Thoracic Surgery News (Archived)

NATIONAL HARBOR, MD. – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after trans-catheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality ( N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty-one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after trans-catheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality ( N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty-one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after trans-catheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality ( N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty-one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

Medicare payments are set to increase 2.8% in fiscal year 2013 to general acute care hospitals that successfully participate in Medicare’s Inpatient Quality Reporting Program. Hospitals that don’t participate will get just a 0.8% increase, though Medicare officials estimate that almost all hospitals will participate.

Medicare payments to long-term care facilities will increase by 1.7% in the coming fiscal years, which starts Oct. 1, according to the Centers for Medicare and Medicaid Services.

The new payment rates were announced Aug. 1 as part of the final rule for the Inpatient Prospective Payment System and the Long-Term Care Hospital Prospective Payment System.

In its original pay proposal published in May, the CMS said it would increase payments to general acute care hospitals by 2.3% because of cuts the agency was making to account for hospital coding that was too high. Based on public comments in opposition to the coding adjustments, the CMS backed off the cuts for now. The American Hospital Association estimates that the initial proposal would have cost hospitals nationwide a total of $850 million.

The final rule, to be published in the Federal Register August 31, also lays out a new quality program that debut in October. Under the Hospital Readmissions Reduction Program, hospitals’ base operating diagnosis-related-group (DRG) payment will be cut by 1% if their readmission rate for three conditions – acute myocardial infarction, heart failure, and pneumonia – is deemed too high. The agency estimates the program will reduce overall payments to hospitals by about $280 million in FY 2013.

For the Hospital Value-Based Purchasing (VBP) Program, which also begins on Oct. 1, the final rule specifies hospitals will receive their total performance scores, indicates how the 1% penalty will be applied to base operating charges, and provides the timeline for making incentive payments. New measures were added to the program for FY 2015: a central line – associated bloodstream infection measure, a patient safety indicator composite measure, and an efficiency measure that looks at Medicare spending per beneficiary.

The CMS is revising its list of hospital-acquired conditions for which it will not pay. Starting this fall, surgical site infection following cardiac implantable electronic device procedures will make the do-not-pay list, along with iatrogenic pneumothorax with venous catheterization.

The agency is adding two new codes to the list of hospital-acquired conditions: bloodstream infection due to central catheter (999.32) and local infection due to central venous catheter (999.33).

Medicare payments are set to increase 2.8% in fiscal year 2013 to general acute care hospitals that successfully participate in Medicare’s Inpatient Quality Reporting Program. Hospitals that don’t participate will get just a 0.8% increase, though Medicare officials estimate that almost all hospitals will participate.

Medicare payments to long-term care facilities will increase by 1.7% in the coming fiscal years, which starts Oct. 1, according to the Centers for Medicare and Medicaid Services.

The new payment rates were announced Aug. 1 as part of the final rule for the Inpatient Prospective Payment System and the Long-Term Care Hospital Prospective Payment System.

In its original pay proposal published in May, the CMS said it would increase payments to general acute care hospitals by 2.3% because of cuts the agency was making to account for hospital coding that was too high. Based on public comments in opposition to the coding adjustments, the CMS backed off the cuts for now. The American Hospital Association estimates that the initial proposal would have cost hospitals nationwide a total of $850 million.

The final rule, to be published in the Federal Register August 31, also lays out a new quality program that debut in October. Under the Hospital Readmissions Reduction Program, hospitals’ base operating diagnosis-related-group (DRG) payment will be cut by 1% if their readmission rate for three conditions – acute myocardial infarction, heart failure, and pneumonia – is deemed too high. The agency estimates the program will reduce overall payments to hospitals by about $280 million in FY 2013.

For the Hospital Value-Based Purchasing (VBP) Program, which also begins on Oct. 1, the final rule specifies hospitals will receive their total performance scores, indicates how the 1% penalty will be applied to base operating charges, and provides the timeline for making incentive payments. New measures were added to the program for FY 2015: a central line – associated bloodstream infection measure, a patient safety indicator composite measure, and an efficiency measure that looks at Medicare spending per beneficiary.

The CMS is revising its list of hospital-acquired conditions for which it will not pay. Starting this fall, surgical site infection following cardiac implantable electronic device procedures will make the do-not-pay list, along with iatrogenic pneumothorax with venous catheterization.

The agency is adding two new codes to the list of hospital-acquired conditions: bloodstream infection due to central catheter (999.32) and local infection due to central venous catheter (999.33).

Medicare payments are set to increase 2.8% in fiscal year 2013 to general acute care hospitals that successfully participate in Medicare’s Inpatient Quality Reporting Program. Hospitals that don’t participate will get just a 0.8% increase, though Medicare officials estimate that almost all hospitals will participate.

Medicare payments to long-term care facilities will increase by 1.7% in the coming fiscal years, which starts Oct. 1, according to the Centers for Medicare and Medicaid Services.

The new payment rates were announced Aug. 1 as part of the final rule for the Inpatient Prospective Payment System and the Long-Term Care Hospital Prospective Payment System.

In its original pay proposal published in May, the CMS said it would increase payments to general acute care hospitals by 2.3% because of cuts the agency was making to account for hospital coding that was too high. Based on public comments in opposition to the coding adjustments, the CMS backed off the cuts for now. The American Hospital Association estimates that the initial proposal would have cost hospitals nationwide a total of $850 million.

The final rule, to be published in the Federal Register August 31, also lays out a new quality program that debut in October. Under the Hospital Readmissions Reduction Program, hospitals’ base operating diagnosis-related-group (DRG) payment will be cut by 1% if their readmission rate for three conditions – acute myocardial infarction, heart failure, and pneumonia – is deemed too high. The agency estimates the program will reduce overall payments to hospitals by about $280 million in FY 2013.

For the Hospital Value-Based Purchasing (VBP) Program, which also begins on Oct. 1, the final rule specifies hospitals will receive their total performance scores, indicates how the 1% penalty will be applied to base operating charges, and provides the timeline for making incentive payments. New measures were added to the program for FY 2015: a central line – associated bloodstream infection measure, a patient safety indicator composite measure, and an efficiency measure that looks at Medicare spending per beneficiary.

