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This summer, I hope everyone found find time to escape the record-breaking heat while spending quality time with family and friends. Recently, while driving to the beach with my family and thinking about what to write for this column, I was surfing the satellite radio channels and was inspired by the title of the 1986 Janet Jackson song, “What Have You Done for Me Lately?” My mission for my day at the beach was clear: Update STS members on the Society’s exciting accomplishments, ongoing projects, and future plans that will directly benefit each one.

Strengthening the STS National Database

In the last President’s Column, I talked about the power of the STS Database and its impact on the specialty. Combined, the four registries of the STS National Database ─ adult cardiac surgery, general thoracic surgery, congenital heart surgery, and STS-Intermacs ─ have accurate, patient-level data on nearly 10 million cardiothoracic surgery operations. STS data along with research trials have been used to develop numerous clinical practice guidelines. Risk calculators are available to help assess the suitability for surgery in patients. Over the last three decades, risk-adjusted data has improved the safety of care, and 30-day outcomes of countless patients.

We now have the ability and opportunity to link our vast data with the National Death Index and with Medicare claims data to demonstrate long-term efficacy, comparative effectiveness, and value-based care compared with other interventional treatments. Over the next six months, we will publish sentinel papers with long-term outcomes on hundreds of thousands of patients demonstrating the efficacy of surgery on specific topics of adult cardiac surgery, general thoracic surgery, congenital heart surgery, and mechanical circulatory support devices. The first sentinel manuscript, which includes more than one million coronary artery bypass grafting patients from our database, demonstrates the long-term survival benefit of multi-arterial grafting and has been submitted to a high-impact journal.

That said, the STS Database is not perfect. Our users have helped to identify gaps and shortcomings as the Database has evolved from its original purpose to provide individual surgeons with tools to benchmark their program’s quality assessment and performance improvement.

Members have asked if the purpose of the database has changed to one of research for the benefit of some academic surgeons rather than serving as a patient care and quality assurance tool for all surgeons. Some members have noted that data collection has become too labor intensive because of the many data elements. Others have complained about the added expense due to abstractors, data coordinators, and third-party vendors needed to manage the data. There continue to be questions about the risk modeling and the relevance of the reported index cases given the rapidly evolving surgical practices related to the increase in transcatheter, endovascular, and endoscopic procedures, and novel drug therapies. 

STS has been listening to this valuable member input, and we have made several changes to decrease the burden, lower the costs, and improve the efficiency of data reporting and return. We recently changed the data warehousing from Duke Clinical Research Institute (DCRI) to IQVIA. We moved most of the data analytics from DCRI to the STS Research Center, which will improve the efficiency and near real-time reporting, analysis, and return of program data. More than 10% of programs are using direct data entry to IQVIA, which allows these programs to bypass the need (and the cost) for third-party data vendors.

Moreover, we are modifying our data dashboard to improve its intuitive appearance and make it more user-friendly. Our goal is to encourage further engagement among surgeons and data coordinators and our STS staff are available to help train more people in direct data entry.

The STS Next Generation Risk Calculator

The STS recently launched a next-generation Operative Risk Calculator to assess the risk of adult cardiac surgery operations. This improved bedside patient care tool includes current risk model adjustment calibrated every three months to ensure up-to-date risk assessment for patients. In addition to the risk of mortality, the risk calculator also provides procedure-specific risk of individual complications associated with index operations (CABG, AVR, MVR, MV repair including one specifically for repair of primary MR, AVR-CABG, MVR-CABG, and MV repair-CABG), as well as the soon to be reported multi-valve and aortic procedures. 

The new risk calculator includes recently added risk factors, such as liver disease, concomitant tricuspid valve procedure, NYHA class, and others not previously included. In addition to providing the calculated risks of individual complications and mortality, the risk calculator also updates and records the impact of each specific risk factor responsible for the composite risk scores to facilitate patient discussions, pre-operative optimization, and medical record charting. A summary page can be easily copied into the electronic medical record. The user-friendly risk calculator is viewable on an intuitively easy-to-use single computer screen and is available on most mobile devices.

