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AGA comments on Quality Payment proposed rule
AGA provided comments on a proposed rule describing potential changes to the Quality Payment Program (QPP) established under the Medicare Access and CHIP Reauthorization Act (MACRA) for the 2018 performance year. AGA thanks the many members who also submitted comments to CMS to tell the agency how proposed changes will impact you.
For year two, CMS proposed many policies that increase flexibility and incentives under the QPP. However, many proposals target solo practitioners, small practices, and other eligible clinicians with special circumstances. While we support these proposals, AGA’s comments to CMS also ask for changes that are needed to make the QPP work for all gastroenterologists, such as reducing the number of points needed to avoid a payment penalty.
CMS will finalize changes to the QPP during the fall of 2017. Final changes will take effect with the performance period that begins on Jan. 1, 2018. Performance during 2018 will impact payment for services in 2020. AGA members will be notified as soon as the rule is made available by CMS.
Still unsure how to participate in year one?
Make sure your practice is prepared for the 2017 performance year. If you are eligible to participate in 2017, but choose not to, your rates will decrease by 4% in 2019. AGA’s MACRA resource center provides customized advice based on your practice situation to get you on track. It’s not too late to start, but if you wait until Oct. 2, 2017, the deadline to start submitting claims, it will be. Get started now, http://www.gastro.org/macra.
AGA provided comments on a proposed rule describing potential changes to the Quality Payment Program (QPP) established under the Medicare Access and CHIP Reauthorization Act (MACRA) for the 2018 performance year. AGA thanks the many members who also submitted comments to CMS to tell the agency how proposed changes will impact you.
For year two, CMS proposed many policies that increase flexibility and incentives under the QPP. However, many proposals target solo practitioners, small practices, and other eligible clinicians with special circumstances. While we support these proposals, AGA’s comments to CMS also ask for changes that are needed to make the QPP work for all gastroenterologists, such as reducing the number of points needed to avoid a payment penalty.
CMS will finalize changes to the QPP during the fall of 2017. Final changes will take effect with the performance period that begins on Jan. 1, 2018. Performance during 2018 will impact payment for services in 2020. AGA members will be notified as soon as the rule is made available by CMS.
Still unsure how to participate in year one?
Make sure your practice is prepared for the 2017 performance year. If you are eligible to participate in 2017, but choose not to, your rates will decrease by 4% in 2019. AGA’s MACRA resource center provides customized advice based on your practice situation to get you on track. It’s not too late to start, but if you wait until Oct. 2, 2017, the deadline to start submitting claims, it will be. Get started now, http://www.gastro.org/macra.
AGA provided comments on a proposed rule describing potential changes to the Quality Payment Program (QPP) established under the Medicare Access and CHIP Reauthorization Act (MACRA) for the 2018 performance year. AGA thanks the many members who also submitted comments to CMS to tell the agency how proposed changes will impact you.
For year two, CMS proposed many policies that increase flexibility and incentives under the QPP. However, many proposals target solo practitioners, small practices, and other eligible clinicians with special circumstances. While we support these proposals, AGA’s comments to CMS also ask for changes that are needed to make the QPP work for all gastroenterologists, such as reducing the number of points needed to avoid a payment penalty.
CMS will finalize changes to the QPP during the fall of 2017. Final changes will take effect with the performance period that begins on Jan. 1, 2018. Performance during 2018 will impact payment for services in 2020. AGA members will be notified as soon as the rule is made available by CMS.
Still unsure how to participate in year one?
Make sure your practice is prepared for the 2017 performance year. If you are eligible to participate in 2017, but choose not to, your rates will decrease by 4% in 2019. AGA’s MACRA resource center provides customized advice based on your practice situation to get you on track. It’s not too late to start, but if you wait until Oct. 2, 2017, the deadline to start submitting claims, it will be. Get started now, http://www.gastro.org/macra.
AGA releases new clinical guideline on therapeutic drug monitoring in IBD
AGA has issued a new clinical guideline on the role of therapeutic drug monitoring (TDM) in the management of IBD, published in the September 2017 issue of Gastroenterology. The guideline focuses on the application of TDM for biologic therapy, specifically anti–tumor necrosis factor-alpha (TNF) agents and thiopurines, and addresses questions about the risks and benefits of reactive TDM, routine proactive TDM, or no TDM in guiding treatment changes. AGA’s recommendations include:
The guideline is accompanied by a technical review, Clinical Decision Support Tool, and patient companion, which provides key points and important information directly to patients about this approach, written at an appropriate reading level. Access the patient companion in the Patient Info Center, www.gastro.org/IBD.
AGA has issued a new clinical guideline on the role of therapeutic drug monitoring (TDM) in the management of IBD, published in the September 2017 issue of Gastroenterology. The guideline focuses on the application of TDM for biologic therapy, specifically anti–tumor necrosis factor-alpha (TNF) agents and thiopurines, and addresses questions about the risks and benefits of reactive TDM, routine proactive TDM, or no TDM in guiding treatment changes. AGA’s recommendations include:
The guideline is accompanied by a technical review, Clinical Decision Support Tool, and patient companion, which provides key points and important information directly to patients about this approach, written at an appropriate reading level. Access the patient companion in the Patient Info Center, www.gastro.org/IBD.
AGA has issued a new clinical guideline on the role of therapeutic drug monitoring (TDM) in the management of IBD, published in the September 2017 issue of Gastroenterology. The guideline focuses on the application of TDM for biologic therapy, specifically anti–tumor necrosis factor-alpha (TNF) agents and thiopurines, and addresses questions about the risks and benefits of reactive TDM, routine proactive TDM, or no TDM in guiding treatment changes. AGA’s recommendations include:
The guideline is accompanied by a technical review, Clinical Decision Support Tool, and patient companion, which provides key points and important information directly to patients about this approach, written at an appropriate reading level. Access the patient companion in the Patient Info Center, www.gastro.org/IBD.
Make a difference – support AGA’s Research Awards program
Many breakthroughs have been achieved through gastroenterological and hepatological research over the past century, forming the basis of the modern medical practice. As the charitable arm of the American Gastroenterological Association (AGA), the AGA Research Foundation contributes to this tradition of discovery by providing a key source of funding at a critical juncture in a young researcher’s career.
“The Research Scholar Award will have a pivotal effect on my future career,” said Michael Dougan, MD, PhD, Massachusetts General Hospital, Boston, 2017 Research Scholar Award recipient. “This award enables me to establish my own research infrastructure, and lay the experimental foundations for my future work as a clinician‐scientist striving to understand the complex interplay between the immune system, metabolism, and cancer.”
By joining others in donating to the AGA Research Foundation, you will help to foster a new pipeline of scientists – the next generation of leaders in GI.
Make a tax-deductible donation and help us keep the best and brightest investigators working in gastroenterology and hepatology. Donate at www.gastro.org/dontateonline or by mail to 4930 Del Ray Avenue, Bethesda, MD 20814.
Many breakthroughs have been achieved through gastroenterological and hepatological research over the past century, forming the basis of the modern medical practice. As the charitable arm of the American Gastroenterological Association (AGA), the AGA Research Foundation contributes to this tradition of discovery by providing a key source of funding at a critical juncture in a young researcher’s career.
“The Research Scholar Award will have a pivotal effect on my future career,” said Michael Dougan, MD, PhD, Massachusetts General Hospital, Boston, 2017 Research Scholar Award recipient. “This award enables me to establish my own research infrastructure, and lay the experimental foundations for my future work as a clinician‐scientist striving to understand the complex interplay between the immune system, metabolism, and cancer.”
By joining others in donating to the AGA Research Foundation, you will help to foster a new pipeline of scientists – the next generation of leaders in GI.
Make a tax-deductible donation and help us keep the best and brightest investigators working in gastroenterology and hepatology. Donate at www.gastro.org/dontateonline or by mail to 4930 Del Ray Avenue, Bethesda, MD 20814.
Many breakthroughs have been achieved through gastroenterological and hepatological research over the past century, forming the basis of the modern medical practice. As the charitable arm of the American Gastroenterological Association (AGA), the AGA Research Foundation contributes to this tradition of discovery by providing a key source of funding at a critical juncture in a young researcher’s career.
“The Research Scholar Award will have a pivotal effect on my future career,” said Michael Dougan, MD, PhD, Massachusetts General Hospital, Boston, 2017 Research Scholar Award recipient. “This award enables me to establish my own research infrastructure, and lay the experimental foundations for my future work as a clinician‐scientist striving to understand the complex interplay between the immune system, metabolism, and cancer.”
By joining others in donating to the AGA Research Foundation, you will help to foster a new pipeline of scientists – the next generation of leaders in GI.
Make a tax-deductible donation and help us keep the best and brightest investigators working in gastroenterology and hepatology. Donate at www.gastro.org/dontateonline or by mail to 4930 Del Ray Avenue, Bethesda, MD 20814.
