JUNE 2007 Volume 92, Number 6

FEATURES Stephen J. Regnier Indian Health Service: Editor Providing care to Native Americans and Alaska Natives 12 Thomas K. Stempel, MD, FACS, CAPT USPHS(Ret) Linn Meyer The ACS Case Log System: A key tool for surgical self-evaluation, Director of privileging, and maintenance of certification 17 Communications M. Michael Shabot, MD, FACS, and Howard Tanzman The ACS Surgical Quality Alliance: Karen Stein Specialty societies improving quality for the surgical patient 21 Associate Editor Frank Opelka, MD, FACS, and Julie Lewis Diane S. Schneidman Surgical research and the new privacy laws 26 Peter K. Henke, MD, FACS; Misty Fewel, MPH; and Matt Fewel, MD Contributing Editor

The COT’s Resident Papers Competition: Tina Woelke Promoting careers in trauma surgery 30 Graphic Design Specialist Gregory J. Jurkovich, MD, FACS Alden H. Harken, MD, FACS DEPARTMENTS Charles D. Mabry, MD, FACS Jack W. McAninch, MD, From my perspective 4 Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director FACS Editorial Advisors Dateline: Washington 6 Division of Advocacy and Health Policy Tina Woelke What surgeons should know about... 8 Front cover design Medicare’s Physician Quality Reporting Initiative Jean A. Harris Socioeconomic tips 36 ACS Coding Hotline: Unusual coding questions Future meetings Division of Advocacy and Health Policy

Clinical Congress 2007 New Orleans, LA, October 7-11 2008 San Francisco, CA, October 12-16 2009 Chicago, IL, October 11-15

On the cover: Surgical research—in particular, large registry studies—is likely to be affected, sometimes negatively, by the Health Insurance Portability and Ac- countability Act (see article, page 26). Photos courtesy of Punchstock. NEWS Bulletin of the American College of Surgeons (ISSN In memoriam: 0002-8045) is published Remembering Edwin W. Gerrish 37 monthly by the American Col- Barbara L. Dean lege of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. It COT 2007 Resident Trauma Papers Competition is distributed without charge to Fellows, to Associate Fellows, winners announced 39 to participants in the Candi- date Group of the American NQF endorses measures developed College of Surgeons, and to by the ACS Commission on Cancer 40 medical libraries. Periodicals postage paid at Chicago, IL, ACS endorses National Time Out Day 41 and additional mailing offices. POSTMASTER: Send address Surgeons Diversified Investment Fund’s (SDIF) changes to Bulletin of the first quarter 2007 performance report 43 American College of Surgeons, 633 N. Saint Clair St., Chicago, ACS resident research scholarships available 45 IL 60611-3211. Canadian Pub- lications Mail Agreement No. ACOSOG news: 40035010. Canada returns to: Neoadjuvant aromatase inhibitor trial for breast cancer 47 Station A, PO Box 54, Windsor, David Ota, MD, FACS, and Heidi Nelson, MD, FACS ON N9A 6J5. The American College of A look at The Joint Commission: Patient safety Surgeons’ headquarters is and health care quality performance of U.S. hospitals 49 located at 633 N. Saint Clair St., Chicago, IL 60611-3211; Disciplinary actions taken 50 tel. 312/202-5000; toll-free: 800/621-4111; fax: 312/202- NTDB® data points: 5001; e-mail:postmaster@ What a disaster 51 facs.org; Web site: www.facs. org. Washington, DC, office Richard J. Fantus, MD, FACS, and Jeffrey S. Hammond, MD, MPH, FACS is located at 1640 Wisconsin Ave., NW, Washington, DC Operation Giving Back: 20007; tel. 202/337-2701, fax Volunteer opportunities available 52 202/337-4271. Unless specifically stated Chapter news 53 otherwise, the opinions ex- Rhonda Peebles pressed and statements made in this publication reflect the authors’ personal observations and do not imply endorse- ment by nor official policy of the American College of Sur- geons.

©2007 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmit- ted in any form by any means without prior written permis- sion of the publisher. Library of Congress number 45-49454. Printed in the USA. The American College of Surgeons is dedicated to improving the care of the sur- Publications Agreement No. gical patient and to safeguarding standards of care in an optimal and ethical 1564382. practice environment.

AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION •

 SYLLABI SELECT: The content of select ACS Clinical Congress postgraduate courses is available on CD-ROM.

 BASIC ULTRASOUND COURSE: This course has been developed on CD-ROM to provide the practicing surgeon and surgical resident with a basic core of education and train- ing in ultrasound imaging as a foundation for specific clinical applications. It replaces the basic course offered at the Clinical Congress and is available for CME credit.

 PROFESSIONALISM IN SURGERY: CHAL- LENGES AND CHOICES: This CD presents 12 case vignettes, each including a scenario followed by multiple-choice questions related to professional responsibilities of the surgeon within the context of the case. The program provides a printable CME certificate upon successful completion.

 PERSONAL FINANCIAL PLANNING AND MANAGEMENT for Residents and Young Sur- geons: This CD uses an interactive/lecture format to equip residents and young surgeons with the knowledge to manage their personal financial future, including debt management and financial planning for surgical practice. This program provides a printable CME certificate upon successful completion.

 PRACTICE MANAGEMENT for Residents and Young Surgeons: This CD uses an interactive/lecture format to equip residents and young surgeons with the knowledge to manage their surgical future, including how to select a practice type and location, the mechanics of setting up or running a pri- vate practice, the essentials of an academic practice and career pathways, and surgical coding basics. This program provides a printable CME certificate upon successful completion.

 BARIATRIC SURGERY PRIMER: This CD addresses various aspects of bariatric surgery, including the biochemistry and physiology of obesity, appropriate candidates, basic bariatric procedures, comorbidity and outcomes, and surgical training, as well as facilities, managed care, liability  NEW: DISCLOSING SURGICAL ERROR: issues, and ethics. VIGNETTES FOR DISCUSSION: This DVD demonstrates two approaches used by a surgeon to disclose to the patient’s  ONLINE CME: Courses from the ACS’ Clinical Con- family a major technical error that occurred in the operating room. gresses are available online for surgeons. Each online course The vignettes demonstrate effective disclosure techniques, as well features a video introduction, slideshow presentations with as approaches that need improvement. This project was supported synchronized audio of session, printable written transcripts, by a grant from the Agency for Healthcare Research and Quality and printable CME certificate upon successful completion. The and is available at no cost. courses are accessible at www.acs-resource.org.

For purchase and pricing information, call ACS Customer Service at 312/202-5474 or visit our E-LEARNING RESOURCE CENTER at www.acs-resource.org

For more information contact Olivier Petinaux, MS, at [email protected], or tel. 866/475-4696.

All-Products-Ad-Bulletin-(revise1 1 3/15/2007 3:50:16 PM From my perspective

he financial constraints and administra- tive burdens associated with our current

health care system are clearly untenable

Tto many surgeons. With considerable frequency, members of this organization contact me to talk about “the good old days” before man- aged care, before government intervention, before ’’ Medicare instituted the resource-based relative value scale, and so on. Their sentiments are com- pletely understandable. The existing structure is riddled with financial inequities for health care professionals and with access disparities for pa- We also cannot ignore the tients. In the effort to reduce health care spend- ing and redistribute payments across specialties, reasons why we went into surgeons have been particularly hard-hit. The good news is that our health care system, surgery in the first place. albeit slowly and incrementally, is being reformed in ways that we anticipate will lead to greater fairness for all. Clearly, the upcoming presidential ’’ election will only focus the spotlight more intently on the need for positive change. We cannot, and will not, ignore the problems facing surgeons and their patients, and the Col- has perceived us as being consumed with concerns lege will continue to do all it can to make sure the about money and disinterested in their health upcoming changes will have positive outcomes for and well being. This erosion of mutual trust has our members so that their practices will not just been to the detriment of both surgeons and their survive, but will thrive. However, we also cannot patients. ignore the reasons why we went into surgery in Fortunately, the nation appears to be on the the first place, and we need to begin to turn a good brink of instituting changes that will lead to a part of our attention away from the spreadsheet new method for reimbursing surgeons for the and refocus on the hospital bed sheet. We need to services they provide. As discussed previously concentrate on the joys of patient care and worry a in this column and in many Bulletin articles, bit less about whether and how we will be paid. If the health care system of the future will center we concentrate on the core mission of our profes- on value-based care. Patients and payors alike sion, which is taking care of the surgical patient, will be looking to take their health care needs to we will reconfirm the value of high-quality surgical health care professionals and institutions with care and, ultimately, build a system that treats our substantiated track records as providers of safe, profession with more equity. high-quality care. These individuals and facilities will, in turn, be rewarded financially. Through Business matters dominate the Division of Advocacy and Health Policy and The existing health care system—which increas- the ongoing development of quality improvement ingly has turned into a big business rather than programs, the College is working to ensure that a means of providing the public with necessary surgeons have input into the design of the revital- services—has perniciously bred cynicism among ized system. surgeons and other health care professionals. As we have turned our focus to the financial bot- “Listen up” tom line, the physician-patient relationship has As the nation proceeds to test the new schematic, eroded. The louder we have complained about the time is ripe for us to look at what we can do as a decreases in payment and increases in liability profession not only to provide efficient and effective costs and practice expenses, the more the public care, but to rebuild the precious physician-patient 

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS relationship. For starters, we need to sharpen our tendencies to once again shine and influence the listening and communication skills. Too often, ways in which we provide care. patients and their loved ones report that surgeons Our patients and their families must once again and other physicians spend scant time listening to be able to trust that we will tend to their most their concerns and explaining what we are doing distressing and painful conditions and experiences and why we are doing it. with the same respect and sensitivity with which The negative effects of ineffectual communi- we would want to be treated. We must be mindful cation are evident when we look at the medical of each patient’s unique needs, fears, and desires, liability situation. For example, the ACS Closed not just to determine how we should proceed in Claims Study, described in the January 2007 treating the individual but to determine what edition of the Bulletin (page 11), showed that 90 we should avoid doing as well. A difficult pill for of 460 medical liability claims (19.8%) were filed many surgeons to swallow is that it is not always largely, if not entirely, because of communication in someone’s best interests to engage in surgical failures. Lawsuits stemming from communica- heroics. We need to do less and do it right. We tion breakdowns occurred predominantly with need to limit unnecessary, unproven, unwanted patients and/or families (36 claims), nurses (19 procedures and expand our willingness to offer claims), laboratory personnel (one claim), and chronic disease management and palliative care physicians (35 claims). Problems arose from both as appropriate and in accordance with a patient’s the failure to listen to or solicit information (47 personal wishes. claims) and the failure to convey information The patient-physician relationship remains (46 claims). uniquely intimate and, therefore, dependent on With respect to listening, claims reviews in- unqualified trust. Our patients must have every dicated defendant-surgeons heard selectively, assurance that we will put their well being ahead interpreting input in favor of the best scenario. of our pocketbooks or our desire to be “number Defendant-surgeons also failed to request more one.” They rely on us to treat them competently information than others volunteered. They re- and humanely, to help them to make informed sisted probing for evidence that confirmed or choices, and to provide the level of care that will contradicted their determinations. help to improve their quality of life. Unquestionably, we surgeons need to disabuse If we turn some of our attention away from our ourselves of the belief that we alone know what financial woes and refocus on providing compas- is best for our patients, that we need not weigh sionate, high-quality care, we will likely regain the input from other team members or from our pa- public’s respect and once again experience the joy tients and their families. To help surgeons develop of surgery as a career. their competence as listeners and presenters of information, the College’s Division of Education formed a Task Force on Interpersonal and Com- munication Skills. Among other activities, this task force offers the course Surgeons As Effective Communicators: Sharpening Skills for Critical Moments. Thomas R. Russell, MD, FACS Empathy sMost of u chose surgery as our life’s work be- cause we wanted to help people. We wanted to do our part in eradicating human suffering and to experience the satisfaction that comes from see- ing others get well and lead productive lives. We had an inherent sense of compassion for human- If you have comments or suggestions about this or ity and empathy for the health problems many other issues, please send them to Dr. Russell at fmp@ people must face. We must allow these intrinsic facs.org. 

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dateline Washington prepared by the Division of Advocacy and Health Policy

In April, the National Quality Forum (NQF) and one of its steer- NQF approves ing committees approved quality measures recommended by the ACS quality American College of Surgeons and related organizations. More specifi- cally, on April 12, the NQF endorsed the first nationally recognized measures hospital-based performance measures for quality of care for breast and colorectal cancer. Leading this effort were the College’s Commission on Cancer, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. For more information about the ap- proved cancer measures, see the article on page 40. In addition, on April 3, the NQF’s Steering Committee on Consen- sus Standards for Hospital Care approved a set of five physician-level performance measures the College proposed. The ACS developed the metrics in collaboration with the American Medical Association’s Physician Consortium for Performance Improvement, the National Committee for Quality Assurance, and numerous surgical specialty and anesthesiology organizations. The measures seek to reduce surgi- cal site infections and focus on timing for administration of antibiotic prophylaxis, selection of prophylactic antibiotics, and discontinuation of prophylactic antibiotics. Each measure has a distinct list of relevant procedures to which it applies. The measures were previously approved in October 2006 by the AQA, a multistakeholder alliance concerned with the implementa- tion of quality measures, and have been adopted by the Centers for Medicare & Medicaid Services (CMS) for use in the Physician Quality Reporting Initiative, a new pay-for-reporting program that begins July 1. The measures are now subject to NQF’s public comment period, which will be followed by final approval. The antibiotic measures are part of the Perioperative Care Measure Set, which also includes a deep vein thrombosis prophylaxis measure that is currently in the NQF voting phase. For further information, contact Courtney Maggiulli at [email protected].

Both the U.S. House of Representatives and Senate passed the Trauma Trauma Care Systems Planning and Development Act of 2007, H.R. reauthorization 727, before Congress’ spring recess. This legislation reauthorizes the Health Resources and Services Administration’s (HRSA’s) Trauma- bill passed Emergency Medical Services (EMS) program through fiscal year (FY) 2012, with authorization set at $12 million for FY 2008, $10 million for FY 2009, and $8 million for 2010–2012. The bill also creates a new competitive grant program for states that have already begun estab- lishing a trauma system using national standards and protocols. At press time, President Bush had not yet signed the legislation. To ensure that the program receives adequate funding, the Col- lege is asking its members to contact their legislators and ask that they support $12 million in the appropriations bill from the Senate Committee on Labor, Health & Human Services, and Education for HRSA’s Trauma-EMS program for FY 2008. To contact members of Congress, go to the College’s Legislative Action Center at http://www. capitolconnect.com/acspa/, and for more information, contact Adrienne Roberts at [email protected]. 

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS On March 21, the U.S. Food and Drug Administration (FDA) an- Tougher standards nounced a new draft guidance that would implement a more stringent set for FDA approach to considering potential conflicts of interest for advisory committee members and meeting participants. The FDA currently advisors screens prospective advisory committee participants before each meet- ing to determine whether they have any potential financial conflicts of interest. However, according to policy, the FDA may grant waivers to a prospective participant if, for example, the individual’s expertise outweighs the potential for a conflict of interest. The draft guidance would replace a directive issued in 2000 on FDA waiver criteria, which addressed the variables that may apply in determining whether an individual qualifies for advisory committee membership and meeting participation. The FDA has since found that the 2000 guidance is too complex to achieve consistent results. The agency anticipates that this new directive would help to standardize the process of recommending waivers. For further information, go to http://www.fda.gov/oc/advisory/waiver/coiguidedft.html.

The Medicare program recently announced rules for competitive bid- Bidding rules ding of durable medical equipment, prosthetics, orthotics, and supplies for DMEPOS (DMEPOS) for 2008. The rules include an exception that allows physicians to furnish items on the list of products to their patients without having to announced participate in the competitive bidding process. The competitive bidding pro- gram will launch in the following metropolitan statistical areas: Charlotte- Gastonia-Concord, NC-SC; Cincinnati-Middletown, OH-KY-IN; Cleveland- Elyria-Mentor, OH; Dallas-Fort Worth-Arlington, TX; Kansas City, MO-KS; Miami-Ft. Lauderdale-Miami Beach, FL; Orlando, FL; Pittsburgh, PA; Riverside-San Bernardino-Ontario, CA; and San Juan-Caguas-Guaynabo, PR. For more information, visit http://www.cms.hhs.gov/apps/media/ press/release.asp?Counter=2097&intNumPerpage=10.

