News & Media

STS News, Summer 2016 -- Cardiothoracic surgeon Larry Bucshon, MD is both an STS member and a member of the United States House of Representatives. Rep. Bucshon (R-IN), who is running for reelection this year in Indiana’s 8th District, shares his thoughts on pressing issues facing the specialty, the value of connecting with legislators at all levels of government, and the change of pace between the operating room and Capitol Hill. What are the most important legislative issues in the health care arena right now? I think the most important thing is what CMS is doing as it relates to MACRA, the SGR replacement legislation. We need to make sure that as members of Congress, we have appropriate oversight. It does sound like for the most part, CMS has been listening to societies like STS during this process, but that’s what we’re working on.  The other thing, which is applicable to all of medicine, is the opioid situation. I have legislation, as do many others in the House and Senate, to address the opioid crisis that we have in our country. I also think that Meaningful Use [requirements related to the mandatory use of electronic health records] is an important issue, in terms of how it affects the ability of people out in the communities to practice medicine and how it’s going to be involved in assessing quality and helping to determine payment. What are some of your biggest achievements in health care? Obviously, one of the biggest achievements has been replacing the SGR with MACRA. It’s pretty hard to top that. It’s been a priority of mine since I’ve been in Congress, since the SGR was putting a lot of uncertainty into the health care system every year for seniors and providers. Also, Dr. Ami Bera from California and I worked in a bipartisan way to essentially stop CMS from eliminating global surgical payments. For cardiovascular and thoracic surgeons, this is a big deal. I feel really good about the fact that we were able to get leadership on both sides to recognize that this would be a failed policy. What can cardiothoracic surgeons do to help you resolve these issues? It’s very important to be engaged, not only at the federal level, but also at the state and local levels. As cardiothoracic surgeons, we carry a lot of credibility. When STS members talk to legislators, their voices are really heard. Here in Washington, I can tell you that it’s important for me—even though I understand cardiothoracic surgery—to continue hearing what’s actually happening in the field day to day and what challenges there are. I performed my last surgery almost 6 years ago, so things have already changed dramatically. There’s no replacement for personal contact and one-on-one conversations with your legislators. That doesn’t mean things are always going to go our way, but I can tell you that they won’t go favorably to our specialty if legislators don’t have input from people who are in the field practicing every day. That’s one of the reasons I ran for Congress in the first place. I felt like we, as physicians, needed to have more of a voice in government. Rep. Bucshon (center, holding plaque) received the Society’s Legislator of the Year Award in recognition of his extraordinary efforts promoting issues of importance to cardiothoracic surgeons. How has the Society in particular contributed to your achievements in Congress? I think STS has been an important player in moving SGR replacement forward and continues to be very important as CMS develops its rules related to MACRA. The Society also has been very involved in talking with CMS and giving advice to legislators like myself on reimbursement issues, as CMS has not necessarily been following the RUC recommendations for reimbursement decisions. I think STS and other specialty societies and primary care organizations have had a tremendous impact on the legislative direction of Congress. Without the input of these organizations, I don’t think the SGR would have been repealed and replaced with MACRA. Also, just helping members of Congress understand what our specialty does, how we help patients, and how important that is to the overall makeup of the health care system has also been very important. Is there anything else you want to say to STS members? I just want to reiterate the importance of being engaged politically at the local, state, and federal levels. The voices of surgeons in practice do matter, and people are listening. Even though the wheels of change seem to be moving slowly, without that engagement, our voices would just not be heard. Trying to advance the goals of our specialty and ensure our continued ability to treat patients would be hampered without that engagement. "The voices of surgeons in practice do matter, and people are listening." Rep. Larry Bucshon, MD Extended Version: Online-Only Questions How has your training and career as a cardiothoracic surgeon prepared you to serve in Congress? I think physicians are very well-prepared to be in government. Throughout our training, we learn to look at a problem, develop a solution, and then act. Legislating is very similar. First, you identify legislative issues, you work together as a team to find solutions, and then you act on those solutions to get to the end goal. Are there any differences between being a Congressman and being a cardiothoracic surgeon? I think the big difference, and something that I miss and that you can’t really get anywhere other than health care, is the personal interaction on a daily basis with patients and family members. You do that in politics, but it’s not as personal and as day-to-day. The other thing that can frustrate me is the pace. The pace of change, solving problems, and coming up with solutions is much more tedious and slow in government than it is in day-to-day cardiothoracic surgery practice. You have to be more patient and persistent as a legislator sometimes than you have to be as a cardiothoracic surgeon. Why is it important for STS members to contribute to the PAC? The STS-PAC is extremely important because STS needs the resources to interact with legislators in Washington. Without the financial resources given to the PAC from STS members, that interaction would not be possible.

