News & Media

The Centers for Medicare & Medicaid Services (CMS) has made it clear that the future of physician payments will be linked to quality and value. It is more necessary than ever for cardiothoracic surgeons to stay informed on how these payment models will affect their practices. In this issue of STS News, Dr. V. Seenu Reddy explains a CMS rule to bundle payments for coronary artery bypass grafting (CABG) surgery.  --Frank L. Fazzalari, MD, MBA, Chair, Workforce on Practice Management V. Seenu Reddy, MD, MBA TriStar Cardiovascular Surgery, Nashville, TN Editor's Note: This text is accurate as of December 20, 2016. In August 2017, the Centers for Medicare & Medicaid Services announced a proposed rule that would cancel the Coronary Artery Bypass Graft Episode Payment Model. STS News, Winter 2017 -- Since the passage of the Affordable Care Act, CMS has been seeking to promote cooperative, value-based care. Alternative payment models are one way CMS is attempting to drive quality and value. This past April, CMS implemented a bundled payment model for hospitals participating in the mandatory Comprehensive Care for Joint Replacement (CJR) program. A few months later, without any results from the CJR program, CMS proposed to mandate that randomly selected hospitals throughout the country participate in new bundled payment models for cardiac care, specifically the care of acute myocardial infarction (AMI) and CABG surgery. What this means for cardiothoracic surgeons may be gleaned from what has gone on in the orthopedic specialty regarding the care of patients undergoing joint replacement. The key premise for CMS is that bundling payments for the episode of care surrounding bypass surgery will incentivize increased quality, lower costs, and more care coordination. Here are some highlights from the final rule, which was issued on December 20. Cases related to Medicare fee-for-service patients admitted for heart attacks and bypass surgeries are eligible for the new cardiac bundled payment program. Cases covered by Medicare Advantage plans and Accountable Care Organizations are excluded. The bundle will make hospitals accountable for the cost and quality of care provided during the inpatient stay and for 90 days after discharge. Hospitals initially will be paid at the current reimbursement rates under the Inpatient Prospective Payment system. However, a retrospective reconciliation will occur relative to a predetermined fixed target price for each episode of care. At the end of each performance year, hospitals will have the opportunity to earn shared savings based on how they performed relative to the target price. Hospitals will be chosen from 98 randomly selected metropolitan statistical areas for the cardiac bundling program. Initially, hospitals outside of these selected areas will not participate in the cardiac bundles. Hospitals in rural counties will be excluded, and financial risk will be limited for rural hospitals that fall into the areas selected. More information on the selected hospitals is available. The bundles will begin on July 1, 2017. CMS will roll out the bundles in phases so that hospitals can adapt to the new payment scheme and establish support processes. Penalties will not be levied until the third program year (although participants are allowed to assume risk in 2018 if they so choose). For those who assume risk in 2018 and for all participants beginning January 1, 2019, through the third program year, penalties will be capped at 5% (referred to as the stop-loss amount). The stop-loss amount will increase to 10% in the fourth year and 20% in the fifth year. Potential gains also will be phased in. In the first two performance years, hospitals will be able to earn maximum bonuses of 5% (referred to as stop-gain amounts). These potential gains will then grow, in step with penalties, up to 20% in performance year 5. Hospitals will receive quality-adjusted target payments for each episode of care. These target payments will be based on a blend of historical hospital-specific and regional data and will be adjusted to account for case complexity. Hospital targets also will be adjusted for quality, so that hospitals delivering the best care have the opportunity to share in more savings. If hospitals do not meet the baseline standards for quality, they cannot share in savings. At the end of each performance year, hospitals that meet quality standards can earn additional payments based on cost. This means CMS will compare the actual spending for each episode to the target prices paid to the hospital. Those that are able to deliver care for less than the target price will be paid the achieved savings. Hospitals that exceed the target will be required to repay Medicare. The proposed rule also includes a model for cardiac rehabilitation services. The model aims to test whether payments incentivize use of cardiac rehabilitation during the 90-day period following hospital discharge. The AMI and CABG bundles can qualify as Advanced Alternative Payment Models in 2018 under the Medicare Access and CHIP Reauthorization Act (MACRA). The cardiac bundled payment program established pathways for physicians potentially to qualify under the Quality Payment Program for Advanced APMs. Surgeons participating in Advanced APMs will earn a 5% bonus payment from 2019 to 2024. The mandatory CABG bundle will qualify as an Advanced APM. Physicians in participating hospitals can get credit for participating in an APM (and therefore be exempt from participating in the Merit-Based Incentive Payment System) as early as January 2018, provided that their hospitals are willing to assume downside financial risk sooner than is required under the rule finalized on December 20. Physicians in these hospitals will be eligible to receive bonus payments in 2019. Much like the "usual and customary" fee schedule of the past, the future of physician payments will be based on and linked to quality, care coordination, and overall value. STS has actively advocated on behalf of cardiothoracic surgeons in relation to this new payment program, including meeting with CMS in person last September and sending a subsequent comment letter outlining specific concerns. In particular, the Society has noted that there are already too many payment policy changes in store for 2017 for physicians to have a reasonable expectation of success under this proposal. STS also has argued that clinical data, such as those in the STS National Database, should be used instead of Medicare claims data to determine the risk methodology of such payments. The final rule issued in late December incorporated some of the Society’s recommendations on quality measurement. The key for cardiothoracic surgeons, whether in an employment or private practice model, is that the system of independent physician payment for volume of services provided will soon be of historic interest. Much like the “usual and customary” fee schedule of the past, the future of physician payments will be based on and linked to quality, care coordination, and overall value.

