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Therese Borden is the editor of CHEST Physician. After 20 years of research, writing, and editing in the field of international development and economics, she began working in the field of medical editing and has held a variety of editorial positions with the company. She holds a PhD in International Economics from American University, Washington, and a BA in history from the University of Washington, Seattle.
Integrated health system builds collegial network of rural surgeons
Recruiting and retaining general surgeons is a longstanding problem for rural hospitals. A regional medical system in the Upper Midwest tackles this challenge by integrating small-town general surgeons into the network and emphasizing professional development, fair compensation, and a sustainable call and leave schedule.
The Gundersen Health System (GHS) is a physician-led, nonprofit health care network that operates in 19 rural counties in parts of Wisconsin, Minnesota, and Iowa, with its main campus in La Crosse, Wis. The network, established over a period of almost 40 years, is a mix of larger GHS medical centers, community hospitals, medical clinics, and GHS-managed and independent critical access hospitals (CAHs).
A sustainable model
“It is clear that the older paradigm of a single rural surgeon providing care 24/7 to an isolated community is vanishing. Design of a more sustainable model involves small groups of rural surgeons working together to provide general surgery and some subspecialty care locally, but who are also part of a larger network for administrative and clinical support,” said Dr. Cogbill in an interview.
Lessons learned
Dr. Cogbill said, “Our 38-year experience with rural surgery in our region has taught us many lessons. The strategy of trying to place a solo general surgeon in every small town with a CAH within our service area was not sustainable nor practical. The development of several rural centers of care within our region has allowed us to be more successful in the recruitment and retention of rural general surgeons who are hired to be part of a small group (optimally three) who provide care to their home community as well as outreach surgical care to several outlying CAHs near their home CAH. This has made it possible to offer a reasonable call schedule, mutual assistance, and the chance to build adequate case volumes. Connectivity to the health system should not mean ‘send all the great cases to the main campus,’ but instead should support the rural surgeons in performing appropriate cases locally.”
The survey respondents were aged 36-55 years, five were male, and all were graduates of U.S. medical schools. Eight are board certified and seven are either fellows or associate members of the American College of Surgeons. Their tenure in the GHS system averaged at least 7 years, ranging from 2 years to more than 20. Their surgical logs for a recent 1-year period show a case mix of endoscopy (63.8%), general surgery (26.7%), and obstetrics (6.1%). Mean annual relative value units for the group were 3,627 (range 2,456-5,846).
One goal of the confidential survey was to explore the reasons behind these surgeons’ choice of a rural practice. Their primary motivations were a preference for a rural lifestyle and a desire for a broad scope of practice. Loan forgiveness motivated some (37.5%), and the influence of a mentor was important for others (25%). The opportunity to join an integrated health system such as GHS was deemed extremely important to seven of the respondents.
Retention of rural surgeons
The most important factors mentioned by survey respondents for remaining in their positions were lifestyle (87.5%), family (75.0%), relationship with patients and colleagues, and scope of practice (75.0%), and compensation (62.6%).
Reasons to consider leaving were call burden (37.5%), relationship with the local hospital (25.0%), and compensation (25.0%).
The survey also looked at potential retention of these general surgeons in the coming 5 years: 37.5% said they were somewhat likely to remain, 25% said they were very likely to remain, and 37.5% said they were extremely likely to stay.
Two successful strategies have been promoting a satisfactory case mix and comanagement of patients who are referred to the main campus. The surgeons from the small towns are encouraged to come to La Crosse to assist in procedures on referred patients, to teach in the surgical residency and the Transition to Practice General Surgery fellowship programs at Gundersen, to participate in clinical research activities, and to engage in a variety of professional activities that strengthen the bonds between GHS and rural surgeons. These interactions help minimize professional isolation, a serious problem for surgeons working on their own in small communities.
Communication is maintained electronically. “Our system includes the use of a common EMR across the entire system allowing mutual access to both inpatient and outpatient records, including full access to digitized diagnostic imaging. GHS has established a number of distance-learning telemedicine links between the main campus and the rural communities that permit real-time patient consultations as well as participation in teaching conferences including Morbidity and Mortality Conferences.”
Reducing burnout in rural surgeons
The GHS model may have some impact on burnout among the rural surgeons in the system, said Dr. Cogbill. “Rural surgeon employment as part of a fully integrated regional network has the potential to reduce the magnitude of burnout by providing administrative assistance to help navigate bureaucratic complexities, easy access for subspecialty consults with colleagues who are known entities, and a model of rural surgery involving pods of three colleagues who can share call, mutual assistance, and case volumes.” Fair and competitive compensation and some degree of loan forgiveness have been in the mix of factors that have helped with recruitment. Administrative assistance from the main campus eases the clerical burden the surgeons face. Guaranteed free time for vacations and educational meetings, as well as a reasonable call schedule, are all built into contracts; this has had a big impact on recruitment. GHS has concluded that three general surgeons in a community is the optimal number to maintain call coverage and mutual assistance. Dr. Cogbill said, “The call schedule is managed by each “pod” of rural general surgeons themselves. With a full complement of three rural surgeons in a pod, they maintain an every third night call schedule. In towns in which there are fewer than three surgeons, the GHS surgeons often share call with surgeons who are not part of GHS to maintain a reasonable/sustainable call schedule.”
The retention track record at GHS is impressive. Since 1978, 19 rural general surgeons have been employed by GHS. Four (21%) rural general surgeons have retired 10 (53%) continue to practice in the network; only 5 (26%) left prior to retirement. Six rural general surgeons practiced in one location for over 20 years.
[email protected]
On Twitter @ThereseBorden
The rural surgeon needs some financial assurance, a reasonable call schedule that allows him/her time away from the job without compromising the care of patients in his/her town, regulatory relief, and a relationship with a “mother ship” referral center that is a true two-way street. The days of the independent private solo practitioner are numbered, and the statistics bear this out. The convergence of declining reimbursement, increasing burden of scrutiny and documentation placed by payers and the government, and an emerging workforce that values work-life balance all contribute to the need to develop programs like this one at Gunderson to maintain the surgical workforce in our small towns. Rural surgery comes with a great deal of intrinsic reward, which makes it an excellent career, if these obstacles can be overcome.
Mark Savarise, MD, FACS, is a general surgeon practicing in South Jordan, Utah, and is clinical associate professor of surgery at the University of Utah, Salt Lake City. He has no disclosures.
The rural surgeon needs some financial assurance, a reasonable call schedule that allows him/her time away from the job without compromising the care of patients in his/her town, regulatory relief, and a relationship with a “mother ship” referral center that is a true two-way street. The days of the independent private solo practitioner are numbered, and the statistics bear this out. The convergence of declining reimbursement, increasing burden of scrutiny and documentation placed by payers and the government, and an emerging workforce that values work-life balance all contribute to the need to develop programs like this one at Gunderson to maintain the surgical workforce in our small towns. Rural surgery comes with a great deal of intrinsic reward, which makes it an excellent career, if these obstacles can be overcome.
Mark Savarise, MD, FACS, is a general surgeon practicing in South Jordan, Utah, and is clinical associate professor of surgery at the University of Utah, Salt Lake City. He has no disclosures.
The rural surgeon needs some financial assurance, a reasonable call schedule that allows him/her time away from the job without compromising the care of patients in his/her town, regulatory relief, and a relationship with a “mother ship” referral center that is a true two-way street. The days of the independent private solo practitioner are numbered, and the statistics bear this out. The convergence of declining reimbursement, increasing burden of scrutiny and documentation placed by payers and the government, and an emerging workforce that values work-life balance all contribute to the need to develop programs like this one at Gunderson to maintain the surgical workforce in our small towns. Rural surgery comes with a great deal of intrinsic reward, which makes it an excellent career, if these obstacles can be overcome.
Mark Savarise, MD, FACS, is a general surgeon practicing in South Jordan, Utah, and is clinical associate professor of surgery at the University of Utah, Salt Lake City. He has no disclosures.
Recruiting and retaining general surgeons is a longstanding problem for rural hospitals. A regional medical system in the Upper Midwest tackles this challenge by integrating small-town general surgeons into the network and emphasizing professional development, fair compensation, and a sustainable call and leave schedule.
The Gundersen Health System (GHS) is a physician-led, nonprofit health care network that operates in 19 rural counties in parts of Wisconsin, Minnesota, and Iowa, with its main campus in La Crosse, Wis. The network, established over a period of almost 40 years, is a mix of larger GHS medical centers, community hospitals, medical clinics, and GHS-managed and independent critical access hospitals (CAHs).
A sustainable model
“It is clear that the older paradigm of a single rural surgeon providing care 24/7 to an isolated community is vanishing. Design of a more sustainable model involves small groups of rural surgeons working together to provide general surgery and some subspecialty care locally, but who are also part of a larger network for administrative and clinical support,” said Dr. Cogbill in an interview.
Lessons learned
Dr. Cogbill said, “Our 38-year experience with rural surgery in our region has taught us many lessons. The strategy of trying to place a solo general surgeon in every small town with a CAH within our service area was not sustainable nor practical. The development of several rural centers of care within our region has allowed us to be more successful in the recruitment and retention of rural general surgeons who are hired to be part of a small group (optimally three) who provide care to their home community as well as outreach surgical care to several outlying CAHs near their home CAH. This has made it possible to offer a reasonable call schedule, mutual assistance, and the chance to build adequate case volumes. Connectivity to the health system should not mean ‘send all the great cases to the main campus,’ but instead should support the rural surgeons in performing appropriate cases locally.”
The survey respondents were aged 36-55 years, five were male, and all were graduates of U.S. medical schools. Eight are board certified and seven are either fellows or associate members of the American College of Surgeons. Their tenure in the GHS system averaged at least 7 years, ranging from 2 years to more than 20. Their surgical logs for a recent 1-year period show a case mix of endoscopy (63.8%), general surgery (26.7%), and obstetrics (6.1%). Mean annual relative value units for the group were 3,627 (range 2,456-5,846).
One goal of the confidential survey was to explore the reasons behind these surgeons’ choice of a rural practice. Their primary motivations were a preference for a rural lifestyle and a desire for a broad scope of practice. Loan forgiveness motivated some (37.5%), and the influence of a mentor was important for others (25%). The opportunity to join an integrated health system such as GHS was deemed extremely important to seven of the respondents.
Retention of rural surgeons
The most important factors mentioned by survey respondents for remaining in their positions were lifestyle (87.5%), family (75.0%), relationship with patients and colleagues, and scope of practice (75.0%), and compensation (62.6%).
Reasons to consider leaving were call burden (37.5%), relationship with the local hospital (25.0%), and compensation (25.0%).
The survey also looked at potential retention of these general surgeons in the coming 5 years: 37.5% said they were somewhat likely to remain, 25% said they were very likely to remain, and 37.5% said they were extremely likely to stay.
Two successful strategies have been promoting a satisfactory case mix and comanagement of patients who are referred to the main campus. The surgeons from the small towns are encouraged to come to La Crosse to assist in procedures on referred patients, to teach in the surgical residency and the Transition to Practice General Surgery fellowship programs at Gundersen, to participate in clinical research activities, and to engage in a variety of professional activities that strengthen the bonds between GHS and rural surgeons. These interactions help minimize professional isolation, a serious problem for surgeons working on their own in small communities.
Communication is maintained electronically. “Our system includes the use of a common EMR across the entire system allowing mutual access to both inpatient and outpatient records, including full access to digitized diagnostic imaging. GHS has established a number of distance-learning telemedicine links between the main campus and the rural communities that permit real-time patient consultations as well as participation in teaching conferences including Morbidity and Mortality Conferences.”
Reducing burnout in rural surgeons
The GHS model may have some impact on burnout among the rural surgeons in the system, said Dr. Cogbill. “Rural surgeon employment as part of a fully integrated regional network has the potential to reduce the magnitude of burnout by providing administrative assistance to help navigate bureaucratic complexities, easy access for subspecialty consults with colleagues who are known entities, and a model of rural surgery involving pods of three colleagues who can share call, mutual assistance, and case volumes.” Fair and competitive compensation and some degree of loan forgiveness have been in the mix of factors that have helped with recruitment. Administrative assistance from the main campus eases the clerical burden the surgeons face. Guaranteed free time for vacations and educational meetings, as well as a reasonable call schedule, are all built into contracts; this has had a big impact on recruitment. GHS has concluded that three general surgeons in a community is the optimal number to maintain call coverage and mutual assistance. Dr. Cogbill said, “The call schedule is managed by each “pod” of rural general surgeons themselves. With a full complement of three rural surgeons in a pod, they maintain an every third night call schedule. In towns in which there are fewer than three surgeons, the GHS surgeons often share call with surgeons who are not part of GHS to maintain a reasonable/sustainable call schedule.”