In a major disappointment to the surgical community, all three cer- Rumors sink tificate of need (CON) reform bills under consideration in the Georgia Georgia CON General Assembly failed to make the “crossover” deadline of March 27. Crossover is the point at which bills are passed in one house and sent bill on to the other chamber or are seen as dead for the year. (Legislative language can still be adopted in the latter instance if amended to a bill that survived the deadline.) One of the bills, H.B. 337, specifically would have redefined general surgery as a single specialty. Currently, general surgery is defined as a multispecialty in Georgia and, there- fore, is ineligible for the single-specialty exemption in the state’s CON law for ambulatory surgery centers. It appeared that H.B. 337 might make it through the business session of the Georgia House on March 27, but then rumors began spreading alleging that approval of the bill would make it possible for general surgeons to perform complex surgical procedures in their offices and to open abortion clinics. As a result, with a procedural vote of 112-52, the bill was recommitted to the House Rules Committee. For more information, contact Jon Sutton at [email protected]. 

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS What surgeons should know about…

Medicare’s Physician Quality Reporting Initiative by Jean A. Harris, Associate Director, Division of Advocacy and Health Policy

provision in the Tax Relief and Healthcare What quality measures are available for Act, which President Bush signed into law surgeons? How were they developed? A on December 20, 2006, did two things: It froze the conversion factor for physician payment The American College of Surgeons developed in 2007 at the 2006 amount, thus averting a 5 six measures that are applicable to many surgi- percent payment cut, and it gave physicians who cal specialties. Three measures applicable to successfully report quality measures on their cataract surgery developed by the American claims for services during the last half of 2007 a Academy of Ophthalmology and four measures bonus of up to 1.5 percent of allowed charges for applicable to coronary artery bypass graft all claims during the same six-month period. (CABG) developed by the Society of Thoracic This article will discuss the new voluntary Surgeons also are included in the PQRI. (See reporting program, known as the Medicare the text box on page 9 for a description of the Physician Quality Reporting Initiative (PQRI). measures.) There is a total of 74 performance If you want to participate in the program, it measures available for use by physicians and many is essential that you begin reporting the qual- nonphysicians, including nurse practitioners and ity measures with dates of service effective on physician assistants. July 1. Physicians will choose three performance The performance measures included in the measures on which they must meet an 80 percent PQRI were developed by physicians, includ- reporting rate. ing many in collaboration with the American Briefly, the PQRI works as follows: Medical Association’s Physician Consortium for • The physician voluntarily reports on qual- Performance Improvement. In addition, the mea- ity measures for procedures performed during sures were vetted through the AQA (formerly July 1 through December 31, 2007. the Ambulatory Quality Association) and/or • Quality measures are reported on the same the National Quality Forum (NQF), both multi- claim as the substantive procedure code, gen- stakeholder organizations. Each of these groups erally using Current Procedural Terminology has a different role to play in ensuring that the (CPT)I level I “procedure” codes.* measures are scientifically valid, represent an • A bonus payment of up to 1.5 percent of area where quality can be improved, and can all allowed charges during the same period will work in a claims-based system. be paid in a lump sum in mid-2008. Complete information on the PQRI can be How do I know when I can report a qual- found on the Web site of the Centers for Medi- ity measure? care & Medicaid Services (CMS) at http://www. cms.hhs.gov/PQRI. The first Web page contains tLook a the specifications for the quality mea- some general information about the PQRI; more sure on the CMS Web site. In the section of the detailed information is on subsequent pages specification labeled “denominator,” surgical listed on the left side of the screen. Additional measures have a list of CPT procedure codes information can be found on the College’s Web site to which the measure applies. Many nonsurgi- at www.facs.org/ahp/pqri. cal measures contain diagnosis codes from the *All specific references to CPT (Current Procedural Terminology) International Classification of Diseases, Ninth terminology and phraseology are © 2006 American Medical Revision, Clinical Modification (ICD-9-CM) and a Association. All rights reserved. range of CPT evaluation and management (E/M) 

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Quality measures related to surgical procedures

To facilitate searches on the Centers for Medicare & Medicaid Services (CMS) Web site, the number as- signed to each measure by CMS is shown in parentheses after the description, followed by the organization that sponsored the measure. Consult the CMS Web site to see other measures surgeons may use that are not specific to a surgical procedure.

• Perioperative care: Selection of prophylactic antibiotic—First or second generation Cephalosporin: Percentage of patients undergoing procedures with the indications for a first- or second- generation cephalosporin prophylactic antibiotic who had an order for cefazolin or cefuroxime for antimi- crobial prophylaxis (21) (ACS)

• Perioperative care: Timing of antibiotic prophylaxis—Ordering physician: Percentage of patients undergoing procedures with the indications for prophylactic parenteral antibiotics who have an order for it to be given within one hour (if fluoroquinolones or vancomycin, two hours) prior to the start of procedure (20) (ACS)

• Perioperative care: Timing of prophylactic antibiotic—Administering physician: Percentage of patients for whom administration of prophylactic parenteral antibiotic has been initiated as ordered (30) (ACS)

• Perioperative care: Discontinuation of prophylactic antibiotics (noncardiac procedures): Percentage of patients undergoing noncardiac procedures who received a prophylactic antibiotic and who have an order for discontinuation of prophylactic antibiotics within 24 hours of surgical end time (22) (ACS)

• Perioperative care: Venous thromboembolism (VTE) prophylaxis: Percentage of patients under- going procedures for which VTE prophylaxis is indicated in all patients who had an order for low molecular weight heparin, low-dose unfractionated heparin, adjusted-dose warfarin, fondaparinux, or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time (23) (ACS)

• Preoperative beta-blocker in patients with isolated coronary artery bypass graft (CABG) surgery: Percentage of patients undergoing CABG surgery who received a betablocker preoperatively (44) (Society of Thoracic Surgeons [STS])

• Use of internal mammary artery (IMA) in CABG surgery: Percentage of patients undergoing CABG surgery using an IMA (43) (STS)

• Perioperative care: Discontinuation of prophylactic antibiotics (cardiac procedures): Per- centage of patients undergoing cardiac procedures who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time (45) (ACS)

• Cataracts: Assessment of visual functional status: Percentage of patients who were assessed for visual functional status within 12 months (15) (American Academy of Ophthalmology [AAO])

• Cataracts: Presurgical dilated fundus evaluation: Percentage of patients who had a fundus evalu- ation performed within six months prior to the procedure (17) (AAO)

• Cataracts: Documentation of presurgical axial length, corneal power measurement, and method of intraocular lens power calculation: Percentage of patients who had the presurgical axial length, corneal power measurement, and method of intraocular lens power calculation performed within six months prior to the procedure (16) (AAO)



JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS codes; the measure is suitable if both the ICD-9- is (15) [(3.00)($100)], or $4,500. That is the maxi- CM and the CPT codes are present on the claim mum that can be paid to that individual. form. While visiting the CMS Web site, look at the material ahead of the “denominator” section How and when will the bonus be paid? to see the details about the measure, including the CPT Category II codes. The statute specifies that for 2007 the payment will be made to the holder of the taxpayer identi- Who decides which quality measures I fication number. A single bonus payment will be should report? What constitutes successful made in mid-2008. The statute requires that the reporting? bonus be based on all claims paid as of February 29, 2008, so CMS cannot do final calculations until Itp is u to the surgeon to decide which quality after that date. Surgeons should be sure they know measures to report. However, reporting must how the bonus payment will be handled by the meet certain criteria to be considered successful, holder of the taxpayer identification number. and only physicians who are considered success- ful qualify for the bonus. If one, two, or three How do I report the quality measure? measures are selected, the reporting will be con- sidered successful if each measure is reported 80 Report the quality measure on either the same percent of the time. If four or more measures are claim form (CMS-1500) or the same electronic selected, at least three of them must be reported transaction (ASC X12N 837) as the substantive 80 percent of the time. procedure code is reported. Necessary data ele- CMS will count the number of times a quality ments include date of service; place of service; measure could have been reported, determine PQRI quality data code and modifier, if appro- whether the quality measure was also reported, priate; submitted charge in dollars and cents; and do the arithmetic to determine if the surgeon and the rendering provider number. The date was successful in reporting the measures. This of service should be the same as the date of the analysis is performed at the individual physi- substantive procedure code even though orders cian level. for or actual performance of the quality measure may have occurred on a different date. If your How much will the bonus be? system cannot accept a charge of the specified dollar amount, a small amount may be substi- For participants who meet the reporting tuted. However, no beneficiary copayment is thresholds, the bonus will be equal to 1.5 percent allowed for quality measures. of the allowed amount for all services performed On the ASC X12N 837, the codes are submitted under the Medicare physician fee schedule in on the SV1 “Professional Service” segment of the the last six months of the year. However, a cap 2400 “Service Line” loop. The data element for has been placed on the amount of the bonus for the procedure code is SV 101-2, “Product/Service someone who reports relatively little quality ID.” You must identify in this segment that you data. Unfortunately, the cap can only be calcu- are supplying a “procedure” code by submitting lated when the bonus payments are made. The the “HC” code for data element SV101-1. formula is: Cap = (I) [300% (A ÷ M)], where I = Number of measures an individual reported, Which data are to be released to inform A = National allowed charges associated with me of the quality of my data reporting? Is measures, and M = National instances of mea- any of this information going to be made sures reported. public? For example, assume the national allowed charges associated with measures (A) divided Physicians who report quality data will get by the national instances of measures reported a single, confidential report at approximately (M) is $100 and that an individual reports only the same time the bonus payment is released. 15 quality measures. The cap for that individual CMS is still working out the details of what is 10

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS to be in that report, but the agency says that, idly growing phenomenon. Physicians are facing a at minimum, the report will contain the data 10 percent cut under the current statute, so there necessary to compute the bonus payment. CMS will be sympathy for taking some action to give will not release to the public any data from the physicians a freeze or a small update in exchange 2007 PQRI. The aim of the 2007 PQRI is for for paying for quality. But such an outcome is far physicians to get experience in reporting quality from being a “done deal.” data and calculating bonus payments. Although CMS is precluded by statute from hav- Why do I have to report quality measures ing an appeals process under the PQRI, the group on the same claim as the substantive pro- is planning some sort of an inquiry process that cedure? would permit the correction of obvious errors. CMSo has n way to reliably associate a claim or What are some factors I should consider electronic transaction with a substantive proce- when deciding whether to pursue a bonus dure code with a claim or electronic transaction payment? with quality measures on it. Remember that most of the quality measures are related to evaluation • You need to know whether it will be worth- and management (E/M) codes reported by a pri- while financially to participate in reporting mary care physician; there typically will be several quality information. When doing a cost-benefit encounters reported by the physician during the analysis, remember that the results of the third reporting period. A surgeon, on the other hand, five-year review, which dramatically changed typically will do only one operation on a patient reimbursement, went into effect on January 1. during the six-month period that quality measures Keep that in mind when you decide to use data are reported. from the last half of 2006 or the first half of 2007. Do I have to register to report quality mea- • Remember that it may be worthwhile for sures? Do I have to sign a Medicare partici- you to get some experience in reporting quality pation agreement to accept assignment on data even though it is not financially viable for all claims? your practice. If you are not already reporting quality data to a payor, the PQRI may represent No registration is necessary, nor do you have a good opportunity to get some experience in a to be a participating physician. You simply begin program that will not be exposed to the public. reporting the measures. • You will need some way of knowing when to collect the quality data and some way of getting it Is the quality measure to be reported on from the hospital medical record into the billing Medicare secondary payor claims? What operation. about claims subject to the deductible? • As stated previously in this article, you need to be able to capture quality data on or very The quality measures are applicable to all soon after July 1. A two-week delay in beginning claims. participation in the PQRI is probably an insur- mountable hindrance. What will I get back from my carrier on the quality line items on the remittance advice What will be the fate of the PQRI in 2008? statement?

It is difficult to predict the future of the PQRI. The carrier will deny the quality items and pay With the change of leadership in the Congress, the substantive procedure code. However, the some newly ranking members object to programs quality codes will be routed through the CMS such as the PQRI. On the other hand, by not payment system, analyzed, and considered in basing reimbursement on outcomes, the biggest bonus eligibility calculations. payor, Medicare, would be out of step with a rap- continued on page 38 11

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Indian Health Service: Providing care to Native Americans and Alaska Natives by Thomas K. Stempel, MD, FACS, CAPT USPHS (Ret), Phoenix, AZ

Editor’s note: This article was adapted from The IHS is an agency of the U.S. Public Health a presentation (GS11) at the 2006 Clinical Con- Service (USPHS) that provides health care to gress in Chicago, IL. American Indians and Alaska Natives. Many representatives of all sectors of our health care n his Bulletin article “Rural surgical practice: community—physicians, engineers, nurses, ther- A personal perspective” (2007;92(2):12-17), apists, and pharmacists—have a common experi- Tyler Hughes, MD, FACS, beautifully elu- ence through their service with Indian Health. cidates the challenges and joys of providing The IHS operates a comprehensive health care Irural surgical services. My career with the Indian delivery system for approximately 1.8 million of Health Service (IHS), which echoes much of what the nation’s 3.3 million American Indians and Dr. Hughes shares, gave me the added pleasure Alaska Natives in 33 states, mainly in the west- of experiencing a world that exists in the very ern U.S. and Alaska. Facilities range in size from heart of our own country but to most Americans the smallest clinic, the Supai clinic in the bottom is a completely unknown culture. of the Grand Canyon, to three regional medical centersf. One o these centers, the Alaska Native Above: The richness of the Indian Health Service experi- Medical Center in Anchorage, is the only level I ence. (Photos and collage courtesy of the author.) trauma center in the State of Alaska. 12

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Health care professionals are drawn to the IHS most important factors in providing care at any from a mixture of altruism; the adventure of visit- of these facilities is maintaining an awareness of ing new regions of our country and the experience the capabilities of both the operating staff and of native culture; and economics, as the IHS is an the facility to handle any given case. Cases that escape from the hassles of private sector health exceed the capability of a given institution are care. Some health care providers come to the IHS either referred to a larger IHS facility or to a remembering stories about Geronimo and Sitting hospital in the private sector. In these communi- Bull, the pony express, Buffalo Bill Cody and his ties 20 years ago, the IHS hospital was often the Wild West show, and General Custer. Most of the only facility available, but today there are many people who have worked for IHS are now aware of private-sector hospitals that have developed in the other side of the story, such as the massacre nearby towns. at Wounded Knee and that as late as the 1950s, The joy of IHS surgery is the freedom to still children were still taken from their families and be a general surgeon not only in the scope of op- placed in boarding schools, where they were erations performed but also in providing overall punished for speaking their native language. medical care. Within the capacity of each indi- Prejudice toward Native Americans still abounds vidual facility, an IHS worker cares for patients in the communities surrounding reservations. All from neonates to elderly. There is no choice but of this history is part of the picture that paints to care for whomever comes through the door. the Indian health experience. There is always the necessity to determine Many providers become frustrated with the whether to treat or to stabilize and transfer. governmental bureaucracy, as well as with the funding restrictions that lead to issues with My surgical experience equipment and staffing. People tend to either In 1977, I accepted a commission in the burn out and leave or seek ways to work within USPHS. My career began at the Gallup Indian and around the system, finding that the rewards Medical Center, a 127-bed referral hospital serv- of service exceed the frustrations encountered. I ing the Navajo, Zuni, and Hopi tribes in north- often reminded my staff that we were providing western New Mexico. I arrived at Gallup fresh care to many people who would not otherwise out of residency and found diseases I thought have any access to care or any resources to were only part of my medical history books. obtain it. Many of our patients were “working These diseases certainly hadn’t been part of my poor,” whose employment did not provide health experiences in Pennsylvania or Massachusetts. insurance. A woman died of diphtheria. Patients were being The IHS has three major referral centers: the treated for plague. We operated on people with Alaska Native Medical Center, the Phoenix In- echinococcal cysts. Presentations of peritoneal dian Medical Center, and Gallup Indian Medical tuberculosis were not uncommon. Center. Multiple smaller facilities exist through- With a population of 200,000, the Navajos are out the U.S. and Alaska. The majority are located the largest tribe in the U.S. The Navajo reser- in the western states. Some are beautiful new vation, which is the home to the Navajo tribe, hospitals, like the Crow Agency (MT) Hospital covers a land mass larger than the states of and the Fort Defiance (AZ) Hospital. The Supai Massachusetts, Connecticut, and Rhode Island facility mentioned previously is the smallest. combined. Our patients frequently drove three This clinic has emergency evacuation available or four hours to see us. In winter, they might only during daylight hours when a helicopter be snowed in for days, either in their homes or can safely see to navigate its way into and out with us, because there are no snow crews on the of the canyon. unpaved reservation roads. In the spring during Surgery services are available at 20 facilities mud season, they leave their homes in the early in Oklahoma, New Mexico, Arizona, the upper morning when the roads are frozen and can’t plains states, and Alaska. Fifteen hospitals have return home until night when the roads freeze full-time surgical services and five have contract again. There are still areas of the reservation surgeons who visit on a regular basis. One of the today that have no water or utilities. We often ad- 13