Joseph E. Bavaria, MD, President STS News, Winter 2017 -- Advances in cardiothoracic surgery have been nothing short of remarkable over the past few decades. We’ve progressed from crude surgical techniques that kept patients in the hospital for weeks to minimally invasive operations that allow patients to be released from the hospital in only a few days. These innovations are good for patients and their families; in many cases, patients experience better outcomes and easier recoveries, which also lead to lower health care costs. Adoption of new technology can be a very slow process, especially in cardiothoracic surgery. We have a mandate for quality, which is critically important, but sometimes great quality can be at odds with innovation, especially for “early adoption.” We can’t stay stuck in old paradigms, however. Quality and innovation need to travel on the same path—in the same direction—so that our patients can lead longer and better lives. Technology at our Doorstep Some of the most recent technological advancements in our specialty relate to treating heart valve disease. Transcatheter aortic valve replacement has evolved rapidly with good outcomes. In late 2011, TAVR received regulatory approval; a few months later, CMS issued a National Coverage Determination for the technology. In the months leading up to the regulatory approval, I personally worked closely with several organizations to establish criteria for the safe introduction of TAVR into clinical practice for high-risk patients. These criteria included participation in the STS/ACC TVT Registry to track short- and long-term outcomes. Now, more than 5 years later, TAVR use has expanded to patients at moderate operative risk and even some with low operative risk. A recent STS survey of surgeon participants in the STS Adult Cardiac Surgery Database found that, among those surgeons with TAVR programs at their hospitals, 91% played an active role in the TAVR process, including participating in multidisciplinary meetings, performing TAVR procedures, and conducting follow-up patient care. I’ll provide more results from this important and revealing survey on Tuesday morning during the upcoming STS Annual Meetingin Houston, which also will feature dozens of presentations on use of new technology, including results from early feasibility trials for transcatheter mitral valve replacement. Other innovations that will be highlighted, discussed, and debated at the Annual Meeting include novel ways to treat the thoracic aorta and the lungs. All of these innovations have been made possible by new technologies and treatments, such as sutureless valves, TEVAR devices, state-of-the-art cardiopulmonary bypass platforms, third or fourth generation LVADs, and advanced VATS techniques. If you’re like me, you get really excited about new technology and dream about ways it can help your patients. But then you realize that the traditional rollout paradigm makes it difficult to adopt these technologies as quickly as we would like. That’s where STS can play a crucial role. Quality and innovation need to travel on the same path—in the same direction—so that our patients can lead longer and better lives. Steering Innovation and Quality in the Same Direction The Annual Meeting and upcoming STS standalone educational programs, including an ECMO course, a robotics course, and a structural heart course, will help you see and experience the present and future of cardiothoracic surgery. It is through educational activities such as these that we learn from the experts, experience hands-on training, and review and analyze outcomes data—all vital in the process to adopt new technologies. Clinical outcomes databases, such as the STS National Database and the STS/ACC TVT Registry, also play a role in the process. Our databases are valuable assets in medicine because they provide opportunities for quality improvement and patient safety. It is through participation in the STS National Database that you also can take part in STS Public Reporting. The initiative, one of the most sophisticated and highly regarded overall measures of quality in health care, offers risk-adjusted outcomes for common cardiothoracic surgical procedures. STS Public Reporting was launched in 2010 and has expanded over time (see related story). Because continuous improvements in quality and rapid adoption of innovation can be inherently at odds with one another, I will use my Presidential Address on Monday at the Annual Meeting to examine these colliding imperatives. Complementary to my address will be the C. Walton Lillehei Lecture on Tuesday by Dr. Samer Nashef, who co-developed the EuroSCORE risk-assessment system. Dr. Nashef, author of The Naked Surgeon: The Power and Peril of Transparency in Medicine, will provide his overview of quality initiatives and their unintended consequences. Clarion Call Although medicine adopts technology very slowly, we can shatter that paradigm by working together to drive innovation and quality along the same path. We need to see the big picture; we need to connect the dots. Please join me in Houston at the STS Annual Meeting so that we can begin an accelerated journey into a new era of medicine where patients benefit more quickly and today’s innovations truly become tomorrow’s standard of care.

STS News, Winter 2017 -- The STS 53rd Annual Meeting is just a few weeks away, but it’s not too late to join your colleagues in Houston, Texas, for one of the largest cardiothoracic surgery meetings in the world. Save $100 off onsite pricing by registering before January 20 at www.sts.org/annualmeeting. Annual Meeting registration has been simplified this year. Registration provides access to all educational sessions on Sunday, January 22, Monday, January 23, and Tuesday, January 24. Additionally, you will receive complimentary access to Annual Meeting Online. Separate tickets are required to attend the STS Social Event (Monday, January 23) and STS University courses (Wednesday, January 25). You also can register for STS/AATS Tech-Con 2017, which will be held on Saturday, January 21. View course descriptions and agendas for educational sessions, as well as oral and poster abstracts, in the STS 53rd Annual Meeting Abstract Book. The Best Forum for Scientific Research The always-popular general session on Monday will include presentation of the J. Maxwell Chamberlain Memorial Papers and the Richard E. Clark Memorial Papers, which represent some of the top-rated abstracts at the meeting. The Chamberlain paper for adult cardiac surgery examines moderate coronary artery stenosis after surgical revascularization. The congenital heart surgery paper takes a look at optimal timing for stage-2 palliation after the Norwood operation. And the general thoracic surgery paper reviews a new risk prediction model for long-term mortality following lung cancer resection in patients older than 65. The Clark papers highlight research that utilizes data from the STS National Database. The adult cardiac surgery paper looks at how surgical ablation affects mortality in contemporary mitral valve repair or replacement operations. The congenital heart surgery paper evaluates risk factors for in-hospital shunt failure. And the general thoracic surgery paper outlines the development of a composite performance measure for esophagectomy in esophageal cancer. Hear from Experts Around the Globe A session to be presented on Monday, January 23, by STS, the Canadian Association of Thoracic Surgeons, and the Canadian Society of Cardiac Surgeons