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MedPAC eyes ‘incident to’ billing
WASHINGTON – Should Medicare abandon “incident to” billing for advanced practice registered nurses (APRNs) and physician assistants (PAs) as part of its move away from fee-for-service payment? Some of the experts on the Medicare Payment Advisory Commission think so.
A proposal presented at a recent MedPAC meeting would eliminate “incident to” billing – a payment policy under which an APRN or PA delivers the care but the claim is filed under a physician’s National Provider Identifier (NPI) and is paid at the Medicare physician fee schedule rate. Instead, APRNs and PAs would file claims under their own NPI and be paid at 85% of the physician fee schedule rate for any claims associated with an episode of care.
About 40% of evaluation and management (E&M) office visits conducted by APRNs on established patients were likely billed “incident to” in 2016, as were about 30% of such visits performed by PAs, MedPAC staff estimated.
“To put these numbers in context, we think that the rates of ‘incident to’ billing for NPs [nurse practitioners] and PAs mean that roughly 5% of all E&M office visits billed by physicians were likely performed by an NP or PA in 2018,” Brian O’Donnell, MedPAC policy analyst, told commissioners.
One reason for eliminating “incident to” billing is that it “obscure[s] the number of services actually furnished by NPs and PAs,” Mr. O’Donnell said. “Given the rapidly expanding number of NPs and PAs, Medicare’s ‘incident to’ rules could apply to an increasing number of services.”
MedPAC commissioner Kathy Buto, former vice president of global health policy at Johnson & Johnson, expressed support for the idea but raised a red flag that the system could be manipulated so that APRN/PA claims could still be paid at 100% of the fee schedule rate.
Commissioner Bruce Pyenson, principal and consulting actuary of Milliman in New York, suggested that APRN and PA claims should be paid at 100% of the fee schedule, mirroring other Medicare efforts to achieve site-neutral payments.
Similarly, commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, said that while she generally does not favor redistributing program savings, if APRN and PA claims were paid at 85%, the saving generated should go back to physicians who would otherwise lose money.
That change in revenue was a key concern for Michael Munger, MD, president of the American Academy of Family Physicians.
“We have a policy on ‘incident to’ billing at the academy,” Dr. Munger said in an interview. “It says that services that are delegated to and provided by nonphysician providers under physician supervision must be provided with the same quality and should be reimbursed at the same level as services directly provided by a physician.”
He said that lowering APRNs and PAs payments to 85% of what physicians make would impact doctors in a negative way, but if the elimination of “incident to” came with a recommendation that they be paid the same as physicians, it “would be less problematic.”
Dr. Munger described primary care as a team sport, and “this is certainly going to be felt in terms of the overall mission of delivering quality care.”
Access to care also could be reduced along with the reduced payment level, he added.
“You have to make business decisions at the end of the day,” he said. “You need to make sure that you can have adequate revenue to offset expenses, and if you are going to take a 15% cut in your revenue in, you have to look at where your expenses are, and obviously salary is your No. 1 expense. If you are not able to count on this revenue and you can’t afford to have NPs and PAs as part of the team, it is going to become an access issue for patients.”
Potential access and quality issues also resonated with the American Osteopathic Association.
“You really could see the elimination of the physician element from that practice environment and that would be to the detriment of patients,” David Pugach, AOA senior vice president of public policy, said in an interview. “Right now, you have the ability for incident billing, which requires the active participation of a physician in the management of patient care. If you end that practice, you are essentially removing the physician from the equation, and that really is an access issue; it’s a safety issue; and it’s a quality issue.”
He also noted that sometimes there is overutilization of diagnostic services with APRNs and PAs, and while costs may be saved by paying for those clinicians at less than the rate of physicians, the overutilization of other services by them could end up offsetting the savings.
“We have some significant concerns,” Mr. Pugach said.
The American Academy of Physician Assistants echoed some concerns expressed by MedPAC commissioners and staff.
“What we feel strongly about is the fact that one of the problems of ‘incident to’ is that it hides the practitioners, in this case the PA who actually renders the service,” Michael Powe, AAPA vice president of reimbursement and professional advocacy, said in an interview.
“We think that’s inappropriate for a number of reasons,” he continued. “Clearly from the issue of trying to figure who’s doing what, who saw the patient, what the quality of care happens to be, we think that PAs ought to be recognized ... and not hidden which happens under the ‘incident to’ methodology.”
He said that transparency helps determine where primary care needs are, whether they are being met, and it helps with determining network adequacy.
“So there are a number of good reasons why the accuracy and transparency should be there whether or not ‘incident to’ goes away.”
Jennifer Winter, committee chair for public education for the Society of Dermatology Physician Assistants, agreed.*
Eliminating “incident to” would grant greater visibility of PA practice “because right now, some of what we do is hidden by what the physician does” because it is billed under the physician and you can’t see what the PA is doing, especially if there is an adverse event, said Ms. Winter, who practices in Olympia, Wash. “It confounds trying to collect data on outcomes.”
She also noted that some physicians might not want to hire an NP or PA “because they can hire a physician and get 100%, but they are also going to have to pay that physician at a physician rate.”
Ms. Winter said that PAs and nurse practitioners should be getting 100% of the pay as they are doing essentially the same work that physicians would be doing.
MedPAC staffers also recommended that APRNs and PAs more clearly identify the specialty that they work in, something they do not currently have to do, to allow for more transparency and accurate data on the work that these types of clinicians are performing.
*An earlier version of this story misspelled Ms. Winter's name.
WASHINGTON – Should Medicare abandon “incident to” billing for advanced practice registered nurses (APRNs) and physician assistants (PAs) as part of its move away from fee-for-service payment? Some of the experts on the Medicare Payment Advisory Commission think so.
A proposal presented at a recent MedPAC meeting would eliminate “incident to” billing – a payment policy under which an APRN or PA delivers the care but the claim is filed under a physician’s National Provider Identifier (NPI) and is paid at the Medicare physician fee schedule rate. Instead, APRNs and PAs would file claims under their own NPI and be paid at 85% of the physician fee schedule rate for any claims associated with an episode of care.
About 40% of evaluation and management (E&M) office visits conducted by APRNs on established patients were likely billed “incident to” in 2016, as were about 30% of such visits performed by PAs, MedPAC staff estimated.
“To put these numbers in context, we think that the rates of ‘incident to’ billing for NPs [nurse practitioners] and PAs mean that roughly 5% of all E&M office visits billed by physicians were likely performed by an NP or PA in 2018,” Brian O’Donnell, MedPAC policy analyst, told commissioners.
One reason for eliminating “incident to” billing is that it “obscure[s] the number of services actually furnished by NPs and PAs,” Mr. O’Donnell said. “Given the rapidly expanding number of NPs and PAs, Medicare’s ‘incident to’ rules could apply to an increasing number of services.”
MedPAC commissioner Kathy Buto, former vice president of global health policy at Johnson & Johnson, expressed support for the idea but raised a red flag that the system could be manipulated so that APRN/PA claims could still be paid at 100% of the fee schedule rate.
Commissioner Bruce Pyenson, principal and consulting actuary of Milliman in New York, suggested that APRN and PA claims should be paid at 100% of the fee schedule, mirroring other Medicare efforts to achieve site-neutral payments.
Similarly, commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, said that while she generally does not favor redistributing program savings, if APRN and PA claims were paid at 85%, the saving generated should go back to physicians who would otherwise lose money.
That change in revenue was a key concern for Michael Munger, MD, president of the American Academy of Family Physicians.
“We have a policy on ‘incident to’ billing at the academy,” Dr. Munger said in an interview. “It says that services that are delegated to and provided by nonphysician providers under physician supervision must be provided with the same quality and should be reimbursed at the same level as services directly provided by a physician.”
He said that lowering APRNs and PAs payments to 85% of what physicians make would impact doctors in a negative way, but if the elimination of “incident to” came with a recommendation that they be paid the same as physicians, it “would be less problematic.”
Dr. Munger described primary care as a team sport, and “this is certainly going to be felt in terms of the overall mission of delivering quality care.”
Access to care also could be reduced along with the reduced payment level, he added.
“You have to make business decisions at the end of the day,” he said. “You need to make sure that you can have adequate revenue to offset expenses, and if you are going to take a 15% cut in your revenue in, you have to look at where your expenses are, and obviously salary is your No. 1 expense. If you are not able to count on this revenue and you can’t afford to have NPs and PAs as part of the team, it is going to become an access issue for patients.”
Potential access and quality issues also resonated with the American Osteopathic Association.
“You really could see the elimination of the physician element from that practice environment and that would be to the detriment of patients,” David Pugach, AOA senior vice president of public policy, said in an interview. “Right now, you have the ability for incident billing, which requires the active participation of a physician in the management of patient care. If you end that practice, you are essentially removing the physician from the equation, and that really is an access issue; it’s a safety issue; and it’s a quality issue.”
He also noted that sometimes there is overutilization of diagnostic services with APRNs and PAs, and while costs may be saved by paying for those clinicians at less than the rate of physicians, the overutilization of other services by them could end up offsetting the savings.
“We have some significant concerns,” Mr. Pugach said.
The American Academy of Physician Assistants echoed some concerns expressed by MedPAC commissioners and staff.
“What we feel strongly about is the fact that one of the problems of ‘incident to’ is that it hides the practitioners, in this case the PA who actually renders the service,” Michael Powe, AAPA vice president of reimbursement and professional advocacy, said in an interview.
“We think that’s inappropriate for a number of reasons,” he continued. “Clearly from the issue of trying to figure who’s doing what, who saw the patient, what the quality of care happens to be, we think that PAs ought to be recognized ... and not hidden which happens under the ‘incident to’ methodology.”
He said that transparency helps determine where primary care needs are, whether they are being met, and it helps with determining network adequacy.
“So there are a number of good reasons why the accuracy and transparency should be there whether or not ‘incident to’ goes away.”
Jennifer Winter, committee chair for public education for the Society of Dermatology Physician Assistants, agreed.*
Eliminating “incident to” would grant greater visibility of PA practice “because right now, some of what we do is hidden by what the physician does” because it is billed under the physician and you can’t see what the PA is doing, especially if there is an adverse event, said Ms. Winter, who practices in Olympia, Wash. “It confounds trying to collect data on outcomes.”
She also noted that some physicians might not want to hire an NP or PA “because they can hire a physician and get 100%, but they are also going to have to pay that physician at a physician rate.”
Ms. Winter said that PAs and nurse practitioners should be getting 100% of the pay as they are doing essentially the same work that physicians would be doing.
MedPAC staffers also recommended that APRNs and PAs more clearly identify the specialty that they work in, something they do not currently have to do, to allow for more transparency and accurate data on the work that these types of clinicians are performing.
*An earlier version of this story misspelled Ms. Winter's name.
WASHINGTON – Should Medicare abandon “incident to” billing for advanced practice registered nurses (APRNs) and physician assistants (PAs) as part of its move away from fee-for-service payment? Some of the experts on the Medicare Payment Advisory Commission think so.
A proposal presented at a recent MedPAC meeting would eliminate “incident to” billing – a payment policy under which an APRN or PA delivers the care but the claim is filed under a physician’s National Provider Identifier (NPI) and is paid at the Medicare physician fee schedule rate. Instead, APRNs and PAs would file claims under their own NPI and be paid at 85% of the physician fee schedule rate for any claims associated with an episode of care.
About 40% of evaluation and management (E&M) office visits conducted by APRNs on established patients were likely billed “incident to” in 2016, as were about 30% of such visits performed by PAs, MedPAC staff estimated.
“To put these numbers in context, we think that the rates of ‘incident to’ billing for NPs [nurse practitioners] and PAs mean that roughly 5% of all E&M office visits billed by physicians were likely performed by an NP or PA in 2018,” Brian O’Donnell, MedPAC policy analyst, told commissioners.
One reason for eliminating “incident to” billing is that it “obscure[s] the number of services actually furnished by NPs and PAs,” Mr. O’Donnell said. “Given the rapidly expanding number of NPs and PAs, Medicare’s ‘incident to’ rules could apply to an increasing number of services.”
MedPAC commissioner Kathy Buto, former vice president of global health policy at Johnson & Johnson, expressed support for the idea but raised a red flag that the system could be manipulated so that APRN/PA claims could still be paid at 100% of the fee schedule rate.
Commissioner Bruce Pyenson, principal and consulting actuary of Milliman in New York, suggested that APRN and PA claims should be paid at 100% of the fee schedule, mirroring other Medicare efforts to achieve site-neutral payments.
Similarly, commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, said that while she generally does not favor redistributing program savings, if APRN and PA claims were paid at 85%, the saving generated should go back to physicians who would otherwise lose money.
That change in revenue was a key concern for Michael Munger, MD, president of the American Academy of Family Physicians.