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS mitted patients for social reasons related to the distance they live from the facility or their lack of resources at home to care for themselves. On my first night on call in Gallup, I was called to evaluate a young father who had pulled his truck off the road to avoid an oncoming drunk driver, who still managed to hit him head-on. The father had a grossly bloody peritoneal tap. When he crashed on me while I was waiting for the operating team to arrive, I had no choice but to explore him in the emergency department. He had a hepatic vein injury that I had no facility to repair and I lost him. We had no intensive care unit and minimal blood banking. The nearest big city with blood services was Albuquerque, NM, a 155-mile drive away. If a patient required Figure 1. Patient with a massive multinodular goiter. mechanical ventilation, we kept him or her in a room near the nurse’s station with our one ven- tilator. The only emergency transport available was ambulances. The breadth and depth of my surgical expe- rience was phenomenal. I became well-versed in biliary surgery. This was gallbladder coun- try. Any surgeon who spends time in the IHS becomes an expert in biliary disease. Elective and acute presentations, empyemas, porcelain gallbladders, common duct stones, Mirrizzi’s syndrome, and gallstone ileus were common. Sphincteroplasties and choledochoduodenosto- mies were our treatment of choice for patients with significant common duct disease. Pancre- atic pseudocysts secondary to biliary disease or Figure 2. Diabetes prevalence in the Sacaton Indian alcohol problems were common and responded community. (Source: Compiled from unpublished NIH very nicely to cystogastrostomy. data.) Gallup is in a goiter belt and we saw signifi- cant thyroid disease (see Figure 1, this page)— thyroids like I had never seen during my resi- lems. The National Institutes of Health (NIH), dency. Biliary and gastric cancers were our two which runs a research ward on the fifth floor of most common neoplasms, followed by intestinal the Phoenix Indian Medical Center, has been and breast malignancies. The majority of pa- studying diabetes in the Sacaton Indian com- tients presented in advanced stages. munity for 0 years. NIH studies have shown During my time in Gallup, I treated and cared an increasing prevalence of diabetes in each for trauma and burn patients. I performed pul- decade studied, with more than three-quarters monary resections and decortications for both of this population now developing diabetes by disease and trauma. I repaired diaphragmatic the time they reach 65 years of age (see Figure hernias, some trauma related and some congeni- 2, this page). tal. I operated on kidneys for trauma, cancer, We cared for the full gamut of diabetic foot stones, and infection. disease—hammer toes, hallux valgus and rigi- When my career shifted to Phoenix, AZ, I dus, onchomycosis, neuropathies, calluses, and gained major exposure to diabetes-related prob- ulcers. Days, nights, and weekends were often 14

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS spent operating on people for osteomyelitis and For providers who remain long term, no matter infections resulting from ischemia and pressure- what facility they may visit, they find someone related injuries. One of the greatest blessings they know or someone who has a connection to during my tenure in Phoenix was the develop- them. A common bond develops—a bond of ser- ment of a podiatry department. The aggressive, vice, a bond of learning how to take advantage fastidious care of the podiatry staff actually of how the system works or doesn’t work. helped to decrease the amputation rate. Our goal And there is the joy of watching people grow was and is to get patients to a state of wellness and flourish, whether it may be coworkers, or to be functional in whatever home situation medical schools students or residents. A full they may live. career allows one the opportunity to witness Yes, there were frustrations with equipment laboratory technicians and nursing assistants and staffing. The story was, and still is, that it obtaining training to become successful clinicians doesn’t matter who is in power in Washington. and administrators. Many facilities have relation- If the Democrats were in charge, our salaries, ships with medical schools and residencies. The which were tied to the military, were flat but our Phoenix Indian Medical Center was a founding operating and equipment budget would go up. member of what is now the Phoenix Integrated If the Republicans were in power, our salaries Surgical Residency. Many surgical residents who would go up, but our budget, which was viewed experienced surgical rotations at IHS facilities as a social program, would be flat. We were al- returned to become IHS surgeons. ways happy with a party change to keep us in Aside from the vast surgical exposure, the rich- balance. ness of the IHS experience is getting to know the people and learning their culture. Gallup afforded The rewards of the system me the opportunity to experience the richness of The long-term providers in IHS find com- the Navajo, Zuni, and Hopi cultures. The Phoenix munity and family throughout the system. As facility serves 45 tribes in Arizona, Nevada, and people move about the nation during their ca- Utah. I met the Native artists—the potters, weav- reers, the web of the IHS community is woven. ers, painters, and carvers—in person and even visited them in their homes. I experienced parades and festi- vals that are unique to Indian country. I experienced, as one of a handful of outsiders, the native dances and ceremonies that are for the people, not for the tourists. I attended rug auc- tions, smelled and tasted bread freshly baked from a horno, enjoyed the biliary stimula- tion of eating fry bread freshly cooked in hot oil, and smelled burning pinon wood on a cold winter night.

Our continuing challenges Much remains to be accom- plished in Indian country. The Native American mortality rate from tuberculosis is six Figure 3: Per capita health care expenditures of the IHS times the national average. Motor vehicle accidents, deaths 15

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS resulting from accidental injury, and suicide together. If we don’t, the whole world will die. plague the youth and young adults with a death First the planet, and next the people.”† rate almost three times the national average. Our so-called advanced culture was not ready A great deal of what we do is based on our to hear them and we spent a century destroying creativity and ingenuity in working in a system Earth and one another. In the ecological crisis that provides one-half to one-third of the health we have created, we need the wisdom of these care expenditure for our patients as it does for leaders now more than ever. An ancient Indian others (see Figure 3, page 15).* Our challenges proverb says, “Treat the earth well: It was not today relate to maintaining our infrastructure given to you by your parents, it was loaned to while continuing to provide quality care with you by your children. We do not inherit the Earth budgets that squeeze resources and manpower from our ancestors, we borrow it from our chil- in the face of growing tribal populations. Our dren.”† My joy in my years of service with Indian federal appropriations are significantly affected Health was the wealth of wisdom I received not by budget deficits and war expenditures. only from my surgical peers and mentors, but Another continual struggle is patient compli- also the richness of wisdom that is exemplified ance issues related to the socioeconomic barriers. by these quotes.  This could relate to drug or alcohol issues for the patient or their caregiver. It could be transporta- The opinions expressed in this paper are those of tion problems. It could be lack of adequate home the author and do not necessarily reflect the views of facilities. We struggle with the ethical dilemma of the Indian Health Service. allocating limited resources for transplant proce- dures or expensive medications versus programs to treat many such as alcohol rehabilitation or suicide prevention.

Listening to their wisdom The joy of working with the Native Americans and Alaska Natives is coming to realize that they are vibrant peoples who adjust to what life brings them. We celebrate the wisdom of their relationship with the universe. They were and are in touch with Earth, with nature, with spirit. They were offering us guidance and warnings a century ago. Chief Luther Standing Bear of the Lakota Sioux said, “The elders were wise. They knew that man’s heart, away from nature, becomes Dr. Stempel was chief hard; they knew that lack of respect for grow- of surgery at Phoenix Indian Medical Center ing, living things, soon led to lack of respect for and chief clinical † humans, too.” consultant in surgery Fools Crow, Ceremonial Chief of the Teton for the Indian Health Sioux, said, “The survival of the world depends Service, Phoenix, AZ. upon our sharing what we have and working He now provides acu- puncture and surgical *National Congress of American Indians. 2005 Budget services to the Whit- Recommendations. Available at: http://www.ncai.org/ncai/ eriver Indian Hospital advocacy/otherissue/docs/2005_budget_recommendations.pdf. in Whiteriver, AZ. Accessed March 26, 2007. †National Institute of Environmental Health Sciences Web site. Available at: http://www.niehs.gov/kids/quotes/qtamind. htm. Accessed April 24, 2007. 16

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 17

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS he ACS Case Log System was launched it fits into their workflow. Data entry via the in October 2005 to fill the growing needs Web (see Figure 1, this page) and via a PDA (see of Fellows and members of the Resident Figure 2, page 19) may be used interchangeably. and Associate Society. As the need for Both data entry protocols have lookup tables lifelongT professional education has increased, for Current Procedural Terminology (CPT)* and so has the need to tailor educational efforts to International Classification of Diseases, Ninth the practice of individual surgeons. The concept Revision, Clinical Modification(I CD-9-CM) codes of maintenance of certification is advancing and both maintain “hotlists” of each surgeon’s through all board specialties, so practice-based most frequent procedures and diagnoses, making learning is becoming the norm. To meet these case data entry extremely quick. CPT and ICD- needs, the Case Log System was developed with 9-CM codes can be unwieldy, but the Case Log the following objectives: System allows surgeons to give them nicknames • To provide a way for surgeons to quickly for easy reference. The Web and PDA databases and confidentially record the essential clinical are automatically updated each time the PDA is aspects of procedures they perform “hot synced.” Security measures have been taken • To provide basic reporting capabilities to protect the data. that allow individual surgeons to confidentially review their procedures, patient comorbidities, Available reports via the Case Log System complications, and outcomes The Web system includes a series of useful • To provide comparative statistics from reports that list procedures by date or frequen- large pools of de-identified patients for the cy, comorbidities by frequency, postoperative surgeon’s private review *All specific references to CPT (Current Procedural Terminology) • To help surgeons identify areas where they terminology and phraseology are © 2006 American Medical may wish to direct their educational efforts, with Association. All rights reserved. learning opportunities available from the College and elsewhere Although little more than a year has passed since the Case Log System was launched, it is not too soon to realize it is a smashing success. More than 100,000 cases have been logged by the surgeons who enrolled early. The database is expected to contain more than a million cases in just a few years. This program will rapidly become the largest surgical database ever collected and will lead to educational and analytic op- portunities that scarcely can be imagined now.

How the system works The Case Log System is a Web- and personal digital as- sistant (PDA)-based system that permits surgeons to enter procedure data in a few min- Figure 1 - Web data entry utes between cases or whenever 18

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS occurrences (or complications) by frequency, and a report comparing the surgeon’s cases with similar cases in the database (see Figure 3, this page). Contained in the database for comparison purposes are more than 4,500 laparoscopic cho- lecystectomies, 4,300 inguinal hernia repairs, 2,700 breast procedures, nearly 10,000 endos- copies, and a large number of other cases. Case Log data may also be exported to a personal computer file if the surgeon wishes to analyze it with other software tools.

Case Log confidentiality The Case Log System truly is confidential. To join the Case Log System, the surgeon signs an agreement that includes a statement of under- standing that the surgeon is the sole owner of patient- and surgeon-identifiable data. The Case Log System is operated by a third party and the College has access only to bulk data that have been stripped of all patient and surgeon identi- fiers. The bulk data allow individual surgeons to privately compare their patients’ comorbidities, Figure 2 - PDA data entry

Figure 3 - Comparative report

19

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS How to join To sign up to use the Case Log System, simply go to the College’s Web site at http://acscase logregister.org and register to become a user. This site is on the College’s Web portal and contains Case Log System documentation and registration information. Try it—100,000 cases say you will like it! 

Mr. Tanzman recently spoke at grand rounds at the University of California, San Francisco, where he explained the Case Log System to the division of plastic surgery.

length of stay, complications, and outcomes with thousands of similar cases in the database.

The Case Log System and credentialing Hospitals in North America are under constant pressure to ensure the current clinical compe- tence of all physicians. For surgeons, maintain- Dr. Shabot is vice- ing privileges for a procedure usually takes the president and chief quality officer, Memo- form of performing a specified minimum number rial Hermann Health- of procedures within the past two years. Many care System, Houston, surgeons operate at multiple inpatient and outpa- TX. In addition, he is tient facilities and the requisite number may not a general surgeon and be performed at each one. The Case Log System surgical intensivist. provides a convenient way for the surgeon to dem- onstrate cumulative experience and outcomes for credentialing wherever it is required. Surgeons will be able to submit their cases electronically from the Case Log System to the American Board of Surgery. Providing this capability is under dis- cussion with other specialty boards. 20

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The ACS Surgical Quality Alliance: Specialty societies improving quality for the surgical patient

S by Frank Opelka, MD, FACS, New Orleans, LA and Julie Lewis, Associate for Quality Programs, Division of Advocacy and Health Policy

ince the Institute of Medicine’s report, To Err is Human,* was published in 1999, there has been a detectable shift toward improving Sthe quality of health care through a variety of new initiatives, such as public reporting and pay for performance. Our nation’s health care system suffers from gaps in consistent care, geographic cost and quality variance, and inappropriate use of Q procedures and technologies, resulting in escalating costs. These breakdowns affect all entities in the system, and consequently, all health care stakehold- ers are taking a closer look at the means for solv- ing these challenges. Indeed, a multistakeholder community of purchasers, payors, providers, and patients has united the efforts of these groups to combine quality improvement with cost savings. Many private insurers, as well as the Centers for Medicare & Medicaid Services (CMS), have developed programs to measure and report on health care providers. CMS Hospital Compare, a

*Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Committee on Quality of Health Care in American, Insitute of Medicine. Washington, DC: National Academy Press; 2000. A 21 JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Web-based tool that allows consumers to view rat- ings of U.S. hospitals, is a likely template for future SQA member organizations physician-level reporting by CMS. Private insurers have taken a number of different approaches to American Academy of Ophthalmology physician accountability. Some health plans merely American Academy of Otolaryngology American Association of Neurological present their enrollees with the performance data, Surgeons whereas other plans actively direct consumers by American College of Obstetricians charging smaller copayments for physicians they and Gynecologists consider “high quality” or “efficient” or by restrict- American Association of Orthopaedic ing physician participation in their networks based Surgeons on performance. American College of Osteopathic Surgeons In addition to insurers, many coalitions have American College of Surgeons formed to collect and disseminate health care data American Society of Anesthesiologists in an effort to inform consumer choice. Both the American Society of Breast Surgeons Wisconsin Collaborative for Healthcare Quality American Society of Cataract and Refractive Surgery and the Massachusetts Health Quality Partners American Society of Colon and Rectal are community-based coalitions trying to increase Surgeons transparency in health care and encourage qual- American Society of General Surgeons ity improvement. With internal quality improve- American Society of Plastic Surgeons ment and cost reduction as the end goals, most of American Urological Association these coalitions believe that change can only be Congress of Neurological Surgeons achieved through public reporting of performance Society for Vascular Surgery and cost data. Society of American Gastrointestinal The Surgical Quality Alliance (SQA) is spon- Endoscopic Surgeons sored by the American College of Surgeons and Society of Gynecologic Oncologists Society of Surgical Oncology chaired by a Fellow (this article’s co-author). The The Society of Thoracic Surgeons SQA seeks to bring surgical specialties and anes- thesiology together to participate in all aspects of quality improvement for the surgical patient. (A list of SQA member organizations can be found in the sidebar on this page.) Participating surgical societies have agreed that if physician perfor- Leavitt championed, performance and cost data mance is going to be measured in the current will be made available to all stakeholders. environment, surgery should participate in de- The SQA interacts with multiple national qual- fining which measures truly evaluate the quality ity organizations tasked with improving health of surgical care and determining how measures care and reducing costs through performance should be attributed, collected, and reported. The measurement and data collection, aggregation, College and many other surgical societies have and reporting. Formed in late 2005 under the a great deal of experience in evaluating systems direction of the College, the SQA comprises more of care but little experience in measuring the than 20 organizations representing specialties performance of an individual physician. The involved in providing surgical care. Over the theory that problems with surgical care can be last two years, the complexity and purpose of addressed within the system of care is no longer the SQA have continued to grow. As a result, the a reasonable answer to health care stakehold- SQA has recently added two vice-chair positions, ers. Purchasers and payors of health insurance which have been filled by representatives of the seek to assess individual surgeon performance, American Academy of Orthopaedic Surgery and as well as the capabilities of health care systems. the Society of Thoracic Surgery. With the continued emphasis on transparency The SQA’s objectives are as follows: in health care, a cause that U.S. Department of • Define the principles of surgical patient qual- Health and Human Services Secretary Michael ity measurement and develop awareness among 22