will focus on implementing quality improvement by describing how surgeons and institutions perceive their practice versus true data-based performance. Also on Monday, experts from around the world will examine the quality versus access debate in cardiothoracic surgical care, including regionalization, building sustainable cardiothoracic surgery programs, and humanitarian crises, at the International Symposium. On Tuesday, January 24, the Society will team with the European Association for Cardio-Thoracic Surgery in a session on the various treatment strategies and techniques for distal thoracic aortic dissection. Later that day, STS will join with the European Society of Thoracic Surgeons to discuss controversial issues in general thoracic surgery, including adjuvant treatment for thymic malignancies, donors for lung transplantation, the role of lung volume reduction surgery for emphysema, and the surgical management of spontaneous esophageal perforations. In addition to collaborative sessions with international participants highlighted above, special presentations with the American College of Cardiology, the Society for Vascular Surgery, the Society of Cardiovascular Anesthesiology, and the American Association for Thoracic Surgery also are part of the program. And in light of recent findings tracing Mycobacterium chimaera infections to heater-cooler devices used in cardiac surgery, a special symposium has been added to the program to help attendees better understand the cause of these infections and develop measures to lower the risk of occurrence.  And that’s just the tip of the iceberg. The Annual Meeting will feature dozens of oral abstract presentations, along with invited talks by renowned speakers, lively debates, and surgical videos. Don’t miss this opportunity! Registration and housing is available at www.sts.org/annualmeeting. If you have questions about registration, contact the Society’s official registration partner, Experient, at (800) 424-5249 (toll free), 00-1-847-996-5829 (for international callers), or sts@experient-inc.com. Put Knowledge into Practice at STS University Cap off your Annual Meeting experience by attending STS University on Wednesday, January 25. These hands-on courses allow attendees to gain experience with a wide variety of cardiothoracic surgical procedures. Course 1: Essentials of TAVR Course 2: TEVAR and Aortic Arch Debranching Procedures Course 3: Mitral Valve Repair Course 4: Valve-Sparing Aortic Root Replacement Course 5: Aortic Root Enlarging Procedures and Aortic Valve Leaflet Reconstruction Course 6: VATS Lobectomy Course 7: Advanced Open Esophageal and Tracheal Procedures Course 8: Chest Wall Resection and Pectus Surgery Course 9: Atrial Fibrillation (Maze Procedure) Course 10: Mechanical Circulatory Support Thank You The Society gratefully acknowledges the following companies for providing educational grants for the STS 53rd Annual Meeting. STS Platinum Benefactors Provided $50,000 or above Abbott Medtronic STS Silver Benefactors Provided $10,000-$24,999 Bard Davol Ethicon St. Jude Medical Zimmer Biomet Thoracic This list is accurate as of January 5, 2017.

STS News, Winter 2017 -- The Society is rolling out several new features and upgrades that will make it easier for STS National Database participants to submit files, access interactive progress reports, and include information on evolving procedures. One new feature is continuous data harvesting. Previously, data files for a particular harvest could be submitted only within a designated 3-week timeframe. Any data errors had to be cleaned up within that same period. At the conclusion of those 3 weeks, sites would sign off on their data files before analysis reports were created. Soon, Adult Cardiac Surgery Database (ACSD) participants will be able to submit data files at any time throughout the year, receive data quality reports after each submission, and clean up their data in smaller batches. “Continuous harvesting will allow Database participants and data managers to submit data in close to real time, which may be a less labor-intensive process and may increase the ease of capturing complete and accurate data,” said Jeffrey P. Jacobs, MD, Chair of the STS Workforce on National Databases.  There still will be a “lockdown” four times per year, when submissions will close and analysis reports will be generated based on the current data submitted. Instead of sites needing to sign off on their data files, sites that do not want their data included in the analysis at that time will need to opt out. ACSD sites can start submitting data on January 9 under this new continuous harvesting protocol, and the first lockdown will be from February 24 through March 6. Reports based on those data will be available by late April. The spring 2017 harvests for the General Thoracic Surgery Database (GTSD) and Congenital Heart Surgery Database (CHSD) will be conducted via the traditional 3-week data submission period, and continuous harvesting will begin this summer for those two Databases. View the complete data submission schedule for 2017. Reporting Dashboard on the Horizon Also in the works is a web-based reporting dashboard that will give sites more flexibility over how they view their feedback reports. Instead of receiving a static PDF report, participants will be provided access to a secure online dashboard where they can drill down into specific procedures. Eventually, individual surgeons will be able to review their own private reports. “These interactive features will allow participants to examine unique aspects of the data not currently available in feedback reports,” said Dr. Jacobs. “In the past, participants were required to submit Minor Data Requests to get access to individualized institutional data benchmarked to national aggregate data. Soon, participants will have real-time access to such data.” With guidance from STS staff and surgeon leaders, professionals from the Duke Clinical Research Institute are working to make the reporting dashboard available for ACSD participants by the third quarter of 2017 and for GTSD and CHSD participants in 2018. "These interactive features will allow participants to examine unique aspects of the data not currently available in feedback reports." Jeffrey P. Jacobs, MD ACSD Spec Upgrade Expands Aortic Fields On July 1, version 2.9 of the ACSD will go into effect, and an extensive section on aortic and aortic root procedures will be included in the Data Collection Form. “These fields are really important as we expand treatment options for our patients. Some of my colleagues started changing their operative notes a few months ago so that their data managers could start adding the information as soon as possible,” said STS President Joseph E. Bavaria, MD, who was a strong promoter of the expanded aortic fields. “People are very excited about this upgrade.” The new section includes detailed fields on primary indication, specific interventions (such as arch procedures, descending thoracic aorta or thoracoabdominal procedures, and endovascular procedures), and inserted devices. These new elements may help improve risk stratification and further harmonization with other registries. “The art and science of analyzing medical and surgical outcomes, as well as the assessment and improvement of medical and surgical quality, continue to evolve; these updates confirm the Society’s commitment to maintaining the STS National Database as the premier platform in the world to facilitate these objectives,” Dr. Jacobs added.