“We have a policy on ‘incident to’ billing at the academy,” Dr. Munger said in an interview. “It says that services that are delegated to and provided by nonphysician providers under physician supervision must be provided with the same quality and should be reimbursed at the same level as services directly provided by a physician.”
He said that lowering APRNs and PAs payments to 85% of what physicians make would impact doctors in a negative way, but if the elimination of “incident to” came with a recommendation that they be paid the same as physicians, it “would be less problematic.”
Dr. Munger described primary care as a team sport, and “this is certainly going to be felt in terms of the overall mission of delivering quality care.”
Access to care also could be reduced along with the reduced payment level, he added.
“You have to make business decisions at the end of the day,” he said. “You need to make sure that you can have adequate revenue to offset expenses, and if you are going to take a 15% cut in your revenue in, you have to look at where your expenses are, and obviously salary is your No. 1 expense. If you are not able to count on this revenue and you can’t afford to have NPs and PAs as part of the team, it is going to become an access issue for patients.”
Potential access and quality issues also resonated with the American Osteopathic Association.
“You really could see the elimination of the physician element from that practice environment and that would be to the detriment of patients,” David Pugach, AOA senior vice president of public policy, said in an interview. “Right now, you have the ability for incident billing, which requires the active participation of a physician in the management of patient care. If you end that practice, you are essentially removing the physician from the equation, and that really is an access issue; it’s a safety issue; and it’s a quality issue.”
He also noted that sometimes there is overutilization of diagnostic services with APRNs and PAs, and while costs may be saved by paying for those clinicians at less than the rate of physicians, the overutilization of other services by them could end up offsetting the savings.
“We have some significant concerns,” Mr. Pugach said.
The American Academy of Physician Assistants echoed some concerns expressed by MedPAC commissioners and staff.
“What we feel strongly about is the fact that one of the problems of ‘incident to’ is that it hides the practitioners, in this case the PA who actually renders the service,” Michael Powe, AAPA vice president of reimbursement and professional advocacy, said in an interview.
“We think that’s inappropriate for a number of reasons,” he continued. “Clearly from the issue of trying to figure who’s doing what, who saw the patient, what the quality of care happens to be, we think that PAs ought to be recognized ... and not hidden which happens under the ‘incident to’ methodology.”
He said that transparency helps determine where primary care needs are, whether they are being met, and it helps with determining network adequacy.
“So there are a number of good reasons why the accuracy and transparency should be there whether or not ‘incident to’ goes away.”
Jennifer Winter, committee chair for public education for the Society of Dermatology Physician Assistants, agreed.*
Eliminating “incident to” would grant greater visibility of PA practice “because right now, some of what we do is hidden by what the physician does” because it is billed under the physician and you can’t see what the PA is doing, especially if there is an adverse event, said Ms. Winter, who practices in Olympia, Wash. “It confounds trying to collect data on outcomes.”
She also noted that some physicians might not want to hire an NP or PA “because they can hire a physician and get 100%, but they are also going to have to pay that physician at a physician rate.”
Ms. Winter said that PAs and nurse practitioners should be getting 100% of the pay as they are doing essentially the same work that physicians would be doing.
MedPAC staffers also recommended that APRNs and PAs more clearly identify the specialty that they work in, something they do not currently have to do, to allow for more transparency and accurate data on the work that these types of clinicians are performing.
*An earlier version of this story misspelled Ms. Winter's name.
REPORTING FROM A MEDPAC MEETING
Black patients present as sicker, more likely to receive liver transplant
PHILADELPHIA – Black patients are more likely to be put on a transplant list because of acute liver failure, be listed as status 1, and receive a liver transplant, compared with white patients, according to a recent presentation at the annual meeting of the American College of Gastroenterology.
Lauren D. Nephew, MD, MSCE, of Indiana University in Indianapolis, and her colleagues performed a retrospective cohort study of black and white patients with a minimum age of 18 years in the United Network of Organ Sharing database who were wait-listed for a liver transplantation during 2002-2016. They examined patient clinical characteristics, acute liver failure (ALF) etiologies, wait-list status, and posttransplant survival outcomes through Kaplan Meier analysis.
“We really wanted to explore this topic in patients with acute liver failure, some of the sickest patients that we see,” Dr. Nephew said in her presentation. “We wanted to really determine whether or not there were differences in clinical characteristics and etiologies of acute liver failure in patients by race who are listed for liver transplantation.”
“Then, we wanted to compare wait-list outcomes,” she added, such as “differences by race in liver transplantation or wait-list removal because of death or becoming too sick for transplant.”
There were 11,289 patients in the white ALF group and 2,112 patients in the black ALF group; 2,876 (25.5%) of patients in the white ALF and 790 (37.4%) in the black ALF group were listed as status 1, which indicated an expected survival of 7 days or less. There were similar clinical characteristics for the white and black ALF status 1 patients regarding age (34.2 years vs. 36.3 years), Model for End-Stage Liver Disease (MELD) score (34 vs. 36; P less than .001), international normalized ratio (INR) test (mean 4.5 vs. mean 5.0; P = .001), creatinine levels (2.1 mg/dL vs. 1.9 mg/dL; P less than .001), and percentage of patients who were hepatic encephalopathy grade 3 or 4 (60.0% vs. 63.2%; P = .10). However, Dr. Nephew noted significantly higher bilirubin levels in the black ALF status 1 cohort (17.9 mg/dL), compared with the white ALF status 1 cohort (11.3 mg/dL; P less than .001).
The causes for ALF in each group included drug-induced liver failure (white status 1 cohort, 34.1%; black status 1 cohort, 20.6%), autoimmune hepatitis (2.7% vs. 9.4%), Wilson’s disease (0.58% vs. 0.13%), unknown etiology (34.5% vs. 42.5%), and other etiology (22.9% vs. 17%). For patients who underwent liver transplant and wait-list removal, there were no significant differences in wait-list removal “despite black patients being sicker at presentation,” Dr. Nephew said. Black patients were more likely to be listed to status 1 and transplanted at 62% (490 patients), compared with white patients at 53% (1,524 patients). There were 713 white patients (24.8%) removed from the transplant list, compared with 114 (13.8%) of black patients.
“If you are transplanted and you don’t die, then you are likely removed from the list for other reasons, and the most common reason is that you improved and became well, and so white patients were significantly more likely to be removed from the wait-list because of improvement, compared with black patients,” Dr. Nephew said.
In a competing risk analysis, the researchers found the hazard ratio for white patients who were status 1 and removed from the wait-list because of death or becoming too sick was 1.04 (95% confidence interval, 0.89-1.21) and those white patients who were listed as status 1 and then transplanted was 1.2 (95% CI, 1.08-1.30). In a multivariate analysis, the hazard ratio for white patients who were listed as status 1 and transplanted, which contained bilirubin at transplant, was 1.08 (95% CI, 0.98-1.19). Kaplan Meier 1-year survival post-transplant was 82.8% in white patients and 79.6% in black patients (P = .09).
“I think the question that we’ve been asking ourselves is, is this because black patients are presenting later with their acute liver disease and are sicker at presentation, or do they just have worse liver disease inherently on presentation that drove these findings?” Dr. Nephew said.
Dr. Nephew reports no relevant conflicts of interest.
SOURCE: Nephew L et al. ACG 2018, Presentation 59.
PHILADELPHIA – Black patients are more likely to be put on a transplant list because of acute liver failure, be listed as status 1, and receive a liver transplant, compared with white patients, according to a recent presentation at the annual meeting of the American College of Gastroenterology.
Lauren D. Nephew, MD, MSCE, of Indiana University in Indianapolis, and her colleagues performed a retrospective cohort study of black and white patients with a minimum age of 18 years in the United Network of Organ Sharing database who were wait-listed for a liver transplantation during 2002-2016. They examined patient clinical characteristics, acute liver failure (ALF) etiologies, wait-list status, and posttransplant survival outcomes through Kaplan Meier analysis.
“We really wanted to explore this topic in patients with acute liver failure, some of the sickest patients that we see,” Dr. Nephew said in her presentation. “We wanted to really determine whether or not there were differences in clinical characteristics and etiologies of acute liver failure in patients by race who are listed for liver transplantation.”
“Then, we wanted to compare wait-list outcomes,” she added, such as “differences by race in liver transplantation or wait-list removal because of death or becoming too sick for transplant.”
There were 11,289 patients in the white ALF group and 2,112 patients in the black ALF group; 2,876 (25.5%) of patients in the white ALF and 790 (37.4%) in the black ALF group were listed as status 1, which indicated an expected survival of 7 days or less. There were similar clinical characteristics for the white and black ALF status 1 patients regarding age (34.2 years vs. 36.3 years), Model for End-Stage Liver Disease (MELD) score (34 vs. 36; P less than .001), international normalized ratio (INR) test (mean 4.5 vs. mean 5.0; P = .001), creatinine levels (2.1 mg/dL vs. 1.9 mg/dL; P less than .001), and percentage of patients who were hepatic encephalopathy grade 3 or 4 (60.0% vs. 63.2%; P = .10). However, Dr. Nephew noted significantly higher bilirubin levels in the black ALF status 1 cohort (17.9 mg/dL), compared with the white ALF status 1 cohort (11.3 mg/dL; P less than .001).
The causes for ALF in each group included drug-induced liver failure (white status 1 cohort, 34.1%; black status 1 cohort, 20.6%), autoimmune hepatitis (2.7% vs. 9.4%), Wilson’s disease (0.58% vs. 0.13%), unknown etiology (34.5% vs. 42.5%), and other etiology (22.9% vs. 17%). For patients who underwent liver transplant and wait-list removal, there were no significant differences in wait-list removal “despite black patients being sicker at presentation,” Dr. Nephew said. Black patients were more likely to be listed to status 1 and transplanted at 62% (490 patients), compared with white patients at 53% (1,524 patients). There were 713 white patients (24.8%) removed from the transplant list, compared with 114 (13.8%) of black patients.
“If you are transplanted and you don’t die, then you are likely removed from the list for other reasons, and the most common reason is that you improved and became well, and so white patients were significantly more likely to be removed from the wait-list because of improvement, compared with black patients,” Dr. Nephew said.
In a competing risk analysis, the researchers found the hazard ratio for white patients who were status 1 and removed from the wait-list because of death or becoming too sick was 1.04 (95% confidence interval, 0.89-1.21) and those white patients who were listed as status 1 and then transplanted was 1.2 (95% CI, 1.08-1.30). In a multivariate analysis, the hazard ratio for white patients who were listed as status 1 and transplanted, which contained bilirubin at transplant, was 1.08 (95% CI, 0.98-1.19). Kaplan Meier 1-year survival post-transplant was 82.8% in white patients and 79.6% in black patients (P = .09).
“I think the question that we’ve been asking ourselves is, is this because black patients are presenting later with their acute liver disease and are sicker at presentation, or do they just have worse liver disease inherently on presentation that drove these findings?” Dr. Nephew said.
Dr. Nephew reports no relevant conflicts of interest.
SOURCE: Nephew L et al. ACG 2018, Presentation 59.
PHILADELPHIA – Black patients are more likely to be put on a transplant list because of acute liver failure, be listed as status 1, and receive a liver transplant, compared with white patients, according to a recent presentation at the annual meeting of the American College of Gastroenterology.
Lauren D. Nephew, MD, MSCE, of Indiana University in Indianapolis, and her colleagues performed a retrospective cohort study of black and white patients with a minimum age of 18 years in the United Network of Organ Sharing database who were wait-listed for a liver transplantation during 2002-2016. They examined patient clinical characteristics, acute liver failure (ALF) etiologies, wait-list status, and posttransplant survival outcomes through Kaplan Meier analysis.
“We really wanted to explore this topic in patients with acute liver failure, some of the sickest patients that we see,” Dr. Nephew said in her presentation. “We wanted to really determine whether or not there were differences in clinical characteristics and etiologies of acute liver failure in patients by race who are listed for liver transplantation.”
“Then, we wanted to compare wait-list outcomes,” she added, such as “differences by race in liver transplantation or wait-list removal because of death or becoming too sick for transplant.”
There were 11,289 patients in the white ALF group and 2,112 patients in the black ALF group; 2,876 (25.5%) of patients in the white ALF and 790 (37.4%) in the black ALF group were listed as status 1, which indicated an expected survival of 7 days or less. There were similar clinical characteristics for the white and black ALF status 1 patients regarding age (34.2 years vs. 36.3 years), Model for End-Stage Liver Disease (MELD) score (34 vs. 36; P less than .001), international normalized ratio (INR) test (mean 4.5 vs. mean 5.0; P = .001), creatinine levels (2.1 mg/dL vs. 1.9 mg/dL; P less than .001), and percentage of patients who were hepatic encephalopathy grade 3 or 4 (60.0% vs. 63.2%; P = .10). However, Dr. Nephew noted significantly higher bilirubin levels in the black ALF status 1 cohort (17.9 mg/dL), compared with the white ALF status 1 cohort (11.3 mg/dL; P less than .001).