CMS releases some good news for ASCs
CMS released the Medicare Inpatient Prospective Payment System (IPPS) final rule, which affects hospital payments and includes provisions for ambulatory surgery centers (ASCs) and physician payments.
Thanks to the AGA members who submitted comments to the proposed rule, CMS withdrew plans to publicly post facility accreditation reviews and correction plans. Below is a summary of AGA’s position and where CMS landed on each issue.
1. Public display of final accreditation surveys and plans of correction.
Summary of AGA position – AGA urged CMS to withdraw its proposal making ASC accreditation surveys open to the public. To support shared transparency objectives, AGA recommended that if CMS were to finalize its proposal, the agency should first develop standards and a framework that considers both violation severity and scope.
CMS final rule – After consideration of the public comments received, CMS will not make ASC accreditation surveys open to the public. CMS was concerned that the suggestion to have accrediting organizations post their survey reports would appear as if it was attempting to circumvent current law, which prohibits CMS from disclosing survey reports or compelling the accrediting organizations to disclose the reports themselves.
2. EHR Incentive Program certification requirements for payment year 2018.
Summary of AGA position – AGA supported increased flexibility for 2018 and urged CMS to allow use of EHR technology certified to the 2014 software edition OR the 2015 software edition for the 2018 EHR Incentive Program.
CMS final rule – CMS will allow health care providers to use either 2014 or 2015 CEHRT or a combination of 2014 and 2015 CEHRT for the 2018 EHR Incentive Program.
3. Exception for ASC-based physicians under the EHR Incentive Program for payment years 2017 and 2018.
Summary of AGA position – AGA encouraged CMS to define ASC-based as a physician or other eligible professional who provides more than 50% of Medicare billed services in an ASC. AGA was concerned that implementing a higher threshold would leave certain physicians exposed to payment penalties, because the meaningful use requirement is set at 50% or more.
CMS final rule – Unfortunately, CMS set the definition of “ASC-based” as those who provide 75% of all services in an ASC, based on previous statutory definitions.
Policy changes are effective on Oct. 1, 2017, and changes to the 2017 and 2018 EHR Incentive Program apply immediately to the 2015 and 2016 reporting period, and provide relief that will impact 2017 and 2018 payments.
CMS released the Medicare Inpatient Prospective Payment System (IPPS) final rule, which affects hospital payments and includes provisions for ambulatory surgery centers (ASCs) and physician payments.
Thanks to the AGA members who submitted comments to the proposed rule, CMS withdrew plans to publicly post facility accreditation reviews and correction plans. Below is a summary of AGA’s position and where CMS landed on each issue.
1. Public display of final accreditation surveys and plans of correction.
Summary of AGA position – AGA urged CMS to withdraw its proposal making ASC accreditation surveys open to the public. To support shared transparency objectives, AGA recommended that if CMS were to finalize its proposal, the agency should first develop standards and a framework that considers both violation severity and scope.
CMS final rule – After consideration of the public comments received, CMS will not make ASC accreditation surveys open to the public. CMS was concerned that the suggestion to have accrediting organizations post their survey reports would appear as if it was attempting to circumvent current law, which prohibits CMS from disclosing survey reports or compelling the accrediting organizations to disclose the reports themselves.
2. EHR Incentive Program certification requirements for payment year 2018.
Summary of AGA position – AGA supported increased flexibility for 2018 and urged CMS to allow use of EHR technology certified to the 2014 software edition OR the 2015 software edition for the 2018 EHR Incentive Program.
CMS final rule – CMS will allow health care providers to use either 2014 or 2015 CEHRT or a combination of 2014 and 2015 CEHRT for the 2018 EHR Incentive Program.
3. Exception for ASC-based physicians under the EHR Incentive Program for payment years 2017 and 2018.
Summary of AGA position – AGA encouraged CMS to define ASC-based as a physician or other eligible professional who provides more than 50% of Medicare billed services in an ASC. AGA was concerned that implementing a higher threshold would leave certain physicians exposed to payment penalties, because the meaningful use requirement is set at 50% or more.
CMS final rule – Unfortunately, CMS set the definition of “ASC-based” as those who provide 75% of all services in an ASC, based on previous statutory definitions.
Policy changes are effective on Oct. 1, 2017, and changes to the 2017 and 2018 EHR Incentive Program apply immediately to the 2015 and 2016 reporting period, and provide relief that will impact 2017 and 2018 payments.
CMS released the Medicare Inpatient Prospective Payment System (IPPS) final rule, which affects hospital payments and includes provisions for ambulatory surgery centers (ASCs) and physician payments.
Thanks to the AGA members who submitted comments to the proposed rule, CMS withdrew plans to publicly post facility accreditation reviews and correction plans. Below is a summary of AGA’s position and where CMS landed on each issue.
1. Public display of final accreditation surveys and plans of correction.
Summary of AGA position – AGA urged CMS to withdraw its proposal making ASC accreditation surveys open to the public. To support shared transparency objectives, AGA recommended that if CMS were to finalize its proposal, the agency should first develop standards and a framework that considers both violation severity and scope.
CMS final rule – After consideration of the public comments received, CMS will not make ASC accreditation surveys open to the public. CMS was concerned that the suggestion to have accrediting organizations post their survey reports would appear as if it was attempting to circumvent current law, which prohibits CMS from disclosing survey reports or compelling the accrediting organizations to disclose the reports themselves.
2. EHR Incentive Program certification requirements for payment year 2018.
Summary of AGA position – AGA supported increased flexibility for 2018 and urged CMS to allow use of EHR technology certified to the 2014 software edition OR the 2015 software edition for the 2018 EHR Incentive Program.
CMS final rule – CMS will allow health care providers to use either 2014 or 2015 CEHRT or a combination of 2014 and 2015 CEHRT for the 2018 EHR Incentive Program.
3. Exception for ASC-based physicians under the EHR Incentive Program for payment years 2017 and 2018.
Summary of AGA position – AGA encouraged CMS to define ASC-based as a physician or other eligible professional who provides more than 50% of Medicare billed services in an ASC. AGA was concerned that implementing a higher threshold would leave certain physicians exposed to payment penalties, because the meaningful use requirement is set at 50% or more.
CMS final rule – Unfortunately, CMS set the definition of “ASC-based” as those who provide 75% of all services in an ASC, based on previous statutory definitions.
Policy changes are effective on Oct. 1, 2017, and changes to the 2017 and 2018 EHR Incentive Program apply immediately to the 2015 and 2016 reporting period, and provide relief that will impact 2017 and 2018 payments.
Young Faculty Hot Topics: How to find mentors
As someone less than 1 year into practice, I believe mentorship is one of the most critical essentials as a trainee and a junior attending. I have been privileged to have excellent mentors throughout my training and now, in my first job. A lot of this is luck, but I also have always put mentorship at the top of my list when looking for fellowships and jobs. In fact, part of the reason I took the job I currently have is because the contract clearly stated who my clinical and academic mentors would be. This showed the department’s dedication to grooming junior staff appropriately. Below is my take on how to find mentors.
Have multiple mentors
It’s good to have multiple mentors, each of whom can provide a different kind of mentorship. For junior faculty, key areas of mentorship include:
- Building clinical volume.
- Establishing your reputation as a safe and competent clinician/surgeon.
- Designing your academic/research career.
- Planning your overall career.
- Solving any political/administrative issues.
Currently, my division chief is my clinical/general mentor, from whom I seek clinical advice, political advice should I find myself in a tough situation as a junior attending, and personal advice, as well. We meet monthly to go over various things including clinical/research projects and any clinical issues. I have an academic mentor, who is a basic scientist; we review research ideas together. He reads over and critiques my grants, and he picks apart my presentations. I also have a very senior mentor, a retired thoracic surgeon, whom I seek when I have a challenging case; it is crucial to identify a senior surgeon who has an abundance of experience so you can pick his or her brain – a true resource. This is in addition to the mentors I have from my training, with whom I am still in contact. I think it is important to have mentors outside of your current work for certain situations.
Mentors do not have to be in your discipline
It’s useful to have mentors from different fields. As I stated above, my academic mentor is a basic scientist. I am a thoracic surgeon, but I consider my general surgery residency chair, who is an accomplished surgical oncologist, and my residency program director, a general surgeon, to be two of my important mentors. I think it’s a good idea to have someone outside of your discipline as your mentor, even someone in a nonsurgical discipline, as long as she or he provides what you need, such as general career decisions and research mentorship. Having people from different disciplines adds more perspective and depth. For women, female mentors may provide input on career decisions at different life stages.
