News & Media

STS News, Summer 2021 — When determining salaries for cardiothoracic surgeons, institutions and health systems often rely on survey data—but these data vary significantly from survey to survey and don’t represent the highly nuanced variables of cardiothoracic surgery discipline, practice type, regional demand, and value units, surgeon leaders say. In the academic realm, for example, the Association of American Medical Colleges (AAMC) ranks cardiothoracic surgeon salaries third among the highest average compensation for combined assistant professor, associate professor, and full professor rankings. The salary range, however, doesn’t make a distinction among the various cardiothoracic disciplines, explained John S. Ikonomidis, MD, PhD, from the University of North Carolina in Chapel Hill. “The primary issue with AAMC data is that they do not separate adult cardiac, general thoracic, and congenital heart surgery,” said Dr. Ikonomidis, who serves on the STS Workforce on Clinical Education and has authored the last two STS practice surveys. “The salary lines for these three disciplines are different in terms of amount, and because that’s not reflected in the AAMC data it impacts the surgeon’s ability to negotiate.” STS recently sent a letter to the AAMC, urging it to report on cardiothoracic surgery salaries by discipline rather than in the aggregate so that the specialty has a clearer representation of the marketplace. Medical Group Surveys Target Similar Datasets, Different Practice Sizes The 2021 report of the American Medical Group Association (AMGA), aggregated from 2020 data, represented two categories of interest to cardiothoracic surgeons: “Cardiac/Thoracic Surgery” and “Cardiac/Thoracic Surgery—Pediatrics.” The mean reported salary, available courtesy of the author, Elizabeth Siemsen, AMGA consulting director, was $810,933 for the former category and $827,618 for the latter. Regional breakdown data will be available from AMGA this summer. The 2020 non-pediatrics category included responses from 54 medical groups and 220 providers, while the pediatrics cohort was comparatively small, including 14 groups and 31 providers. Dr. Ikonomidis points out that this smaller response was not due to there being such a small community of providers but to a low response rate—underscoring the value of active participation and transparent responses from surgeons. “Cardiothoracic surgeons in negotiation should be individually prepared to advocate for favorable arrangements related to their personal high-priority issues, perhaps in exchange for less-favorable arrangements on matters less important to them.” J. Michael DiMaio, MD Whereas AMGA data are derived mainly from larger medical groups (approximately 64% of its survey base is composed of groups employing 151 physicians or more), the Medical Group Management Association (MGMA) surveys a similarly sized cohort but leans toward smaller medical groups or individual  providers. The average number of providers per group in the AMGA dataset is 430, while MGMA averages around 24.5 per group. MGMA also takes a different approach to distinguishing surgical disciplines, employing the categories “Surgery: Cardiovascular” and “Surgery: Thoracic (Primary)” in the cardiovascular surgery realm. It uses 50th percentile results to report median salaries of $799,663 for cardiovascular and $650,000 for  thoracic surgeons. STS Workforce Report Drills Down to Disciplines   Both overall averages and breakdowns by discipline are illustrated in the STS practice survey, conducted every 5 years. In the most recent survey, 60.9% of responding surgeons reported an income of $200,000 to $799,999 per year, compared with 74.5% for respondents in the previous survey in 2014. Salaries increased for many—the percentage of surgeons reporting an income of $800,000 or more increased from 13.4% in 2014 to 27.0% in 2019. The most selected income range among those provided, reported by 24.8% of respondents overall, was $600,000 to $799,000 per year.   The STS Special Report published in the September 2020 issue of in The Annals of Thoracic Surgery further delineates salary ranges for adult cardiac, general thoracic, and congenital heart surgeons, and while all disciplines experienced a jump in income between 2014 and 2019, the variance among each group was significant. Among adult cardiac surgeons, the percentage reporting incomes in the $600,000 to $799,999 range was 27.9%, in contrast to 20.8% for general thoracic and 23.1% for congenital. As incomes rose, they did so most dramatically for adult cardiac surgeons—33.6% reported an income of $800,000 or above. The largest percentage of respondents in the $800,000 or above range were congenital heart