The causes for ALF in each group included drug-induced liver failure (white status 1 cohort, 34.1%; black status 1 cohort, 20.6%), autoimmune hepatitis (2.7% vs. 9.4%), Wilson’s disease (0.58% vs. 0.13%), unknown etiology (34.5% vs. 42.5%), and other etiology (22.9% vs. 17%). For patients who underwent liver transplant and wait-list removal, there were no significant differences in wait-list removal “despite black patients being sicker at presentation,” Dr. Nephew said. Black patients were more likely to be listed to status 1 and transplanted at 62% (490 patients), compared with white patients at 53% (1,524 patients). There were 713 white patients (24.8%) removed from the transplant list, compared with 114 (13.8%) of black patients.
“If you are transplanted and you don’t die, then you are likely removed from the list for other reasons, and the most common reason is that you improved and became well, and so white patients were significantly more likely to be removed from the wait-list because of improvement, compared with black patients,” Dr. Nephew said.
In a competing risk analysis, the researchers found the hazard ratio for white patients who were status 1 and removed from the wait-list because of death or becoming too sick was 1.04 (95% confidence interval, 0.89-1.21) and those white patients who were listed as status 1 and then transplanted was 1.2 (95% CI, 1.08-1.30). In a multivariate analysis, the hazard ratio for white patients who were listed as status 1 and transplanted, which contained bilirubin at transplant, was 1.08 (95% CI, 0.98-1.19). Kaplan Meier 1-year survival post-transplant was 82.8% in white patients and 79.6% in black patients (P = .09).
“I think the question that we’ve been asking ourselves is, is this because black patients are presenting later with their acute liver disease and are sicker at presentation, or do they just have worse liver disease inherently on presentation that drove these findings?” Dr. Nephew said.
Dr. Nephew reports no relevant conflicts of interest.
SOURCE: Nephew L et al. ACG 2018, Presentation 59.
REPORTING FROM ACG 2018
Key clinical point: Black patients are sicker than white patients when they present with acute liver failure and are awaiting liver transplantation.
Major finding: Black patients with acute liver failure were more likely to be wait-listed, listed as status 1, and have higher Model for End-Stage Liver Disease (MELD) scores, creatinine levels, and INR tests, compared with white patients.
Study details: A retrospective cohort analysis of patients with acute liver failure awaiting a liver transplant in the United Network of Organ Sharing database.
Disclosures: Dr. Nephew reports no relevant conflicts of interest.
Source: Nephew L et al. ACG 2018, Presentation 59.
Your ACS Benefits: ACS guidelines and statements help you deliver quality care
One of the primary goals of the American College of Surgeons (ACS) is to provide surgeons with knowledge and skills to deliver the highest quality of patient care. The guidelines and statements developed by the ACS are intended to inform and guide Fellows in the care of their patients and to educate their patients and their institutions on best practices in those situations that may warrant specific guidance and direction.
Guidelines
Over the last decade, the College has participated in the development of guidelines and “point of care” modules that address those diagnoses most relevant to general surgeons. The Evidence-Based Decisions in Surgery (EBDS) are clinical guideline summaries that provide recommendations based on the latest practice guidelines in an easy-to-use, widely accessible format, including mobile devices and tablets. Module development involves a rigorous multi-step process, including contributions from experts on the ACS Board of Governors and the ACS Advisory Council for General Surgery. It is important to note that EBDS is not intended to reflect standards of care as defined by the ACS, but rather to serve as educational resources that practicing surgeons can use within the context of their respective practices. These guidelines should be used when appropriate based on the surgical condition and the surgeon’s experience, as well as the patient’s needs and preferences.
EBDS now comprises more than 70 point of care modules covering the following categories—bariatric surgery, biliary tract and pancreas, breast disease, colon, rectum and anus, critical care, endocrine, gastrointestinal surgery, geriatrics and palliative care, miscellaneous surgical conditions, perioperative care, surgical oncology, and vascular.
The complete list of guidelines is available at ebds.facs.org/topics, and new modules are released regularly. To access individual guidelines, members are required to log in. Contact [email protected] for member log-in information, and go to facs.org/ebds for more information about the program.
The Trauma Quality Improvement Program (TQIP®) generates the ACS TQIP Best Practice Guidelines to provide recommendations for managing patient populations or injury types. The TQIP Best Practices Project Team and a panel of guest experts from appropriate specialties work together over the course of the year to create each guideline. The guidelines are created from evidence-based literature when available and the consensus of the group when evidence is lacking. To date, the following guidelines have been created for use by trauma centers and are available for download at facs.org/quality-programs/trauma/tqip/best-practice:
• Geriatric Trauma Management
• Massive Transfusion in Trauma
• Management of Traumatic Brain Injury
• Management of Orthopaedic Trauma
• Palliative Care
The College’s National Surgical Quality Improvement Program (ACS NSQIP®) and the American Geriatrics Society’s Geriatrics for Specialists Initiative have developed two best practice guidelines that address management of older patients: Optimal Preoperative Assessment of the Geriatric Surgical Patient and Optimal Perioperative Management of the Geriatric Patient. These consensus-based recommendations were developed with support from the John A. Hartford Foundation and are available for download at facs.org/quality-programs/acs-nsqip/geriatric-periop-guideline.
Statements
Founded to provide opportunities for the continuing education of surgeons, the ACS has had a deep concern for the improvement of patient care and for the ethical practice of medicine. These values are reflected in the ACS Statements on Principles, which serve as the guidepost resource for all ACS Fellows. In addition to the Fellowship Pledge and Code of Professional Conduct, the Statements on Principles address the qualifications of the responsible surgeon, the surgeon-patient relationship, interprofessional relations, medical education, and surgeons and society. Fellows are encouraged to familiarize themselves with the contents of the Statements on Principles, which can be accessed at facs.org/about-acs/statements/stonprin.
In addition to the Statements on Principles, the ACS has issued more than 90 statements that have been adopted by the Board of Regents and address topics of importance to surgeons and the surgical profession. These statements have been developed by a range of volunteer committees and workgroups within the College, including the ACS Board of Governors, the ACS Advisory Councils, and various ACS standing committees. Statements are reviewed and updated annually, and new statements are created as appropriate. Statements are generally communicated to the membership via the Bulletin and are posted to the ACS website. Thus far in 2018, the Board of Regents has approved seven new statements and two revised statements. To review the complete list of ACS statements, go to facs.org/about-acs/statements and share those of interest with your colleagues and your institution.
Ms. Bura is Associate Director, ACS Division of Member Services, Chicago, IL.
One of the primary goals of the American College of Surgeons (ACS) is to provide surgeons with knowledge and skills to deliver the highest quality of patient care. The guidelines and statements developed by the ACS are intended to inform and guide Fellows in the care of their patients and to educate their patients and their institutions on best practices in those situations that may warrant specific guidance and direction.
Guidelines
Over the last decade, the College has participated in the development of guidelines and “point of care” modules that address those diagnoses most relevant to general surgeons. The Evidence-Based Decisions in Surgery (EBDS) are clinical guideline summaries that provide recommendations based on the latest practice guidelines in an easy-to-use, widely accessible format, including mobile devices and tablets. Module development involves a rigorous multi-step process, including contributions from experts on the ACS Board of Governors and the ACS Advisory Council for General Surgery. It is important to note that EBDS is not intended to reflect standards of care as defined by the ACS, but rather to serve as educational resources that practicing surgeons can use within the context of their respective practices. These guidelines should be used when appropriate based on the surgical condition and the surgeon’s experience, as well as the patient’s needs and preferences.
EBDS now comprises more than 70 point of care modules covering the following categories—bariatric surgery, biliary tract and pancreas, breast disease, colon, rectum and anus, critical care, endocrine, gastrointestinal surgery, geriatrics and palliative care, miscellaneous surgical conditions, perioperative care, surgical oncology, and vascular.
The complete list of guidelines is available at ebds.facs.org/topics, and new modules are released regularly. To access individual guidelines, members are required to log in. Contact [email protected] for member log-in information, and go to facs.org/ebds for more information about the program.
The Trauma Quality Improvement Program (TQIP®) generates the ACS TQIP Best Practice Guidelines to provide recommendations for managing patient populations or injury types. The TQIP Best Practices Project Team and a panel of guest experts from appropriate specialties work together over the course of the year to create each guideline. The guidelines are created from evidence-based literature when available and the consensus of the group when evidence is lacking. To date, the following guidelines have been created for use by trauma centers and are available for download at facs.org/quality-programs/trauma/tqip/best-practice:
• Geriatric Trauma Management
• Massive Transfusion in Trauma
• Management of Traumatic Brain Injury
• Management of Orthopaedic Trauma
• Palliative Care
The College’s National Surgical Quality Improvement Program (ACS NSQIP®) and the American Geriatrics Society’s Geriatrics for Specialists Initiative have developed two best practice guidelines that address management of older patients: Optimal Preoperative Assessment of the Geriatric Surgical Patient and Optimal Perioperative Management of the Geriatric Patient. These consensus-based recommendations were developed with support from the John A. Hartford Foundation and are available for download at facs.org/quality-programs/acs-nsqip/geriatric-periop-guideline.
Statements
Founded to provide opportunities for the continuing education of surgeons, the ACS has had a deep concern for the improvement of patient care and for the ethical practice of medicine. These values are reflected in the ACS Statements on Principles, which serve as the guidepost resource for all ACS Fellows. In addition to the Fellowship Pledge and Code of Professional Conduct, the Statements on Principles address the qualifications of the responsible surgeon, the surgeon-patient relationship, interprofessional relations, medical education, and surgeons and society. Fellows are encouraged to familiarize themselves with the contents of the Statements on Principles, which can be accessed at facs.org/about-acs/statements/stonprin.
In addition to the Statements on Principles, the ACS has issued more than 90 statements that have been adopted by the Board of Regents and address topics of importance to surgeons and the surgical profession. These statements have been developed by a range of volunteer committees and workgroups within the College, including the ACS Board of Governors, the ACS Advisory Councils, and various ACS standing committees. Statements are reviewed and updated annually, and new statements are created as appropriate. Statements are generally communicated to the membership via the Bulletin and are posted to the ACS website. Thus far in 2018, the Board of Regents has approved seven new statements and two revised statements. To review the complete list of ACS statements, go to facs.org/about-acs/statements and share those of interest with your colleagues and your institution.
Ms. Bura is Associate Director, ACS Division of Member Services, Chicago, IL.
One of the primary goals of the American College of Surgeons (ACS) is to provide surgeons with knowledge and skills to deliver the highest quality of patient care. The guidelines and statements developed by the ACS are intended to inform and guide Fellows in the care of their patients and to educate their patients and their institutions on best practices in those situations that may warrant specific guidance and direction.
Guidelines
Over the last decade, the College has participated in the development of guidelines and “point of care” modules that address those diagnoses most relevant to general surgeons. The Evidence-Based Decisions in Surgery (EBDS) are clinical guideline summaries that provide recommendations based on the latest practice guidelines in an easy-to-use, widely accessible format, including mobile devices and tablets. Module development involves a rigorous multi-step process, including contributions from experts on the ACS Board of Governors and the ACS Advisory Council for General Surgery. It is important to note that EBDS is not intended to reflect standards of care as defined by the ACS, but rather to serve as educational resources that practicing surgeons can use within the context of their respective practices. These guidelines should be used when appropriate based on the surgical condition and the surgeon’s experience, as well as the patient’s needs and preferences.
EBDS now comprises more than 70 point of care modules covering the following categories—bariatric surgery, biliary tract and pancreas, breast disease, colon, rectum and anus, critical care, endocrine, gastrointestinal surgery, geriatrics and palliative care, miscellaneous surgical conditions, perioperative care, surgical oncology, and vascular.
The complete list of guidelines is available at ebds.facs.org/topics, and new modules are released regularly. To access individual guidelines, members are required to log in. Contact [email protected] for member log-in information, and go to facs.org/ebds for more information about the program.
The Trauma Quality Improvement Program (TQIP®) generates the ACS TQIP Best Practice Guidelines to provide recommendations for managing patient populations or injury types. The TQIP Best Practices Project Team and a panel of guest experts from appropriate specialties work together over the course of the year to create each guideline. The guidelines are created from evidence-based literature when available and the consensus of the group when evidence is lacking. To date, the following guidelines have been created for use by trauma centers and are available for download at facs.org/quality-programs/trauma/tqip/best-practice:
• Geriatric Trauma Management
• Massive Transfusion in Trauma
• Management of Traumatic Brain Injury
• Management of Orthopaedic Trauma
• Palliative Care
The College’s National Surgical Quality Improvement Program (ACS NSQIP®) and the American Geriatrics Society’s Geriatrics for Specialists Initiative have developed two best practice guidelines that address management of older patients: Optimal Preoperative Assessment of the Geriatric Surgical Patient and Optimal Perioperative Management of the Geriatric Patient. These consensus-based recommendations were developed with support from the John A. Hartford Foundation and are available for download at facs.org/quality-programs/acs-nsqip/geriatric-periop-guideline.