Jess L. Thompson III, MD Assistant Professor of Surgery, Section of Congenital Heart Surgery, University of Oklahoma 2016 STS Key Contact of the Year STS News, Spring 2017 -- “Politicians and diapers must be changed often, and for the same reason.” - Mark Twain In the 5th grade, my teacher asked what job I wanted when I grew up. My response – a United States Senator. When asked to provide the rationale for my choice, I replied, “Because people will think I’m important, but I don’t have to do anything.” Whether I was displaying youthful naiveté or a precocious understanding of our political process is open to debate, but what is certain is that being engaged in the Society’s advocacy efforts has been a fulfilling professional experience. I have come to better understand and appreciate the history and machinations of the American political process. During my cardiothoracic surgical training, I had the opportunity to attend my first STS Legislative Fly-In. Prior to meeting with our representatives on Capitol Hill, we were given a thorough briefing by the Society’s Government Relations staff. I was impressed by how the more seasoned surgeons in attendance displayed a deep understanding of the pressing issues confronting cardiothoracic surgeons. Feeling a little intimidated, I initially wondered how I could contribute. The DC staff, however, did a wonderful job preparing me so that I could advocate our positions. It also was very reassuring to make visits with other surgeons who had done it before. When the time came to meet our legislators, I was struck by several things. First, it is much more common to meet with a legislative aide than an actual member of Congress. The aides appeared young, but were obviously very bright and inquisitive. Second, having clearly defined “asks” (the actions we were requesting members of Congress to perform on our behalf) increased our chances of success. Third, we were treated with respect, in part because of our professional status, but perhaps even more so because we were advocating not for ourselves, but for issues that would benefit our patients. Fourth, proactively steering the direction of a policy from its inception is infinitely easier than changing a policy that has already gained momentum. Ultimately, I left Washington feeling like I had made a positive contribution to the specialty and to our patients. Proactively steering the direction of a policy from its inception is infinitely easier than changing a policy that has already gained momentum. “If you’re not at the table, you’re on the menu” goes the saying in Washington. With our advocacy efforts giving us the proverbial seat at the table, potentially catastrophic changes to our specialty have been avoided. For example, it was only through our advocacy that the Centers for Medicare & Medicaid Services (CMS) mandated that a multidisciplinary heart team approach be used for transcatheter aortic valve replacement (TAVR). Certainly, embedding a cardiothoracic surgeon in TAVR protects the surgeon’s ability to provide this therapeutic modality, enhances patient safety, and continues patient access to optimal care (see page 1 for more on surgeon involvement in TAVR). More recently, CMS proposed to eliminate 10- and 90-day global surgical payments. The leadership provided by STS rallied the surgical community so that we could stop this disastrous policy before it was implemented. It has been said that the first noble truth of politics is frustration. Certainly, this emotion has been experienced by everyone who has engaged in any level of political advocacy. When I feel this way, I try to remember that most of our advocacy focuses on policies and practices that are long-term in nature. Securing meaningful change in government is more akin to turning an aircraft carrier as opposed to maneuvering a nimble speedboat. That said, once we point the aircraft carrier in the direction we want, it is difficult to move it off course. During the most recent Fly-In, our attentive STS legislative staff made me aware that my member of Congress was having an early morning meet-and-greet for people in his district. I was able to have a long discussion with Rep. Steve Russell and invite him to visit the hospital where I work. When he toured my hospital, I pointed out the economic impact of and jobs created by the hospital. We visited the operating rooms and the ICU, and he interacted with one of our patients and her grateful parents (our best advocates!). STS members Jess L. Thompson III, MD (left) and Harold M. Burkhart, MD (right) took Rep. Steve Russell on a tour of the operating rooms and ICU at the University of Oklahoma. I have enjoyed a great deal of professional satisfaction by participating in STS advocacy efforts. I believe that the successes we have achieved on Capitol Hill are significant contributions to our specialty and are for the betterment of our patients. Plato is attributed with the observation that one of the penalties for refusing to participate in politics is that you end up being governed by someone worse. I would invite those STS members not currently participating in the Society’s advocacy activities to reconsider their involvement in this vital effort.