surgeons—39.6%—while only 9.6% of general thoracic surgeons reached that range. Relative Value Units Prove of Relative Value More than half of surgeons in the STS workforce survey reported that their income included a bonus structure, and the most common basis for these bonuses were work relative value units (RVUs), quality metrics, or “citizenship”—which can include anything from patient and staff satisfaction to community outreach to committee participation and meeting attendance. These bonus measures can be problematic at every career level, and salary reports may not take them into consideration, said J. Michael DiMaio, MD, who serves as chair of the STS Workforce on Practice Management and practices at Baylor Scott & White Cardiac Surgery Specialists in Plano, Texas. As Medicare reimbursement rates decline and advocates fight to stave off massive cuts for cardiac and thoracic surgery, surgeons find themselves increasingly pressed upon to demonstrate their value to patients and the health care system, said Dr. DiMaio. “However, the overall contribution of a cardiothoracic surgeon can be difficult to measure, and it varies widely depending on a host of factors, including practice setting, experience, subspecialization, and the local market,” he said. RVUs are assigned by the Centers for Medicare & Medicaid Services based on surgeon billing of CPT and ICD-10 codes. Each code carries a corresponding RVU that determines the total surgeon payment, and the formula distributes one RVU each for physician work, practice expense, and professional liability expense. Each component is adjusted depending on the surgeon’s geographic location, accounting for variations in cost of living, overhead expenses, and practice premiums. “Virtually all of the clinical tasks a cardiothoracic surgeon performs have been assigned a work RVU, but complexity arises in determining how much each RVU is worth and how much of that value should go directly to physician compensation,” said Dr. DiMaio. He noted that a surgeon’s practice setting—private, academic, or hybrid—plays a major role in determining the model for compensation. Surgeons in private, non-academic practices are usually heavily focused on clinical productivity because that’s what generates income, while for academic surgeons, non-clinical responsibilities like research, education, and national leadership roles—which unarguably benefit the mission of the academic center—aren’t typically tied to any direct form of reimbursement, leading them to seek income from other sources. A hybrid model accounting for both clinical and academic activities could be mutually advantageous to both the surgeon and the health care system, Dr. DiMaio points out, because it allows the surgeon to offload financial risk without a total sacrifice of autonomy in practice. “Meanwhile, the health care system ensures a minimum availability of the desired surgeon’s services with persistent motivation for the surgeon to remain clinically busy and generate high-quality outcomes.” “Cardiothoracic surgeons must consider a host of other issues that impact their personal salary negotiations,” Dr. DiMaio explained. “These include practice focus, subspecialization, unique surgeon skills, practice location, length of training, and educational debt. And with the increasing subspecialization of cardiothoracic trainees into dedicated cardiac, thoracic, and congenital tracks, not all ‘cardiothoracic’ surgeons should be lumped together when negotiating compensation.” Surgeons Should Be Advocates—for Themselves and the Specialty So what can individual surgeons do to safeguard their own salaries? Drs. Ikonomidis and DiMaio advise reading up on the nuances. Also importantly, respond to workforce surveys. “When I first got involved with the Workforce, 10 or 15 years ago, we had response rates of over 50% from our membership,” Dr. Ikonomidis said. “Now the response rates have dropped considerably. And I think the reasons for that are myriad—we’re all inundated with emails, we’re all inundated with survey requests, and this is yet another survey. But it’s very valuable.” Surgeons also should keep in mind what’s personally important to them, Dr. DiMaio advised. Non-financial benefits such as parental leave, vacation policy, call coverage, awarded titles and academic rank, and protected time for research and professional development are valuable in different degrees among individual surgeons. “Cardiothoracic surgeons in negotiation should be individually prepared to advocate for favorable arrangements related to their personal high-priority issues, perhaps in exchange for less-favorable arrangements on matters less important to them,” he said.  The next STS practice survey will be conducted in 2024.