The retention track record at GHS is impressive. Since 1978, 19 rural general surgeons have been employed by GHS. Four (21%) rural general surgeons have retired 10 (53%) continue to practice in the network; only 5 (26%) left prior to retirement. Six rural general surgeons practiced in one location for over 20 years.
[email protected]
On Twitter @ThereseBorden
Recruiting and retaining general surgeons is a longstanding problem for rural hospitals. A regional medical system in the Upper Midwest tackles this challenge by integrating small-town general surgeons into the network and emphasizing professional development, fair compensation, and a sustainable call and leave schedule.
The Gundersen Health System (GHS) is a physician-led, nonprofit health care network that operates in 19 rural counties in parts of Wisconsin, Minnesota, and Iowa, with its main campus in La Crosse, Wis. The network, established over a period of almost 40 years, is a mix of larger GHS medical centers, community hospitals, medical clinics, and GHS-managed and independent critical access hospitals (CAHs).
A sustainable model
“It is clear that the older paradigm of a single rural surgeon providing care 24/7 to an isolated community is vanishing. Design of a more sustainable model involves small groups of rural surgeons working together to provide general surgery and some subspecialty care locally, but who are also part of a larger network for administrative and clinical support,” said Dr. Cogbill in an interview.
Lessons learned
Dr. Cogbill said, “Our 38-year experience with rural surgery in our region has taught us many lessons. The strategy of trying to place a solo general surgeon in every small town with a CAH within our service area was not sustainable nor practical. The development of several rural centers of care within our region has allowed us to be more successful in the recruitment and retention of rural general surgeons who are hired to be part of a small group (optimally three) who provide care to their home community as well as outreach surgical care to several outlying CAHs near their home CAH. This has made it possible to offer a reasonable call schedule, mutual assistance, and the chance to build adequate case volumes. Connectivity to the health system should not mean ‘send all the great cases to the main campus,’ but instead should support the rural surgeons in performing appropriate cases locally.”
The survey respondents were aged 36-55 years, five were male, and all were graduates of U.S. medical schools. Eight are board certified and seven are either fellows or associate members of the American College of Surgeons. Their tenure in the GHS system averaged at least 7 years, ranging from 2 years to more than 20. Their surgical logs for a recent 1-year period show a case mix of endoscopy (63.8%), general surgery (26.7%), and obstetrics (6.1%). Mean annual relative value units for the group were 3,627 (range 2,456-5,846).
One goal of the confidential survey was to explore the reasons behind these surgeons’ choice of a rural practice. Their primary motivations were a preference for a rural lifestyle and a desire for a broad scope of practice. Loan forgiveness motivated some (37.5%), and the influence of a mentor was important for others (25%). The opportunity to join an integrated health system such as GHS was deemed extremely important to seven of the respondents.
Retention of rural surgeons
The most important factors mentioned by survey respondents for remaining in their positions were lifestyle (87.5%), family (75.0%), relationship with patients and colleagues, and scope of practice (75.0%), and compensation (62.6%).
Reasons to consider leaving were call burden (37.5%), relationship with the local hospital (25.0%), and compensation (25.0%).
The survey also looked at potential retention of these general surgeons in the coming 5 years: 37.5% said they were somewhat likely to remain, 25% said they were very likely to remain, and 37.5% said they were extremely likely to stay.
Two successful strategies have been promoting a satisfactory case mix and comanagement of patients who are referred to the main campus. The surgeons from the small towns are encouraged to come to La Crosse to assist in procedures on referred patients, to teach in the surgical residency and the Transition to Practice General Surgery fellowship programs at Gundersen, to participate in clinical research activities, and to engage in a variety of professional activities that strengthen the bonds between GHS and rural surgeons. These interactions help minimize professional isolation, a serious problem for surgeons working on their own in small communities.
Communication is maintained electronically. “Our system includes the use of a common EMR across the entire system allowing mutual access to both inpatient and outpatient records, including full access to digitized diagnostic imaging. GHS has established a number of distance-learning telemedicine links between the main campus and the rural communities that permit real-time patient consultations as well as participation in teaching conferences including Morbidity and Mortality Conferences.”
Reducing burnout in rural surgeons
The GHS model may have some impact on burnout among the rural surgeons in the system, said Dr. Cogbill. “Rural surgeon employment as part of a fully integrated regional network has the potential to reduce the magnitude of burnout by providing administrative assistance to help navigate bureaucratic complexities, easy access for subspecialty consults with colleagues who are known entities, and a model of rural surgery involving pods of three colleagues who can share call, mutual assistance, and case volumes.” Fair and competitive compensation and some degree of loan forgiveness have been in the mix of factors that have helped with recruitment. Administrative assistance from the main campus eases the clerical burden the surgeons face. Guaranteed free time for vacations and educational meetings, as well as a reasonable call schedule, are all built into contracts; this has had a big impact on recruitment. GHS has concluded that three general surgeons in a community is the optimal number to maintain call coverage and mutual assistance. Dr. Cogbill said, “The call schedule is managed by each “pod” of rural general surgeons themselves. With a full complement of three rural surgeons in a pod, they maintain an every third night call schedule. In towns in which there are fewer than three surgeons, the GHS surgeons often share call with surgeons who are not part of GHS to maintain a reasonable/sustainable call schedule.”
The retention track record at GHS is impressive. Since 1978, 19 rural general surgeons have been employed by GHS. Four (21%) rural general surgeons have retired 10 (53%) continue to practice in the network; only 5 (26%) left prior to retirement. Six rural general surgeons practiced in one location for over 20 years.
[email protected]
On Twitter @ThereseBorden
ABS offers a new path to board certification
The American Board of Surgery announced a revised and reformulated path for surgeons to board certification that will replace the current Maintenance of Certification process now in place.
The new program will offer surgeons greater flexibility and more practice-relevant options to achieve lifelong learning in their field and continuous board certification. The ABS based the program on feedback from diplomates (ABS-certified surgeons) including the findings from a 2016 survey sent to 5,000 diplomates.
Effective immediately, diplomates will be asked to report their professional standing, CME activities, and practice assessment participation every 5 years, rather than every 3 years. All diplomates will have their current reporting cycle extended by 2 years. The self-assessment CME requirement has been has been reduced by half. For 2018, more options for recertification will be offered with a greater focus on ongoing, high-value, and practice-relevant learning. The current 10-year interval recertification examination will continue to be offered for those who choose it. Input from diplomates will be sought in the coming months to provide input on the new program.
Find the full statement at http://www.absurgery.org/default.jsp?news_mocchange0717.
The American Board of Surgery announced a revised and reformulated path for surgeons to board certification that will replace the current Maintenance of Certification process now in place.
The new program will offer surgeons greater flexibility and more practice-relevant options to achieve lifelong learning in their field and continuous board certification. The ABS based the program on feedback from diplomates (ABS-certified surgeons) including the findings from a 2016 survey sent to 5,000 diplomates.
Effective immediately, diplomates will be asked to report their professional standing, CME activities, and practice assessment participation every 5 years, rather than every 3 years. All diplomates will have their current reporting cycle extended by 2 years. The self-assessment CME requirement has been has been reduced by half. For 2018, more options for recertification will be offered with a greater focus on ongoing, high-value, and practice-relevant learning. The current 10-year interval recertification examination will continue to be offered for those who choose it. Input from diplomates will be sought in the coming months to provide input on the new program.
Find the full statement at http://www.absurgery.org/default.jsp?news_mocchange0717.
The American Board of Surgery announced a revised and reformulated path for surgeons to board certification that will replace the current Maintenance of Certification process now in place.
The new program will offer surgeons greater flexibility and more practice-relevant options to achieve lifelong learning in their field and continuous board certification. The ABS based the program on feedback from diplomates (ABS-certified surgeons) including the findings from a 2016 survey sent to 5,000 diplomates.
Effective immediately, diplomates will be asked to report their professional standing, CME activities, and practice assessment participation every 5 years, rather than every 3 years. All diplomates will have their current reporting cycle extended by 2 years. The self-assessment CME requirement has been has been reduced by half. For 2018, more options for recertification will be offered with a greater focus on ongoing, high-value, and practice-relevant learning. The current 10-year interval recertification examination will continue to be offered for those who choose it. Input from diplomates will be sought in the coming months to provide input on the new program.
Find the full statement at http://www.absurgery.org/default.jsp?news_mocchange0717.
Outpatient appendectomy success depends on patient selection, communication
Outpatient laparoscopic surgery for uncomplicated appendicitis can be safely implemented in a large county hospital that serves a poor, underserved population, findings from a prospective, observational trial have shown.
Outpatient appendectomy has gradually gained acceptance in the United States, and numerous studies support the practice. David R. Rosen, MD, of the University of Southern California, Los Angeles, and his colleagues considered the possible advantages of outpatient laparoscopic appendectomy for their institution, such as decreased length of stay, decreased costs, and fewer admissions.
The research team hypothesized that with a “well-defined protocol consisting of strict inclusion and exclusion criteria, clear patient instructions, and close observation to identify patients who would not succeed with the outpatient appendectomy treatment strategy, outpatient appendectomy would be feasible without worsening patient outcomes or satisfaction.”
The findings were published in the Journal of the American College of Surgeons (2017 May;224[5]:862-7).
The investigators conducted a study of patients presenting at a safety-net county hospital and diagnosed with acute appendicitis. A year-long observation period produced a control group of 178 admitted patients.
The outpatient protocol was then introduced. Patients were counseled on the possibility of their being discharged from the postanesthesia care unit (PACU), depending on intraoperative findings and their capacity to arrange a ride home and willingness to participate in postoperative follow-up. Patient education was a key element of the protocol. In all, 173 patients were identified for the outpatient program.
The intraoperative criteria for discharge from the PACU included no evidence of perforation or gangrene, and no surgical complications or adverse events. Patients were cleared for discharge if they met the following criteria: heart rate less than 100 beats/min; systolic blood pressure greater than 110 mm Hg; pain well controlled (less than 4 on a 1-10 scale); ambulatory; urinated since surgery; oral intake; and dressings dry without evidence of bleeding.
The patients had been thoroughly briefed on what to expect and problems that would necessitate a return to the emergency department. The physician assessed each patient’s readiness to be discharged, wrote a discharge order, and confirmed the pain medication prescription and follow-up appointment.
Of the 173 patients selected for the outpatient program, 113 (65%) ended up being discharged from the PACU. The reasons for these admissions included interoperative findings, failure to pass the discharge criteria, homelessness, and no transportation to get home.
The control and outpatient groups were similar demographically, except that the latter were on average significantly older (mean age 32.4 years vs. 36.6 years, respectively). The outpatient group had a significantly shorter operative time (69 minutes vs. 83 minutes), a significantly longer stay in the PACU (242 minutes vs.141 minutes), and a significantly shorter total postoperative length of stay (9 hours vs.19 hours).
There were no differences between the groups in terms of complications, postdischarge ED visits, or readmissions. Those who were discharged from the PACU had no postoperative complications and no readmissions.
The length of stay in the PACU gradually decreased for the outpatient group. “This can be attributed to the adoption of a new protocol,” the researchers noted. However, “we purposely did not want to rush the discharge process to ensure our patients and families had all questions answered and were comfortable leaving the hospital.”
A key component of the protocol was the follow-up appointment for all appendectomy patients; about one-third of both groups did not return for their follow-up appointments. Those missed follow-ups could mean some patients returned to another hospital, but the investigators suggested that this was unlikely.
“Because our hospital serves a patient population of low socioeconomic status and often without health insurance, our public hospital is often the only hospital to which they would present,” the investigators wrote.
Most of those who did return completed a questionnaire on their level of satisfaction. Survey results showed no differences in satisfaction between the groups and a generally positive view of the protocol among the outpatient group.
The study did not account for actual cost savings, but reduced hospital admissions and readmissions were achieved. Investigators assert that other studies have shown that each day of hospitalization avoided saves about $1,900.
“It is challenging to deliver high-quality, efficient care to an underserved population in a public hospital,” Dr. Rosen said in an interview. “In this setting, communication and patient education are vital components for success. By setting clear expectations and empowering patients to participate in their care, we can maximize our patients’ outcomes.”
The investigators had no disclosures.
Outpatient laparoscopic surgery for uncomplicated appendicitis can be safely implemented in a large county hospital that serves a poor, underserved population, findings from a prospective, observational trial have shown.
Outpatient appendectomy has gradually gained acceptance in the United States, and numerous studies support the practice. David R. Rosen, MD, of the University of Southern California, Los Angeles, and his colleagues considered the possible advantages of outpatient laparoscopic appendectomy for their institution, such as decreased length of stay, decreased costs, and fewer admissions.