Do your homework about your would-be mentors
When deciding among different jobs, I did as much homework as possible in researching my would-be clinical mentors, who in most cases are also your senior partners. This included speaking with other junior faculty members within the division, people who had worked with the person in the past, and current mentors who may know them. In my mind, I found the most valuable resources to be people who had worked in the past with potential new mentors or senior partners. They can provide unbiased, sometimes negative, opinions that others might be less willing to provide. In fact, I probably spent more time trying to understand to the negative comments, since this provided valuable information, too.
I always asked questions specific to the mentorship. Were they around to help you in the OR when needed, or was it more of a verbal “I’ll be around”? Were they good about giving the juniors clinical volume and sharing OR time? Did you feel like you grew under his or her mentorship?
In conclusion, my advice about mentorship is to have multiple mentors, each for different purposes. For those looking for fellowships and jobs, learning all you can about your would-be mentors goes a long way toward ensuring an ideal position.
Dr. Suzuki is a general thoracic surgeon at Boston Medical Center.
As someone less than 1 year into practice, I believe mentorship is one of the most critical essentials as a trainee and a junior attending. I have been privileged to have excellent mentors throughout my training and now, in my first job. A lot of this is luck, but I also have always put mentorship at the top of my list when looking for fellowships and jobs. In fact, part of the reason I took the job I currently have is because the contract clearly stated who my clinical and academic mentors would be. This showed the department’s dedication to grooming junior staff appropriately. Below is my take on how to find mentors.
Have multiple mentors
It’s good to have multiple mentors, each of whom can provide a different kind of mentorship. For junior faculty, key areas of mentorship include:
- Building clinical volume.
- Establishing your reputation as a safe and competent clinician/surgeon.
- Designing your academic/research career.
- Planning your overall career.
- Solving any political/administrative issues.
Currently, my division chief is my clinical/general mentor, from whom I seek clinical advice, political advice should I find myself in a tough situation as a junior attending, and personal advice, as well. We meet monthly to go over various things including clinical/research projects and any clinical issues. I have an academic mentor, who is a basic scientist; we review research ideas together. He reads over and critiques my grants, and he picks apart my presentations. I also have a very senior mentor, a retired thoracic surgeon, whom I seek when I have a challenging case; it is crucial to identify a senior surgeon who has an abundance of experience so you can pick his or her brain – a true resource. This is in addition to the mentors I have from my training, with whom I am still in contact. I think it is important to have mentors outside of your current work for certain situations.
Mentors do not have to be in your discipline
It’s useful to have mentors from different fields. As I stated above, my academic mentor is a basic scientist. I am a thoracic surgeon, but I consider my general surgery residency chair, who is an accomplished surgical oncologist, and my residency program director, a general surgeon, to be two of my important mentors. I think it’s a good idea to have someone outside of your discipline as your mentor, even someone in a nonsurgical discipline, as long as she or he provides what you need, such as general career decisions and research mentorship. Having people from different disciplines adds more perspective and depth. For women, female mentors may provide input on career decisions at different life stages.
Do your homework about your would-be mentors
When deciding among different jobs, I did as much homework as possible in researching my would-be clinical mentors, who in most cases are also your senior partners. This included speaking with other junior faculty members within the division, people who had worked with the person in the past, and current mentors who may know them. In my mind, I found the most valuable resources to be people who had worked in the past with potential new mentors or senior partners. They can provide unbiased, sometimes negative, opinions that others might be less willing to provide. In fact, I probably spent more time trying to understand to the negative comments, since this provided valuable information, too.
I always asked questions specific to the mentorship. Were they around to help you in the OR when needed, or was it more of a verbal “I’ll be around”? Were they good about giving the juniors clinical volume and sharing OR time? Did you feel like you grew under his or her mentorship?
In conclusion, my advice about mentorship is to have multiple mentors, each for different purposes. For those looking for fellowships and jobs, learning all you can about your would-be mentors goes a long way toward ensuring an ideal position.
Dr. Suzuki is a general thoracic surgeon at Boston Medical Center.
As someone less than 1 year into practice, I believe mentorship is one of the most critical essentials as a trainee and a junior attending. I have been privileged to have excellent mentors throughout my training and now, in my first job. A lot of this is luck, but I also have always put mentorship at the top of my list when looking for fellowships and jobs. In fact, part of the reason I took the job I currently have is because the contract clearly stated who my clinical and academic mentors would be. This showed the department’s dedication to grooming junior staff appropriately. Below is my take on how to find mentors.
Have multiple mentors
It’s good to have multiple mentors, each of whom can provide a different kind of mentorship. For junior faculty, key areas of mentorship include:
- Building clinical volume.
- Establishing your reputation as a safe and competent clinician/surgeon.
- Designing your academic/research career.
- Planning your overall career.
- Solving any political/administrative issues.
Currently, my division chief is my clinical/general mentor, from whom I seek clinical advice, political advice should I find myself in a tough situation as a junior attending, and personal advice, as well. We meet monthly to go over various things including clinical/research projects and any clinical issues. I have an academic mentor, who is a basic scientist; we review research ideas together. He reads over and critiques my grants, and he picks apart my presentations. I also have a very senior mentor, a retired thoracic surgeon, whom I seek when I have a challenging case; it is crucial to identify a senior surgeon who has an abundance of experience so you can pick his or her brain – a true resource. This is in addition to the mentors I have from my training, with whom I am still in contact. I think it is important to have mentors outside of your current work for certain situations.
Mentors do not have to be in your discipline
It’s useful to have mentors from different fields. As I stated above, my academic mentor is a basic scientist. I am a thoracic surgeon, but I consider my general surgery residency chair, who is an accomplished surgical oncologist, and my residency program director, a general surgeon, to be two of my important mentors. I think it’s a good idea to have someone outside of your discipline as your mentor, even someone in a nonsurgical discipline, as long as she or he provides what you need, such as general career decisions and research mentorship. Having people from different disciplines adds more perspective and depth. For women, female mentors may provide input on career decisions at different life stages.
Do your homework about your would-be mentors
When deciding among different jobs, I did as much homework as possible in researching my would-be clinical mentors, who in most cases are also your senior partners. This included speaking with other junior faculty members within the division, people who had worked with the person in the past, and current mentors who may know them. In my mind, I found the most valuable resources to be people who had worked in the past with potential new mentors or senior partners. They can provide unbiased, sometimes negative, opinions that others might be less willing to provide. In fact, I probably spent more time trying to understand to the negative comments, since this provided valuable information, too.
I always asked questions specific to the mentorship. Were they around to help you in the OR when needed, or was it more of a verbal “I’ll be around”? Were they good about giving the juniors clinical volume and sharing OR time? Did you feel like you grew under his or her mentorship?
In conclusion, my advice about mentorship is to have multiple mentors, each for different purposes. For those looking for fellowships and jobs, learning all you can about your would-be mentors goes a long way toward ensuring an ideal position.
Dr. Suzuki is a general thoracic surgeon at Boston Medical Center.
Young Faculty Hot Topics: Saying “yes” or saying “no”
The vast majority of us did not end up where we are today by saying “no” to opportunities throughout medical school, surgical training and now early in our clinical practice. In fact, many of us likely said “yes” to just about everything that came our way, and this was reasonable as the number of opportunities was manageable. As you move along your career as a cardiothoracic surgeon, the opportunities increase, especially if you consistently turn in a high performance.
A discussion of what to say “yes” or “no” to would be remiss without considering your individual career goals and time management. You’ve heard it before and here it is again: Write down your 5- and 10-year career plan. If you do not know where you are heading, you cannot plot the course. Then, based on those long-term career goals, drill down to your annual goals. Begin by identifying deadlines on the academic calendar each year and then work backward to determine what needs to be done in the months prior to those deadlines. Once you have a clear idea of what needs to be done on a month-by-month basis, on the Sunday of each week, create a list of daily goals. This method turns your long-term career goals into doable-size pieces of a larger puzzle that will keep you on trajectory.
Once you have charted your course using the above methods or some variation of them, you will have a clear idea of what opportunities are aligned with your long-term career plan. For example, if your goals are to build your clinical practice and become a program director, you may prioritize attending a course to introduce a new surgical technique into your practice and becoming the clerkship director for medical students instead of serving on hospital committees. Solicit advice from mentors and colleagues regarding certain opportunities if you are unsure whether these will help you achieve your career goals. Furthermore, identify senior cardiothoracic surgeons who have achieved the goals you are aiming for and ask them how they arrived at their position.
Oftentimes, it’s not about saying “yes” or “no,” but rather seeking out opportunities. Saying “yes” to opportunities that are pertinent to your career goals is critical, but there are other factors to consider when deciding whether to accept an opportunity. A major factor is the ratio of benefit to time commitment; clearly, the greater the benefit and the lower the time commitment, the better. However, there may be some opportunities that are beneficial and require a fair amount of time. Only you can decide whether the time necessary to commit to an opportunity is worth the benefit. Another factor to consider is what academic milestones are necessary for promotion at your institution; this may also vary by academic track within an institution. Be familiar with these requirements, and factor them into your goals as they are the foundation upon which you climb the academic ladder within your department.