Statements
Founded to provide opportunities for the continuing education of surgeons, the ACS has had a deep concern for the improvement of patient care and for the ethical practice of medicine. These values are reflected in the ACS Statements on Principles, which serve as the guidepost resource for all ACS Fellows. In addition to the Fellowship Pledge and Code of Professional Conduct, the Statements on Principles address the qualifications of the responsible surgeon, the surgeon-patient relationship, interprofessional relations, medical education, and surgeons and society. Fellows are encouraged to familiarize themselves with the contents of the Statements on Principles, which can be accessed at facs.org/about-acs/statements/stonprin.
In addition to the Statements on Principles, the ACS has issued more than 90 statements that have been adopted by the Board of Regents and address topics of importance to surgeons and the surgical profession. These statements have been developed by a range of volunteer committees and workgroups within the College, including the ACS Board of Governors, the ACS Advisory Councils, and various ACS standing committees. Statements are reviewed and updated annually, and new statements are created as appropriate. Statements are generally communicated to the membership via the Bulletin and are posted to the ACS website. Thus far in 2018, the Board of Regents has approved seven new statements and two revised statements. To review the complete list of ACS statements, go to facs.org/about-acs/statements and share those of interest with your colleagues and your institution.
Ms. Bura is Associate Director, ACS Division of Member Services, Chicago, IL.
Surgical palliative care – 20 years on
It was a banner year in 1998 for the moral and ethical evolution of the College. That year saw the release of its Statement of Principles of End-of-Life Care, a seminal document for the emerging framework of surgical palliative care and the first light of the work of my colleague, Peter Angelos, MD, FACS, which did much to make made ethics a less arcane element of surgical practice. These developments followed the 1997 Clinical Congress during which the College joined the then-active national debate about physician-assisted suicide.
The national debate eventually culminated with the U.S. Supreme Court’s two 1997 rulings that physician-assisted suicide is not a protected liberty interest under the Constitution. These rulings in Vacco v. Quill and Washington v. Glucksberg deferred to the states the legalization of physician-assisted suicide.
Kill the suffering, not the patient
It was ironic that the College’s attention to surgical palliative care started, literally, with a dead end. The 1997 symposium’s focus on physician-assisted suicide revealed how little there was in the surgeon’s toolbox to assist seriously ill patients and their families. At this well-attended event with a distinguished panel of surgeons and ethicists moderated by the late Thomas Krizek, MD, FACS, I heard fear of death, fear of suffering, and fear of our helplessness as practitioners in the face of our patients’ deaths. The debate was about control, not the effective response to the many species of suffering encountered in surgical practice.
Hospice care and the nascent concept of palliative care were acknowledged by both sides of the debate as beneficial but as distinctly apart from surgery. The need for improved palliative care was the one unifying idea that emerged from that day’s discussion. All sides seemed to agree that striving to mitigate suffering during the course of any serious illness would be preferable to allowing it to continue unabated until silencing it with deliberate death as a last resort. The ensuing challenge for surgeons would be the reconciliation of cure and palliation, each so much a part of surgical history, especially in the past 200 years. This would prove to be a tall order as surgeons had done such a tidy job separating these two priorities without even realizing it since the second World War. Nothing less than the soul of surgery (and medicine) would be at stake from the relentless technocratic “progress” that threatened to swallow health care and so many other aspects of our culture – a culture that perhaps has been too intoxicated by the individual “pursuit of life, liberty, and happiness” while overlooking the suffering of one’s neighbor.
Recent evidence of burnout raises the possibility that we surgeons have internalized this conflict. Because of our sacred fellowship in healing, are we now, as we were 20 years ago, in the midst of a new spiritual crisis? As the operative repertoire and our professional status become increasingly transient we will be compelled to ground our identities in something more fulfilling and enduring.
Hope in fellowship
Now, as in 1998, there is hope. Hope lies in our fellowship. The focus of palliative care as understood by surgeons has broadened considerably, encouraged by the gradual public acceptance of palliative approaches to care extending beyond hospice care and the generally favorable experiences surgeons have had with palliative care teams, some of which have been directed by surgeons. There are now dozens of surgeons currently certified in Hospice and Palliative Medicine by the American Board of Surgery who are much more skilled in palliative care than anyone practicing in 1998. The ABS’s decision (2006) to offer certification in Hospice and Palliative Medicine was, in itself, an indication of how far things had progressed since 1998.
Several challenges to contemporary surgery will benefit from the growing reservoir of palliative care expertise such as enhanced communication skill, opioid management, and burnout. The concept of shared decision making is only one example. The multidimensional understanding of suffering, a cardinal principle of palliative philosophy, could transform the current dilemma of “What do we do about opioids?” to the scientific and social research question, “What should be done with opioid receptors and countless other receptors that shape the pain experience?” And lastly, the current postgraduate educational focus on communication and burnout indicate a readiness for introspection and fellowship by surgeons, a necessary prerequisite in meeting any existential or spiritual challenge to our art.
We have come a long way in 20 years but there are still miles to go before we sleep.
Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.
It was a banner year in 1998 for the moral and ethical evolution of the College. That year saw the release of its Statement of Principles of End-of-Life Care, a seminal document for the emerging framework of surgical palliative care and the first light of the work of my colleague, Peter Angelos, MD, FACS, which did much to make made ethics a less arcane element of surgical practice. These developments followed the 1997 Clinical Congress during which the College joined the then-active national debate about physician-assisted suicide.
The national debate eventually culminated with the U.S. Supreme Court’s two 1997 rulings that physician-assisted suicide is not a protected liberty interest under the Constitution. These rulings in Vacco v. Quill and Washington v. Glucksberg deferred to the states the legalization of physician-assisted suicide.
Kill the suffering, not the patient
It was ironic that the College’s attention to surgical palliative care started, literally, with a dead end. The 1997 symposium’s focus on physician-assisted suicide revealed how little there was in the surgeon’s toolbox to assist seriously ill patients and their families. At this well-attended event with a distinguished panel of surgeons and ethicists moderated by the late Thomas Krizek, MD, FACS, I heard fear of death, fear of suffering, and fear of our helplessness as practitioners in the face of our patients’ deaths. The debate was about control, not the effective response to the many species of suffering encountered in surgical practice.
Hospice care and the nascent concept of palliative care were acknowledged by both sides of the debate as beneficial but as distinctly apart from surgery. The need for improved palliative care was the one unifying idea that emerged from that day’s discussion. All sides seemed to agree that striving to mitigate suffering during the course of any serious illness would be preferable to allowing it to continue unabated until silencing it with deliberate death as a last resort. The ensuing challenge for surgeons would be the reconciliation of cure and palliation, each so much a part of surgical history, especially in the past 200 years. This would prove to be a tall order as surgeons had done such a tidy job separating these two priorities without even realizing it since the second World War. Nothing less than the soul of surgery (and medicine) would be at stake from the relentless technocratic “progress” that threatened to swallow health care and so many other aspects of our culture – a culture that perhaps has been too intoxicated by the individual “pursuit of life, liberty, and happiness” while overlooking the suffering of one’s neighbor.
Recent evidence of burnout raises the possibility that we surgeons have internalized this conflict. Because of our sacred fellowship in healing, are we now, as we were 20 years ago, in the midst of a new spiritual crisis? As the operative repertoire and our professional status become increasingly transient we will be compelled to ground our identities in something more fulfilling and enduring.
Hope in fellowship
Now, as in 1998, there is hope. Hope lies in our fellowship. The focus of palliative care as understood by surgeons has broadened considerably, encouraged by the gradual public acceptance of palliative approaches to care extending beyond hospice care and the generally favorable experiences surgeons have had with palliative care teams, some of which have been directed by surgeons. There are now dozens of surgeons currently certified in Hospice and Palliative Medicine by the American Board of Surgery who are much more skilled in palliative care than anyone practicing in 1998. The ABS’s decision (2006) to offer certification in Hospice and Palliative Medicine was, in itself, an indication of how far things had progressed since 1998.
Several challenges to contemporary surgery will benefit from the growing reservoir of palliative care expertise such as enhanced communication skill, opioid management, and burnout. The concept of shared decision making is only one example. The multidimensional understanding of suffering, a cardinal principle of palliative philosophy, could transform the current dilemma of “What do we do about opioids?” to the scientific and social research question, “What should be done with opioid receptors and countless other receptors that shape the pain experience?” And lastly, the current postgraduate educational focus on communication and burnout indicate a readiness for introspection and fellowship by surgeons, a necessary prerequisite in meeting any existential or spiritual challenge to our art.
We have come a long way in 20 years but there are still miles to go before we sleep.
Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.
It was a banner year in 1998 for the moral and ethical evolution of the College. That year saw the release of its Statement of Principles of End-of-Life Care, a seminal document for the emerging framework of surgical palliative care and the first light of the work of my colleague, Peter Angelos, MD, FACS, which did much to make made ethics a less arcane element of surgical practice. These developments followed the 1997 Clinical Congress during which the College joined the then-active national debate about physician-assisted suicide.
The national debate eventually culminated with the U.S. Supreme Court’s two 1997 rulings that physician-assisted suicide is not a protected liberty interest under the Constitution. These rulings in Vacco v. Quill and Washington v. Glucksberg deferred to the states the legalization of physician-assisted suicide.
Kill the suffering, not the patient
It was ironic that the College’s attention to surgical palliative care started, literally, with a dead end. The 1997 symposium’s focus on physician-assisted suicide revealed how little there was in the surgeon’s toolbox to assist seriously ill patients and their families. At this well-attended event with a distinguished panel of surgeons and ethicists moderated by the late Thomas Krizek, MD, FACS, I heard fear of death, fear of suffering, and fear of our helplessness as practitioners in the face of our patients’ deaths. The debate was about control, not the effective response to the many species of suffering encountered in surgical practice.
Hospice care and the nascent concept of palliative care were acknowledged by both sides of the debate as beneficial but as distinctly apart from surgery. The need for improved palliative care was the one unifying idea that emerged from that day’s discussion. All sides seemed to agree that striving to mitigate suffering during the course of any serious illness would be preferable to allowing it to continue unabated until silencing it with deliberate death as a last resort. The ensuing challenge for surgeons would be the reconciliation of cure and palliation, each so much a part of surgical history, especially in the past 200 years. This would prove to be a tall order as surgeons had done such a tidy job separating these two priorities without even realizing it since the second World War. Nothing less than the soul of surgery (and medicine) would be at stake from the relentless technocratic “progress” that threatened to swallow health care and so many other aspects of our culture – a culture that perhaps has been too intoxicated by the individual “pursuit of life, liberty, and happiness” while overlooking the suffering of one’s neighbor.
Recent evidence of burnout raises the possibility that we surgeons have internalized this conflict. Because of our sacred fellowship in healing, are we now, as we were 20 years ago, in the midst of a new spiritual crisis? As the operative repertoire and our professional status become increasingly transient we will be compelled to ground our identities in something more fulfilling and enduring.
Hope in fellowship
Now, as in 1998, there is hope. Hope lies in our fellowship. The focus of palliative care as understood by surgeons has broadened considerably, encouraged by the gradual public acceptance of palliative approaches to care extending beyond hospice care and the generally favorable experiences surgeons have had with palliative care teams, some of which have been directed by surgeons. There are now dozens of surgeons currently certified in Hospice and Palliative Medicine by the American Board of Surgery who are much more skilled in palliative care than anyone practicing in 1998. The ABS’s decision (2006) to offer certification in Hospice and Palliative Medicine was, in itself, an indication of how far things had progressed since 1998.
Several challenges to contemporary surgery will benefit from the growing reservoir of palliative care expertise such as enhanced communication skill, opioid management, and burnout. The concept of shared decision making is only one example. The multidimensional understanding of suffering, a cardinal principle of palliative philosophy, could transform the current dilemma of “What do we do about opioids?” to the scientific and social research question, “What should be done with opioid receptors and countless other receptors that shape the pain experience?” And lastly, the current postgraduate educational focus on communication and burnout indicate a readiness for introspection and fellowship by surgeons, a necessary prerequisite in meeting any existential or spiritual challenge to our art.
We have come a long way in 20 years but there are still miles to go before we sleep.
Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.
Visit ACS Central at Clinical Congress 2018 and View ACS Theatre Sessions
Make the most of your American College of Surgeons (ACS) Clinical Congress experience by visiting ACS Central in the Exhibit Hall. Open 9:00 am–4:30 pm Monday, October 22, to Wednesday, October 24, ACS Central is the place to meet with staff, learn about ACS products and programs, purchase ACS-branded items and publications, and relax during the meeting. Other select ACS programs will have a presence in the main lobby of the center, including ACSPA-SurgeonsPAC, Wi-fi and Clinical Congress App Support, Become a Member/Member Services, MyCME, SESAP® (Surgical Education and Self-Assessment Program), and Webcast Sales.