With all the new changes, one constant remains: STS’s commitment to ensure that the database exists for all CT surgeons, not just selected large academic centers. The STS database captures 98% of all cardiac surgery operations performed in the United States, allowing every program of every size to benchmark data with the outcomes of “like institutions,” as well as the entire STS cohort.

We have been collecting and analyzing data on the evolving practice of cardiac surgery and will soon be reporting outcomes of multiple-valve operations with and without coronary artery surgery, as well as proximal aortic surgery, including aortic root procedures.

2024 Strategy and Planning

The STS Board of Directors, Council Chairs, and senior staff recently completed a strategic planning process. In this post-COVID world, much has changed in our profession, our specialty, and our membership. A new strategic plan is essential to reaffirm our mission and to set the STS’s top priorities and objectives for the next five years.

As you know, the STS is committed to championing the value and impact of the specialty through quality and research initiatives, advocacy, and strategic partnership. We also are steadfast in our commitment to advance the health, well-being, and inclusion of all CT surgeons from medical school through retirement. But we can’t do it alone. We must do it together.

As part of the 2024 planning process, STS commissioned a survey to collect member feedback, ideas, and insights that will help us explore new ways to enhance membership value, advocate for the specialty and deliver quality educational experiences.

Based on your feedback, we have initiated efforts to address concerns regarding inclusion, selection of STS leaders, and surgeon compensation disparities.

We hired an external consultant to evaluate STS’s DEI policies. I created two new Presidential Task Forces: The Nominating Committee Advisory Task Force to review and improve the current process for identifying, mentoring, and nominating senior STS leaders; and The Surgeon Compensation Task Force to create an annual cardiothoracic surgeon survey to help us better understand workplace-related compensation issues and negotiation matters. The regional, subspecialty, and practice-type specific salary/benefits data will be available to better equip cardiothoracic surgeons to advocate for themselves during contracting and salary negotiations.

STS's Reach Is Extraordinary

STS is everywhere we need it to be to help advance this specialty. The Annals of Thoracic Surgery is the most widely read CT surgery journal in the world. The Thoracic Surgery Foundation, STS’s philanthropic arm, has awarded $1 million in educational, research, and outreach grants in the past year. STS Advocacy is making unprecedented progress to represent your voice in Washington, DC.

As president of the STS, I recently was invited to testify on the value of medical registries at the U.S. House of Representatives Subcommittee on Health regarding Medicare coverage pathways for innovative drugs, medical devices, and technology. Of all the witnesses testifying at this hearing, the STS was one of only two medical specialty societies invited. The impact of our database and the effectiveness of our advocacy efforts literally give the STS a seat at the table in Washington, DC.

After spending the afternoon at the beach, my family and I packed up the car and started to drive back to our hotel. It was a great day at the beach. As luck would have it, the 1974 Bachman-Turner Overdrive song “You Ain’t Seen Nothin’ Yet” came on the radio as we pulled out of the beach parking lot. In one day, two classic rock song titles have proven to be an inspiration to help me write this article. What an exciting time to be a CT surgeon and a member of the STS!

Note: Check out the print magazine mailed directly to you for more informative and inspirational news and stories. Not a member? Join today.

On behalf of STS’s 7,600 member surgeons and their clinician partners, Thomas MacGillivray, MD, president of The Society of Thoracic Surgeons, testified before the US House of Representatives Committee on Energy and Commerce, Subcommittee on Health, about Medicare coverage pathways for innovative drugs, medical devices, and technology that saves lives.

In his statement, Dr. MacGillivray highlighted how the STS’s National Database provides a true clinical benchmark and contains data on more than 9.4 million cardiothoracic surgeries performed by more than 4,300 surgeons. The Database is a powerful quality improvement tool that facilitates increased patient access to break-through technology. He explained the value of real-world evidence and using data to monitor new technology and expand indications for new therapies.  And he underscored that through big data, cardiothoracic surgeons across the country and around the world can work together to find solutions and transform patient care.