STS News, Summer 2021 — Just as the STS National Database experience features more visual, easy-to-understand graphical data, so too does the STS Public Reporting program. Substantial changes have been implemented to improve the stakeholder experience. These updates help participants better understand their performance and make real advances toward quality improvement—and view a more balanced representation of publicly reported results, said Benjamin D. Kozower, MD, MPH, chair of the Database’s Public Reporting Task Force.  “In addition, the public reporting website has been redesigned and will be easier to use for the many different stakeholders seeking STS outcomes data,” Dr. Kozower said. These include patients, physicians, data managers, hospital executives, and marketing teams.  Seeing More than Stars The updated Public Reporting site presents individual participant group scores in addition to—and in comparison to—overall participant outcomes. Not only does a participant webpage publicly report a participant’s numeric score and range for each composite measure, it also displays a graph demonstrating where those unique scores fall in relation to overall STS participant ratings. For each composite measure and its domains, the corresponding graph incudes a participant’s results (represented by a black vertical line), the statistical credible intervals around the results (dark blue shading), the overall/average STS results (red line), and the lowest-to-highest range across all North American Adult Cardiac Surgery Database participants (light blue shading). This contextual representation gives a realistic snapshot of what star ratings mean. With the new enhancements, publicly reported star ratings will always include a display of “out-of-how-many” possible stars, accompanied with a “Better Than Expected,” “As Expected,” or “Worse Than Expected” definition.    ACSD Hospital-Level Reporting Eliminated Since the STS Public Reporting initiative launched in 2010, results at both the participant group and hospital levels have been reported for the Adult Cardiac Surgery Database (ACSD), the largest registry component. While the majority of participant groups practice at only a single hospital, some practice at multiple locations. Correspondingly, some single hospitals house only one participant group, while other hospitals house multiple groups.  Hospital-level results were not provided to participants prior to being publicly reported, whereas participant-level data matched harvest reports exactly. Understandably, participants as well as consumers found it confusing that a single site could have two slightly different results because of differences in the denominator populations.  As a result, STS discontinued hospital-level reporting. This move matches the reporting system of the General Thoracic Surgery Database (GTSD), which also is publicly reported only at the participant level. Overall Enhancements Enable More Participant- and Public-Friendly Experience Visitors to the public reporting pages for ACSD, GTSD, and the Congenital Heart Surgery Database (CHSD) participants now have the convenience of a site-wide search feature pinned to the top of all pages, allowing them to search by participant group, hospital, or location, regardless of database component.  For the ACSD pages, the site offers a search feature that is specific to ACSD participant surgery groups and the ability to search by location. Embedded maps on ACSD search and participant pages show hospital locations so that visitors may drill down via geographic location or view what’s in their local areas. ACSD CABG and Multiprocedure Composite Measures on Horizon “We’re very excited about a number of quality enhancements that will be implemented later this year and in early 2022,” said David M. Shahian, MD, chair of the STS Workforce on Quality. “The STS ACSD CABG composite measure, the first of our composites developed more than a decade ago, has now been updated to use 3-year analytic data windows and 95% credible intervals.” This update makes the CABG composite methodology consistent with that of all subsequent ACSD composite measures, he explained. “These changes will help to more accurately classify the performance of lower-volume programs that consistently perform better or worse than expected, but whose 1-year sample sizes were too small to categorize them as outliers.” STS also has developed an ACSD multiprocedure composite measure that drills down to the level of an STS participant, such as a medical center or a practice group, said Dr. Shahian. “This is similar to our individual surgeon composite measure developed in 2015. This new multiprocedure composite will provide a broad overview of a participant’s performance across all the major adult cardiac procedure types and is designed to complement individual procedure composite measures.” STS Public Reporting is voluntary. Currently, 81% of ACSD participants, 91% of CHSD participants, and 44% of GTSD participants publicly report their outcomes. To learn more about the STS National Database, contact STSDB@sts.org.    

