Thoracic Surgery News (Archived)

SAN DIEGO -- Facebook, Twitter, and other social media have their rightful place in surgeons' busy schedules, according to several surgeons who participated in a social media symposium at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

In fact, these media just might help you land your dream job, raise money, screen applicants to your fellowship program, enhance communication with your peers, or strengthen relationships with your patients.

Dr. Gretchen Purcell Jackson noted that 61% of adults in the United States look online for health information. In addition, 41% of patients have read a commentary or shared experiences about health or medical issues in an online news group, website, or blog; 24% of online patients have consulted rankings or reviews of physicians, providers, and hospitals; 60% of active online patients report that using the Web affected a medical decision; and more than 700 hospitals currently use social networking tools.

"People seek and give advice about their health care concerns, they seek and share information about medical problems, and they share stories about their health care experiences. Some people use social media to raise money for health-related causes. Patients are using social media in a wide variety of ways, and they might be talking about you," said Dr. Jackson, an ACS Fellow and assistant professor of surgery and biomedical informatics at Vanderbilt University, Nashville, Tenn.

Facebook has 845 million active users making more than 1 billion posts per day, while Twitter has more than 465 million accounts and grows by 11 accounts per second.

Facebook is used by 64% of surgeons, compared with 42% of the general population in the United States, according to Dr. Kiran K. Turaga. "As usual, we surgeons are ahead of the curve, but Facebook has unique characteristics that can affect every single aspect of our lives," said Dr. Turaga, assistant professor of surgery at the Medical College of Wisconsin, Milwaukee. "In terms of trainees, it can affect medical student and resident education, and it can affect recruitment. For patients, you can use this for fund-raising, marketing, forming support groups, increasing awareness [about an aspect of health], recruiting for clinical trials, and monitoring for diseases."

More than 95% of U.S. medical schools have a Facebook presence, Dr. Turaga said, and 71% of these have active student group accounts. In addition, 70% of medical students have active individual Facebook accounts. However, 60% of medical schools have reported incidents of students posting unprofessional content, including profanity (in 52% of cases), breach of patient confidentiality (in 13% of cases), or photos of themselves in a state of intoxication (in 39% of cases) (JAMA 2009;302:1309-15).

Through a sister organization known as Causes (www.causes.com), Facebook has 170 million users who have generated $40 million for 27,000 not-for-profit groups, including hospitals. This makes Facebook "a remarkable tool for fund-raising," Dr. Turaga said. "This could be as simple as raising $1,000 for a new east wing in your hospital."

Furthermore, he said, creating an ad on Facebook allows you to reach 19 million people with an interest in cancer, 600,000 people with an interest in surgery, and 5,000 people with an interest in laparoscopy. Facebook also offers physicians unique opportunities for peer-to-peer interaction by providing a platform for online consultations, virtual tumor boards, journals and summaries of medical news and blogs, and discussions of health care reform and other topics of interest. There are currently 757 Facebook health groups with 300,000 members, he said.

Dr. Turaga warned that posting recognizable patient information on Facebook or other social media channels can violate the Health Insurance Portability and Accountability Act, state criminal laws regarding patient health information, state licensure laws, state professional misconduct laws, and standards set by the Joint Commission.

"If you are considering posting any information that is patient specific, make sure you have exclusive consent of the patient," he said. "The other thing to consider is unnecessary patient-provider interaction, which would mean that you start engaging in a relationship with a patient in which you start giving advice. Then you become liable for that advice, so there can be medical-legal consequences."

Before you start using Facebook or another type of social media, Dr. Turaga recommends considering the acronym POST, which stands for people (whom do you want to target with your social media?), objectives (why do you want to target them?), strategy (how are you going to target them?), and technology (which social media will you use to do so?).

Twitter, a microblogging site that allows communication by posts of no more than 140 characters in length, is an open platform of communication rather than a closed platform, explained Dr. Niraj J. Gusani. "This adds a level of complexity – and possibly risk – that may make this medium less ideal for health care professional use. Anything that you post can be seen by anyone in the world at any time. There’s no filter. On the other hand, Twitter has a wide reach, and it’s easy for people to find you," said Dr. Gusani, an ACS Fellow and assistant professor of surgery, medicine, and public health sciences at Pennsylvania State University, Hershey.

A recent survey of 315 members of the American College of Surgeons found that 79% never use Twitter, while 6% use it daily and 3% use it weekly (Bull. Am. Coll. Surg. 2011;96:46-8). In Dr. Gusani’s opinion, surgeons can use Twitter to update the public about the latest news, events, and research highlights; respond to other tweets related to their field, area of research, or organization; participate in tweet chats or Q&A sessions; and tweet highlights from professional events and meetings.

While some clinicians use Twitter for patient contact and marketing, Dr. Gusani cautioned that it’s important to be wary of violating patient confidentiality. A review of 260 physician Twitter accounts revealed that 144 of 5,156 tweets (3%) were categorized as unprofessional (JAMA 2011;305:566-8). Of these, 38 (0.7%) represented potential patient privacy violations and 33 (0.6%) contained profanity.

Dr. Gusani said that he uses Twitter to "push information, studies, and observations related mainly to oncology and surgical oncology patient education. I post perspectives about medical news and occasional retweets." Twitter-based resources and chats that are recommended by Dr. Gusani include #twitJP, a journal club; #hcsm, a global health care chat that takes place at 9 p.m. ET every Sunday; #CMEchat, which takes place every Wednesday at 11 a.m. ET; and #Meded chat, which takes place every Thursday at 4 p.m. and 9 p.m. ET.

Dr. Seung S. Gwon spoke about the potential benefits of LinkedIn, a professional networking site that allows users to strengthen and expand their network of contacts. It currently has more than 15 million members in more than 200 countries and territories, including 44 million-plus members in the U. S. alone.

"The best part about LinkedIn is that it only takes a few minutes to set up your online profile, where you might list your experience, education, and accomplishments," said Dr. Gwon, an ACS Fellow with El Centro (Calif.) Regional Medical Center. The overall purpose is to connect to other users and build a network of trusted contacts, including personal e-mail contacts, professional colleagues, coworkers, and former classmates.

Dr. Gwon said that physicians have been slow to join LinkedIn because it doesn’t allow them to directly connect with their patients. "However, it does provide you with a digital footprint, so if patients want to look, they can," she said. "Also, a lot of people feel there is no value to networking if they’re already employed. If you like your job and you like where you are, there’s no reason to set up a big profile, primarily because most physicians work in a narrowly defined geography and we don’t really see the need to sell ourselves. We rely on word-of-mouth, the reputations that we create in our communities, [and] physicians who refer patients to us."

Even so, she advises physicians to consider joining LinkedIn because it improves Google search rankings, and it is a cost-effective and efficient means to share information and maintain professional relationships.

No speaker had relevant conflicts.

SAN DIEGO -- Facebook, Twitter, and other social media have their rightful place in surgeons' busy schedules, according to several surgeons who participated in a social media symposium at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

In fact, these media just might help you land your dream job, raise money, screen applicants to your fellowship program, enhance communication with your peers, or strengthen relationships with your patients.

Dr. Gretchen Purcell Jackson noted that 61% of adults in the United States look online for health information. In addition, 41% of patients have read a commentary or shared experiences about health or medical issues in an online news group, website, or blog; 24% of online patients have consulted rankings or reviews of physicians, providers, and hospitals; 60% of active online patients report that using the Web affected a medical decision; and more than 700 hospitals currently use social networking tools.

"People seek and give advice about their health care concerns, they seek and share information about medical problems, and they share stories about their health care experiences. Some people use social media to raise money for health-related causes. Patients are using social media in a wide variety of ways, and they might be talking about you," said Dr. Jackson, an ACS Fellow and assistant professor of surgery and biomedical informatics at Vanderbilt University, Nashville, Tenn.

Facebook has 845 million active users making more than 1 billion posts per day, while Twitter has more than 465 million accounts and grows by 11 accounts per second.

Facebook is used by 64% of surgeons, compared with 42% of the general population in the United States, according to Dr. Kiran K. Turaga. "As usual, we surgeons are ahead of the curve, but Facebook has unique characteristics that can affect every single aspect of our lives," said Dr. Turaga, assistant professor of surgery at the Medical College of Wisconsin, Milwaukee. "In terms of trainees, it can affect medical student and resident education, and it can affect recruitment. For patients, you can use this for fund-raising, marketing, forming support groups, increasing awareness [about an aspect of health], recruiting for clinical trials, and monitoring for diseases."

More than 95% of U.S. medical schools have a Facebook presence, Dr. Turaga said, and 71% of these have active student group accounts. In addition, 70% of medical students have active individual Facebook accounts. However, 60% of medical schools have reported incidents of students posting unprofessional content, including profanity (in 52% of cases), breach of patient confidentiality (in 13% of cases), or photos of themselves in a state of intoxication (in 39% of cases) (JAMA 2009;302:1309-15).

Through a sister organization known as Causes (www.causes.com), Facebook has 170 million users who have generated $40 million for 27,000 not-for-profit groups, including hospitals. This makes Facebook "a remarkable tool for fund-raising," Dr. Turaga said. "This could be as simple as raising $1,000 for a new east wing in your hospital."

Furthermore, he said, creating an ad on Facebook allows you to reach 19 million people with an interest in cancer, 600,000 people with an interest in surgery, and 5,000 people with an interest in laparoscopy. Facebook also offers physicians unique opportunities for peer-to-peer interaction by providing a platform for online consultations, virtual tumor boards, journals and summaries of medical news and blogs, and discussions of health care reform and other topics of interest. There are currently 757 Facebook health groups with 300,000 members, he said.

Dr. Turaga warned that posting recognizable patient information on Facebook or other social media channels can violate the Health Insurance Portability and Accountability Act, state criminal laws regarding patient health information, state licensure laws, state professional misconduct laws, and standards set by the Joint Commission.

"If you are considering posting any information that is patient specific, make sure you have exclusive consent of the patient," he said. "The other thing to consider is unnecessary patient-provider interaction, which would mean that you start engaging in a relationship with a patient in which you start giving advice. Then you become liable for that advice, so there can be medical-legal consequences."

Before you start using Facebook or another type of social media, Dr. Turaga recommends considering the acronym POST, which stands for people (whom do you want to target with your social media?), objectives (why do you want to target them?), strategy (how are you going to target them?), and technology (which social media will you use to do so?).

Twitter, a microblogging site that allows communication by posts of no more than 140 characters in length, is an open platform of communication rather than a closed platform, explained Dr. Niraj J. Gusani. "This adds a level of complexity – and possibly risk – that may make this medium less ideal for health care professional use. Anything that you post can be seen by anyone in the world at any time. There’s no filter. On the other hand, Twitter has a wide reach, and it’s easy for people to find you," said Dr. Gusani, an ACS Fellow and assistant professor of surgery, medicine, and public health sciences at Pennsylvania State University, Hershey.

A recent survey of 315 members of the American College of Surgeons found that 79% never use Twitter, while 6% use it daily and 3% use it weekly (Bull. Am. Coll. Surg. 2011;96:46-8). In Dr. Gusani’s opinion, surgeons can use Twitter to update the public about the latest news, events, and research highlights; respond to other tweets related to their field, area of research, or organization; participate in tweet chats or Q&A sessions; and tweet highlights from professional events and meetings.

While some clinicians use Twitter for patient contact and marketing, Dr. Gusani cautioned that it’s important to be wary of violating patient confidentiality. A review of 260 physician Twitter accounts revealed that 144 of 5,156 tweets (3%) were categorized as unprofessional (JAMA 2011;305:566-8). Of these, 38 (0.7%) represented potential patient privacy violations and 33 (0.6%) contained profanity.

Dr. Gusani said that he uses Twitter to "push information, studies, and observations related mainly to oncology and surgical oncology patient education. I post perspectives about medical news and occasional retweets." Twitter-based resources and chats that are recommended by Dr. Gusani include #twitJP, a journal club; #hcsm, a global health care chat that takes place at 9 p.m. ET every Sunday; #CMEchat, which takes place every Wednesday at 11 a.m. ET; and #Meded chat, which takes place every Thursday at 4 p.m. and 9 p.m. ET.