Lastly, consider all the potential advantages of certain opportunities. For example, every year the STS solicits self-nominations for committees: Are there any committees that pertain to your career goals that will allow you to network with other cardiothoracic surgeons who may then become a mentor, sponsor, or collaborator?
I’m going to state the obvious: Only you know how you are spending every minute of every hour of each day. Why do I mention this? If you have said “yes” to too many things and are stretched too thin, you are at risk of underperforming and may begin to feel underappreciated; nobody else may realize how many hours you are working, but they will notice if your performance is subpar. Not only that, but you may be at risk of burnout. Unlike residency training, where we sprinted every day (and sometimes all night) and the light at the end of the tunnel was within view, we are now in an endurance race and need to pace ourselves for long, successful, and fulfilling careers. Ideally, we deliver what we promise, but if that balance is tipped, err on the side of underpromising and overdelivering. That scenario is much better than overpromising and underdelivering since the latter not only leads to a performance that might be less than your best but also could decrease your future opportunities.
When offered an opportunity, do not say “yes” immediately; collect some intel regarding the time commitment, determine whether it is aligned with your career goals and, if need be, discuss it with mentors and trusted colleagues before you say “yes.” Once you decide to say “yes,” jump in and hit the ground running! The beginning of your career is an exciting time with some flexibility in terms of choosing your own career adventures. Always be realistic about your goals and time to ensure a long, rewarding career.
Dr. Brown is a general thoracic surgeon at UC Davis Medical Center, Calif.
The vast majority of us did not end up where we are today by saying “no” to opportunities throughout medical school, surgical training and now early in our clinical practice. In fact, many of us likely said “yes” to just about everything that came our way, and this was reasonable as the number of opportunities was manageable. As you move along your career as a cardiothoracic surgeon, the opportunities increase, especially if you consistently turn in a high performance.
A discussion of what to say “yes” or “no” to would be remiss without considering your individual career goals and time management. You’ve heard it before and here it is again: Write down your 5- and 10-year career plan. If you do not know where you are heading, you cannot plot the course. Then, based on those long-term career goals, drill down to your annual goals. Begin by identifying deadlines on the academic calendar each year and then work backward to determine what needs to be done in the months prior to those deadlines. Once you have a clear idea of what needs to be done on a month-by-month basis, on the Sunday of each week, create a list of daily goals. This method turns your long-term career goals into doable-size pieces of a larger puzzle that will keep you on trajectory.
Once you have charted your course using the above methods or some variation of them, you will have a clear idea of what opportunities are aligned with your long-term career plan. For example, if your goals are to build your clinical practice and become a program director, you may prioritize attending a course to introduce a new surgical technique into your practice and becoming the clerkship director for medical students instead of serving on hospital committees. Solicit advice from mentors and colleagues regarding certain opportunities if you are unsure whether these will help you achieve your career goals. Furthermore, identify senior cardiothoracic surgeons who have achieved the goals you are aiming for and ask them how they arrived at their position.
Oftentimes, it’s not about saying “yes” or “no,” but rather seeking out opportunities. Saying “yes” to opportunities that are pertinent to your career goals is critical, but there are other factors to consider when deciding whether to accept an opportunity. A major factor is the ratio of benefit to time commitment; clearly, the greater the benefit and the lower the time commitment, the better. However, there may be some opportunities that are beneficial and require a fair amount of time. Only you can decide whether the time necessary to commit to an opportunity is worth the benefit. Another factor to consider is what academic milestones are necessary for promotion at your institution; this may also vary by academic track within an institution. Be familiar with these requirements, and factor them into your goals as they are the foundation upon which you climb the academic ladder within your department.
Lastly, consider all the potential advantages of certain opportunities. For example, every year the STS solicits self-nominations for committees: Are there any committees that pertain to your career goals that will allow you to network with other cardiothoracic surgeons who may then become a mentor, sponsor, or collaborator?
I’m going to state the obvious: Only you know how you are spending every minute of every hour of each day. Why do I mention this? If you have said “yes” to too many things and are stretched too thin, you are at risk of underperforming and may begin to feel underappreciated; nobody else may realize how many hours you are working, but they will notice if your performance is subpar. Not only that, but you may be at risk of burnout. Unlike residency training, where we sprinted every day (and sometimes all night) and the light at the end of the tunnel was within view, we are now in an endurance race and need to pace ourselves for long, successful, and fulfilling careers. Ideally, we deliver what we promise, but if that balance is tipped, err on the side of underpromising and overdelivering. That scenario is much better than overpromising and underdelivering since the latter not only leads to a performance that might be less than your best but also could decrease your future opportunities.
When offered an opportunity, do not say “yes” immediately; collect some intel regarding the time commitment, determine whether it is aligned with your career goals and, if need be, discuss it with mentors and trusted colleagues before you say “yes.” Once you decide to say “yes,” jump in and hit the ground running! The beginning of your career is an exciting time with some flexibility in terms of choosing your own career adventures. Always be realistic about your goals and time to ensure a long, rewarding career.
Dr. Brown is a general thoracic surgeon at UC Davis Medical Center, Calif.
The vast majority of us did not end up where we are today by saying “no” to opportunities throughout medical school, surgical training and now early in our clinical practice. In fact, many of us likely said “yes” to just about everything that came our way, and this was reasonable as the number of opportunities was manageable. As you move along your career as a cardiothoracic surgeon, the opportunities increase, especially if you consistently turn in a high performance.
A discussion of what to say “yes” or “no” to would be remiss without considering your individual career goals and time management. You’ve heard it before and here it is again: Write down your 5- and 10-year career plan. If you do not know where you are heading, you cannot plot the course. Then, based on those long-term career goals, drill down to your annual goals. Begin by identifying deadlines on the academic calendar each year and then work backward to determine what needs to be done in the months prior to those deadlines. Once you have a clear idea of what needs to be done on a month-by-month basis, on the Sunday of each week, create a list of daily goals. This method turns your long-term career goals into doable-size pieces of a larger puzzle that will keep you on trajectory.
Once you have charted your course using the above methods or some variation of them, you will have a clear idea of what opportunities are aligned with your long-term career plan. For example, if your goals are to build your clinical practice and become a program director, you may prioritize attending a course to introduce a new surgical technique into your practice and becoming the clerkship director for medical students instead of serving on hospital committees. Solicit advice from mentors and colleagues regarding certain opportunities if you are unsure whether these will help you achieve your career goals. Furthermore, identify senior cardiothoracic surgeons who have achieved the goals you are aiming for and ask them how they arrived at their position.
Oftentimes, it’s not about saying “yes” or “no,” but rather seeking out opportunities. Saying “yes” to opportunities that are pertinent to your career goals is critical, but there are other factors to consider when deciding whether to accept an opportunity. A major factor is the ratio of benefit to time commitment; clearly, the greater the benefit and the lower the time commitment, the better. However, there may be some opportunities that are beneficial and require a fair amount of time. Only you can decide whether the time necessary to commit to an opportunity is worth the benefit. Another factor to consider is what academic milestones are necessary for promotion at your institution; this may also vary by academic track within an institution. Be familiar with these requirements, and factor them into your goals as they are the foundation upon which you climb the academic ladder within your department.
Lastly, consider all the potential advantages of certain opportunities. For example, every year the STS solicits self-nominations for committees: Are there any committees that pertain to your career goals that will allow you to network with other cardiothoracic surgeons who may then become a mentor, sponsor, or collaborator?
I’m going to state the obvious: Only you know how you are spending every minute of every hour of each day. Why do I mention this? If you have said “yes” to too many things and are stretched too thin, you are at risk of underperforming and may begin to feel underappreciated; nobody else may realize how many hours you are working, but they will notice if your performance is subpar. Not only that, but you may be at risk of burnout. Unlike residency training, where we sprinted every day (and sometimes all night) and the light at the end of the tunnel was within view, we are now in an endurance race and need to pace ourselves for long, successful, and fulfilling careers. Ideally, we deliver what we promise, but if that balance is tipped, err on the side of underpromising and overdelivering. That scenario is much better than overpromising and underdelivering since the latter not only leads to a performance that might be less than your best but also could decrease your future opportunities.
When offered an opportunity, do not say “yes” immediately; collect some intel regarding the time commitment, determine whether it is aligned with your career goals and, if need be, discuss it with mentors and trusted colleagues before you say “yes.” Once you decide to say “yes,” jump in and hit the ground running! The beginning of your career is an exciting time with some flexibility in terms of choosing your own career adventures. Always be realistic about your goals and time to ensure a long, rewarding career.
Dr. Brown is a general thoracic surgeon at UC Davis Medical Center, Calif.