Sean C. Grondin, MD, MPH, FRCSC STS News, Summer 2021 — In mid-June, STS hosted its first Town Hall webinar during which Society leaders listened to key issues of concern to our members.   In addition to this new forum for member feedback, we also look very closely at direct communications sent to Society leaders and results from our member needs assessment, which we disseminate every 3 years; the most recent survey closed on July 1.  Based on this feedback, the STS Board prioritizes efforts and responds to areas of need. In this column, I will highlight broadly the top five priorities identified by STS members, and describe the initiatives that STS leadership currently is undertaking to address these concerns. Improving Quality of Care for Our Patients STS has an award-winning, internationally recognized quality improvement registry. Keeping the STS National Database the gold standard of clinical outcomes registries remains a top priority.  We also are driving new quality initiatives as a founding member and the only CT surgery organization in the Surgical Care Coalition (SCC). Comprising 12 surgical professional associations, including the American College of Surgeons and Society of Vascular Surgeons, this group represents more than 150,000 surgeons in America and the patients they serve. Ongoing, key initiatives include active lobbying for maintaining and expanding access to necessary surgical procedures for patients, as well as addressing the surgeon workforce shortage. Furthermore, STS—separately and as part of the coalition—has undertaken initiatives to streamline preauthorization for surgical treatments and protect patients from unanticipated medical bills. Championing Fair Reimbursement In 2020, STS was successful in halting, at least temporarily, proposed cuts to Medicare reimbursements for CT surgery. With these reimbursement cuts now planned for January 2022, STS is focusing efforts toward not only encouraging Congress and the Centers for Medicare & Medicaid Services (CMS) to stop reductions in Medicare physician payments, but instead provide a modest increase in Medicare reimbursements. As well, we are working with our SCC partners on initiatives that encourage congressional leaders to establish a revised payment system compatible with the current health care environment and ensure that 10- and 90-day global codes are adjusted to reflect the increased payments for postoperative and evaluation management services.  Ensuring CT Surgeons Are Essential Leaders of the Care Team As new technologies to assist in the diagnosis and treatment of our patients are developed and implemented, it is imperative that surgeons remain essential leaders of the care team. As such, STS has increased its education offerings and content delivery to encourage continuous learning throughout the year. Currently, STS members can access journal club webinars, wellness sessions and roundtables, online curricula, and virtual conferences, as well as dedicated leadership skill development seminars.  STS also has completed the much anticipated Cardiothoracic Surgery E-Book, which includes Pearson’s Thoracic. The e-book is the most complete and authoritative online resource for CT surgery in the world. Accessible online and from mobile platforms 24/7/365, this continuously updated multimedia textbook brings together 600 leading international surgeon authors in more than 300 interactive chapters covering all main CT surgery domains. In addition to assisting members with expanded educational programs, the Society has partnered with other organizations to deliver innovative, multidisciplinary educational content for all career stages. For example, STS now funds and manages a national resident boot camp in conjunction with the Thoracic Surgery Directors Association and the Thoracic Surgery Residents Association, ensuring that trainees have access to the latest technologies taught by world leaders.  STS also is committed to partnering with non-surgical organizations such as the American College of Cardiology (ACC) to develop collaborative initiatives like coauthoring influential clinical practice guidelines. In doing so, STS leaders and members provide important input and perspectives on the management of CT patients. Another STS/ACC joint activity is the CMS-approved Transcatheter Valve Therapy (TVT) Registry. This state-of-the-art database monitors patient safety and real-world outcomes related to transcatheter valve replacement and repair procedures and also helps guide emerging treatments for valve disease patients using precise scientific data.   Supporting Surgeon Wellness Surgeon burnout is recognized as a serious problem that may have significant personal and professional consequences. STS leadership has heard from its members that one of the major sources of physician burnout is frustration with time-consuming administrative tasks related to meeting regulatory requirements that do not add value to patient care or outcomes.  To support the mental and physical wellbeing of CT surgeons and increase access to mental health services for physicians, trainees, and other health care team members, the SCC is lobbying policymakers to implement the “Dr. Lorna Breen Health Care Provider Protection Act.” The Society also has created a dedicated Task Force on Wellness led by Dr. Michael Maddaus. This group has been busy expanding current STS resources such as the recent webinar and new podcast series on resilience, launching a new podcast series (see page 2), and developing focused content on physician wellness—a topic that also will play an important role at the upcoming STS Annual Meeting.  Programs such as the STS Mentorship Program and the STS Leadership Series also are important resources designed to support the growth and wellbeing of future generations of cardiothoracic surgeons. Wanting to Interact in Person Again Many STS members have communicated that they want our annual meetings to not only deliver relevant educational content, but also provide opportunities to safely network with colleagues and industry partners in person again.  To accomplish this, the STS Annual Meeting Planning Committee led by Dr. John Mitchell is working hard to deliver an exceptional in-person meeting at the newly renovated conference center in Miami Beach, Florida, January 29-31, 2022. At this time, STS also is exploring platforms to simultaneously offer a virtual meeting component for those who are unable to travel and join us in person.  Please note the deadline for submitting abstracts for STS 2022 is August 3, 3021. Additional meeting information available at sts.org/annualmeeting. I look forward to seeing you there.   