STS News, Spring 2017 -- More than 4,100 people, including more than 2,100 cardiothoracic surgeons and allied health care professionals, gathered in Houston January 21–25 for the STS 53rd Annual Meeting. To view meeting photos, program content, and daily editions of the STS Meeting Bulletin, visit www.sts.org/AMarchive. Bavaria Urges Out-of-the-Box Thinking The fine line between delivering quality treatment and embracing innovation may sometimes make cardiothoracic surgeons feel trapped between conflicting goals. In his Presidential Address at the STS 53rd Annual Meeting, Joseph E. Bavaria, MD challenged that paradigm. “What if these two fundamentally important obligations, which go so far as to almost define us, are at odds with each other? If they are in fact colliding, then this is a challenge that we must sort out,” he said. In his Presidential Address, Joseph E. Bavaria, MD urged his colleagues to experiment and continually adapt. Pointing out that there is even conflict within innovation and quality, he asked if it was better to always be an innovator, adopting promising technology and navigating a difficult learning curve, or wait for guidelines on that new technology. “Innovation has become absolutely critical to the survival of our specialty. We must experiment. We must continually adapt. And I know we are up to the challenge,” Dr. Bavaria said, suggesting that cardiothoracic surgery should work to build a culture of innovation by emphasizing democracy and freedom of inquiry within the specialty. “Is a culture that requires rigid conformity capable of significant innovation by its people?,” Dr. Bavaria asked. “Liberated surgeons can be ingenious. So innovation—or importantly, early adoption of innovation—is an imperative.” Moving to the issue of quality, STS has been a leader in this area with its long-established collection of outcomes data and its ongoing development and refinement of risk-adjustment models and metrics. “The STS National Database has had a long evolution toward improving its ability to generate meaningful measures that can discriminate and point to a ‘quality’ program,” Dr. Bavaria said, adding that using complex data to create simple grades is a challenge. “Are the risk-adjustment models strong enough? Do they penalize or reward larger, tertiary institutions doing more complex cases?" He suggested exploring the concept of patient-centered and patient-reported outcomes. "Remember, we make the boxes. We construct those boxes that constrain our thinking." Joseph E. Bavaria, MD “The collision is not necessary if we keep the patient in mind. In this model, we convert the collision into a merger. The patients and their families become deeply involved with the decision making,” he said. “By discussing all the treatment options, with full consent, including high-risk and alternative options, we can affect a patient-centered outcome, and risk aversion can be moderated.” Dr. Bavaria concluded his address by urging cardiothoracic surgeons to continue embracing innovation and quality: “I ask you to search for solutions for yourselves and your programs so that these two important imperatives don’t collide. This requires out-of-the-box thinking. But remember, we make the boxes. We construct those boxes that constrain our thinking.” Award Winners Honored The STS Annual Meeting offered the opportunity to recognize those who are making an impact on the specialty. The following were honored by the Society in Houston: Distinguished Service Award STS presented the Distinguished Service Award to David M. Shahian, MD. This award recognizes those who have made significant and far-reaching contributions to the Society and the specialty. Dr. Shahian is a renowned quality improvement expert and public reporting advocate who previously led the STS Workforce on National Databases and currently serves as Chair of the STS Council on Quality, Research, and Patient Safety. Earl Bakken Scientific Achievement Award The Earl Bakken Scientific Achievement Award was presented to Eric A. Rose, MD, who is best known for making history in 1984 when he performed the world’s first successful pediatric heart transplant. The Bakken Award honors individuals who have made outstanding scientific contributions that have enhanced the practice of cardiothoracic surgery and patients’ quality of life. President's Award The President’s Award was presented to Panos Vardas, MD from the Indiana University School of Medicine for his paper, “Current Status of Endovascular Training for Cardiothoracic Surgery Residents in the United States.” Selected by the STS President, this award recognizes an outstanding scientific abstract by a lead author who is either a resident or a surgeon 5 years or less in practice. Poster Awards Adult Cardiac Surgery Permanent Pacemaker Placement in Transcatheter Aortic Valve Replacement Patients Is Not Associated With Increased Mortality or Readmission (Fenton H. McCarthy, MD) Cardiothoracic Surgical Education Creation of a Coronary Anastomotic Checklist Using a Delphi Technique Reveals Significant Variability Among Experts (Ara A. Vaporciyan, MD) Congenital Heart Surgery Surgical Ligation of Patent Ductus Arteriosus in Preterm Infants: An Exceptionally Safe and Beneficial Approach to Management (Todd Crawford, MD) Critical Care Early Glycemic Variability Is Associated With Adverse Outcomes in Normoglycemic Patients Following Cardiac Surgery (Lily E. Johnston, MD, MPH) General Thoracic Surgery Long-Term Outcomes Following Surgical Management of Bronchopulmonary Carcinoid Tumors Using the National Cancer Database (Caitlin Harrington Brown) Photo Gallery View photos from the Annual Meeting, including highlights such as Shark Tank, the Presidential Address by Joseph E. Bavaria, MD, award winners, and popular hands-on STS University courses. Access STS 53rd Annual Meeting Online STS Annual Meeting Online provides access to more than 100 hours of recorded sessions. Access to Annual Meeting Online was included with Annual Meeting registration. Non-attendees can purchase the online product at www.sts.org/AMonline. Annual Meeting by the Numbers 2,155 professional registrants 168 exhibiting companies and organizations 66 countries represented by registrants, with the most professional registrants coming from the United States, Japan, Canada, Mexico, and United Kingdom 286 pieces of bovine and porcine tissue purchased for STS University  

Robert A. Wynbrandt Robert A. Wynbrandt, Executive Director & General Counsel Avidan J. Stern, Associate General Counsel STS News, Spring 2017 -- With this edition of STS News, we return to our continuing series of guest columns from other members of the Society’s management team discussing their respective areas of (apropos of this installment) jurisdiction. This time, Avi Stern, who joined the Society in January 2016 as its new Associate General Counsel, provides an overview of the role played by the STS legal team in both facilitating day-to-day operations and implementing STS strategic initiatives. Before joining the Society, Avi was a partner in the Chicago-based law firm of Jenner & Block, after which he established his own boutique law firm at which he worked for 8 years. We have been hearing a lot lately about “the rule of law.” The United States is a country founded upon the principle that it is a democracy governed by “the rule of law,” as those of us raised here were taught in social studies classes since childhood. At its most basic level, the rule of law covers everything from how we govern ourselves to how we interact socially and in business. At STS, we have a keen awareness of both the rule of law and the role of law because virtually every function performed by the Society has some legal facet. When it comes to the day-to-day operations of the Society, the legal team provides assistance to every STS department on a regular, ongoing basis. This is due largely to the numerous contracts necessary to advance our mission; STS members may not think about it, but practically every member service, program, meeting, publication, and