Learn More about Medicare Reimbursement, Reporting Requirements
The Society for Vascular Surgery will hold two Q&A town-hall webinars Sept. 12 and 19 on Medicare reimbursement and how it will affect members’ practices.
The webinars will feature an open Q&A forum to provide information to those still struggling with how they will obtain the required data for Medicare reimbursement. Participants need to submit their questions in advance at the end of the linked short survey, to eliminate duplicate questions and assure complete answers can be prepared for presentation.
The first webinar will be at 1 p.m. Eastern Time, Tuesday, Sept. 12, and the second will be at 7 p.m. Eastern Time Tuesday, Sept. 19. Register here and complete the survey here.
The Society for Vascular Surgery will hold two Q&A town-hall webinars Sept. 12 and 19 on Medicare reimbursement and how it will affect members’ practices.
The webinars will feature an open Q&A forum to provide information to those still struggling with how they will obtain the required data for Medicare reimbursement. Participants need to submit their questions in advance at the end of the linked short survey, to eliminate duplicate questions and assure complete answers can be prepared for presentation.
The first webinar will be at 1 p.m. Eastern Time, Tuesday, Sept. 12, and the second will be at 7 p.m. Eastern Time Tuesday, Sept. 19. Register here and complete the survey here.
The Society for Vascular Surgery will hold two Q&A town-hall webinars Sept. 12 and 19 on Medicare reimbursement and how it will affect members’ practices.
The webinars will feature an open Q&A forum to provide information to those still struggling with how they will obtain the required data for Medicare reimbursement. Participants need to submit their questions in advance at the end of the linked short survey, to eliminate duplicate questions and assure complete answers can be prepared for presentation.
The first webinar will be at 1 p.m. Eastern Time, Tuesday, Sept. 12, and the second will be at 7 p.m. Eastern Time Tuesday, Sept. 19. Register here and complete the survey here.
Sleep Strategies
The definition of mild obstructive sleep apnea (OSA) has varied over the years depending upon several factors, but based upon all definitions, it is highly prevalent. Depending upon presence of symptoms and gender, the prevalence may be as high 28% in men and 26% in women. (Young et al. N Engl J Med. 1993;328:1230).
Typically, a combination of symptoms and frequency of respiratory events is required to make the diagnosis. Based upon the International Classification of Sleep Disorders-3rd edition (ICSD-3), the threshold apnea hypopnea index (AHI) for diagnosis depends upon the presence or absence of symptoms. If an individual has no symptoms, an AHI of 15 events per hour or more is required to make a diagnosis of OSA. However, there are several concerns about whether or not an individual may be “symptomatic.” This is most relevant when driving privileges may be at risk, such as with a commercial drivers’ licensing.
The presence of other comorbid disease can be used as criteria, including hypertension, mood disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, and type 2 diabetes mellitus. If no signs, symptoms, or comorbid diseases are present, then an AHI greater than 15 events per hour or more is required to make the diagnosis of OSA (Chowdrui et al. Am J Respir Crit Care Med. 2016;193:e37).
There is still debate regarding the association of mild OSA and cardiovascular disease and whether treatment may prevent or reduce cardiovascular outcomes. The four main clinical outcomes typically reported are hypertension, cardiovascular events, cardiovascular and all-cause mortality, and arrhythmias.
A large clinical cohort of patients referred for sleep studies showed no association of mild OSA with different composite outcomes. Kendzerska and colleagues evaluated a composite outcome (myocardial infarction, stroke, CHF, revascularization procedures, or death from any cause) during a median follow-up of 68 months. No association of mild OSA with the composite cardiovascular endpoint was identified compared with those without OSA (Kendzerska et al. PLoS Med. 2014;11[2]:e1001599). Only one population-based study (MrOS Sleep Study) looked at the association between mild OSA and nocturnal arrhythmias in elderly men. The study did not find an increased risk for atrial fibrillation or complex ventricular ectopy in patients with mild OSA vs no OSA (Mehra et al. Arch Intern Med. 2009; 169:1147).
Several cohort studies have reported mild OSA is not associated with increased cardiovascular mortality. In the 18-year follow-up of the Wisconsin Cohort Study, it was found that mild OSA was not associated with cardiovascular mortality (HR, 1.8; 95% CI, 0.7–4.9). All-cause mortality was also not significantly increased in the mild OSA group compared with the no-OSA group in the Wisconsin cohort after 8 years of follow-up (adjusted HR, 1.6; 95% CI, 0.8–2.8). In summary, compared with subjects without OSA, available evidence from population-based longitudinal studies indicates that mild OSA is not associated with increased cardiovascular or all-cause mortality.
Does treatment of mild OSA vs no treatment change cardiovascular or mortality outcomes? This is still debated with no definitive answer. There have been several studies that have examined different therapies for OSA to reduce cardiovascular events. Typical events include coronary artery disease, hypertension, heart failure, stroke, arrhythmias, and cardiovascular disease-related mortality. However, most studies have examined cohorts with moderate to severe OSA with limited evaluation in the mild OSA category.
An observational study evaluated the effects of CPAP specifically in patients with mild OSA. There was no significant difference in the risk of developing hypertension among those patients ineligible for CPAP therapy, active on therapy, or those who declined therapy (Marin et al. JAMA. 2012; 307:2169). In contrast, a retrospective longitudinal cohort with normal blood pressure at baseline (mild OSA without preexisting cardiovascular disease, diabetes, or hyperlipidemia) did show decrease in mean arterial blood pressure of 2 mm Hg in the treatment group (Jaimchariyatam et al. Sleep Med. 2010;11:837). The MOSAIC trial was a multicenter randomized trial that evaluated the effects of CPAP on cardiac function in minimally symptomatic patients with OSA. The use of CPAP reduced the oxygen desaturation index (ODI) and Epworth Sleepiness Scale values. However, 6 months of therapy did not change functional or structural parameters measured by echocardiogram or cardiac magnetic resonance scanning in patients with mild to moderate OSA (Craig et al. J Clin Sleep Med. 2015;11[9]:967). A single retrospective study reported the effects of CPAP in patients with mild OSA and all-cause mortality. The study compared treatment with patients using CPAP more than 4 hours vs a combined group of nonadherent and those who refused therapy (Hudgel et al. J Clin Sleep Med. 2012;8:9). There was no significant difference in all-cause mortality in the two groups. However, this study did not analyze the impact of therapy on cardiovascular-specific mortality.
To date, there have been no studies that have evaluated the impact of treatment of mild OSA on cardiovascular events, arrhythmias, or stroke. In addition, there have been no randomized studies assessing treatment of mild OSA on fatal and nonfatal cardiovascular events. There is inadequate evidence regarding the effect of mild OSA on elevated blood pressure, neurologic cognition, quality of life, and cardiovascular consequences. Future research is needed to investigate the impact of mild OSA on these outcomes.
In summary, mild OSA is a very prevalent disease but the association with hypertension remains unclear and the literature to date suggests no association with other cardiovascular outcomes. In addition, no clear prevention of cardiovascular outcomes with treatment has been proven in the setting of mild OSA.
Dr. Duthuluru is Assistant Professor, Dr. Nazir is Assistant Professor, and Dr. Stevens is Associate Professor at the University of Kansas Medical Center.
The definition of mild obstructive sleep apnea (OSA) has varied over the years depending upon several factors, but based upon all definitions, it is highly prevalent. Depending upon presence of symptoms and gender, the prevalence may be as high 28% in men and 26% in women. (Young et al. N Engl J Med. 1993;328:1230).
Typically, a combination of symptoms and frequency of respiratory events is required to make the diagnosis. Based upon the International Classification of Sleep Disorders-3rd edition (ICSD-3), the threshold apnea hypopnea index (AHI) for diagnosis depends upon the presence or absence of symptoms. If an individual has no symptoms, an AHI of 15 events per hour or more is required to make a diagnosis of OSA. However, there are several concerns about whether or not an individual may be “symptomatic.” This is most relevant when driving privileges may be at risk, such as with a commercial drivers’ licensing.
The presence of other comorbid disease can be used as criteria, including hypertension, mood disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, and type 2 diabetes mellitus. If no signs, symptoms, or comorbid diseases are present, then an AHI greater than 15 events per hour or more is required to make the diagnosis of OSA (Chowdrui et al. Am J Respir Crit Care Med. 2016;193:e37).
There is still debate regarding the association of mild OSA and cardiovascular disease and whether treatment may prevent or reduce cardiovascular outcomes. The four main clinical outcomes typically reported are hypertension, cardiovascular events, cardiovascular and all-cause mortality, and arrhythmias.