Dr. MacGillivray’s key talking points:

• The STS National Database is the gold standard for clinical registries.
• The Database allows hospitals and cardiothoracic surgeons to identify best practices and potential gaps, and evaluate their performance against national and regional competitors. The Database is updated continuously and participants can monitor their progress and make critical decisions daily.
• Without ongoing evidence collection in the real-world setting coupled with access to longitudinal claims data, the efficacy and appropriateness of emerging innovative technologies is uncertain, impairing physicians’ ability to make the best decisions for our patients.
• The STS believes it is essential that any reforms to coverage for emerging therapies:
  • Prioritize the collection of real-world data, particularly for new, innovative medical devices.  Data collection creates opportunities to fill post-market evidence gaps and better define patient benefits and risks.
  • Permit early discussions and coordination between the agency and relevant stakeholders to allow sufficient time for the appropriate application, design, and implementation of any CED requirements.
  • Provide flexibility for data collection mechanisms to adjust based on new developments in the evidence.
  • Registries need timely, cost-effective, and continuous access to Medicare claims data to perform longitudinal studies.    
  • Dr. MacGillivray urged Congress to advance reforms such as the H.R. 5394, the Meaningful Access to Federal Health Plan Claims Data Act of 2021, from Reps. Larry Bucshon, MD, and Kim Schrier, MD, which would require that enhanced access to Medicare claims data be provided to clinician-led registries, such as the STS National Database.

Watch Dr. MacGillivray's testimony.

The Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2024 Medicare Physician Fee Schedule Proposed Rule today. STS has compiled a summary of key provisions affecting cardiothoracic surgery in the rule.  

Payment Cuts

CMS is proposing severe cuts to cardiothoracic surgery reimbursement. According to CMS, cardiothoracic surgeons will see a 3% cut in 2024. CMS estimates the CY 2024 conversion factor (CF) to be $32.7476. STS will continue to fight these cuts by lobbying Congress and CMS to provide an inflationary update to Medicare payments. While physicians have been subjected to across-the-board cuts for the last several years, Medicare continues to increase payments to hospitals, most recently proposing a 2.8% increase for inpatient hospital payments. Physicians deserve similar treatment.  

Changes to physician reimbursement are often driven by Medicare’s budget neutrality requirement combined with no built-in mechanism for inflationary or other increases in resources for the Medicare fee schedule. Disruptions to reimbursement occur when there are changes to the value of specific services, which negatively affects how other services are reimbursed to maintain budget neutrality. An inflationary update would be the first step toward resolving the constant downward pressures created by this dynamic. Urge your lawmakers to support H.R. 2474, a bipartisan bill that would create an automatic inflation update for physician payments for the first time. 

Global Surgical Codes

Once again, CMS has failed to apply the increased value of evaluation and management (E/M) codes services packaged in global surgical payments. STS has repeatedly recommended that CMS follow its own precedent and apply commensurate values for the office/outpatient E/Ms, inpatient E/Ms, and discharge day management visits packaged in the procedural global payments. This has been CMS’s policy every time E/M services have undergone a significant overhaul.  

Previously Delayed Complexity Code

CMS is once again proposing to implement payment of the flawed G2211 add-on code for E/M office visits, which was previously delayed by Congress through legislation. These visits are defined as a “visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition.” STS successfully advocated for the congressional delay to this code in 2020 and continues to have significant concerns with its proposed implementation, which will impact the Physician Fee Schedule by redistributing billions of dollars between specialties. STS has and will continue to vehemently advocate against this proposal in its current flawed form.  

Telehealth

CMS is retaining Category 3 codes on the Medicare telehealth list through CY 2024. STS is supportive of this proposal as data collected during COVID-19 demonstrates the positive impact telehealth has had on both patient clinical outcomes and patient experiences.  

Additionally, CMS proposes to provide coverage and payment of certain audio-only telehealth services until December 31, 2024. STS supports the provision of continued payment for audio-only visits in appropriate circumstances to help address health disparities and individuals without strong internet access, although we do not believe audio-only is adequate for more complex visits. 