STS National Database function involves one or more contracts somewhere in the process. Separately, many aspects of STS operations require the consideration of legal implications, ranging from compliance with STS Bylaws to the organization’s statutory corporate and tax obligations. This breadth of legal activity is illustrated by a sampling of the legal work performed by the team in 2016: Finance & Administration: engaging a CPA firm for the annual audit, addressing STS lease amendment matters, and handling STS employment issues Education & Member Services: preparing documentation regarding the Society’s relationships with faculty for the Annual Meeting and STS standalone educational programs, arranging joint providerships in order to issue CME credit for third-party organizations, and drafting third-party endorsement and co-sponsorship contracts Quality: drafting and negotiating all of the contracts that pertain to the STS National Database, including those with participants, software vendors, auditors, and the data warehouse and analytics center, as well as addressing subpoenas relating to STS National Database information and negotiating agreements involving the STS/ACC TVT Registry STS Research Center: drafting and negotiating data licensing agreements, preparing research grant applications and related submissions and agreements for the federal government and private entities, and developing the legal architecture of the PUF Research program Marketing & Communications: entering into publishing and videotaping contracts for the Annual Meeting, preparing for media interviews, and licensing STS intellectual property Meetings & Conventions: negotiating convention center, hotel, security, temporary employment, social venue, and other contracts required for the Annual Meeting and all of the other meetings and programs presented by the Society and its affiliated organizations Government Relations: drafting agreements for the retention of health policy consultants, addressing STS-PAC operations for purposes of compliance with federal law, addressing employment, real estate, and other issues pertaining to the Society’s maintenance of a Washington office Information Services: drafting and negotiating software license and consulting agreements Executive Office: preparing a wide range of corporate documents, including various meeting agendas and minutes and the Illinois Annual Report required for maintenance of the Society’s not-for-profit corporate status, drafting STS Bylaws amendments and policy documents, managing the legal aspects of STS Standards and Ethics Committee activity (esp. disciplinary proceedings), and addressing legal issues related to the publication of The Annals of Thoracic Surgery. The team also "papered over" the Society’s acquisition of the annual CVT Critical Care Conference and began negotiating contracts for an educational program in Cartageña, Colombia. Beyond the ordinary course of STS operations, the legal team also has played an important role in implementing the Society’s strategic initiatives. For example, in 2016, the legal team guided STS through the procedures required in order to merge with The Joint Council on Thoracic Surgery Education, assisted with contract negotiations for a new online Learning Management System, and helped engage the services of consultants and contributors to migrate existing electronic textbooks and create a new one. The team also ”papered over” the Society’s acquisition of the annual CVT Critical Care Conference and began negotiating contracts for an educational program in Cartageña, Colombia. The list of ongoing special projects with which the STS legal team is involved is too long to include here. Indeed, given the pervasiveness of legal issues at STS and the constant evolution of the law, the work of the STS legal team will remain active and challenging as the Society continues to expand its reach and fulfill its mission of enhancing the ability of cardiothoracic surgeons to provide the highest quality patient care through education, research, and advocacy.

After patient care, professional satisfaction and financial security are significant concerns for STS members. This was clearly evident by the standing-room-only attendance at the 2017 Practice Management Summit, held during the STS 53rd Annual Meeting this past January. In this issue of STS News, Dr. Paul Levy shares some of the most important lessons from the Summit. –Frank L. Fazzalari, MD, MBA, Chair, Workforce on Practice Management Paul S. Levy, MD, MBA, Chief of Surgical Services, Northeast Arkansas Baptist Hospital & Clinic, Jonesboro STS News, Spring 2017 -- Proposed changes in health care finance and delivery have stimulated renewed interest in securing our specialty’s place in this new order. At the 2017 Practice Management Summit, several experts shared how cardiothoracic surgeons can best function in this evolving environment. The first speaker was Aaron Robinson, CEO of Community Hospitals at Health First in Melbourne, Florida. He discussed how physician-hospital partnerships and cost transparency will be important moving forward. “As we dig into more and more research on patient choice and the evolving space that it’s in, patients are defining quality along the components of service and cost,” he said. “Cost is certainly more important than we think.” Several talks dealt specifically with contract negotiation. Health care consultant Michael N. Heaton explained best practices, how fair market value is determined and utilized, and how to strengthen and leverage one’s professional position. The importance of competent representation during a contract negotiation became very evident. Michael G. Moront, MD, of ProMedica Toledo Hospital in Ohio, provided a surgeon’s perspective of why using a professional medical contract consultant is so important. When his practice first entered an employment contract with a local hospital, they did not consult with an advisor. Years later, they realized that the work Relative Value Unit compensation model had many downsides, such as internal competition and increasing unpaid administrative work. The group retained a consultant who helped them shift to a salary model, which has been successful for both the surgeons and the hospital. Health care attorney Mark Kopson, JD discussed important aspects of employment contract negotiation, such as verbal promises, fraud and abuse, and fair market practice valuations. “If it’s important enough to make a difference in whether or not you accept the position, it ought to be in black and white,” he said. “Please, please, please do not accept the fact that we have standard contracts and they can’t be changed—because they can if they want you." "Do not accept the fact that we have standard contracts and they can’t be changed—because they can if they want you." Mark Kopson, JD Steven V. Manoukian, MD, who is the Cardiovascular Service Line Leader for Health Corporation of America, highlighted the value of the service line structure. He pointed to the importance of defined expectations for stakeholders (both administrators and physicians) and data-driven health care delivery. Richard I. Whyte, MD, Chair of the STS Standards and Ethics Committee, discussed potential ethical conflicts that employed physicians may face. He emphasized the importance of always staying focused upon our “true north”—the patient. Alan M. Speir, MD, Chair of the STS Council on Health Policy and Relationships, explained how the Medicare Access and CHIP Reauthorization Act may affect cardiothoracic surgeons, including the concept of “risk-sharing” and a bundled payment pilot for coronary artery bypass grafting surgery. In the final presentation, Steven F. Bolling, MD, of the University of Michigan Health System, spoke about the logistics of taking an innovative idea to market. He warned that significant financial investment may be required—but that good ideas are worth the effort. If you would like to experience the full Practice Management Summit, it is included in STS 53rd Annual Meeting Online.