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS cialty societies on quality-related initiatives in the related Web sites federal and private sectors and for coordinating surgery’s response to those initiatives Agency for Healthcare Research • Provide a forum for shared and coordinated and Quality efforts among the specialties so that our collective http://www.ahrq.gov/ staff and resources can monitor and participate AMA Physician Consortium for effectively in the many organizations involved Performance Improvement in data aggregation and reporting, as well as the http://www.ama-assn.org/ama/pub/catego- development, validation, and implementation of ry/2946.html physician performance measures Health care performance measurements are AQA of growing interest to patient advocates, payors, http://www.aqaalliance.org and the major purchasers of health insurance as a means of increasing accountability and spurring CMS Hospital Compare internal quality improvement. (Additional infor- http://www.hospitalcompare.hhs.gov/ mation about the organizations mentioned in this CMS Physician Quality Reporting Initia- article may be found in the sidebar on this page.) tive Many aspects of performance can be evaluated by http://www.cms.hhs.gov/pqri/ measuring the structure, process, outcomes, and cost of care. Arriving at more complex measures Consumer Assessment of Healthcare of the efficiency and appropriateness of care are Providers and Systems the next steps in better defining our health care https://www.cahps.ahrq.gov/ system and improving preventive care and ap- propriate utilization of care. Massachusetts Health Quality Partners The national organizations focusing on health http://www.mhqp.org/ care quality improvement include the National National Committee for Quality Assurance Quality Forum (NQF), the Agency for Health http://web.ncqa.org/ Research and Quality (AHRQ), the National Committee for Quality Assurance (NCQA), AQA National Quality Forum (formerly the Ambulatory Care Quality Alliance), http://www.qualityforum.org the Hospital Quality Alliance (HQA), the Qual- ity Alliance Steering Committee, the American Surgical Quality Alliance Medical Association’s Physician Consortium for http://www.facs.org/ahp/sqa/index.html Performance Improvement (AMA’s PCPI) and CMS. The creation of a multistakeholder com- Wisconsin Collaborative for Healthcare Quality munity represents a significant change in the http://www.wiqualitycollaborative.org/ nation’s approach to solving the health care chal- lenges. For the first time, all stakeholders have been organized nationally in a forum focused on health care system redesign to improve quality and reduce waste. Buried within the matrix of performance measurements are sophisticated interested parties about issues related to surgical rules for defining and implementing a cohesive care and quality in all surgical settings national set of measures that will be promoted • Collate measures of surgical care quality, for use by all payors. share methodologies across specialties to assist in The SQA formed as specialty societies realized the development of meaningful tools for quality the importance of serving as leaders for the sur- improvement, and evaluate the use of registries gical patients. Individual specialty efforts were • Advance our own knowledge by serving as a quickly overwhelmed by the multiple programs point for disseminating information among spe- already well under way and were unable to match 23

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the efforts of multiple national meetings. The SQA billing system.† This requirement means the devel- brought forth a solution by allowing the surgical opment of a measure must fit within the framework societies to share their resources and ideas about of an administrative system rather than a clinical all aspects of quality improvement. Instead of a decision support system. In addition, the current representative from every specialty trying to cover design relies on payor support for collection, aggre- every call, meeting, and event, the SQA provides gation, and distribution of the data. This presents a structure for division of labor and dissemination operational problems for physicians whose patient of information among societies. population includes multiple payors. If data are col- The SQA’s initial foray focused on developing lected by individual payors and never aggregated, a starter set of “global” physician-level measures performance determinations may be made on a that would reach across most surgical disciplines. very small number of cases. Working closely with the AMA’s PCPI and under With approved physician measures, each payor, the leadership of the College, SQA representatives including CMS, has interest in collecting and took positions on the consortium’s workgroup for aggregating the measures for the purpose of as- development of the Perioperative Care Measure sessing individual physician performance. The Set. Each specialty contributed to the measure payor data registries allow each insurer to collect set, which includes six performance measures information on each claim for each provider. In aimed at improving the use of appropriate anti- order to create a comprehensive provider profile, biotic and venous thromboembolism prophylaxis. all payors need a means of aggregating the col- During the consortium’s workgroup process, SQA lected data in a central, interoperable system. For membership reviewed clinical practice guidelines example, a surgeon would submit claims data with and other evidence-based literature to make deter- the quality codes to the commercial payors, the minations regarding the inclusion of procedures. insurance plans, and the federal and state fiscal in- In addition, the SQA participated in the review of termediaries. Each payor would need to pass along public comments and refinement of the measure the individual provider’s performance data to a set. The PCPI approved the Perioperative Care central repository. The central repository would Measure Set in October 2006, followed by approval return a report to each payor with an overview of by the AQA. the surgeon’s comprehensive performance. Once developed, measures can be submitted to To create interoperable systems that would solve the NQF for endorsement, which includes a rigor- the data collection, aggregation, and reporting is- ous review of the level of evidence, importance, sues is a significant challenge. Meanwhile, several usability, and feasibility of a measure. Once again, medical and surgical specialties have developed the SQA worked together to coordinate and collate registries to assist in maintenance of certification evidence for each specialty involved in the Peri- and other quality and patient safety pursuits. More operative Care Measure Set. The measures have sophisticated data registries that reach beyond the been approved by NQF’s technical advisory panels administrative data and become part of a clinical and the project steering committee and are now decision support system seem the obvious next in the NQF’s public comment process. Through step for collection of physician performance data. the hard work of the SQA members to develop a The SQA has formed a Data Registry Workgroup set of performance measures for surgery, surgeons to study a means for meeting the data aggregation from across the country were able to participate in needs of a physician measurement system. Many the CMS Physician Voluntary Reporting Program surgical specialties have well-developed registries, (PVRP) in 2006 and will be eligible to participate whereas others have no means of data collection. in the CMS Physician Quality Reporting Initia- Harnessing the current surgical efforts into a set tive, which includes a 1.5 percent bonus payment of data aggregation options that bring value to all on all Medicare claims, in 2007. surgical disciplines as well as other stakeholders Collection of the clinical data that are needed to is the goal of the workgroup. ensure compliance with these performance mea- †All specific references to CPT (Current Procedural Terminology) sures is done using the AMA’s Current Procedural terminology and phraseology are © 2006 American Medical Terminology (CPT) within the provider coding and 24 Association. All rights reserved.

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The SQA is exploring clinical registries as a As the SQA continues to evolve, we look forward means of collecting and aggregating data within to strengthening collaboration both internally each specialty society. These registries may oper- with surgical specialties and externally with pur- ate through a portal that allows physicians to ef- chasers, payors, and patients. The SQA continues ficiently collect the performance measures by run- to develop projects that increase participation ning collected data through quality analytics. The by member organizations and highlight each aggregated data would be shared with the payors organization’s strengths and focus. The SQA and the surgical specialties to develop reports for realizes performance measures will continue to quality improvement. evolve. The initial measures were basic measures A key focus in performance measurement in- of processes of care and limited outcomes. More volves patient satisfaction. The SQA evaluated sophisticated measures will include efficiencies the existing patient satisfaction survey instru- in care and appropriateness measures. Properly ments and concluded that they lacked a surgical developed measures are an essential step in reduc- patient focus. To address this gap, the SQA formed ing overutilized care and creating cost savings. a Patient Satisfaction Survey Workgroup, which In addition, the SQA is researching the role of will work on development of a tool for evaluating risk-adjusted outcomes systems. The ACS hopes surgical care. Upon development of the survey, the to launch a pilot for combining measures of pro- SQA will submit the tool to AHRQ for approval as vider performance, system performance, cost, and an official Consumer Assessment of Healthcare patient satisfaction. Providers and Systems survey. The project is on The SQA outreach program will continue to track for completion by January 1, 2008. invite experts to present at coalition meetings in A major focus of the SQA is to increase surgery’s these areas of quality and to partner with the SQA cooperation and understanding of other health on relevant projects. As time passes, the SQA’s care stakeholders. In addition to participating in mission, goals, and common message of quality external quality organizations and initiatives, the improvement for patients continues to solidify. SQA hosts three meetings per year at which other In the coming months, the SQA will begin to stakeholders are invited to share their perspectives evaluate its membership structure and discuss the with the SQA membership. Former presenters have possibility of extending invitations to nonphysi- included Carolyn Clancy, MD, director of AHRQ; cian organizations that participate in the care of Carol Flamm, MD, medical director for Blue Cross surgical patients. Most importantly, the SQA will Blue Shield Association; Robert Berenson, MD, continue to educate its members and others about senior fellow at the Urban Institute; Tom Valuck, surgery’s willingness to partner and collaborate MD, JD, Medical Director and Senior Advisor at with any organization trying to improve quality, CMS; and Denise Remus, PhD, RN, vice-president efficiency, or patient satisfaction.  of clinical informatics at Premier, Inc. The SQA has also written multiple letters in an effort to present a consistent, unified message Dr. Opelka is associ- from surgery. Over the past two years, the SQA ate dean for clinical affairs, Louisiana State has sent formal letters to CMS regarding the University School of PVRP; to NQF on surgery-related performance Medicine, New Orleans, measures and in support of surgeons to serve LA. on the NQF board of directors; and to the AQA, addressing concerns and challenges. In addition, the SQA provided formal comment to NCQA on its 2008 HEDIS (Health Plan Employer Data and Information Set) specifications. To respect the unique perspectives of each society, sign-on to SQA letters is optional. However, the SQA has enjoyed nearly unanimous support from societies for all correspondence. 25

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS he Health Insurance Por- tability and Accountability Act (HIPAA) became effec- tive April 14, 2003, with theT goal of improving patient privacy and putting patients in greater con- trol of their personal health infor- mation. HIPAA implementation has been costly on institutions and in le- gal departments.1 Although the gold standard of clinical research (the randomized, prospective, controlled trial) is unlikely to be significantly affected by HIPAA because consent and protocol procedures are already comprehensive, evidence is coming forth that large registry studies are being negatively affected by consent bias, likely related to the require- ment that consent be obtained ret- rospectively.2 26

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgical research and the progress therefrom, sue composed 71 percent of all articles in these however, are usually not initially based on ran- journals and overall variation in article number domized, controlled trials. Randomized, controlled between journals was not substantial (see Figure trials for carotid endarterectomy, laparoscopic her- 1, this page). Similarly, over a three-year period, niorrhaphy, and colectomy have been published, for a slight majority of articles originated from the example, but the preliminary basis for these large U.S. (57%) (see Figure 2, this page). Prospective studies were retrospective case-controlled series surgical studies were documented in a mean of 23 that compared one type of surgical option versus percent of articles (no significant difference over another. Data from these smaller retrospective re- the three years), whereas retrospective case series ports were crucial to raise the important questions accounted for the remaining majority of human that influenced later, larger trials. In the recent subject studies. IRB approval was documented in a past, institutional review board (IRB) approval for retrospective studies was a waiver of informed con- sent, as long as no intervention or patient contact Figure 1 was made. Since HIPAA implementation, informed consent must be obtained from patients for use of any of their personal health information (and/or tissue) based on the privacy rules, unless obtain- ing consent is “not practicable.” Although local IRBs may interpret this criterion differently, most are likely to interpret it conservatively in order to prevent possibly hefty fines or litigation.3 The aim of this brief report is to characterize the current state of surgical published research and to determine the types of articles published, notation of IRB, and origin of publication before HIPAA implementation.

Survey of clinical research journals Clinical research articles over time in the American We reviewed three common surgical journals Journal of Surgery (AJS), Surgery, and Archives of that are fully peer reviewed, to survey the dis- Surgery (Arch Surg). tribution and type of clinical research publica- tions. From January 2001 to December 2003, a Figure 2 total of 2,035 articles in the American Journal of Surgery, Surgery, and Archives of Surgery were characterized by Medline database abstract review. Abstracted data included type of article— specifically, clinical research, involving human subjects or their tissue, basic laboratory studies involving animals, or in vitro experiments—and miscellaneous articles involving small case series (fewer than four patients, reviews, organizations’ presidential addresses, and so on). Review of the abstracted data was done to determine the status of IRB approval, number of patients in the study, and duration of follow-up. The country of origin was defined as either U.S. or international. The 2002 Science Citation Index for each jour- Clinical research articles over time originating from nal was 1.7, 2.55, and 2.63, respectively. Clinical the U.S. studies involving human subjects or their tis- 27

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS mean of 24 percent of human subject studies, with- Figure 3 out a significant difference per year (see Figure 3, this page). The mean number of patients included in these studies was 496, with a mean follow-up of 12 months. Basic science reports made up 9.6 percent, whereas miscellaneous topical reviews, technical notes, and small case reports (fewer than four patients) made up 19 percent of articles.

Negative impact of HIPAA The potential negative impact of HIPAA on surgi- cal research is significant. O’Herrin and colleagues recently reported that although overall applications for IRB approval increased, nearly 70 percent failed to complete the process, likely related to the markedly increased demands for documentation Figure 3. Clinical research articles with notation of from the IRB.4 Based on approximately 500 clinical Institutional Review Board approval. research articles published per year between these three journals, if one assumes a conservative 25 percent drop in retrospective case research data are similar between retrospective and prospective resulting from HIPAA-imposed obligations, then projects, the investigator may choose a study of a potential decrease of 125 reports fewer per year longer duration that might yield more rigorous will be made. This may have a negative impact data. Similarly, extended case series and anecdotal on the following: trainees whose first research reports seemingly carry little weight in the era of publication is often a case series; overall surgical evidence-based medicine. research, as much surgical therapy is not ethical Another potential compensation is the avail- or practical for a randomized, controlled trial; and ability and use of large patient databases, which the ability to get background published data to put bring significantly more statistical power to deter- forth solid and fruitful hypotheses when proposing mine treatment and therapeutic effects of surgi- a randomized, prospective surgical trial. Although cal disease. For example, the use of the Medicare not specifically related to surgical research, others database to delineate the surgical volume–outcome have called for preventive change for HIPAA on the effect is valid and useful and would not have been national level.5 possible with single or even multi-institution evalu- ation.6 However, detailed patient-specific outcomes Possible solutions and compensations are less reliable with these databases that rely Several solutions are suggested, and some sil- on codes from the International Classification of ver linings are present. A first simple step would Diseases, Ninth Revision, Clinical Modification, be a standard exclusion addendum for IRBs to often without hard chart confirmation. Studies uniformly allow waiver of consent for retrospec- combining these data sets often produce different tive research. This might also take the form of conclusions.7 More detailed, prospectively acquired an expedited IRB review process. An addendum data are currently available from the Veterans Af- to HIPAA specifically related to clinical research fairs Hospital System with the National Surgical could be created, but this involves lawmakers and Quality Improvement Program, and multiple ar- politics and might be unpopular, given the recent ticles have been published.8 Currently, this program concern with patient data security. has now moved to the nonfederal hospitals with a The added burdens for retrospective clinical private sector academic consortium that is rapidly research might stimulate more externally funded, expanding. These data are robust for perioperative surgical investigator-initiated research with resul- outcomes and risk factor analysis and, as these are tant higher impact on patient care. Put another deidentified patient data, HIPAA consent proce- way, if the administrative hurdles with the IRBs dures do not apply. 28

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Lastly, institution-wide deidentified databases controlled program for the measurement and en- could be constructed to allow detailed patient hancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann analysis that is prefiltered to eliminate any patient Surg. 1998;228:491-507. identifiers, at least for preliminary studies. If an interesting observation is uncovered, then formal IRB approval and consent for follow-up could then be obtained. Dr. Henke is associ- Currently, surgical research for the academi- ate professor, section cian who is trying to balance personal time and of vascular surgery, department of surgery, increased operative and clinical supervision is University of Michigan harder than ever. The HIPAA burden is personal Medical Center, Ann in terms of workload, and societal through the Arbor, MI. implementation of more obstacles for investiga- tion of surgical questions. Certainly, support for a system-wide change would require a more formal, large-scale, longitudinal study of multi- institutional IRB and institutional research pat- terns. This report serves as a snapshot in time that may be useful for a review in several years after the full effects of HIPAA have become manifest. 