Litle Is Thoracic Chief in Utah Virginia R. Litle, MD, has joined Intermountain Healthcare in Murray, Utah, as chief of thoracic surgery and system-wide medical director of thoracic surgery. Prior to this role, she was chief of thoracic surgery at Boston Medical Center and professor of surgery at Boston University School of Medicine, both in Massachusetts. An STS member since 2007, Dr. Litle is treasurer of The Thoracic Surgery Foundation.  Mangi Heads Cardiac Surgery at MedStar  Abeel A. Mangi, MD, has joined MedStar Health System in Washington, DC, as the cardiac surgeon-in-chief for the health system and the chair of cardiac surgery at the Medstar Washington Hospital Center. Before accepting this role, he was surgical director of the structural heart and cardiac valve program and managing director of the cardiac surgery network at Yale New Haven Heart and Vascular Center in Connecticut. Dr. Mangi also served as professor of surgery at the Yale University School of Medicine in New Haven, Connecticut. He has been an STS member since 2011. Cooke Named TSDA President-Elect  David Tom Cooke has been voted president-elect of the Thoracic Surgery Directors Association (TSDA), becoming the first African American to hold the position. He will transition to a 2-year term as president in May 2023. Dr. Cooke is chief of the Division of General Thoracic Surgery at the University of California Davis Health in Sacramento and vice chair for faculty development and wellness, as well as director of the general thoracic surgery robotics program. An STS member since 2010, he leads the STS Workforce on Diversity and Inclusion.  Mascio Leads WVU Children’s Heart Center  Christopher E. Mascio, MD, now serves as executive director of the West Virginia University (WVU) Medicine Children’s Heart Center in Morgantown and division chief of pediatric cardiothoracic surgery in the Department of Cardiovascular and Thoracic Surgery. Previously, he was an attending surgeon in the Cardiac Center at Children’s Hospital of Philadelphia in Pennsylvania and associate clinical chief of the Division of Pediatric Cardiothoracic Surgery. Dr. Mascio has been an STS member since 2007. Meyer Moves Up at Northwell David B. Meyer, MD, has been appointed system chief of pediatric and adult congenital cardiothoracic surgery for the Northwell Health System in New York, which includes Cohen Children’s Medical Center, Long Island Jewish Medical Center, North Shore University Hospital, and Lenox Hill Hospital. He has been an attending surgeon with Northwell since 2008. Dr. Meyer also is associate professor of cardiothoracic surgery and pediatrics at the Zucker School of Medicine at Hofstra/Northwell in Uniondale, New York. He has been an STS member since 2007. Anderson Promoted to Chair  Richard C. Anderson, MD, is the new chair of the Department of Surgery at the University of Illinois College of Medicine at Peoria (UICOMP). He has been on the UICOMP faculty in the Department of Surgery for more than 20 years, serving as the surgery clerkship director, professor of clinical surgery, and section chief of cardiothoracic surgery. Dr. Anderson has been an STS member since 2003. Kim Helps Guide Quality in Houston  Min P. Kim, MD, was named vice chair of the Department of Surgery in Quality at Houston Methodist Hospital in Texas. He will continue to serve as the David M. Underwood Distinguished Professor of Surgery and head of the Division of Thoracic Surgery and associate program director of thoracic fellowship, as well as associate professor of surgery and cardiothoracic surgery at both Weill Cornell Medical College in New York City, New York, and Houston Methodist Institute for Academic Medicine in Texas. Dr. Kim has been an STS member since 2013.    Gleason Moves to Maryland Thomas G. Gleason, MD, recently began a new position as director of cardiac surgery research and professor of surgery at the University of Maryland in Baltimore. Prior to this role, he was co-executive director of the Heart and Vascular Center and chief of the Division of Cardiac Surgery at Brigham and Women’s Hospital in Boston, Massachusetts. Dr. Gleason also was formerly chief of the Division of Cardiac Surgery, co-director of the Heart and Vascular Institute, and director of the Center for Thoracic Aortic Disease at the University of Pittsburgh Medical Center in Pennsylvania. An STS member since 2004, he serves on the STS Board of Directors. Shariati Takes on Two Director Roles at Mountainside  Nazly M. Shariati, MD, has been named medical director of thoracic surgery and surgical director of the Lung Cancer Screening/Lung Nodule Program at Hackensack Meridian Mountainside Medical Center in New Jersey. Previously, she served as associate chief of the department of thoracic surgery at Hackensack University Medical Center in New Jersey. Dr. Shariati will continue as associate clinical professor of thoracic surgery at the Seton Hall University School of Health and Medical Sciences in Nutley, New Jersey. She has been an STS member since 2005.