Dr. Seung S. Gwon spoke about the potential benefits of LinkedIn, a professional networking site that allows users to strengthen and expand their network of contacts. It currently has more than 15 million members in more than 200 countries and territories, including 44 million-plus members in the U. S. alone.

"The best part about LinkedIn is that it only takes a few minutes to set up your online profile, where you might list your experience, education, and accomplishments," said Dr. Gwon, an ACS Fellow with El Centro (Calif.) Regional Medical Center. The overall purpose is to connect to other users and build a network of trusted contacts, including personal e-mail contacts, professional colleagues, coworkers, and former classmates.

Dr. Gwon said that physicians have been slow to join LinkedIn because it doesn’t allow them to directly connect with their patients. "However, it does provide you with a digital footprint, so if patients want to look, they can," she said. "Also, a lot of people feel there is no value to networking if they’re already employed. If you like your job and you like where you are, there’s no reason to set up a big profile, primarily because most physicians work in a narrowly defined geography and we don’t really see the need to sell ourselves. We rely on word-of-mouth, the reputations that we create in our communities, [and] physicians who refer patients to us."

Even so, she advises physicians to consider joining LinkedIn because it improves Google search rankings, and it is a cost-effective and efficient means to share information and maintain professional relationships.

No speaker had relevant conflicts.

SAN DIEGO -- Facebook, Twitter, and other social media have their rightful place in surgeons' busy schedules, according to several surgeons who participated in a social media symposium at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

In fact, these media just might help you land your dream job, raise money, screen applicants to your fellowship program, enhance communication with your peers, or strengthen relationships with your patients.

Dr. Gretchen Purcell Jackson noted that 61% of adults in the United States look online for health information. In addition, 41% of patients have read a commentary or shared experiences about health or medical issues in an online news group, website, or blog; 24% of online patients have consulted rankings or reviews of physicians, providers, and hospitals; 60% of active online patients report that using the Web affected a medical decision; and more than 700 hospitals currently use social networking tools.

"People seek and give advice about their health care concerns, they seek and share information about medical problems, and they share stories about their health care experiences. Some people use social media to raise money for health-related causes. Patients are using social media in a wide variety of ways, and they might be talking about you," said Dr. Jackson, an ACS Fellow and assistant professor of surgery and biomedical informatics at Vanderbilt University, Nashville, Tenn.

Facebook has 845 million active users making more than 1 billion posts per day, while Twitter has more than 465 million accounts and grows by 11 accounts per second.

Facebook is used by 64% of surgeons, compared with 42% of the general population in the United States, according to Dr. Kiran K. Turaga. "As usual, we surgeons are ahead of the curve, but Facebook has unique characteristics that can affect every single aspect of our lives," said Dr. Turaga, assistant professor of surgery at the Medical College of Wisconsin, Milwaukee. "In terms of trainees, it can affect medical student and resident education, and it can affect recruitment. For patients, you can use this for fund-raising, marketing, forming support groups, increasing awareness [about an aspect of health], recruiting for clinical trials, and monitoring for diseases."

More than 95% of U.S. medical schools have a Facebook presence, Dr. Turaga said, and 71% of these have active student group accounts. In addition, 70% of medical students have active individual Facebook accounts. However, 60% of medical schools have reported incidents of students posting unprofessional content, including profanity (in 52% of cases), breach of patient confidentiality (in 13% of cases), or photos of themselves in a state of intoxication (in 39% of cases) (JAMA 2009;302:1309-15).

Through a sister organization known as Causes (www.causes.com), Facebook has 170 million users who have generated $40 million for 27,000 not-for-profit groups, including hospitals. This makes Facebook "a remarkable tool for fund-raising," Dr. Turaga said. "This could be as simple as raising $1,000 for a new east wing in your hospital."

Furthermore, he said, creating an ad on Facebook allows you to reach 19 million people with an interest in cancer, 600,000 people with an interest in surgery, and 5,000 people with an interest in laparoscopy. Facebook also offers physicians unique opportunities for peer-to-peer interaction by providing a platform for online consultations, virtual tumor boards, journals and summaries of medical news and blogs, and discussions of health care reform and other topics of interest. There are currently 757 Facebook health groups with 300,000 members, he said.

Dr. Turaga warned that posting recognizable patient information on Facebook or other social media channels can violate the Health Insurance Portability and Accountability Act, state criminal laws regarding patient health information, state licensure laws, state professional misconduct laws, and standards set by the Joint Commission.

"If you are considering posting any information that is patient specific, make sure you have exclusive consent of the patient," he said. "The other thing to consider is unnecessary patient-provider interaction, which would mean that you start engaging in a relationship with a patient in which you start giving advice. Then you become liable for that advice, so there can be medical-legal consequences."

Before you start using Facebook or another type of social media, Dr. Turaga recommends considering the acronym POST, which stands for people (whom do you want to target with your social media?), objectives (why do you want to target them?), strategy (how are you going to target them?), and technology (which social media will you use to do so?).

Twitter, a microblogging site that allows communication by posts of no more than 140 characters in length, is an open platform of communication rather than a closed platform, explained Dr. Niraj J. Gusani. "This adds a level of complexity – and possibly risk – that may make this medium less ideal for health care professional use. Anything that you post can be seen by anyone in the world at any time. There’s no filter. On the other hand, Twitter has a wide reach, and it’s easy for people to find you," said Dr. Gusani, an ACS Fellow and assistant professor of surgery, medicine, and public health sciences at Pennsylvania State University, Hershey.

A recent survey of 315 members of the American College of Surgeons found that 79% never use Twitter, while 6% use it daily and 3% use it weekly (Bull. Am. Coll. Surg. 2011;96:46-8). In Dr. Gusani’s opinion, surgeons can use Twitter to update the public about the latest news, events, and research highlights; respond to other tweets related to their field, area of research, or organization; participate in tweet chats or Q&A sessions; and tweet highlights from professional events and meetings.

While some clinicians use Twitter for patient contact and marketing, Dr. Gusani cautioned that it’s important to be wary of violating patient confidentiality. A review of 260 physician Twitter accounts revealed that 144 of 5,156 tweets (3%) were categorized as unprofessional (JAMA 2011;305:566-8). Of these, 38 (0.7%) represented potential patient privacy violations and 33 (0.6%) contained profanity.

Dr. Gusani said that he uses Twitter to "push information, studies, and observations related mainly to oncology and surgical oncology patient education. I post perspectives about medical news and occasional retweets." Twitter-based resources and chats that are recommended by Dr. Gusani include #twitJP, a journal club; #hcsm, a global health care chat that takes place at 9 p.m. ET every Sunday; #CMEchat, which takes place every Wednesday at 11 a.m. ET; and #Meded chat, which takes place every Thursday at 4 p.m. and 9 p.m. ET.

Dr. Seung S. Gwon spoke about the potential benefits of LinkedIn, a professional networking site that allows users to strengthen and expand their network of contacts. It currently has more than 15 million members in more than 200 countries and territories, including 44 million-plus members in the U. S. alone.

"The best part about LinkedIn is that it only takes a few minutes to set up your online profile, where you might list your experience, education, and accomplishments," said Dr. Gwon, an ACS Fellow with El Centro (Calif.) Regional Medical Center. The overall purpose is to connect to other users and build a network of trusted contacts, including personal e-mail contacts, professional colleagues, coworkers, and former classmates.

Dr. Gwon said that physicians have been slow to join LinkedIn because it doesn’t allow them to directly connect with their patients. "However, it does provide you with a digital footprint, so if patients want to look, they can," she said. "Also, a lot of people feel there is no value to networking if they’re already employed. If you like your job and you like where you are, there’s no reason to set up a big profile, primarily because most physicians work in a narrowly defined geography and we don’t really see the need to sell ourselves. We rely on word-of-mouth, the reputations that we create in our communities, [and] physicians who refer patients to us."

Even so, she advises physicians to consider joining LinkedIn because it improves Google search rankings, and it is a cost-effective and efficient means to share information and maintain professional relationships.

No speaker had relevant conflicts.

Every year at the AATS Annual Meeting, the STS/AATS Advocacy Center provides an opportunity to meet the Government Relations staff and find out how you can make a difference. Between meetings, learn about STS PAC and contribute at www.sts.org/advocacy/get-involved/pac. STS-PAC is the only organization in Washington exclusively representing cardiothoracic surgeons. We need the support of every cardiothoracic surgeon to meet our advocacy goals.

Every year at the AATS Annual Meeting, the STS/AATS Advocacy Center provides an opportunity to meet the Government Relations staff and find out how you can make a difference. Between meetings, learn about STS PAC and contribute at www.sts.org/advocacy/get-involved/pac. STS-PAC is the only organization in Washington exclusively representing cardiothoracic surgeons. We need the support of every cardiothoracic surgeon to meet our advocacy goals.

Every year at the AATS Annual Meeting, the STS/AATS Advocacy Center provides an opportunity to meet the Government Relations staff and find out how you can make a difference. Between meetings, learn about STS PAC and contribute at www.sts.org/advocacy/get-involved/pac. STS-PAC is the only organization in Washington exclusively representing cardiothoracic surgeons. We need the support of every cardiothoracic surgeon to meet our advocacy goals.

Whether by an ‘Occupation’, a ‘Tea Party’ or continued ‘Change,’ the 2012 national Senate, House and Presidential elections will affect cardiothoracic surgeons in the United States. Twenty-three of the total thirty three senate seats up for election this cycle belong to the Democratic party and were key to the passing of health care reform. Through multiple fronts the elections will change patient access, tax laws, and future regulatory policy for the nation. This article will review key health care disputes likely to be decided by the results of the next election cycle. These should be of key concern to residents, as they are likely to impact dramatically their future careers.

The Patient Protection and Affordable Care Act (PPACA), even if repealed by Republican challengers, will change the face of cardiothoracic surgery. Patient groups such as adults with histories of congenital heart defects, cancer survivors, and arteriopaths will be among many others directly affected by every governing seat that does or does not change.

Health care reform of any flavor, however economically viewed, will increase the amount of patients that qualify for physician care in the United States. In the field of cardiothoracic surgery, this numerical challenge will fly in the face of a medical field with relatively decreasing numbers and increasing scrutiny for quality results.

Paying for health care reform is of course the most heated debate during the 2012 election cycle. The Act’s provisions are intended to be funded by a variety of taxes and offsets. Major sources of new revenue include a much broadened Medicare tax on incomes over $200,000 and $250,00, for individual and joint filers respectively (adding $210 billion in total), an annual fee on insurance providers ($60 billion), and a 40% tax on the "Cadillac" insurance policies ($32 billion).

There are also taxes on pharmaceuticals, outlier diagnostic equipment ($47 billion) and an increase of tax on services deemed to threaten health such as tanning beds. The patient mandate, key to the plans financial viability, is at the heart of the judicial and economic debate.

The run up to the election will include a decision by the Supreme Court likely in June to approve, partially approve or completely refute the current bill.

The patient mandate though is a small part of the fundamental changes that are occurring with the current payer/payee system. Many aspects of the PPACA have already been phased in with more coming in 2012. The majority of the moves will occur in the administrative offices of clinics and hospitals as quality measures, patient satisfaction, and efficiency drive the shift away from fee for service.

Republican challengers have countered these tax increases with alternatives that favor increasing competition into the health care market. Permitting insurance companies to compete across state lines is one example of this method. In place of a mandate, Republicans have sought to expand tax deductions to individuals who purchase their own insurance and expand Health Savings Accounts so they can be used on insurance premiums.

To indemnify the individual, they favor individuals and small business forming purchasing pools lowering insurance costs. An April 3rd New York Times article has highlighted the fact though that the Republicans have yet to agree on an overall alternative to the PPACA should it be struck down by the Supreme Court.

Controversies of access such as those seen earlier this year in debates on paying for birth control have so far not occurred within the field of cardiothoracic surgery. Controversy of access within cardiothoracic surgery is likely to be monetary. Societal pressures to control costs have and will continue to question expenditures at the extreme ends of life. Services with high up-front costs such as ventricular assist devices, transplants ,and innovative chemotherapy regimens will need to run a gauntlet in an atmosphere increasingly hostile to inefficiency.