Acknowledgments Ms. Fewel, at the time of the study, was in the The authors appreciate helpful critique from La- school of Public Health, zar J. Greenfield, MD, FACS; Hiram C. Polk, Jr., MD, University of Michigan FACS; and Michael W. Mulholland, MD, FACS. Medical Center, Ann Arbor, MI. References 1. Kilbridge P. The cost of HIPAA compliance. N Engl J Med. 2003;348:1423-1424. 2. Tu JV, Willison DJ, Silver FL, et al. Impracticability of informed consent in the Registry of the Canadian Stroke Network. N Engl J Med. 2004;350:1414- 1421. 3. Annas GJ. HIPAA regulations—A new era of medical-record privacy? N Engl J Med. 2003;348: 1486-1490. 4. O’Herrin JK, Fost N, Kudsk KA. Health Insurance Dr. Fewel, at the time Portability and Accountability Act (HIPAA) regula- of the study, was a tions: Effect on medical record research. Ann Surg. resident in the depart- 2004;239:772-778. ment of neurosurgery, 5. Kulynych J, Korn D. The effect of the new federal University of Michigan medical-privacy rule on research. N Engl J Med. Medical Center, Ann 2002;346:201-204. 6. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Arbor, MI. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128-1137. 7. Eliason JL, Wainess RM, Proctor MP, et al. A na- tional and single institutional experience in the contemporary treatment of acute lower extremity ischemia. Ann Surg. 2003;238:382-390. 8. Khuri SF, Daley J, Henderson W, et al. The Depart- ment of Veterans Affairs’ NSQIP: The first national, validated, outcome-based, risk-adjusted, and peer- 29

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The COT’s Resident Papers Competition: Promoting careers in trauma surgery by Gregory J. Jurkovich, MD, FACS, Seattle, WA

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VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ince 1978, the Committee on Trauma That year saw the first international presenter, (COT) of the American College of Sur- Tomasso Bochicchio, MD, of Mexico, who pre- geons has held an annual Resident Pa- sented Crush Syndrome—Urinary Ortholidine S pers Competition. Henry C. Cleveland, Reaction and a Clinical Injury Index As Predic- MD, FACS, founded the competition during the tors of Acute Renal Failure, which took second tenure of C. Thomas Thompson, MD, FACS, as place in the clinical research category. Chairman of the COT. Dr. Cleveland was joined Venezuela (1988), Peru (1989), Ecuador (1994), by Charles C. Wolferth, MD, FACS, in 1981 in and Panama (1999) were subsequently added to sponsoring the competition; they ran the com- the Latin American Region 14 as they developed petition from 1978 to 1990, when Ernest E. COTs. In 1995, Region 14 was renamed the In- Moore, MD, FACS, then Chair of the Regional ternational Region but still consisted entirely Committees, took on this responsibility. Since of Latin American countries until 2000, when 1990, the Chair of the Regional Committees Israel was added. However, participation by the has enjoyed the responsibility of managing the International Region in the Resident Papers Resident Papers Competition. Competition has waned in part due to the lack Throughout its existence, the Resident Papers of a region chief. Competition has encouraged scientific explora- Because the Resident Papers Competition tion, fostered collegial exchange, and promoted begins with a local chapter of the COT sponsor- careers in trauma surgery for residents and fel- ing, encouraging, and supporting resident and lows across the U.S., Canada, and Latin America, fellow investigations, the role of the chair of and it has now expanded its reach to all parts state and provincial and international COTs is of the world. crucial. The “Blue Book” of the COT provides The process starts with a local competition at a detailed guide to the organization, activities, the state, province, or international level, with and responsibilities of these and other ACS COT the winners advancing to a regional competition. members (see http://www.facs.org/trauma/pub- At the regional competition, the best basic sci- lications/bluebook2005.pdf). ence paper and a best clinical paper are selected In an effort to be consistent with the rapidly to represent the region. A panel of judges from expanding international activities of the Ad- the COT then selects only one paper to represent vanced Trauma Life Support® (ATLS®) subcom- each region at the national competition, striving mittee, and to encourage and promote inter- to maintain a balance between basic science and national trauma care activities and education, clinical research, yet providing each region with two new international regions were added in representation at the annual program. 2006. The international regions of the COT now Although originally numbered with Roman consist of Regions 14, 15 (Europe-Middle East- numerals, the regions are now listed with Arabic Africa), and 16 (Australasia). Each of these numbers. The U.S. is composed of 10 regions three regions is to have a region chief who will (1–10); Canada has two regions (11 and 12); and be appointed by the COT’s Medical Director— the military has one region (13), which includes currently J. Wayne Meredith, MD, FACS—in a the U.S. Army, Navy, Air Force, and Veterans process similar to any state chair or other re- Administration. In 2003, the Canadian Military gion chief. The chief of an international region Committee was added to Region 13. must be a member of the College, but it is not From 1978 until 1987, there was no interna- essential that he or she be from a country with tional region in the COT, although there was an ACS chapter. Residents within each of the an Inter-America Region consisting of Panama, three international regions can participate in Western Mexico, and Colombia. No international the annual Resident Papers Competition, with papers were presented during these early years. the same rules and rewards applied as with all In 1988, Region 14 was created, consisting of other regions. This arrangement of countries Argentina, Brazil, Chile, Colombia, Mexico, and and their regional affiliation is best considered Panama, with Ricardo Sonneborn, MD, FACS, a work in progress, as regional political and of Santiago, Chile, appointed as Region Chief. historical influences might better define how 31

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS best to exchange ideas and educational activities. The ACS Web site also provides up-to-date information on ACS chapters (visit http://www. facs.org/about/chapters/index. html) Eligible participants in the paper competition are general surgery residents, surgical spe- cialty residents, and trauma fellows in the U.S., Canada, and international regions. Medical students are not eli- gible. Residents or fellows in the military must submit their abstracts via the military re- gion (Region 13) regardless of where the work was done. To be eligible for competition at the national level, papers submitted may have been pre- At the 2006 Trauma Banquet, Dr. Cleveland (left) accepted an award from sented but may not have been John J. Fildes, MD, FACS, Chair of the COT. The COT honored Dr. Cleveland published (except in the Surgi- as founder of the Resident Trauma Papers Competition to mark the cal Forum) before the annual occasion of the competition’s 30th year. meeting of the COT convenes, usually in March. The presentations are judged on scientific merit, relevance, and importance to trauma; originality and individual work; the quality of lected at this year’s COT annual meeting. the presentation; the ability of the presenter At the COT meeting, the Resident Papers to answer questions about the presentation; Competition occupies an important half-day and the quality of the submitted three-page segment of the annual meeting and follows with abstract or manuscript. Further details on a reception in honor of the presenters, provid- eligibility and the timeline for submission ing an opportunity for socializing with each can be found at http://www.facs.org/trauma/ other and members of the COT. All regional traumapapers.html. representatives and their spouses/guests have In his review of the first 16 years of the papers expenses paid by the COT to attend the entire competition, which was published in the Bulletin annual meeting, although the international re- (1994;79[9]:24-28), Ernest E. Moore, MD, FACS, gions are asked, but not required, to help with detailed the 53 papers from the Resident Papers those expenses. Monetary awards are given for Competition between 1978 and 1994 that were Best Basic Science and Best Clinical Papers, as published in a wide array of journals. Authors are well as to runners-up for both categories, with encouraged to publish their papers, but until this total award money varying between $8,000 to year, there had been no official publishing journal. $9,500 over the past five years. Total expenses But Timothy Eberlein, MD, FACS, the current of the Resident Papers Competition have Editor of the Journal of the American College of ranged from $23,000 to $28,000 over the past Surgeons, has offered to publish the two winning five years. papers, beginning with the papers that were se- continued on page 35 32

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Past winners of the Resident Papers Competition Following is a list of the winners of the ACS COT annual Resident Papers Competition since its inception in 1978 through 2006.

1978 1st Place John A. Weigelt, MD 1989 Basic Laboratory Science Runner-Up Mary H. McGrath, MD 1st Place David K. Magnuson, MD 2nd Place Matthew L. Cooper, MD 1979 1st Place Joseph V. Boykin, MD Clinical Research Runners-Up Christopher C. Baker, MD 1st Place Bradley Reeves, MD Frank D. Manart, MD 2nd Place Danielle Desloges, MD

1980 1st Place Robert Tranbaugh, MD 1990 Basic Laboratory Science Runners-Up Gary M. Gartsman, MD 1st Place William J. Mileski, MD John B. Moore, MD 2nd Place (tie) Gary A. Gelfand, MD 2nd Place (tie) Jon C. Walsh, MD 1981 1st Place Kenneth Kollmeyer, MD Clinical Research Runners-Up Kenneth A. Kudsk, MD 1st Place Miguel Lopez Viego, MD James Hammesfahr, MD 1991 Basic Laboratory Science 1982 1st Place Raj K. Narayan, MD 1st Place Roy W. Hong, MD Runners-Up George S. Fortner, MD 2nd Place Benjamin O. Anderson, MD Hani Shennib, MD Clinical Research 1st Place Karl Illig, MD 1983 1st Place Mark DeGroot, MD 2nd Place Carson Agee, MD Runners-Up Gregory Luna, MD Mercedes Dullum, MD 1992 Basic Laboratory Science 1st Place Michael O’Reilly, MD 1984 1st Place Ronald B. O’Gorman, MD 2nd Place David Bensard, MD Runners-Up Louis Ostrow, MD Clinical Research Frederick A. Moore, MD 1st Place William S. Hoff, MD 2nd Place Juan Manuel Sarmiento-Martinez, MD 1985 1st Place Lawrence Reed, MD Runners-Up Frank Shannon, MD 1993 Basic Laboratory Science M. Rebot, MD 1st Place Thomas T. Sato, MD 2nd Place (tie) Paul A. Taheri, MD 1986 1st Place Richard S. Downey, MD 2nd Place (tie) Alastair C. J. Windsor, MD Runners-Up Richard Kiplovic, MD Clinical Research Wiley W. Souba, MD 1st Place Patricia I. Yugueros, MD

1987 Basic Laboratory Science 1994 Basic Laboratory Science 1st Place Nicholas B. Vedder, MD 1st Place James T. Wilson, MD 2nd Place B. Timothy Baxter, MD 2nd Place Robert F. Noel, Jr., MD Clinical Research Clinical Research 1st Place Eric DeMaria, MD 1st Place Stefan J. Konasiewicz, MD 2nd Place John D. S. Reid, MD 2nd Place Paul J. Gagne, MD

1988 Basic Laboratory Science 1995 Basic Laboratory Science 1st Place Gary Fantini, MD 1st Place Donald W. Pate, MD 2nd Place David H. Livingston, MD 2nd Place Carol J. Cornejo, MD Clinical Research Clinical Research 1st Place Christoph Kaufmann, MD 1st Place Russell R. Lonser, MD 2nd Place Tomasso Bochicchio, MD 2nd Place John J. Keleman, MD continued on next page 33

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Past winners of the Resident Papers Competition (continued)

1996 Basic Laboratory Science 2003 Basic Laboratory Science 1st Place Jenneth E. Drazan, MD 1st Place Eve C. Tsai, MD 2nd Place Carlton C. Barnett, Jr., MD 2nd Place Katherine Barsness, MD Clinical Research Clinical Research 1st Place Peter D. Wearden, MD 1st Place Steven Fox, MD 2nd Place Nicholas Namias, MD 2nd Place David J. Schultz, MD

1997 Basic Laboratory Science 2004 Basic Laboratory Science 1st Place Randy J. Irwin, MD 1st Place Rachel G. Khadaroo, MD 2nd Place Molly M. Buzdon, MD 2nd Place Manuel B. Torres, MD Clinical Research Clinical Research 1st Place Preston R. Miller, MD 1st Place Matthew Rosengart, MD 2nd Place Katharina Pellegrin J., MD 2nd Place Carlos V. R. Brown, MD

1998 Basic Laboratory Science 2005 Basic Laboratory Science 1st Place Geoffrey Manley, MD 1st Place John M. Hwang, MD 2nd Place Gregory J. McKenna, MD 2nd Place Aaron M. Cheng, MD Clinical Research Clinical Research 1st Place E. Lynne Henderson, MD 1st Place Felicia Ivascu, MD 2nd Place Juan P. Carbonell, MD 2nd Place Stephanie P. Acierno, MD

1999 Basic Laboratory Science 2006 Basic Laboratory Science 1st Place Andrew Kramer, MD 1st Place Preya Ananthakrishman, MD 2nd Place D. Kirk Lawlor, MD 2nd Place Jessica Deree, MD Clinical Research Clinical Research 1st Place Garrett Zallen, MD 1st Place Alexander Eastman, MD 2nd Place Avery B. Nathens, MD 2nd Place David Francis, MD

2000 Basic Laboratory Science 1st Place Philip P. Narini, MD 2nd Place George D. Oreopoulos, MD Clinical Research 1st Place Joseph T. Rabban, MD 2nd Place Avery B. Nathens, MD Chairs of the 2001 Basic Laboratory Science Regonal Committees of the COT 1st Place Deepa Soni, MD 2nd Place Daron C. Hitt, MD Richard J. Field, MD, FACS, 1978–1982 Clinical Research Gerald O. Strauch, MD, FACS, 1982–1986 1st Place John-Paul Veri, MD Kimball I. Maull, MD, FACS, 1986–1990 2nd Place Moishe Lieberman, MD Ernest E. Moore, MD, FACS, 1990–1994 Charles F. Rinker II, MD, FACS, 1994–1998 2002 Basic Laboratory Science L. D. Britt, MD, FACS, 1998–2002 1st Place Jonas Gopez, MD Gregory J. Jurkovich, MD, FACS, 2002–2006 2nd Place Steven Casha, MD M. Margaret Knudson, MD, FACS, 2006–present Clinical Research 1st Place Ram Nirula, MD 2nd Place Seong K. Lee, MD

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VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Financial support for the competition has began in 1978 (see sidebar inset on page 34 for a largely come from the three COT-sponsored list of the Chairs). trauma education courses: the Region 7 Ad- The author also wishes to thank Carol Williams vances in Trauma Course (Kansas City); the and Irvene Hughes of the ACS Trauma Programs Trauma, Critical Care, Acute Care Surgery for their help with this article. Course (Las Vegas); and the Eastern States Point/Counterpoint Course (Atlantic City). Frank L. Mitchell, Jr., MD, FACS, initiated the Kansas City course 29 years ago and chaired it for almost 20 years. It subsequently has been chaired by the following Region 7 Chiefs: Frank Mitchell III, MD, FACS; Bob Coscia, MD, FACS; Mike Metzler, MD, FACS; and Ste- ven Smith, MD, FACS, the current Chair. Drs. Cleveland and Wolferth were the originators of the Western States (Las Vegas) and Eastern States (Atlantic City) postgraduate courses, now directed by Kenneth Mattox, MD, FACS, and Kimball I. Maull, MD, FACS, respectively. It is from the funds generated by these courses that the Resident Papers Competition could be launched. Additional support has come from the American College of Surgeons, and cor- porate support is currently being provided by Wyeth Pharmaceuticals. Participation in the competition is highly respected by the trauma community, and the presenters are valued for their important role in shaping the future of trauma care. Many of the previous awardees (see sidebar on pages 33-34) are currently internationally recognized for their ongoing contribution to education, training, and research in the field of trauma. Their presentations are an important and well-attended component of the COT’s annual meeting. Presenting residents and fellows are encouraged to attend all COT activities and Dr. Jurkovich is pro- events during the annual meeting, with the fessor of surgery, Uni- versity of Washington, winners announced at the annual black-tie and chief of trauma, banquet. Camaraderie with fellow presenters Harborview Medical is readily established, and sets the stage for a Center, Seattle, WA. He lifelong career in trauma care and participation is Immediate Past-Vice- in other activities of the American College of Chair and Chair of Surgeons.  Regional Committees of the American College of Surgeons Committee on Acknowledgment Trauma. The author acknowledges the individuals who have served as Chairs of the Regional Committees of the ACS COT since the Resident Papers Competition 35