The CMS is revising its list of hospital-acquired conditions for which it will not pay. Starting this fall, surgical site infection following cardiac implantable electronic device procedures will make the do-not-pay list, along with iatrogenic pneumothorax with venous catheterization.

The agency is adding two new codes to the list of hospital-acquired conditions: bloodstream infection due to central catheter (999.32) and local infection due to central venous catheter (999.33).

Questions and uncertainty abound as state governments begin deciding whether they will participate in the expansion of Medicaid called for by the Affordable Care Act. In light of the Supreme Court’s decision that the federal government cannot penalize states that don’t participate, the governors of Texas, South Carolina, Nebraska, Iowa, Louisiana, Mississippi, and Florida have said that their states will opt out.

Leaders in other states say they need more information.

"The original act was very punitive for states that didn’t expand Medicaid. [The Supreme Court decision] now gives some options which, honestly, I don’t think a lot of us expected," Gov. Bob McDonnell (R-Va.) said at a press conference held at the National Governors Association annual meeting. "I don’t think it’s responsible fully for my state to make a decision now, because there’s still more information I need."

Gov. Jack Markell (D-Del.) said he sees the expansion as a "good deal for Delaware taxpayers," but agreed that most states will need more guidance from the federal government before making a decision.

As the ruling allows states to opt out of Medicaid expansion without losing existing federal monies, health care reform likely will look very different from state to state, said Sheila Burke of Harvard University, Cambridge, Mass.

"These states are going to respond to this very differently, and they are very different in terms of their preparation and their capacity to take on these changes. Governors, state legislators, exchange directors, and insurance commissioners all may have a different view," Ms. Burke said at a briefing held by the Alliance for Health Reform. She pointed out that many states legislatures won’t meet again until next year, so meaningful decision making may be on hold until then.

Prior to passage of the ACA, Medicaid provided health care coverage for the indigent, especially those who were dependent children, pregnant women, disabled, or elderly. Under the expansion, Medicaid would also cover anyone younger than age 65 years with an annual income less than 133% of the federal poverty level. The law also provides tax credits for people with incomes between 100% and 400% of the federal poverty level to purchase insurance.

If a state decides to opt out of Medicaid expansion, people whose income is above the federal poverty level, those who are single, childless, or don’t live with their children would not be covered. In addition, those who qualify for premium subsidies under the law but can’t find affordable coverage (that is, mostly low-wage workers) would not be covered.

States that opt out of the expansion also could have a harder time balancing impending cuts to providers and hospitals, according to Chris Jennings, president of Jennings Policy Strategies and former top health aide to President Clinton.

Physicians face a 27% Medicare pay cut in January according to the Sustainable Growth Rate (SGR) formula; hospitals, too, face cuts to their Disproportionate Share Hospital (DSH) payments.

Although there may be other ways to balance the cuts, the easiest is expanding Medicaid to get the extra funding, said Mr. Jennings. "It’s a harder road to go than just taking the money."

While added federal funding would help states offset other cuts, it’s unlikely that it would be enough for physicians to rebound from a huge SGR cut, said Dr. Glen R. Stream, president of the American Academy of Family Physicians.

"If the SGR-indicated payment cut was to go into place, there’s no way that the expansion of Medicaid is going to offset the devastating financial impact that that’s going to have for practices," he said in an interview. But he added that expanding Medicaid is currently the best option for providing much-needed care for low-income Americans.

"I don’t think anyone necessarily envisions expansion of Medicaid as the ideal means to expand coverage, but it is the one that’s on the table. My hope would be that if states chose to opt out of the Medicaid expansion, they would do so with some other plan to meet the needs of their citizens. The challenge would be that the plan wouldn’t be coming with any federal dollars," Dr. Stream said.

Officials with the American College of Physicians said states should move forward with expansion as soon as possible.

The "ACP also strongly urges states to move forward on expanding Medicaid to all persons with incomes up to 133% of the federal poverty level, notwithstanding the court’s ruling that states may not be denied existing Medicaid dollars for failing to do so," ACP president David L. Bronson said in a statement following the court’s ruling.

Mr. Jennings speculated that more will participate in the Medicaid expansion than most people currently think.

Dr. Stream agreed. "I suspect, at the end of the day, that we’ll have a lot more states coming in than we currently are hearing, primarily because I have some confidence in stakeholders’ abilities to encourage legislatures and governors to move ahead," he said.

Maryland is one of those states. Dr. Joshua Sharfstein, the state Secretary of Health and Mental Hygiene, said that implementing the law will give states an edge over those that opt out.

"I’ve heard [Gov. Martin O’Malley (D-Md.)] say that he ultimately sees successful implementation of the law as a competitive advantage for Maryland [and] for businesses to locate in the state if there’s real investment in the workforce," Dr. Sharfstein said at the briefing.

Questions and uncertainty abound as state governments begin deciding whether they will participate in the expansion of Medicaid called for by the Affordable Care Act. In light of the Supreme Court’s decision that the federal government cannot penalize states that don’t participate, the governors of Texas, South Carolina, Nebraska, Iowa, Louisiana, Mississippi, and Florida have said that their states will opt out.

Leaders in other states say they need more information.

"The original act was very punitive for states that didn’t expand Medicaid. [The Supreme Court decision] now gives some options which, honestly, I don’t think a lot of us expected," Gov. Bob McDonnell (R-Va.) said at a press conference held at the National Governors Association annual meeting. "I don’t think it’s responsible fully for my state to make a decision now, because there’s still more information I need."

Gov. Jack Markell (D-Del.) said he sees the expansion as a "good deal for Delaware taxpayers," but agreed that most states will need more guidance from the federal government before making a decision.

As the ruling allows states to opt out of Medicaid expansion without losing existing federal monies, health care reform likely will look very different from state to state, said Sheila Burke of Harvard University, Cambridge, Mass.

