Published: October 19, 2013

Dates to Remember

January 1 Bulletin feature: Committee Highlights; Summary of Guideline on Guidelines; read it online at www.entnet.org/bulletin. January 21 Annual Meeting & OTO EXPOSM Call for Papers Deadlines for Scientific Oral & Poster: Jan. 21-Feb. 18 at www.entnet.org/annual_meeting. January 30 Nomination forms for the 2013 Jerome C. Goldstein Public Service Award due. Email elaguna@entnet.org. February 1 2013 Committee Application Opens on November 15 and closes on February 1. See www.entnet.org/committees. February 1-2 Coding and Reimbursement Workshop, Dallas, TX at www.entnet.org/conferencesandevents. In Otolaryngology Details at www.entnet.org/conferencesandevents. January 13-14 AACE Advances in Thyroid Cancer Diagnosis and Therapy January 15-18 10th GCC Otorhinolaryngology HNS Conference January 18-19 AACE Advances in Thyroid Cancer Diagnosis and Therapy February 2-3 ACS Thyroid and Parathyroid Ultrasound Skills-Oriented Course February 8-9 81st Midwinter Research Study Club of Los Angeles Recent Advances in Otolaryngology—Earn up to 16 CME Credits February 14-17 2013 Advanced Techniques in Endoscopic Sinus Surgery February 15-17 19th Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring February 16-19 UCSF/Tripler Pacific Rim Otolaryngology Head and Neck Surgery Update Conference February 16-19 The UC Irvine 2013 Otolaryngology Updates, 28.0 AMA PRA Category 1 CreditsTM February 16 Head & Neck Radiology Bootcamp, 3.25 AMA PRA Category 1 CreditsTM February 17 The Fourth Annual Injectable Fillers and Neuromodulators Course, 3.25 AMA PRA Category 1 CreditsTM

January 1 Bulletin feature: Committee Highlights; Summary of Guideline on Guidelines; read it online at www.entnet.org/bulletin.

January 21 Annual Meeting & OTO EXPOSM Call for Papers Deadlines for Scientific Oral & Poster: Jan. 21-Feb. 18 at www.entnet.org/annual_meeting.

January 30 Nomination forms for the 2013 Jerome C. Goldstein Public Service Award due. Email elaguna@entnet.org.

February 1 2013 Committee Application Opens on November 15 and closes on February 1. See www.entnet.org/committees.

February 1-2 Coding and Reimbursement Workshop, Dallas, TX at www.entnet.org/conferencesandevents.

In Otolaryngology

Details at www.entnet.org/conferencesandevents.

January 13-14 AACE Advances in Thyroid Cancer Diagnosis and Therapy

January 15-18 10th GCC Otorhinolaryngology HNS Conference

January 18-19 AACE Advances in Thyroid Cancer Diagnosis and Therapy

February 2-3 ACS Thyroid and Parathyroid Ultrasound Skills-Oriented Course

February 8-9 81st Midwinter Research Study Club of Los Angeles Recent Advances in Otolaryngology—Earn up to 16 CME Credits

February 14-17 2013 Advanced Techniques in Endoscopic Sinus Surgery

February 15-17 19th Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring

February 16-19 UCSF/Tripler Pacific Rim Otolaryngology Head and Neck Surgery Update Conference

February 16-19 The UC Irvine 2013 Otolaryngology Updates, 28.0 AMA PRA Category 1 CreditsTM

February 16 Head & Neck Radiology Bootcamp, 3.25 AMA PRA Category 1 CreditsTM

February 17 The Fourth Annual Injectable Fillers and Neuromodulators Course, 3.25 AMA PRA Category 1 CreditsTM

Mack’s Earplugs

Dr. Royer on post-operative ICU rounds caring for a 25-year-old patient after resection and pectoralis flap reconstruction of a large facial mass.

Surgical Humanitarian Trip to Moi University Teaching and Referral Hospital, Eldoret, Kenya

