News & Media

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.

STS News, Summer 2017 -- Cardiothoracic surgeons participating in the STS Adult Cardiac Surgery Database (ACSD) can avoid a Medicare penalty by reporting Quality measures to the Centers for Medicare & Medicaid Services (CMS) through the STS National Database. The Merit-Based Incentive Payment System (MIPS) is a new CMS program that combines elements of existing Medicare physician quality programs, including the Physician Quality Reporting System, the Value Modifier, and the Electronic Health Record Incentive Program. Clinicians will be evaluated on four categories under MIPS, with the Quality category carrying the most weight. Eligible professionals who do not satisfactorily report on at least one MIPS category during the January 1–December 31, 2017 reporting period will be subject to an automatic 4% negative payment adjustment in the 2019 Medicare Part B Fee Schedule. ACSD participants can consent to have STS submit data on 14 different measures to CMS on their behalf, thus fulfilling the reporting requirement, avoiding the penalty, and potentially qualifying for a small to a moderate upward payment adjustment, depending on performance and the number of measures and activities reported under MIPS. A consent form must be submitted by Tuesday, October 31, 2017. This service is free for STS members. Non-members participating in the ACSD will each be assessed a $500 fee for the Society to transmit data on their behalf. Please note that STS will not report for surgeons who are enrolled in or part of an Accountable Care Organization or who plan to report in a group through the MIPS group reporting option known as GPRO. As a result, surgeons who are employed by hospitals or health systems are encouraged to check and see if other reporting arrangements have been made before submitting a MIPS consent form to STS. Reporting Quality data is just one component of the MIPS program. To receive a bonus payment, clinicians can elect to report data in other MIPS categories, including Improvement Activities and Advancing Care Information. If you have questions about MIPS Quality reporting, contact Derek Steck, STS National Database Coordinator, at Derek Steck or (312) 202-5818. Access New MACRA Toolkit MIPS falls under the umbrella of the Quality Payment Program, which was established by the Medicare Access and CHIP Reauthorization Act (MACRA). The Society has compiled a MACRA Toolkit for Cardiothoracic Surgeons that includes detailed overviews of both MIPS and Advanced Alternative Payment Models, a checklist of steps to take this year, and additional CMS resources. Access the MACRA toolkit. 2017 - MIPS Transitional Reporting Year NO PARTICIPATION • Submit nothing and receive 4% penalty in 2019 AVOID PENALTY REPORT: • 1 Quality Measure* OR • 1 Improvement Activity* OR • Required ACI Measures* PARTIAL PARTICIPATION REPORT: • >1 Quality Measure AND/OR • >1 Improvement Activity AND/OR • “More than required” ACI FULL PARTICIPATION • Full Reporting Across All Categories • Eligible for “Exceptional Performance” Bonus Payment *Must be for Medicare Part B patients

Robert A. Wynbrandt Robert A. Wynbrandt, Executive Director & General Counsel Donna McDonald, Director of Quality STS News, Summer 2017 -- If we were hard-pressed to identify the one thing that distinguishes The Society of Thoracic Surgeons from all of the other national medical specialty societies, most of us would probably identify the STS National Database, particularly in light of its international recognition and all of the other STS initiatives and activities that are dependent on it. In this next guest column by another member of the management team, STS Director of Quality Donna McDonald (whose department is responsible for the care and feeding of the Database, among other things) takes us on a grand tour of the STS Quality world. Donna was initially employed as a registered nurse, and spent a significant portion of her career in the Cardiac Surgery ICU at the former Michael Reese Hospital in Chicago before moving on to the world of clinical research and informatics. She joined the STS staff in 2009, and was promoted to the position of Director of Quality last year. Any tour of the STS Quality world necessarily starts with the National Database, which was developed by and for cardiothoracic surgeons to assess quality and improve outcomes for their patients. The Database currently has three components—the Adult Cardiac Surgery Database (ACSD), the Congenital Heart Surgery Database (CHSD), and the General