A large clinical cohort of patients referred for sleep studies showed no association of mild OSA with different composite outcomes. Kendzerska and colleagues evaluated a composite outcome (myocardial infarction, stroke, CHF, revascularization procedures, or death from any cause) during a median follow-up of 68 months. No association of mild OSA with the composite cardiovascular endpoint was identified compared with those without OSA (Kendzerska et al. PLoS Med. 2014;11[2]:e1001599). Only one population-based study (MrOS Sleep Study) looked at the association between mild OSA and nocturnal arrhythmias in elderly men. The study did not find an increased risk for atrial fibrillation or complex ventricular ectopy in patients with mild OSA vs no OSA (Mehra et al. Arch Intern Med. 2009; 169:1147).
Several cohort studies have reported mild OSA is not associated with increased cardiovascular mortality. In the 18-year follow-up of the Wisconsin Cohort Study, it was found that mild OSA was not associated with cardiovascular mortality (HR, 1.8; 95% CI, 0.7–4.9). All-cause mortality was also not significantly increased in the mild OSA group compared with the no-OSA group in the Wisconsin cohort after 8 years of follow-up (adjusted HR, 1.6; 95% CI, 0.8–2.8). In summary, compared with subjects without OSA, available evidence from population-based longitudinal studies indicates that mild OSA is not associated with increased cardiovascular or all-cause mortality.
Does treatment of mild OSA vs no treatment change cardiovascular or mortality outcomes? This is still debated with no definitive answer. There have been several studies that have examined different therapies for OSA to reduce cardiovascular events. Typical events include coronary artery disease, hypertension, heart failure, stroke, arrhythmias, and cardiovascular disease-related mortality. However, most studies have examined cohorts with moderate to severe OSA with limited evaluation in the mild OSA category.
An observational study evaluated the effects of CPAP specifically in patients with mild OSA. There was no significant difference in the risk of developing hypertension among those patients ineligible for CPAP therapy, active on therapy, or those who declined therapy (Marin et al. JAMA. 2012; 307:2169). In contrast, a retrospective longitudinal cohort with normal blood pressure at baseline (mild OSA without preexisting cardiovascular disease, diabetes, or hyperlipidemia) did show decrease in mean arterial blood pressure of 2 mm Hg in the treatment group (Jaimchariyatam et al. Sleep Med. 2010;11:837). The MOSAIC trial was a multicenter randomized trial that evaluated the effects of CPAP on cardiac function in minimally symptomatic patients with OSA. The use of CPAP reduced the oxygen desaturation index (ODI) and Epworth Sleepiness Scale values. However, 6 months of therapy did not change functional or structural parameters measured by echocardiogram or cardiac magnetic resonance scanning in patients with mild to moderate OSA (Craig et al. J Clin Sleep Med. 2015;11[9]:967). A single retrospective study reported the effects of CPAP in patients with mild OSA and all-cause mortality. The study compared treatment with patients using CPAP more than 4 hours vs a combined group of nonadherent and those who refused therapy (Hudgel et al. J Clin Sleep Med. 2012;8:9). There was no significant difference in all-cause mortality in the two groups. However, this study did not analyze the impact of therapy on cardiovascular-specific mortality.
To date, there have been no studies that have evaluated the impact of treatment of mild OSA on cardiovascular events, arrhythmias, or stroke. In addition, there have been no randomized studies assessing treatment of mild OSA on fatal and nonfatal cardiovascular events. There is inadequate evidence regarding the effect of mild OSA on elevated blood pressure, neurologic cognition, quality of life, and cardiovascular consequences. Future research is needed to investigate the impact of mild OSA on these outcomes.
In summary, mild OSA is a very prevalent disease but the association with hypertension remains unclear and the literature to date suggests no association with other cardiovascular outcomes. In addition, no clear prevention of cardiovascular outcomes with treatment has been proven in the setting of mild OSA.
Dr. Duthuluru is Assistant Professor, Dr. Nazir is Assistant Professor, and Dr. Stevens is Associate Professor at the University of Kansas Medical Center.
The definition of mild obstructive sleep apnea (OSA) has varied over the years depending upon several factors, but based upon all definitions, it is highly prevalent. Depending upon presence of symptoms and gender, the prevalence may be as high 28% in men and 26% in women. (Young et al. N Engl J Med. 1993;328:1230).
Typically, a combination of symptoms and frequency of respiratory events is required to make the diagnosis. Based upon the International Classification of Sleep Disorders-3rd edition (ICSD-3), the threshold apnea hypopnea index (AHI) for diagnosis depends upon the presence or absence of symptoms. If an individual has no symptoms, an AHI of 15 events per hour or more is required to make a diagnosis of OSA. However, there are several concerns about whether or not an individual may be “symptomatic.” This is most relevant when driving privileges may be at risk, such as with a commercial drivers’ licensing.
The presence of other comorbid disease can be used as criteria, including hypertension, mood disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, and type 2 diabetes mellitus. If no signs, symptoms, or comorbid diseases are present, then an AHI greater than 15 events per hour or more is required to make the diagnosis of OSA (Chowdrui et al. Am J Respir Crit Care Med. 2016;193:e37).
There is still debate regarding the association of mild OSA and cardiovascular disease and whether treatment may prevent or reduce cardiovascular outcomes. The four main clinical outcomes typically reported are hypertension, cardiovascular events, cardiovascular and all-cause mortality, and arrhythmias.
A large clinical cohort of patients referred for sleep studies showed no association of mild OSA with different composite outcomes. Kendzerska and colleagues evaluated a composite outcome (myocardial infarction, stroke, CHF, revascularization procedures, or death from any cause) during a median follow-up of 68 months. No association of mild OSA with the composite cardiovascular endpoint was identified compared with those without OSA (Kendzerska et al. PLoS Med. 2014;11[2]:e1001599). Only one population-based study (MrOS Sleep Study) looked at the association between mild OSA and nocturnal arrhythmias in elderly men. The study did not find an increased risk for atrial fibrillation or complex ventricular ectopy in patients with mild OSA vs no OSA (Mehra et al. Arch Intern Med. 2009; 169:1147).
Several cohort studies have reported mild OSA is not associated with increased cardiovascular mortality. In the 18-year follow-up of the Wisconsin Cohort Study, it was found that mild OSA was not associated with cardiovascular mortality (HR, 1.8; 95% CI, 0.7–4.9). All-cause mortality was also not significantly increased in the mild OSA group compared with the no-OSA group in the Wisconsin cohort after 8 years of follow-up (adjusted HR, 1.6; 95% CI, 0.8–2.8). In summary, compared with subjects without OSA, available evidence from population-based longitudinal studies indicates that mild OSA is not associated with increased cardiovascular or all-cause mortality.
Does treatment of mild OSA vs no treatment change cardiovascular or mortality outcomes? This is still debated with no definitive answer. There have been several studies that have examined different therapies for OSA to reduce cardiovascular events. Typical events include coronary artery disease, hypertension, heart failure, stroke, arrhythmias, and cardiovascular disease-related mortality. However, most studies have examined cohorts with moderate to severe OSA with limited evaluation in the mild OSA category.
An observational study evaluated the effects of CPAP specifically in patients with mild OSA. There was no significant difference in the risk of developing hypertension among those patients ineligible for CPAP therapy, active on therapy, or those who declined therapy (Marin et al. JAMA. 2012; 307:2169). In contrast, a retrospective longitudinal cohort with normal blood pressure at baseline (mild OSA without preexisting cardiovascular disease, diabetes, or hyperlipidemia) did show decrease in mean arterial blood pressure of 2 mm Hg in the treatment group (Jaimchariyatam et al. Sleep Med. 2010;11:837). The MOSAIC trial was a multicenter randomized trial that evaluated the effects of CPAP on cardiac function in minimally symptomatic patients with OSA. The use of CPAP reduced the oxygen desaturation index (ODI) and Epworth Sleepiness Scale values. However, 6 months of therapy did not change functional or structural parameters measured by echocardiogram or cardiac magnetic resonance scanning in patients with mild to moderate OSA (Craig et al. J Clin Sleep Med. 2015;11[9]:967). A single retrospective study reported the effects of CPAP in patients with mild OSA and all-cause mortality. The study compared treatment with patients using CPAP more than 4 hours vs a combined group of nonadherent and those who refused therapy (Hudgel et al. J Clin Sleep Med. 2012;8:9). There was no significant difference in all-cause mortality in the two groups. However, this study did not analyze the impact of therapy on cardiovascular-specific mortality.
To date, there have been no studies that have evaluated the impact of treatment of mild OSA on cardiovascular events, arrhythmias, or stroke. In addition, there have been no randomized studies assessing treatment of mild OSA on fatal and nonfatal cardiovascular events. There is inadequate evidence regarding the effect of mild OSA on elevated blood pressure, neurologic cognition, quality of life, and cardiovascular consequences. Future research is needed to investigate the impact of mild OSA on these outcomes.