Consolidation of care with quality measures aimed at the disease as a whole rather than one individual procedure underline the importance of being on a winning team, not just being the star player. The best, but not solitary, example of this consolidation is the phase in of the Accountable Care Organizations (ACOs).

If Accountable Care Organizations provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save. Again consolidation linked to increased quality. Another example is the Medicare Value-Based Purchasing Program (VBP) that will link payments made by Medicare to the quality of the outcome they achieve. Often cited in the debate is the fact that 1 out of 3 Medicare patients are readmitted a month after they have been discharged.

The VBP program will provide financial incentive to decrease hospital recidivism. Linking quality measures to compensation is popular with both parties and unlikely to be repealed.

Insurance companies are also facing regulatory changes to increase efficiency and quality. Medical loss ratio (MLR) requirements of the PPACA will issue rebates to customers whose insurance companies fail to spend 80% of premium dollars received from individual and small business policy holders to improving care.

Of great interest to the insurance industry is if the mandate is struck down, and they are still required to supply insurance regardless of age or past history of disease. With no incentive to have health insurance until sick, the unequal ratio of healthy to sick patients will cause premiums to skyrocket. Ironically a proposed insurance industry alternative to the mandate is for the industry to gain the right to penalize those not signing up for coverage.

Outside of voting and direct campaigning, the surgeon is represented directly or indirectly through multiple Political Action Committees (PACs). Specific to the cardiothoracic surgeon is the Society of Thoracic Surgeon’s (STS) PAC. The STS Political Action Committee has raised $196,000 so far this election cycle with $32,000 being raised at the STS 48th Annual Meeting in Fort Lauderdale alone.

Recently, the STS PAC has joined other medical societies in expressing to CMS a concern about the simultaneous implementation of multiple programs that will create extraordinary financial and administrative burden as well as mass confusion for physicians. Programs such as the value based modifier, electronic prescribing, and electronic health record incentive will all go online simultaneously which some worry may lead to a meltdown at the clinical level.

The STS PAC also continues to advocate for a permanent SGR repeal that would avoid a 20%-30% decrease in Medicare reimbursements. As the health care industrial complex transforms, the PAC will strive to allow physicians generating savings by quality improvements to keep their share rather than have it be siphoned off to pay for alternative expenditures.

The STS has developed excellent tools and information to help the surgeon have their individual voice heard at the national level. The website, sts.org/advocacy/get-involved, includes suggestions and a kit to reach out to others and encourage citizen participation.

In the end this election will be one where expenditures and the health of America are tied together like no other election cycle. More than the findings of any randomized controlled study, changes in medical access, distribution of funds, and markers of quality will all follow the electoral results.

Dr. Robroy MacIver is a pediatric cardiothoracic surgery fellow at Seattle Children’s Hospital and a resident editor of Thoracic Surgery News.

Whether by an ‘Occupation’, a ‘Tea Party’ or continued ‘Change,’ the 2012 national Senate, House and Presidential elections will affect cardiothoracic surgeons in the United States. Twenty-three of the total thirty three senate seats up for election this cycle belong to the Democratic party and were key to the passing of health care reform. Through multiple fronts the elections will change patient access, tax laws, and future regulatory policy for the nation. This article will review key health care disputes likely to be decided by the results of the next election cycle. These should be of key concern to residents, as they are likely to impact dramatically their future careers.

The Patient Protection and Affordable Care Act (PPACA), even if repealed by Republican challengers, will change the face of cardiothoracic surgery. Patient groups such as adults with histories of congenital heart defects, cancer survivors, and arteriopaths will be among many others directly affected by every governing seat that does or does not change.

Health care reform of any flavor, however economically viewed, will increase the amount of patients that qualify for physician care in the United States. In the field of cardiothoracic surgery, this numerical challenge will fly in the face of a medical field with relatively decreasing numbers and increasing scrutiny for quality results.

Paying for health care reform is of course the most heated debate during the 2012 election cycle. The Act’s provisions are intended to be funded by a variety of taxes and offsets. Major sources of new revenue include a much broadened Medicare tax on incomes over $200,000 and $250,00, for individual and joint filers respectively (adding $210 billion in total), an annual fee on insurance providers ($60 billion), and a 40% tax on the "Cadillac" insurance policies ($32 billion).

There are also taxes on pharmaceuticals, outlier diagnostic equipment ($47 billion) and an increase of tax on services deemed to threaten health such as tanning beds. The patient mandate, key to the plans financial viability, is at the heart of the judicial and economic debate.

The run up to the election will include a decision by the Supreme Court likely in June to approve, partially approve or completely refute the current bill.

The patient mandate though is a small part of the fundamental changes that are occurring with the current payer/payee system. Many aspects of the PPACA have already been phased in with more coming in 2012. The majority of the moves will occur in the administrative offices of clinics and hospitals as quality measures, patient satisfaction, and efficiency drive the shift away from fee for service.

Republican challengers have countered these tax increases with alternatives that favor increasing competition into the health care market. Permitting insurance companies to compete across state lines is one example of this method. In place of a mandate, Republicans have sought to expand tax deductions to individuals who purchase their own insurance and expand Health Savings Accounts so they can be used on insurance premiums.

To indemnify the individual, they favor individuals and small business forming purchasing pools lowering insurance costs. An April 3rd New York Times article has highlighted the fact though that the Republicans have yet to agree on an overall alternative to the PPACA should it be struck down by the Supreme Court.

Controversies of access such as those seen earlier this year in debates on paying for birth control have so far not occurred within the field of cardiothoracic surgery. Controversy of access within cardiothoracic surgery is likely to be monetary. Societal pressures to control costs have and will continue to question expenditures at the extreme ends of life. Services with high up-front costs such as ventricular assist devices, transplants ,and innovative chemotherapy regimens will need to run a gauntlet in an atmosphere increasingly hostile to inefficiency.

Consolidation of care with quality measures aimed at the disease as a whole rather than one individual procedure underline the importance of being on a winning team, not just being the star player. The best, but not solitary, example of this consolidation is the phase in of the Accountable Care Organizations (ACOs).

If Accountable Care Organizations provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save. Again consolidation linked to increased quality. Another example is the Medicare Value-Based Purchasing Program (VBP) that will link payments made by Medicare to the quality of the outcome they achieve. Often cited in the debate is the fact that 1 out of 3 Medicare patients are readmitted a month after they have been discharged.

The VBP program will provide financial incentive to decrease hospital recidivism. Linking quality measures to compensation is popular with both parties and unlikely to be repealed.

Insurance companies are also facing regulatory changes to increase efficiency and quality. Medical loss ratio (MLR) requirements of the PPACA will issue rebates to customers whose insurance companies fail to spend 80% of premium dollars received from individual and small business policy holders to improving care.

Of great interest to the insurance industry is if the mandate is struck down, and they are still required to supply insurance regardless of age or past history of disease. With no incentive to have health insurance until sick, the unequal ratio of healthy to sick patients will cause premiums to skyrocket. Ironically a proposed insurance industry alternative to the mandate is for the industry to gain the right to penalize those not signing up for coverage.

Outside of voting and direct campaigning, the surgeon is represented directly or indirectly through multiple Political Action Committees (PACs). Specific to the cardiothoracic surgeon is the Society of Thoracic Surgeon’s (STS) PAC. The STS Political Action Committee has raised $196,000 so far this election cycle with $32,000 being raised at the STS 48th Annual Meeting in Fort Lauderdale alone.

Recently, the STS PAC has joined other medical societies in expressing to CMS a concern about the simultaneous implementation of multiple programs that will create extraordinary financial and administrative burden as well as mass confusion for physicians. Programs such as the value based modifier, electronic prescribing, and electronic health record incentive will all go online simultaneously which some worry may lead to a meltdown at the clinical level.

The STS PAC also continues to advocate for a permanent SGR repeal that would avoid a 20%-30% decrease in Medicare reimbursements. As the health care industrial complex transforms, the PAC will strive to allow physicians generating savings by quality improvements to keep their share rather than have it be siphoned off to pay for alternative expenditures.

The STS has developed excellent tools and information to help the surgeon have their individual voice heard at the national level. The website, sts.org/advocacy/get-involved, includes suggestions and a kit to reach out to others and encourage citizen participation.

In the end this election will be one where expenditures and the health of America are tied together like no other election cycle. More than the findings of any randomized controlled study, changes in medical access, distribution of funds, and markers of quality will all follow the electoral results.

Dr. Robroy MacIver is a pediatric cardiothoracic surgery fellow at Seattle Children’s Hospital and a resident editor of Thoracic Surgery News.

Whether by an ‘Occupation’, a ‘Tea Party’ or continued ‘Change,’ the 2012 national Senate, House and Presidential elections will affect cardiothoracic surgeons in the United States. Twenty-three of the total thirty three senate seats up for election this cycle belong to the Democratic party and were key to the passing of health care reform. Through multiple fronts the elections will change patient access, tax laws, and future regulatory policy for the nation. This article will review key health care disputes likely to be decided by the results of the next election cycle. These should be of key concern to residents, as they are likely to impact dramatically their future careers.

The Patient Protection and Affordable Care Act (PPACA), even if repealed by Republican challengers, will change the face of cardiothoracic surgery. Patient groups such as adults with histories of congenital heart defects, cancer survivors, and arteriopaths will be among many others directly affected by every governing seat that does or does not change.

Health care reform of any flavor, however economically viewed, will increase the amount of patients that qualify for physician care in the United States. In the field of cardiothoracic surgery, this numerical challenge will fly in the face of a medical field with relatively decreasing numbers and increasing scrutiny for quality results.

Paying for health care reform is of course the most heated debate during the 2012 election cycle. The Act’s provisions are intended to be funded by a variety of taxes and offsets. Major sources of new revenue include a much broadened Medicare tax on incomes over $200,000 and $250,00, for individual and joint filers respectively (adding $210 billion in total), an annual fee on insurance providers ($60 billion), and a 40% tax on the "Cadillac" insurance policies ($32 billion).

There are also taxes on pharmaceuticals, outlier diagnostic equipment ($47 billion) and an increase of tax on services deemed to threaten health such as tanning beds. The patient mandate, key to the plans financial viability, is at the heart of the judicial and economic debate.

The run up to the election will include a decision by the Supreme Court likely in June to approve, partially approve or completely refute the current bill.

The patient mandate though is a small part of the fundamental changes that are occurring with the current payer/payee system. Many aspects of the PPACA have already been phased in with more coming in 2012. The majority of the moves will occur in the administrative offices of clinics and hospitals as quality measures, patient satisfaction, and efficiency drive the shift away from fee for service.

Republican challengers have countered these tax increases with alternatives that favor increasing competition into the health care market. Permitting insurance companies to compete across state lines is one example of this method. In place of a mandate, Republicans have sought to expand tax deductions to individuals who purchase their own insurance and expand Health Savings Accounts so they can be used on insurance premiums.

To indemnify the individual, they favor individuals and small business forming purchasing pools lowering insurance costs. An April 3rd New York Times article has highlighted the fact though that the Republicans have yet to agree on an overall alternative to the PPACA should it be struck down by the Supreme Court.

Controversies of access such as those seen earlier this year in debates on paying for birth control have so far not occurred within the field of cardiothoracic surgery. Controversy of access within cardiothoracic surgery is likely to be monetary. Societal pressures to control costs have and will continue to question expenditures at the extreme ends of life. Services with high up-front costs such as ventricular assist devices, transplants ,and innovative chemotherapy regimens will need to run a gauntlet in an atmosphere increasingly hostile to inefficiency.

Consolidation of care with quality measures aimed at the disease as a whole rather than one individual procedure underline the importance of being on a winning team, not just being the star player. The best, but not solitary, example of this consolidation is the phase in of the Accountable Care Organizations (ACOs).

If Accountable Care Organizations provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save. Again consolidation linked to increased quality. Another example is the Medicare Value-Based Purchasing Program (VBP) that will link payments made by Medicare to the quality of the outcome they achieve. Often cited in the debate is the fact that 1 out of 3 Medicare patients are readmitted a month after they have been discharged.

The VBP program will provide financial incentive to decrease hospital recidivism. Linking quality measures to compensation is popular with both parties and unlikely to be repealed.

Insurance companies are also facing regulatory changes to increase efficiency and quality. Medical loss ratio (MLR) requirements of the PPACA will issue rebates to customers whose insurance companies fail to spend 80% of premium dollars received from individual and small business policy holders to improving care.