Thoracic Surgery Database (GTSD), and the Society is planning to expand its scope with the addition of the Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) next year. The ACSD is the largest component of the Database, including more than 6.2 million procedure records submitted by the vast majority of adult cardiac surgery programs in the United States, and also serving 21 international participants. The Society’s Workforce on National Databases is responsible for developing and enhancing all of the components of the STS National Database. This includes modernizing data collection and leveraging existing resources such as the electronic medical record to reduce the data collection burden for participants. One recent major Database advancement includes dashboard reporting, which will be fully implemented within the next year to allow more timely feedback for quality improvement initiatives (see cover story). Other coming attractions include linkages to datasets such as cancer registries and the National Death Index, which will improve the specialty’s ability to track long-term outcomes. Patient-reported outcomes and quality-of-life assessments also are on the horizon. In addition to serving as a quality improvement tool, the STS National Database provides a mechanism to assess new technologies and techniques, monitor device safety, and support research. The Database can even put money in your pocket by providing data for the Relative Value Scale Update Committee (RUC) process and through quality reporting to CMS for the Merit-Based Incentive Payment System. Public Reporting Participants in the STS National Database have the opportunity to share their risk-adjusted surgical outcomes with the public on a voluntary basis. Public reporting started with the ACSD in 2010 in collaboration with Consumer Reports, and that arrangement continues today. In addition, it is now available for all three Database components via the STS website (publicreporting.sts.org). The Society believes that publicly reporting surgical outcomes is an ethical responsibility of the specialty and continues to refine its associated tools in order to provide the public with scientifically valid, user-friendly information. Quality Measurement Our next stop on the tour is quality measurement territory. The STS Quality Measurement Task Force is responsible for developing risk models and quality measures. Risk modeling allows for fair comparisons of outcomes involving the most commonly performed procedures in cardiothoracic surgery. Quality measures are tools used to promote process, structure, or outcome goals for providers using language that is understandable to patients, and STS has more quality measures endorsed by the National Quality Forum than any other medical specialty society. These measures are used to benchmark quality for cardiothoracic surgery programs, payers, and patients. Quality is a journey—not a destination. Clinical Practice Documents The Workforce on Evidence Based Surgery develops clinical practice documents, including clinical practice guidelines and expert consensus papers, which provide surgeons with practical, point-of-care assistance. Each guideline topic undergoes an exhaustive, collaborative review of clinical information and scientific evidence published in the medical literature, and is subject to development and adoption processes that follow Institute of Medicine standards. There’s even an app that will connect you to the Society’s clinical practice guidelines! You can download the app and find other valuable resources at www.sts.org/guidelines. Patient Safety Cardiothoracic surgeons have long been recognized as safety leaders in health care. The Workforce on Patient Safety provides resources and plans educational programs to enhance awareness of safety issues in cardiothoracic surgery. This includes the Patient Safety Symposium at the STS Annual Meeting. Past topics have included resilience, avoiding burnout, building strong teams, how to safely introduce new techniques and technology, how to deal with patients, families, and staff following unanticipated events, and optimizing communication during care transitions. You can access narrated PowerPoint slides of past symposia at learningcenter.sts.org. The STS staff recognizes that quality is a journey—not a destination—and appreciates all of you who travel with us! We believe that the specialty of cardiothoracic surgery and its practitioners personify the words of Ralph Waldo Emerson: “Do not go where the path may lead. Go instead where there is no path and leave a trail.”