In summary, mild OSA is a very prevalent disease but the association with hypertension remains unclear and the literature to date suggests no association with other cardiovascular outcomes. In addition, no clear prevention of cardiovascular outcomes with treatment has been proven in the setting of mild OSA.
Dr. Duthuluru is Assistant Professor, Dr. Nazir is Assistant Professor, and Dr. Stevens is Associate Professor at the University of Kansas Medical Center.
CHEST Foundation NetWorks Challenge
The CHEST Foundation is proud to announce the winners of the first round of the 2017 NetWorks Challenge! Our first place winner, Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork, and our second place finisher, Women’s Health NetWork, both receive session time at CHEST 2017 on a topic of their choice and two travel grants to help their NetWork members attend CHEST 2017.
The Women’s Health NetWork was directly behind our first place finishers with more than 90% participation. Their session, “Care of the Critically Ill Pregnant Woman: Balancing Two Patients and Two Lives” will be on Monday, October 30, 1:30 
Don’t forget, there is still time to win Round 2 and Round 3 of the NetWorks Challenge.
Learn more about the challenge at chestfoundation.org/networkschallenge.
The CHEST Foundation is proud to announce the winners of the first round of the 2017 NetWorks Challenge! Our first place winner, Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork, and our second place finisher, Women’s Health NetWork, both receive session time at CHEST 2017 on a topic of their choice and two travel grants to help their NetWork members attend CHEST 2017.
The Women’s Health NetWork was directly behind our first place finishers with more than 90% participation. Their session, “Care of the Critically Ill Pregnant Woman: Balancing Two Patients and Two Lives” will be on Monday, October 30, 1:30
Don’t forget, there is still time to win Round 2 and Round 3 of the NetWorks Challenge.
Learn more about the challenge at chestfoundation.org/networkschallenge.
The CHEST Foundation is proud to announce the winners of the first round of the 2017 NetWorks Challenge! Our first place winner, Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork, and our second place finisher, Women’s Health NetWork, both receive session time at CHEST 2017 on a topic of their choice and two travel grants to help their NetWork members attend CHEST 2017.
The Women’s Health NetWork was directly behind our first place finishers with more than 90% participation. Their session, “Care of the Critically Ill Pregnant Woman: Balancing Two Patients and Two Lives” will be on Monday, October 30, 1:30
Don’t forget, there is still time to win Round 2 and Round 3 of the NetWorks Challenge.
Learn more about the challenge at chestfoundation.org/networkschallenge.
NetWorks
Gender Disparities in Occupational Health
Over the past few decades, the presence of women in the workforce has changed significantly. According to the US Bureau of Labor Statistics Current Population Survey, in 2015, 46.8% of the workforce included women compared with 28.6% in 1948. Along with this change, there has been an increased focus on gender disparities in occupational health.
Gender differences in occupational asthma were also seen in snow crab processing plant workers. Women were significantly more likely to have occupational asthma than men. However, they found that overall, women had a greater cumulative exposure to crab allergens, which may be a major contributor to this disparity (Howse et al. Environ Res. 2006;101[2]:163).
Although several occupational health studies are beginning to highlight gender disparities, a major confounding factor is that of occupational segregation, meaning the under-representation of one gender in some jobs and over-representation in others. Differences in jobs and tasks even within the same job title between men and women are often major contributors to gender disparities [WHO Dept of Gender, Women and Health, 2006]. Also, several studies suggest that more women should be included in toxicology and occupational cancer studies, since currently, they have included mostly men (Sorrentino et al. Ann Ist Super Sanità. 2016;52[2]:190). Perhaps future studies can improve the overall understanding of these important contributing factors to gender disparities in occupational health.
Krystal Cleven, MD
Fellow-in-Training Member
Does Beta-agonist Therapy With Albuterol Cause Lactic Acidosis?
Cohen and associates (Clin Sci Mol Med. 1977;53:405) suggested that lactic acidosis can occur in at least two different physiologic clinical presentations. Type A occurs when oxygen delivery to the tissues is compromised. Dodda and Spiro (Respir Care. 2012;57[12]:2115) indicated that type A lactic acidosis was due to hypoxemia, as seen in inadequate tissue oxygenation during an exacerbation of asthma. In severe asthma, pulsus paradoxus and air trapping (causing intrinsic positive end-expiratory pressure, or PEEP) served to decrease tissue oxygenation by decreasing cardiac output and venous return, leading to type A lactic acidosis. Bates and associates (Pediatrics. 2014;133[4]:e1087) considered the role of intrapulmonary arteriovenous anastomoses (IPAVs) when a status asthmaticus patient improved after cessation of beta-agonist therapy. Type B lactic acidosis occurs when lactate production was increased or lactate removal was decreased even when oxygen was delivered to tissue. Amaducci (http://www.emresident.org/gasping-air-albuterol-induced-lactic-acidosis/) explained how high dosages of albuterol, beyond 1 mg/kg, created an increased adrenergic state that, with reduced tissue perfusion, increased glycolysis and pyruvate production, resulting in measurable hyperlactatemia. The authors (Br J Med Pract. 2011;4[2]:a420) noted that lactic acidosis also occurs in acute severe asthma due to inadequate oxygen delivery to the respiratory muscles to meet an elevated oxygen demand or due to fatiguing respiratory muscles. Ganaie and Hughes reported a case of lactic acidosis caused by treatment with salbutamol. Salbutamol is the most commonly used short-acting beta-agonist. Stimulation of beta-adrenergic receptors leads to a variety of metabolic effects, including increase in glycogenolysis, gluconeogenesis, and lipolysis, thus contributing to lactic acidosis. All authors agreed that the mechanism of albuterol-caused lactic acidosis was poorly understood.
Douglas E. Masini, EdD, FCCP
Steering Committee Member
Withdrawal of OSA Screening Regulation for Commercial Motor Vehicle Operators
Compared with the general US population, the prevalence of sleep apnea (SA) is higher among commercial motor vehicle (CMV) drivers (Berger et al. J Occup Environ Med. 2012;54[8]:1017). Additionally, the risk of motor vehicle accidents is higher among individuals with SA compared with those without SA (Tregear et al. J Clin Sleep Med. 2009;5[6]:573), and treatment of SA is associated with a reduction in this risk (Mahssa et al. Sleep. 2015;38[3]341).
However, after reviewing the public input and data, the FRA and FMCSA recently announced that there was “not enough information available to support moving forward with a rulemaking action,” and, therefore, they are no longer pursuing the regulation that would require SA screening for truck drivers and train engineers (Federal Register August 2017;49 CFR 391,240,242). See CHEST’s press release at www.chestnet.org/News/Press-Releases/2017/08/American-College-of-Chest-Physicians-Responds-to-DOT-Withdrawal-of-Sleep-Apnea-Screening. The FMCSA endorses existing resources,such as the North American Fatigue Management Program (NAFMP) (www.nafmp.org), which is a web-based program designed to reduce driver fatigue and includes information on SA screening and treatment. The medical examiners, however, will have the ultimate responsibility to screen, diagnose, and treat SA based on their medical knowledge and clinical experience.
Vaishnavi Kundel, MD
NetWork Member
Steering Committee Member
Corrections to previous NetWork articles
July 2017
Clinical Research
Mohsin Ijaz’s name was misspelled.
August 2017
Transplant
The name under Shruti Gadre’s photograph is wrong. It says Dr. Ahya instead of Dr. Gadre.
The authorship of the article at the end of the article is incorrect. It says Vivek Ahya, instead of Shruti Gadre and Marie Budev.
Gender Disparities in Occupational Health
Over the past few decades, the presence of women in the workforce has changed significantly. According to the US Bureau of Labor Statistics Current Population Survey, in 2015, 46.8% of the workforce included women compared with 28.6% in 1948. Along with this change, there has been an increased focus on gender disparities in occupational health.
Gender differences in occupational asthma were also seen in snow crab processing plant workers. Women were significantly more likely to have occupational asthma than men. However, they found that overall, women had a greater cumulative exposure to crab allergens, which may be a major contributor to this disparity (Howse et al. Environ Res. 2006;101[2]:163).
Although several occupational health studies are beginning to highlight gender disparities, a major confounding factor is that of occupational segregation, meaning the under-representation of one gender in some jobs and over-representation in others. Differences in jobs and tasks even within the same job title between men and women are often major contributors to gender disparities [WHO Dept of Gender, Women and Health, 2006]. Also, several studies suggest that more women should be included in toxicology and occupational cancer studies, since currently, they have included mostly men (Sorrentino et al. Ann Ist Super Sanità. 2016;52[2]:190). Perhaps future studies can improve the overall understanding of these important contributing factors to gender disparities in occupational health.
Krystal Cleven, MD
Fellow-in-Training Member
Does Beta-agonist Therapy With Albuterol Cause Lactic Acidosis?