Of great interest to the insurance industry is if the mandate is struck down, and they are still required to supply insurance regardless of age or past history of disease. With no incentive to have health insurance until sick, the unequal ratio of healthy to sick patients will cause premiums to skyrocket. Ironically a proposed insurance industry alternative to the mandate is for the industry to gain the right to penalize those not signing up for coverage.

Outside of voting and direct campaigning, the surgeon is represented directly or indirectly through multiple Political Action Committees (PACs). Specific to the cardiothoracic surgeon is the Society of Thoracic Surgeon’s (STS) PAC. The STS Political Action Committee has raised $196,000 so far this election cycle with $32,000 being raised at the STS 48th Annual Meeting in Fort Lauderdale alone.

Recently, the STS PAC has joined other medical societies in expressing to CMS a concern about the simultaneous implementation of multiple programs that will create extraordinary financial and administrative burden as well as mass confusion for physicians. Programs such as the value based modifier, electronic prescribing, and electronic health record incentive will all go online simultaneously which some worry may lead to a meltdown at the clinical level.

The STS PAC also continues to advocate for a permanent SGR repeal that would avoid a 20%-30% decrease in Medicare reimbursements. As the health care industrial complex transforms, the PAC will strive to allow physicians generating savings by quality improvements to keep their share rather than have it be siphoned off to pay for alternative expenditures.

The STS has developed excellent tools and information to help the surgeon have their individual voice heard at the national level. The website, sts.org/advocacy/get-involved, includes suggestions and a kit to reach out to others and encourage citizen participation.

In the end this election will be one where expenditures and the health of America are tied together like no other election cycle. More than the findings of any randomized controlled study, changes in medical access, distribution of funds, and markers of quality will all follow the electoral results.

Dr. Robroy MacIver is a pediatric cardiothoracic surgery fellow at Seattle Children’s Hospital and a resident editor of Thoracic Surgery News.

WASHINGTON – By implementing a series of payment reforms now – and adopting MedPAC’s recommendations on replacing the SGR – Congress can fix the Medicare physician pay problem and come closer to paying for it, too.

That’s the bottom line of the March 2012 Report to Congress from the Medicare Payment Advisory Commission (MedPAC), released March 15.

While the recommended cuts may cause some physicians to wince, according to Mark Miller, the blow would be much harder if Congress allows the nearly 30% physician pay cut called for by the Medicare SGR Growth Rate formula to go through, Mr. Miller, MedPAC executive director, said at a press conference.

Key among those recommendations was freezing most Medicare payments to primary care physicians for 10 years and cutting specialists’ payments by 17% over 3 years, followed by a freeze for 7 years more.

"That’s hard medicine," Mr. Miller said. "But one of the things that it does is it reduces the cost of the fix."

MedPAC estimates their recommendations will bring the price tag of repealing the SGR to approximately $200 billion. To pick up another $60 billion to $65 billion in savings, the MedPAC March report lists 29 recommended program and policy changes.

Key among the changes:

• Freeze payments to skilled nursing facilities in 2013, then cut them by 4% in 2014.
• Equalize payments for office-based and hospital outpatient services.
• Modify Medicare Part D low-income subsidies to favor more generic drugs.

"The biggest reason that Congress doesn’t move forward on this issue is that it costs $300 billion. ... It’s a big cost."

WASHINGTON – By implementing a series of payment reforms now – and adopting MedPAC’s recommendations on replacing the SGR – Congress can fix the Medicare physician pay problem and come closer to paying for it, too.

That’s the bottom line of the March 2012 Report to Congress from the Medicare Payment Advisory Commission (MedPAC), released March 15.

While the recommended cuts may cause some physicians to wince, according to Mark Miller, the blow would be much harder if Congress allows the nearly 30% physician pay cut called for by the Medicare SGR Growth Rate formula to go through, Mr. Miller, MedPAC executive director, said at a press conference.

Key among those recommendations was freezing most Medicare payments to primary care physicians for 10 years and cutting specialists’ payments by 17% over 3 years, followed by a freeze for 7 years more.

"That’s hard medicine," Mr. Miller said. "But one of the things that it does is it reduces the cost of the fix."

MedPAC estimates their recommendations will bring the price tag of repealing the SGR to approximately $200 billion. To pick up another $60 billion to $65 billion in savings, the MedPAC March report lists 29 recommended program and policy changes.

Key among the changes:

• Freeze payments to skilled nursing facilities in 2013, then cut them by 4% in 2014.
• Equalize payments for office-based and hospital outpatient services.
• Modify Medicare Part D low-income subsidies to favor more generic drugs.

"The biggest reason that Congress doesn’t move forward on this issue is that it costs $300 billion. ... It’s a big cost."

WASHINGTON – By implementing a series of payment reforms now – and adopting MedPAC’s recommendations on replacing the SGR – Congress can fix the Medicare physician pay problem and come closer to paying for it, too.

That’s the bottom line of the March 2012 Report to Congress from the Medicare Payment Advisory Commission (MedPAC), released March 15.

While the recommended cuts may cause some physicians to wince, according to Mark Miller, the blow would be much harder if Congress allows the nearly 30% physician pay cut called for by the Medicare SGR Growth Rate formula to go through, Mr. Miller, MedPAC executive director, said at a press conference.

Key among those recommendations was freezing most Medicare payments to primary care physicians for 10 years and cutting specialists’ payments by 17% over 3 years, followed by a freeze for 7 years more.

"That’s hard medicine," Mr. Miller said. "But one of the things that it does is it reduces the cost of the fix."

MedPAC estimates their recommendations will bring the price tag of repealing the SGR to approximately $200 billion. To pick up another $60 billion to $65 billion in savings, the MedPAC March report lists 29 recommended program and policy changes.

Key among the changes:

• Freeze payments to skilled nursing facilities in 2013, then cut them by 4% in 2014.
• Equalize payments for office-based and hospital outpatient services.
• Modify Medicare Part D low-income subsidies to favor more generic drugs.

"The biggest reason that Congress doesn’t move forward on this issue is that it costs $300 billion. ... It’s a big cost."

A panel of 10 serum biomarkers for lung cancer could offer more accurate interpretation of nodules detected on computed tomography, avoiding invasive biopsies and radiographic follow-up.

"CT-screening detection of an indeterminate pulmonary nodule, a nonspecific but frequent finding in high-risk subjects with a smoking history, creates a diagnostic dilemma," wrote investigator William L. Bigbee, Ph.D., and his colleagues in the April issue of the Journal of Thoracic Oncology.

"Although the biomarker model we described could not detect every lung cancer, it offers a significant clinical improvement over CT imaging alone.... Also, patients with nodules not identified as cancer by the model would continue to receive follow-up clinical monitoring and would be biopsied if the nodules grew in size, which is the current standard of care," the researchers said (J. Thorac. Oncol. 2012;7:698-708).

Dr. Bigbee of the University of Pittsburgh and his colleagues cite results of the National Lung Screening Trial (NLST), published in June 2011, which showed for the first time that low-dose CT screening of heavy smokers could reduce lung cancer mortality by 20%. But, as Dr. Bigbee et al. note in the current study, the "vast majority" of positive results in the NLST program turned out to be false after diagnostic evaluation. Moreover, smaller nodules are least likely to be malignant and least likely to be considered for biopsy or surgery.

For the current study, the researchers initially looked at a "training" set of 56 patients with non–small cell lung cancer in the University of Pittsburgh Cancer Institute Georgia Cooper Lung Research Registry. These cases were matched with 56 controls from the Pittsburgh Lung Screening Study (PLuSS), a volunteer cohort at high risk for lung cancer. All controls were known to be cancer free. The authors then analyzed serum samples from both groups for the presence of 70 potential cancer-associated biomarkers.

"Together, these biomarkers incorporate a wide range of host and tumor derived factors that allow a broad analysis of the lung cancer/host interaction, and includes a number of previously described epithelial cell cancer-associated serological markers," wrote the investigators. "The initial goal of this discovery study was to identify the most robust subset of these biomarkers to discriminate lung cancer and matched control samples."

Using a rule-learning algorithm, they whittled the field of potential biomarkers down to eight: prolactin, transthyretin, E-selectin, C-C motif, thrombospondin-1, chemokine 5, macrophage migration inhibitory factor, plasminogen activator inhibitor 1, and receptor tyrosine-protein kinase erbB-2.

"This rule model distinguished the lung cancer case samples from the control samples in the training set with a sensitivity of 92.9% and specificity of 87.5%," they reported.

Ultimately, two additional biomarkers were added to the panel – cytokeratin fragment 19-9 and serum amyloid A protein – and an additional set of cases and controls, 30 in each cohort, was assessed, in a blinded "verification" set.

In this set, the authors calculated an overall classification performance of 73.3% sensitivity and 93.3% specificity. Only 10 misclassifications occurred among 60 predictions made. Moreover, when looking at accuracy according to patient demographic factors, the researchers found that the 10-biomarker panel was equally good at distinguishing males and females as either cases or controls and that neither current smoking status nor airway obstruction skewed the results.

Nor did the presence of nodules visible on CT scan confound the biomarkers’ predictive value. "In fact, those PLuSS subjects with a suspicious nodule were more often correctly classified as controls than those with no nodule or a benign nodule," wrote the authors.

They add that all nodules found in controls remained clinically noncancerous at least 3 years after initial detection, with either resolution or no further growth on subsequent CT scans.

Finally, Dr. Bigbee assessed the model’s accuracy with early- vs. late-stage tumors.

"Among stage I/II lung tumors, the 10-biomarker panel misclassified 15% of stage I/II tumors in the verification set, compared to 50% of the stage III/IV tumors, suggesting the model performs well in discriminating early-stage lung cancer," he wrote. "With a specificity of 93.3%, the 10-biomarker model [balanced accuracy] was 89.2% in stage I/II disease."

The authors conceded that the biomarker panel presented here would not suffice for general population screening. However, in a clinical context, among high-risk patients, the model "may provide clinical utility in guiding interpretation of screening CT scans, even in tobacco-exposed persons with COPD or emphysema," they wrote.

"Formal validation in larger patient cohorts will be needed to confirm these initial findings."

The authors disclosed that funding for this study was supplied by grants from the National Cancer Institute. Dr. Bigbee stated that there were no personal disclosures.

A panel of 10 serum biomarkers for lung cancer could offer more accurate interpretation of nodules detected on computed tomography, avoiding invasive biopsies and radiographic follow-up.

"CT-screening detection of an indeterminate pulmonary nodule, a nonspecific but frequent finding in high-risk subjects with a smoking history, creates a diagnostic dilemma," wrote investigator William L. Bigbee, Ph.D., and his colleagues in the April issue of the Journal of Thoracic Oncology.

"Although the biomarker model we described could not detect every lung cancer, it offers a significant clinical improvement over CT imaging alone.... Also, patients with nodules not identified as cancer by the model would continue to receive follow-up clinical monitoring and would be biopsied if the nodules grew in size, which is the current standard of care," the researchers said (J. Thorac. Oncol. 2012;7:698-708).

Dr. Bigbee of the University of Pittsburgh and his colleagues cite results of the National Lung Screening Trial (NLST), published in June 2011, which showed for the first time that low-dose CT screening of heavy smokers could reduce lung cancer mortality by 20%. But, as Dr. Bigbee et al. note in the current study, the "vast majority" of positive results in the NLST program turned out to be false after diagnostic evaluation. Moreover, smaller nodules are least likely to be malignant and least likely to be considered for biopsy or surgery.

For the current study, the researchers initially looked at a "training" set of 56 patients with non–small cell lung cancer in the University of Pittsburgh Cancer Institute Georgia Cooper Lung Research Registry. These cases were matched with 56 controls from the Pittsburgh Lung Screening Study (PLuSS), a volunteer cohort at high risk for lung cancer. All controls were known to be cancer free. The authors then analyzed serum samples from both groups for the presence of 70 potential cancer-associated biomarkers.

"Together, these biomarkers incorporate a wide range of host and tumor derived factors that allow a broad analysis of the lung cancer/host interaction, and includes a number of previously described epithelial cell cancer-associated serological markers," wrote the investigators. "The initial goal of this discovery study was to identify the most robust subset of these biomarkers to discriminate lung cancer and matched control samples."