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Socioeconomic tips

ACS Coding Hotline: Unusual coding questions by the Division of Advocacy and Health Policy

his column lists some questions regarding Current Procedural Terminology (CPT)* Tcoding recently posed to the ACS Coding Around the corner Hotline and the responses. As a benefit of mem- bership in the College, ACS Fellows and their June 2007 staff may consult the hotline 10 times annually • Economedix will hold two teleconferences without charge. If your office has coding questions, this month. The first, on June 6, is Practice Mar- please contact the Coding Hotline at 800/227-7911 keting Strategies and Techniques. The second, between 7:00 am and 5:00 pm Mountain Time, on June 13, is Negotiating Better Third-Party holidays excluded. Contracts. For more information and to register, go to http://yourmedpractice.com/ACS/. What is the code for accessory breast exci- sion? July 2007 • For an update on the Centers for Medicare The appropriate procedure code to use is code & Medicaid Services’ Physician Quality Report- 19120, Excision of cyst, fibroadenoma, or other ing Initiative, a voluntary quality reporting pro- benign or malignant tumor, aberrant breast tissue, gram, please visit its Web site at www.cms.hhs. duct lesion, nipple or areolar lesion (except 19300), gov/pqri. open, male or female, one or more lesions. Surgeons who successfully report a designated set of quality measures on claims for dates of ser- How do I code when the physician is doing vice from July 1 to December 31, 2007, will earn a reexcision of breast tissue needing larger a bonus of up to 1.5 percent of all their Medicare margins? billing. The bonus payments will be awarded in Use procedure code 19301–58, Mastectomy, par- early 2008. The Web site currently presents a tial (eg, lumpectomy, tylectomy, quadrantectomy, series of frequently asked questions. segmentectomy); modifier –58, Staged or related • Economedix will hold two teleconferences procedure or service by the same physician during this month. The first, on July 12, is Creating an the postoperative period. Effective OSHA Compliance Program. The sec- ond, on July 26, is Practice Valuations… What’s The surgeon performed an ultrasound Your Practice Worth? needle biopsy of the breast. How should this For more information and to register, go to procedure be coded? http://yourmedpractice.com/ACS/. • ACS-sponsored basic and advanced coding The following procedure codes can be used, workshops for surgeons will be presented July depending on the needle biopsy device used. If 12–13, 2007, in Chicago, IL. the standard 12- to 18-gauge tru-cut type needle Visit the ACS coding workshop Web page at is used, then use code 19102, Biopsy of breast; http://www.facs.org/ahp/workshops/index.html continued on page 42 or contact Stephanie Flynn at 312/202-5244 to *All specific references to CPT (Current Procedural Terminology) register. terminology and phraseology are © 2006 American Medical Association. All rights reserved. 36

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

In memoriam Remembering Edwin W. Gerrish by Barbara L. Dean, Director, Executive Services

Edwin W. Gerrish, MD, FACS, Gerrish was extremely busy as the former Director of the As- the only board-certified surgeon sembly Department at the Amer- within approximately 100 miles. ican College of Surgeons and a Joining the College in 1953, he recipient of the Distinguished served as President of the South Service Award—the College’s Dakota Chapter from 1969 to highest honor—died March 18 1970. He moved his family to in Watertown, SD, at age 88. the Chicago, IL, area in 1970 Though it is sad to write a final when he accepted the position as remembrance for a respected Director of the Assembly Depart- coworker and beloved friend, it ment at the American College of is also gratifying to reflect on the Surgeons. During his career, he measure of the man, through his was also a member of a number close family ties, his contribu- of general and pediatric surgical tions to surgery in his role as a organizations. practicing general surgeon and Dr. Gerrish as a leader in surgical education Service to the ACS for an organization he held dear, In July 1970, Dr. Gerrish as- and the esteem in which he was Hospitals. In 1950, he began an sumed the responsibility for held by his surgical and nonsur- eight-year academic progression planning and coordinating the gical colleagues. at Western Reserve University educational programs for the School of Medicine, first as an Clinical Congress and other Beginnings instructor in surgery, then as a scientific meetings sponsored by Dr. G. (as he was casually senior instructor, then as an as- the College. During his 18 years and fondly known to many on sistant professor of surgery, and as the Director of the Assembly the College staff) was born in finally as an assistant professor Department, important changes Cleveland, OH, in 1918; received of pediatric surgery. During occurred, including the change an AB degree from Kenyon Col- this time, he was also on the from three annual sectional lege in Gambier, OH, in 1939; staff of University Hospitals of meetings to an annual Spring and received his medical degree Cleveland as assistant surgeon, Meeting, which debuted in 1973. (MD) from Western Reserve associate surgeon, and as sur- Dr. Gerrish often spoke of the University School of Medicine geon in charge of the outpatient complex task of scouting out in Cleveland in 1943. He in- department. meeting sites, especially for the terned at University Hospitals Clinical Congress. He was proud in Cleveland. From 1944 to 1946, Private practice of how this process evolved over he served stateside in the U.S. to executive staff the years as the meetings grew in Army Medical Corps and in the In 1959, he moved to South Da- size and in diversity of needs. Philippines as a neurosurgeon, kota (a place he came to love and Under Dr. Gerrish’s watch, for which he received special returned to late in his life) and Atlantic City, NJ, was dropped army training. began an 11-year private practice as the third city in the Clinical In 1949, he completed his resi- in the small town of Mobridge. In Congress rotation, and Miami, dency in surgery at University this beautiful, rural setting, Dr. FL, Dallas, TX, and Atlanta, 37

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS GA, were tried as alternates. In compressed time period and yet tor of the College’s Department 1986, New Orleans, LA, became meet critical deadlines. He had of Assembly; and in gratitude the third city in the rotation, a great admiration and respect for for contributions to the College spot that would be held through the College’s Program Commit- in committee work, as Chapter this year. (After this year’s final tee, and he praised its volunteer President, and as a valued co- Clinical Congress in the Cres- members for contributing so ordinator of continuing surgical cent City, Washington, DC, will much knowledge, time, and ef- education with unparalleled skill replace New Orleans in 2010.) fort to making sure the scientific and devotion.” One of the biggest changes program was of high quality. that took place for the Assembly Personal loss Department was when Conven- Retirement and Dr. Gerrish is survived by his tion Services began to handle recognition by ACS wife, Ann; four children—Ed- the intricate details of planning Dr. Gerrish retired on July win S. Gerrish, MD, FACS (a meetings, including registration, 15, 1988, and in October of that general surgeon in Watertown, the social program, and the sci- year he received the College’s SD), Michael Haines Gerrish, entific and technical exhibits. Dr. Distinguished Service Award, Lon William Gerrish, and Betsy Gerrish and his staff were well “…in acknowledgment of 35 Ann Gerrish; and nine grand- known for their organized and years of accomplishment as a children. He will be remembered efficient approach to all these Fellow of the College, in clinical as a loving husband, father, and components of the meeting, and practice, academic teaching, and grandfather, as a contributor Dr. G. always gave credit to his administrative service to pediat- to surgery as a whole and to staff members for their ability to ric and general surgery; and in his own patients, and as a dear coordinate so many activities in a recognition of 18 years as Direc- friend and colleague to many.

WHAT SURGEONS SHOULD KNOW ABOUT (from page 11)

What is the College going to do to evaluate data. For more information about the College’s PQRI? Case Log System, see the article on page 17 of this issue. The College is recruiting a number of practices of differing sizes, geographical locations, and so It is well established that something like on, to track their experience under PQRI. We will the National Surgical Quality Improve- report any problems to CMS and, if necessary, to ment Program (NSQIP) is a far more ro- Congress. If you are interested in being a part of bust means of measuring outcomes than this effort, contact the Division of Advocacy and claims-based data. Where does it fit in with Health Policy via e-mail at [email protected]. the PQRI?

It seems like the College’s Case Log System NSQIP is a very successful program for measur- is an excellent tool for capturing these ing systems of care. However, due to the limited data. Can we use it for quality reporting? sampling methodology, it is not possible to consis- tently measure the data for individual physicians. The ACS Case Log System is an excellent tool In addition, NSQIP is in a limited number of hospi- for capturing the data, but there simply was not tals and does not apply to physicians who practice enough time to adapt the program to be compat- in ambulatory surgery centers or physician offices. ible with the PQRI for the last half of 2007. CMS As NSQIP and physician quality initiatives evolve, also has some concerns about dealing with all the College will continue to look for methods to the databases in existence, so the agency wants reduce the burden on physicians by building on to determine a way of reducing the variance in existing data collection systems.  38

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS COT 2007 Resident Trauma Papers Competition winners announced

The Committee on Trauma (COT) announced the winners of this year’s Resident Trauma Papers Competition at its an- nual meeting in Denver, CO, on March. There were 14 regional winners, who each received a prize of $500. An extra $1,000 was awarded to the two first- place winners and an additional $500 was received by the two second-place winners. The competition is funded by the Eastern and Western States Committees on Trauma, Re- gion 7 (Iowa, Kansas, Missouri, and Nebraska), Wyeth Phar- maceuticals, and the American College of Surgeons. The competition is open to surgical residents and trauma Competition winners, left to right: Dr. Damle, Dr. Ereso, Dr. Mihailovic, and fellows. Papers are first sub- Dr. Pidcoke. mitted for state or provincial competitions. Those winners are then judged at a regional level. Papers should describe original research in the area of mark the occasion of its 30th of Pediatric Injury in the De- trauma care and/or prevention year. (See page 30 of this issue veloping World: Quantifying in one of two categories: basic for a historical overview of the the Problem and Translating laboratory research or clinical competition that includes a Research into a Sustainable investigation. photo of Dr. Cleveland receiving Solution The regional winning papers his award.) Second Place, Basic Labora- were presented at the scien- The 2007 final winners are tory Research: Sagar S. Damle, tific session of the COT meet- as follows: Denver, CO: Therapeutic In- ing, which was moderated by First Place, Basic Labora- duction of Heme-Oxygenase-1 M. Margaret Knudson, MD, tory Research: Alexander Q. Using a Hemoglobin-Based FACS, Vice-Chair of the COT Ereso, MD, Oakland, CA: The Oxygen Carrier and Chair of the COT Regional Angiotensin II Type 2 Recep- Second Place, Clinical Inves- Committees. The four final tor: An “Endogenous Brake” in tigation: Heather F. Pidcoke, winners were announced at Inflammation-Induced Micro- MD, San Antonio, TX: Occult the Trauma Banquet, where vascular Fluid Leak Hypoglycemia Unmasked with the COT members also honored First Place, Clinical Investi- an Algorithm to Correct Hema- Henry C. Cleveland, MD, FACS, gation: Alexandra Mihailovic, tocrit Effect in Point-of-Care founder of the competition, to MD, Toronto, ON: The Burden Glucometers 39

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS NQF endorses measures developed by the ACS Commission on Cancer

In a move more than two Quality Integration Committee. receptor-positive breast cancer years in the making, the first “These measures help close the that is either larger than 1 cm nationally recognized hospital- loop on quality improvement. with no nodal or distant organ based performance measures for Data collected by hospitals and metastasis, or has spread to in- quality of care for breast and submitted nationally to the CoC volve regional lymph nodes but colorectal cancer were endorsed can now be used by hospitals has not metastasized to organs by the National Quality Forum and doctors to assess how they outside the breast. (NQF). The pioneering effort perform in comparison to oth- to develop these measures was ers, and to address any issues Colon cancer led by the American College in quality. The public can now • Postoperative chemothera- of Surgeons’ Commission on have confidence that when their py is considered or administered Cancer (CoC) in concert with hospitals perform well in using within four months of diagnosis the American Society of Clinical these measures, they are receiv- for patients younger than 80 Oncology (ASCO) and the Na- ing the nationally recognized with colon cancer that involves tional Comprehensive Cancer standard of care as put forth regional lymph nodes. Network (NCCN). The NQF by the nation’s leading cancer “The endorsement of these first issued a call for breast and organizations.” new cancer care measures by the colorectal measures in 2004 The measures endorsed by the NQF is an important step for- and 2005. NQF include the following: ward,” said Carolyn M. Clancy, The CoC is a consortium MD, director of the Agency for of more than 0 professional Breast cancer Healthcare Research and Qual- organizations, including rep- • Radiation therapy is ad- ity and a NQF board member. resentatives from all medical ministered within one year of “These measures, championed disciplines that treat and care diagnosis for women younger by leading cancer organizations for cancer patients and are than 70 who receive breast- and others, will help set clear dedicated to improving the conserving surgery for breast standards for treating breast survival and quality of life for cancer. and colorectal cancer and help cancer patients. The CoC ac- • Combination chemother- patients receive the best care credits more than 1,400 cancer apy is considered or adminis- possible.” programs across the U.S. that tered within four months of In developing the measures, are committed to providing diagnosis for women younger the organizations’ members the best in cancer care and are than 70 with hormone receptor- made the deliberate decision able to comply with established negative breast cancer that is to evaluate the performance standards. either larger than 1 cm with no of hospitals and health care “This is an important ad- nodal or distant organ metasta- systems, not individual physi- vancement for the public and sis, or has spread to involve re- cians. for the health care community gional lymph nodes but has not “Treating and managing can- because it marks the first time metastasized to organs outside cer is an interdisciplinary, not a we have nationally accepted the breast. solo, practice; therefore, it was measures of quality for treat- • Tamoxifen o r t h i r d - essential that we focused on ing people with breast and generation aromatase inhibitor hospitals and systems,” accord- colon cancer,” said Stephen is considered or administered ing to Clifford Ko, MD, FACS, Edge, MD, FACS, who co-led within one year of diagno- Director of the ACS Division of the CoC’s effort as Chair of its sis for women with hormone Research and Optimal Patient 40

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Care and co-leader of the ini- cant advancement in cancer said. “Consumers, patients, tiative. patient care, Thomas R. Russell, and others need tools like these Through its Cancer Program MD, FACS, ACS Executive Di- agreed-upon standards of care Practice Profile Reports and rector, said, “Through its Elec- to measure quality of care. This Electronic Quality Improve- tronic Quality Improvement is an important step in the pay- ment Packets effort, the CoC Packets effort, the ACS has for-performance initiative.” has positioned itself over the already demonstrated that im- The standard of care mea- past two years to assist its provements in data quality and sures for breast and colon dis- approved cancer programs to patient care are possible when ease are now posted on the ACS prepare for the arrival of these the entire cancer community Web site at http://www.facs.org/ quality measures. The goal of supports system-level enhance- cancer/qualitymeasures.html. these feedback reports has been ments to ensure complete and The measures are also on the to foster preemptive awareness precise documentation.” Web sites of the ASCO (http:// of the importance of chart- “When credible quality mea- www.asco.org/qualitymeasures) ing and coding accuracy and surement standards like these and NCCN (http://www.nccn. the improvement of clinical are in place, from a clinical org/ ). These organizations will management and coordination perspective we think it is ap- also proactively distribute the of patient care in the multi- propriate to link reimburse- measures to the entire cancer disciplinary setting. ment by health insurance plans community. Commenting on this signifi- to standards of care,” Dr. Ko

ACS endorses National Time Out Day

The American College of Sur- and to prevent errors in the op- cedure. The day reinforces the geons has given its endorsement erating room. It also serves to re- good practice of overall clear to the 4th annual National Time inforce the third element of The communication, which should al- Out Day, on June 20. This day Joint Commission’s Universal ways be part of a surgical team’s is promoted among all members Protocol, which is as follows: routine.” of the surgical team to highlight • Preoperative verification Dr. Russell continued, “It is The Joint Commission’s Uni- process one of our best safety tools for versal Protocol and other initia- • Marking of the operative preventing medical errors. We tives that have been developed site encourage all surgeons to take to reduce medical and surgical • Time out immediately be- the lead in serving as facilitators errors. The Universal Protocol fore starting the procedure of this process.” took effect July 21, 2004, and is “The American College of Sur- For more information, visit the a requirement for all hospitals, geons views National Time Out following Web sites: ambulatory surgery centers, and Day as an important event for • http://www.jointcommission. office-based surgery facilities the entire surgical care team,” org/PatientSafety/Universal accredited by The Joint Com- ACS Executive Director Thomas Protocol/ mission. National Time Out Day R. Russell, MD, FACS, said. • h ttp://www.facs.org/ is sponsored by the Association “This is an important patient fellows_info/statements/st-41. of peri-Operative Registered safety initiative that reminds all html Nurses and has been endorsed members of the operating room • h ttp://www.facs.org/ by The Joint Commission. team about the importance of public_info/correctsite.html The surgical time out provides maintaining clear communica- • h ttp://www.aorn.org/ an opportunity for the surgical tion as they review the case of toolkit/ team to identify inconsistencies the patient before them and • http://www.patientsafety in reviewing the patient’s case during the actual surgical pro- first.org/ 41

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS SOCIOECONOMIC TIPS, from page 36 percutaneous, needle core, using imaging guidance. How do I code an excision of excess tissue If a vacuum-assisted rotating cutter type of device in the right axillary area when there is no (which is increasingly employed under ultrasound carcinoma or aberrant tissue? guidance) is used, then use code 19103, Biopsy of breast; percutaneous, automated vacuum assisted or The appropriate procedure code is 15839, Ex- rotating biopsy device, using imaging guidance. cision, excessive skin and subcutaneous tissue (includes lipectomy); other area. What modifier is used after breast surgery when a port needs to be placed for chemo- What code should be used for postoperative therapy? hemorrhage after breast surgery?