Richard L. Prager, MD, President STS News, Spring 2017 -- At our Annual Meeting in Houston this past January, I was humbled by my election as the Society’s 53rd President. This unique Society formed as thoracic surgery was recognized as a “highly specialized discipline which should demand ones’ entire energy and attention” and, as such, “dignifies and justifies the creation of a society for thoracic surgeons.” These comments were from a letter by J. Maxwell Chamberlain, Chairman of the Steering Committee tasked with creating The Society of Thoracic Surgeons, that was sent to all prospective members. With this foundation, STS since 1964 has had a vision that was reiterated in our strategic plan adopted last year: “improving the lives of patients with cardiothoracic diseases.” As our specialty evolved, so did The Society of Thoracic Surgeons, placing itself at the forefront of quality, innovation, professionalism, inclusiveness, and teamwork. As all of the leaders who have come before me advanced our Society, it is my goal, as well, that we will continue to make advances based on our core values and focus on our objectives. Focusing on these overarching goals and objectives, which were developed by STS leadership during a strategic planning process, and following the established momentum of our Society, in the arena of leading innovation and education we recently held meetings on ECMO in Tampa and on robotic cardiac surgery in Chicago. The STS/EACTS cardiac surgery meeting in Latin America is coming to fruition in Cartagena, Colombia this September; it will focus on valvular, ischemic, and thoracic aortic diseases, as well as new technologies. We also will continue the FACTS-Care tradition by offering the 14th Annual Multidisciplinary Cardiovascular and Thoracic Critical Care Conference in October in Washington, DC. Recognizing the importance of fostering collaboration and connection, STS is working to facilitate a relationship with health care analytics company Avant-garde that would offer—without charge and at the request of Adult Cardiac Surgery Database (ACSD) participants—hospital payment data on six coronary artery bypass DRGs. This service is meant to help us further our understanding of cost-payment relationships and the value of our role as leaders in creating and facilitating efficient and appropriate care. On the cover of this issue, you’ll find results of an important survey that we conducted in 2016 on cardiothoracic surgeon involvement in transcatheter aortic valve replacement (TAVR). The results were very exciting for two reasons. First, they showed that surgeons are involved in all aspects of patient care during TAVR procedures. Second, they showed that the relationship between surgeons and cardiologists on the heart team is very strong. In fact, the multidisciplinary team approach to TAVR is working so well that the heart team concept is now being tested in other areas of structural heart disease. When we make decisions together and work well together, our patients benefit. We are piloting patient reported outcomes in adult cardiac surgery, which is of major importance to patients, payers, and all of us. The relationships with our sister organizations throughout the world are also critically important. STS surgeon leaders will continue to be active attendees at meetings of our colleagues’ organizations throughout the world and discuss further opportunities for collaboration and broad member engagement throughout all of these societies. Intermacs is a further example of collaboration and connection. STS, The University of Alabama at Birmingham, and NHLBI are concluding discussions aimed at facilitating Intermacs becoming an addition to the Adult Cardiac, Congenital Heart, and General Thoracic Surgery Databases that are a part of the STS National Database. We continue to be a leader in the quality arena, anticipating a July 1 rollout of Version 2.9 of the ACSD with expanded aortic data fields, as well as further upgrades. We are also initiating trial sites for an online dashboard and have already started offering daily input of data with limited ongoing data summaries. In addition, we are piloting patient reported outcomes in adult cardiac surgery, which is of major importance to patients, payers, and all of us. As we look to the future and its challenges and realities, STS will continue to represent all of its members and continue to advance our specialty working with you—our members—and our colleagues throughout the world. Please feel free to contact me at my STS e-mail address, rprager@sts.org, and I look forward to seeing you at our upcoming meetings.

STS News, Spring 2017 -- New STS officers and directors were elected during the Annual Membership (Business) Meeting on Monday, January 23, at the 53rd Annual Meeting in Houston. The membership elected Richard L. Prager, MD as STS President for 2017-2018. Additionally, Keith S. Naunheim, MD was elected First Vice President, and Robert S.D. Higgins, MD, MSHA was elected Second Vice President. Joseph F. Sabik III, MD was elected Secretary, and Thomas E. MacGillivray, MD was elected Treasurer. The following also were elected or reelected by the STS voting membership: Resident Director: Edo K.S. Bedzra, MD, MBA International Director: A. Pieter Kappetein, MD, PhD Canadian Director: Sean C. Grondin, MD, MPH Public Director: Christopher M. Draft Historian: Douglas J. Mathisen, MD Directors-at-Large: Shanda H. Blackmon, MD, MPH and Joseph C. Cleveland Jr., MD

STS News, Spring 2017 -- An STS survey on transcatheter aortic valve replacement (TAVR) shows that cardiac surgeons are involved in all facets of managing patients with aortic stenosis. “These results are exciting,” said Thomas E. MacGillivray, MD, STS Treasurer. “Not only are cardiac surgeons actively participating during the preoperative and intraoperative phases of TAVR, but they also are involved in the postoperative care of TAVR patients.” Last summer, led by 2016-2017 President Joseph E. Bavaria, MD, the Society surveyed surgeon participants in the Adult Cardiac Surgery Database to learn the extent of their involvement in TAVR. Approximately 500 surgeons completed the survey. The results were presented at the STS Annual Meeting in Houston and are available online in The Annals of Thoracic Surgery. Among the respondents whose institutions offered TAVR, 84% said that they were involved in the heart team. In addition, more than three-quarters (77.5%) said that their TAVR programs were either jointly administered by cardiology and cardiac surgery divisions/departments or administered exclusively by cardiac surgery. “I was surprised but pleased to see that a majority of patients were managed by some sort of combination of cardiac surgeons and cardiologists,” explained Dr. Bavaria. “I didn’t expect it to be such a team effort.” STS Director-at-Large Vinod H. Thourani, MD agreed: “When we started the original PARTNER trials—the goal being partnering cardiology and cardiac surgery together—I was concerned that we would lose some of the team momentum when TAVR was more widely adopted. This survey shows that we are doing really well; cardiologists and cardiac surgeons are working together at three out of four centers.” The survey also looked at surgeon involvement in 11 technical components of the operation, from access to valve placement, positioning, and closure (see graph). “It was interesting to me that at least 50% of respondents were involved in every one of those conduct of operation time points, except for operating the endovascular table,” said Dr. Bavaria. 