The research team hypothesized that with a “well-defined protocol consisting of strict inclusion and exclusion criteria, clear patient instructions, and close observation to identify patients who would not succeed with the outpatient appendectomy treatment strategy, outpatient appendectomy would be feasible without worsening patient outcomes or satisfaction.”
The findings were published in the Journal of the American College of Surgeons (2017 May;224[5]:862-7).
The investigators conducted a study of patients presenting at a safety-net county hospital and diagnosed with acute appendicitis. A year-long observation period produced a control group of 178 admitted patients.
The outpatient protocol was then introduced. Patients were counseled on the possibility of their being discharged from the postanesthesia care unit (PACU), depending on intraoperative findings and their capacity to arrange a ride home and willingness to participate in postoperative follow-up. Patient education was a key element of the protocol. In all, 173 patients were identified for the outpatient program.
The intraoperative criteria for discharge from the PACU included no evidence of perforation or gangrene, and no surgical complications or adverse events. Patients were cleared for discharge if they met the following criteria: heart rate less than 100 beats/min; systolic blood pressure greater than 110 mm Hg; pain well controlled (less than 4 on a 1-10 scale); ambulatory; urinated since surgery; oral intake; and dressings dry without evidence of bleeding.
The patients had been thoroughly briefed on what to expect and problems that would necessitate a return to the emergency department. The physician assessed each patient’s readiness to be discharged, wrote a discharge order, and confirmed the pain medication prescription and follow-up appointment.
Of the 173 patients selected for the outpatient program, 113 (65%) ended up being discharged from the PACU. The reasons for these admissions included interoperative findings, failure to pass the discharge criteria, homelessness, and no transportation to get home.
The control and outpatient groups were similar demographically, except that the latter were on average significantly older (mean age 32.4 years vs. 36.6 years, respectively). The outpatient group had a significantly shorter operative time (69 minutes vs. 83 minutes), a significantly longer stay in the PACU (242 minutes vs.141 minutes), and a significantly shorter total postoperative length of stay (9 hours vs.19 hours).
There were no differences between the groups in terms of complications, postdischarge ED visits, or readmissions. Those who were discharged from the PACU had no postoperative complications and no readmissions.
The length of stay in the PACU gradually decreased for the outpatient group. “This can be attributed to the adoption of a new protocol,” the researchers noted. However, “we purposely did not want to rush the discharge process to ensure our patients and families had all questions answered and were comfortable leaving the hospital.”
A key component of the protocol was the follow-up appointment for all appendectomy patients; about one-third of both groups did not return for their follow-up appointments. Those missed follow-ups could mean some patients returned to another hospital, but the investigators suggested that this was unlikely.
“Because our hospital serves a patient population of low socioeconomic status and often without health insurance, our public hospital is often the only hospital to which they would present,” the investigators wrote.
Most of those who did return completed a questionnaire on their level of satisfaction. Survey results showed no differences in satisfaction between the groups and a generally positive view of the protocol among the outpatient group.
The study did not account for actual cost savings, but reduced hospital admissions and readmissions were achieved. Investigators assert that other studies have shown that each day of hospitalization avoided saves about $1,900.
“It is challenging to deliver high-quality, efficient care to an underserved population in a public hospital,” Dr. Rosen said in an interview. “In this setting, communication and patient education are vital components for success. By setting clear expectations and empowering patients to participate in their care, we can maximize our patients’ outcomes.”
The investigators had no disclosures.
Outpatient laparoscopic surgery for uncomplicated appendicitis can be safely implemented in a large county hospital that serves a poor, underserved population, findings from a prospective, observational trial have shown.
Outpatient appendectomy has gradually gained acceptance in the United States, and numerous studies support the practice. David R. Rosen, MD, of the University of Southern California, Los Angeles, and his colleagues considered the possible advantages of outpatient laparoscopic appendectomy for their institution, such as decreased length of stay, decreased costs, and fewer admissions.
The research team hypothesized that with a “well-defined protocol consisting of strict inclusion and exclusion criteria, clear patient instructions, and close observation to identify patients who would not succeed with the outpatient appendectomy treatment strategy, outpatient appendectomy would be feasible without worsening patient outcomes or satisfaction.”
The findings were published in the Journal of the American College of Surgeons (2017 May;224[5]:862-7).
The investigators conducted a study of patients presenting at a safety-net county hospital and diagnosed with acute appendicitis. A year-long observation period produced a control group of 178 admitted patients.
The outpatient protocol was then introduced. Patients were counseled on the possibility of their being discharged from the postanesthesia care unit (PACU), depending on intraoperative findings and their capacity to arrange a ride home and willingness to participate in postoperative follow-up. Patient education was a key element of the protocol. In all, 173 patients were identified for the outpatient program.
The intraoperative criteria for discharge from the PACU included no evidence of perforation or gangrene, and no surgical complications or adverse events. Patients were cleared for discharge if they met the following criteria: heart rate less than 100 beats/min; systolic blood pressure greater than 110 mm Hg; pain well controlled (less than 4 on a 1-10 scale); ambulatory; urinated since surgery; oral intake; and dressings dry without evidence of bleeding.
The patients had been thoroughly briefed on what to expect and problems that would necessitate a return to the emergency department. The physician assessed each patient’s readiness to be discharged, wrote a discharge order, and confirmed the pain medication prescription and follow-up appointment.
Of the 173 patients selected for the outpatient program, 113 (65%) ended up being discharged from the PACU. The reasons for these admissions included interoperative findings, failure to pass the discharge criteria, homelessness, and no transportation to get home.
The control and outpatient groups were similar demographically, except that the latter were on average significantly older (mean age 32.4 years vs. 36.6 years, respectively). The outpatient group had a significantly shorter operative time (69 minutes vs. 83 minutes), a significantly longer stay in the PACU (242 minutes vs.141 minutes), and a significantly shorter total postoperative length of stay (9 hours vs.19 hours).
There were no differences between the groups in terms of complications, postdischarge ED visits, or readmissions. Those who were discharged from the PACU had no postoperative complications and no readmissions.
The length of stay in the PACU gradually decreased for the outpatient group. “This can be attributed to the adoption of a new protocol,” the researchers noted. However, “we purposely did not want to rush the discharge process to ensure our patients and families had all questions answered and were comfortable leaving the hospital.”
A key component of the protocol was the follow-up appointment for all appendectomy patients; about one-third of both groups did not return for their follow-up appointments. Those missed follow-ups could mean some patients returned to another hospital, but the investigators suggested that this was unlikely.
“Because our hospital serves a patient population of low socioeconomic status and often without health insurance, our public hospital is often the only hospital to which they would present,” the investigators wrote.
Most of those who did return completed a questionnaire on their level of satisfaction. Survey results showed no differences in satisfaction between the groups and a generally positive view of the protocol among the outpatient group.
The study did not account for actual cost savings, but reduced hospital admissions and readmissions were achieved. Investigators assert that other studies have shown that each day of hospitalization avoided saves about $1,900.
“It is challenging to deliver high-quality, efficient care to an underserved population in a public hospital,” Dr. Rosen said in an interview. “In this setting, communication and patient education are vital components for success. By setting clear expectations and empowering patients to participate in their care, we can maximize our patients’ outcomes.”
The investigators had no disclosures.
FROM JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Key clinical point: .
Major finding: The outpatient group had a shorter postoperative hospital length of stay (9 hours vs. 19 hours).
Data source: A prospective, observational study of 351 patients with a diagnosis of acute appendicitis at a public safety-net hospital that serves poor and mostly uninsured patients.
Disclosures: The authors had no disclosures.
Research gaps identified for palliative surgical care
Palliative care is a well-established specialty of medicine with several decades of research to guide its implementation in a variety of contexts. Palliative care for surgical patients, however, remains understudied, according to a work group convened by the National Institutes of Health and the National Palliative Care Research Center. The work group, comprising palliative specialists from a range of medical institutions, reviewed the existing literature on palliative surgical care to identify areas in which research is needed to support palliative programs and clinicians.
Despite the 2003 call to action by the American College of Surgeons’ Palliative Care Workgroup for research in seven priority areas of palliative care (surgical, patient-oriented, and end-of-life decision making; symptom management; communications; processes of care; and surgical education on palliative care), few studies have been conducted specifically targeting surgical palliative care. The empirical basis for implementation in the surgical context remains thin, according to the work group, which argues that when it comes to palliative care – and the research to support it – the needs of surgical and nonsurgical patients differ significantly.
The report, published in the Annals of Surgery (2017 May 3. doi: 10.1097/SLA.0000000000002253), outlines an ambitious agenda of recommended research priorities in the areas of outcomes, communication, and delivery aimed at filling the gap.
Measuring outcomes
The report pointed to two areas of outcomes research that are understudied. One is defining outcomes that are meaningful to patients. Surgical research frequently defines outcomes in terms of survival, 30-day readmission, and morbidity, but patients accessing palliative surgical care may not prioritize these outcomes. “Measures of functional independence, disability-free survival, days spent at home, or freedom from pain after surgery provide information on outcomes that are both clinically meaningful and important to patients,” the study authors wrote.
In addition, measures of timely and appropriate delivery of high-quality palliative care in surgery are in scant supply for surgeons and institutions looking to identify targets for improvement. Surgeons searching for studies on effective documentation of advance directives, and quality indicators for care at the end of life, such as hospice enrollment and death on life-sustaining treatments, will find the research cupboard nearly bare.
Communication and decision making
Decision making and communication with patients, family, and surgical team members are made especially challenging by the short time frames and crisis situations in which palliative surgical care typically occurs. For many of these patients, the “trade-offs between cure and quality of life (that is, impaired functional status and prolonged pain and suffering) are typically value sensitive.” But surgeons who want to communicate information about these trade-offs “are severely hampered by the paucity of data comparing longer-term survival, quality of life, and function ... the lack of data hinders the consideration of palliative care as an adjunct or alternative to surgery,” the study authors wrote.
Surgeons have few studies and little evidence to guide them on issues such as advance care planning conversations with surrogates in the crisis-prone surgical ICU setting. Future studies are needed to develop communication tools for in-the-moment crises in which patients, surrogates, and surgeons must choose a course of action that is both clinically sound and in accordance with patient values or wishes.
Delivery of palliative care to surgical patients
The work group reviewed the scanty literature on integrating palliative care principles into routine surgical practice and concluded that much work remains to be done in this area. “Studies of physician- and systems-targeted interventions are needed to redirect treatment options so that surgery is not the default modality for patients known to have extremely poor survival due to baseline serious illness or acute surgical conditions.” Optimal timing of palliative care, patient selection, development of scalable models of palliative care in different settings, and residency training models are all understudied, according to the report. And yet, the demand for evidence and data on these issues continues to rise.
The work group concluded, “As the population ages and technical innovation advances, surgical patients will become increasingly complex as surgeons and patients navigate the blurred boundaries between technically feasible, clinically appropriate, and value-concordant care.”
The study was supported by the National Institute on Aging, a division of NIH, and the National Palliative Care Research Center. The authors report no disclosures relevant to this study.
This report is an overdue assessment of an American College of Surgeons’ initiative to improve palliative care for surgical patients. The initiative commenced 15 years ago, and it is safe to say that at that time we surgeons didn’t know what we didn’t know about palliative care.
This move would eliminate much of the dated, pejorative connotation of palliative surgery as well as the incentive to intervene surgically on behalf of highly symptomatic, fragile patients, which was imposed by fear of the 30-day postop mortality metric. This research agenda is a realistic and compassionate appeal to the engagement of all surgeons in the assimilation of palliative principles in surgical practice.
Geoffrey P. Dunn, MD, FACS, is medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot, and vice chair of the ACS Committee on Surgical Palliative Care.
This report is an overdue assessment of an American College of Surgeons’ initiative to improve palliative care for surgical patients. The initiative commenced 15 years ago, and it is safe to say that at that time we surgeons didn’t know what we didn’t know about palliative care.
This move would eliminate much of the dated, pejorative connotation of palliative surgery as well as the incentive to intervene surgically on behalf of highly symptomatic, fragile patients, which was imposed by fear of the 30-day postop mortality metric. This research agenda is a realistic and compassionate appeal to the engagement of all surgeons in the assimilation of palliative principles in surgical practice.
Geoffrey P. Dunn, MD, FACS, is medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot, and vice chair of the ACS Committee on Surgical Palliative Care.
This report is an overdue assessment of an American College of Surgeons’ initiative to improve palliative care for surgical patients. The initiative commenced 15 years ago, and it is safe to say that at that time we surgeons didn’t know what we didn’t know about palliative care.
This move would eliminate much of the dated, pejorative connotation of palliative surgery as well as the incentive to intervene surgically on behalf of highly symptomatic, fragile patients, which was imposed by fear of the 30-day postop mortality metric. This research agenda is a realistic and compassionate appeal to the engagement of all surgeons in the assimilation of palliative principles in surgical practice.