Using a rule-learning algorithm, they whittled the field of potential biomarkers down to eight: prolactin, transthyretin, E-selectin, C-C motif, thrombospondin-1, chemokine 5, macrophage migration inhibitory factor, plasminogen activator inhibitor 1, and receptor tyrosine-protein kinase erbB-2.

"This rule model distinguished the lung cancer case samples from the control samples in the training set with a sensitivity of 92.9% and specificity of 87.5%," they reported.

Ultimately, two additional biomarkers were added to the panel – cytokeratin fragment 19-9 and serum amyloid A protein – and an additional set of cases and controls, 30 in each cohort, was assessed, in a blinded "verification" set.

In this set, the authors calculated an overall classification performance of 73.3% sensitivity and 93.3% specificity. Only 10 misclassifications occurred among 60 predictions made. Moreover, when looking at accuracy according to patient demographic factors, the researchers found that the 10-biomarker panel was equally good at distinguishing males and females as either cases or controls and that neither current smoking status nor airway obstruction skewed the results.

Nor did the presence of nodules visible on CT scan confound the biomarkers’ predictive value. "In fact, those PLuSS subjects with a suspicious nodule were more often correctly classified as controls than those with no nodule or a benign nodule," wrote the authors.

They add that all nodules found in controls remained clinically noncancerous at least 3 years after initial detection, with either resolution or no further growth on subsequent CT scans.

Finally, Dr. Bigbee assessed the model’s accuracy with early- vs. late-stage tumors.

"Among stage I/II lung tumors, the 10-biomarker panel misclassified 15% of stage I/II tumors in the verification set, compared to 50% of the stage III/IV tumors, suggesting the model performs well in discriminating early-stage lung cancer," he wrote. "With a specificity of 93.3%, the 10-biomarker model [balanced accuracy] was 89.2% in stage I/II disease."

The authors conceded that the biomarker panel presented here would not suffice for general population screening. However, in a clinical context, among high-risk patients, the model "may provide clinical utility in guiding interpretation of screening CT scans, even in tobacco-exposed persons with COPD or emphysema," they wrote.

"Formal validation in larger patient cohorts will be needed to confirm these initial findings."

The authors disclosed that funding for this study was supplied by grants from the National Cancer Institute. Dr. Bigbee stated that there were no personal disclosures.

A panel of 10 serum biomarkers for lung cancer could offer more accurate interpretation of nodules detected on computed tomography, avoiding invasive biopsies and radiographic follow-up.

"CT-screening detection of an indeterminate pulmonary nodule, a nonspecific but frequent finding in high-risk subjects with a smoking history, creates a diagnostic dilemma," wrote investigator William L. Bigbee, Ph.D., and his colleagues in the April issue of the Journal of Thoracic Oncology.

"Although the biomarker model we described could not detect every lung cancer, it offers a significant clinical improvement over CT imaging alone.... Also, patients with nodules not identified as cancer by the model would continue to receive follow-up clinical monitoring and would be biopsied if the nodules grew in size, which is the current standard of care," the researchers said (J. Thorac. Oncol. 2012;7:698-708).

Dr. Bigbee of the University of Pittsburgh and his colleagues cite results of the National Lung Screening Trial (NLST), published in June 2011, which showed for the first time that low-dose CT screening of heavy smokers could reduce lung cancer mortality by 20%. But, as Dr. Bigbee et al. note in the current study, the "vast majority" of positive results in the NLST program turned out to be false after diagnostic evaluation. Moreover, smaller nodules are least likely to be malignant and least likely to be considered for biopsy or surgery.

For the current study, the researchers initially looked at a "training" set of 56 patients with non–small cell lung cancer in the University of Pittsburgh Cancer Institute Georgia Cooper Lung Research Registry. These cases were matched with 56 controls from the Pittsburgh Lung Screening Study (PLuSS), a volunteer cohort at high risk for lung cancer. All controls were known to be cancer free. The authors then analyzed serum samples from both groups for the presence of 70 potential cancer-associated biomarkers.

"Together, these biomarkers incorporate a wide range of host and tumor derived factors that allow a broad analysis of the lung cancer/host interaction, and includes a number of previously described epithelial cell cancer-associated serological markers," wrote the investigators. "The initial goal of this discovery study was to identify the most robust subset of these biomarkers to discriminate lung cancer and matched control samples."

Using a rule-learning algorithm, they whittled the field of potential biomarkers down to eight: prolactin, transthyretin, E-selectin, C-C motif, thrombospondin-1, chemokine 5, macrophage migration inhibitory factor, plasminogen activator inhibitor 1, and receptor tyrosine-protein kinase erbB-2.

"This rule model distinguished the lung cancer case samples from the control samples in the training set with a sensitivity of 92.9% and specificity of 87.5%," they reported.

Ultimately, two additional biomarkers were added to the panel – cytokeratin fragment 19-9 and serum amyloid A protein – and an additional set of cases and controls, 30 in each cohort, was assessed, in a blinded "verification" set.

In this set, the authors calculated an overall classification performance of 73.3% sensitivity and 93.3% specificity. Only 10 misclassifications occurred among 60 predictions made. Moreover, when looking at accuracy according to patient demographic factors, the researchers found that the 10-biomarker panel was equally good at distinguishing males and females as either cases or controls and that neither current smoking status nor airway obstruction skewed the results.

Nor did the presence of nodules visible on CT scan confound the biomarkers’ predictive value. "In fact, those PLuSS subjects with a suspicious nodule were more often correctly classified as controls than those with no nodule or a benign nodule," wrote the authors.

They add that all nodules found in controls remained clinically noncancerous at least 3 years after initial detection, with either resolution or no further growth on subsequent CT scans.

Finally, Dr. Bigbee assessed the model’s accuracy with early- vs. late-stage tumors.

"Among stage I/II lung tumors, the 10-biomarker panel misclassified 15% of stage I/II tumors in the verification set, compared to 50% of the stage III/IV tumors, suggesting the model performs well in discriminating early-stage lung cancer," he wrote. "With a specificity of 93.3%, the 10-biomarker model [balanced accuracy] was 89.2% in stage I/II disease."

The authors conceded that the biomarker panel presented here would not suffice for general population screening. However, in a clinical context, among high-risk patients, the model "may provide clinical utility in guiding interpretation of screening CT scans, even in tobacco-exposed persons with COPD or emphysema," they wrote.

"Formal validation in larger patient cohorts will be needed to confirm these initial findings."

The authors disclosed that funding for this study was supplied by grants from the National Cancer Institute. Dr. Bigbee stated that there were no personal disclosures.

A panel of 10 serum biomarkers for lung cancer could offer more accurate interpretation of nodules detected on computed tomography, avoiding invasive biopsies and radiographic follow-up.

"CT-screening detection of an indeterminate pulmonary nodule, a nonspecific but frequent finding in high-risk subjects with a smoking history, creates a diagnostic dilemma," wrote investigator William L. Bigbee, Ph.D., and his colleagues in the April issue of the Journal of Thoracic Oncology.

"Although the biomarker model we described could not detect every lung cancer, it offers a significant clinical improvement over CT imaging alone.... Also, patients with nodules not identified as cancer by the model would continue to receive follow-up clinical monitoring and would be biopsied if the nodules grew in size, which is the current standard of care," the researchers said (J. Thorac. Oncol. 2012;7:698-708).

Dr. Bigbee of the University of Pittsburgh and his colleagues cite results of the National Lung Screening Trial (NLST), published in June 2011, which showed for the first time that low-dose CT screening of heavy smokers could reduce lung cancer mortality by 20%. But, as Dr. Bigbee et al. note in the current study, the "vast majority" of positive results in the NLST program turned out to be false after diagnostic evaluation. Moreover, smaller nodules are least likely to be malignant and least likely to be considered for biopsy or surgery.

For the current study, the researchers initially looked at a "training" set of 56 patients with non–small cell lung cancer in the University of Pittsburgh Cancer Institute Georgia Cooper Lung Research Registry. These cases were matched with 56 controls from the Pittsburgh Lung Screening Study (PLuSS), a volunteer cohort at high risk for lung cancer. All controls were known to be cancer free. The authors then analyzed serum samples from both groups for the presence of 70 potential cancer-associated biomarkers.

"Together, these biomarkers incorporate a wide range of host and tumor derived factors that allow a broad analysis of the lung cancer/host interaction, and includes a number of previously described epithelial cell cancer-associated serological markers," wrote the investigators. "The initial goal of this discovery study was to identify the most robust subset of these biomarkers to discriminate lung cancer and matched control samples."

Using a rule-learning algorithm, they whittled the field of potential biomarkers down to eight: prolactin, transthyretin, E-selectin, C-C motif, thrombospondin-1, chemokine 5, macrophage migration inhibitory factor, plasminogen activator inhibitor 1, and receptor tyrosine-protein kinase erbB-2.

"This rule model distinguished the lung cancer case samples from the control samples in the training set with a sensitivity of 92.9% and specificity of 87.5%," they reported.

Ultimately, two additional biomarkers were added to the panel – cytokeratin fragment 19-9 and serum amyloid A protein – and an additional set of cases and controls, 30 in each cohort, was assessed, in a blinded "verification" set.

In this set, the authors calculated an overall classification performance of 73.3% sensitivity and 93.3% specificity. Only 10 misclassifications occurred among 60 predictions made. Moreover, when looking at accuracy according to patient demographic factors, the researchers found that the 10-biomarker panel was equally good at distinguishing males and females as either cases or controls and that neither current smoking status nor airway obstruction skewed the results.

Nor did the presence of nodules visible on CT scan confound the biomarkers’ predictive value. "In fact, those PLuSS subjects with a suspicious nodule were more often correctly classified as controls than those with no nodule or a benign nodule," wrote the authors.

They add that all nodules found in controls remained clinically noncancerous at least 3 years after initial detection, with either resolution or no further growth on subsequent CT scans.

Finally, Dr. Bigbee assessed the model’s accuracy with early- vs. late-stage tumors.

"Among stage I/II lung tumors, the 10-biomarker panel misclassified 15% of stage I/II tumors in the verification set, compared to 50% of the stage III/IV tumors, suggesting the model performs well in discriminating early-stage lung cancer," he wrote. "With a specificity of 93.3%, the 10-biomarker model [balanced accuracy] was 89.2% in stage I/II disease."

The authors conceded that the biomarker panel presented here would not suffice for general population screening. However, in a clinical context, among high-risk patients, the model "may provide clinical utility in guiding interpretation of screening CT scans, even in tobacco-exposed persons with COPD or emphysema," they wrote.

"Formal validation in larger patient cohorts will be needed to confirm these initial findings."

The authors disclosed that funding for this study was supplied by grants from the National Cancer Institute. Dr. Bigbee stated that there were no personal disclosures.

A panel of 10 serum biomarkers for lung cancer could offer more accurate interpretation of nodules detected on computed tomography, avoiding invasive biopsies and radiographic follow-up.

"CT-screening detection of an indeterminate pulmonary nodule, a nonspecific but frequent finding in high-risk subjects with a smoking history, creates a diagnostic dilemma," wrote investigator William L. Bigbee, Ph.D., and his colleagues in the April issue of the Journal of Thoracic Oncology.

"Although the biomarker model we described could not detect every lung cancer, it offers a significant clinical improvement over CT imaging alone.... Also, patients with nodules not identified as cancer by the model would continue to receive follow-up clinical monitoring and would be biopsied if the nodules grew in size, which is the current standard of care," the researchers said (J. Thorac. Oncol. 2012;7:698-708).

Dr. Bigbee of the University of Pittsburgh and his colleagues cite results of the National Lung Screening Trial (NLST), published in June 2011, which showed for the first time that low-dose CT screening of heavy smokers could reduce lung cancer mortality by 20%. But, as Dr. Bigbee et al. note in the current study, the "vast majority" of positive results in the NLST program turned out to be false after diagnostic evaluation. Moreover, smaller nodules are least likely to be malignant and least likely to be considered for biopsy or surgery.