When the surgeon placed the port, use modifier For this procedure, use code 35820, Explora- –58, Staged or related procedure or service by the tion for postoperative hemorrhage, thrombosis or same physician during the postoperative period, infection; chest.  because it is a disease process.

The Residency Assist Page of the American College of Surgeons offers a medium for program directors to acquire updates and advice on topics relevant to their needs as administrators and teachers. Our goals are to offer practical information and approaches from summaries of published articles, invited editorials, and specific descriptions of lessons learned from program directors’ successful and not-so-successful strategies. Through the development of the Residency Assist Page, the ACS intends to support program directors and faculty by providing succinctly presented information helpful in addressing the challenges associated with administering state-of-art residency education. www.facs.org/education/rap For additional information, please contact Olivier Petinaux, MS, at [email protected], or tel. 866/475-4696

42

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Surgeons Diversified Investment Fund’s first quarter 2007 performance report Surgeons Diversified Investment Fund first quarter 2007 performance report (continued)

If you have any questions, contact Savi Pai, tel. 312/202-5056, e-mail [email protected]; or Tom Kiley, tel. 312/202-5019, e-mail [email protected]. You may also visit www.surgeonsfund.com or contact SDIF directly at 800/208-6070 for more information. ACS resident research scholarships available

The American College of Surgeons is offering two- be given to the projects of residents involved in year resident research scholarships for July 2008 full-time laboratory investigation. Study outside through June 2010. Eligibility for these scholar- the U.S. or Canada is permissible. Renewal of the ships is limited to the research projects of residents scholarship for the second year is required and is in surgery or a surgical specialty. American College contingent on the acceptance of a progress report of Surgeons’ Resident Research Scholarships are and research study protocol for the second year, supported by the generosity of Fellows, chapters, as submitted to the Scholarships Section of the and friends of the College to encourage residents College by May 1, 2009. to pursue careers in academic surgery. Application for these scholarships may be sub- The Ethicon Scholarship of the American Col- mitted even if comparable application to other or- lege of Surgeons for the Study of Surgical Wound ganizations has been made. If the recipient accepts Healing is funded by a grant from Ethicon, Inc., to a scholarship/fellowship from another agency or encourage residents to pursue careers in academic organization, the ACS Resident Research Scholar- surgery. The scholarship is intended primarily ship will be withdrawn. It is the responsibility of to stimulate interest in the healing of soft tissue the applicant to notify the Scholarships Section and minimally invasive surgery. Proposals may of the College of competing awards. include the biology of wound repair, complica- • The scholarship is $30,000 per year; the total tions of wound repair, or the application of new amount is to support the research of the recipi- technologies to clinical problems. ent and is not to diminish or replace the usual or Wyeth Pharmaceuticals has provided an unre- expected compensation or benefits of the recipient. stricted educational grant to the ACS to fund a Indirect costs are not paid to the recipient or to Resident Research Scholarship. The purpose of the recipient’s institution. the scholarship is provide two years of labora- • The scholar is expected to attend the Clinical tory experience to residents performing surgical Congress of the American College of Surgeons in research related to biological and physiological 2010 to present a report on the research as part aspects of inflammation. of the Surgical Forum and to receive a certificate at the Annual Business Meeting of Members. General policies • Approval of the application is required from The policies for granting of the American Col- the administration (dean or fiscal officer) of the in- lege of Surgeons Resident Research Scholarships stitution. Supporting letters from the head of the are as follows: department of surgery (or the surgical specialty) • The applicant must be a Resident Member of and from the mentor who will be supervising the the College who has completed two postdoctoral applicant’s research should be submitted. Only years in an accredited surgical training program in exceptional circumstances will more than one in the U.S. or Canada at the time the scholarship scholarship be granted in a single year to appli- is awarded (July 1, 2008) and shall not complete cants from the same institution. formal residency training before June 2010. Schol- The closing date for receipt of completed ap- arships do not support research after completion plications and all supporting documents is Sep- of the chief residency year. tember 1, 2007. • The scholarship is awarded for two years, Application forms may be obtained upon request and acceptance of it requires commitment for from: Scholarships Section, American College the two-year period. The award is to support a of Surgeons, 633 N. Saint Clair St., Chicago, IL research plan for the two years of the scholar- 60611-3211 or by visiting http://www.facs.org/ ship, July 2008 through June 2010. Priority will memberservices/acsresident.html. 45

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS PG 22: Principles of cancer Surgery

PG 23: the Hernia course (Parts i & ii)

Nine Courses PG 24: update on mechanical ventilation

for Surgeons on the Go PG 25: unresolved issues in trauma and critical care The American College of Surgeons’ Division of PG 27: minimally invasive esophageal Education is pleased to make available the content Surgery of nine postgraduate courses on a CD-ROM, Syllabi Select 2006. This CD-ROM is able to run in the PG 28: Benign Disease of the gastrointes- tinal tract (Parts i & ii) PC and Mac environments and offers you the ability to word-search throughout the CD, along with the PG 29: Surgery of the Pancreas

convenience of accessing any of the courses when you PG 32: What’s new in vascular Surgery want and where you want. 2006: update on management of common vascular Problems These syllabi can be purchased by calling 312/202-5474 PG 33: minimally invasive Surgery: or through the College’s Web site at www.facs.org. the next Steps

$69 for Fellows of the American College of Surgeons; $45 for Resident or Associate Members; $99 for nonmembers; $60 for surgical resident nonmembers* (Additional $16 shipping and handling charge for international orders.)

*Nonmember residents must supply a letter confirming status as a resident from a program director or administrator and are limited to one CD-ROM.

AmericAn college of SurgeonS • DiviSion of eDucAtion

Syllabi Select - 2006.indd 1 9/7/2006 12:12:05 PM ACOSOG news Neoadjuvant aromatase inhibitor trial for breast cancer by David Ota, MD, FACS, Durham, NC, and Heidi Nelson, MD, FACS, Rochester, MN

Surgeons frequently choose systemic chemotherapy, but not Patients are randomized to neoadjuvant systemic therapy all patients need chemotherapy receive 16 to 18 weeks of either for locally advanced breast in this situation. ACOSOG neoadjuvant exemestane, letro- cancer. Patients with relatively Z1031 is a randomized phase III zole, or anastrozole. Z1031 will large breast cancers (T2 or T3) trial of neoadjuvant aromatase determine if AI therapy for ER+ may not be eligible for breast- inhibitor (AI) therapy for lo- tumors is appropriate for tumor conserving therapy until tumor cally advanced ER+ (estrogen- downstaging. regression is induced. Tumor re- receptor positive) breast can- An important aspect of this gression is often achieved with cer in postmenopausal women. trial is pretreatment tissue col-

Z1031 (Stage II and III breast cancer trial) investigators

The following investigators have enrolled patients in Z1031 and submitted tissue to the ACOSOG Central Specimen Bank for microarray analysis. —Dr. Gildy Babiera, M.D. Anderson Cancer Center, —Dr. A. Marilyn Leitch, UT Southwestern Medical Center, Houston, TX Dallas, TX —Dr. Charles Balch, Johns Hopkins University Hospital, —Dr. Edward Levine, Wake Forest University, Baltimore, MD Winston-Salem, NC —Dr. Peter Beitsch, Dallas Surgical Group, Dallas, TX —Dr. Rogerio Lilenbaum, Mt. Sinai Medical Center, Miami, FL —Dr. Kaye Budway, Western Pennsylvania Hospital, —Dr. Cynthia Ma, Washington University School of Medicine, Pittsburgh, PA St. Louis, MO —Dr. William Dooley, Oklahoma University, Oklahoma City, —Dr. Kelly Marcom, Duke University Medical Center, OK Durham, NC —Dr. John Ellerton, Neveda Cancer Research, Las Vegas, —Dr. Joseph Merchant, McFarland Clinic, Ames, IA NV —Dr. Funda Meric-Bernstam, M.D. Anderson Cancer Center, —Dr. Matt Ellis, Washington University School of Medicine, Houston, TX St. Louis, MO —Dr. Eric Miller, Virtua Memorial Hospital, Burlington, NJ —Dr. Shamila Garg, Kansas City CCOP, Kansas City, KS —Dr. Paul Mosca, Lehigh Valley Hospital, Allentown, PA —Dr. Mark Gittleman, Sacred Heart Hospital, Allentown, PA —Dr. S. David Nathanson, Henry Ford Hospital, Detroit, MI —Dr. Michael Guenther, Good Samaritan Hospital, —Dr. Roshni Rao, UT Southwestern Medical Center, Cincinnati, OH Dallas, TX —Dr. Virginia Herrmann, Memorial Health University —Dr. Catherine Ronaghan, Covenant Medical Center, Medical Center, Savannah, GA Lakeside, TX —Dr. David Hetzel, Hope, A Women’s Cancer Center, —Dr. Perry Shen, Wake Forest University, Winston-Salem, NC Asheville, NC —Dr. Ali Shwaki, Kansas City CCOP, Kansas City, KS —Dr. Robert Hird, Upstate Carolina CCOP, —Dr. Danny Sims, Exeter Hospital, Exeter, NH Spartanburg, SC —Dr. Robert Sticca, Altru Cancer Center, Grand Forks, ND —Dr. Kelly Hunt, M.D. Anderson Cancer Center, —Dr. Peter Tate, Central Baptist Hospital, Lexington, KY Houston, TX —Dr. Mark Taylor, St. Joseph’s Hospital, Savannah, GA —Dr. Lisa Jacobs, Johns Hopkins University Hospital, —Dr. Debasish Tripathy, UT Southwestern Medical Center, Baltimore, MD Dallas, TX —Dr. John Kuebler, Columbus CCOP, Columbus, OH —Dr. Gary Unzeitig, Doctors Hospital, Laredo, TX —Dr. James Leibmann, New Mexico Onc Heme, —Dr. Alonzo Walker, Froedtert Memorial Lutheran Hospital, Albuquerque, NM Milwaukee, WI 47

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS lection for genomic profiling to AI therapy.* Surgeons play a trial is estimated to complete of the primary tumor and to critical role in this trial because accrual in March 2009. There are correlate the genomic signa- tissue collection is needed and the 104 IRB (Institutional Review ture with tumor response. primary treating oncologist must Board)-approved investigators at Although Z1031 requires ER recognize that patients can ben- 223 IRB-approved institutions. and/or PR+ (progesterone efit from neoadjuvant therapy. Continued patient accrual into receptor positive) tumors, not In the March 2006 issue of the this clinical trial is critical to all primary tumors will be re- Bulletin (ACOSOG news: ACS ACOSOG’s future and we would sponsive to the anti-hormonal surgical trial accrual campaign: encourage the ACS membership therapy. The problem is that Get involved, make a differ- to obtain IRB approval and to hormone receptor assays are ence. 2006;92[3]:51), ACOSOG participate in this trial. Z1031 not accurate enough to predict described Z1031 and called trial information is available at response and additional bio- upon ACS members to evalu- www.acosog.org or www.clinical markers of tumor sensitivity ate their breast cancer patients trials.gov (search Z1031). to AI therapy is needed. Tissue for enrollment into Z1031. As We want to take this oppor- is being collected and micro- of March 31, 2007, 82 patients tunity to thank those who an- array studies are being done in have been enrolled in this trial swered our call to service and order to address this problem. (targeted accrual is 375). At enrolled patients into Z1031 as The hypothesis is that genomic the current accrual rate, this of March 31. profiling using microarray *Ma CX, Ellis MJ. Neoadjuvant endocrine methods can identify hormon- therapy for locally advanced breast cancer. Dr. Ota and Dr. Nelson are ally sensitive breast cancers Semin Oncol. 2006;33:650-656. ACOSOG Group Co-Chairs.

Online educatiOn center fOr cancer PrOgrams Promoting Quality Cancer Care An educational resource providing Webcast presentations for cancer program staff, physicians, and administrators.

Webcasts — Convenient, Self-Directed Distance Learning 24/7/365 • Fee-based sessions are hosted online in their entirety. (Staff from CoC-Approved Cancer Programs receive a 25% discount.)

• Synchronized audio and slides with written transcripts.

• Key topics include: • CoC Cancer Program Standards • Cancer Staging • Data and Quality Improvement • Stereotactic Breast Biopsy Accreditation

To Learn More, Visit the Online Education Center for Cancer Programs. www.facs.org/cancer/webcast The CoC is a multidisciplinary program of Sponsored jointly by the American College of Surgeons. the Commission on Cancer and the American Joint Committee on Cancer 48

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS A look at The Joint Commission Patient safety and health care quality performance of U.S. hospitals

A new report from The Joint are receiving the life-saving common clinical conditions. Commission, Improving Amer- benefits of aspirin when they These measures may not apply ica’s Hospitals: A Report on arrive at the hospital, yet to specialty hospitals, such as Quality and Safety, shows hos- many heart failure patients do pediatric hospitals. The Joint pitals across the U.S. have sig- not receive specific discharge Commission and the Centers nificantly improved the quality instructions about their con- for Medicare & Medicaid Ser- of care provided for patients dition and necessary follow- vices (CMS) have worked to- suffering from heart attacks, up care when they leave the gether to align the measures heart failure, or pneumonia hospital. Hospital performance used by both organizations. over the past four years. in complying with the require- These standardized common The report also shows, how- ments of the National Patient measures, called hospital qual- ever, that the effectiveness Safety Goals has also been ity measures, are integral to with which hospitals carry variable. Most hospitals do improving the quality of care out safe practices and provide well in using objective meth- provided to hospitalized pa- patients proven treatments ods to identify patients before tients and bringing value to for common clinical conditions undertaking treatments, but stakeholders by focusing on varies by state. many are finding it challeng- the actual care processes and This report, the first of what ing to put processes in place to results. Measure alignment is to become an annual report, avoid medication mix-ups. benefits hospitals by making covers the time period from “The real and potential im- it easier and less costly to col- 2002 through 2005. It includes provements in patient safety lect and report data because national performance rates for and health care quality identi- the same data set can be used 2005 hospital compliance with fied in this report underscore to satisfy both CMS and Joint surgical infection prevention the value of ongoing measure- Commission requirements. measures, including the fol- ment of hospital performance All of the hospital quality lowing: against standards and perfor- measures used by The Joint • Prophylactic antibiotic mance measures,” says Dennis Commission and CMS are en- received within one hour be- S. O’Leary, MD, president of dorsed by the National Quality fore surgical incision The Joint Commission. “This Forum (NQF). These measures • Prophylactic antibiotic is the kind of information that are also used for Hospital discontinued within 24 hours will truly create informed Quality Alliance: Improving after surgical end time consumers who can ask good Care through Information, The report details the perfor- questions about their care and a voluntary public reporting mance of accredited hospitals even become involved in hospi- initiative led by the American against standardized national tal performance improvement Hospital Association, the Fed- performance measures and processes.” eration of American Hospitals, The Joint Commission’s Na- The Joint Commission re- and the Association of Ameri- tional Patient Safety Goals. quires accredited hospitals can Medical Colleges. This For example, The Joint Com- to collect and report data on initiative is supported by The mission report found that al- three of five performance Joint Commission, CMS, the most all heart attack patients measure sets that apply to NQF, the Agency for Health- 49

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS care Research and Quality, merly the American Associa- Report on Quality and Safe- American Federation of Labor tion of Retired Persons). ty, is available on The Joint and Congress of Industrial A complete copy of Improv- Commission’s Web site, www. Organizations, and AARP (for- ing America’s Hospitals: A jointcommission.org.