  STS News, Summer 2021 — A provocative new STS podcast series aims to help surgeons be their best selves inside and outside of the operating room. “The Resilient Surgeon” series—part of the STS Surgical Hot Topics podcast—features renowned guests who will explain their own struggles with anger, depression, burnout, and career challenges before they learned strategies and techniques that helped energize them and improve their wellness, work-life balance, and optimal performance. “Our goal with ‘The Resilient Surgeon’ is to inspire cardiothoracic surgeons to be their best selves, in and out of the OR, using scientifically proven tools and recovery strategies of the world’s top performers from all walks of life,” said podcast host Michael A. Maddaus, MD, chair of the new STS Task Force on Wellness. The episodes will be released biweekly beginning on July 9: Monique Valcour, PhD, executive coach, shares advice and strategies on integrating work and life and thriving in a high-demand world. Daniel Z. Lieberman, MD, author of The Molecule of More, provides a master class in dopamine and explains why happiness comes only in the here and now. Suniya S. Luthar, PhD, cofounder and chief research officer at Authentic Connections, provides tips on managing stress and anxiety, especially for mothers and women in medicine. Chris Germer, PhD, clinical psychologist, offers insights on mindfulness and self-compassion. Christopher M. Barnes, PhD, who worked in the Fatigue Countermeasures branch of the Air Force Research Laboratory, explains why sleep deprivation takes a toll on our ability to be charismatic leaders and creative entrepreneurs. Robert H. Lustig, MD, MSL, pediatric endocrinologist, details metabolic health and nutrition, exposing some of the leading myths that underlie diet-related disease. Dorie Clark—described by The New York Times as an “expert at self-reinvention and helping others make changes in their lives”—tackles topics such as personal branding, professional reinvention, leadership, networking, and social media. Additional guests will include Wendy Wood, PhD, MS, Brian Ferguson, Wayne M. Sotile, PhD, Judson A. Brewer, MD, PhD, Sara B. Algoe, PhD, and Michael Maddaus, himself. Subscribe to Surgical Hot Topics via your favorite podcast app, or find the episodes at sts.org/podcast. New episodes will be added regularly and social media postings about the series will include the hashtag #BeYourBestSelf.

STS News, Summer 2021 — The Society, along with three other leading medical specialty societies, recently released a new clinical practice guideline that includes recommendations for reducing blood loss during heart surgery and optimizing patient outcomes.  Since 2011—when the guideline was last updated—there has been a “remarkable increase” in minimally invasive procedures that has contributed to a favorable shift in blood product utilization and management, according to coauthor Victor A. Ferraris, MD, PhD, from the University of Kentucky College of Medicine in Lexington.  “Blood management guidelines are a ‘moving target’ that change with the advent of new or modified evidence,” he said. As a result, the new comprehensive, well-researched document—a multidisciplinary collaboration among STS, the Society of Cardiovascular Anesthesiologists, the American Society of ExtraCorporeal Technology, and the Society for the Advancement of Patient Blood Management (SABM)—features 23 new or updated recommendations. This is the third iteration of the guideline on blood management and the first in 10 years.  “This guideline provides clinicians with a detailed assessment of patient blood management in the cardiac surgical patient—what has been proven to work and what has not, as well as the ability to incorporate these techniques with the most up-to-date evidence,” said lead author Pierre R. Tibi, MD, from Yavapai Regional Medical Center in Prescott, Arizona. Patient-Centered Blood Management  It’s important to note that in previous guidelines, the term “blood conservation” was used; the new recommendations yield to the broader term “patient blood management” (PBM).  PBM—developed in 2008—is “the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort to improve patient outcomes,” according to SABM. Based on a growing body of evidence published over the years (much of which was reviewed by the writing committee), PBM has moved away from simply reducing the use of blood components and now focuses more on developing multidisciplinary and multimodal strategies centered on patient outcomes. The major tenets of PBM, which are confirmed in this guideline, are: Managing anemia Minimizing blood loss Reducing the need for allogeneic blood transfusions  This approach also places patients at the heart of the decision-making process, helping to ensure that they are fully informed of the risks and benefits of their treatments and that their values and choices are incorporated into the treatment pathway. “As medicine evolves and we learn more, it always is important to review past assumptions, validate new information, and concisely present the best current recommendations,” said senior author Susan D.  