For the current study, the researchers initially looked at a "training" set of 56 patients with non–small cell lung cancer in the University of Pittsburgh Cancer Institute Georgia Cooper Lung Research Registry. These cases were matched with 56 controls from the Pittsburgh Lung Screening Study (PLuSS), a volunteer cohort at high risk for lung cancer. All controls were known to be cancer free. The authors then analyzed serum samples from both groups for the presence of 70 potential cancer-associated biomarkers.

"Together, these biomarkers incorporate a wide range of host and tumor derived factors that allow a broad analysis of the lung cancer/host interaction, and includes a number of previously described epithelial cell cancer-associated serological markers," wrote the investigators. "The initial goal of this discovery study was to identify the most robust subset of these biomarkers to discriminate lung cancer and matched control samples."

Using a rule-learning algorithm, they whittled the field of potential biomarkers down to eight: prolactin, transthyretin, E-selectin, C-C motif, thrombospondin-1, chemokine 5, macrophage migration inhibitory factor, plasminogen activator inhibitor 1, and receptor tyrosine-protein kinase erbB-2.

"This rule model distinguished the lung cancer case samples from the control samples in the training set with a sensitivity of 92.9% and specificity of 87.5%," they reported.

Ultimately, two additional biomarkers were added to the panel – cytokeratin fragment 19-9 and serum amyloid A protein – and an additional set of cases and controls, 30 in each cohort, was assessed, in a blinded "verification" set.

In this set, the authors calculated an overall classification performance of 73.3% sensitivity and 93.3% specificity. Only 10 misclassifications occurred among 60 predictions made. Moreover, when looking at accuracy according to patient demographic factors, the researchers found that the 10-biomarker panel was equally good at distinguishing males and females as either cases or controls and that neither current smoking status nor airway obstruction skewed the results.

Nor did the presence of nodules visible on CT scan confound the biomarkers’ predictive value. "In fact, those PLuSS subjects with a suspicious nodule were more often correctly classified as controls than those with no nodule or a benign nodule," wrote the authors.

They add that all nodules found in controls remained clinically noncancerous at least 3 years after initial detection, with either resolution or no further growth on subsequent CT scans.

Finally, Dr. Bigbee assessed the model’s accuracy with early- vs. late-stage tumors.

"Among stage I/II lung tumors, the 10-biomarker panel misclassified 15% of stage I/II tumors in the verification set, compared to 50% of the stage III/IV tumors, suggesting the model performs well in discriminating early-stage lung cancer," he wrote. "With a specificity of 93.3%, the 10-biomarker model [balanced accuracy] was 89.2% in stage I/II disease."

The authors conceded that the biomarker panel presented here would not suffice for general population screening. However, in a clinical context, among high-risk patients, the model "may provide clinical utility in guiding interpretation of screening CT scans, even in tobacco-exposed persons with COPD or emphysema," they wrote.

"Formal validation in larger patient cohorts will be needed to confirm these initial findings."

The authors disclosed that funding for this study was supplied by grants from the National Cancer Institute. Dr. Bigbee stated that there were no personal disclosures.

A panel of 10 serum biomarkers for lung cancer could offer more accurate interpretation of nodules detected on computed tomography, avoiding invasive biopsies and radiographic follow-up.

"CT-screening detection of an indeterminate pulmonary nodule, a nonspecific but frequent finding in high-risk subjects with a smoking history, creates a diagnostic dilemma," wrote investigator William L. Bigbee, Ph.D., and his colleagues in the April issue of the Journal of Thoracic Oncology.

"Although the biomarker model we described could not detect every lung cancer, it offers a significant clinical improvement over CT imaging alone.... Also, patients with nodules not identified as cancer by the model would continue to receive follow-up clinical monitoring and would be biopsied if the nodules grew in size, which is the current standard of care," the researchers said (J. Thorac. Oncol. 2012;7:698-708).

Dr. Bigbee of the University of Pittsburgh and his colleagues cite results of the National Lung Screening Trial (NLST), published in June 2011, which showed for the first time that low-dose CT screening of heavy smokers could reduce lung cancer mortality by 20%. But, as Dr. Bigbee et al. note in the current study, the "vast majority" of positive results in the NLST program turned out to be false after diagnostic evaluation. Moreover, smaller nodules are least likely to be malignant and least likely to be considered for biopsy or surgery.

For the current study, the researchers initially looked at a "training" set of 56 patients with non–small cell lung cancer in the University of Pittsburgh Cancer Institute Georgia Cooper Lung Research Registry. These cases were matched with 56 controls from the Pittsburgh Lung Screening Study (PLuSS), a volunteer cohort at high risk for lung cancer. All controls were known to be cancer free. The authors then analyzed serum samples from both groups for the presence of 70 potential cancer-associated biomarkers.

"Together, these biomarkers incorporate a wide range of host and tumor derived factors that allow a broad analysis of the lung cancer/host interaction, and includes a number of previously described epithelial cell cancer-associated serological markers," wrote the investigators. "The initial goal of this discovery study was to identify the most robust subset of these biomarkers to discriminate lung cancer and matched control samples."

Using a rule-learning algorithm, they whittled the field of potential biomarkers down to eight: prolactin, transthyretin, E-selectin, C-C motif, thrombospondin-1, chemokine 5, macrophage migration inhibitory factor, plasminogen activator inhibitor 1, and receptor tyrosine-protein kinase erbB-2.

"This rule model distinguished the lung cancer case samples from the control samples in the training set with a sensitivity of 92.9% and specificity of 87.5%," they reported.

Ultimately, two additional biomarkers were added to the panel – cytokeratin fragment 19-9 and serum amyloid A protein – and an additional set of cases and controls, 30 in each cohort, was assessed, in a blinded "verification" set.

In this set, the authors calculated an overall classification performance of 73.3% sensitivity and 93.3% specificity. Only 10 misclassifications occurred among 60 predictions made. Moreover, when looking at accuracy according to patient demographic factors, the researchers found that the 10-biomarker panel was equally good at distinguishing males and females as either cases or controls and that neither current smoking status nor airway obstruction skewed the results.

Nor did the presence of nodules visible on CT scan confound the biomarkers’ predictive value. "In fact, those PLuSS subjects with a suspicious nodule were more often correctly classified as controls than those with no nodule or a benign nodule," wrote the authors.

They add that all nodules found in controls remained clinically noncancerous at least 3 years after initial detection, with either resolution or no further growth on subsequent CT scans.

Finally, Dr. Bigbee assessed the model’s accuracy with early- vs. late-stage tumors.

"Among stage I/II lung tumors, the 10-biomarker panel misclassified 15% of stage I/II tumors in the verification set, compared to 50% of the stage III/IV tumors, suggesting the model performs well in discriminating early-stage lung cancer," he wrote. "With a specificity of 93.3%, the 10-biomarker model [balanced accuracy] was 89.2% in stage I/II disease."

The authors conceded that the biomarker panel presented here would not suffice for general population screening. However, in a clinical context, among high-risk patients, the model "may provide clinical utility in guiding interpretation of screening CT scans, even in tobacco-exposed persons with COPD or emphysema," they wrote.

"Formal validation in larger patient cohorts will be needed to confirm these initial findings."

The authors disclosed that funding for this study was supplied by grants from the National Cancer Institute. Dr. Bigbee stated that there were no personal disclosures.

Physicians who opt out of participating in social media risk losing control of their reputations to a certain extent, according to Dr. Danielle S. Walsh.

"People are creating accounts and information about you whether you do it or not. Google your name and I promise you will find something there. You can either contribute to this and police what’s said about you and add to that information, or you can let everyone else do it for you," Dr. Walsh said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

If you choose to become a social media player, one of the best ways to protect yourself from a legal standpoint is to establish a social media policy, said Dr. Walsh, an ACS Fellow in the division of pediatric surgery at the Brody School of Medicine at East Carolina University, Greenville, N.C. "You want to ensure that you can place accurate information on there and correct any inaccuracies that are posted to your site. You also want to give guidance to employees who already use or want to use social media appropriately," she explained.

Templates of social media policies can be found at www.SocialMediaGovernance.com, and the American Medical Association’s guidelines for professionalism in the use of social media can be viewed at www.ama-assn.org/ama/pubmeeting/professionalism-social-media.html.

As you devise a policy, identify all of the involved parties, including your information technology department if you have one, the risk management team of your employer or your hospital, and the legal department and administrative leaders of your institution. "Make sure they all have an opportunity to review what you’re about to do, why you’re doing it; and get their feedback," she advised. Next, decide who will have ultimate ownership and oversight of the social media sites you plan to launch. She offered five "Ws" to include in the policy:

• Who it applies to and who manages the content.

• What types of information/statements are covered by the policy, including legal issues.

• Where it applies, that is, whether it applies to computers used at home, in the workplace, or both.

• When to bring information to top-level managers (e.g., in cases of threats of harm to office staff or patients, complaints about the practice, or privacy violations).

• Why the policy is important: Your guidelines should be designed to keep you out of legal trouble.

Dr. Walsh emphasized the importance of protecting patient privacy online and noted that physicians’ identities can be traced through posts referring to patients, even if physicians omit their names.

"If they know where you work and you describe a patient scenario, or if you post a photograph, and a story about that person eventually hits the media, they can go back and put the pieces together and identify you," she said.

If a patient posts a complaint about you or your practice, a carefully worded response can offset negativity, Dr. Walsh said, by showing that you care and that you are responding in a proactive way.

Dr. Walsh said that she had no relevant financial disclosures.

Physicians who opt out of participating in social media risk losing control of their reputations to a certain extent, according to Dr. Danielle S. Walsh.

"People are creating accounts and information about you whether you do it or not. Google your name and I promise you will find something there. You can either contribute to this and police what’s said about you and add to that information, or you can let everyone else do it for you," Dr. Walsh said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

If you choose to become a social media player, one of the best ways to protect yourself from a legal standpoint is to establish a social media policy, said Dr. Walsh, an ACS Fellow in the division of pediatric surgery at the Brody School of Medicine at East Carolina University, Greenville, N.C. "You want to ensure that you can place accurate information on there and correct any inaccuracies that are posted to your site. You also want to give guidance to employees who already use or want to use social media appropriately," she explained.

Templates of social media policies can be found at www.SocialMediaGovernance.com, and the American Medical Association’s guidelines for professionalism in the use of social media can be viewed at www.ama-assn.org/ama/pubmeeting/professionalism-social-media.html.

As you devise a policy, identify all of the involved parties, including your information technology department if you have one, the risk management team of your employer or your hospital, and the legal department and administrative leaders of your institution. "Make sure they all have an opportunity to review what you’re about to do, why you’re doing it; and get their feedback," she advised. Next, decide who will have ultimate ownership and oversight of the social media sites you plan to launch. She offered five "Ws" to include in the policy:

• Who it applies to and who manages the content.

• What types of information/statements are covered by the policy, including legal issues.

• Where it applies, that is, whether it applies to computers used at home, in the workplace, or both.

• When to bring information to top-level managers (e.g., in cases of threats of harm to office staff or patients, complaints about the practice, or privacy violations).

• Why the policy is important: Your guidelines should be designed to keep you out of legal trouble.

Dr. Walsh emphasized the importance of protecting patient privacy online and noted that physicians’ identities can be traced through posts referring to patients, even if physicians omit their names.

"If they know where you work and you describe a patient scenario, or if you post a photograph, and a story about that person eventually hits the media, they can go back and put the pieces together and identify you," she said.

If a patient posts a complaint about you or your practice, a carefully worded response can offset negativity, Dr. Walsh said, by showing that you care and that you are responding in a proactive way.

Dr. Walsh said that she had no relevant financial disclosures.

Physicians who opt out of participating in social media risk losing control of their reputations to a certain extent, according to Dr. Danielle S. Walsh.

"People are creating accounts and information about you whether you do it or not. Google your name and I promise you will find something there. You can either contribute to this and police what’s said about you and add to that information, or you can let everyone else do it for you," Dr. Walsh said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

If you choose to become a social media player, one of the best ways to protect yourself from a legal standpoint is to establish a social media policy, said Dr. Walsh, an ACS Fellow in the division of pediatric surgery at the Brody School of Medicine at East Carolina University, Greenville, N.C. "You want to ensure that you can place accurate information on there and correct any inaccuracies that are posted to your site. You also want to give guidance to employees who already use or want to use social media appropriately," she explained.

Templates of social media policies can be found at www.SocialMediaGovernance.com, and the American Medical Association’s guidelines for professionalism in the use of social media can be viewed at www.ama-assn.org/ama/pubmeeting/professionalism-social-media.html.

As you devise a policy, identify all of the involved parties, including your information technology department if you have one, the risk management team of your employer or your hospital, and the legal department and administrative leaders of your institution. "Make sure they all have an opportunity to review what you’re about to do, why you’re doing it; and get their feedback," she advised. Next, decide who will have ultimate ownership and oversight of the social media sites you plan to launch. She offered five "Ws" to include in the policy:

• Who it applies to and who manages the content.

• What types of information/statements are covered by the policy, including legal issues.

• Where it applies, that is, whether it applies to computers used at home, in the workplace, or both.

• When to bring information to top-level managers (e.g., in cases of threats of harm to office staff or patients, complaints about the practice, or privacy violations).

• Why the policy is important: Your guidelines should be designed to keep you out of legal trouble.

Dr. Walsh emphasized the importance of protecting patient privacy online and noted that physicians’ identities can be traced through posts referring to patients, even if physicians omit their names.

"If they know where you work and you describe a patient scenario, or if you post a photograph, and a story about that person eventually hits the media, they can go back and put the pieces together and identify you," she said.

If a patient posts a complaint about you or your practice, a carefully worded response can offset negativity, Dr. Walsh said, by showing that you care and that you are responding in a proactive way.

Dr. Walsh said that she had no relevant financial disclosures.

Medicare officials have released a coverage proposal for transcatheter aortic valve replacement 3 months after the procedure was approved in the United States.

The Centers for Medicare and Medicaid Services’ proposal restricts the procedure’s coverage to situations in which all of the following five criteria are met:

• The procedure meets Food and Drug Administration–approved criteria, and an FDA-approved device is used.

• Two cardiac surgeons evaluate the patient’s suitability for open valve replacement surgery.

• The procedure is performed in a facility that meets a certain level of experience. The document breaks down the criteria by centers with or without previous transcatheter aortic valve replacement (TAVR) clinical trial experience. All centers are required to participate in a prospective national TAVR stud, and be committed to the Heart Team concept.

• The cardiac surgeon and interventionalist meet certain qualifications and levels of experience.

• The patient is enrolled in the prospective national registry for TAVR. The treating physician team also needs to be participating in the national registry.

The memo arrived ahead of its March 28 due date, just days after four cardiovascular societies issued a document providing detailed guidance on TAVR implementation in centers across the United States. Heart teams, a national registry, and careful selection of patients are also among the societies’ consensus document highlights.

In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011. The valve is currently approved for use in inoperable patients with severe aortic stenosis. Other use of the Sapien valve is limited to clinical trials. Medtronic’s CoreValve is also in being studied in large U.S. trials.

In a joint statement, the Society of Thoracic Surgeons and the American College of Cardiology said they were pleased with CMS’s comprehensive approach to the coverage of TAVR, balancing the patients’ needs with measures that would ensure quality of care.

"This coverage analysis achieves these goals through the use of specialized centers with multidisciplinary heart teams and registry enrollment," said STS President Dr. Jeffrey B. Rich, in a statement. "We are especially pleased that CMS has proposed to provide a smooth path to Medicare coverage as the technology continues to evolve and improve," said ACC President Dr. David R. Holmes, in a statement.

CMS opened the national coverage analysis in September, before Sapien was even approved, in response to a request from the ACC and STS to establish the criteria for national Medicare coverage of the minimally invasive valve procedure. The CMS proposal is a step in the national coverage analysis process, in which the agency decides whether an item or service is covered by Medicare.

The agency is expected to have made a final decision by May of this year.

Medicare officials have released a coverage proposal for transcatheter aortic valve replacement 3 months after the procedure was approved in the United States.

The Centers for Medicare and Medicaid Services’ proposal restricts the procedure’s coverage to situations in which all of the following five criteria are met:

• The procedure meets Food and Drug Administration–approved criteria, and an FDA-approved device is used.

• Two cardiac surgeons evaluate the patient’s suitability for open valve replacement surgery.

• The procedure is performed in a facility that meets a certain level of experience. The document breaks down the criteria by centers with or without previous transcatheter aortic valve replacement (TAVR) clinical trial experience. All centers are required to participate in a prospective national TAVR stud, and be committed to the Heart Team concept.

• The cardiac surgeon and interventionalist meet certain qualifications and levels of experience.

• The patient is enrolled in the prospective national registry for TAVR. The treating physician team also needs to be participating in the national registry.

The memo arrived ahead of its March 28 due date, just days after four cardiovascular societies issued a document providing detailed guidance on TAVR implementation in centers across the United States. Heart teams, a national registry, and careful selection of patients are also among the societies’ consensus document highlights.

In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011. The valve is currently approved for use in inoperable patients with severe aortic stenosis. Other use of the Sapien valve is limited to clinical trials. Medtronic’s CoreValve is also in being studied in large U.S. trials.

In a joint statement, the Society of Thoracic Surgeons and the American College of Cardiology said they were pleased with CMS’s comprehensive approach to the coverage of TAVR, balancing the patients’ needs with measures that would ensure quality of care.

"This coverage analysis achieves these goals through the use of specialized centers with multidisciplinary heart teams and registry enrollment," said STS President Dr. Jeffrey B. Rich, in a statement. "We are especially pleased that CMS has proposed to provide a smooth path to Medicare coverage as the technology continues to evolve and improve," said ACC President Dr. David R. Holmes, in a statement.

CMS opened the national coverage analysis in September, before Sapien was even approved, in response to a request from the ACC and STS to establish the criteria for national Medicare coverage of the minimally invasive valve procedure. The CMS proposal is a step in the national coverage analysis process, in which the agency decides whether an item or service is covered by Medicare.

The agency is expected to have made a final decision by May of this year.

Medicare officials have released a coverage proposal for transcatheter aortic valve replacement 3 months after the procedure was approved in the United States.

The Centers for Medicare and Medicaid Services’ proposal restricts the procedure’s coverage to situations in which all of the following five criteria are met:

• The procedure meets Food and Drug Administration–approved criteria, and an FDA-approved device is used.

• Two cardiac surgeons evaluate the patient’s suitability for open valve replacement surgery.

• The procedure is performed in a facility that meets a certain level of experience. The document breaks down the criteria by centers with or without previous transcatheter aortic valve replacement (TAVR) clinical trial experience. All centers are required to participate in a prospective national TAVR stud, and be committed to the Heart Team concept.

• The cardiac surgeon and interventionalist meet certain qualifications and levels of experience.

• The patient is enrolled in the prospective national registry for TAVR. The treating physician team also needs to be participating in the national registry.

The memo arrived ahead of its March 28 due date, just days after four cardiovascular societies issued a document providing detailed guidance on TAVR implementation in centers across the United States. Heart teams, a national registry, and careful selection of patients are also among the societies’ consensus document highlights.

In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011. The valve is currently approved for use in inoperable patients with severe aortic stenosis. Other use of the Sapien valve is limited to clinical trials. Medtronic’s CoreValve is also in being studied in large U.S. trials.

In a joint statement, the Society of Thoracic Surgeons and the American College of Cardiology said they were pleased with CMS’s comprehensive approach to the coverage of TAVR, balancing the patients’ needs with measures that would ensure quality of care.

"This coverage analysis achieves these goals through the use of specialized centers with multidisciplinary heart teams and registry enrollment," said STS President Dr. Jeffrey B. Rich, in a statement. "We are especially pleased that CMS has proposed to provide a smooth path to Medicare coverage as the technology continues to evolve and improve," said ACC President Dr. David R. Holmes, in a statement.

CMS opened the national coverage analysis in September, before Sapien was even approved, in response to a request from the ACC and STS to establish the criteria for national Medicare coverage of the minimally invasive valve procedure. The CMS proposal is a step in the national coverage analysis process, in which the agency decides whether an item or service is covered by Medicare.

The agency is expected to have made a final decision by May of this year.

Medicare officials have released a coverage proposal for transcatheter aortic valve replacement 3 months after the procedure was approved in the United States.

The Centers for Medicare and Medicaid Services’ proposal restricts the procedure’s coverage to situations in which all of the following five criteria are met:

• The procedure meets Food and Drug Administration–approved criteria, and an FDA-approved device is used.

• Two cardiac surgeons evaluate the patient’s suitability for open valve replacement surgery.

• The procedure is performed in a facility that meets a certain level of experience. The document breaks down the criteria by centers with or without previous transcatheter aortic valve replacement (TAVR) clinical trial experience. All centers are required to participate in a prospective national TAVR stud, and be committed to the Heart Team concept.

• The cardiac surgeon and interventionalist meet certain qualifications and levels of experience.

• The patient is enrolled in the prospective national registry for TAVR. The treating physician team also needs to be participating in the national registry.

The memo arrived ahead of its March 28 due date, just days after four cardiovascular societies issued a document providing detailed guidance on TAVR implementation in centers across the United States. Heart teams, a national registry, and careful selection of patients are also among the societies’ consensus document highlights.

In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011. The valve is currently approved for use in inoperable patients with severe aortic stenosis. Other use of the Sapien valve is limited to clinical trials. Medtronic’s CoreValve is also in being studied in large U.S. trials.

In a joint statement, the Society of Thoracic Surgeons and the American College of Cardiology said they were pleased with CMS’s comprehensive approach to the coverage of TAVR, balancing the patients’ needs with measures that would ensure quality of care.

"This coverage analysis achieves these goals through the use of specialized centers with multidisciplinary heart teams and registry enrollment," said STS President Dr. Jeffrey B. Rich, in a statement. "We are especially pleased that CMS has proposed to provide a smooth path to Medicare coverage as the technology continues to evolve and improve," said ACC President Dr. David R. Holmes, in a statement.

CMS opened the national coverage analysis in September, before Sapien was even approved, in response to a request from the ACC and STS to establish the criteria for national Medicare coverage of the minimally invasive valve procedure. The CMS proposal is a step in the national coverage analysis process, in which the agency decides whether an item or service is covered by Medicare.

The agency is expected to have made a final decision by May of this year.

Medicare officials have released a coverage proposal for transcatheter aortic valve replacement 3 months after the procedure was approved in the United States.

The Centers for Medicare and Medicaid Services’ proposal restricts the procedure’s coverage to situations in which all of the following five criteria are met:

• The procedure meets Food and Drug Administration–approved criteria, and an FDA-approved device is used.

• Two cardiac surgeons evaluate the patient’s suitability for open valve replacement surgery.

• The procedure is performed in a facility that meets a certain level of experience. The document breaks down the criteria by centers with or without previous transcatheter aortic valve replacement (TAVR) clinical trial experience. All centers are required to participate in a prospective national TAVR stud, and be committed to the Heart Team concept.

• The cardiac surgeon and interventionalist meet certain qualifications and levels of experience.

• The patient is enrolled in the prospective national registry for TAVR. The treating physician team also needs to be participating in the national registry.

The memo arrived ahead of its March 28 due date, just days after four cardiovascular societies issued a document providing detailed guidance on TAVR implementation in centers across the United States. Heart teams, a national registry, and careful selection of patients are also among the societies’ consensus document highlights.

In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011. The valve is currently approved for use in inoperable patients with severe aortic stenosis. Other use of the Sapien valve is limited to clinical trials. Medtronic’s CoreValve is also in being studied in large U.S. trials.

In a joint statement, the Society of Thoracic Surgeons and the American College of Cardiology said they were pleased with CMS’s comprehensive approach to the coverage of TAVR, balancing the patients’ needs with measures that would ensure quality of care.

"This coverage analysis achieves these goals through the use of specialized centers with multidisciplinary heart teams and registry enrollment," said STS President Dr. Jeffrey B. Rich, in a statement. "We are especially pleased that CMS has proposed to provide a smooth path to Medicare coverage as the technology continues to evolve and improve," said ACC President Dr. David R. Holmes, in a statement.

CMS opened the national coverage analysis in September, before Sapien was even approved, in response to a request from the ACC and STS to establish the criteria for national Medicare coverage of the minimally invasive valve procedure. The CMS proposal is a step in the national coverage analysis process, in which the agency decides whether an item or service is covered by Medicare.