STS News, Summer 2016 -- Data from the STS National Database are being utilized in a study to understand predictors of 30-day readmission and 30-day death after heart surgery in children and adults. The study, which began in 2014 and is expected to conclude in 2018, is funded by a $3.2 million grant from the National Heart, Lung, and Blood Institute. Jeffrey P. Jacobs, MD, Chair of the STS Workforce on National Databases, is the site principal investigator (PI) for the Society. The project PI is STS Associate Member Jeremiah R. Brown, PhD, Associate Professor of Health Policy and Clinical Practice at The Dartmouth Institute and Geisel School of Medicine at Dartmouth. More than 253,000 people undergo cardiac surgery each year, and approximately 20% of them are readmitted within 30 days for complications from surgery or comorbid conditions, Dr. Brown said. But little is known about the predictors of readmission. The researchers are working to develop a novel, multi-systemic predictive model that combines perioperative biomarkers of cardiac injury (ST2, B-type natriuretic peptide, cardiac troponin T), renal injury (cystatin C), and non-specific inflammation (galectin-3, cytokines). “Preliminary work by others in heart failure and by our investigators suggests that these novel biomarkers could help to identify patients at higher risk of readmission or mortality prior to discharge,” Dr. Brown said.  The congenital arm of the research will utilize the STS Congenital Heart Surgery Database for data on 30-day readmission. “This study is unique because it represents the first time that data about biomarkers are being linked to clinical data from the STS National Database,” said Dr. Jacobs, Chief of Cardiovascular Surgery at Johns Hopkins All Children’s Hospital and Professor of Surgery at Johns Hopkins University. “This may be the first example of a strategy that allows the clinical data in the STS National Database to facilitate precision medicine, where medical and surgical therapy is tailored to the unique genetic or biochemical profile of the individual patient. Indeed, this initiative represents an initial attempt to link clinical data from STS to data related to genomics, proteomics, lipidomics, and metabolomics, and therefore, this analysis explores an exciting new frontier with unlimited potential.” "This may be the first example of a strategy that allows the clinical data in the STS National Database to facilitate precision medicine." Jeffrey P. Jacobs, MD Early results were presented at the STS 52nd Annual Meeting this past January and are expected to be published in The Annals of Thoracic Surgery. Additional results will be submitted as abstracts for the STS 53rd Annual Meeting in January 2017 and as papers to The Annals. Ultimately, the researchers plan to create an online risk calculator that physicians can use to predict 30-day readmission or mortality in their cardiac surgery patients. “If we can improve our ability to identify high-risk patients for readmission or mortality before they leave the hospital, we may succeed in reducing 30-day readmission rates and 30-day mortality while improving transitions from the hospital,” Dr. Brown said. For more information about this study or the STS Research Center, contact Robert Habib, STS Research Center Director, at Robert Habib.

STS News, Summer 2016 -- STS members and subscribers to The Annals of Thoracic Surgery are loyal readers. A new survey found that 85% of respondents read The Annals at least once per month, and nearly all respondents (97%) said the journal keeps them up-to-date with the latest advances in the field. “There are many changes taking place for The Annals, and this survey was an important step in learning what the readership thinks is valuable,” said Editor G. Alexander Patterson, MD, FRCS(C). “I was impressed with the response rate, which indicates good engagement with the journal. These survey results will give us a baseline against which to evaluate our new initiatives.” Elsevier Inc., which has published The Annals since 1989, distributed a 36-question online survey to 6,750 members and subscribers last fall. The overall response rate was 17% (1,158), with 40% of respondents residing outside of the United States. “The results tell us that The Annals is successfully serving its readers and the medical communities. We assumed this to be true, but now we have the data to prove it,” said Andrew Berin, Publishing Director at Elsevier. “For example, fully 90% of those surveyed find the ‘How To Do It’ feature very useful or useful. This percentage rises to 96% when asked about original research published in The Annals. That’s powerful.” "The results tell us that The Annals is successfully serving its readers and the medical communities." Andrew Berin Digital Resources Expanding While the majority of subscribers (53%) primarily read the journal in print form, use of digital media is popular. Close to half (46%) of readers reported visiting the journal’s website (www.annalsthoracicsurgery.org) at least monthly, while more than one-third (35%) have accessed The Annals through its mobile app. Available on both iOS and Android platforms, the app allows users to create reading lists, add notes, and save articles for offline viewing. The app also includes interactive figures, tables, multimedia presentations, and supplementary content. The Annals recently added enhanced multimedia content, including video interviews with authors and editorial board members. That content will expand as more authors include supplemental content, specifically videos, with their submissions. The journal also started tracking how online communities engage with the content. “All of the discussions people are having about certain articles—whether in the popular press, blogs, or social media—are now tracked and measured on Annals article homepages. This is but one additional means of measuring the impact of research,” Berin said. New Submission Site Available In April, the journal launched a new manuscript submission site: www.editorialmanager.com/annals. Early feedback has been very positive. “Authors will experience a more intuitive submission process, and editors and reviewers will have a streamlined yet powerful system for peer review,” said Kavitha Reinhold, Managing Editor of The Annals. Users of the previous manuscript system do not need to create another account; login information was carried over to the new manuscript tracking system. For more information on submitting a manuscript to The Annals, visit www.annalsthoracicsurgery.org/content/authorinfo.

STS News, Summer 2016 -- Accurate coding of cardiothoracic surgery procedures is essential for receiving optimal reimbursement. Surgeons and coders must work together to correctly describe the work being performed. The following represent some of the common topics handled by the STS Coding Help Desk, a free resource offered to STS members and their staffs. To submit your questions or comments about Current Procedural Terminology*, billing, and/or reimbursement, go to www.sts.org/codinghelpdesk. Adult Cardiac Conduit Creation to Facilitate Cardiopulmonary Bypass The work of placing a patient on cardiopulmonary bypass to accomplish a cardiac procedure is included in the work of the primary procedure, unless otherwise indicated in the code (for example: 33300 – Repair of cardiac wound; without bypass). However, there are situations in which central cardiopulmonary bypass is contraindicated (such as ascending aortic atherosclerotic disease) and the ascending aorta cannot be cannulated, so peripheral cardiopulmonary bypass is required. For peripheral cardiopulmonary bypass in which the cannula(s) is placed directly into the artery (femoral, iliac, axillary, other), the placement of the cannula(s), initiation of bypass, cannula removal, and suture repair of the vessel(s) are included in the primary procedure. No additional codes may be reported. However, when direct cannulation of the peripheral artery is felt to be ill-advised, a graft conduit, anastomosed directly to the peripheral artery for purposes of accomplishing cardiopulmonary bypass, may be required. The work of creating the graft conduit for initiation of cardiopulmonary bypass, as well as the cutting or oversewing of the graft stump with sutures when cardiopulmonary bypass is no longer needed, may be reported separately. Example: The axillary artery is surgically exposed. After heparinization, a graft is sewn to the axillary artery. The graft is connected to an arterial cannula, a venous cannula is placed (centrally and/or peripherally), and cardiopulmonary bypass is established. The cardiac procedure is performed. After the cardiac procedure is accomplished, the patient is weaned from cardiopulmonary bypass. The axillary artery graft is clamped and cut as short as possible. The graft stump is closed with sutures. Currently, with the exception of the TAVR and ECMO codes, there is no code to report the creation of a graft conduit to facilitate arterial access. In order to report this service, the unlisted code 33999 – Unlisted procedure, cardiac surgery should be used. Creation of the graft conduit is included in the work of the TAVR procedures (33361–33369). To report this service in conjunction with ECMO, use add-on code 33987 - Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to code for primary procedure) (Use 33987 in conjunction with 33953, 33954, 33955, 33956). General Thoracic Coverage of the Bronchial Stump Coverage of the bronchial stump typically is included in lung resection procedures when intrathoracic local tissue or structures are utilized. Examples of intrathoracic local tissues include pericardial fat pad, pericardium, pleura, and thymus. Using these local structures is considered part of the procedure and would not be separately reportable work. This is in contrast to the use of extrathoracic soft tissue—for example, muscle flaps. Coverage of the bronchial stump with intercostal, latissimus dorsi, serratus anterior, pectoralis, or other muscle flaps is reportable separately with code 15734 – Muscle, myocutaneous, or fasciocutaneous flap; trunk. Bronchoplasty Add-on code 32501 - Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately in addition to code for primary procedure) only may be reported in conjunction with codes 32480 - Removal of lung, other than pneumonectomy; single lobe (lobectomy), 32482 - Removal of lung, other than pneumonectomy; 2 lobes (bilobectomy), or 32484 - Removal of lung, other than pneumonectomy; single segment (segmentectomy). 32501 would be reported when a portion of the bronchus is removed or resected in a situation other than sleeve lobectomy (32486) or sleeve pneumonectomy (32442). Closure of the remaining bronchus most often involves complex suturing. An example would be reconstruction of the bronchus with a V-plasty technique by approximating the edges of the wedge. Code 32501 should not be used simply for suture closure of the proximal end of a resected bronchus. Congenital Cardiac ASDs and VSDs Several codes may be used to report atrial septal defect (ASD) repairs, ventricular septal defect (VSD) repairs, and combined ASD and VSD repairs. The code that most accurately describes the procedure performed should be reported. For example, if an ASD (or patent foramen ovale [PFO]) and VSD repair are performed in the same session, the combined code 33647 must be reported; you cannot separately report an ASD (33641) and VSD (33681) repair code. There is no code for repair of multiple ASDs, as there is for closure of multiple VSDs (33675, 33676, and 33677). In circumstances where multiple ASDs are repaired in the same session, code 33641 (or the appropriate ASD repair code) only may be reported once. There is a medically unlikely edit (MUE) of “1” for Medicaid and Medicare for the ASD and VSD codes. An MUE typically represents the maximum number of units reportable on the same date of service. If different types of ASDs are repaired, such as a secundum or PFO (33641) and an ostium primum ASD (33660), both codes may be reported. Check the bundling edits for the codes; some coding combinations are bundled and will require an appropriate unbundling modifier (e.g., 59) in addition to the multiple procedure modifier (51). It does not matter if the ASD or VSD is closed primarily (suture closure) or with a patch; the same code is used in either case. For the multiple VSD codes (33675, 33676, 33677), the code can be used only once per session—i.e., 33675 is used once for closing two, three, or more VSDs. Also, one cannot use the single VSD closure codes (33681, 33684, 33688) at the same time as the multiple VSD closure codes. The following codes may be reported for ASD, VSD, or combined ASD and VSD repairs. The tips under each code outline additional terms associated with the code, as well as highlight some of the work components that may or may not be specifically included in the code.  Atrial Septal Defect Repairs 33641 - Repair atrial septal defect, with cardiopulmonary bypass, with or without patch Secundum ASD Patent foramen ovale (PFO) closure Partial closure PFO (neonatal TOF repair) Includes suture closure 33645 - Direct or patch closure, sinus venosus ASD, with or without anomalous pulmonary venous drainage Includes Warden procedure Can't use with 33724 - partial anomalous pulmonary venous connection (scimitar syndrome) Can't use with 33726 - pulmonary venous stenosis 33660 - Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with or without atrioventricular valve repair Ostium Primum ASD Atrioventricular (AV) septal defect or endocardial cushion defect Report 33641 with 51 modifier and appropriate unbundling modifier for additional secundum ASD or PFO repairs Repair of common atrium or partition of common atrium—use 33641 or 33660 Can’t use with mitral valve repair or annuloplasty codes 33665 - Repair of intermediate or transitional atrioventricular canal, with or without atrioventricular valve repair Has restrictive VSD component Ventricular Septal Defect Repairs 33681 - Closure of ventricular septal defect, with or without patch; (includes suture closure) 33684 -           with pulmonary valvotomy or infundibular resection (acyanotic)—double chambered right ventricle 33688 -           with removal of pulmonary artery band, with or without gusset 33675 - Closure of multiple ventricular septal defects; 33676 -           with pulmonary valvotomy or infundibular resection (acyanotic) 33677 -           with removal of pulmonary artery band, with or without gusset Combined ASD and VSD Repair 33647 - Repair of atrial septal defect and ventricular septal defect, with direct or patch closure Can’t use 63 modifier (Procedure Performed on Infants less than 4 kg) *Current Procedural Terminology (CPT®) copyright 2015 American Medical Association. All Rights Reserved. The material presented here is, to the best of our knowledge, accurate and factual to date. The information and suggestions are provided as guidelines for coding and reimbursement, however, and should not be construed as organizational policy. The Society of Thoracic Surgeons disclaims any responsibility for the consequences of actions taken based on the information presented in this article.