Featured areas in ACS Central include the following:
• ACS Foundation
• ACS Store
• Advocacy and Regulatory Affairs
• Education
• Manage Your Profile (receive a free professional photo)
• Member Engagement
• My Specialty and Quality Programs
• Publications and Online Resources
• Surgeon Specific Registry (SSR)
ACS Central also features the ACS Theatre. The following programs will take place during the lunch hour, so grab a bite to eat and stop by to listen.
Monday, October 22: 1:15 pm–2:15 pm
Life Skills for the Surgeon: Savings Advice for Retirement
Mark Aeder, MD, FACS, will provide advice on how to handle your debt, how to find the right financial advisor, and how to protect your family and your income?
Special Considerations for a Successful Simulation Program
Rick Feins, MD, FACS, will explain why surgical simulation is an important pathway for achieving competency in surgical resident performance and adoption of new technology by established surgeons.
Tuesday, October 23: 11:30 am–12:30 pm
Efforts to Reduce Administrative Burdens and Regulations and State Level Advocacy
Come listen to how the ACS is addressing the increasing administrative burdens and regulations that are frustrating our Fellows across the country with Vinita Ollapally, JD, ACS Manager of Regulatory Affairs.
Wednesday, October 24: 11:30 am–12:30 pm
Addressing Intimate Partner Violence in the Surgical Community: Is there a need?
ACS President Barbara Lee Bass, MD, FACS, formed an ACS Task Force earlier this year to begin to consider what the ACS should do to address and prevent intimate partner violence (IPV) within the surgical community. Dr. Bass will address the work of the task force and the resources that have been developed to address this issue.
Make the most of your American College of Surgeons (ACS) Clinical Congress experience by visiting ACS Central in the Exhibit Hall. Open 9:00 am–4:30 pm Monday, October 22, to Wednesday, October 24, ACS Central is the place to meet with staff, learn about ACS products and programs, purchase ACS-branded items and publications, and relax during the meeting. Other select ACS programs will have a presence in the main lobby of the center, including ACSPA-SurgeonsPAC, Wi-fi and Clinical Congress App Support, Become a Member/Member Services, MyCME, SESAP® (Surgical Education and Self-Assessment Program), and Webcast Sales.
Featured areas in ACS Central include the following:
• ACS Foundation
• ACS Store
• Advocacy and Regulatory Affairs
• Education
• Manage Your Profile (receive a free professional photo)
• Member Engagement
• My Specialty and Quality Programs
• Publications and Online Resources
• Surgeon Specific Registry (SSR)
ACS Central also features the ACS Theatre. The following programs will take place during the lunch hour, so grab a bite to eat and stop by to listen.
Monday, October 22: 1:15 pm–2:15 pm
Life Skills for the Surgeon: Savings Advice for Retirement
Mark Aeder, MD, FACS, will provide advice on how to handle your debt, how to find the right financial advisor, and how to protect your family and your income?
Special Considerations for a Successful Simulation Program
Rick Feins, MD, FACS, will explain why surgical simulation is an important pathway for achieving competency in surgical resident performance and adoption of new technology by established surgeons.
Tuesday, October 23: 11:30 am–12:30 pm
Efforts to Reduce Administrative Burdens and Regulations and State Level Advocacy
Come listen to how the ACS is addressing the increasing administrative burdens and regulations that are frustrating our Fellows across the country with Vinita Ollapally, JD, ACS Manager of Regulatory Affairs.
Wednesday, October 24: 11:30 am–12:30 pm
Addressing Intimate Partner Violence in the Surgical Community: Is there a need?
ACS President Barbara Lee Bass, MD, FACS, formed an ACS Task Force earlier this year to begin to consider what the ACS should do to address and prevent intimate partner violence (IPV) within the surgical community. Dr. Bass will address the work of the task force and the resources that have been developed to address this issue.
Make the most of your American College of Surgeons (ACS) Clinical Congress experience by visiting ACS Central in the Exhibit Hall. Open 9:00 am–4:30 pm Monday, October 22, to Wednesday, October 24, ACS Central is the place to meet with staff, learn about ACS products and programs, purchase ACS-branded items and publications, and relax during the meeting. Other select ACS programs will have a presence in the main lobby of the center, including ACSPA-SurgeonsPAC, Wi-fi and Clinical Congress App Support, Become a Member/Member Services, MyCME, SESAP® (Surgical Education and Self-Assessment Program), and Webcast Sales.
Featured areas in ACS Central include the following:
• ACS Foundation
• ACS Store
• Advocacy and Regulatory Affairs
• Education
• Manage Your Profile (receive a free professional photo)
• Member Engagement
• My Specialty and Quality Programs
• Publications and Online Resources
• Surgeon Specific Registry (SSR)
ACS Central also features the ACS Theatre. The following programs will take place during the lunch hour, so grab a bite to eat and stop by to listen.
Monday, October 22: 1:15 pm–2:15 pm
Life Skills for the Surgeon: Savings Advice for Retirement
Mark Aeder, MD, FACS, will provide advice on how to handle your debt, how to find the right financial advisor, and how to protect your family and your income?
Special Considerations for a Successful Simulation Program
Rick Feins, MD, FACS, will explain why surgical simulation is an important pathway for achieving competency in surgical resident performance and adoption of new technology by established surgeons.
Tuesday, October 23: 11:30 am–12:30 pm
Efforts to Reduce Administrative Burdens and Regulations and State Level Advocacy
Come listen to how the ACS is addressing the increasing administrative burdens and regulations that are frustrating our Fellows across the country with Vinita Ollapally, JD, ACS Manager of Regulatory Affairs.
Wednesday, October 24: 11:30 am–12:30 pm
Addressing Intimate Partner Violence in the Surgical Community: Is there a need?
ACS President Barbara Lee Bass, MD, FACS, formed an ACS Task Force earlier this year to begin to consider what the ACS should do to address and prevent intimate partner violence (IPV) within the surgical community. Dr. Bass will address the work of the task force and the resources that have been developed to address this issue.
Second volume of Operative Standards for Cancer Surgery Manual now available
Operative Standards for Cancer Surgery, Volume 2, a collaborative manual from the American College of Surgeons (ACS) and the Alliance for Clinical Trials in Oncology, is now available for print and electronic purchase. This second volume focuses on thyroid cancer, gastric cancer, rectal cancer, esophageal cancer, and melanoma. The goal of the manual is to recommend the steps that need to occur in the operating room, from skin incision to skin closure, that ensure the best oncological outcomes for patients. Recommendations from the first two volumes serve as an initial point of discussion as the ACS Commission on Cancer (CoC) works to revise its accreditation manual and requirements. Preliminary work is being done to incorporate a portion of the recommendations into the new CoC standards for implementation by 2020.
The recommendations in the manual are part of a shift in the way surgeons perform cancer operations to ensure the procedures are guided by the strongest available evidence, according to the leadership of the Alliance/ACS Clinical Research Program (ACS CRP) Cancer Care Standards Development Committee, which led development of both volumes.
Similar to the first volume of the manual, which covered cancer of the breast, colon, lung, and pancreas, this volume breaks down the major cancer operations for each of the five disease sites into the critical steps that teams of experts and stakeholders around the country have identified as having the most significant influence on outcomes.
“We hope that the recommendations become actively used and achieve greater legitimacy,” said Committee Chair Mathew H. G. Katz, MD, FACS.
Operative Standards for Cancer Surgery, Volume 2, is available for purchase on the Wolters Kluwer website at bit.ly/2PCHUCn. For more information, contact [email protected].
Operative Standards for Cancer Surgery, Volume 2, a collaborative manual from the American College of Surgeons (ACS) and the Alliance for Clinical Trials in Oncology, is now available for print and electronic purchase. This second volume focuses on thyroid cancer, gastric cancer, rectal cancer, esophageal cancer, and melanoma. The goal of the manual is to recommend the steps that need to occur in the operating room, from skin incision to skin closure, that ensure the best oncological outcomes for patients. Recommendations from the first two volumes serve as an initial point of discussion as the ACS Commission on Cancer (CoC) works to revise its accreditation manual and requirements. Preliminary work is being done to incorporate a portion of the recommendations into the new CoC standards for implementation by 2020.
The recommendations in the manual are part of a shift in the way surgeons perform cancer operations to ensure the procedures are guided by the strongest available evidence, according to the leadership of the Alliance/ACS Clinical Research Program (ACS CRP) Cancer Care Standards Development Committee, which led development of both volumes.
Similar to the first volume of the manual, which covered cancer of the breast, colon, lung, and pancreas, this volume breaks down the major cancer operations for each of the five disease sites into the critical steps that teams of experts and stakeholders around the country have identified as having the most significant influence on outcomes.
“We hope that the recommendations become actively used and achieve greater legitimacy,” said Committee Chair Mathew H. G. Katz, MD, FACS.
Operative Standards for Cancer Surgery, Volume 2, is available for purchase on the Wolters Kluwer website at bit.ly/2PCHUCn. For more information, contact [email protected].
Operative Standards for Cancer Surgery, Volume 2, a collaborative manual from the American College of Surgeons (ACS) and the Alliance for Clinical Trials in Oncology, is now available for print and electronic purchase. This second volume focuses on thyroid cancer, gastric cancer, rectal cancer, esophageal cancer, and melanoma. The goal of the manual is to recommend the steps that need to occur in the operating room, from skin incision to skin closure, that ensure the best oncological outcomes for patients. Recommendations from the first two volumes serve as an initial point of discussion as the ACS Commission on Cancer (CoC) works to revise its accreditation manual and requirements. Preliminary work is being done to incorporate a portion of the recommendations into the new CoC standards for implementation by 2020.
The recommendations in the manual are part of a shift in the way surgeons perform cancer operations to ensure the procedures are guided by the strongest available evidence, according to the leadership of the Alliance/ACS Clinical Research Program (ACS CRP) Cancer Care Standards Development Committee, which led development of both volumes.
Similar to the first volume of the manual, which covered cancer of the breast, colon, lung, and pancreas, this volume breaks down the major cancer operations for each of the five disease sites into the critical steps that teams of experts and stakeholders around the country have identified as having the most significant influence on outcomes.
“We hope that the recommendations become actively used and achieve greater legitimacy,” said Committee Chair Mathew H. G. Katz, MD, FACS.
Operative Standards for Cancer Surgery, Volume 2, is available for purchase on the Wolters Kluwer website at bit.ly/2PCHUCn. For more information, contact [email protected].
Exciting changes in the Scientific Forum this year
The Scientific Forum of the American College of Surgeons (ACS) Clinical Congress has evolved since the concept was first introduced as the Surgical Forum in 1951. This year’s Scientific Forum will build on these transformations and will offer attendees greater exposure to the surgical research conducted by the ACS community.
Background
The Surgical Forum was established in 1951 to provide a supportive venue for trainees and junior faculty to present and discuss their research. Presenting at the Forum has always been a rite of passage for aspiring academic surgeon-scientists. In 1993, the Surgical Forum was renamed to honor the program founder, Owen H. Wangensteen, MD, PhD, FACS, past-chair, department of surgery, University of Minnesota, Minneapolis.
As surgical science evolved, the Program Committee developed a separate Scientific Papers session for established investigators and Fellows who were not early in their career. As these two programs evolved, it became increasingly clear that there was substantial overlap. In 2014, the Surgical Forum and Scientific Papers merged into a single entity under the oversight of the existing Surgical Forum Committee.
The merged program was renamed the Scientific Forum to reflect the contributions of the Surgical Forum and the Scientific Papers, and the committee was renamed the Scientific Forum Committee. Because of the increase in scientific abstracts resulting from this merger, the committee expanded its membership to reflect the type of scientific abstracts in the broader program. The basic and translational research focus of the Surgical Forum was expanded to include clinical research in health services, education, global surgery, ethics, and other evolving areas of surgical science.
These changes have revitalized the scientific effort. The number and quality of the abstracts submitted to the Scientific Forum has grown significantly—more than 2,000 abstracts were submitted for review for Clinical Congress 2018.
The spirit of the Surgical Forum has been maintained in the new Scientific Forum, continuing with the clustering of focused areas of research to encourage discussion and collaboration among the attendees. The Program Committee continues to place great emphasis on highlighting the work of young investigators while incorporating the expertise of senior investigators into the sessions.
Changes at Clinical Congress 2017
Quick Shots and e-Posters were introduced at Clinical Congress 2017 in San Diego, CA. Quick Shots are three-minute oral abstract presentations, which were incorporated into the Scientific Forum sessions. This addition, which allowed for more presenters in a session, was met with a positive reception.
The poster sessions were restructured to an electronic format. The e-Posters were placed in a central, dedicated location among the Scientific Forum sessions rather than the Exhibit Hall. The modern e-Poster sessions brought greater visibility to the poster presentations and energized the format. In the e-Poster room, special sessions were scheduled to highlight the exceptional research efforts of the surgical trainees through the Excellence in Research Awards and the Posters of Exceptional Merit. In addition, the Scientific Forum is dedicated to a senior surgeon-scientist who has demonstrated a career-long commitment to training surgeon-scientists and the academic mission.
To further promote and support surgical research, the Scientific Forum Committee partnered with the Journal of the American College of Surgeons (JACS) to solicit the highest-rated abstracts for publication in JACS. In the first year, the top 5 percent of abstracts in the clinical sciences were solicited for manuscript submissions. More than half of those authors submitted a manuscript for review. All accepted manuscripts will be electronically published concurrently with the ACS Clinical Congress 2018 to provide greater visibility to the high-quality research being generated by the ACS community.
Clinical trials session added in 2018
The Scientific Forum Committee strongly believes the Clinical Congress is the premier venue to present practice-changing research. New for 2018, a call for late-breaking clinical trials abstracts was issued, and the committee selected six clinical trials that have the potential to change practice and improve patient care. This new clinical trials session will be presented at Clinical Congress 2018 Monday, October 22, at 9:45 am.
The ACS Clinical Congress is the largest surgical meeting in the U.S. The vision of the Scientific Forum Committee is for leaders of surgical trials to view the Clinical Congress as the premier venue to present their results. These exciting and transformative changes to the Scientific Forum will bring greater exposure to the leading-edge research in clinical care, while continuing to support and encourage young surgeon-scientists—the future of the study and practice of surgery—in their work. ♦
Note
The authors of this article are part of the Owen H. Wangensteen Scientific Forum Committee—Mary T. Hawn, MD, FACS; Edith Tzeng, MD, FACS; and Valerie W. Rusch, MD, FACS, are members, and M. Jane Burns, MJHL; Richard V. King, PhD; and Ajit K. Sachdeva, MD, FACS, FRCSC, are ACS staff.
Dr. Hawn is professor of surgery and chair, department of surgery, Stanford University, CA. She is Chair, ACS Scientific Forum Committee.
Dr. Tzeng is professor of surgery, University of Pittsburgh, and chief, vascular surgery, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, PA. She is Vice-Chair, ACS Scientific Forum Committee.
Dr. Rusch is vice-chair, clinical research, department of surgery; Miner Family Chair in Intrathoracic Cancers; attending surgeon, thoracic service, department of surgery, Memorial Sloan-Kettering Cancer Center; and professor of surgery, Weill Cornell Medical College. She is a consultant for the ACS Program Committee.
Ms. Burns is Senior Manager, Clinical Congress Program, ACS Division of Education, Chicago.
Mr. King is Assistant Director, Clinical Congress Program and Skills Courses, ACS Division of Education.
Dr. Sachdeva is Director, ACS Division of Education.
The Scientific Forum of the American College of Surgeons (ACS) Clinical Congress has evolved since the concept was first introduced as the Surgical Forum in 1951. This year’s Scientific Forum will build on these transformations and will offer attendees greater exposure to the surgical research conducted by the ACS community.
Background
The Surgical Forum was established in 1951 to provide a supportive venue for trainees and junior faculty to present and discuss their research. Presenting at the Forum has always been a rite of passage for aspiring academic surgeon-scientists. In 1993, the Surgical Forum was renamed to honor the program founder, Owen H. Wangensteen, MD, PhD, FACS, past-chair, department of surgery, University of Minnesota, Minneapolis.
As surgical science evolved, the Program Committee developed a separate Scientific Papers session for established investigators and Fellows who were not early in their career. As these two programs evolved, it became increasingly clear that there was substantial overlap. In 2014, the Surgical Forum and Scientific Papers merged into a single entity under the oversight of the existing Surgical Forum Committee.
The merged program was renamed the Scientific Forum to reflect the contributions of the Surgical Forum and the Scientific Papers, and the committee was renamed the Scientific Forum Committee. Because of the increase in scientific abstracts resulting from this merger, the committee expanded its membership to reflect the type of scientific abstracts in the broader program. The basic and translational research focus of the Surgical Forum was expanded to include clinical research in health services, education, global surgery, ethics, and other evolving areas of surgical science.
These changes have revitalized the scientific effort. The number and quality of the abstracts submitted to the Scientific Forum has grown significantly—more than 2,000 abstracts were submitted for review for Clinical Congress 2018.
The spirit of the Surgical Forum has been maintained in the new Scientific Forum, continuing with the clustering of focused areas of research to encourage discussion and collaboration among the attendees. The Program Committee continues to place great emphasis on highlighting the work of young investigators while incorporating the expertise of senior investigators into the sessions.
Changes at Clinical Congress 2017
Quick Shots and e-Posters were introduced at Clinical Congress 2017 in San Diego, CA. Quick Shots are three-minute oral abstract presentations, which were incorporated into the Scientific Forum sessions. This addition, which allowed for more presenters in a session, was met with a positive reception.
The poster sessions were restructured to an electronic format. The e-Posters were placed in a central, dedicated location among the Scientific Forum sessions rather than the Exhibit Hall. The modern e-Poster sessions brought greater visibility to the poster presentations and energized the format. In the e-Poster room, special sessions were scheduled to highlight the exceptional research efforts of the surgical trainees through the Excellence in Research Awards and the Posters of Exceptional Merit. In addition, the Scientific Forum is dedicated to a senior surgeon-scientist who has demonstrated a career-long commitment to training surgeon-scientists and the academic mission.
To further promote and support surgical research, the Scientific Forum Committee partnered with the Journal of the American College of Surgeons (JACS) to solicit the highest-rated abstracts for publication in JACS. In the first year, the top 5 percent of abstracts in the clinical sciences were solicited for manuscript submissions. More than half of those authors submitted a manuscript for review. All accepted manuscripts will be electronically published concurrently with the ACS Clinical Congress 2018 to provide greater visibility to the high-quality research being generated by the ACS community.
Clinical trials session added in 2018
The Scientific Forum Committee strongly believes the Clinical Congress is the premier venue to present practice-changing research. New for 2018, a call for late-breaking clinical trials abstracts was issued, and the committee selected six clinical trials that have the potential to change practice and improve patient care. This new clinical trials session will be presented at Clinical Congress 2018 Monday, October 22, at 9:45 am.
The ACS Clinical Congress is the largest surgical meeting in the U.S. The vision of the Scientific Forum Committee is for leaders of surgical trials to view the Clinical Congress as the premier venue to present their results. These exciting and transformative changes to the Scientific Forum will bring greater exposure to the leading-edge research in clinical care, while continuing to support and encourage young surgeon-scientists—the future of the study and practice of surgery—in their work. ♦
Note
The authors of this article are part of the Owen H. Wangensteen Scientific Forum Committee—Mary T. Hawn, MD, FACS; Edith Tzeng, MD, FACS; and Valerie W. Rusch, MD, FACS, are members, and M. Jane Burns, MJHL; Richard V. King, PhD; and Ajit K. Sachdeva, MD, FACS, FRCSC, are ACS staff.
Dr. Hawn is professor of surgery and chair, department of surgery, Stanford University, CA. She is Chair, ACS Scientific Forum Committee.
Dr. Tzeng is professor of surgery, University of Pittsburgh, and chief, vascular surgery, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, PA. She is Vice-Chair, ACS Scientific Forum Committee.
Dr. Rusch is vice-chair, clinical research, department of surgery; Miner Family Chair in Intrathoracic Cancers; attending surgeon, thoracic service, department of surgery, Memorial Sloan-Kettering Cancer Center; and professor of surgery, Weill Cornell Medical College. She is a consultant for the ACS Program Committee.
Ms. Burns is Senior Manager, Clinical Congress Program, ACS Division of Education, Chicago.
Mr. King is Assistant Director, Clinical Congress Program and Skills Courses, ACS Division of Education.
Dr. Sachdeva is Director, ACS Division of Education.
The Scientific Forum of the American College of Surgeons (ACS) Clinical Congress has evolved since the concept was first introduced as the Surgical Forum in 1951. This year’s Scientific Forum will build on these transformations and will offer attendees greater exposure to the surgical research conducted by the ACS community.
Background
The Surgical Forum was established in 1951 to provide a supportive venue for trainees and junior faculty to present and discuss their research. Presenting at the Forum has always been a rite of passage for aspiring academic surgeon-scientists. In 1993, the Surgical Forum was renamed to honor the program founder, Owen H. Wangensteen, MD, PhD, FACS, past-chair, department of surgery, University of Minnesota, Minneapolis.
As surgical science evolved, the Program Committee developed a separate Scientific Papers session for established investigators and Fellows who were not early in their career. As these two programs evolved, it became increasingly clear that there was substantial overlap. In 2014, the Surgical Forum and Scientific Papers merged into a single entity under the oversight of the existing Surgical Forum Committee.
The merged program was renamed the Scientific Forum to reflect the contributions of the Surgical Forum and the Scientific Papers, and the committee was renamed the Scientific Forum Committee. Because of the increase in scientific abstracts resulting from this merger, the committee expanded its membership to reflect the type of scientific abstracts in the broader program. The basic and translational research focus of the Surgical Forum was expanded to include clinical research in health services, education, global surgery, ethics, and other evolving areas of surgical science.
These changes have revitalized the scientific effort. The number and quality of the abstracts submitted to the Scientific Forum has grown significantly—more than 2,000 abstracts were submitted for review for Clinical Congress 2018.
The spirit of the Surgical Forum has been maintained in the new Scientific Forum, continuing with the clustering of focused areas of research to encourage discussion and collaboration among the attendees. The Program Committee continues to place great emphasis on highlighting the work of young investigators while incorporating the expertise of senior investigators into the sessions.
Changes at Clinical Congress 2017
Quick Shots and e-Posters were introduced at Clinical Congress 2017 in San Diego, CA. Quick Shots are three-minute oral abstract presentations, which were incorporated into the Scientific Forum sessions. This addition, which allowed for more presenters in a session, was met with a positive reception.
The poster sessions were restructured to an electronic format. The e-Posters were placed in a central, dedicated location among the Scientific Forum sessions rather than the Exhibit Hall. The modern e-Poster sessions brought greater visibility to the poster presentations and energized the format. In the e-Poster room, special sessions were scheduled to highlight the exceptional research efforts of the surgical trainees through the Excellence in Research Awards and the Posters of Exceptional Merit. In addition, the Scientific Forum is dedicated to a senior surgeon-scientist who has demonstrated a career-long commitment to training surgeon-scientists and the academic mission.
To further promote and support surgical research, the Scientific Forum Committee partnered with the Journal of the American College of Surgeons (JACS) to solicit the highest-rated abstracts for publication in JACS. In the first year, the top 5 percent of abstracts in the clinical sciences were solicited for manuscript submissions. More than half of those authors submitted a manuscript for review. All accepted manuscripts will be electronically published concurrently with the ACS Clinical Congress 2018 to provide greater visibility to the high-quality research being generated by the ACS community.
Clinical trials session added in 2018
The Scientific Forum Committee strongly believes the Clinical Congress is the premier venue to present practice-changing research. New for 2018, a call for late-breaking clinical trials abstracts was issued, and the committee selected six clinical trials that have the potential to change practice and improve patient care. This new clinical trials session will be presented at Clinical Congress 2018 Monday, October 22, at 9:45 am.
The ACS Clinical Congress is the largest surgical meeting in the U.S. The vision of the Scientific Forum Committee is for leaders of surgical trials to view the Clinical Congress as the premier venue to present their results. These exciting and transformative changes to the Scientific Forum will bring greater exposure to the leading-edge research in clinical care, while continuing to support and encourage young surgeon-scientists—the future of the study and practice of surgery—in their work. ♦
Note
The authors of this article are part of the Owen H. Wangensteen Scientific Forum Committee—Mary T. Hawn, MD, FACS; Edith Tzeng, MD, FACS; and Valerie W. Rusch, MD, FACS, are members, and M. Jane Burns, MJHL; Richard V. King, PhD; and Ajit K. Sachdeva, MD, FACS, FRCSC, are ACS staff.
Dr. Hawn is professor of surgery and chair, department of surgery, Stanford University, CA. She is Chair, ACS Scientific Forum Committee.
Dr. Tzeng is professor of surgery, University of Pittsburgh, and chief, vascular surgery, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, PA. She is Vice-Chair, ACS Scientific Forum Committee.
Dr. Rusch is vice-chair, clinical research, department of surgery; Miner Family Chair in Intrathoracic Cancers; attending surgeon, thoracic service, department of surgery, Memorial Sloan-Kettering Cancer Center; and professor of surgery, Weill Cornell Medical College. She is a consultant for the ACS Program Committee.