The agency is expected to have made a final decision by May of this year.

Medicare officials have released a coverage proposal for transcatheter aortic valve replacement 3 months after the procedure was approved in the United States.

The Centers for Medicare and Medicaid Services’ proposal restricts the procedure’s coverage to situations in which all of the following five criteria are met:

• The procedure meets Food and Drug Administration–approved criteria, and an FDA-approved device is used.

• Two cardiac surgeons evaluate the patient’s suitability for open valve replacement surgery.

• The procedure is performed in a facility that meets a certain level of experience. The document breaks down the criteria by centers with or without previous transcatheter aortic valve replacement (TAVR) clinical trial experience. All centers are required to participate in a prospective national TAVR stud, and be committed to the Heart Team concept.

• The cardiac surgeon and interventionalist meet certain qualifications and levels of experience.

• The patient is enrolled in the prospective national registry for TAVR. The treating physician team also needs to be participating in the national registry.

The memo arrived ahead of its March 28 due date, just days after four cardiovascular societies issued a document providing detailed guidance on TAVR implementation in centers across the United States. Heart teams, a national registry, and careful selection of patients are also among the societies’ consensus document highlights.

In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011. The valve is currently approved for use in inoperable patients with severe aortic stenosis. Other use of the Sapien valve is limited to clinical trials. Medtronic’s CoreValve is also in being studied in large U.S. trials.

In a joint statement, the Society of Thoracic Surgeons and the American College of Cardiology said they were pleased with CMS’s comprehensive approach to the coverage of TAVR, balancing the patients’ needs with measures that would ensure quality of care.

"This coverage analysis achieves these goals through the use of specialized centers with multidisciplinary heart teams and registry enrollment," said STS President Dr. Jeffrey B. Rich, in a statement. "We are especially pleased that CMS has proposed to provide a smooth path to Medicare coverage as the technology continues to evolve and improve," said ACC President Dr. David R. Holmes, in a statement.

CMS opened the national coverage analysis in September, before Sapien was even approved, in response to a request from the ACC and STS to establish the criteria for national Medicare coverage of the minimally invasive valve procedure. The CMS proposal is a step in the national coverage analysis process, in which the agency decides whether an item or service is covered by Medicare.

The agency is expected to have made a final decision by May of this year.

MIAMI BEACH – Researchers have developed a way to quickly and objectively assess the risk for aortic valve regurgitation based on the measurement of aortic blood pressures immediately after transcatheter valvevale replacement (TAVR). This new measure, the "aortic regurgitation index," showed significant correlation with periprocedural aortic regurgitation as well as with patients’ 1-year survival following their procedure, Dr. Eberhard Grube said at the ISET 2012 meeting.

Until now, "there has been no way to quantify aortic regurgitation; it’s subjective," said Dr. Grube, professor and chief of cardiology and angiology at the Helios Heart Centre in Siegburg, Germany. The aortic regurgitation index (ARI) allows physicians "to quantify aortic regurgitation periprocedurally by objectively looking at the patient’s hemodynamics, regardless of the subjective evaluation of aortic insufficiency by angiography or by echo," he said. "We can see the ARI and know what we need to do for post-deployment treatment."

Dr. Grube and his associates set the ARI as equal to the patient’s diastolic aortic pressure minus the left ventricular end diastolic pressure, all divided by the aortic systolic pressure, andthen multiplied by 100.

For example, a patient with mild periprocedural aortic regurgitation might have an aortic diastolic pressure of 60 mm Hg, a left ventricular end diastolic pressure of 15 mm Hg, and an aortic systolic pressure of 150 mm Hg, which would produce an ARI of 30, showing that the patient had a low risk for dying during the subsequent year. In contrast, a patient with moderate or severe periprocedural aortic regurgitation could have an aortic diastolic pressure of 40 mm Hg, a left ventricular end diastolic pressure of 20 mm Hg, and an aortic systolic pressure of 120 mm Hg, which would produce an ARI of 16.7, flagging a higher mortality risk in the following year.

His group assessed the prognostic ability of the ARI in a series of 146 patients who underwent TAVR. The group included 124 patients with no or mild aortic regurgitation following TAVR and 22 who showed moderate or severe regurgitation. During 1-year follow-up, the 96 patients with a periprocedural ARI of 25 or greater had an 83% survival rate; the 50 patients with a periprocedural ARI of less than 25 had a survival rate of 54%, a statistically significant difference. The analysis also showed a significant correlation between the ARI and the severity of aortic regurgitation. Among patients with no discerniable regurgitation, the average ARI was about 30, in those with mild regurgitation the average ARI was about 25, in patients with moderate regurgitation the average was about 18, and in patients with severe regurgitation the ARI averaged about 10.

One recently identified key to limiting aortic regurgitation following TAVR is proper valve sizing relative to the patient’s aortic annulus. "Appropriate valve sizing is likely the most important factor that will influence both the degree of perivalvular regurgitation and pacemaker need after TAVR," said Dr. Jeffrey J. Popma in a separate talk at the meeting.

Until recently, many operators used transthoracic echocardiography for annulus sizing, but recently published evidence showed that imaging by CT or by MRI provides superior information, said Dr. Popma, director of interventional cardiology at Beth Israel Deaconess Medical Center in Boston. He cited a British report published last November that compared transthoracic echo, CT, and MRI in 202 patients who underwent TAVR, which found both CT and MRI superior to echo for annulus measurement prior to TAVR (J. Am. Coll. Cardiol. 2011;58:2165-73).

Dr. Grube and Dr. Popma disclosed financial relationships with several medical device manufacturers including Boston Scientific, Medtronic, and Cordis.

MIAMI BEACH – Researchers have developed a way to quickly and objectively assess the risk for aortic valve regurgitation based on the measurement of aortic blood pressures immediately after transcatheter valvevale replacement (TAVR). This new measure, the "aortic regurgitation index," showed significant correlation with periprocedural aortic regurgitation as well as with patients’ 1-year survival following their procedure, Dr. Eberhard Grube said at the ISET 2012 meeting.

Until now, "there has been no way to quantify aortic regurgitation; it’s subjective," said Dr. Grube, professor and chief of cardiology and angiology at the Helios Heart Centre in Siegburg, Germany. The aortic regurgitation index (ARI) allows physicians "to quantify aortic regurgitation periprocedurally by objectively looking at the patient’s hemodynamics, regardless of the subjective evaluation of aortic insufficiency by angiography or by echo," he said. "We can see the ARI and know what we need to do for post-deployment treatment."

Dr. Grube and his associates set the ARI as equal to the patient’s diastolic aortic pressure minus the left ventricular end diastolic pressure, all divided by the aortic systolic pressure, andthen multiplied by 100.

For example, a patient with mild periprocedural aortic regurgitation might have an aortic diastolic pressure of 60 mm Hg, a left ventricular end diastolic pressure of 15 mm Hg, and an aortic systolic pressure of 150 mm Hg, which would produce an ARI of 30, showing that the patient had a low risk for dying during the subsequent year. In contrast, a patient with moderate or severe periprocedural aortic regurgitation could have an aortic diastolic pressure of 40 mm Hg, a left ventricular end diastolic pressure of 20 mm Hg, and an aortic systolic pressure of 120 mm Hg, which would produce an ARI of 16.7, flagging a higher mortality risk in the following year.

His group assessed the prognostic ability of the ARI in a series of 146 patients who underwent TAVR. The group included 124 patients with no or mild aortic regurgitation following TAVR and 22 who showed moderate or severe regurgitation. During 1-year follow-up, the 96 patients with a periprocedural ARI of 25 or greater had an 83% survival rate; the 50 patients with a periprocedural ARI of less than 25 had a survival rate of 54%, a statistically significant difference. The analysis also showed a significant correlation between the ARI and the severity of aortic regurgitation. Among patients with no discerniable regurgitation, the average ARI was about 30, in those with mild regurgitation the average ARI was about 25, in patients with moderate regurgitation the average was about 18, and in patients with severe regurgitation the ARI averaged about 10.

One recently identified key to limiting aortic regurgitation following TAVR is proper valve sizing relative to the patient’s aortic annulus. "Appropriate valve sizing is likely the most important factor that will influence both the degree of perivalvular regurgitation and pacemaker need after TAVR," said Dr. Jeffrey J. Popma in a separate talk at the meeting.

Until recently, many operators used transthoracic echocardiography for annulus sizing, but recently published evidence showed that imaging by CT or by MRI provides superior information, said Dr. Popma, director of interventional cardiology at Beth Israel Deaconess Medical Center in Boston. He cited a British report published last November that compared transthoracic echo, CT, and MRI in 202 patients who underwent TAVR, which found both CT and MRI superior to echo for annulus measurement prior to TAVR (J. Am. Coll. Cardiol. 2011;58:2165-73).

Dr. Grube and Dr. Popma disclosed financial relationships with several medical device manufacturers including Boston Scientific, Medtronic, and Cordis.

MIAMI BEACH – Researchers have developed a way to quickly and objectively assess the risk for aortic valve regurgitation based on the measurement of aortic blood pressures immediately after transcatheter valvevale replacement (TAVR). This new measure, the "aortic regurgitation index," showed significant correlation with periprocedural aortic regurgitation as well as with patients’ 1-year survival following their procedure, Dr. Eberhard Grube said at the ISET 2012 meeting.

Until now, "there has been no way to quantify aortic regurgitation; it’s subjective," said Dr. Grube, professor and chief of cardiology and angiology at the Helios Heart Centre in Siegburg, Germany. The aortic regurgitation index (ARI) allows physicians "to quantify aortic regurgitation periprocedurally by objectively looking at the patient’s hemodynamics, regardless of the subjective evaluation of aortic insufficiency by angiography or by echo," he said. "We can see the ARI and know what we need to do for post-deployment treatment."

Dr. Grube and his associates set the ARI as equal to the patient’s diastolic aortic pressure minus the left ventricular end diastolic pressure, all divided by the aortic systolic pressure, andthen multiplied by 100.

For example, a patient with mild periprocedural aortic regurgitation might have an aortic diastolic pressure of 60 mm Hg, a left ventricular end diastolic pressure of 15 mm Hg, and an aortic systolic pressure of 150 mm Hg, which would produce an ARI of 30, showing that the patient had a low risk for dying during the subsequent year. In contrast, a patient with moderate or severe periprocedural aortic regurgitation could have an aortic diastolic pressure of 40 mm Hg, a left ventricular end diastolic pressure of 20 mm Hg, and an aortic systolic pressure of 120 mm Hg, which would produce an ARI of 16.7, flagging a higher mortality risk in the following year.

His group assessed the prognostic ability of the ARI in a series of 146 patients who underwent TAVR. The group included 124 patients with no or mild aortic regurgitation following TAVR and 22 who showed moderate or severe regurgitation. During 1-year follow-up, the 96 patients with a periprocedural ARI of 25 or greater had an 83% survival rate; the 50 patients with a periprocedural ARI of less than 25 had a survival rate of 54%, a statistically significant difference. The analysis also showed a significant correlation between the ARI and the severity of aortic regurgitation. Among patients with no discerniable regurgitation, the average ARI was about 30, in those with mild regurgitation the average ARI was about 25, in patients with moderate regurgitation the average was about 18, and in patients with severe regurgitation the ARI averaged about 10.

One recently identified key to limiting aortic regurgitation following TAVR is proper valve sizing relative to the patient’s aortic annulus. "Appropriate valve sizing is likely the most important factor that will influence both the degree of perivalvular regurgitation and pacemaker need after TAVR," said Dr. Jeffrey J. Popma in a separate talk at the meeting.

Until recently, many operators used transthoracic echocardiography for annulus sizing, but recently published evidence showed that imaging by CT or by MRI provides superior information, said Dr. Popma, director of interventional cardiology at Beth Israel Deaconess Medical Center in Boston. He cited a British report published last November that compared transthoracic echo, CT, and MRI in 202 patients who underwent TAVR, which found both CT and MRI superior to echo for annulus measurement prior to TAVR (J. Am. Coll. Cardiol. 2011;58:2165-73).

Dr. Grube and Dr. Popma disclosed financial relationships with several medical device manufacturers including Boston Scientific, Medtronic, and Cordis.