Robert A. Wynbrandt Robert A. Wynbrandt, Executive Director & General Counsel Keith J. Bura, Director of Finance & Administration STS News, Summer 2016 -- With this edition of STS News, we return to an old favorite: the guest column by a member of our management team who shares insights with the membership about his or her area of expertise and operational activity. In the installment below, Keith Bura, our Director of Finance and Administration, discusses our annual budgeting process that consumes members of our staff for much of the summer. Keith joined the STS management team in February of 2015, after having served in senior finance capacities at the American College of Surgeons, the Academy of General Dentistry, and the Association Forum of Chicagoland. Summer is here in full force, and so is budget season at STS. Although budgeting probably is not a favorite task for most, it is critically important to the Society’s operational and financial success. One key ingredient to this success is participation by both staff and surgeon leaders. The first step in the budget process is for staff to build a bottom up (zero-based) budget that reflects the organization’s operational and strategic initiatives. One major operational initiative that will be reflected in the 2017 budget relates to an anticipated lease renewal or relocation of STS Headquarters in Chicago. The current lease with the American College of Surgeons expires on April 30, 2018. To help with this initiative, the Society has retained CBRE Group, Inc., the largest commercial real estate service firm in the world. In addition, an architect will be selected to assist and advise the Society on space planning options. As detailed in the Spring 2016 issue of STS News, the Society has a new strategic plan that includes three broad-based strategic initiatives: database optimization, education, and global activities. Earlier this year, senior staff outlined milestones for each initiative to be completed over the next 2 to 3 years and provided estimated costs; these milestones were presented to the Board by Associate Executive Director Bill Seward in May. Milestones that have major budget implications for 2017 include: Database enhancements that will allow for continuous data harvests, web-based reporting dashboards, and expanded integration; A comprehensive e-textbook for adult cardiac and congenital heart surgery; and Collaborative educational programs in Asia, Central America, and/or South America. In addition to the operational and strategic initiatives outlined above, the budget needs to reflect the ongoing activities of the Society. With a zero-based budgeting approach, every detail and every dollar has to be provided and justified. Once individual department budgets are drafted, senior management performs a comprehensive review to validate assumptions, confirm to the extent possible that all figures are realistic, and analyze the bottom line results. Based on this review, the proposed budget is further adjusted so that operating income is breakeven or better. During this whole process, staff members communicate with their respective council, workforce, and task force chairs regarding projects and budget assumptions. Surgeon leaders also are consulted after changes from senior management are incorporated. The next step in the process is a Finance Committee meeting that involves the review and discussion of detailed narratives highlighting major budget assumptions, explanations about all major favorable and unfavorable revenue and expense variances from the prior year’s projection, and comprehensive financial statements that include historical comparisons. Based on this meeting, the Committee adjusts the proposed budget as appropriate and makes a recommendation to the Board of Directors. These funds are for initiatives aimed at giving back to the specialty, such as contributions to The Thoracic Surgery Foundation. Included in the proposed budget are funds for the Spending Policy. These funds are for initiatives aimed at giving back to the specialty, such as contributions to The Thoracic Surgery Foundation. The Spending Policy calls for an annual allocation of approximately 2% of the Society’s investment portfolio, as measured at the close of business on June 30 of year preceding the budget year. Since the adoption of this policy in 2013, more than $1.2 million has been spent by STS to support various CT surgery initiatives, with another $748,000 allocated for 2016, a significant portion of which already has been spent or committed by the Board. The final step in the process is for the Board to review detailed financial documents and approve the budget at its fall meeting. At the meeting, the Finance Committee Chair—currently STS Past President Doug Wood—provides an overview of the budget and answers questions before Board members vote.  Although these activities may be invisible to most STS members, the process is rigorous and lasts nearly as long as the Major League Baseball season. (I was told that it’s mandatory to make at least one sports reference in this article.) Unfortunately for me, as a native Chicago South Sider and diehard White Sox fan, what started out as an extremely promising spring quickly turned into a disappointing summer. And, to make matters even worse for me and fellow White Sox fans who often have deeply contemptuous feelings about Chicago’s other baseball team, it looks like the Cubs remain the frontrunners to win the World Series. At least I have the budget process to keep me occupied.

Joseph E. Bavaria, MD, President STS News, Summer 2016 -- As surgeons, we are on an eternal quest to achieve the best outcomes for our patients. The questions we ask ourselves include: Should we perform an invasive procedure or can we use a minimally invasive approach? Which valve do we use? Which access point is the best? The answers often lie in results from research based on quality data. Prescient leaders of the Society, including Richard Clark, Bob Replogle, Dick Anderson, and Fred Grover, among others, launched the STS National Database in 1989 so that we could use high-quality, risk-adjusted clinical data for practice improvement. The STS National Database now houses more than 6 million procedure records and has become the envy of many other specialty societies. Data from the Database form the foundation for groundbreaking clinical research, participation in the Database is at the heart of new physician payment models being developed in Washington, and processes for the Database are setting important and unifying standards worldwide. Similarly, the Transcatheter Valve Therapy Registry that STS and the American College of Cardiology launched in 2011 offers rich opportunities for innovation in cardiothoracic surgery. You can read about some of the latest clinical trial results for TAVR. These findings and the resulting positive changes for our patients would not have been possible without someone trying to scratch an itch by asking the right questions and conducting research. Finding the answers starts with good data. When I’m socializing with colleagues, the conversation often turns to job frustrations and then leads into how STS can help.  One way is through the STS National Database. By submitting data to the Database, publicly reporting outcomes, and conducting research, you can help improve your practice and the specialty itself. In this era of increasing demand for transparency, accountability, and access to quality data, STS leadership is placing an even higher priority on the Database. In the coming months, the user interface will be modernized so that participants can enter data continuously and receive next-day feedback of basic information. Customizable participant reports will help make it easier to detect important performance signals early. We’re also working on making data elements conform to electronic standards, which will facilitate linkages with other data sources and allow some information, such as demographics, dates, and times, to be extracted automatically from EHRs. Additionally, we have increased funding for Access & Publications (A&P) projects to help more investigators access data for research. Submitting Data Requests Some of our members have said that submitting requests to use STS data can be daunting. But it doesn’t have to be.  Make sure the research proposal you submit is realistic, has an original hypothesis, and asks for data that the STS National Database collects; submission instructions and data endpoints are listed on the website. STS accepts several types of data requests. Forms are available on the STS website, and Research Center Coordinator Kristin Mathis is available to answer any process questions you may have. Research proposals made through the A&P process are reviewed twice per year in each discipline. For the upcoming review cycle, adult cardiac proposals are due on August 1, general thoracic proposals are due on September 1, and congenital heart proposals are due on October 1. Once you have your research results, it is important to share that new knowledge. Two projects currently in the manuscript development process involve one from Penn on longitudinal outcomes following surgical repair of post-infarction ventricular septal defect and one from The University of Chicago on the relationship between body mass index extremes and morbidity after lung resection. Research projects also may be submitted through the Longitudinal Follow-up and Linked Registries process. Read about one of these types of projects on biomarkers to predict readmission. The TVT Registry currently has more than 63,000 patient records submitted from more than 400 sites in the United States. I encourage you to consider helping us build the body of knowledge about transcatheter procedures by using data from the TVT Registry for research. Expanding our understanding of transcatheter therapy, coupled with our surgical valve experience and knowledge, will enable surgeons to assist patients in making informed decisions concerning valve therapy. The process for requesting data from the TVT Registry can be found at tvtregistry.org. Presenting New Knowledge Once you have your research results, it is important to share that new knowledge with your colleagues. My bias is for presenting that information at the STS Annual Meeting and in The Annals of Thoracic Surgery. Although the deadline has passed to submit an abstract for presentation consideration at the upcoming STS Annual Meetingin Houston, we plan to open a late-breaking abstract submission site this fall. I’m looking forward to reading your abstracts and learning more about the questions you have about cardiothoracic surgery, so that by using quality data, we can work together to make positive incremental changes for our patients and the specialty.

STS News, Summer 2016 -- Institutions participating in STS Public Reporting Online for adult cardiac surgery soon will receive extra credit in U.S. News & World Report’s rankings of best hospitals. The publication recently updated the methodology for its Best Hospitals in Cardiology & Heart Surgery rankings to include a maximum of three points for hospitals that publicly report via both STS.org and the American College of Cardiology’s National Cardiovascular Data Registry. Hospitals that report via just one outlet will receive two points, and hospitals that do not participate in either will receive no credit. “Our goal in reporting on provider performance is to assist patients in making informed health care decisions,” said Ben Harder, Chief of Health Analysis at U.S. News. “STS’s analyses yield important, high-quality data that can benefit the patients who use our decision support tools. But that information is only available to patients and the public if STS participants choose to voluntarily report it.” "Our goal in reporting on provider performance is to assist patients in making informed health care decisions." Ben Harder Previously, U.S. News awarded hospitals credit in the publication’s Heart Bypass Surgery ratings for publicly reporting their isolated coronary artery bypass grafting outcomes via STS.org. The amount of credit  given was based on both the fact that a hospital publicly reported and how well the institution performed. U.S. News will continue to allocate credit in this way for the Heart Bypass Surgery ratings. The new credit for the Cardiology & Heart Surgery rankings is based just on the fact that the institution reports, not what its score is. “That’s because STS.org reports ratings for hospitals in three different procedures, none of which is an exact match with the inclusion criteria we use for our Cardiology & Heart Surgery analysis,” Harder said. “We want more clinician input before we decide on whether and how to assign relative weights in our Cardiology & Heart Surgery rankings to each of STS’s publicly reported measures.” U.S. News reviewed the STS website in late February to gather information for its analysis. The updated Cardiology & Heart Surgery rankings are expected to be published in early August.  Institutions that do not currently participate in STS Public Reporting Online can ensure that they receive credit in the 2017 U.S. News rankings by signing up before mid-October.

STS News, Summer 2016 -- The world of transcatheter aortic valve replacement (TAVR) is changing rapidly, and cardiothoracic surgeons have the opportunity to “help drive the train”—or get left behind. TAVR was approved in 2011 for use in patients who are at high risk for conventional surgical aortic valve replacement (SAVR). Recently, trials in intermediate-risk patients have shown that TAVR is equivalent and possibly superior to SAVR. These findings have now opened the door to trials in low-risk patients, who make up about 80% of patients with aortic stenosis, according to an analysis of data in the STS Adult Cardiac Surgery Database and the STS/ACC TVT RegistryTM. “The results from these low-risk trials likely will change surgical practice forevermore,” said STS Past President Michael J. Mack, MD. “Over the next 10 years, I think we’re going to see an 80% shift from open procedures to transcatheter procedures. Surgeons need to be totally engaged and proficient at performing TAVR.” Results from Intermediate-Risk Trials Data from two trials in intermediate-risk patients were presented at the American College of Cardiology Annual Scientific Sessions in Chicago this past April. PARTNER IIA, a randomized trial comparing TAVR with the SAPIEN XT to SAVR, found equivalent outcomes of death and stroke between the two procedures at 2 years. However, when transfemoral TAVR—which was performed in almost 90% of patients—was considered separately, these outcomes were better for TAVR patients than SAVR patients. The PARTNER II SAPIEN 3 (S3i) trial compared SAVR data from PARTNER IIA to outcomes from TAVR procedures using a third-generation SAPIEN 3 valve. At 1 year, the researchers found that TAVR was superior to SAVR for mortality and stroke, as well as the combined endpoint of mortality, stroke, and aortic regurgitation greater than moderate. “In this group of 3,000 intermediate-risk patients, we’re seeing superiority of transfemoral valve replacement to surgical valve therapies,” said STS Director-at-Large Vinod H. Thourani, MD, who was the co-principal investigator (PI) for the S3i trial and chairs the TVT Registry Research and Publications Subcommittee. Vinod H. Thourani, MD presented results from intermediate-risk TAVR trials at ACC 2016. Importantly, the S3i data showed the lowest 1-year mortality rate (7.5%) and 1-year moderate or severe paravalvular leak rate (1.5%) for TAVR published thus far. “The improved results may be due to aspects of the SAPIEN 3 third-generation valve. This includes the left ventricular cuff to minimize paravalvular leaks, consistent use of CT scans to assess the valve preoperatively, availability of four valve sizes, and smaller sheath sizes to allow an almost 90% transfemoral access. I believe those are the biggest factors in why we’re seeing such low mortality and paravalvular leak rates,” Dr. Thourani said. Next year, data are expected to be reported from the SURTAVI trial, which is evaluating all-cause mortality and major stroke at 2 years between SAVR and intermediate-risk TAVR using the CoreValve system, said co-PI Michael J. Reardon, MD. Huge Potential in Low-Risk Patients Now that TAVR has shown positive results in intermediate-risk patients, the next frontier is low-risk patients. Two randomized trials currently are enrolling patients. One trial (PARTNER III) will evaluate all-cause mortality, stroke, and rehospitalization at 1 year between TAVR using the SAPIEN 3 valve and SAVR in low-risk patients; the second will utilize the CoreValve Evolut R and examine all-cause mortality and disabling stroke at 2 years. Both trials will include a patient substudy using 4D CT scans looking at leaflet motion abnormalities indicative of valve thrombosis in both TAVR and SAVR. As the landscape shifts, Dr. Reardon emphasized the importance of cardiothoracic surgeons embracing new technology. “Surgeons can ignore what’s going on and be run over by the train, or they can get on board and help drive the train,” he said. "The results from these low-risk trials likely will change surgical practice forevermore." Michael J. Mack, MD New Risk Model Available As surgeons await the results of the low-risk trials, there is now a tool they can use to help identify which of their high-risk patients may be good candidates for TAVR. The TVT Registry recently released a patient-level risk model predicting the probability of in-hospital mortality after TAVR, which is available as an app in the Apple App Store and Google Play. Search for “TAVR Risk Calculator.” “The model provides an objective assessment of risk based on the large national experience embodied in the TVT Registry,” said Fred H. Edwards, MD, a former member of the TVT Registry Steering Committee and former Director of the STS Research Center. “Most existing TAVR models are based on patients having undergone procedures other than TAVR. We recognized the compelling need for a large-scale US TAVR population that could be used to develop a reliable TAVR risk model.” The model was developed from more than 13,000 patients who underwent TAVR from November 2011 to February 2014. “Results from the model will provide valuable objective information that can inform the decision-making process, but should not dictate management decisions,” said Dr. Edwards. Last year, the TVT Registry released a center-level, in-hospital mortality risk model as a benchmarking and quality assessment tool for TAVR patient populations. Additional risk models currently are being developed to predict the probability of stroke and mortality at 30 days. In the future, the plan is to develop models that will predict patient benefit as well as patient risk.

STS News, Fall 2016 -- A 2015 article in The Annals of Thoracic Surgery by Alan M. Speir, MD cautioned that the devil of post-SGR Medicare physician payment would be in the details. Those details are now being unveiled, and STS members need to be aware of them. The following information outlines the various payment policies stemming from the Medicare Access and CHIP Reauthorization Act (MACRA) and explains how the Society is working to ensure that cardiothoracic surgeons have the opportunity for success. Merit-Based Incentive Payment System (MIPS) The MIPS program will replace the current Medicare fee-for-service infrastructure and consolidate many existing Medicare reporting requirements. Under MIPS, physicians will receive composite scores based on four performance categories. Thresholds will be established annually, with physicians whose scores are in the top tier receiving bonus payments and those in the lowest receiving pay cuts. The four MIPS performance categories are: Quality: Physicians will be required to provide the Centers for Medicare & Medicaid Services (CMS) with certain quality metrics. Participants in the STS National Database will be able to report through the Database. Resource Use: CMS has released patient attribution criteria and other ways it plans to quantify resource use by Medicare providers. STS is working to ensure that cardiothoracic surgeons are not unfairly assigned costs. However, as currently proposed, CMS will calculate the resource use performance score based on claims data, and there will be no data submission requirements under this category. Clinical Practice Improvement Activities: Physicians will be rewarded for implementing policies and procedures that have been demonstrated to have a positive impact on patient care. Participating in the STS National Database likely will contribute to the score available under this category. Advancing Care Information: This category incentivizes providers to utilize electronic health records. Under CMS’s proposed implementation, physicians were to be evaluated starting in January 2017, with the first payments under this model coming in 2019. However, after being pressured by STS and others in the medical community, CMS recently announced plans for a modified rollout of the data reporting requirements. Under the revised schedule, physicians can avoid penalties by submitting minimal amounts of data to CMS in 2017. Those who choose to report more extensive data for some or all of the year will be eligible for bonus payments. While further details will not be available until CMS issues its Final Rule (anticipated in November 2016), 2017 STS National Database participation may help physicians avoid negative payment adjustments in 2019. Alternative Payment Models (APMs) MACRA also incentivizes the development of APMs that demonstrate new and innovative ways to provide, coordinate, and pay for quality health care. Providers participating in certain APMs can receive bonus payments of up to 5%. MACRA sets a pathway for providers and physician organizations to submit their ideas, and STS is developing an APM that uses the STS National Database to demonstrate how quality improvements and cost reductions are related. STS also is partnering with the American College of Surgeons and other surgical specialty organizations to make an APM available for surgeons in the near future. Bundled Payments for CABG In addition to the previously mentioned changes, CMS has published a proposed rule aimed at establishing a mandatory bundled payment for coronary artery bypass grafting (CABG) procedures. It is proposed that this mandatory bundle be piloted in certain regions of the country beginning in July 2017 and that surgeons who participate be eligible to receive the APM bonus payment. Global Surgical Payments Despite the current policy focus on bundled payment as a mechanism to incentivize improvements in patient care, CMS continues to undermine global surgical payments. STS led an aggressive campaign in 2015 to preserve global surgical payments. Because of the Society’s leadership, Congress passed legislation requiring CMS to collect data on global services from a “representative sample” of physicians before any changes could take effect. However, CMS has disregarded congressional direction and recently proposed to collect data from allphysicians who perform these services. The proposal would require all surgeons to submit data in 10-minute increments for all 10- and 90-day global surgery code services through the use of eight nonpayable G-codes. This would create an undue administrative burden on physician practices, and STS is working with a coalition of surgical subspecialties to prevent this policy from taking effect. Learn More at the Health Policy Forum The above programs will be discussed at the Early Riser Health Policy Forum at the STS 53rd Annual Meeting in Houston, Texas, on Tuesday, January 24, 2017. Visit www.sts.org/annualmeeting for registration information.