Ms. Burns is Senior Manager, Clinical Congress Program, ACS Division of Education, Chicago.
Mr. King is Assistant Director, Clinical Congress Program and Skills Courses, ACS Division of Education.
Dr. Sachdeva is Director, ACS Division of Education.
For surgeons, 1 on-call night equals 3 sleep-disrupted nights
SAN DIEGO – Almost 70% of surgeons who pull in-house call duty may be sleep deprived, Jamie Jones Coleman, MD, said at the annual meeting of the American Association for the Surgery of Trauma.
Even extra sleep the night after call doesn’t even things out, said Dr. Coleman of the University of Colorado, Denver. Her prospective study found that it takes 3 nights for sleep patterns to return to normal – a potential problem for surgeons who have frequent on-call nights.
“Sleep deprivation slows reaction time, decreases fine motor coordination, and increases the risk of chronic disease,” said Dr. Coleman. “A single period of 24 hours without sleep results in a neurocognitive performance that’s similar to having a blood alcohol content of 0.1%. It’s also associated with decreased empathy and increased depression. We need to take this issue seriously.”
Dr. Coleman measured sleep hours and architecture on 17 surgeons over 3 months, collecting data on 1,421 nights. Each surgeon wore a biometric measuring device called “Whoop” for the entire study. Worn on the wrist, the device measures heart rate, heart rate variability, and movement 100 times per second. It also records sleep onset and termination and can determine stages of sleep (light, slow wave, and REM).
In addition to wearing the device, the subjects also recorded all of their call schedules. The study compared sleep patterns on pre-call day 1 to those on post-call days 1, 2, and 3. Acute sleep deprivation was defined as two or more cycles of slow-wave sleep before REM; chronic sleep deprivation was one or more cycles of REM before slow-wave sleep onset.
Most of the subjects (65%) were men; the mean age was 45 years. Of the 1,421 nights recorded, 227 were on-call. Surgeons were already getting fewer hours of sleep than generally recommended, averaging 6.5 hours excluding call nights.
Subjects tried to “catch up” on sleep the day after call, Dr. Coleman said. On the day before call, they recorded an average of 6.4 hours of sleep; that increased to about 7 hours on post-call day 1. On post-call day 2, the average sleep time was about 6.3 hours, and increased to 6.5 hours by the third day.
Most of these recovery nights (70%) had abnormal amounts of REM sleep; 56% had abnormal amounts of slow-wave sleep. The majority of subjects (65%) showed patterns that qualified as either acute or chronic sleep deprivation.
“A recent study of football players found that correcting sleep issues was associated with both decreased alcohol consumption and decreased injuries,” Dr. Coleman said. “Well, we are being injured too. Shouldn’t surgeons take this as seriously as people who throw a ball for a living?”
She had no financial disclosures.
[email protected]
SOURCE: Coleman JJ et al. AAST 2018, Abstract 29.
SAN DIEGO – Almost 70% of surgeons who pull in-house call duty may be sleep deprived, Jamie Jones Coleman, MD, said at the annual meeting of the American Association for the Surgery of Trauma.
Even extra sleep the night after call doesn’t even things out, said Dr. Coleman of the University of Colorado, Denver. Her prospective study found that it takes 3 nights for sleep patterns to return to normal – a potential problem for surgeons who have frequent on-call nights.
“Sleep deprivation slows reaction time, decreases fine motor coordination, and increases the risk of chronic disease,” said Dr. Coleman. “A single period of 24 hours without sleep results in a neurocognitive performance that’s similar to having a blood alcohol content of 0.1%. It’s also associated with decreased empathy and increased depression. We need to take this issue seriously.”
Dr. Coleman measured sleep hours and architecture on 17 surgeons over 3 months, collecting data on 1,421 nights. Each surgeon wore a biometric measuring device called “Whoop” for the entire study. Worn on the wrist, the device measures heart rate, heart rate variability, and movement 100 times per second. It also records sleep onset and termination and can determine stages of sleep (light, slow wave, and REM).
In addition to wearing the device, the subjects also recorded all of their call schedules. The study compared sleep patterns on pre-call day 1 to those on post-call days 1, 2, and 3. Acute sleep deprivation was defined as two or more cycles of slow-wave sleep before REM; chronic sleep deprivation was one or more cycles of REM before slow-wave sleep onset.
Most of the subjects (65%) were men; the mean age was 45 years. Of the 1,421 nights recorded, 227 were on-call. Surgeons were already getting fewer hours of sleep than generally recommended, averaging 6.5 hours excluding call nights.
Subjects tried to “catch up” on sleep the day after call, Dr. Coleman said. On the day before call, they recorded an average of 6.4 hours of sleep; that increased to about 7 hours on post-call day 1. On post-call day 2, the average sleep time was about 6.3 hours, and increased to 6.5 hours by the third day.
Most of these recovery nights (70%) had abnormal amounts of REM sleep; 56% had abnormal amounts of slow-wave sleep. The majority of subjects (65%) showed patterns that qualified as either acute or chronic sleep deprivation.
“A recent study of football players found that correcting sleep issues was associated with both decreased alcohol consumption and decreased injuries,” Dr. Coleman said. “Well, we are being injured too. Shouldn’t surgeons take this as seriously as people who throw a ball for a living?”
She had no financial disclosures.
[email protected]
SOURCE: Coleman JJ et al. AAST 2018, Abstract 29.
SAN DIEGO – Almost 70% of surgeons who pull in-house call duty may be sleep deprived, Jamie Jones Coleman, MD, said at the annual meeting of the American Association for the Surgery of Trauma.
Even extra sleep the night after call doesn’t even things out, said Dr. Coleman of the University of Colorado, Denver. Her prospective study found that it takes 3 nights for sleep patterns to return to normal – a potential problem for surgeons who have frequent on-call nights.
“Sleep deprivation slows reaction time, decreases fine motor coordination, and increases the risk of chronic disease,” said Dr. Coleman. “A single period of 24 hours without sleep results in a neurocognitive performance that’s similar to having a blood alcohol content of 0.1%. It’s also associated with decreased empathy and increased depression. We need to take this issue seriously.”
Dr. Coleman measured sleep hours and architecture on 17 surgeons over 3 months, collecting data on 1,421 nights. Each surgeon wore a biometric measuring device called “Whoop” for the entire study. Worn on the wrist, the device measures heart rate, heart rate variability, and movement 100 times per second. It also records sleep onset and termination and can determine stages of sleep (light, slow wave, and REM).
In addition to wearing the device, the subjects also recorded all of their call schedules. The study compared sleep patterns on pre-call day 1 to those on post-call days 1, 2, and 3. Acute sleep deprivation was defined as two or more cycles of slow-wave sleep before REM; chronic sleep deprivation was one or more cycles of REM before slow-wave sleep onset.
Most of the subjects (65%) were men; the mean age was 45 years. Of the 1,421 nights recorded, 227 were on-call. Surgeons were already getting fewer hours of sleep than generally recommended, averaging 6.5 hours excluding call nights.
Subjects tried to “catch up” on sleep the day after call, Dr. Coleman said. On the day before call, they recorded an average of 6.4 hours of sleep; that increased to about 7 hours on post-call day 1. On post-call day 2, the average sleep time was about 6.3 hours, and increased to 6.5 hours by the third day.
Most of these recovery nights (70%) had abnormal amounts of REM sleep; 56% had abnormal amounts of slow-wave sleep. The majority of subjects (65%) showed patterns that qualified as either acute or chronic sleep deprivation.
“A recent study of football players found that correcting sleep issues was associated with both decreased alcohol consumption and decreased injuries,” Dr. Coleman said. “Well, we are being injured too. Shouldn’t surgeons take this as seriously as people who throw a ball for a living?”
She had no financial disclosures.
[email protected]
SOURCE: Coleman JJ et al. AAST 2018, Abstract 29.
REPORTING FROM THE AAST ANNUAL MEETING
Key clinical point: On-call duty disrupts sleep for many surgeons.
Major finding: About 65% qualify as having acute or chronic sleep deprivation.
Study details: The prospective study involved 17 surgeons.
Disclosures: Dr. Coleman had no relevant financial disclosures.
Source: Coleman JJ et al. AAST 2018, Abstract 29.
Half of outpatient antibiotics prescribed with no infectious disease code
based on a review of more than half a million outpatient prescriptions to more than a quarter million patients at 514 clinics around Chicago.
The researchers looked to see if prescriptions had an ICD-10 code that indicated an antibiotic; they were liberal in their approach, considering over 21,000 codes to at least possibly signal the need for an antibiotic.
Almost half the time, there was nothing in the codes related to bacterial infection: 29% of scripts were written in connection with codes for high blood pressure, annual visits, and other noninfectious disorders; 17% of prescriptions were written with no diagnosis code at all.
The study is likely the largest to date to look at outpatient antibiotic prescribing patterns in the United States, and the findings are worrisome. “Nearly half the time, clinicians have either a bad reason for prescribing antibiotics, or don’t provide a reason at all. When you consider about 80% of antibiotics are prescribed on an outpatient basis, that’s a concern,” lead investigator Jeffrey A. Linder, MD, MPH, chief of the division of general internal medicine and geriatrics at Northwestern University, Chicago, said in a written statement.
“At busy clinics, sadly, the most efficient thing to do is just call in an antibiotic prescription. We need to dig into the data more, but we believe there is a lot of antibiotic prescribing for colds, the flu, and non-specific symptoms such as just not feeling well,” he said.
With all the concern in recent years about overuse, it’s hard to imagine that prescribers are still being free and easy with antibiotics, and Dr. Linder’s study will certainly have its skeptics.
Sloppy record keeping could be one explanation for the findings. A patient could really have needed an antibiotic, but it just wasn’t captured in coding. There are also valid reasons for prescribing antibiotics over the phone, such as acne and recurrent UTIs.
Dr. Linder, however, thinks it’s more than that. He explained his study, its implications, and the next steps in an interview at ID Week, an annual scientific meeting on infectious diseases.
The 2,413 prescribers in the study included physicians, surgeons, residents, fellows, nurse practitioners, and physician assistants in general and specialty practices. Patients were a mean of 43 years old: 60% were women and 75% were white. The most common antibiotic classes were penicillins, macrolides, and cephalosporins. Prescriptions were written from November 2015 through October 2017.
The work was funded by the Agency for Healthcare Research and Quality. Dr. Linder did not have any disclosures.
SOURCE: Linder JA et al. ID Week 2018 abstract 1632.
based on a review of more than half a million outpatient prescriptions to more than a quarter million patients at 514 clinics around Chicago.
The researchers looked to see if prescriptions had an ICD-10 code that indicated an antibiotic; they were liberal in their approach, considering over 21,000 codes to at least possibly signal the need for an antibiotic.
Almost half the time, there was nothing in the codes related to bacterial infection: 29% of scripts were written in connection with codes for high blood pressure, annual visits, and other noninfectious disorders; 17% of prescriptions were written with no diagnosis code at all.
The study is likely the largest to date to look at outpatient antibiotic prescribing patterns in the United States, and the findings are worrisome. “Nearly half the time, clinicians have either a bad reason for prescribing antibiotics, or don’t provide a reason at all. When you consider about 80% of antibiotics are prescribed on an outpatient basis, that’s a concern,” lead investigator Jeffrey A. Linder, MD, MPH, chief of the division of general internal medicine and geriatrics at Northwestern University, Chicago, said in a written statement.
“At busy clinics, sadly, the most efficient thing to do is just call in an antibiotic prescription. We need to dig into the data more, but we believe there is a lot of antibiotic prescribing for colds, the flu, and non-specific symptoms such as just not feeling well,” he said.
With all the concern in recent years about overuse, it’s hard to imagine that prescribers are still being free and easy with antibiotics, and Dr. Linder’s study will certainly have its skeptics.
Sloppy record keeping could be one explanation for the findings. A patient could really have needed an antibiotic, but it just wasn’t captured in coding. There are also valid reasons for prescribing antibiotics over the phone, such as acne and recurrent UTIs.
Dr. Linder, however, thinks it’s more than that. He explained his study, its implications, and the next steps in an interview at ID Week, an annual scientific meeting on infectious diseases.
The 2,413 prescribers in the study included physicians, surgeons, residents, fellows, nurse practitioners, and physician assistants in general and specialty practices. Patients were a mean of 43 years old: 60% were women and 75% were white. The most common antibiotic classes were penicillins, macrolides, and cephalosporins. Prescriptions were written from November 2015 through October 2017.
The work was funded by the Agency for Healthcare Research and Quality. Dr. Linder did not have any disclosures.
SOURCE: Linder JA et al. ID Week 2018 abstract 1632.
based on a review of more than half a million outpatient prescriptions to more than a quarter million patients at 514 clinics around Chicago.
The researchers looked to see if prescriptions had an ICD-10 code that indicated an antibiotic; they were liberal in their approach, considering over 21,000 codes to at least possibly signal the need for an antibiotic.
Almost half the time, there was nothing in the codes related to bacterial infection: 29% of scripts were written in connection with codes for high blood pressure, annual visits, and other noninfectious disorders; 17% of prescriptions were written with no diagnosis code at all.
The study is likely the largest to date to look at outpatient antibiotic prescribing patterns in the United States, and the findings are worrisome. “Nearly half the time, clinicians have either a bad reason for prescribing antibiotics, or don’t provide a reason at all. When you consider about 80% of antibiotics are prescribed on an outpatient basis, that’s a concern,” lead investigator Jeffrey A. Linder, MD, MPH, chief of the division of general internal medicine and geriatrics at Northwestern University, Chicago, said in a written statement.
“At busy clinics, sadly, the most efficient thing to do is just call in an antibiotic prescription. We need to dig into the data more, but we believe there is a lot of antibiotic prescribing for colds, the flu, and non-specific symptoms such as just not feeling well,” he said.
With all the concern in recent years about overuse, it’s hard to imagine that prescribers are still being free and easy with antibiotics, and Dr. Linder’s study will certainly have its skeptics.
Sloppy record keeping could be one explanation for the findings. A patient could really have needed an antibiotic, but it just wasn’t captured in coding. There are also valid reasons for prescribing antibiotics over the phone, such as acne and recurrent UTIs.
Dr. Linder, however, thinks it’s more than that. He explained his study, its implications, and the next steps in an interview at ID Week, an annual scientific meeting on infectious diseases.
The 2,413 prescribers in the study included physicians, surgeons, residents, fellows, nurse practitioners, and physician assistants in general and specialty practices. Patients were a mean of 43 years old: 60% were women and 75% were white. The most common antibiotic classes were penicillins, macrolides, and cephalosporins. Prescriptions were written from November 2015 through October 2017.
The work was funded by the Agency for Healthcare Research and Quality. Dr. Linder did not have any disclosures.
SOURCE: Linder JA et al. ID Week 2018 abstract 1632.
REPORTING FROM ID WEEK 2018
MELD sodium score tied to better transplant outcomes
Factoring hyponatremic status into liver graft allocations led to significant reductions in wait-list mortality, researchers reported in the November issue of Gastroenterology.
Hyponatremic patients with low MELD scores benefited significantly from allocation based on the end-stage liver disease–sodium (MELD-Na) score, while its survival benefit was less evident among patients with higher scores, said Shunji Nagai, MD, PhD, of Henry Ford Hospital, Detroit, and his associates. “Therefore, liver allocation rules such as Share 15 and Share 35 need to be revised to fulfill the Final Rule under the MELD-Na based allocation,” they wrote.
The Share 35 rule offers liver grafts locally and regionally to wait-listed patients with MELD-Na scores of at least 35. Under the Share 15 rule, livers are offered regionally or nationally before considering local candidates with MELD scores under 15. The traditional MELD scoring system excluded hyponatremia, which has since been found to independently predict death from cirrhosis. Therefore, in January 2016, a modified MELD-Na score was implemented for patients with traditional MELD scores of at least 12. The MELD-Na score assigns patients between 1 and 11 additional points, and patients with low MELD scores and severe hyponatremia receive the most points. To assess the impact of this change, Dr. Nagai and his associates compared wait-list and posttransplantation outcomes during the pre and post–MELD-Na eras and the survival benefit of liver transplantation during the MELD-Na period. The study included all adults wait-listed for livers from June 2013, when Share 35 was implemented, through September 2017.
Mortality within 90 days on the wait list fell significantly during the MELD-Na era (hazard ratio, 0.74; P less than .001). Transplantation conferred a “definitive” survival benefit when MELD-Na scores were 21-23 (HR versus wait list, 0.34; P less than .001). During the traditional MELD period, the equivalent cutoff was 15-17 (HR, 0.36; P less than .001). “As such, the current rules for liver allocation may be suboptimal under the MELD-Na–based allocation and the criteria for Share 15 may need to be revisited,” the researchers wrote. They recommended raising the cutoff to 21.
The study also confirmed mild hyponatremia (130-134 mmol/L), moderate hyponatremia (125-129 mmol/L), and severe hyponatremia (less than 125 mmol/L) as independent predictors of wait-list mortality during the traditional MELD era. Hazard ratios were 1.4, 1.8, and 1.7, respectively (all P less than .001). The implementation of MELD-Na significantly weakened these associations, with HRs of 1.1 (P = .3), 1.3 (P = .02), and 1.4 (P = .04), respectively).
The probability of transplantation also rose significantly during the MELD-Na era (HR, 1.2; P less than .001), possibly because of the opioid epidemic, the researchers said. Although greater availability of liver grafts might have improved wait-list outcomes, all score categories would have shown a positive impact if this was the only reason, they added. Instead, MELD-Na most benefited patients with lower scores.
Finally, posttransplantation outcomes worsened during the MELD-Na era, perhaps because of transplant population aging. However, the survival benefit of transplant shifted to higher score ranges during the MELD-Na era even after the researchers controlled for this effect. “According to this analysis,” they wrote, “the survival benefit of liver transplant was definitive in patients with score category of 21-23, which could further validate our proposal to revise Share 15 rule to ‘Share 21.’ ”
The investigators reported having no external funding sources or conflicts of interest.
SOURCE: Nagai S et al. Gastroenterology. 2018 Jul 26. doi: 10.1053/j.gastro.2018.07.025.
Factoring hyponatremic status into liver graft allocations led to significant reductions in wait-list mortality, researchers reported in the November issue of Gastroenterology.
Hyponatremic patients with low MELD scores benefited significantly from allocation based on the end-stage liver disease–sodium (MELD-Na) score, while its survival benefit was less evident among patients with higher scores, said Shunji Nagai, MD, PhD, of Henry Ford Hospital, Detroit, and his associates. “Therefore, liver allocation rules such as Share 15 and Share 35 need to be revised to fulfill the Final Rule under the MELD-Na based allocation,” they wrote.
The Share 35 rule offers liver grafts locally and regionally to wait-listed patients with MELD-Na scores of at least 35. Under the Share 15 rule, livers are offered regionally or nationally before considering local candidates with MELD scores under 15. The traditional MELD scoring system excluded hyponatremia, which has since been found to independently predict death from cirrhosis. Therefore, in January 2016, a modified MELD-Na score was implemented for patients with traditional MELD scores of at least 12. The MELD-Na score assigns patients between 1 and 11 additional points, and patients with low MELD scores and severe hyponatremia receive the most points. To assess the impact of this change, Dr. Nagai and his associates compared wait-list and posttransplantation outcomes during the pre and post–MELD-Na eras and the survival benefit of liver transplantation during the MELD-Na period. The study included all adults wait-listed for livers from June 2013, when Share 35 was implemented, through September 2017.
Mortality within 90 days on the wait list fell significantly during the MELD-Na era (hazard ratio, 0.74; P less than .001). Transplantation conferred a “definitive” survival benefit when MELD-Na scores were 21-23 (HR versus wait list, 0.34; P less than .001). During the traditional MELD period, the equivalent cutoff was 15-17 (HR, 0.36; P less than .001). “As such, the current rules for liver allocation may be suboptimal under the MELD-Na–based allocation and the criteria for Share 15 may need to be revisited,” the researchers wrote. They recommended raising the cutoff to 21.
The study also confirmed mild hyponatremia (130-134 mmol/L), moderate hyponatremia (125-129 mmol/L), and severe hyponatremia (less than 125 mmol/L) as independent predictors of wait-list mortality during the traditional MELD era. Hazard ratios were 1.4, 1.8, and 1.7, respectively (all P less than .001). The implementation of MELD-Na significantly weakened these associations, with HRs of 1.1 (P = .3), 1.3 (P = .02), and 1.4 (P = .04), respectively).
The probability of transplantation also rose significantly during the MELD-Na era (HR, 1.2; P less than .001), possibly because of the opioid epidemic, the researchers said. Although greater availability of liver grafts might have improved wait-list outcomes, all score categories would have shown a positive impact if this was the only reason, they added. Instead, MELD-Na most benefited patients with lower scores.
Finally, posttransplantation outcomes worsened during the MELD-Na era, perhaps because of transplant population aging. However, the survival benefit of transplant shifted to higher score ranges during the MELD-Na era even after the researchers controlled for this effect. “According to this analysis,” they wrote, “the survival benefit of liver transplant was definitive in patients with score category of 21-23, which could further validate our proposal to revise Share 15 rule to ‘Share 21.’ ”
The investigators reported having no external funding sources or conflicts of interest.
SOURCE: Nagai S et al. Gastroenterology. 2018 Jul 26. doi: 10.1053/j.gastro.2018.07.025.
Factoring hyponatremic status into liver graft allocations led to significant reductions in wait-list mortality, researchers reported in the November issue of Gastroenterology.
Hyponatremic patients with low MELD scores benefited significantly from allocation based on the end-stage liver disease–sodium (MELD-Na) score, while its survival benefit was less evident among patients with higher scores, said Shunji Nagai, MD, PhD, of Henry Ford Hospital, Detroit, and his associates. “Therefore, liver allocation rules such as Share 15 and Share 35 need to be revised to fulfill the Final Rule under the MELD-Na based allocation,” they wrote.
The Share 35 rule offers liver grafts locally and regionally to wait-listed patients with MELD-Na scores of at least 35. Under the Share 15 rule, livers are offered regionally or nationally before considering local candidates with MELD scores under 15. The traditional MELD scoring system excluded hyponatremia, which has since been found to independently predict death from cirrhosis. Therefore, in January 2016, a modified MELD-Na score was implemented for patients with traditional MELD scores of at least 12. The MELD-Na score assigns patients between 1 and 11 additional points, and patients with low MELD scores and severe hyponatremia receive the most points. To assess the impact of this change, Dr. Nagai and his associates compared wait-list and posttransplantation outcomes during the pre and post–MELD-Na eras and the survival benefit of liver transplantation during the MELD-Na period. The study included all adults wait-listed for livers from June 2013, when Share 35 was implemented, through September 2017.
Mortality within 90 days on the wait list fell significantly during the MELD-Na era (hazard ratio, 0.74; P less than .001). Transplantation conferred a “definitive” survival benefit when MELD-Na scores were 21-23 (HR versus wait list, 0.34; P less than .001). During the traditional MELD period, the equivalent cutoff was 15-17 (HR, 0.36; P less than .001). “As such, the current rules for liver allocation may be suboptimal under the MELD-Na–based allocation and the criteria for Share 15 may need to be revisited,” the researchers wrote. They recommended raising the cutoff to 21.
The study also confirmed mild hyponatremia (130-134 mmol/L), moderate hyponatremia (125-129 mmol/L), and severe hyponatremia (less than 125 mmol/L) as independent predictors of wait-list mortality during the traditional MELD era. Hazard ratios were 1.4, 1.8, and 1.7, respectively (all P less than .001). The implementation of MELD-Na significantly weakened these associations, with HRs of 1.1 (P = .3), 1.3 (P = .02), and 1.4 (P = .04), respectively).
The probability of transplantation also rose significantly during the MELD-Na era (HR, 1.2; P less than .001), possibly because of the opioid epidemic, the researchers said. Although greater availability of liver grafts might have improved wait-list outcomes, all score categories would have shown a positive impact if this was the only reason, they added. Instead, MELD-Na most benefited patients with lower scores.
Finally, posttransplantation outcomes worsened during the MELD-Na era, perhaps because of transplant population aging. However, the survival benefit of transplant shifted to higher score ranges during the MELD-Na era even after the researchers controlled for this effect. “According to this analysis,” they wrote, “the survival benefit of liver transplant was definitive in patients with score category of 21-23, which could further validate our proposal to revise Share 15 rule to ‘Share 21.’ ”
The investigators reported having no external funding sources or conflicts of interest.
SOURCE: Nagai S et al. Gastroenterology. 2018 Jul 26. doi: 10.1053/j.gastro.2018.07.025.
FROM GASTROENTEROLOGY
Key clinical point: The implementation of the MELD sodium (MELD-Na) score for liver allocation was associated with significantly improved outcomes for wait-listed patients.
Major finding: During the MELD-Na era, mortality within 90 days on the liver wait list dropped significantly (HR, 0.74; P less than .001) while the probability of transplant rose significantly (HR, 1.2; P less than .001).
Study details: Comparison of 18,850 adult transplant candidates during the traditional MELD era versus 14,512 candidates during the MELD-Na era.
Disclosures: The investigators had no external funding sources or conflicts of interest.
Source: Nagai S et al. Gastroenterology. 2018 Jul 26. doi: 10.1053/j.gastro.2018.07.025.