Geoffrey P. Dunn, MD, FACS, is medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot, and vice chair of the ACS Committee on Surgical Palliative Care.
Palliative care is a well-established specialty of medicine with several decades of research to guide its implementation in a variety of contexts. Palliative care for surgical patients, however, remains understudied, according to a work group convened by the National Institutes of Health and the National Palliative Care Research Center. The work group, comprising palliative specialists from a range of medical institutions, reviewed the existing literature on palliative surgical care to identify areas in which research is needed to support palliative programs and clinicians.
Despite the 2003 call to action by the American College of Surgeons’ Palliative Care Workgroup for research in seven priority areas of palliative care (surgical, patient-oriented, and end-of-life decision making; symptom management; communications; processes of care; and surgical education on palliative care), few studies have been conducted specifically targeting surgical palliative care. The empirical basis for implementation in the surgical context remains thin, according to the work group, which argues that when it comes to palliative care – and the research to support it – the needs of surgical and nonsurgical patients differ significantly.
The report, published in the Annals of Surgery (2017 May 3. doi: 10.1097/SLA.0000000000002253), outlines an ambitious agenda of recommended research priorities in the areas of outcomes, communication, and delivery aimed at filling the gap.
Measuring outcomes
The report pointed to two areas of outcomes research that are understudied. One is defining outcomes that are meaningful to patients. Surgical research frequently defines outcomes in terms of survival, 30-day readmission, and morbidity, but patients accessing palliative surgical care may not prioritize these outcomes. “Measures of functional independence, disability-free survival, days spent at home, or freedom from pain after surgery provide information on outcomes that are both clinically meaningful and important to patients,” the study authors wrote.
In addition, measures of timely and appropriate delivery of high-quality palliative care in surgery are in scant supply for surgeons and institutions looking to identify targets for improvement. Surgeons searching for studies on effective documentation of advance directives, and quality indicators for care at the end of life, such as hospice enrollment and death on life-sustaining treatments, will find the research cupboard nearly bare.
Communication and decision making
Decision making and communication with patients, family, and surgical team members are made especially challenging by the short time frames and crisis situations in which palliative surgical care typically occurs. For many of these patients, the “trade-offs between cure and quality of life (that is, impaired functional status and prolonged pain and suffering) are typically value sensitive.” But surgeons who want to communicate information about these trade-offs “are severely hampered by the paucity of data comparing longer-term survival, quality of life, and function ... the lack of data hinders the consideration of palliative care as an adjunct or alternative to surgery,” the study authors wrote.
Surgeons have few studies and little evidence to guide them on issues such as advance care planning conversations with surrogates in the crisis-prone surgical ICU setting. Future studies are needed to develop communication tools for in-the-moment crises in which patients, surrogates, and surgeons must choose a course of action that is both clinically sound and in accordance with patient values or wishes.
Delivery of palliative care to surgical patients
The work group reviewed the scanty literature on integrating palliative care principles into routine surgical practice and concluded that much work remains to be done in this area. “Studies of physician- and systems-targeted interventions are needed to redirect treatment options so that surgery is not the default modality for patients known to have extremely poor survival due to baseline serious illness or acute surgical conditions.” Optimal timing of palliative care, patient selection, development of scalable models of palliative care in different settings, and residency training models are all understudied, according to the report. And yet, the demand for evidence and data on these issues continues to rise.
The work group concluded, “As the population ages and technical innovation advances, surgical patients will become increasingly complex as surgeons and patients navigate the blurred boundaries between technically feasible, clinically appropriate, and value-concordant care.”
The study was supported by the National Institute on Aging, a division of NIH, and the National Palliative Care Research Center. The authors report no disclosures relevant to this study.
Palliative care is a well-established specialty of medicine with several decades of research to guide its implementation in a variety of contexts. Palliative care for surgical patients, however, remains understudied, according to a work group convened by the National Institutes of Health and the National Palliative Care Research Center. The work group, comprising palliative specialists from a range of medical institutions, reviewed the existing literature on palliative surgical care to identify areas in which research is needed to support palliative programs and clinicians.
Despite the 2003 call to action by the American College of Surgeons’ Palliative Care Workgroup for research in seven priority areas of palliative care (surgical, patient-oriented, and end-of-life decision making; symptom management; communications; processes of care; and surgical education on palliative care), few studies have been conducted specifically targeting surgical palliative care. The empirical basis for implementation in the surgical context remains thin, according to the work group, which argues that when it comes to palliative care – and the research to support it – the needs of surgical and nonsurgical patients differ significantly.
The report, published in the Annals of Surgery (2017 May 3. doi: 10.1097/SLA.0000000000002253), outlines an ambitious agenda of recommended research priorities in the areas of outcomes, communication, and delivery aimed at filling the gap.
Measuring outcomes
The report pointed to two areas of outcomes research that are understudied. One is defining outcomes that are meaningful to patients. Surgical research frequently defines outcomes in terms of survival, 30-day readmission, and morbidity, but patients accessing palliative surgical care may not prioritize these outcomes. “Measures of functional independence, disability-free survival, days spent at home, or freedom from pain after surgery provide information on outcomes that are both clinically meaningful and important to patients,” the study authors wrote.
In addition, measures of timely and appropriate delivery of high-quality palliative care in surgery are in scant supply for surgeons and institutions looking to identify targets for improvement. Surgeons searching for studies on effective documentation of advance directives, and quality indicators for care at the end of life, such as hospice enrollment and death on life-sustaining treatments, will find the research cupboard nearly bare.
Communication and decision making
Decision making and communication with patients, family, and surgical team members are made especially challenging by the short time frames and crisis situations in which palliative surgical care typically occurs. For many of these patients, the “trade-offs between cure and quality of life (that is, impaired functional status and prolonged pain and suffering) are typically value sensitive.” But surgeons who want to communicate information about these trade-offs “are severely hampered by the paucity of data comparing longer-term survival, quality of life, and function ... the lack of data hinders the consideration of palliative care as an adjunct or alternative to surgery,” the study authors wrote.
Surgeons have few studies and little evidence to guide them on issues such as advance care planning conversations with surrogates in the crisis-prone surgical ICU setting. Future studies are needed to develop communication tools for in-the-moment crises in which patients, surrogates, and surgeons must choose a course of action that is both clinically sound and in accordance with patient values or wishes.
Delivery of palliative care to surgical patients
The work group reviewed the scanty literature on integrating palliative care principles into routine surgical practice and concluded that much work remains to be done in this area. “Studies of physician- and systems-targeted interventions are needed to redirect treatment options so that surgery is not the default modality for patients known to have extremely poor survival due to baseline serious illness or acute surgical conditions.” Optimal timing of palliative care, patient selection, development of scalable models of palliative care in different settings, and residency training models are all understudied, according to the report. And yet, the demand for evidence and data on these issues continues to rise.
The work group concluded, “As the population ages and technical innovation advances, surgical patients will become increasingly complex as surgeons and patients navigate the blurred boundaries between technically feasible, clinically appropriate, and value-concordant care.”
The study was supported by the National Institute on Aging, a division of NIH, and the National Palliative Care Research Center. The authors report no disclosures relevant to this study.
FROM ANNALS OF SURGERY
Low-income uninsured trauma patients at risk for ruinous medical costs
Almost three-quarters of uninsured adults admitted for traumatic injury are at risk of catastrophic health expenditures (CHEs), according to a large retrospective study from a national patient database.
Since enactment of the Affordable Care Act in 2010, the number of uninsured individuals has dropped substantially, but there remains a large population of younger adults, many from low-income areas, who still are not covered. The Centers for Disease Control and Prevention reported in 2015 that 12.8% of individuals aged 18-64 years were uninsured. The financial impact of a traumatic injury is likely to be significant for those paying out of pocket, but the question of who is at risk and to what degree is understudied, according to John W. Scott, MD, of Brigham and Women’s Hospital, Boston, and his colleagues.
“Defining populations at risk of financial catastrophe after medical expense is a necessary step towards elucidating the effect of health care reforms intended to increase access to healthcare through insurance expansion,” they wrote in the Annals of Surgery (2017 Apr 7. doi: 10.1097/SLA.0000000000002254).
Dr. Scott and his colleagues analyzed trauma diagnoses in adults aged 18-64 years from Nationwide Inpatient Sample 2007-2011. They used the U.S. Census data to estimate post-subsistence income (income remaining after paying for food) and hospital charges for trauma diagnoses. The sample of 117,502 patient encounters was weighted to represent 579,683 trauma patients in the national database.
CHEs were defined conservatively as expenses that exceed 40% of a patient’s post-subsistence income; they also applied a lower threshold of CHEs – 10% of a patient’s entire income – without accounting for subsistence needs.
The investigators wanted to look at who was at greatest risk for CHEs and used the Census data to sort trauma patients by residential zip code to identify the distribution of income in the sample.
Costs to trauma patients varied by injury severity score (ISS) and by income quartile. Patients in the 25th income quartile paid less for their treatment, even accounting for ISS, but despite this difference, poorer patients were at a much greater risk for CHEs.
The median charge for all of these uninsured trauma patients was $27,420. Those trauma patients in the 25th percentile of income were charged an average of $15,196, while those in 75th quartile were charged $49,696. The difference in costs also was evident when comparing patients in different ISS categories: for ISS 9-15, median trauma costs for the lower-quartile patients was $31,095, but costs for the upper quartile patients was $52,639.
With cost, income, and injury severity data, the investigators found that overall the proportion of adults aged 18-64 years at risk for CHEs was 70.8% (95% confidence interval, 70.7%-71.1%). Subpopulations (ethnicity/race, age, sex) were within a few percentage point of each other.
Risk of CHEs varied widely by income quartile and ISS. Uninsured trauma patients in the highest income quartile had a 52.9% risk of CHEs, compared with 77.5% of those in the lowest-income quartile. Overall, 81.8% of patients with ISS greater than 24 were at risk for CHEs. In addition, the study found that patients treated at large or urban teaching hospitals – those most likely to handle the most-severely injured patients – were at a heightened risk for CHEs.
When the investigators conducted the same analysis with a lower threshold of CHEs (10% of income, not including subsistence expenses), the overall risk for uninsured trauma patients for catastrophic health expenses was more than 90%.
“Trauma patients are at particularly high risk for CHE because trauma disproportionately affects uninsured patients with little disposable income and because trauma injuries commonly affect multiple organ systems and incur expensive, multispecialty care,” Dr. Scott and his colleagues wrote. “Large unpaid medical debts may have longstanding impacts on patients’ financial well-being, affecting credit ratings and overall financial solvency. These financial stresses may be further compounded by an inability to return to work caused by injury.”
Dr. Scott and his coauthors added that having health insurance does not entirely eliminate the risk for CHEs and that individuals in the lower income brackets covered by employer-based plans or Medicaid had difficulty paying medical bills.
Only hospital costs were examined, which may not reflect forgiven debts, the investigators noted. In addition, the costs may be underreported because they do not include physician charges, postacute care, home health care, or rehabilitation. Incomes were estimated by zip code analysis, which may misclassify some individuals.
“Efforts are needed to ensure that the lifesaving care provided by our highly coordinated trauma systems do not have the unintended consequence of curing patients into destitution,” Dr. Scott and his colleagues wrote
The authors declared no conflicts of interest.
Almost three-quarters of uninsured adults admitted for traumatic injury are at risk of catastrophic health expenditures (CHEs), according to a large retrospective study from a national patient database.
Since enactment of the Affordable Care Act in 2010, the number of uninsured individuals has dropped substantially, but there remains a large population of younger adults, many from low-income areas, who still are not covered. The Centers for Disease Control and Prevention reported in 2015 that 12.8% of individuals aged 18-64 years were uninsured. The financial impact of a traumatic injury is likely to be significant for those paying out of pocket, but the question of who is at risk and to what degree is understudied, according to John W. Scott, MD, of Brigham and Women’s Hospital, Boston, and his colleagues.
“Defining populations at risk of financial catastrophe after medical expense is a necessary step towards elucidating the effect of health care reforms intended to increase access to healthcare through insurance expansion,” they wrote in the Annals of Surgery (2017 Apr 7. doi: 10.1097/SLA.0000000000002254).
Dr. Scott and his colleagues analyzed trauma diagnoses in adults aged 18-64 years from Nationwide Inpatient Sample 2007-2011. They used the U.S. Census data to estimate post-subsistence income (income remaining after paying for food) and hospital charges for trauma diagnoses. The sample of 117,502 patient encounters was weighted to represent 579,683 trauma patients in the national database.
CHEs were defined conservatively as expenses that exceed 40% of a patient’s post-subsistence income; they also applied a lower threshold of CHEs – 10% of a patient’s entire income – without accounting for subsistence needs.