Robert Lancey, MD, MBA, Medical Director, Heart and Vascular Institute Bon Secours Hampton Roads | Portsmouth, VA STS News, Fall 2016 -- The health care industry has undergone historic changes at a precipitous pace over the past two decades. The changes—which include a complete redesign of how we are reimbursed (volume vs. value), how we are employed (private practice vs. hospital-employed), and to whom we are beholden (patients vs. regulators)—have impacted physicians at all levels. This shifting environment has been accompanied by the erosion of many key drivers of physician satisfaction, including the maintenance of clinical autonomy, the sense of personal and professional accomplishment, and feeling aligned with one’s institution in delivering patient-focused care. The steady decline in professional satisfaction has been accompanied by an increase in occupational burnout. Physicians experience the highest rate of burnout in the US workforce, with the frequency of those reporting at least one symptom rising from 45% in 2011 to 54% in 2014, according to a 2015 article in Mayo Clinic Proceedings by Tait D. Shanafelt, MD and colleagues. This syndrome, characterized by emotional exhaustion, depersonalization, cynicism, and a low sense of personal accomplishment, likewise has been exhibited in up to one-half of medical students and is associated in this population with a higher likelihood of engaging in unprofessional behaviors. Its prevalence in the physician workforce should come as no surprise when considering the six facets of work life in which a decoupling between the organization and the individual contribute to burnout: workload, control, reward, fairness, values, and the sense of community or collegiality. As cardiothoracic surgeons, we are challenged to varying degrees in each of these areas, whether it be too much (or for some, too little) work, declining reimbursement, lack of alignment with organizational values, and loss of autonomy and control over clinical workflow. Recognizing the Signs There are well-described warning signs of burnout to watch for in ourselves and our colleagues: deteriorating interpersonal work relationships, difficulties at home or in personal life, absenteeism, or falling behind with record keeping. There may be signs of chronic fatigue, exhaustion of emotional energy, the onset of patient biases, and losing a sense of purpose in one’s professional life. Physician leaders play critical roles in reducing the frequency of burnout. Shanafelt also demonstrated a strong inverse correlation between physician burnout rates and the strength of leadership exhibited by direct physician supervisors. The most effective physician leaders help their colleagues connect with what is most meaningful in their work and provide the opportunity to reflect on gratifying professional experiences, rather than focusing on the “last worst case.” They share ways that they worked through personally difficult clinical situations and emphasize the value of introspection and resiliency—the latter being the ability to respond to stress in a healthy way with minimal psychological and personal costs, while attaining personal and professional goals. Physician leaders play critical roles in reducing the frequency of burnout. How to Reduce Your Risk Faced with the growing problem of physician burnout, it is time not only to acknowledge the problem, but also to devise strategies that remove the stigma, provide means of early identification for those at risk, and deal effectively with colleagues already exhibiting signs of burnout that are impacting them, their families, and their patients. It is important to disseminate information and engage in conversations within our societies and professional working environments about ways to minimize the factors that contribute to burnout. These may take the form of self-regulation (getting regular sleep, keeping nutritionally and physically fit, and setting aside protected time for family or for purely personal, enjoyable activities and hobbies) or developing self-awareness through guided meditation. This latter strategy, which may focus on mindful stress-reduction techniques, is the cornerstone of programs that are available for physicians, such as the Cleveland Clinic’s Stress Free Now program. Developing wellness programs for employees is recognized by most health care organizations as not only providing intrinsic value for the employees themselves, but also carrying high value for the organization by improving productivity and reducing absences and attrition, while also increasing the quality of care and patient satisfaction and compliance. As physicians, we need to support similar efforts for our colleagues. Patient Safety Symposium to Tackle Burnout Issues For more on this important topic, attend the Patient Safety Symposium at the STS 53rd Annual Meeting in January. The 2017 Symposium is titled “Resilience or Burnout: Do We Have a Choice?” and speakers will discuss how physicians can develop resilience, what institutions can do about physician burnout, and the use of mindfulness to reduce work-related stress. The Symposium will be held on Tuesday, January 24, from 1:00 p.m. to 5:30 p.m., and is included with Annual Meeting registration. Register for the meeting today at www.sts.org/annualmeeting.  

