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Disaster Response
Lessons from Orlando
The recent nightclub shootings in Orlando have forced my colleagues and I at our Level I Trauma Center to reexamine the way we do business. Our typical approach to injury involves resource-intense therapy with a gang of clinicians, while anticipating no more than one or two patients at a time. While this model is excellent for training, we would struggle with the scale of casualties seen in Orlando.
Several observations may be made internally and have been made in the press. Triage should take place prior to the emergency department so that patients are appropriately prioritized to high-intensity support. Fundamental high-impact interventions requiring simple application, such as tourniquets, should be part of the training for all medical and nonmedical first responders. Perhaps most importantly, we need to reexamine the concept that health care is provided by competing geographic and economic entities. Evolution of trauma care has “followed the money” but not necessarily the need. An approach viewing trauma care as a right and acute response as a community resource may be necessary.
In 2008, the Republican Party held its convention in St. Paul, Minn. Reports indicated that 20,000-50,000 individuals were expected to enter the city, including protesters and anarchist groups. We prepared together for events ranging from vehicular crashes to biologic agents or explosive events (Dries et al. J Trauma. 2012; 73[6]:1614). Since then, however, there has been little community-wide planning.
Orlando reminds us that we dare not leave these plans on the shelf.
David Dries, MD, FCCP
Steering Committee Member
Practice Operations
MACRA, QPP, MIPS, APM: Know these acronyms
In October 2015, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). A bipartisan legislation, it replaces the flawed Sustainable Growth Rate (SGR) formula that would have forced a 21% cut in Medicare payments to clinicians. MACRA established Quality Payment Program (QPP) that has two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).
MIPS streamlines three currently independent programs – (Physician Quality Reporting Program [PQRS], Value-Based Payment Modifier [VM], and Medicare Electronic Health Records Incentive Program) – into a single program in which eligible professions (EPs) will be measured on quality (50%), resource use/cost (10%), clinical practice improvement activities (15%), and advancing care information (25%). The resulting composite performance score (CPS, scale 0-100) is used to determine and apply a +/- or neutral payment adjustment based on a performance threshold. Payment adjustments will begin in 2019 (based on 2017 performance period). Most physicians will be subject to MIPS, which does not apply to hospitals or facilities.
APMs are new approaches to paying for medical care incentivizing quality and value. As defined by MACRA, APMs include CMS Innovation Center models, the Medicare Shared Saving program, and certain demonstration programs. To qualify for payments, the APMs must also use certified EHR technology, report on certain quality measures, and bear more than nominal financial risk.
Both MIPS and APMs are value-based payment models that incentivize providers on quality, outcomes, and cost containment. Most physicians who see Medicare patients will be required to report either the MIPS or Advanced APM track starting in January 2017.
Editor’s Note – See additional article on MACRA on page in this issue.
Adel Bassily-Marcus, MD, FCCP
Vice-Chair
Transplant
Extracorporeal circulatory support in thoracic medicine and surgery – evolving technology and expanding role
There is growing interest in the use of extracorporeal support (ECS) beyond intraoperative and perioperative utility. This has been driven by improvements in safety and efficacy resulting from corresponding technological advances and enhanced user ability. The paucity of donors, however, remains a significant limiting factor in lung transplantation (LT), and there is a growing number of recipients on the waiting list getting too sick for transplantation. ECS is now commonly used to bridge recipients to LT, and reported outcomes show great promise. Indeed, there is even a growing interest in combining ECS with the ex vivo reconditioning of lungs in a further attempt to broaden the donor pool.
This newly developing paradigm constitutes a confluence of contemporary technologies that should allow more marginal or previously unacceptable donor lungs to be procured and also for the use of cardiopulmonary support to bridge sicker recipients safely. As with most technologies, the prerequisite capital outlay, training, and logistical resources will be required to allow for the acquisition of skill and safety. Furthermore, these trends will likely stimulate development of standards and guidelines to ensure a continuing quest for excellence.
The ongoing use of ECS in transplantation has a ripple effect that may prompt its use in other clinical scenarios, such as a rescue therapy in acute exacerbations of COPD, an alternative to mechanical ventilation following complex thoracic pulmonary or esophageal resections, and in cases of unexpected intraoperative cardiopulmonary collapse. One thing remains likely, however, ECS is here to stay.