"These states are going to respond to this very differently, and they are very different in terms of their preparation and their capacity to take on these changes. Governors, state legislators, exchange directors, and insurance commissioners all may have a different view," Ms. Burke said at a briefing held by the Alliance for Health Reform. She pointed out that many states legislatures won’t meet again until next year, so meaningful decision making may be on hold until then.

Prior to passage of the ACA, Medicaid provided health care coverage for the indigent, especially those who were dependent children, pregnant women, disabled, or elderly. Under the expansion, Medicaid would also cover anyone younger than age 65 years with an annual income less than 133% of the federal poverty level. The law also provides tax credits for people with incomes between 100% and 400% of the federal poverty level to purchase insurance.

If a state decides to opt out of Medicaid expansion, people whose income is above the federal poverty level, those who are single, childless, or don’t live with their children would not be covered. In addition, those who qualify for premium subsidies under the law but can’t find affordable coverage (that is, mostly low-wage workers) would not be covered.

States that opt out of the expansion also could have a harder time balancing impending cuts to providers and hospitals, according to Chris Jennings, president of Jennings Policy Strategies and former top health aide to President Clinton.

Physicians face a 27% Medicare pay cut in January according to the Sustainable Growth Rate (SGR) formula; hospitals, too, face cuts to their Disproportionate Share Hospital (DSH) payments.

Although there may be other ways to balance the cuts, the easiest is expanding Medicaid to get the extra funding, said Mr. Jennings. "It’s a harder road to go than just taking the money."

While added federal funding would help states offset other cuts, it’s unlikely that it would be enough for physicians to rebound from a huge SGR cut, said Dr. Glen R. Stream, president of the American Academy of Family Physicians.

"If the SGR-indicated payment cut was to go into place, there’s no way that the expansion of Medicaid is going to offset the devastating financial impact that that’s going to have for practices," he said in an interview. But he added that expanding Medicaid is currently the best option for providing much-needed care for low-income Americans.

"I don’t think anyone necessarily envisions expansion of Medicaid as the ideal means to expand coverage, but it is the one that’s on the table. My hope would be that if states chose to opt out of the Medicaid expansion, they would do so with some other plan to meet the needs of their citizens. The challenge would be that the plan wouldn’t be coming with any federal dollars," Dr. Stream said.

Officials with the American College of Physicians said states should move forward with expansion as soon as possible.

The "ACP also strongly urges states to move forward on expanding Medicaid to all persons with incomes up to 133% of the federal poverty level, notwithstanding the court’s ruling that states may not be denied existing Medicaid dollars for failing to do so," ACP president David L. Bronson said in a statement following the court’s ruling.

Mr. Jennings speculated that more will participate in the Medicaid expansion than most people currently think.

Dr. Stream agreed. "I suspect, at the end of the day, that we’ll have a lot more states coming in than we currently are hearing, primarily because I have some confidence in stakeholders’ abilities to encourage legislatures and governors to move ahead," he said.

Maryland is one of those states. Dr. Joshua Sharfstein, the state Secretary of Health and Mental Hygiene, said that implementing the law will give states an edge over those that opt out.

"I’ve heard [Gov. Martin O’Malley (D-Md.)] say that he ultimately sees successful implementation of the law as a competitive advantage for Maryland [and] for businesses to locate in the state if there’s real investment in the workforce," Dr. Sharfstein said at the briefing.

Questions and uncertainty abound as state governments begin deciding whether they will participate in the expansion of Medicaid called for by the Affordable Care Act. In light of the Supreme Court’s decision that the federal government cannot penalize states that don’t participate, the governors of Texas, South Carolina, Nebraska, Iowa, Louisiana, Mississippi, and Florida have said that their states will opt out.

Leaders in other states say they need more information.

"The original act was very punitive for states that didn’t expand Medicaid. [The Supreme Court decision] now gives some options which, honestly, I don’t think a lot of us expected," Gov. Bob McDonnell (R-Va.) said at a press conference held at the National Governors Association annual meeting. "I don’t think it’s responsible fully for my state to make a decision now, because there’s still more information I need."

Gov. Jack Markell (D-Del.) said he sees the expansion as a "good deal for Delaware taxpayers," but agreed that most states will need more guidance from the federal government before making a decision.

As the ruling allows states to opt out of Medicaid expansion without losing existing federal monies, health care reform likely will look very different from state to state, said Sheila Burke of Harvard University, Cambridge, Mass.

"These states are going to respond to this very differently, and they are very different in terms of their preparation and their capacity to take on these changes. Governors, state legislators, exchange directors, and insurance commissioners all may have a different view," Ms. Burke said at a briefing held by the Alliance for Health Reform. She pointed out that many states legislatures won’t meet again until next year, so meaningful decision making may be on hold until then.

Prior to passage of the ACA, Medicaid provided health care coverage for the indigent, especially those who were dependent children, pregnant women, disabled, or elderly. Under the expansion, Medicaid would also cover anyone younger than age 65 years with an annual income less than 133% of the federal poverty level. The law also provides tax credits for people with incomes between 100% and 400% of the federal poverty level to purchase insurance.

If a state decides to opt out of Medicaid expansion, people whose income is above the federal poverty level, those who are single, childless, or don’t live with their children would not be covered. In addition, those who qualify for premium subsidies under the law but can’t find affordable coverage (that is, mostly low-wage workers) would not be covered.

States that opt out of the expansion also could have a harder time balancing impending cuts to providers and hospitals, according to Chris Jennings, president of Jennings Policy Strategies and former top health aide to President Clinton.

Physicians face a 27% Medicare pay cut in January according to the Sustainable Growth Rate (SGR) formula; hospitals, too, face cuts to their Disproportionate Share Hospital (DSH) payments.

Although there may be other ways to balance the cuts, the easiest is expanding Medicaid to get the extra funding, said Mr. Jennings. "It’s a harder road to go than just taking the money."

While added federal funding would help states offset other cuts, it’s unlikely that it would be enough for physicians to rebound from a huge SGR cut, said Dr. Glen R. Stream, president of the American Academy of Family Physicians.

"If the SGR-indicated payment cut was to go into place, there’s no way that the expansion of Medicaid is going to offset the devastating financial impact that that’s going to have for practices," he said in an interview. But he added that expanding Medicaid is currently the best option for providing much-needed care for low-income Americans.

"I don’t think anyone necessarily envisions expansion of Medicaid as the ideal means to expand coverage, but it is the one that’s on the table. My hope would be that if states chose to opt out of the Medicaid expansion, they would do so with some other plan to meet the needs of their citizens. The challenge would be that the plan wouldn’t be coming with any federal dollars," Dr. Stream said.

Officials with the American College of Physicians said states should move forward with expansion as soon as possible.

The "ACP also strongly urges states to move forward on expanding Medicaid to all persons with incomes up to 133% of the federal poverty level, notwithstanding the court’s ruling that states may not be denied existing Medicaid dollars for failing to do so," ACP president David L. Bronson said in a statement following the court’s ruling.

Mr. Jennings speculated that more will participate in the Medicaid expansion than most people currently think.

Dr. Stream agreed. "I suspect, at the end of the day, that we’ll have a lot more states coming in than we currently are hearing, primarily because I have some confidence in stakeholders’ abilities to encourage legislatures and governors to move ahead," he said.

Maryland is one of those states. Dr. Joshua Sharfstein, the state Secretary of Health and Mental Hygiene, said that implementing the law will give states an edge over those that opt out.

"I’ve heard [Gov. Martin O’Malley (D-Md.)] say that he ultimately sees successful implementation of the law as a competitive advantage for Maryland [and] for businesses to locate in the state if there’s real investment in the workforce," Dr. Sharfstein said at the briefing.

Radiation oncologists could see a nearly 15% cut to their payments under the proposed 2013 Medicare Physician Fee Schedule.

About half of the planned cut is as a result of changes in the way Medicare calculates the time involved in performing intensity-modulated radiation treatment (IMRT) delivery and stereotactic body radiation therapy (SBRT) delivery. Using patient education materials published by leading medical societies, officials at the Centers for Medicare and Medicaid Services determined that they were paying too much for IMRT and SBRT because these services don’t take as long to perform as had previously been calculated.

For example, the current CPT code for IMRT treatment delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly faster procedure time. As a result, the CMS is proposing to base payment on a procedure time of 30 minutes.

For SBRT treatment delivery (CPT code 77373), the current procedure time assumption is 90 minutes. The proposed procedure time assumption is 60 minutes, based on publicly available patient education materials.

The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

Officials at ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, criticized the proposal, saying that it would curb patient access to treatment, particularly in rural communities. They pointed to the preliminary results of a member survey that showed that some radiation oncology practices may be forced to close, while others would delay the purchase of new equipment, lay off staff, or limit the new Medicare patients they treat.

The organization also took issue with the process the CMS used in evaluating the procedures.

"ASTRO believes that [the CMS] should utilize the rigorous processes and methodologies already in place and utilized for the past 20 years to set reimbursement rates," Dr. Leonard L. Gunderson, chairman of ASTRO’s Board of Directors, said in a statement.

Dr. Gunderson said that ASTRO would like to see a comprehensive review of treatment costs through the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC), a panel of 31 physicians who offer advice to the CMS on how to value physician services.

Radiation oncologists could see a nearly 15% cut to their payments under the proposed 2013 Medicare Physician Fee Schedule.

About half of the planned cut is as a result of changes in the way Medicare calculates the time involved in performing intensity-modulated radiation treatment (IMRT) delivery and stereotactic body radiation therapy (SBRT) delivery. Using patient education materials published by leading medical societies, officials at the Centers for Medicare and Medicaid Services determined that they were paying too much for IMRT and SBRT because these services don’t take as long to perform as had previously been calculated.

For example, the current CPT code for IMRT treatment delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly faster procedure time. As a result, the CMS is proposing to base payment on a procedure time of 30 minutes.

For SBRT treatment delivery (CPT code 77373), the current procedure time assumption is 90 minutes. The proposed procedure time assumption is 60 minutes, based on publicly available patient education materials.

The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

Officials at ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, criticized the proposal, saying that it would curb patient access to treatment, particularly in rural communities. They pointed to the preliminary results of a member survey that showed that some radiation oncology practices may be forced to close, while others would delay the purchase of new equipment, lay off staff, or limit the new Medicare patients they treat.

The organization also took issue with the process the CMS used in evaluating the procedures.

"ASTRO believes that [the CMS] should utilize the rigorous processes and methodologies already in place and utilized for the past 20 years to set reimbursement rates," Dr. Leonard L. Gunderson, chairman of ASTRO’s Board of Directors, said in a statement.

Dr. Gunderson said that ASTRO would like to see a comprehensive review of treatment costs through the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC), a panel of 31 physicians who offer advice to the CMS on how to value physician services.

Radiation oncologists could see a nearly 15% cut to their payments under the proposed 2013 Medicare Physician Fee Schedule.

About half of the planned cut is as a result of changes in the way Medicare calculates the time involved in performing intensity-modulated radiation treatment (IMRT) delivery and stereotactic body radiation therapy (SBRT) delivery. Using patient education materials published by leading medical societies, officials at the Centers for Medicare and Medicaid Services determined that they were paying too much for IMRT and SBRT because these services don’t take as long to perform as had previously been calculated.

For example, the current CPT code for IMRT treatment delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly faster procedure time. As a result, the CMS is proposing to base payment on a procedure time of 30 minutes.

For SBRT treatment delivery (CPT code 77373), the current procedure time assumption is 90 minutes. The proposed procedure time assumption is 60 minutes, based on publicly available patient education materials.

The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

Officials at ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, criticized the proposal, saying that it would curb patient access to treatment, particularly in rural communities. They pointed to the preliminary results of a member survey that showed that some radiation oncology practices may be forced to close, while others would delay the purchase of new equipment, lay off staff, or limit the new Medicare patients they treat.

The organization also took issue with the process the CMS used in evaluating the procedures.

"ASTRO believes that [the CMS] should utilize the rigorous processes and methodologies already in place and utilized for the past 20 years to set reimbursement rates," Dr. Leonard L. Gunderson, chairman of ASTRO’s Board of Directors, said in a statement.

Dr. Gunderson said that ASTRO would like to see a comprehensive review of treatment costs through the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC), a panel of 31 physicians who offer advice to the CMS on how to value physician services.

Systematically lengthening the duration of resuscitation efforts for patients who have in-hospital cardiac arrests could improve survival with no adverse impact on neurological status, according to researchers.

In a study of 64,339 patients who had in-hospital cardiac arrests at 435 U.S. hospitals over an 8-year period, this survival benefit was independent of numerous patient factors, wrote Dr. Zachary D. Goldberger of the division of cardiovascular medicine, University of Michigan, Ann Arbor, and his associates. The report was published Sept. 4 in The Lancet.

Importantly, they wrote, neurologic status was not affected by the duration of resuscitation efforts, so patients revived after relatively long CPR attempts of 30 minutes or more were as neurologically intact as were those revived after brief attempts of less than 15 minutes.

"Our most notable result was that long resuscitation attempts might be linked to increased rates of return of spontaneous circulation and survival to discharge," they said.

At present, resuscitation guidelines do not address the issue of when to terminate such efforts, and there are not enough data available to guide practice. "Clinicians are frequently reluctant to continue efforts when return of spontaneous circulation does not occur shortly after initiation of resuscitation, in view of the overall poor prognosis for such patients," the researchers noted.

They examined the issue using information from the Get With The Guidelines?Resuscitation database, the largest registry of in-hospital cardiac arrests in the world. A total of 31,198 patients (48.5%) achieved return of spontaneous circulation, while 33,141 (51.5%) died after termination of resuscitation efforts.

Approximately 80% of patients who survived to hospital discharge had favorable neurologic status. The rate of favorable status did not differ significantly by duration of resuscitation: It was 81.2% for patients in whom resuscitation attempts lasted less than 15 minutes, 80.0% for those in whom resuscitation attempts lasted 15-30 minutes, and 78.4% for those in whom resuscitation attempts lasted longer than 30 minutes.

As expected when there is no consensus on the appropriate duration of resuscitation attempts, the investigators found wide variation among hospitals in this practice.

Overall, the median duration of resuscitation efforts was 17 minutes. When the hospitals were divided into quartiles based on this duration, those in the quartile with the shortest interval had a median duration of 16 minutes, while those in the quartile with the longest interval had a median duration of 25 minutes.

Resuscitation efforts lasted more than 50% longer at hospitals in the longest quartile compared with those in the shortest quartile.

Patients at the hospitals with longer durations of resuscitation efforts had significantly higher overall survival and significantly higher survival to hospital discharge than did those at hospitals with shorter durations of resuscitation efforts, Dr. Goldberger and his colleagues said (Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)60862-9]).

The study findings suggest that standardizing resuscitation procedures and identifying a minimum duration could improve patient survival. "Prolongation of resuscitation attempts by 10 or 15 minutes might have only a slight effect on resources once efforts have already begun, but could improve outcomes," the investigators noted.

"We are unable to provide a specific cutoff from these data and are hesitant to speculate," especially because this was an observational study that cannot establish cause and effect. Moreover, several variables that almost certainly affected the duration of resuscitation efforts were not addressed in this study, such as the quality of chest compressions and the availability at each hospital of percutaneous intervention.

It is even possible that the duration of resuscitation attempts is merely a marker for "more comprehensive care" with longer CPR performed at centers where resuscitation guidelines are reliably implemented, they added.

It should also be noted that this study did not address long-term outcomes in survivors of resuscitation. "The extent to which critically ill patients benefit from survival months to years after cardiac arrest should be the ultimate measure of the usefulness of resuscitation measures," Dr. Goldberger and his associates said.

This study was funded by the American Heart Association, the Robert Wood Johnson Foundation, and the National Heart, Lung, and Blood Institute. Dr. Goldberger reported no financial conflicts of interest, and one of his associates reported ties to Medtronic and United Health Care.

Systematically lengthening the duration of resuscitation efforts for patients who have in-hospital cardiac arrests could improve survival with no adverse impact on neurological status, according to researchers.

In a study of 64,339 patients who had in-hospital cardiac arrests at 435 U.S. hospitals over an 8-year period, this survival benefit was independent of numerous patient factors, wrote Dr. Zachary D. Goldberger of the division of cardiovascular medicine, University of Michigan, Ann Arbor, and his associates. The report was published Sept. 4 in The Lancet.

Importantly, they wrote, neurologic status was not affected by the duration of resuscitation efforts, so patients revived after relatively long CPR attempts of 30 minutes or more were as neurologically intact as were those revived after brief attempts of less than 15 minutes.

"Our most notable result was that long resuscitation attempts might be linked to increased rates of return of spontaneous circulation and survival to discharge," they said.

At present, resuscitation guidelines do not address the issue of when to terminate such efforts, and there are not enough data available to guide practice. "Clinicians are frequently reluctant to continue efforts when return of spontaneous circulation does not occur shortly after initiation of resuscitation, in view of the overall poor prognosis for such patients," the researchers noted.

They examined the issue using information from the Get With The Guidelines?Resuscitation database, the largest registry of in-hospital cardiac arrests in the world. A total of 31,198 patients (48.5%) achieved return of spontaneous circulation, while 33,141 (51.5%) died after termination of resuscitation efforts.

Approximately 80% of patients who survived to hospital discharge had favorable neurologic status. The rate of favorable status did not differ significantly by duration of resuscitation: It was 81.2% for patients in whom resuscitation attempts lasted less than 15 minutes, 80.0% for those in whom resuscitation attempts lasted 15-30 minutes, and 78.4% for those in whom resuscitation attempts lasted longer than 30 minutes.

As expected when there is no consensus on the appropriate duration of resuscitation attempts, the investigators found wide variation among hospitals in this practice.

Overall, the median duration of resuscitation efforts was 17 minutes. When the hospitals were divided into quartiles based on this duration, those in the quartile with the shortest interval had a median duration of 16 minutes, while those in the quartile with the longest interval had a median duration of 25 minutes.

Resuscitation efforts lasted more than 50% longer at hospitals in the longest quartile compared with those in the shortest quartile.

Patients at the hospitals with longer durations of resuscitation efforts had significantly higher overall survival and significantly higher survival to hospital discharge than did those at hospitals with shorter durations of resuscitation efforts, Dr. Goldberger and his colleagues said (Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)60862-9]).

The study findings suggest that standardizing resuscitation procedures and identifying a minimum duration could improve patient survival. "Prolongation of resuscitation attempts by 10 or 15 minutes might have only a slight effect on resources once efforts have already begun, but could improve outcomes," the investigators noted.

"We are unable to provide a specific cutoff from these data and are hesitant to speculate," especially because this was an observational study that cannot establish cause and effect. Moreover, several variables that almost certainly affected the duration of resuscitation efforts were not addressed in this study, such as the quality of chest compressions and the availability at each hospital of percutaneous intervention.

It is even possible that the duration of resuscitation attempts is merely a marker for "more comprehensive care" with longer CPR performed at centers where resuscitation guidelines are reliably implemented, they added.

It should also be noted that this study did not address long-term outcomes in survivors of resuscitation. "The extent to which critically ill patients benefit from survival months to years after cardiac arrest should be the ultimate measure of the usefulness of resuscitation measures," Dr. Goldberger and his associates said.

This study was funded by the American Heart Association, the Robert Wood Johnson Foundation, and the National Heart, Lung, and Blood Institute. Dr. Goldberger reported no financial conflicts of interest, and one of his associates reported ties to Medtronic and United Health Care.

Systematically lengthening the duration of resuscitation efforts for patients who have in-hospital cardiac arrests could improve survival with no adverse impact on neurological status, according to researchers.

In a study of 64,339 patients who had in-hospital cardiac arrests at 435 U.S. hospitals over an 8-year period, this survival benefit was independent of numerous patient factors, wrote Dr. Zachary D. Goldberger of the division of cardiovascular medicine, University of Michigan, Ann Arbor, and his associates. The report was published Sept. 4 in The Lancet.

Importantly, they wrote, neurologic status was not affected by the duration of resuscitation efforts, so patients revived after relatively long CPR attempts of 30 minutes or more were as neurologically intact as were those revived after brief attempts of less than 15 minutes.

"Our most notable result was that long resuscitation attempts might be linked to increased rates of return of spontaneous circulation and survival to discharge," they said.

At present, resuscitation guidelines do not address the issue of when to terminate such efforts, and there are not enough data available to guide practice. "Clinicians are frequently reluctant to continue efforts when return of spontaneous circulation does not occur shortly after initiation of resuscitation, in view of the overall poor prognosis for such patients," the researchers noted.

They examined the issue using information from the Get With The Guidelines?Resuscitation database, the largest registry of in-hospital cardiac arrests in the world. A total of 31,198 patients (48.5%) achieved return of spontaneous circulation, while 33,141 (51.5%) died after termination of resuscitation efforts.

Approximately 80% of patients who survived to hospital discharge had favorable neurologic status. The rate of favorable status did not differ significantly by duration of resuscitation: It was 81.2% for patients in whom resuscitation attempts lasted less than 15 minutes, 80.0% for those in whom resuscitation attempts lasted 15-30 minutes, and 78.4% for those in whom resuscitation attempts lasted longer than 30 minutes.

As expected when there is no consensus on the appropriate duration of resuscitation attempts, the investigators found wide variation among hospitals in this practice.

Overall, the median duration of resuscitation efforts was 17 minutes. When the hospitals were divided into quartiles based on this duration, those in the quartile with the shortest interval had a median duration of 16 minutes, while those in the quartile with the longest interval had a median duration of 25 minutes.

Resuscitation efforts lasted more than 50% longer at hospitals in the longest quartile compared with those in the shortest quartile.

Patients at the hospitals with longer durations of resuscitation efforts had significantly higher overall survival and significantly higher survival to hospital discharge than did those at hospitals with shorter durations of resuscitation efforts, Dr. Goldberger and his colleagues said (Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)60862-9]).

The study findings suggest that standardizing resuscitation procedures and identifying a minimum duration could improve patient survival. "Prolongation of resuscitation attempts by 10 or 15 minutes might have only a slight effect on resources once efforts have already begun, but could improve outcomes," the investigators noted.

"We are unable to provide a specific cutoff from these data and are hesitant to speculate," especially because this was an observational study that cannot establish cause and effect. Moreover, several variables that almost certainly affected the duration of resuscitation efforts were not addressed in this study, such as the quality of chest compressions and the availability at each hospital of percutaneous intervention.

It is even possible that the duration of resuscitation attempts is merely a marker for "more comprehensive care" with longer CPR performed at centers where resuscitation guidelines are reliably implemented, they added.

It should also be noted that this study did not address long-term outcomes in survivors of resuscitation. "The extent to which critically ill patients benefit from survival months to years after cardiac arrest should be the ultimate measure of the usefulness of resuscitation measures," Dr. Goldberger and his associates said.

This study was funded by the American Heart Association, the Robert Wood Johnson Foundation, and the National Heart, Lung, and Blood Institute. Dr. Goldberger reported no financial conflicts of interest, and one of his associates reported ties to Medtronic and United Health Care.

Systematically lengthening the duration of resuscitation efforts for patients who have in-hospital cardiac arrests could improve survival with no adverse impact on neurological status, according to researchers.

In a study of 64,339 patients who had in-hospital cardiac arrests at 435 U.S. hospitals over an 8-year period, this survival benefit was independent of numerous patient factors, wrote Dr. Zachary D. Goldberger of the division of cardiovascular medicine, University of Michigan, Ann Arbor, and his associates. The report was published Sept. 4 in The Lancet.

Importantly, they wrote, neurologic status was not affected by the duration of resuscitation efforts, so patients revived after relatively long CPR attempts of 30 minutes or more were as neurologically intact as were those revived after brief attempts of less than 15 minutes.

"Our most notable result was that long resuscitation attempts might be linked to increased rates of return of spontaneous circulation and survival to discharge," they said.

At present, resuscitation guidelines do not address the issue of when to terminate such efforts, and there are not enough data available to guide practice. "Clinicians are frequently reluctant to continue efforts when return of spontaneous circulation does not occur shortly after initiation of resuscitation, in view of the overall poor prognosis for such patients," the researchers noted.

They examined the issue using information from the Get With The Guidelines?Resuscitation database, the largest registry of in-hospital cardiac arrests in the world. A total of 31,198 patients (48.5%) achieved return of spontaneous circulation, while 33,141 (51.5%) died after termination of resuscitation efforts.

Approximately 80% of patients who survived to hospital discharge had favorable neurologic status. The rate of favorable status did not differ significantly by duration of resuscitation: It was 81.2% for patients in whom resuscitation attempts lasted less than 15 minutes, 80.0% for those in whom resuscitation attempts lasted 15-30 minutes, and 78.4% for those in whom resuscitation attempts lasted longer than 30 minutes.

As expected when there is no consensus on the appropriate duration of resuscitation attempts, the investigators found wide variation among hospitals in this practice.

Overall, the median duration of resuscitation efforts was 17 minutes. When the hospitals were divided into quartiles based on this duration, those in the quartile with the shortest interval had a median duration of 16 minutes, while those in the quartile with the longest interval had a median duration of 25 minutes.

Resuscitation efforts lasted more than 50% longer at hospitals in the longest quartile compared with those in the shortest quartile.

Patients at the hospitals with longer durations of resuscitation efforts had significantly higher overall survival and significantly higher survival to hospital discharge than did those at hospitals with shorter durations of resuscitation efforts, Dr. Goldberger and his colleagues said (Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)60862-9]).

The study findings suggest that standardizing resuscitation procedures and identifying a minimum duration could improve patient survival. "Prolongation of resuscitation attempts by 10 or 15 minutes might have only a slight effect on resources once efforts have already begun, but could improve outcomes," the investigators noted.

"We are unable to provide a specific cutoff from these data and are hesitant to speculate," especially because this was an observational study that cannot establish cause and effect. Moreover, several variables that almost certainly affected the duration of resuscitation efforts were not addressed in this study, such as the quality of chest compressions and the availability at each hospital of percutaneous intervention.

It is even possible that the duration of resuscitation attempts is merely a marker for "more comprehensive care" with longer CPR performed at centers where resuscitation guidelines are reliably implemented, they added.

It should also be noted that this study did not address long-term outcomes in survivors of resuscitation. "The extent to which critically ill patients benefit from survival months to years after cardiac arrest should be the ultimate measure of the usefulness of resuscitation measures," Dr. Goldberger and his associates said.

This study was funded by the American Heart Association, the Robert Wood Johnson Foundation, and the National Heart, Lung, and Blood Institute. Dr. Goldberger reported no financial conflicts of interest, and one of his associates reported ties to Medtronic and United Health Care.

Systematically lengthening the duration of resuscitation efforts for patients who have in-hospital cardiac arrests could improve survival with no adverse impact on neurological status, according to researchers.

In a study of 64,339 patients who had in-hospital cardiac arrests at 435 U.S. hospitals over an 8-year period, this survival benefit was independent of numerous patient factors, wrote Dr. Zachary D. Goldberger of the division of cardiovascular medicine, University of Michigan, Ann Arbor, and his associates. The report was published Sept. 4 in The Lancet.

Importantly, they wrote, neurologic status was not affected by the duration of resuscitation efforts, so patients revived after relatively long CPR attempts of 30 minutes or more were as neurologically intact as were those revived after brief attempts of less than 15 minutes.

"Our most notable result was that long resuscitation attempts might be linked to increased rates of return of spontaneous circulation and survival to discharge," they said.

At present, resuscitation guidelines do not address the issue of when to terminate such efforts, and there are not enough data available to guide practice. "Clinicians are frequently reluctant to continue efforts when return of spontaneous circulation does not occur shortly after initiation of resuscitation, in view of the overall poor prognosis for such patients," the researchers noted.

They examined the issue using information from the Get With The Guidelines?Resuscitation database, the largest registry of in-hospital cardiac arrests in the world. A total of 31,198 patients (48.5%) achieved return of spontaneous circulation, while 33,141 (51.5%) died after termination of resuscitation efforts.

Approximately 80% of patients who survived to hospital discharge had favorable neurologic status. The rate of favorable status did not differ significantly by duration of resuscitation: It was 81.2% for patients in whom resuscitation attempts lasted less than 15 minutes, 80.0% for those in whom resuscitation attempts lasted 15-30 minutes, and 78.4% for those in whom resuscitation attempts lasted longer than 30 minutes.

As expected when there is no consensus on the appropriate duration of resuscitation attempts, the investigators found wide variation among hospitals in this practice.

Overall, the median duration of resuscitation efforts was 17 minutes. When the hospitals were divided into quartiles based on this duration, those in the quartile with the shortest interval had a median duration of 16 minutes, while those in the quartile with the longest interval had a median duration of 25 minutes.

Resuscitation efforts lasted more than 50% longer at hospitals in the longest quartile compared with those in the shortest quartile.

Patients at the hospitals with longer durations of resuscitation efforts had significantly higher overall survival and significantly higher survival to hospital discharge than did those at hospitals with shorter durations of resuscitation efforts, Dr. Goldberger and his colleagues said (Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)60862-9]).

The study findings suggest that standardizing resuscitation procedures and identifying a minimum duration could improve patient survival. "Prolongation of resuscitation attempts by 10 or 15 minutes might have only a slight effect on resources once efforts have already begun, but could improve outcomes," the investigators noted.

"We are unable to provide a specific cutoff from these data and are hesitant to speculate," especially because this was an observational study that cannot establish cause and effect. Moreover, several variables that almost certainly affected the duration of resuscitation efforts were not addressed in this study, such as the quality of chest compressions and the availability at each hospital of percutaneous intervention.

It is even possible that the duration of resuscitation attempts is merely a marker for "more comprehensive care" with longer CPR performed at centers where resuscitation guidelines are reliably implemented, they added.

It should also be noted that this study did not address long-term outcomes in survivors of resuscitation. "The extent to which critically ill patients benefit from survival months to years after cardiac arrest should be the ultimate measure of the usefulness of resuscitation measures," Dr. Goldberger and his associates said.

This study was funded by the American Heart Association, the Robert Wood Johnson Foundation, and the National Heart, Lung, and Blood Institute. Dr. Goldberger reported no financial conflicts of interest, and one of his associates reported ties to Medtronic and United Health Care.

Systematically lengthening the duration of resuscitation efforts for patients who have in-hospital cardiac arrests could improve survival with no adverse impact on neurological status, according to researchers.

In a study of 64,339 patients who had in-hospital cardiac arrests at 435 U.S. hospitals over an 8-year period, this survival benefit was independent of numerous patient factors, wrote Dr. Zachary D. Goldberger of the division of cardiovascular medicine, University of Michigan, Ann Arbor, and his associates. The report was published Sept. 4 in The Lancet.

Importantly, they wrote, neurologic status was not affected by the duration of resuscitation efforts, so patients revived after relatively long CPR attempts of 30 minutes or more were as neurologically intact as were those revived after brief attempts of less than 15 minutes.

"Our most notable result was that long resuscitation attempts might be linked to increased rates of return of spontaneous circulation and survival to discharge," they said.

At present, resuscitation guidelines do not address the issue of when to terminate such efforts, and there are not enough data available to guide practice. "Clinicians are frequently reluctant to continue efforts when return of spontaneous circulation does not occur shortly after initiation of resuscitation, in view of the overall poor prognosis for such patients," the researchers noted.

They examined the issue using information from the Get With The Guidelines?Resuscitation database, the largest registry of in-hospital cardiac arrests in the world. A total of 31,198 patients (48.5%) achieved return of spontaneous circulation, while 33,141 (51.5%) died after termination of resuscitation efforts.

Approximately 80% of patients who survived to hospital discharge had favorable neurologic status. The rate of favorable status did not differ significantly by duration of resuscitation: It was 81.2% for patients in whom resuscitation attempts lasted less than 15 minutes, 80.0% for those in whom resuscitation attempts lasted 15-30 minutes, and 78.4% for those in whom resuscitation attempts lasted longer than 30 minutes.

As expected when there is no consensus on the appropriate duration of resuscitation attempts, the investigators found wide variation among hospitals in this practice.

Overall, the median duration of resuscitation efforts was 17 minutes. When the hospitals were divided into quartiles based on this duration, those in the quartile with the shortest interval had a median duration of 16 minutes, while those in the quartile with the longest interval had a median duration of 25 minutes.

Resuscitation efforts lasted more than 50% longer at hospitals in the longest quartile compared with those in the shortest quartile.

Patients at the hospitals with longer durations of resuscitation efforts had significantly higher overall survival and significantly higher survival to hospital discharge than did those at hospitals with shorter durations of resuscitation efforts, Dr. Goldberger and his colleagues said (Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)60862-9]).

The study findings suggest that standardizing resuscitation procedures and identifying a minimum duration could improve patient survival. "Prolongation of resuscitation attempts by 10 or 15 minutes might have only a slight effect on resources once efforts have already begun, but could improve outcomes," the investigators noted.

"We are unable to provide a specific cutoff from these data and are hesitant to speculate," especially because this was an observational study that cannot establish cause and effect. Moreover, several variables that almost certainly affected the duration of resuscitation efforts were not addressed in this study, such as the quality of chest compressions and the availability at each hospital of percutaneous intervention.

It is even possible that the duration of resuscitation attempts is merely a marker for "more comprehensive care" with longer CPR performed at centers where resuscitation guidelines are reliably implemented, they added.

It should also be noted that this study did not address long-term outcomes in survivors of resuscitation. "The extent to which critically ill patients benefit from survival months to years after cardiac arrest should be the ultimate measure of the usefulness of resuscitation measures," Dr. Goldberger and his associates said.

This study was funded by the American Heart Association, the Robert Wood Johnson Foundation, and the National Heart, Lung, and Blood Institute. Dr. Goldberger reported no financial conflicts of interest, and one of his associates reported ties to Medtronic and United Health Care.

Implementation of the diagnosis and procedure codes in the 10th edition of the International Classification of Diseases has been put off for another year, the Centers for Medicare and Medicaid Services announced Aug. 24.

Many hospitals and physicians have expressed deep concern that they would not be able to meet the Oct. 1, 2013, deadline for using ICD-10. In April, the federal agency said in a proposed rule that it would delay compliance by a year; the final decision was announced in a rule that primarily establishes a standard unique identifier for health plans to help smooth payment transactions for hospitals and physicians.

"We believe the change in the compliance date for ICD-10 gives covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities," CMS officials wrote.

Implementation of the diagnosis and procedure codes in the 10th edition of the International Classification of Diseases has been put off for another year, the Centers for Medicare and Medicaid Services announced Aug. 24.

Many hospitals and physicians have expressed deep concern that they would not be able to meet the Oct. 1, 2013, deadline for using ICD-10. In April, the federal agency said in a proposed rule that it would delay compliance by a year; the final decision was announced in a rule that primarily establishes a standard unique identifier for health plans to help smooth payment transactions for hospitals and physicians.

"We believe the change in the compliance date for ICD-10 gives covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities," CMS officials wrote.

Implementation of the diagnosis and procedure codes in the 10th edition of the International Classification of Diseases has been put off for another year, the Centers for Medicare and Medicaid Services announced Aug. 24.

Many hospitals and physicians have expressed deep concern that they would not be able to meet the Oct. 1, 2013, deadline for using ICD-10. In April, the federal agency said in a proposed rule that it would delay compliance by a year; the final decision was announced in a rule that primarily establishes a standard unique identifier for health plans to help smooth payment transactions for hospitals and physicians.

"We believe the change in the compliance date for ICD-10 gives covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities," CMS officials wrote.