In this installment of STS News, Dr. Paul Levy describes his institution’s approach to increasing value in the care of cardiac surgery patients. By incorporating a team approach to postoperative management, NEA Baptist Memorial Hospital has been able to demonstrate remarkable improvement in extubation times. --Frank L. Fazzalari, MD, MBA, Chair, Workforce on Practice Management Paul S. Levy, MD, MBA, Director of Surgical Services, NEA Baptist Memorial Hospital, Jonesboro, Ark. STS News, Summer 2017 -- With recent efforts by the Centers for Medicare & Medicaid Services to bundle payments for cardiac surgical services, alternative payment models (APMs) are now front and center in health care reform. An emphasis has been placed on coordination of care and stakeholder collaboration. Payer demand for value is here to stay. At our institution, we heard this message loud and clear. We have aggressively focused our efforts toward driving cardiac surgery production costs down. The high-cost environments of the operating room and intensive care unit were targeted. The ability to extubate patients expeditiously following open heart surgery is dependent upon a multitude of factors. Many stakeholder groups are involved, with each having its own entrenched practice patterns. Needless to say, there are many moving parts. Organizational culture and stakeholder “tribal knowledge” can stall the most driven change agents. In 2015, we investigated the current state of our post-cardiac surgery extubation times and were surprised to find that only 9% of patients were extubated within 8 hours of their surgery (the average extubation time was 14 hours). Additionally, 65% of our patients had a 2-day ICU length of stay (LOS). Certainly, we could do better. Identifying our barriers was fundamental to achieving our goals, which were to reduce the average extubation time to 8 hours or less, reduce ICU LOS, and maintain patient safety. The first steps involved educating stakeholder groups—anesthesia, ICU RN, respiratory therapy, and step-down RN staff—on how our current state compared to STS National Database benchmark data and describing the potential negative clinical impact of prolonged mechanical ventilation. Our initiative’s goals were then clarified, and each stakeholder group developed plans to close performance gaps. Our anesthesia group adopted a best practice, standardized approach to cardiac anesthesia. As a result, patients arrived at the ICU less sedated. ICU RN and respiratory therapy staff members developed a “protocol-driven” extubation process and, as a result, fewer arterial blood gas (ABG) tests were required with no reintubations. Educational in-services helped the step-down RN staff close clinical care gaps in the postoperative day #1 cardiac care pathway. Deming’s scientific method was employed to monitor the initiative’s progress and help stakeholders make appropriate adjustments. The financial impact was a substantive decrease of at least $650/case. In 2016 (12 months after taking these steps), 62% of our patients were extubated within 8 hours, compared to only 9% in 2015. In fact, in the last quarter of 2016, average time to extubation was 6.1 hours. ICU LOS has similarly improved, with 78% of patients having a 1-day LOS in 2016 compared to only 35% in 2015. The collaboration between the ICU RN and respiratory therapy staffs also has resulted in improved collegiality, a reduction in the average number of ABG tests per case (3.4 in 2016 versus 7.0 in 2015), and preserved patient safety. The financial impact was a substantive decrease of at least $650/case. As is evident by our win, teamwork with clear, unified goals is an effective strategy to cost reduction in cardiac surgery.

STS News, Summer 2017 -- STS is partnering with the European Association for Cardio-Thoracic Surgery (EACTS) on a new educational program in Latin America that is designed for all members of the cardiac surgical team. “A key goal of the Society’s new strategic plan is to foster collaboration and connection, especially among the global cardiothoracic surgery community,” explained STS Immediate Past President Joseph E. Bavaria, MD. “During a recent workforce meeting, surgeons from Latin America noted the lack of an all-inclusive cardiovascular surgery educational program held in their region of the world. STS and EACTS jumped on the opportunity to provide that education.” EACTS Past President Jose Luis Pomar, MD, PhD said that the collaboration was a natural fit. “Sharing experiences from different parts of the world will help improve our knowledge and better serve our patients,” Dr. Pomar said. “It also will help strengthen relations at a personal level; the face-to-face contact will be crucial.” The STS/EACTS Latin America Cardiovascular Surgery Conference is planned for September 21-22 at the Hilton Cartagena in Cartagena, Colombia. It will highlight the management of coronary artery disease, valvular heart disease, thoracic aortic disease, and atrial fibrillation, as well as the surgical management of heart failure. In addition to Drs. Bavaria (from Philadelphia) and Pomar (from Barcelona), Program Directors include Juan P. Umana, MD (from Bogota) and Vinod H. Thourani, MD (from Washington, DC). The faculty will be a mix of experts from North America, Europe, and Latin America. The Hilton Cartagena offers ocean views, secluded beach access, an expansive swimming pool complex, and tennis courts. The 2-day conference will begin with general sessions on management of the mitral valve before splitting into separate tracks on adult congenital, heart failure, atrial fibrillation, and the tricuspid valve. The second day starts off with dual tracks of “Stump the Professor,” followed by general sessions on the aortic valve and quality initiatives, and in the afternoon will feature tracks on coronary artery disease and the aorta and aortic arch. The program closes with another general session on the aortic root. “The program covers a wide array of topics, with special emphasis on valvular disease. We believe this is an area that holds great potential in Latin America, particularly as it pertains to valvular preservation and repair,” Dr. Umana said. “The program design highlights the importance of the Heart Team approach as a means to offer patients the best possible treatment available, regardless of geographic location.” Scientific abstracts and panel discussions will be incorporated into each session. “This course features a heavily case-based format,” said Dr. Thourani. “Our goal is for it to be very interactive.” An exciting component of the program will be invited technical videos displaying procedural expertise in these disease processes, which Dr. Umana described as “very powerful teaching tools.” The session on quality and outcomes initiatives will explore the history of the STS National Database, the challenges of implementing multicentric registries in Latin America, and how to maintain quality in a surgical program. “As quality initiatives and registries become increasingly important, a specific session dedicated to performing research and measuring quality will look at the cross-pollination of what’s been done in Europe and the United States,” Dr. Thourani said. To learn more about the conference and register, visit www.CardiovascularSurgeryConference.org. If you have questions, contact STS Education Manager Michelle Taylor or (312) 202-5864.