Quality Payment Program

CMS will discontinue the Alternative Payment Model (APM) incentive payment as required under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) in CY 2024. Instead, for performance year 2024, CMS is proposing APM participants receive a higher payment rate using a specific qualifying APM conversion factor. If CMS’s goal is to encourage providers to prioritize value-based care by participating in APMs instead of the traditional MIPS program, then CMS should work with Congress to reauthorize the 5% APM incentive payment. Additionally, the Centers for Medicare and Medicaid Innovation (CMMI) will need to test APMs that directly recognize the role of specialists. 

CMS also proposes to expand the inventory of MIPS Value Pathways (MVPs), which is a new voluntary participation option aimed at providing clinicians with a more focused and cohesive MIPS experience. While MVPs offer a slight reduction in reporting burden, STS continues to believe that it fails to address fundamental flaws that have hampered meaningful participation by cardiac and thoracic surgeons.  

On June 3, 2023, in Miami Beach, Florida, cardiothoracic surgeons from around the world convened for the second annual STS Coronary Conference. Distinguished speakers and luminary surgeons painted a modern, ever-changing landscape of coronary surgery with new technologies, such as medical robotics, increasingly integrated into the specialty daily. Attendees experienced game-changing ideas, back-to-the-basics techniques, and ground-breaking science in diagnostic and therapeutic approaches to heart disease.

“The meeting brought together international leaders in the treatment of coronary artery disease and focused on the fundamentals and advanced therapies for coronary artery disease, including medical management, arterial conduits, and minimally invasive surgical revascularization,” said Joseph F. Sabik III, MD, surgeon-in-chief and vice president for surgical operations at University Hospitals Cleveland Medical Center, and a course director of the conference. “The conversations were engaging and the atmosphere was electric.”

Sessions covered a wide range of topics, including heart team patient selection and approaches; conduit selection and harvest; non-invasive and invasive preoperative workups; and postoperative medical therapy.

Here’s a look at a few key presentations:

Two Decades of Coronary Artery Bypass Grafting in Females: Has Anything Changed? ​

Elizabeth Norton, MD, Emory University School of Medicine, and a team of surgeons representing the division of cardiothoracic surgery and the division of cardiology at the institution, examined trends in females undergoing isolated coronary artery bypass grafting during the past two decades. What they found is that female CABG mortality at their institution was higher than the male cohort and the overall national average and did not improve over time.​ Females undergoing isolated CABG were increasingly diverse, experienced more preoperative comorbidities, were more likely to undergo urgent CABG, and had greater IMA utilization.

External Stenting for Saphenous Vein Grafts in Coronary Surgery

Saphenous vein grafts have high failure rates with 3% to 12% occluding before hospital discharge, 8% to 25% failing at 1 year, and only 50% to 60% remaining patent after a decade.​ As a research fellow with the department of cardiothoracic surgery at Weill Cornell Medicine, Giovanni Jr. Soletti, MD, wanted to know - can neointima formation be prevented?​

By conducting a study-level meta-analysis of randomized clinical trials and other research methods, Dr. Soletti found that VEST reduces intimal hyperplasia and thickness of SVGs after CABG. This reduction does not translate into fewer graft occlusion events or repeat revascularization compared to non-VEST SVGs at a follow-up of 1.5 years. SVGs harvested with no-touch technique or arterial conduits, when clinically adequate, may be safely used to improve long-term patency. Further long-term data and larger studies are needed.

Intraoperative Extubation After Isolated CABG and Post-Operative Outcomes

There is a well-known association between post-op ventilator time and morbidity in CABG surgery. Les James, MD, a resident cardiothoracic surgeon at NYU Langone Health, explored the impact of routine OR extubation on postoperative outcomes. She studied risk factors and outcomes based on a patient’s age, BMI, EF% STS risk score, STS prolonged vent score, CPB, and XC and concluded that routine OR extubation after isolated CABG is safe and that expanded use of planned OR extubation may be warranted.

All three highlighted abstract presentations were conducted by cardiothoracic fellows. STS encourages residents and fellows to submit original research to an international expert faculty for future presentations.

Review all conference abstracts.