Moffatt-Bruce, MD, PhD, MBA, from the Royal College of Physicians and Surgeons of Canada in Ottawa. “These recommendations are really centered on the patient and how they would want to be treated during complex cardiothoracic procedures.” Blood Is a ‘Liquid Organ’ Among the most important changes to the practice guideline is the adoption of PBM as a treatment of the whole patient, with blood considered a “liquid organ” or “vital entity” in taking care of the surgical patient, rather than focusing simply on when or when not to transfuse, explained Dr. Tibi.  Blood transfusions—which can be a critical and life-saving facet of cardiothoracic surgery patient care—date back to the 17th Century when British physician William Harvey, MD, discovered the circulation of blood and attempted the first blood transfusion.  In the hundreds of years since, the practice has certainly evolved, being proven generally safe and saving millions of lives. However, it does carry the risk of serious side effects, according to Dr. Tibi. With the potential to introduce disease and cause potent immunological reactions or even death, transfused blood does not work as well as a patient’s own blood.  “Blood transfusions can be harmful to the body. Therefore, unless the proven benefit of blood transfusions outweighs the known risks, it is better to treat patients before, during, and after surgery in ways that decrease the risks of needing blood as much as possible for the best outcomes,” he said. These risks can be lessened through the use of PBM, by safeguarding the patient’s own blood and ensuring transfusions are not needed. In fact, some hospital systems in the US have experienced as much as a 45% overall reduction in the rate of transfusions since starting PBM programs.   “Patient safety is well supported in this guideline, as it reduces the risks associated with blood transfusions,” said Dr. Moffatt-Bruce. Avoiding Blood Transfusions For example, the guideline includes preoperative interventions related to identifying and managing anemia, which is “extremely prevalent” in the cardiac surgical population, especially in elderly patients or those with multiple comorbidities and chronic diseases.   The most common cause of anemia is iron deficiency, occurring in up to 50% of anemic patients, according to the guideline. Historically, patients with preoperative anemia are more likely to require transfusions, so treating iron-deficiency anemia should be done before surgery. If successful, this can dramatically reduce the need for a blood transfusion. The new guideline also suggests that in cardiac operations with cardiopulmonary bypass, the “well-established method” of red cell salvage via centrifugation may be routinely used. Red cell salvage is an important part of the blood conservation aspect of PBM.  Another new addition to the guideline is the recommendation to administer human albumin after cardiac surgery, which also has been shown to minimize the need for transfusion. Also, retrograde autologous priming should be used wherever possible, according to the guideline. This simple, safe, and effective process has been shown to decrease transfusion rates, especially for cardiac operations that result in excessive blood loss. “The guideline has been assembled by experts from different specialties and backgrounds who have reviewed the most recent data,” said Dr. Moffatt-Bruce. “This guidance allows clinicians to standardize treatment with the knowledge that they are utilizing the best information while considering all aspects of patient care.” Dr. Tibi expects that some clinicians will be surprised by several of the recommendations, especially those that carry a “great deal of evidence” and likely will require changes to routine treatments for their patients undergoing cardiac surgery (e.g., the information related to the preoperative treatment of anemia and the assorted perfusion techniques). For patients, it’s important that their hospitals, surgeons, and care teams are aware of PBM and that they are utilizing the “best, most proven techniques available,” Dr. Tibi advises. “Patients should certainly ask, ‘What do you do so that my chances of receiving blood are minimized?’” In developing this guideline and identifying relevant evidence, a systematic review was outlined and extensive literature searches were conducted by a workgroup. The group then wrote and developed recommendations based on the critical appraisal of approximately 90 highly cited articles included in the final review. The guideline is available at annalsthoracicsurgery.org.