Disciplinary actions taken

The following disciplinary ac- Admonition: A written no- Yearbook and from the mailing tions were taken by the Board tification, warning, or serious list of the College; (c) surrenders of Regents at its February 9, rebuke. his or her Fellowship certificate 2007, meeting: Censure: A written judg- to the College, and no longer • Peter Christian Hudson, a ment, condemning the Fellow explicitly or implicitly claims general surgeon from Corvallis, or member’s actions as wrong. to be a Fellow of the American OR, had his Fellowship placed This is a firm reprimand. College of Surgeons; (d) pays the on probation with conditions Probation: A punitive action visitor’s registration fee when for reinstatement. Dr. Hudson for a stated period of time, dur- attending College programs; (e) was charged with violating the ing which the member (a) loses is not subject to the payment of ACS Bylaws, Article VII, Sec- the rights to hold office and to annual dues. tion 1b, following disciplinary participate as a leader in Col- When the suspension is lifted, action by the Oregon Board of lege programs; (b) retains other the Fellow or member is returned Medical Examiners. On January privileges and obligations of to full privileges and obligations 31, 2007, Dr. Hudson’s license to membership; (c) will be recon- of Fellowship. practice medicine in that state sidered by the Central Judiciary Expulsion: The certificate was placed on probation follow- Committee periodically and at of Fellowship and all other ing a finding that he wrongfully the end of the stated term. indicia of Fellowship or mem- took samples of a controlled Suspension: A severe punitive bership previously issued by substance for his own use. action for a period of time, dur- the College must be forthwith • Donald W. Marion, a neuro- ing which the Fellow or member, returned to the College. The surgeon from Wayland, MA, was according to the membership surgeon thereafter shall not expelled from the College. Dr. status, (a) loses the rights to explicitly or implicitly claim to Marion’s license to practice medi- attend and vote at College be a Fellow or member of the cine in the State of Massachu- meetings, to hold office, and to American College of Surgeons setts was revoked pursuant to an participate as a leader, speaker, and may not participate as a October 2005 consent order after or panelist in College programs; leader, speaker, or panelist in being found to have committed (b) is subject to the removal of College programs. conduct that placed into ques- the member’s name from the tion his ability to practice medi- cine, including gross misconduct. Dr. Marion was charged with a violation of ACS Bylaws Article VII, Sections 1(b) and (f). Change your address online!

Definition of terms Following are the disciplinary Go to the College’s “members only” actions that may be imposed for violations of the principles of Web portal at www.efacs.org the College. 50

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS NTDB® data points What a disaster by Richard J. Fantus, MD, FACS, Chicago, IL, and Jeffrey S. Hammond, MD, MPH, FACS, New Brunswick, NJ

It has been almost two years since Hurricane Katrina, one Hospital discharge status of the deadliest and costliest hurricanes in the history of the U.S., hit New Orleans, LA. The aftermath of that category 5 hurricane and accompany- ing floods were responsible for more than 1,800 deaths and more than $80 billion in damage. In the ensuing days, there was an overwhelming outpouring of support and offers of medical assistance from all around the country. This offer of help took many forms, from the provision of needed supplies all the way to surgeons offering to close their practices, drive to Louisiana, and donate their surgical skills on-site. The eager volunteers who offers a perspective on plan- cause of injury code E 908 for were geographically remote ning, prehospital response, cataclysmic storms and floods from the disaster site learned incident command, triage, and resulting from storms, and that the local and surround- patterns of injury. The hope is E 909 for cataclysmic earth ing communities provide the that surgeons who complete surface movements and erup- early primary response to a this course would return to tions. These codes include natural or man-made disas- their respective communities hurricane, tornado, flood, ter. This lesson is one reason and become actively involved blizzard, earthquake, volcanic that the Disaster and Mass in their hospital disaster and eruptions, avalanche, dam col- Casualty Subcommittee of the emergency preparedness plan- lapse, tidal wave, and tsunami. American College of Surgeons ning process. Of the 244 records found, 185 Committee on Trauma has In order to examine the oc- were discharged to home, 38 developed and promoted a currence of injuries that result to acute care/rehabilitation, course on disaster and mass from cataclysmic events in and 12 to nursing homes; nine casualty management. The the National Trauma Data died. These data are depicted in belief behind this course is Bank Dataset 6.0, we utilized the figure on this page. Among that all surgeons should know the International Classifica- the victims, two-thirds were what to do if a disaster hits tion of Diseases, Ninth Revi- male and on average 37 years their community. This course sion, Clinical Modification, of age, with an average length 51

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS of hospital stay of 8.1 days, or mass casualty incident. What ACS Committee on Trauma, at and an average injury severity a disaster it would be if we did [email protected]. score of 12.1. not get educated on disaster Throughout the year, this col- The numbers in the data management or take an active umn will provide brief monthly bank may be small, but given role in disaster planning at our reports. The full NTDB Annual the geopolitical climate in own hospital and in our own Report Version 6.0 is available which we live, the potential for communities. on the ACS Web site as a PDF mass injury constantly looms To learn more about the Di- file and a PowerPoint presenta- on the horizon. Surgeons, by saster Management and Emer- tion at http://www.ntdb.org. their training and practice, gency Preparedness (DMEP) If you are interested in sub- are uniquely qualified to deal course, contact Jeffrey Ham- mitting your trauma center’s with the acute care problems mond MD, MPH, FACS, Chair- data, contact Melanie L. Neal, confronted during the planning man, Disaster and Mass Ca- Manager, NTDB, at mneal@ for and response to a disaster sualty Subcommittee of the facs.org

Operation Giving Back Volunteer opportunities available

The Operation Giving Back nurses to complete the team. of hearing loss. GEO has oppor- (OGB) database is continually Volunteers are usually re- tunities for otolaryngologists expanding with new volunteer quested to provide clinical or experienced in otologic surgery opportunities, including open- didactic education as a part of to provide clinical services, ings with the following agen- the mission. training, and education for pe- cies: • Global ENT Outreach riods of two weeks in Ethiopia • Healing the Children– (GEO) is dedicated to provid- and El Salvador. Southwest Chapter (HTCSW) ing education to ear, nose, and OGB provides surgical vol- makes medical treatment avail- throat (ENT) specialists and unteers with a wealth of re- able to children in Guatemala humanitarian surgical services sources, including a directory City, Guatemala, and San Sal- to the underserved in develop- of books that surgeons might vador, El Salvador. Surgical ing countries. GEO focuses on find helpful and interesting in specialties for these missions three strategic areas: training preparation for volunteer out- may include the following: foreign ENT physicians in reach. This information can be ophthalmology, otolaryngology, surgical procedures that en- found on the OGB Web site in urology, and pediatric and plas- able them to better meet their the “Book Corner” under the tic surgery. Once a surgeon has country’s needs; providing heading “Resource Center” on indicated an interest, HTCSW opportunities for medical stu- the main toolbar. contacts the host country to dents, ENT residents, fellows, To learn more about these discuss the needs related to and practitioners to participate and other volunteer opportu- that specialty. When the mis- in international humanitarian nities and resources, please sion is further defined, HTCSW service; and providing surgical visit the OGB Web site at www. will locate volunteer anesthe- services to the underserved operationgivingback.org.

52 siologists, pediatricians, and who suffer from the disabilities

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Chapter news

by Rhonda Peebles, Division of Member Services

To report your chapter’s news, contact Rhonda in New Delhi. The theme of the 2007 activity was Peebles toll-free at 888/857-7545, or via e-mail “Frontiers in Surgical Practice,” which featured at [email protected]. presentations by residents and Fellows and a poster session. Hari Shankar Asopa, MBBS, India hosts annual conference FACS, was the chief guest for the education The India Chapter hosted its annual confer- program. In addition, a business meeting was ence January 27–28 at the India Habitat Centre convened (see photo, this page).

India Chapter: At podium, valedictory speaker Narendra Kumar Pandey, MBBS, FACS, Secretary; guest of honor Dr. Vishwajeet Singh, Ex Union Minister and presently Member of Rajya Sabha (Upper House of Parliament); Dr. Asopa; T.E. Udwadia, MBBS, FACS, Governor; and Sandee Mukherjee, MD, FACS, Past-President.

Ireland Chapter: Fellows of the chapter, left to right (all FACS): Prof. Niall O’Higgins, MBBCh, FACS(Hon); Harold J. Browne; Prof. Gerald C. O’Sullivan, RCSI President, MBBCh; Prof. David John Bouchier-Hayes, MBBCH; Prof. Thomas Francis Gorey, MBBCh; John M. P. Mr. Hyland, MBBCH; David Martin Quinlan, MBBCh; Prof. Barry O’Donnell, MCh, FACS(Hon); Francis Oliver Cunningham, MBBCH; Joseph M. Deasy, MBBCh; and Parnell Keeling, MBBCh.

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JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Ireland Chapter meets at RCSI Surgeons in Ireland (RCSI). Gerald O’Sullivan, The College’s Ireland Chapter conducted a social MBBCh, FACS, President of the RCSI and Gov- and professional networking program for Fellows ernor for the Ireland Chapter, presided over the in Ireland on February 5 at the Royal College of event. (See photo, page 53.)

Chapter meetings For a complete listing of the ACS chapter education programs and meetings, please visit the ACS Web site at http://www.facs.org/about/chapters/index.html. (CS) following the chapter name indicates that the ACS is providing AMA PRA Category 1 Credit™ for this activity.

Date/time Event Location/contact information July 2007 Location: Grove Park Inn, Asheville, NC July 6–8 North Carolina (CS) Contact: Carol Russell, 919/467-3818; [email protected] Location: Belo Horizonte, Brazil Contact: Samir Rasslan, MD, FACS; 55-11-255-9129; [email protected] July 9–10 Brazil ACS representatives: Jorge Reyes, MD, FACS; Andrew Peitzman, MD, FACS; Hugo Villar, MD, FACS; and Murray Brennan, MD, FACS Location: Paris Landing State Park, Buchanan, TN July 27–29 Tennessee (CS) Contact: Wanda Johnson, 931/967-4700; [email protected] August 2007 Location: Coeur d’Alene Resort, Coeur d’Alene, ID Idaho and Montana/ August 16–18 Contact: Adam Deutchman, MD, FACS, or Lori Schneider, 208/756-5612; Wyoming (CS) [email protected] September 2007 Location: Holiday Inn Select, Little Rock, AR September 8 Arkansas (CS) Contact: Linda Clayton, 501/526-7053; [email protected] ACS representative: Edward M. Copeland III, MD, FACS Location: Sheraton Hotel, Overland, Park, KS September 8–9 Kansas (CS) Contact: Chip Wheelen, 785/234-3319; [email protected] September Location: The Cloister, Sea Island, GA Georgia (CS) 20–23 Contact: Lois Shinall, 912/925-8969; [email protected] October 2007 Location: The American Club, Kohler, WI October 19–20 Wisconsin Contact: Terry Estness, 414/453-9957; [email protected] November 2007 Location: Delaware Art Museum, Wilmington, DE Delaware (CS) November 3 Contact: Dianna Garvey, 302/658-7596l; [email protected] 50th Anniversary ACS representative: Edward M. Copeland III, MD, FACS 54

VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS South Texas Chapter: Pictured left to right are Lillian South Texas Chapter officers (left to right, all MD, Kao, MD, FACS; Donald Leslie, MD, Jeopardy winner; FACS): Robert Todd, Councillor; Matt Wall, President; Rob Todd, MD, FACS, chair of the Jeopardy contest; and Kevin Lally, Immediate Past-President and Governor; Shinil Shah, MD (Resident Member), Jeopardy winner. and Bradford Scott, Secretary-Treasurer.

from across the Chapter entered the contest; the winning residents were from the University of Texas Medical School in Houston (see photo, this page). New Jersey Chapter hosts hospital liaisons The New Jersey Chapter conducted its annual Hospital Liaison Representatives Meeting on March 7. The half-day program featured pre- sentations by Thomas R. Russell, MD, FACS, New Jersey Chapter: left to right, back row (all MD, ACS Executive Director; Harold L. Kent, MD, FACS): Frank Padberg, Jr., Secretary; Mark Moritz, FACS, editorial and opinion-editorial writer for President-Elect; Paul J. Carniol, Program Chair and General Surgery News; and Clark Martin, Esq., Councillor; Stephen J. Pilipshen, Treasurer; Dr. Kent; who provided an update on political activities in H. Stephen Fletcher, Governor; and Bruce Brener, Past- New York. (See photo, this page.) President. Front row: Mr. Arthur Ellenberger, Executive Director; William A Rough, MD, FACS, President and Lebanon Chapter conducts Governor; and Dr. Russell. portal education program On April 5, the Lebanon Chapter conducted an education program, Introduction to the American South Texas meets in Houston College of Surgeons Web Portal: A Personalized The South Texas Chapter met February 22–24 Gateway to the Internet. The activity was led by and a diverse education program was presented, Michel Daher, MD, FACS, a Past-President and including resident presentations on basic and Webmaster of the Lebanon Chapter. clinical sciences and a breast ultrasound course. During the annual meeting, new officers were New York Chapter reaches out elected (see photo, this page). In addition, for the to practice administrators first time, the South Texas Chapter conducted Later this month, the New York Chapter will Resident Surgical Jeopardy Bowl; six teams conduct a one-day education program for ad- 55

JUNE 2007 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ministrators of surgical practices in three separate Chapter anniversaries locations: Rochester (June 27), Albany (June 28), and Plainview (June 29). The topics to be covered Month Chapter Years include business law, customer service training, scheduling, and electronic medical records. The May Colorado 50 program, Managing a Medical Practice: Effective Maryland 50 Strategies & Solutions, also is being cosponsored June Alberta 17 Arkansas 32 by the New York College of Physicians and the Connecticut 40 New York State Ophthalmological Society. Metropolitan Washington (DC) 33 For more information, contact Amy Clinton, Ecuador 40 Executive Director, at 518/283-1601, or NYC Germany 17 [email protected]. Greece 21 Idaho 57 Revised CME procedures Ireland 24 for chapters Israel 10 Last March, the continuing medical education Maine 56 (CME) procedures for chapters were revised so that Mexico—Northeast 33 Mexico—Nor-Occidental 36 the College’s members’ CME credits can be posted Minnesota 36 on each member’s “My CME” page, located on the New Mexico 22 Web portal. In addition, the revised procedures also New York 41 comply with the requirements of the American Western New York 42 Medical Association Physician Recognition Award. North Dakota 52 For more information or assistance with the CME Oregon 42 procedures, visit the chapters homepage at http:// Philippines 36 www.facs.org/about/chapters/index.html , or call the Spain 24 chapter hotline at 888/857-7545. Wisconsin 36

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VOLUME 92, NUMBER 6, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS