis and treatment of breast cancer via innovative technology and clinical trials. She has led investigations in hernia repair techniques, breast cancer treatment, surgical quality and outcomes, and surgical education techniques. Dr. Neumayer has mentored students, residents, and colleagues in these and other pursuits.
Dr. Neumayer studied biomedical engineering at Colorado State University, Fort Collins, before getting her medical degree from Baylor College of Medicine, Houston, TX. She trained in general surgery at the University of California, San Francisco, and at the University of Arizona, Tuscon. Dr. Neumayer then studied clinical research design and statistical analysis at the University of Michigan, Ann Arbor.
Dr. Schwartz elected Vice-Chair
A Fellow of the College since 1982, Dr. Schwartz has been a Regent since 2009 and has served on many ACS Committees. He was Chair of the Advisory Council Chairs (2004–2008), the Advisory Council for Pediatric Surgery (2004–2008), and the Health Policy and Advocacy Group (2014–2017). At present, he is Chair of the Comprehensive Communications Committee and a Member of the Surgical History Group Executive Committee.
Leigh A. Neumayer, MD, MS, FACS, Tucson, AZ, is the 2017–2018 Chair of the Board of Regents (B/R) of the American College of Surgeons (ACS). She was elected at the Annual Business Meeting of Members, October 25, 2017, in San Diego, CA.
A general surgeon, Dr. Neumayer is professor and chair, department of surgery, and the Margaret and Fenton Maynard Endowed Chair in Breast Cancer Research, University of Arizona (UA) College of Medicine, Tucson. She also is the interim senior vice-president for UA Health Sciences. Before accepting these positions in Arizona, Dr. Neumayer was professor, department of surgery, University of Utah Health Sciences Center, and the Jon and Karen Huntsman Presidential Professor, University of Utah/Huntsman Cancer Institute, Salt Lake City.
Previous leadership roles
A Fellow of the ACS since 1994 and a member of the B/R since 2009, Dr. Neumayer has served in many leadership roles within the organization. She was Chair of the Committee on Medical Student Education (2001–2003), Vice-Chair of the Surgical Research Committee (2015–2016), a Governor for the ACS Utah Chapter (2002–2008), and Vice-Chair of the Board of Regents (2016–2017). Dr. Neumayer also was Vice-Chair of the Nominating Committee of the Board of Governors (2004–2006) and a Board of Governors Executive Committee Member (2008–2011).
Nationally, Dr. Neumayer has served on the board of directors of the American Board of Surgery (2005–2011) and as the President of the Association of Women Surgeons (1997–1998), the Association for Surgical Education (2001–2002), the Association of Veterans Administration Surgeons (2002–2003), and the Society of Clinical Surgery (2012–2014).
At present, she serves on the editorial boards for the Journal of the American College of Surgeons and Annals of Surgery.
Dr. Neumayer’s most recent work is focused on the diagnosis and treatment of breast cancer via innovative technology and clinical trials. She has led investigations in hernia repair techniques, breast cancer treatment, surgical quality and outcomes, and surgical education techniques. Dr. Neumayer has mentored students, residents, and colleagues in these and other pursuits.
Dr. Neumayer studied biomedical engineering at Colorado State University, Fort Collins, before getting her medical degree from Baylor College of Medicine, Houston, TX. She trained in general surgery at the University of California, San Francisco, and at the University of Arizona, Tuscon. Dr. Neumayer then studied clinical research design and statistical analysis at the University of Michigan, Ann Arbor.
Dr. Schwartz elected Vice-Chair
A Fellow of the College since 1982, Dr. Schwartz has been a Regent since 2009 and has served on many ACS Committees. He was Chair of the Advisory Council Chairs (2004–2008), the Advisory Council for Pediatric Surgery (2004–2008), and the Health Policy and Advocacy Group (2014–2017). At present, he is Chair of the Comprehensive Communications Committee and a Member of the Surgical History Group Executive Committee.