The investigators wanted to look at who was at greatest risk for CHEs and used the Census data to sort trauma patients by residential zip code to identify the distribution of income in the sample.
Costs to trauma patients varied by injury severity score (ISS) and by income quartile. Patients in the 25th income quartile paid less for their treatment, even accounting for ISS, but despite this difference, poorer patients were at a much greater risk for CHEs.
The median charge for all of these uninsured trauma patients was $27,420. Those trauma patients in the 25th percentile of income were charged an average of $15,196, while those in 75th quartile were charged $49,696. The difference in costs also was evident when comparing patients in different ISS categories: for ISS 9-15, median trauma costs for the lower-quartile patients was $31,095, but costs for the upper quartile patients was $52,639.
With cost, income, and injury severity data, the investigators found that overall the proportion of adults aged 18-64 years at risk for CHEs was 70.8% (95% confidence interval, 70.7%-71.1%). Subpopulations (ethnicity/race, age, sex) were within a few percentage point of each other.
Risk of CHEs varied widely by income quartile and ISS. Uninsured trauma patients in the highest income quartile had a 52.9% risk of CHEs, compared with 77.5% of those in the lowest-income quartile. Overall, 81.8% of patients with ISS greater than 24 were at risk for CHEs. In addition, the study found that patients treated at large or urban teaching hospitals – those most likely to handle the most-severely injured patients – were at a heightened risk for CHEs.
When the investigators conducted the same analysis with a lower threshold of CHEs (10% of income, not including subsistence expenses), the overall risk for uninsured trauma patients for catastrophic health expenses was more than 90%.
“Trauma patients are at particularly high risk for CHE because trauma disproportionately affects uninsured patients with little disposable income and because trauma injuries commonly affect multiple organ systems and incur expensive, multispecialty care,” Dr. Scott and his colleagues wrote. “Large unpaid medical debts may have longstanding impacts on patients’ financial well-being, affecting credit ratings and overall financial solvency. These financial stresses may be further compounded by an inability to return to work caused by injury.”
Dr. Scott and his coauthors added that having health insurance does not entirely eliminate the risk for CHEs and that individuals in the lower income brackets covered by employer-based plans or Medicaid had difficulty paying medical bills.
Only hospital costs were examined, which may not reflect forgiven debts, the investigators noted. In addition, the costs may be underreported because they do not include physician charges, postacute care, home health care, or rehabilitation. Incomes were estimated by zip code analysis, which may misclassify some individuals.
“Efforts are needed to ensure that the lifesaving care provided by our highly coordinated trauma systems do not have the unintended consequence of curing patients into destitution,” Dr. Scott and his colleagues wrote
The authors declared no conflicts of interest.
Almost three-quarters of uninsured adults admitted for traumatic injury are at risk of catastrophic health expenditures (CHEs), according to a large retrospective study from a national patient database.
Since enactment of the Affordable Care Act in 2010, the number of uninsured individuals has dropped substantially, but there remains a large population of younger adults, many from low-income areas, who still are not covered. The Centers for Disease Control and Prevention reported in 2015 that 12.8% of individuals aged 18-64 years were uninsured. The financial impact of a traumatic injury is likely to be significant for those paying out of pocket, but the question of who is at risk and to what degree is understudied, according to John W. Scott, MD, of Brigham and Women’s Hospital, Boston, and his colleagues.
“Defining populations at risk of financial catastrophe after medical expense is a necessary step towards elucidating the effect of health care reforms intended to increase access to healthcare through insurance expansion,” they wrote in the Annals of Surgery (2017 Apr 7. doi: 10.1097/SLA.0000000000002254).
Dr. Scott and his colleagues analyzed trauma diagnoses in adults aged 18-64 years from Nationwide Inpatient Sample 2007-2011. They used the U.S. Census data to estimate post-subsistence income (income remaining after paying for food) and hospital charges for trauma diagnoses. The sample of 117,502 patient encounters was weighted to represent 579,683 trauma patients in the national database.
CHEs were defined conservatively as expenses that exceed 40% of a patient’s post-subsistence income; they also applied a lower threshold of CHEs – 10% of a patient’s entire income – without accounting for subsistence needs.
The investigators wanted to look at who was at greatest risk for CHEs and used the Census data to sort trauma patients by residential zip code to identify the distribution of income in the sample.
Costs to trauma patients varied by injury severity score (ISS) and by income quartile. Patients in the 25th income quartile paid less for their treatment, even accounting for ISS, but despite this difference, poorer patients were at a much greater risk for CHEs.
The median charge for all of these uninsured trauma patients was $27,420. Those trauma patients in the 25th percentile of income were charged an average of $15,196, while those in 75th quartile were charged $49,696. The difference in costs also was evident when comparing patients in different ISS categories: for ISS 9-15, median trauma costs for the lower-quartile patients was $31,095, but costs for the upper quartile patients was $52,639.
With cost, income, and injury severity data, the investigators found that overall the proportion of adults aged 18-64 years at risk for CHEs was 70.8% (95% confidence interval, 70.7%-71.1%). Subpopulations (ethnicity/race, age, sex) were within a few percentage point of each other.
Risk of CHEs varied widely by income quartile and ISS. Uninsured trauma patients in the highest income quartile had a 52.9% risk of CHEs, compared with 77.5% of those in the lowest-income quartile. Overall, 81.8% of patients with ISS greater than 24 were at risk for CHEs. In addition, the study found that patients treated at large or urban teaching hospitals – those most likely to handle the most-severely injured patients – were at a heightened risk for CHEs.
When the investigators conducted the same analysis with a lower threshold of CHEs (10% of income, not including subsistence expenses), the overall risk for uninsured trauma patients for catastrophic health expenses was more than 90%.
“Trauma patients are at particularly high risk for CHE because trauma disproportionately affects uninsured patients with little disposable income and because trauma injuries commonly affect multiple organ systems and incur expensive, multispecialty care,” Dr. Scott and his colleagues wrote. “Large unpaid medical debts may have longstanding impacts on patients’ financial well-being, affecting credit ratings and overall financial solvency. These financial stresses may be further compounded by an inability to return to work caused by injury.”
Dr. Scott and his coauthors added that having health insurance does not entirely eliminate the risk for CHEs and that individuals in the lower income brackets covered by employer-based plans or Medicaid had difficulty paying medical bills.
Only hospital costs were examined, which may not reflect forgiven debts, the investigators noted. In addition, the costs may be underreported because they do not include physician charges, postacute care, home health care, or rehabilitation. Incomes were estimated by zip code analysis, which may misclassify some individuals.
“Efforts are needed to ensure that the lifesaving care provided by our highly coordinated trauma systems do not have the unintended consequence of curing patients into destitution,” Dr. Scott and his colleagues wrote
The authors declared no conflicts of interest.
FROM ANNALS OF SURGERY
MACRA: Not going away any time soon
MACRA is now a fact of life.
Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.
1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?
A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.
Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.
From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.
So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.
Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.
Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.
2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?
The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.
Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.
Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.
3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?
There is a relatively straightforward process, which revolves around a series of questions and individual decisions.
First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.
If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.
However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.
If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.
For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit facs.org/qpp where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.
4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?
If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:
A) The required base score measures for your EHR (now known as Advancing Care Information) OR
B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR
C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims
One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.
Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.
Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.
It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.
5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?
That question is perhaps best addressed in the form of a comparison between 2016 and 2017.
In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.
In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.
However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.
6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?
The ACS one-stop shop is the Quality Payment Program Resource Center found at www.facs.org/qpp.
Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the facs.org/qpp webpage.
Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.
The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.
We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.
I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.
Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.
Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.
MACRA is now a fact of life.
Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.
1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?
A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.
Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.
From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.
So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.
Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.
Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.
2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?
The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.
Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.
Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.
3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?
There is a relatively straightforward process, which revolves around a series of questions and individual decisions.
First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.
If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.
However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.
If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.
For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit facs.org/qpp where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.
4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?
If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:
A) The required base score measures for your EHR (now known as Advancing Care Information) OR
B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR
C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims
One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.
Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.
Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.
It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.
5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?
That question is perhaps best addressed in the form of a comparison between 2016 and 2017.
In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.
In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.
However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.
6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?
The ACS one-stop shop is the Quality Payment Program Resource Center found at www.facs.org/qpp.
Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the facs.org/qpp webpage.
Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.
The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.
We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.
I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.
Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.
Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.
MACRA is now a fact of life.
Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.
1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?
A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.
Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.
From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.
So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.
Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.
Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.
2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?
The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.
Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.
Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.
3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?
There is a relatively straightforward process, which revolves around a series of questions and individual decisions.
First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.
If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.
However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.
If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.
For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit facs.org/qpp where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.
4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?
If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:
A) The required base score measures for your EHR (now known as Advancing Care Information) OR
B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR
C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims
One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.
Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.
Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.
It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.
5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?
That question is perhaps best addressed in the form of a comparison between 2016 and 2017.
In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.
In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.
However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.
6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?
The ACS one-stop shop is the Quality Payment Program Resource Center found at www.facs.org/qpp.
Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the facs.org/qpp webpage.
Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.
The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.
We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.
I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.
Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.
Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.
Fresh Press: ACS Surgery News January issue now online
The January issue of ACS Surgery News is available on the website. This month’s issue features a special report on burnout. A new paradigm of burnout is emerging: The roots of the problem may be institutional. Addressing physician burnout must begin with recognition of the challenge and a commitment to change from the top levels of management, according to a study by Tait D. Shanafelt, MD, and John Noseworthy, MD, of the Mayo Clinic.
Don’t miss our annual Meet the Editorial Advisory Board feature. This year, we welcome seven new members: Joshua A. Broghammer, MD, FACS; Samer G. Mattar, MD, FACS; Arden M. Morris, MD, FACS; Rudolfo J. Oviedo, MD, FACS; Kevin M. Reavis, MD, FACS; Michael D. Sarap, MD, FACS; and Gary Timmerman, MD, FACS. On behalf of the editors and our readers, we sincerely thank our members who have finished their term. These colleagues have given of their time and expertise for the benefit of their fellow surgeons. They have earned our admiration and gratitude.
The January issue of ACS Surgery News is available on the website. This month’s issue features a special report on burnout. A new paradigm of burnout is emerging: The roots of the problem may be institutional. Addressing physician burnout must begin with recognition of the challenge and a commitment to change from the top levels of management, according to a study by Tait D. Shanafelt, MD, and John Noseworthy, MD, of the Mayo Clinic.
Don’t miss our annual Meet the Editorial Advisory Board feature. This year, we welcome seven new members: Joshua A. Broghammer, MD, FACS; Samer G. Mattar, MD, FACS; Arden M. Morris, MD, FACS; Rudolfo J. Oviedo, MD, FACS; Kevin M. Reavis, MD, FACS; Michael D. Sarap, MD, FACS; and Gary Timmerman, MD, FACS. On behalf of the editors and our readers, we sincerely thank our members who have finished their term. These colleagues have given of their time and expertise for the benefit of their fellow surgeons. They have earned our admiration and gratitude.
The January issue of ACS Surgery News is available on the website. This month’s issue features a special report on burnout. A new paradigm of burnout is emerging: The roots of the problem may be institutional. Addressing physician burnout must begin with recognition of the challenge and a commitment to change from the top levels of management, according to a study by Tait D. Shanafelt, MD, and John Noseworthy, MD, of the Mayo Clinic.
Don’t miss our annual Meet the Editorial Advisory Board feature. This year, we welcome seven new members: Joshua A. Broghammer, MD, FACS; Samer G. Mattar, MD, FACS; Arden M. Morris, MD, FACS; Rudolfo J. Oviedo, MD, FACS; Kevin M. Reavis, MD, FACS; Michael D. Sarap, MD, FACS; and Gary Timmerman, MD, FACS. On behalf of the editors and our readers, we sincerely thank our members who have finished their term. These colleagues have given of their time and expertise for the benefit of their fellow surgeons. They have earned our admiration and gratitude.
Burnout: Time to stop blaming the victims
Most surgeons today are familiar with professional burnout – in their colleagues, in surgical trainees, and perhaps, in themselves. But the understanding of burnout is evolving. The discussion is moving away from blaming physicians for their poor coping skills toward identifying the structural and organizational roots of burnout.
Burnout is a syndrome cause by work-related stress that features emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. A recent study of nearly 7,000 physicians using the Maslach Burnout Inventory found that 54.4% of those surveyed reported at least one symptom of burnout (Mayo Clin Proc. 2015 Dec;90[12]:1600-19). Other studies have found similar rates of burnout in the surgical specialties such as orthopedic, oncologic, cardiothoracic, and plastic surgery (JAMA Surg. 2014 Sep;149:948-53; Ann Surg Oncol 2011 May;18:1229-35; Internat J Cardiol. 2015 Jan 20;179:7-72; Aesthet Surg J. 2016 Sep 27. E-pub ahead of print).