2016-2017 STS President Joseph E. Bavaria, MD released the results of the STS TAVR Survey at the Annual Meeting in Houston. Expanding the Heart Team Approach Now that the paradigm has been set for the heart team approach in the treatment of aortic valve disease, Drs. Bavaria, MacGillivray, and Thourani are advocating for expanding the heart team concept to other areas of structural heart disease. “We have a proven proof of principle that the team concept works and works well,” said Dr. MacGillivray. “Cardiac surgery is the quintessential medical team sport. We have multidisciplinary teams that take care of patients for all kinds of cardiac problems. The natural place is for a patient to rely on a cardiac team that is set up to manage patients with all kinds of comorbidities and other problems.” In some centers, interventional cardiologists and cardiac surgeons routinely work with heart failure specialists. Dr. Thourani said that he’s involved in early feasibility trials where an imager also is part of the heart team. “We need to make sure that surgeons and cardiologists who aren’t as familiar with some treatment options have the support they need from other areas. We have an expanded team that is now looking into new mitral and tricuspid valve technologies.” To see the full survey results, access “Surgeon Involvement in Transcatheter Aortic Valve Replacement in the United States: A 2016 Society of Thoracic Surgeons Survey” in The Annals of Thoracic Surgery. A video roundtable featuring Drs. Bavaria, MacGillivray, and Thourani discussing the results is available. Dr. Bavaria’s Annual Meeting presentation is available via Annual Meeting Online in General Session II.

STS News, Summer 2017 -- By all accounts, the June 12-13 STS Legislative Fly-In was a big win for the Society. Eleven STS members representing all career stages, from medical student to seasoned surgeon, joined the Society’s new Public Director Chris Draft in meetings with lawmakers and legislative aides on Capitol Hill. They discussed a number of issues important to cardiothoracic surgeons, including physician reimbursement, ways to reduce the resident physician shortage, passage of legislation providing medical liability reform, funding for the Agency for Healthcare Research and Quality, and both lung cancer prevention and early detection. Lung cancer is a topic about which Draft is especially passionate. The former NFL player lost his young wife to lung cancer in 2011; she was a non-smoker. He also lost an uncle to lung cancer. His uncle was an Army veteran who had spent years smoking cigarettes. “In my meetings, I pushed for a bill that would prohibit smoking in VA facilities,” explained Draft. “When we talk about this bill, it’s not just about getting people to stop smoking. It’s about helping people. Veterans took care of us and, unfortunately, many are addicted to smoking. We’ve got to help them now. We can’t continue to enable them by allowing them to smoke on VA campuses.” Fly-In participants also spoke out against proposed payment cuts for low-dose computed tomography scans for patients at high risk for lung cancer. The messages were delivered to veterans such as Sen. Gary Peters, Rep. Ruben Gallego, and Rep. Jimmy Panetta, the ranking member on the VA Subcommittee on Health (Rep. Julia Brownley), and high-profile lawmakers such as House Minority Leader Nancy Pelosi, House Minority Whip Steny Hoyer, Sen. Ted Cruz, and Rep. John Lewis. Chris Draft with Rep. John Lewis “You have to be excited when you meet Congressman Lewis,” said Draft. “He’s an American hero, and he’s my congressman from Atlanta, so it was even more special.” Todd Rosengart, MD, from Baylor College of Medicine in Houston, described his Fly-In experience as amazing: "Government regulation, oversight, and payment strategies—as we all know—are an increasingly unavoidable and heavily influential part of our professional lives. Meeting with legislators and their aides provided us with a real chance to influence these processes and the fate of our professional experience. It was enlightening and positive. All of our membership CAN and SHOULD partake!” STS Legislator of the Year The night before the Capitol Hill meetings, Fly-In participants gathered for a preparatory dinner and to meet with Rep. Ami Bera, an internal medicine physician, who was presented with the STS Legislator of the Year award for exceptional support of cardiothoracic surgeons and their patients. “It’s an honor to be a doctor in Congress,” Rep. Bera said as he accepted the award. “Most of us went into the profession because we wanted to serve our communities and serve our patients. We live in a unique time; we all have an obligation to step up and serve and move our nation forward. Every physician and surgeon has a role, and, right now, the country needs our leadership." STS Legislator of the Year Ami Bera, MD (center) with Fly-In participants (from left) Drs. Eric Jeng, Jess Thompson, Todd Rosengart, Natalie Lui, Alan Speir, Malini Daniel, David Blitzer, Paula Guinnip, Fred Grover, Paul Linsky, Bryan Steinberg, and Raymond Strobel Draft agreed: “We’ve got some tremendously intelligent people with us today that are making a difference in this world. To share what they’re seeing on the ground is important. But at the end of the day, this is bigger than me; it’s bigger than STS. We have to work as a team, take advantage of our strengths, and play to those strengths to make a difference.” To see a video of the award presentation to Rep. Bera, visit the STS YouTube Channel at www.youtube.com/user/ThoracicSurgeons. To see more photos from the Fly-In, visit the Society's Flickr album.