Jeremiah Hayanga, MD
Steering Committee Member
Norihisa Shigemura, MD
Steering Committee Member
Women’s Health
Exposure of adolescents to electronic cigarettes: still a cause for alarm despite recent FDA ruling
Developed in 2003, electronic cigarettes (e-cigarettes) have been available in the United States since 2007. Between 2010 and 2013, adult use doubled. By 2013, the major tobacco companies had entered the market, and e-cigarettes were marketed widely (television, Internet, and print) as healthier alternatives to tobacco, useful for quitting smoking, and a way to circumvent smoke-free laws by allowing smokers to “smoke anywhere” (Grana et al. Circulation. 2014;129[19]:1972).
For adolescents, e-cigarette use tripled between 2013 and 2014, from 4.5% (660,000) to 13.4% (2 million) for high school students and from 1.1% (120,000) to 3.9% (450,000) for middle school students (CDC Press Release. http://www.cdc.gov/media/releases/2015/p0416-e-cigarette-use.html). Teenage experimentation, in conjunction with susceptibility to brain-modifying effects of nicotine, places this population at risk for lifelong nicotine addiction. Teenagers who use e-cigarettes are more likely to become regular cigarette smokers than nonusers (Dutra et al. JAMA Pediatr. 2014;168[7]:610; Levanthal et al. JAMA. 2015;314[7]:700). Local and state municipalities have enacted legislation, adding e-cigarettes and other electronic nicotine delivery systems (ENDS) to existing tobacco regulations. On May 5, 2016, a long-anticipated ruling from the FDA extended oversight to include all tobacco products, including e-cigarettes and hookahs, allowing the agency to address public health concerns, such as youth access. However, a key provision of the new tobacco “deeming” rules was subsequently removed less than a month later – one that would have removed flavored e-cigarettes, cigars, hookahs, and other flavored tobacco products from the market in November pending review by the Food and Drug Administration (Boyles. MedPage Today. medpagetoday.com/pulmonology/smoking/58274).
ENDS as a smoking cessation tool, a “safer” alternative to combustible tobacco, is much debated (Green et al. N Engl J Med. 2016;374[14]:1301). There is accumulating evidence of its in vivo and in vitro toxicity (Bhatnagar et al. Circulation. 2014;130[16]:1418; Gibbs et al. Chest. 2016;149[2]:552). Studies have shown that the varied concentration and flavorings used are cytotoxic to human embryonic stem cells as well as mice neural stem cells (Bahl et al. Reprod Toxicol. 2012[4];34:529) and that exposure to propylene glycol and glycerin, main base ingredients in e-liquids, can result in eye and respiratory irritation (Grana et al. Circulation. 2014; 129[19]:1972). Additionally, current evidence does not support e-cigarettes for smoking cessation (Grana et al. Circulation. 2014;129[19]:1972). The accumulating evidence of adverse effects and the increased use in adolescents underscores the need for stricter regulations by the FDA in order to prevent renormalization of the smoking behavior and to protect public health. The rollout of the FDA’s ruling will warrant ongoing evaluation.
Linda S. Efferen, MD, MBA
Consultant
Amanpreet Kaur, MD
Steering Committee Member
Disaster Response
Lessons from Orlando
The recent nightclub shootings in Orlando have forced my colleagues and I at our Level I Trauma Center to reexamine the way we do business. Our typical approach to injury involves resource-intense therapy with a gang of clinicians, while anticipating no more than one or two patients at a time. While this model is excellent for training, we would struggle with the scale of casualties seen in Orlando.
Several observations may be made internally and have been made in the press. Triage should take place prior to the emergency department so that patients are appropriately prioritized to high-intensity support. Fundamental high-impact interventions requiring simple application, such as tourniquets, should be part of the training for all medical and nonmedical first responders. Perhaps most importantly, we need to reexamine the concept that health care is provided by competing geographic and economic entities. Evolution of trauma care has “followed the money” but not necessarily the need. An approach viewing trauma care as a right and acute response as a community resource may be necessary.
In 2008, the Republican Party held its convention in St. Paul, Minn. Reports indicated that 20,000-50,000 individuals were expected to enter the city, including protesters and anarchist groups. We prepared together for events ranging from vehicular crashes to biologic agents or explosive events (Dries et al. J Trauma. 2012; 73[6]:1614). Since then, however, there has been little community-wide planning.
Orlando reminds us that we dare not leave these plans on the shelf.
David Dries, MD, FCCP
Steering Committee Member
Practice Operations
MACRA, QPP, MIPS, APM: Know these acronyms
In October 2015, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). A bipartisan legislation, it replaces the flawed Sustainable Growth Rate (SGR) formula that would have forced a 21% cut in Medicare payments to clinicians. MACRA established Quality Payment Program (QPP) that has two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).
MIPS streamlines three currently independent programs – (Physician Quality Reporting Program [PQRS], Value-Based Payment Modifier [VM], and Medicare Electronic Health Records Incentive Program) – into a single program in which eligible professions (EPs) will be measured on quality (50%), resource use/cost (10%), clinical practice improvement activities (15%), and advancing care information (25%). The resulting composite performance score (CPS, scale 0-100) is used to determine and apply a +/- or neutral payment adjustment based on a performance threshold. Payment adjustments will begin in 2019 (based on 2017 performance period). Most physicians will be subject to MIPS, which does not apply to hospitals or facilities.
APMs are new approaches to paying for medical care incentivizing quality and value. As defined by MACRA, APMs include CMS Innovation Center models, the Medicare Shared Saving program, and certain demonstration programs. To qualify for payments, the APMs must also use certified EHR technology, report on certain quality measures, and bear more than nominal financial risk.
Both MIPS and APMs are value-based payment models that incentivize providers on quality, outcomes, and cost containment. Most physicians who see Medicare patients will be required to report either the MIPS or Advanced APM track starting in January 2017.
Editor’s Note – See additional article on MACRA on page in this issue.
Adel Bassily-Marcus, MD, FCCP
Vice-Chair
Transplant
Extracorporeal circulatory support in thoracic medicine and surgery – evolving technology and expanding role
There is growing interest in the use of extracorporeal support (ECS) beyond intraoperative and perioperative utility. This has been driven by improvements in safety and efficacy resulting from corresponding technological advances and enhanced user ability. The paucity of donors, however, remains a significant limiting factor in lung transplantation (LT), and there is a growing number of recipients on the waiting list getting too sick for transplantation. ECS is now commonly used to bridge recipients to LT, and reported outcomes show great promise. Indeed, there is even a growing interest in combining ECS with the ex vivo reconditioning of lungs in a further attempt to broaden the donor pool.
This newly developing paradigm constitutes a confluence of contemporary technologies that should allow more marginal or previously unacceptable donor lungs to be procured and also for the use of cardiopulmonary support to bridge sicker recipients safely. As with most technologies, the prerequisite capital outlay, training, and logistical resources will be required to allow for the acquisition of skill and safety. Furthermore, these trends will likely stimulate development of standards and guidelines to ensure a continuing quest for excellence.
The ongoing use of ECS in transplantation has a ripple effect that may prompt its use in other clinical scenarios, such as a rescue therapy in acute exacerbations of COPD, an alternative to mechanical ventilation following complex thoracic pulmonary or esophageal resections, and in cases of unexpected intraoperative cardiopulmonary collapse. One thing remains likely, however, ECS is here to stay.
Jeremiah Hayanga, MD
Steering Committee Member
Norihisa Shigemura, MD
Steering Committee Member
Women’s Health
Exposure of adolescents to electronic cigarettes: still a cause for alarm despite recent FDA ruling
Developed in 2003, electronic cigarettes (e-cigarettes) have been available in the United States since 2007. Between 2010 and 2013, adult use doubled. By 2013, the major tobacco companies had entered the market, and e-cigarettes were marketed widely (television, Internet, and print) as healthier alternatives to tobacco, useful for quitting smoking, and a way to circumvent smoke-free laws by allowing smokers to “smoke anywhere” (Grana et al. Circulation. 2014;129[19]:1972).
For adolescents, e-cigarette use tripled between 2013 and 2014, from 4.5% (660,000) to 13.4% (2 million) for high school students and from 1.1% (120,000) to 3.9% (450,000) for middle school students (CDC Press Release. http://www.cdc.gov/media/releases/2015/p0416-e-cigarette-use.html). Teenage experimentation, in conjunction with susceptibility to brain-modifying effects of nicotine, places this population at risk for lifelong nicotine addiction. Teenagers who use e-cigarettes are more likely to become regular cigarette smokers than nonusers (Dutra et al. JAMA Pediatr. 2014;168[7]:610; Levanthal et al. JAMA. 2015;314[7]:700). Local and state municipalities have enacted legislation, adding e-cigarettes and other electronic nicotine delivery systems (ENDS) to existing tobacco regulations. On May 5, 2016, a long-anticipated ruling from the FDA extended oversight to include all tobacco products, including e-cigarettes and hookahs, allowing the agency to address public health concerns, such as youth access. However, a key provision of the new tobacco “deeming” rules was subsequently removed less than a month later – one that would have removed flavored e-cigarettes, cigars, hookahs, and other flavored tobacco products from the market in November pending review by the Food and Drug Administration (Boyles. MedPage Today. medpagetoday.com/pulmonology/smoking/58274).
ENDS as a smoking cessation tool, a “safer” alternative to combustible tobacco, is much debated (Green et al. N Engl J Med. 2016;374[14]:1301). There is accumulating evidence of its in vivo and in vitro toxicity (Bhatnagar et al. Circulation. 2014;130[16]:1418; Gibbs et al. Chest. 2016;149[2]:552). Studies have shown that the varied concentration and flavorings used are cytotoxic to human embryonic stem cells as well as mice neural stem cells (Bahl et al. Reprod Toxicol. 2012[4];34:529) and that exposure to propylene glycol and glycerin, main base ingredients in e-liquids, can result in eye and respiratory irritation (Grana et al. Circulation. 2014; 129[19]:1972). Additionally, current evidence does not support e-cigarettes for smoking cessation (Grana et al. Circulation. 2014;129[19]:1972). The accumulating evidence of adverse effects and the increased use in adolescents underscores the need for stricter regulations by the FDA in order to prevent renormalization of the smoking behavior and to protect public health. The rollout of the FDA’s ruling will warrant ongoing evaluation.
Linda S. Efferen, MD, MBA
Consultant
Amanpreet Kaur, MD
Steering Committee Member
Disaster Response
Lessons from Orlando
The recent nightclub shootings in Orlando have forced my colleagues and I at our Level I Trauma Center to reexamine the way we do business. Our typical approach to injury involves resource-intense therapy with a gang of clinicians, while anticipating no more than one or two patients at a time. While this model is excellent for training, we would struggle with the scale of casualties seen in Orlando.
Several observations may be made internally and have been made in the press. Triage should take place prior to the emergency department so that patients are appropriately prioritized to high-intensity support. Fundamental high-impact interventions requiring simple application, such as tourniquets, should be part of the training for all medical and nonmedical first responders. Perhaps most importantly, we need to reexamine the concept that health care is provided by competing geographic and economic entities. Evolution of trauma care has “followed the money” but not necessarily the need. An approach viewing trauma care as a right and acute response as a community resource may be necessary.
In 2008, the Republican Party held its convention in St. Paul, Minn. Reports indicated that 20,000-50,000 individuals were expected to enter the city, including protesters and anarchist groups. We prepared together for events ranging from vehicular crashes to biologic agents or explosive events (Dries et al. J Trauma. 2012; 73[6]:1614). Since then, however, there has been little community-wide planning.
Orlando reminds us that we dare not leave these plans on the shelf.
David Dries, MD, FCCP
Steering Committee Member
Practice Operations
MACRA, QPP, MIPS, APM: Know these acronyms
In October 2015, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). A bipartisan legislation, it replaces the flawed Sustainable Growth Rate (SGR) formula that would have forced a 21% cut in Medicare payments to clinicians. MACRA established Quality Payment Program (QPP) that has two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).
MIPS streamlines three currently independent programs – (Physician Quality Reporting Program [PQRS], Value-Based Payment Modifier [VM], and Medicare Electronic Health Records Incentive Program) – into a single program in which eligible professions (EPs) will be measured on quality (50%), resource use/cost (10%), clinical practice improvement activities (15%), and advancing care information (25%). The resulting composite performance score (CPS, scale 0-100) is used to determine and apply a +/- or neutral payment adjustment based on a performance threshold. Payment adjustments will begin in 2019 (based on 2017 performance period). Most physicians will be subject to MIPS, which does not apply to hospitals or facilities.
APMs are new approaches to paying for medical care incentivizing quality and value. As defined by MACRA, APMs include CMS Innovation Center models, the Medicare Shared Saving program, and certain demonstration programs. To qualify for payments, the APMs must also use certified EHR technology, report on certain quality measures, and bear more than nominal financial risk.
Both MIPS and APMs are value-based payment models that incentivize providers on quality, outcomes, and cost containment. Most physicians who see Medicare patients will be required to report either the MIPS or Advanced APM track starting in January 2017.
Editor’s Note – See additional article on MACRA on page in this issue.
Adel Bassily-Marcus, MD, FCCP
Vice-Chair
Transplant
Extracorporeal circulatory support in thoracic medicine and surgery – evolving technology and expanding role
There is growing interest in the use of extracorporeal support (ECS) beyond intraoperative and perioperative utility. This has been driven by improvements in safety and efficacy resulting from corresponding technological advances and enhanced user ability. The paucity of donors, however, remains a significant limiting factor in lung transplantation (LT), and there is a growing number of recipients on the waiting list getting too sick for transplantation. ECS is now commonly used to bridge recipients to LT, and reported outcomes show great promise. Indeed, there is even a growing interest in combining ECS with the ex vivo reconditioning of lungs in a further attempt to broaden the donor pool.
This newly developing paradigm constitutes a confluence of contemporary technologies that should allow more marginal or previously unacceptable donor lungs to be procured and also for the use of cardiopulmonary support to bridge sicker recipients safely. As with most technologies, the prerequisite capital outlay, training, and logistical resources will be required to allow for the acquisition of skill and safety. Furthermore, these trends will likely stimulate development of standards and guidelines to ensure a continuing quest for excellence.
The ongoing use of ECS in transplantation has a ripple effect that may prompt its use in other clinical scenarios, such as a rescue therapy in acute exacerbations of COPD, an alternative to mechanical ventilation following complex thoracic pulmonary or esophageal resections, and in cases of unexpected intraoperative cardiopulmonary collapse. One thing remains likely, however, ECS is here to stay.
Jeremiah Hayanga, MD
Steering Committee Member
Norihisa Shigemura, MD
Steering Committee Member
Women’s Health
Exposure of adolescents to electronic cigarettes: still a cause for alarm despite recent FDA ruling
Developed in 2003, electronic cigarettes (e-cigarettes) have been available in the United States since 2007. Between 2010 and 2013, adult use doubled. By 2013, the major tobacco companies had entered the market, and e-cigarettes were marketed widely (television, Internet, and print) as healthier alternatives to tobacco, useful for quitting smoking, and a way to circumvent smoke-free laws by allowing smokers to “smoke anywhere” (Grana et al. Circulation. 2014;129[19]:1972).
For adolescents, e-cigarette use tripled between 2013 and 2014, from 4.5% (660,000) to 13.4% (2 million) for high school students and from 1.1% (120,000) to 3.9% (450,000) for middle school students (CDC Press Release. http://www.cdc.gov/media/releases/2015/p0416-e-cigarette-use.html). Teenage experimentation, in conjunction with susceptibility to brain-modifying effects of nicotine, places this population at risk for lifelong nicotine addiction. Teenagers who use e-cigarettes are more likely to become regular cigarette smokers than nonusers (Dutra et al. JAMA Pediatr. 2014;168[7]:610; Levanthal et al. JAMA. 2015;314[7]:700). Local and state municipalities have enacted legislation, adding e-cigarettes and other electronic nicotine delivery systems (ENDS) to existing tobacco regulations. On May 5, 2016, a long-anticipated ruling from the FDA extended oversight to include all tobacco products, including e-cigarettes and hookahs, allowing the agency to address public health concerns, such as youth access. However, a key provision of the new tobacco “deeming” rules was subsequently removed less than a month later – one that would have removed flavored e-cigarettes, cigars, hookahs, and other flavored tobacco products from the market in November pending review by the Food and Drug Administration (Boyles. MedPage Today. medpagetoday.com/pulmonology/smoking/58274).
ENDS as a smoking cessation tool, a “safer” alternative to combustible tobacco, is much debated (Green et al. N Engl J Med. 2016;374[14]:1301). There is accumulating evidence of its in vivo and in vitro toxicity (Bhatnagar et al. Circulation. 2014;130[16]:1418; Gibbs et al. Chest. 2016;149[2]:552). Studies have shown that the varied concentration and flavorings used are cytotoxic to human embryonic stem cells as well as mice neural stem cells (Bahl et al. Reprod Toxicol. 2012[4];34:529) and that exposure to propylene glycol and glycerin, main base ingredients in e-liquids, can result in eye and respiratory irritation (Grana et al. Circulation. 2014; 129[19]:1972). Additionally, current evidence does not support e-cigarettes for smoking cessation (Grana et al. Circulation. 2014;129[19]:1972). The accumulating evidence of adverse effects and the increased use in adolescents underscores the need for stricter regulations by the FDA in order to prevent renormalization of the smoking behavior and to protect public health. The rollout of the FDA’s ruling will warrant ongoing evaluation.
Linda S. Efferen, MD, MBA
Consultant
Amanpreet Kaur, MD
Steering Committee Member