A new paradigm of burnout
The paradigm of burnout as a personal issue that can be managed by individual coping strategies is giving way to an understanding that the structural roots of burnout require the shared responsibility of individuals and their work organizations to solve the problem. A revised approach has emerged: Physician burnout as a symptom not of personal failure to cope, but of institutional failure to adapt to new circumstances in the health care milieu. The growing number of physicians employed in large group practices and medical centers has come with a whole array of management problems that are only beginning to be recognized, and burnout may be one of the most challenging.
Tait D. Shanafelt, MD, of the Mayo Foundation for Medical Education and Research, and John H. Noseworthy, MD, president and CEO of the Mayo Clinic, both in Rochester, Minn., have partnered to distill years of study and practice on the issue of burnout to a set of organizational strategies to tackle the problem and describe the Mayo Clinic experience. The study, “Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout” (Mayo Clin Proc. 2016 Nov 18. doi. org/10.1016/j.mayocp.2016.10.004) reverses the conventional “blame the victim” approach and identifies instead institutional responsibility to address burnout.
“Increasing evidence over the last 10 years demonstrating links to quality of care, productivity, and turnover have raised appreciation … by organizations that they have a substantial stake in this issue and that they control many of the factors that contribute to this problem,” said Dr. Shanafelt in an interview.
Unintended consequences of the individual solution
The focus on individual responsibility can have unintended consequences. A physician suffering from burnout can take action by leaving his or her job or cutting back. Staff turnover, a phenomenon closely tied to burnout, is costly and damaging to productivity and patient care (Physician Leadersh J. 2015 May-Jun;2[3]:22-5); Health Care Manage Rev. 2004;29[1]2-7). These personal strategies may help individuals cope but can end up harming the institution and the work life of other staff members. Physicians experiencing burnout in their own lives can trigger the same condition in their colleagues.
The Mayo paper by Dr. Shanafelt and Dr. Noseworthy states, “Mistakenly, most hospitals, medical centers, and practice groups operate under the framework that burnout and professional satisfaction are solely the responsibility of the individual physician. This frequently results in organizations pursuing a narrow list of ‘solutions’ that are unlikely to result in meaningful progress (e.g., stress management workshops and individual training in mindfulness/resilience). Such strategies neglect the organizational factors that are the primary drivers of physician burnout and are correctly viewed with skepticism by physicians as an insincere effort by the organization to address the problem.”
Organizational strategies to reduce burnout
Dr. Shanafelt and Dr. Noseworthy developed a list of nine organizational strategies that have been shown to reduce burnout among doctors. A critical piece of this approach is the accumulated evidence of the financial burden of burnout among physicians in health care institutions. The approach is based on an informed leadership that recognizes the costs of inaction, without which a systemic solution is unlikely to be achieved.
1. Naming the issue and assessing the problem
Acknowledgment of burnout as an institutional problem and meaningful measurement of physician well-being are the initial steps in tackling the problem. This requires a sincere commitment at the highest level of management to listen and to recognize what staff physicians are saying. “At Mayo Clinic, we have incorporated town halls, radio broadcasts, letters, and video interviews along with face-to-face meetings involving clinical divisions, work units, and small groups as formats or [by using] the CEO to reach the staff.” Assessing physician well-being and quality of work life using one or more of the many available tools has to be an ongoing “a barometer of organization health,” and not just a one-off, crisis management activity.
2. Harnessing the power of leadership
Studies have found that management behaviors and strategies of supervisors are key components of physician well-being. The bottom line is that physician supervisors must accept a share of responsibility for burnout in those they manage. Leaders can be chosen on the basis of their ability to listen, engage, develop, and lead, and but they can also be trained to improve. In addition, leaders should be regularly assessed by those whom they lead. Dr. Shanafelt and Dr. Noseworthy argue that a crucial element of successful leadership involves recognizing unique interests and talents of individual physicians whom they manage and facilitating professional development so that each staff member spends about 20% of work time engaged in activities that he or she finds most meaningful.
3. Developing targeted interventions
Just as all politics is local, the study suggests that many sources of burnout are local as well. For example, although a high clerical burden on physicians may be a universal driver of burnout, it manifests differently in each institutional setting. The key here is to dig into the specific structural driver at the unit or ward level, engage physicians in analysis and problem-solving, and implement a plan to address the problem.
Dr. Shanafelt noted, “We organize the drivers of engagement and burnout around seven dimensions: workload, efficiency, flexibility/control, community at work, organizational culture and values, work-life integration, and meaning in work. Each of these dimensions has organizational and individual components. Work units should begin by identifying which one or two dimensions are the biggest challenges for the group and then begin a stepwise process to address them.”
4. Cultivating community at work
Peer support, a long-standing source of strength among surgeons and other physicians, unintentionally has been eroded in many modern medical institutions. There is ample evidence that this loss of collegiality is tied to burnout. “These interactions have been an unintended casualty of increasing productivity expectations, documentation requirements, and clerical burden. [Many organizations have eliminated] formal spaces for physicians to interact (e.g., physicians’ lounge or dining room) without recognizing the important role that this dedicated space played in fostering interpersonal connections among physicians.” The Mayo Clinic and other institutions are reversing this trend by creating dedicated physician rooms for breaks, snacks, and a venue for peer interaction and camaraderie.
5. Rethinking rewards and incentives
Compensation is now commonly linked to productivity in many health care organizations, but this approach has some profound drawbacks: It can lead to physician burnout. Incentive structures based on patient satisfaction and quality metrics can have similar unintended consequences. All these incentive structures can combine to drive physicians to overwork. “Physicians may be particularly vulnerable to overwork due to high levels of education debt, their desire to ‘do everything for their patients,’ unhealthy role modeling by colleagues, and normalization of extreme work hours during the training process.” The investigators do not claim to have the ultimate answer to the problem of incentives that create unhealthy work patterns, but they argue that it is critical for leaders to recognize the potential unintended consequences of the productivity reward/incentive model and consider strategies to prevent overwork leading to burnout.
6. Aligning values and strengthening culture
The investigators also describe Mayo’s efforts to pursue self-appraisal of alignment of mission, values, and culture. They also describe the regular use of an all-staff survey, which has on occasion yielded candid feedback that, while not always flattering, has been the basis of a profound institutional rethink. The willingness of leadership to be receptive to hard truths from physicians is the foundation of institutional learning about burnout prevention and encourages engagement of the staff.
7. Promoting flexibility and work-life integration
Allowing employees greater flexibility in how and when they work is a management strategy that is gaining ground in many industries. Increasing part-time positions and expanding options for the work day have both been found to help prevent burnout and also help physicians recover from burnout. In addition, “institutions should also comprehensively examine the structure of their vacation benefits, coverage for life events (e.g., birth of a child, illness/death in family), approach to scheduling, and strategy for coverage of nights and weekends. Compensation practices that disincentivize using vacation time are shortsighted and should be eliminated.”
8. Providing resources to promote resilience and self-care
The solutions to burnout have been aimed at the individual and involve stress-reduction training and other personal management strategies. A metastudy of the interventions mentions psychoeducation, counseling, wellness management, interpersonal communication, and mindfulness meditation (J Nerv Ment Dis. 2014 May;202:353-9). But without concomitant structural reform, these individual solutions can backfire. “When individually focused offerings are not coupled with sincere efforts to address the system-based issues contributing to burnout, this approach is typically met with skepticism and resistance by physicians (‘They are implying I am the problem’). In this context, the response to well-intentioned ‘resilience training’ is frequently a cynical one (‘You only want to make me more resilient so you can further increase my workload’).”
9. Funding organizational research
Organizational science is a well-developed field of study. But cutting-edge management models such as the learning organization, participatory management, and collaborative action planning have been slow in coming to health care institutions. Dr. Shanafelt and Dr. Noseworthy argue that “vanguard institutions” such as the Mayo Clinic (which began its Program on Physician Well-Being in 2008), Stanford (Calif.) University, and other innovative institutions have the responsibility of developing evidence-based strategies to combat burnout that smaller institutions can implement.
Burnout among physicians is now on the radar of leadership in many health care institutions. Evidence on the cost and consequences is accumulating, and it becoming increasingly difficult to ignore what is happening to many physicians. Dr. Shanafelt projected an increasing need for operational solutions at the organizational level to address the problem. He said, “We need evidence to guide organizations to implement changes that truly make a difference, not well-intentioned but ineffective programs. Now that organizations recognize the strong business case, they are ready to invest resources to address this issue but they need to know it is money well spent and that there is an evidence-base to justify the investment.”
Most surgeons today are familiar with professional burnout – in their colleagues, in surgical trainees, and perhaps, in themselves. But the understanding of burnout is evolving. The discussion is moving away from blaming physicians for their poor coping skills toward identifying the structural and organizational roots of burnout.
Burnout is a syndrome cause by work-related stress that features emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. A recent study of nearly 7,000 physicians using the Maslach Burnout Inventory found that 54.4% of those surveyed reported at least one symptom of burnout (Mayo Clin Proc. 2015 Dec;90[12]:1600-19). Other studies have found similar rates of burnout in the surgical specialties such as orthopedic, oncologic, cardiothoracic, and plastic surgery (JAMA Surg. 2014 Sep;149:948-53; Ann Surg Oncol 2011 May;18:1229-35; Internat J Cardiol. 2015 Jan 20;179:7-72; Aesthet Surg J. 2016 Sep 27. E-pub ahead of print).
A new paradigm of burnout
The paradigm of burnout as a personal issue that can be managed by individual coping strategies is giving way to an understanding that the structural roots of burnout require the shared responsibility of individuals and their work organizations to solve the problem. A revised approach has emerged: Physician burnout as a symptom not of personal failure to cope, but of institutional failure to adapt to new circumstances in the health care milieu. The growing number of physicians employed in large group practices and medical centers has come with a whole array of management problems that are only beginning to be recognized, and burnout may be one of the most challenging.
Tait D. Shanafelt, MD, of the Mayo Foundation for Medical Education and Research, and John H. Noseworthy, MD, president and CEO of the Mayo Clinic, both in Rochester, Minn., have partnered to distill years of study and practice on the issue of burnout to a set of organizational strategies to tackle the problem and describe the Mayo Clinic experience. The study, “Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout” (Mayo Clin Proc. 2016 Nov 18. doi. org/10.1016/j.mayocp.2016.10.004) reverses the conventional “blame the victim” approach and identifies instead institutional responsibility to address burnout.
“Increasing evidence over the last 10 years demonstrating links to quality of care, productivity, and turnover have raised appreciation … by organizations that they have a substantial stake in this issue and that they control many of the factors that contribute to this problem,” said Dr. Shanafelt in an interview.
Unintended consequences of the individual solution
The focus on individual responsibility can have unintended consequences. A physician suffering from burnout can take action by leaving his or her job or cutting back. Staff turnover, a phenomenon closely tied to burnout, is costly and damaging to productivity and patient care (Physician Leadersh J. 2015 May-Jun;2[3]:22-5); Health Care Manage Rev. 2004;29[1]2-7). These personal strategies may help individuals cope but can end up harming the institution and the work life of other staff members. Physicians experiencing burnout in their own lives can trigger the same condition in their colleagues.
The Mayo paper by Dr. Shanafelt and Dr. Noseworthy states, “Mistakenly, most hospitals, medical centers, and practice groups operate under the framework that burnout and professional satisfaction are solely the responsibility of the individual physician. This frequently results in organizations pursuing a narrow list of ‘solutions’ that are unlikely to result in meaningful progress (e.g., stress management workshops and individual training in mindfulness/resilience). Such strategies neglect the organizational factors that are the primary drivers of physician burnout and are correctly viewed with skepticism by physicians as an insincere effort by the organization to address the problem.”
Organizational strategies to reduce burnout
Dr. Shanafelt and Dr. Noseworthy developed a list of nine organizational strategies that have been shown to reduce burnout among doctors. A critical piece of this approach is the accumulated evidence of the financial burden of burnout among physicians in health care institutions. The approach is based on an informed leadership that recognizes the costs of inaction, without which a systemic solution is unlikely to be achieved.
1. Naming the issue and assessing the problem
Acknowledgment of burnout as an institutional problem and meaningful measurement of physician well-being are the initial steps in tackling the problem. This requires a sincere commitment at the highest level of management to listen and to recognize what staff physicians are saying. “At Mayo Clinic, we have incorporated town halls, radio broadcasts, letters, and video interviews along with face-to-face meetings involving clinical divisions, work units, and small groups as formats or [by using] the CEO to reach the staff.” Assessing physician well-being and quality of work life using one or more of the many available tools has to be an ongoing “a barometer of organization health,” and not just a one-off, crisis management activity.