Cohen and associates (Clin Sci Mol Med. 1977;53:405) suggested that lactic acidosis can occur in at least two different physiologic clinical presentations. Type A occurs when oxygen delivery to the tissues is compromised. Dodda and Spiro (Respir Care. 2012;57[12]:2115) indicated that type A lactic acidosis was due to hypoxemia, as seen in inadequate tissue oxygenation during an exacerbation of asthma. In severe asthma, pulsus paradoxus and air trapping (causing intrinsic positive end-expiratory pressure, or PEEP) served to decrease tissue oxygenation by decreasing cardiac output and venous return, leading to type A lactic acidosis. Bates and associates (Pediatrics. 2014;133[4]:e1087) considered the role of intrapulmonary arteriovenous anastomoses (IPAVs) when a status asthmaticus patient improved after cessation of beta-agonist therapy. Type B lactic acidosis occurs when lactate production was increased or lactate removal was decreased even when oxygen was delivered to tissue. Amaducci (http://www.emresident.org/gasping-air-albuterol-induced-lactic-acidosis/) explained how high dosages of albuterol, beyond 1 mg/kg, created an increased adrenergic state that, with reduced tissue perfusion, increased glycolysis and pyruvate production, resulting in measurable hyperlactatemia. The authors (Br J Med Pract. 2011;4[2]:a420) noted that lactic acidosis also occurs in acute severe asthma due to inadequate oxygen delivery to the respiratory muscles to meet an elevated oxygen demand or due to fatiguing respiratory muscles. Ganaie and Hughes reported a case of lactic acidosis caused by treatment with salbutamol. Salbutamol is the most commonly used short-acting beta-agonist. Stimulation of beta-adrenergic receptors leads to a variety of metabolic effects, including increase in glycogenolysis, gluconeogenesis, and lipolysis, thus contributing to lactic acidosis. All authors agreed that the mechanism of albuterol-caused lactic acidosis was poorly understood.
Douglas E. Masini, EdD, FCCP
Steering Committee Member
Withdrawal of OSA Screening Regulation for Commercial Motor Vehicle Operators
Compared with the general US population, the prevalence of sleep apnea (SA) is higher among commercial motor vehicle (CMV) drivers (Berger et al. J Occup Environ Med. 2012;54[8]:1017). Additionally, the risk of motor vehicle accidents is higher among individuals with SA compared with those without SA (Tregear et al. J Clin Sleep Med. 2009;5[6]:573), and treatment of SA is associated with a reduction in this risk (Mahssa et al. Sleep. 2015;38[3]341).
However, after reviewing the public input and data, the FRA and FMCSA recently announced that there was “not enough information available to support moving forward with a rulemaking action,” and, therefore, they are no longer pursuing the regulation that would require SA screening for truck drivers and train engineers (Federal Register August 2017;49 CFR 391,240,242). See CHEST’s press release at www.chestnet.org/News/Press-Releases/2017/08/American-College-of-Chest-Physicians-Responds-to-DOT-Withdrawal-of-Sleep-Apnea-Screening. The FMCSA endorses existing resources,such as the North American Fatigue Management Program (NAFMP) (www.nafmp.org), which is a web-based program designed to reduce driver fatigue and includes information on SA screening and treatment. The medical examiners, however, will have the ultimate responsibility to screen, diagnose, and treat SA based on their medical knowledge and clinical experience.
Vaishnavi Kundel, MD
NetWork Member
Steering Committee Member
Corrections to previous NetWork articles
July 2017
Clinical Research
Mohsin Ijaz’s name was misspelled.
August 2017
Transplant
The name under Shruti Gadre’s photograph is wrong. It says Dr. Ahya instead of Dr. Gadre.
The authorship of the article at the end of the article is incorrect. It says Vivek Ahya, instead of Shruti Gadre and Marie Budev.
Gender Disparities in Occupational Health
Over the past few decades, the presence of women in the workforce has changed significantly. According to the US Bureau of Labor Statistics Current Population Survey, in 2015, 46.8% of the workforce included women compared with 28.6% in 1948. Along with this change, there has been an increased focus on gender disparities in occupational health.
Gender differences in occupational asthma were also seen in snow crab processing plant workers. Women were significantly more likely to have occupational asthma than men. However, they found that overall, women had a greater cumulative exposure to crab allergens, which may be a major contributor to this disparity (Howse et al. Environ Res. 2006;101[2]:163).
Although several occupational health studies are beginning to highlight gender disparities, a major confounding factor is that of occupational segregation, meaning the under-representation of one gender in some jobs and over-representation in others. Differences in jobs and tasks even within the same job title between men and women are often major contributors to gender disparities [WHO Dept of Gender, Women and Health, 2006]. Also, several studies suggest that more women should be included in toxicology and occupational cancer studies, since currently, they have included mostly men (Sorrentino et al. Ann Ist Super Sanità. 2016;52[2]:190). Perhaps future studies can improve the overall understanding of these important contributing factors to gender disparities in occupational health.
Krystal Cleven, MD
Fellow-in-Training Member
Does Beta-agonist Therapy With Albuterol Cause Lactic Acidosis?
Cohen and associates (Clin Sci Mol Med. 1977;53:405) suggested that lactic acidosis can occur in at least two different physiologic clinical presentations. Type A occurs when oxygen delivery to the tissues is compromised. Dodda and Spiro (Respir Care. 2012;57[12]:2115) indicated that type A lactic acidosis was due to hypoxemia, as seen in inadequate tissue oxygenation during an exacerbation of asthma. In severe asthma, pulsus paradoxus and air trapping (causing intrinsic positive end-expiratory pressure, or PEEP) served to decrease tissue oxygenation by decreasing cardiac output and venous return, leading to type A lactic acidosis. Bates and associates (Pediatrics. 2014;133[4]:e1087) considered the role of intrapulmonary arteriovenous anastomoses (IPAVs) when a status asthmaticus patient improved after cessation of beta-agonist therapy. Type B lactic acidosis occurs when lactate production was increased or lactate removal was decreased even when oxygen was delivered to tissue. Amaducci (http://www.emresident.org/gasping-air-albuterol-induced-lactic-acidosis/) explained how high dosages of albuterol, beyond 1 mg/kg, created an increased adrenergic state that, with reduced tissue perfusion, increased glycolysis and pyruvate production, resulting in measurable hyperlactatemia. The authors (Br J Med Pract. 2011;4[2]:a420) noted that lactic acidosis also occurs in acute severe asthma due to inadequate oxygen delivery to the respiratory muscles to meet an elevated oxygen demand or due to fatiguing respiratory muscles. Ganaie and Hughes reported a case of lactic acidosis caused by treatment with salbutamol. Salbutamol is the most commonly used short-acting beta-agonist. Stimulation of beta-adrenergic receptors leads to a variety of metabolic effects, including increase in glycogenolysis, gluconeogenesis, and lipolysis, thus contributing to lactic acidosis. All authors agreed that the mechanism of albuterol-caused lactic acidosis was poorly understood.
Douglas E. Masini, EdD, FCCP
Steering Committee Member
Withdrawal of OSA Screening Regulation for Commercial Motor Vehicle Operators
Compared with the general US population, the prevalence of sleep apnea (SA) is higher among commercial motor vehicle (CMV) drivers (Berger et al. J Occup Environ Med. 2012;54[8]:1017). Additionally, the risk of motor vehicle accidents is higher among individuals with SA compared with those without SA (Tregear et al. J Clin Sleep Med. 2009;5[6]:573), and treatment of SA is associated with a reduction in this risk (Mahssa et al. Sleep. 2015;38[3]341).
However, after reviewing the public input and data, the FRA and FMCSA recently announced that there was “not enough information available to support moving forward with a rulemaking action,” and, therefore, they are no longer pursuing the regulation that would require SA screening for truck drivers and train engineers (Federal Register August 2017;49 CFR 391,240,242). See CHEST’s press release at www.chestnet.org/News/Press-Releases/2017/08/American-College-of-Chest-Physicians-Responds-to-DOT-Withdrawal-of-Sleep-Apnea-Screening. The FMCSA endorses existing resources,such as the North American Fatigue Management Program (NAFMP) (www.nafmp.org), which is a web-based program designed to reduce driver fatigue and includes information on SA screening and treatment. The medical examiners, however, will have the ultimate responsibility to screen, diagnose, and treat SA based on their medical knowledge and clinical experience.
Vaishnavi Kundel, MD
NetWork Member
Steering Committee Member
Corrections to previous NetWork articles
July 2017
Clinical Research
Mohsin Ijaz’s name was misspelled.
August 2017
Transplant
The name under Shruti Gadre’s photograph is wrong. It says Dr. Ahya instead of Dr. Gadre.
The authorship of the article at the end of the article is incorrect. It says Vivek Ahya, instead of Shruti Gadre and Marie Budev.