STS News, Fall 2016 -- Members now have more opportunities to fulfill their continuing medical education and maintenance of certification requirements through the Society, which has significantly increased its online educational resources as a result of its merger with the Joint Council on Thoracic Surgery Education (JCTSE). “This merger will help enhance the education of not just our trainees, but also practicing cardiothoracic surgeons seeking to expand their knowledge base,” said Ara A. Vaporciyan, MD, Chair of the STS Workforce on Thoracic Surgery Resident Issues. Many former Joint Council activities will fall under the new STS Workforce on E-Learning and Educational Innovation, chaired by STS Past President Mark S. Allen, MD.  “Now that many of the JCTSE functions are within the STS structure, members will soon have new and innovative ways to learn within the CT surgery arena,” said Dr. Allen, who was the most recent Chair of the JCTSE Board of Directors. "Now that many of the JCTSE functions are within the STS structure, members will soon have new and innovative ways to learn within the CT surgery arena." Mark S. Allen, MD Online Offerings One of the most significant assets that STS acquired as a result of its merger with JCTSE is the Thoracic Surgery Curriculum hosted on a robust Learning Management System (LMS). The Curriculum currently is accessible only by cardiothoracic surgery residency program directors, coordinators, faculty, and residents, but access will be expanded to all STS members in the future. The LMS houses a wealth of educational materials, including the entire Thoracic Surgical Curriculum and a variety of textbooks, videos, and case presentations. Program directors and coordinators easily can set up a 1-, 2-, or 3-year curriculum, as well as create customized assignments and offer National Benchmarked Quizzes for resident comparison across programs. Access the Thoracic Surgical Curriculum, textbook chapters, case presentations, and more in the Library section of the new LMS. “The core benefit of the LMS is the multitenant design of the system. Each program has access to all of the content, but the content can be organized and presented in a way that meets the specific needs of an individual program,” Dr. Vaporciyan said. In the future, all of the Society’s online educational programs, including the STS Annual Meeting Online and webinars, will be housed in the LMS. “The Society now has an innovative education resource that will serve resident education, STS member education, and individual continuing medical education for years to come,” said Edward D. Verrier, MD, who served as JCTSE Surgical Director of Education and continues to fulfill this function for the Society. In-Person Learning One of the most popular in-person educational courses developed by JCTSE was the Jeopardy competition for residents. STS will continue organizing the event, with a North American championship competition at the Southern Thoracic Surgical Association Annual Meeting in November and a grand championship competition between the North American and European winners at the STS Annual Meeting in January. For more information about the LMS, contact Amanda Wright. New Features Added to the STS Learning Center The STS Learning Center recently added two new features that allow for better tracking and completeness of your CME transcript. The first new feature allows you to add any and all CME credits that you have earned—including non-STS approved activities—to your personal transcript. Click “External Certificates” and upload or drag and drop certificates as PDFs or Word documents. The second new feature allows you to view and print your personal transcript by clicking "View Your Transcript.” You can pull from a specific year or time range or from specific certificates that align with certain credits. To check out these new features, visit learningcenter.sts.org, log in with your STS member username and password, and click “My Account” in the upper right corner. If you have any questions, contact Education.  

Robert A. Wynbrandt Robert A. Wynbrandt, Executive Director & General Counsel Robert H. Habib, Director of the STS Research Center STS News, Fall 2016 -- As we prepare to launch an exciting new initiative that will enhance the value of the STS National Database for our members and their patients, the following is the latest installment in our series of guest columns by other members of the STS management team – this one from Robert Habib, who joined us earlier this year as the new Director of the STS Research Center. Robert comes to us from the American University of Beirut, where he was a Professor in the Department of Internal Medicine, the Director of the Clinical Research Institute’s Outcomes Research Unit, Co-Director of the Vascular Medicine Program, and Director of the Scholars in Health Research Program. Robert earned a PhD in interdisciplinary studies (engineering and physiology) and a master of science degree in biomedical engineering from Boston University; as reflected below, he is making no small plans to take the STS Research Center into new and promising directions. For nearly three decades, STS and its members have led the way with an unparalleled commitment to collect comprehensive patient data in the STS National Database and analyze these data as a means of measuring quality and providing better care to patients. The Society is again poised to lead its peers in a different, albeit related way. STS surgeon leaders and senior staff are developing a high-quality clinical research infrastructure that would increase the options and opportunities for STS members to conduct research based on the Database. It certainly makes sense. Much like a great quarterback needs receivers capable of catching passes, a standout clinical database such as the STS National Database needs a commensurate standout research program that appropriately leverages its rich and comprehensive data.   STS is fully committed to building a bigger and better research enterprise for the specialty. Surgeon leaders are aiming to profoundly transform STS research with a year 2020 vision featuring a forward-looking research agenda. The Society is developing a new business plan for the STS Research Center that will provide a road map for future investment and new research opportunities. We anticipate that many of these new research initiatives could be game-changers that increase productivity and expand research capacity to previously unavailable areas. A Different Kind of PUF! By the time STS members read this article, the STS Participant User File (PUF) Research Program likely will have been announced. The PUF Program will allow—for the first time—analysis of national-scale de-identified data from the Database at investigators’ institutions. This STS initiative will be steered by a PUF Task Force and will be guided by three primary principles: 1) facilitating STS National Database participant research, 2) ensuring research output of the highest quality, and 3) protecting STS and participant data, as well as patient privacy. The Society was purposely deliberate in its planning because it wanted to present members with a truly different kind of PUF! The STS PUF Program will be rolled out in three stages, starting with the Adult Cardiac Surgery Database in the fourth quarter of this year, followed by the General Thoracic Surgery Database and the Congenital Heart Surgery Database in the first and second quarters of 2017, respectively. The STS PUF Program is unique in many respects and was designed primarily as an option for investigators to pose research questions, quickly obtain quality data, analyze these data themselves given appropriate biostatistics resources, receive feedback, and develop their efforts into abstracts and manuscripts. Key features that distinguish the STS PUF Program from similar programs offered by other medical societies include: PUF Task Force review of the submission materials (application and proposal) for scientific merit and appropriate analytic capacity of the investigative team; Data ready for analysis—investigators will receive quality-checked data for variables that are relevant to the research question only after study inclusion and exclusion criteria have been applied; Valuable feedback from the PUF Task Force on the quality and completeness of an investigative team’s analysis and interpretation of the results, as well as the ensuing abstract and/or manuscript derived from the study; and   Affordable research fees—these fees will be used to offset the technical and scientific support needed for sustained high-quality PUF research productivity. Many of these new research initiatives could be game-changers. More STS Research Initiatives on the Horizon STS PUF is only the beginning. Several other new research-related initiatives currently are being developed. In 2017, STS will launch in-house analytics capabilities that will contribute to all forms of STS research. Such new data analytics services promise to be a meaningful addition to the STS Research Center, particularly for investigators interested in PUF research who do not have statistical resources at their own institutions. Another major near-term focus of the STS Research Center is to acquire long-term follow-up data for patients in the STS National Database. This need is well recognized, and success on this front would be transformational, providing a whole new dimension to STS research. Long-term follow-up data would allow investigators to pursue clinical outcomes and comparative effectiveness questions with genuine potential for grant funding success. Please stay tuned!