STS News, Summer 2017 -- Surgeons and data managers from 25 Adult Cardiac Surgery Database (ACSD) sites participated this spring in a month-long pilot aimed at developing an online reporting dashboard that would offer interactivity and more detailed analyses of data from the national report PDF than participating sites currently receive. The Society is making adjustments to the dashboard based on the pilot group’s feedback, and the dashboard is expected to be released to all ACSD participants this fall. General Thoracic Surgery Database and Congenital Heart Surgery Database participants should receive access to the dashboard next year. Once participants log in, they will see an executive summary showing 3-year overall numbers of procedures, post-procedure length of stay, and unadjusted mortality by procedure for all participating sites. A menu on the left-hand side allows users to drill down into their specific institution’s data, including star ratings, National Quality Forum measures, comorbidities, demographics, operative information, outcomes, postoperative events, and more. This draft mockup of the new dashboard homepage displays a snapshot of national data. “It’s a lot easier to navigate than trying to scroll through a PDF,” said pilot tester Gaetano Paone, MD, MHSA, Division Head of Cardiac Surgery at Henry Ford Hospital in Detroit and Chair of the STS Task Force on Quality Initiatives. “For example, if I want to look at our blood transfusion rate for coronary bypass surgery in the current report, I have to find it on, let’s say, page 127; if I then want to see the same data for aortic valves, I might have to scroll through another 70 pages before I get there. With the new dashboard, all I have to do is unclick the CABG box and click the valve box, and the same dataset pops up. That’s an enormous improvement.” More Frequent Data Updates Another advantage of the dashboard is the speed with which new data will be incorporated. Site data will be refreshed daily; analytics will be updated once per quarter. Being able to access data so quickly, rather than waiting for quarterly reports, is a big plus for Mary Barry, Database Coordinator for the ACSD at the University of Michigan, who also participated in the pilot. “I anticipate using the dashboard to more quickly query our data,” she said. “I also like being able to download reports that show the specific Record ID associated with a selected variable.” Tool for Quality Improvement The dashboard will make it even easier for participating sites to improve quality and patient outcomes at their institutions. “I generally know how our division is doing day to day, but there are some specific things I don’t know—Have we been transfusing more patients or having more patients with longer times on the ventilator? The dashboard allows me to quickly assess these variables,” Dr. Paone said. “You also can create aggregate subsets of patients with specific morbidities and see the rate of major complications and operative mortality outcomes that occurred within that group. It’s a much more granular way of assessing where your problem areas might be.” "It’s a much more granular way of assessing where your problem areas might be." Gaetano Paone, MD, MHSA Other pilot testers agreed. “We like the ability to see the benchmarks easily,” said Amy Geltz, Quality Data Manager at the University of Michigan Health System. “I think if we ever do continuous harvesting at our site, the dashboard would be even more helpful. I also could see us using this dashboard in quality improvement meetings, allowing us to quickly look at certain data points.” Barry added that the interactivity of the dashboard will help her track ongoing projects. “I anticipate that I will use it to assist in monitoring work related to a quality project, as well as checking consistency of data abstraction,” she said. More information on the dashboard will be shared in future issues of STS News and STS National Database News. If you have questions about the dashboard, contact Carole Krohn, STS National Database Manager, Adult Cardiac Surgery, at Carole Krohn or (312) 202-5847.