2. Harnessing the power of leadership
Studies have found that management behaviors and strategies of supervisors are key components of physician well-being. The bottom line is that physician supervisors must accept a share of responsibility for burnout in those they manage. Leaders can be chosen on the basis of their ability to listen, engage, develop, and lead, and but they can also be trained to improve. In addition, leaders should be regularly assessed by those whom they lead. Dr. Shanafelt and Dr. Noseworthy argue that a crucial element of successful leadership involves recognizing unique interests and talents of individual physicians whom they manage and facilitating professional development so that each staff member spends about 20% of work time engaged in activities that he or she finds most meaningful.
3. Developing targeted interventions
Just as all politics is local, the study suggests that many sources of burnout are local as well. For example, although a high clerical burden on physicians may be a universal driver of burnout, it manifests differently in each institutional setting. The key here is to dig into the specific structural driver at the unit or ward level, engage physicians in analysis and problem-solving, and implement a plan to address the problem.
Dr. Shanafelt noted, “We organize the drivers of engagement and burnout around seven dimensions: workload, efficiency, flexibility/control, community at work, organizational culture and values, work-life integration, and meaning in work. Each of these dimensions has organizational and individual components. Work units should begin by identifying which one or two dimensions are the biggest challenges for the group and then begin a stepwise process to address them.”
4. Cultivating community at work
Peer support, a long-standing source of strength among surgeons and other physicians, unintentionally has been eroded in many modern medical institutions. There is ample evidence that this loss of collegiality is tied to burnout. “These interactions have been an unintended casualty of increasing productivity expectations, documentation requirements, and clerical burden. [Many organizations have eliminated] formal spaces for physicians to interact (e.g., physicians’ lounge or dining room) without recognizing the important role that this dedicated space played in fostering interpersonal connections among physicians.” The Mayo Clinic and other institutions are reversing this trend by creating dedicated physician rooms for breaks, snacks, and a venue for peer interaction and camaraderie.
5. Rethinking rewards and incentives
Compensation is now commonly linked to productivity in many health care organizations, but this approach has some profound drawbacks: It can lead to physician burnout. Incentive structures based on patient satisfaction and quality metrics can have similar unintended consequences. All these incentive structures can combine to drive physicians to overwork. “Physicians may be particularly vulnerable to overwork due to high levels of education debt, their desire to ‘do everything for their patients,’ unhealthy role modeling by colleagues, and normalization of extreme work hours during the training process.” The investigators do not claim to have the ultimate answer to the problem of incentives that create unhealthy work patterns, but they argue that it is critical for leaders to recognize the potential unintended consequences of the productivity reward/incentive model and consider strategies to prevent overwork leading to burnout.
6. Aligning values and strengthening culture
The investigators also describe Mayo’s efforts to pursue self-appraisal of alignment of mission, values, and culture. They also describe the regular use of an all-staff survey, which has on occasion yielded candid feedback that, while not always flattering, has been the basis of a profound institutional rethink. The willingness of leadership to be receptive to hard truths from physicians is the foundation of institutional learning about burnout prevention and encourages engagement of the staff.
7. Promoting flexibility and work-life integration
Allowing employees greater flexibility in how and when they work is a management strategy that is gaining ground in many industries. Increasing part-time positions and expanding options for the work day have both been found to help prevent burnout and also help physicians recover from burnout. In addition, “institutions should also comprehensively examine the structure of their vacation benefits, coverage for life events (e.g., birth of a child, illness/death in family), approach to scheduling, and strategy for coverage of nights and weekends. Compensation practices that disincentivize using vacation time are shortsighted and should be eliminated.”
8. Providing resources to promote resilience and self-care
The solutions to burnout have been aimed at the individual and involve stress-reduction training and other personal management strategies. A metastudy of the interventions mentions psychoeducation, counseling, wellness management, interpersonal communication, and mindfulness meditation (J Nerv Ment Dis. 2014 May;202:353-9). But without concomitant structural reform, these individual solutions can backfire. “When individually focused offerings are not coupled with sincere efforts to address the system-based issues contributing to burnout, this approach is typically met with skepticism and resistance by physicians (‘They are implying I am the problem’). In this context, the response to well-intentioned ‘resilience training’ is frequently a cynical one (‘You only want to make me more resilient so you can further increase my workload’).”
9. Funding organizational research
Organizational science is a well-developed field of study. But cutting-edge management models such as the learning organization, participatory management, and collaborative action planning have been slow in coming to health care institutions. Dr. Shanafelt and Dr. Noseworthy argue that “vanguard institutions” such as the Mayo Clinic (which began its Program on Physician Well-Being in 2008), Stanford (Calif.) University, and other innovative institutions have the responsibility of developing evidence-based strategies to combat burnout that smaller institutions can implement.
Burnout among physicians is now on the radar of leadership in many health care institutions. Evidence on the cost and consequences is accumulating, and it becoming increasingly difficult to ignore what is happening to many physicians. Dr. Shanafelt projected an increasing need for operational solutions at the organizational level to address the problem. He said, “We need evidence to guide organizations to implement changes that truly make a difference, not well-intentioned but ineffective programs. Now that organizations recognize the strong business case, they are ready to invest resources to address this issue but they need to know it is money well spent and that there is an evidence-base to justify the investment.”
Most surgeons today are familiar with professional burnout – in their colleagues, in surgical trainees, and perhaps, in themselves. But the understanding of burnout is evolving. The discussion is moving away from blaming physicians for their poor coping skills toward identifying the structural and organizational roots of burnout.
Burnout is a syndrome cause by work-related stress that features emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. A recent study of nearly 7,000 physicians using the Maslach Burnout Inventory found that 54.4% of those surveyed reported at least one symptom of burnout (Mayo Clin Proc. 2015 Dec;90[12]:1600-19). Other studies have found similar rates of burnout in the surgical specialties such as orthopedic, oncologic, cardiothoracic, and plastic surgery (JAMA Surg. 2014 Sep;149:948-53; Ann Surg Oncol 2011 May;18:1229-35; Internat J Cardiol. 2015 Jan 20;179:7-72; Aesthet Surg J. 2016 Sep 27. E-pub ahead of print).
A new paradigm of burnout
The paradigm of burnout as a personal issue that can be managed by individual coping strategies is giving way to an understanding that the structural roots of burnout require the shared responsibility of individuals and their work organizations to solve the problem. A revised approach has emerged: Physician burnout as a symptom not of personal failure to cope, but of institutional failure to adapt to new circumstances in the health care milieu. The growing number of physicians employed in large group practices and medical centers has come with a whole array of management problems that are only beginning to be recognized, and burnout may be one of the most challenging.
Tait D. Shanafelt, MD, of the Mayo Foundation for Medical Education and Research, and John H. Noseworthy, MD, president and CEO of the Mayo Clinic, both in Rochester, Minn., have partnered to distill years of study and practice on the issue of burnout to a set of organizational strategies to tackle the problem and describe the Mayo Clinic experience. The study, “Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout” (Mayo Clin Proc. 2016 Nov 18. doi. org/10.1016/j.mayocp.2016.10.004) reverses the conventional “blame the victim” approach and identifies instead institutional responsibility to address burnout.
“Increasing evidence over the last 10 years demonstrating links to quality of care, productivity, and turnover have raised appreciation … by organizations that they have a substantial stake in this issue and that they control many of the factors that contribute to this problem,” said Dr. Shanafelt in an interview.
Unintended consequences of the individual solution
The focus on individual responsibility can have unintended consequences. A physician suffering from burnout can take action by leaving his or her job or cutting back. Staff turnover, a phenomenon closely tied to burnout, is costly and damaging to productivity and patient care (Physician Leadersh J. 2015 May-Jun;2[3]:22-5); Health Care Manage Rev. 2004;29[1]2-7). These personal strategies may help individuals cope but can end up harming the institution and the work life of other staff members. Physicians experiencing burnout in their own lives can trigger the same condition in their colleagues.
The Mayo paper by Dr. Shanafelt and Dr. Noseworthy states, “Mistakenly, most hospitals, medical centers, and practice groups operate under the framework that burnout and professional satisfaction are solely the responsibility of the individual physician. This frequently results in organizations pursuing a narrow list of ‘solutions’ that are unlikely to result in meaningful progress (e.g., stress management workshops and individual training in mindfulness/resilience). Such strategies neglect the organizational factors that are the primary drivers of physician burnout and are correctly viewed with skepticism by physicians as an insincere effort by the organization to address the problem.”
Organizational strategies to reduce burnout
Dr. Shanafelt and Dr. Noseworthy developed a list of nine organizational strategies that have been shown to reduce burnout among doctors. A critical piece of this approach is the accumulated evidence of the financial burden of burnout among physicians in health care institutions. The approach is based on an informed leadership that recognizes the costs of inaction, without which a systemic solution is unlikely to be achieved.
1. Naming the issue and assessing the problem
Acknowledgment of burnout as an institutional problem and meaningful measurement of physician well-being are the initial steps in tackling the problem. This requires a sincere commitment at the highest level of management to listen and to recognize what staff physicians are saying. “At Mayo Clinic, we have incorporated town halls, radio broadcasts, letters, and video interviews along with face-to-face meetings involving clinical divisions, work units, and small groups as formats or [by using] the CEO to reach the staff.” Assessing physician well-being and quality of work life using one or more of the many available tools has to be an ongoing “a barometer of organization health,” and not just a one-off, crisis management activity.
2. Harnessing the power of leadership
Studies have found that management behaviors and strategies of supervisors are key components of physician well-being. The bottom line is that physician supervisors must accept a share of responsibility for burnout in those they manage. Leaders can be chosen on the basis of their ability to listen, engage, develop, and lead, and but they can also be trained to improve. In addition, leaders should be regularly assessed by those whom they lead. Dr. Shanafelt and Dr. Noseworthy argue that a crucial element of successful leadership involves recognizing unique interests and talents of individual physicians whom they manage and facilitating professional development so that each staff member spends about 20% of work time engaged in activities that he or she finds most meaningful.
3. Developing targeted interventions
Just as all politics is local, the study suggests that many sources of burnout are local as well. For example, although a high clerical burden on physicians may be a universal driver of burnout, it manifests differently in each institutional setting. The key here is to dig into the specific structural driver at the unit or ward level, engage physicians in analysis and problem-solving, and implement a plan to address the problem.
Dr. Shanafelt noted, “We organize the drivers of engagement and burnout around seven dimensions: workload, efficiency, flexibility/control, community at work, organizational culture and values, work-life integration, and meaning in work. Each of these dimensions has organizational and individual components. Work units should begin by identifying which one or two dimensions are the biggest challenges for the group and then begin a stepwise process to address them.”
4. Cultivating community at work
Peer support, a long-standing source of strength among surgeons and other physicians, unintentionally has been eroded in many modern medical institutions. There is ample evidence that this loss of collegiality is tied to burnout. “These interactions have been an unintended casualty of increasing productivity expectations, documentation requirements, and clerical burden. [Many organizations have eliminated] formal spaces for physicians to interact (e.g., physicians’ lounge or dining room) without recognizing the important role that this dedicated space played in fostering interpersonal connections among physicians.” The Mayo Clinic and other institutions are reversing this trend by creating dedicated physician rooms for breaks, snacks, and a venue for peer interaction and camaraderie.
5. Rethinking rewards and incentives
Compensation is now commonly linked to productivity in many health care organizations, but this approach has some profound drawbacks: It can lead to physician burnout. Incentive structures based on patient satisfaction and quality metrics can have similar unintended consequences. All these incentive structures can combine to drive physicians to overwork. “Physicians may be particularly vulnerable to overwork due to high levels of education debt, their desire to ‘do everything for their patients,’ unhealthy role modeling by colleagues, and normalization of extreme work hours during the training process.” The investigators do not claim to have the ultimate answer to the problem of incentives that create unhealthy work patterns, but they argue that it is critical for leaders to recognize the potential unintended consequences of the productivity reward/incentive model and consider strategies to prevent overwork leading to burnout.
6. Aligning values and strengthening culture
The investigators also describe Mayo’s efforts to pursue self-appraisal of alignment of mission, values, and culture. They also describe the regular use of an all-staff survey, which has on occasion yielded candid feedback that, while not always flattering, has been the basis of a profound institutional rethink. The willingness of leadership to be receptive to hard truths from physicians is the foundation of institutional learning about burnout prevention and encourages engagement of the staff.
7. Promoting flexibility and work-life integration
Allowing employees greater flexibility in how and when they work is a management strategy that is gaining ground in many industries. Increasing part-time positions and expanding options for the work day have both been found to help prevent burnout and also help physicians recover from burnout. In addition, “institutions should also comprehensively examine the structure of their vacation benefits, coverage for life events (e.g., birth of a child, illness/death in family), approach to scheduling, and strategy for coverage of nights and weekends. Compensation practices that disincentivize using vacation time are shortsighted and should be eliminated.”
8. Providing resources to promote resilience and self-care
The solutions to burnout have been aimed at the individual and involve stress-reduction training and other personal management strategies. A metastudy of the interventions mentions psychoeducation, counseling, wellness management, interpersonal communication, and mindfulness meditation (J Nerv Ment Dis. 2014 May;202:353-9). But without concomitant structural reform, these individual solutions can backfire. “When individually focused offerings are not coupled with sincere efforts to address the system-based issues contributing to burnout, this approach is typically met with skepticism and resistance by physicians (‘They are implying I am the problem’). In this context, the response to well-intentioned ‘resilience training’ is frequently a cynical one (‘You only want to make me more resilient so you can further increase my workload’).”
9. Funding organizational research
Organizational science is a well-developed field of study. But cutting-edge management models such as the learning organization, participatory management, and collaborative action planning have been slow in coming to health care institutions. Dr. Shanafelt and Dr. Noseworthy argue that “vanguard institutions” such as the Mayo Clinic (which began its Program on Physician Well-Being in 2008), Stanford (Calif.) University, and other innovative institutions have the responsibility of developing evidence-based strategies to combat burnout that smaller institutions can implement.
Burnout among physicians is now on the radar of leadership in many health care institutions. Evidence on the cost and consequences is accumulating, and it becoming increasingly difficult to ignore what is happening to many physicians. Dr. Shanafelt projected an increasing need for operational solutions at the organizational level to address the problem. He said, “We need evidence to guide organizations to implement changes that truly make a difference, not well-intentioned but ineffective programs. Now that organizations recognize the strong business case, they are ready to invest resources to address this issue but they need to know it is money well spent and that there is an evidence-base to justify the investment.”
Patients want surgery for ventral hernia despite risks and comorbidity obstacles
An in-depth qualitative survey of patients’ expectations and satisfaction regarding ventral hernia management showed that while most were satisfied with surgical outcomes, many were uninformed about postoperative adverse outcomes and many were dissatisfied with nonoperative management.
Zeinab M. Alawadi, MD, and a team of researchers at the University of Texas Health Sciences Center, Houston, initially interviewed 30 patients seeking care for ventral hernia at a safety-net hospital prior to their surgical consultation about factors guiding their decision-making framework. A second interview was conducted 6 months later, asking about their level of satisfaction with their care and outcomes. The study appeared online Oct. 11 in the Journal of the American College of Surgeons.
The initial interview revealed that most patients had limited knowledge about risks and potential adverse outcomes of surgery, but nearly three-quarters of them wanted to undergo surgery for their ventral hernias. Only 7 of the 30 patients were treated surgically and of those, 2 reported an unexpected level of postoperative pain and dissatisfaction with the surgery outcome. The remaining five patients who had surgery were extremely satisfied with their decision.
Most of those interviewed had nonoperative management of their hernias, due to factors such as obesity, diabetes, and smoking. These patients expressed dissatisfaction with the obstacles of meeting surgical criteria, in particular the difficulties of losing weight and coping with diabetes. “From patients’ perspectives, the additional challenges of managing their diabetes and difficulties with exercising due to painful hernias represent overwhelming barriers to treating their obesity. Patients’ accounts do not reflect a simple failure to adhere to medical recommendations but substantial obstacles to losing weight,” the researchers noted. But these patients also expressed willingness to try to meet surgical criteria and to take responsibility for recurrence prevention by self-management.
This study provides insight into patient perceptions and expectation of ventral hernia surgery. “Several findings in this study suggest a need for better education and counseling of patients regarding the natural history of hernias and the risks and benefits of different management strategies. Self-contradicting patient responses regarding knowledge of surgical risks and benefits may represent poor communication by the physicians or poor understanding by the patients. As a result, patients appeared to have unrealistic expectations of surgery. In addition, contrary to the literature, patients appeared to disregard the physicians’ risk assessment and persisted in their preferences for surgical management, even after counseling.”
This work was supported by the Center for Clinical and Translational Sciences, which is funded by National Institutes of Health Clinical and Translational Award UL1 TR000371 and KL2 TR000370 from the National Center for Advancing Translational Sciences. The authors had no disclosures.
Read the complete study at goo.gl/pq4fjz.
An in-depth qualitative survey of patients’ expectations and satisfaction regarding ventral hernia management showed that while most were satisfied with surgical outcomes, many were uninformed about postoperative adverse outcomes and many were dissatisfied with nonoperative management.
Zeinab M. Alawadi, MD, and a team of researchers at the University of Texas Health Sciences Center, Houston, initially interviewed 30 patients seeking care for ventral hernia at a safety-net hospital prior to their surgical consultation about factors guiding their decision-making framework. A second interview was conducted 6 months later, asking about their level of satisfaction with their care and outcomes. The study appeared online Oct. 11 in the Journal of the American College of Surgeons.
The initial interview revealed that most patients had limited knowledge about risks and potential adverse outcomes of surgery, but nearly three-quarters of them wanted to undergo surgery for their ventral hernias. Only 7 of the 30 patients were treated surgically and of those, 2 reported an unexpected level of postoperative pain and dissatisfaction with the surgery outcome. The remaining five patients who had surgery were extremely satisfied with their decision.
Most of those interviewed had nonoperative management of their hernias, due to factors such as obesity, diabetes, and smoking. These patients expressed dissatisfaction with the obstacles of meeting surgical criteria, in particular the difficulties of losing weight and coping with diabetes. “From patients’ perspectives, the additional challenges of managing their diabetes and difficulties with exercising due to painful hernias represent overwhelming barriers to treating their obesity. Patients’ accounts do not reflect a simple failure to adhere to medical recommendations but substantial obstacles to losing weight,” the researchers noted. But these patients also expressed willingness to try to meet surgical criteria and to take responsibility for recurrence prevention by self-management.
This study provides insight into patient perceptions and expectation of ventral hernia surgery. “Several findings in this study suggest a need for better education and counseling of patients regarding the natural history of hernias and the risks and benefits of different management strategies. Self-contradicting patient responses regarding knowledge of surgical risks and benefits may represent poor communication by the physicians or poor understanding by the patients. As a result, patients appeared to have unrealistic expectations of surgery. In addition, contrary to the literature, patients appeared to disregard the physicians’ risk assessment and persisted in their preferences for surgical management, even after counseling.”
This work was supported by the Center for Clinical and Translational Sciences, which is funded by National Institutes of Health Clinical and Translational Award UL1 TR000371 and KL2 TR000370 from the National Center for Advancing Translational Sciences. The authors had no disclosures.
Read the complete study at goo.gl/pq4fjz.
An in-depth qualitative survey of patients’ expectations and satisfaction regarding ventral hernia management showed that while most were satisfied with surgical outcomes, many were uninformed about postoperative adverse outcomes and many were dissatisfied with nonoperative management.
Zeinab M. Alawadi, MD, and a team of researchers at the University of Texas Health Sciences Center, Houston, initially interviewed 30 patients seeking care for ventral hernia at a safety-net hospital prior to their surgical consultation about factors guiding their decision-making framework. A second interview was conducted 6 months later, asking about their level of satisfaction with their care and outcomes. The study appeared online Oct. 11 in the Journal of the American College of Surgeons.
The initial interview revealed that most patients had limited knowledge about risks and potential adverse outcomes of surgery, but nearly three-quarters of them wanted to undergo surgery for their ventral hernias. Only 7 of the 30 patients were treated surgically and of those, 2 reported an unexpected level of postoperative pain and dissatisfaction with the surgery outcome. The remaining five patients who had surgery were extremely satisfied with their decision.
Most of those interviewed had nonoperative management of their hernias, due to factors such as obesity, diabetes, and smoking. These patients expressed dissatisfaction with the obstacles of meeting surgical criteria, in particular the difficulties of losing weight and coping with diabetes. “From patients’ perspectives, the additional challenges of managing their diabetes and difficulties with exercising due to painful hernias represent overwhelming barriers to treating their obesity. Patients’ accounts do not reflect a simple failure to adhere to medical recommendations but substantial obstacles to losing weight,” the researchers noted. But these patients also expressed willingness to try to meet surgical criteria and to take responsibility for recurrence prevention by self-management.
This study provides insight into patient perceptions and expectation of ventral hernia surgery. “Several findings in this study suggest a need for better education and counseling of patients regarding the natural history of hernias and the risks and benefits of different management strategies. Self-contradicting patient responses regarding knowledge of surgical risks and benefits may represent poor communication by the physicians or poor understanding by the patients. As a result, patients appeared to have unrealistic expectations of surgery. In addition, contrary to the literature, patients appeared to disregard the physicians’ risk assessment and persisted in their preferences for surgical management, even after counseling.”
This work was supported by the Center for Clinical and Translational Sciences, which is funded by National Institutes of Health Clinical and Translational Award UL1 TR000371 and KL2 TR000370 from the National Center for Advancing Translational Sciences. The authors had no disclosures.
Read the complete study at goo.gl/pq4fjz.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Risk model predicts chronic postop pain for VHR patients
Postoperative pain that lingers for months is a common outcome of ventral hernia repair surgery. A predictive model has been developed by investigators at the Carolina Medical Center in Charlotte, N.C., to determine which hernia patients are at risk for chronic postoperative pain.
Tiffany C. Cox, MD, and the research team used the International Hernia Mesh Registry to obtain a sample of 887 ventral hernia repair patients that had surgery between 2007 and 2014. Data on postoperative pain was based on the Carolinas Comfort Scale questionnaire administered at 1, 6 and 12 months after surgery. Logistic regression analyses were used to determine independent predictors of postoperative chronic pain and a risk model was developed (Am J Surg. 2016 Sep; 212[3]:501-10).
The investigators concluded that the statistically significant predictors of risk for developing chronic postoperative pain at 1 year were preoperative pain and pain at 1 month of 2 or greater on the Carolina Comfort Scale (odds ratio, 2.97 and 2.64, respectively), female sex (OR, 1.74), and repair of recurrent hernias (OR, 1.59).
The predictive model for chronic postoperative pain may be helpful to surgeons in counseling patients and in devising postoperative interventions.
The investigators had no disclosures.
Read the full study at goo.gl/MRjM66.
Postoperative pain that lingers for months is a common outcome of ventral hernia repair surgery. A predictive model has been developed by investigators at the Carolina Medical Center in Charlotte, N.C., to determine which hernia patients are at risk for chronic postoperative pain.
Tiffany C. Cox, MD, and the research team used the International Hernia Mesh Registry to obtain a sample of 887 ventral hernia repair patients that had surgery between 2007 and 2014. Data on postoperative pain was based on the Carolinas Comfort Scale questionnaire administered at 1, 6 and 12 months after surgery. Logistic regression analyses were used to determine independent predictors of postoperative chronic pain and a risk model was developed (Am J Surg. 2016 Sep; 212[3]:501-10).
The investigators concluded that the statistically significant predictors of risk for developing chronic postoperative pain at 1 year were preoperative pain and pain at 1 month of 2 or greater on the Carolina Comfort Scale (odds ratio, 2.97 and 2.64, respectively), female sex (OR, 1.74), and repair of recurrent hernias (OR, 1.59).
The predictive model for chronic postoperative pain may be helpful to surgeons in counseling patients and in devising postoperative interventions.
The investigators had no disclosures.
Read the full study at goo.gl/MRjM66.
Postoperative pain that lingers for months is a common outcome of ventral hernia repair surgery. A predictive model has been developed by investigators at the Carolina Medical Center in Charlotte, N.C., to determine which hernia patients are at risk for chronic postoperative pain.
Tiffany C. Cox, MD, and the research team used the International Hernia Mesh Registry to obtain a sample of 887 ventral hernia repair patients that had surgery between 2007 and 2014. Data on postoperative pain was based on the Carolinas Comfort Scale questionnaire administered at 1, 6 and 12 months after surgery. Logistic regression analyses were used to determine independent predictors of postoperative chronic pain and a risk model was developed (Am J Surg. 2016 Sep; 212[3]:501-10).
The investigators concluded that the statistically significant predictors of risk for developing chronic postoperative pain at 1 year were preoperative pain and pain at 1 month of 2 or greater on the Carolina Comfort Scale (odds ratio, 2.97 and 2.64, respectively), female sex (OR, 1.74), and repair of recurrent hernias (OR, 1.59).
The predictive model for chronic postoperative pain may be helpful to surgeons in counseling patients and in devising postoperative interventions.
The investigators had no disclosures.
Read the full study at goo.gl/MRjM66.
FROM THE AMERICAN JOURNAL OF SURGERY