Mark C. Royer, MD My recent surgical outreach trip to Moi University Teaching and Referral Hospital (MTRH) in Eldoret in western Kenya was a continuation of the strong relationship that has developed between the otolaryngology departments at MTRH and Indiana University School of Medicine (IUSM), Indianapolis, IN, as part of the institution-wide partnership, the IU-Kenya Program. The otolaryngology relationship commenced when Susan R. Cordes, MD, traveled to Eldoret to search for ways the IUSM otolaryngology department could develop an international presence. Since this initial visit, Dr. Cordes and surgeons from our department have taken part in several surgical and teaching trips. I was fortunate to be included in the February 2012 trip and performed a variety of otolaryngology procedures including pediatric cleft lip and palate repairs, osteosarcoma resection with pectoralis flap reconstruction, endoscopic sinus surgery, and various otologic procedures. The physician team consisted of four from IUSM— Dr. Cordes (residency program director), Taha Z. Shipchandler, MD, (facial plastics and reconstructive surgery), Charles W. Yates, MD (neurotology), and myself (PGY-5), andKimberly Rutherford, MD (PGY-5, University of Connecticut). In addition to seeing patients in clinic and performing surgeries, Dr. Rutherford and I spent time teaching Moi University medical students. During this trip, I especially enjoyed the camaraderie between the IUSM team and the Kenyan otolaryngologists, meeting patients and their families from all across western Kenya, and developing the requisite problem-solving skills necessary to perform complicated procedures within the limitations of developing world operating rooms. A highlight of the trip was again seeing and working with my friend, Henry N. Nono, MD, a Moi University otolaryngologist, who was awarded an AAO-HNSF International Visiting Scholarship to attend the AAO-HNSF 2011 Annual Meeting & OTO EXPOSM and spent several weeks with the IUSM otolaryngology department. With our support, Dr. Nono hopes to complete a head and neck fellowship to increase the acuity of care he can provide for patients in western Kenya. The IUSM-Moi otolaryngology partnership continues to develop the scope and patient care abilities for the future. I look forward to participating in and supporting these efforts for years to come. Many thanks to the AAO-HNSF Humanitarian Efforts Committee and the Alcon Foundation, for their support which made my participation in this trip possible.

Dr. Dilyana Vicheva, Bulgaria (L), and Prof. Haruo Takahashi, Japan, at Belinov Symposium.

Academy Highlights Success: Changes in Coding and Reimbursement for ENT Services in 2013

It is critical that Academy members keep in mind that maintaining value for otolaryngology-head and neck surgery services is an enormous success in light of the rigorous review and cost-saving focus of both the AMA RUC and CMS. Therefore, the Academy is pleased that we were able to maintain, or increase, relative value units for nearly all codes reviewed in the 2012 RUC cycle. The table below includes values approved by CMS for CY 2013. As was mentioned in the November 2012 edition of the Bulletin, members can expect several coding changes for ENT services in CY 2013. Many of these changes are discussed in our summary of the 2013 final Medicare Physician Fee Schedule, which is posted on the Academy website at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm. The Academy also provided comments to CMS on all provisions of the final fee schedule that affect our members, including the valuation information for 2013. Specific fluctuations in reimbursement for these services are demonstrated by the table below this article. The Academy participated either directly, or via comment and/or monitoring, in the development of recommendations to the AMA RUC for all of the following procedures. For several codes, such as the complex wound repair family of codes, the Academy was asked to collaborate with other specialty societies (e.g., American Society of Plastic Surgery and American Academy of Dermatology) to develop relative value and practice expense recommendations. Those recommendations are then reviewed by the AMA RUC and either approved or modified. CMS is then presented with the AMA RUC’s value recommendations and may either approve or modify the values for these services. They then post their final determinations in the final Medicare physician fee schedule final rule each year. In the event members have any questions regarding the above information or modifications to specific codes, please email us at healthpolicy@entnet.org.

Academy Summary of the Final CY 2013 Medicare Physician Fee Schedule (MPFS)

On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final Medicare physician fee schedule (MPFS) rule for calendar year (CY) 2013. The Academy submitted comments to CMS on the final rule, which can be viewed at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm#CL. Some key provisions finalized in the 2013 rule included: Medicare Sustainable Growth Rate (SGR) The Medicare law includes the standard statutory formula that will require (absent congressional intervention) a CMS projected reduction of 26.5 percent to the MPFS conversion factor (CF), which would result in a CF of $25.0008 in 2013. Contractors are required to issue fee schedule files to their participating physicians in their locality, which include the estimated SGR cut that you may receive. Since Congress has not taken action for 2013 to fix the SGR at press time, the contractors cannot show payment rates that assume the problem will be resolved until legislation has actually been passed to do so. Thus, the fee schedules from contractors may assume the SGR cuts to all services for 2013. As in previous years, however, it is expected that Congress will take action to avoid the impending cut due to the sustainable growth rate (SGR) before the January 1, 2013, deadline. Impact for Otolaryngology-Head and Neck Surgery Overall, our specialty fared well regarding the impact of policy changes within the Medicare physician fee schedule for CY 2013. Otolaryngology-head and neck surgery saw a 2 percent cumulative increase in allowed charges for 2013, but physicians may see fluctuations in the Practice Expense (PE) for some services due to several policy changes. Other related specialties that saw an increase were allergy, plastic surgery, and oral-maxillofacial. Unfortunately, audiology saw a slight decrease. Depending on the make up of services provided in your practice, the affects of these changes will vary in their effect on reimbursement rates. One modification in the final rule is the change in formula for determining a maximum interest rate for equipment-related PE RVUs. In addition, increases to some PE RVUs for otolaryngology-head and neck surgery services may also occur as a result of the last of a four year transition of the Physician Practice Expense Information Survey (PPIS) data used to calculate practice expense RVUs for services. Improving Valuation of the Global Surgical Package Since 1992, CMS has applied the concept of payment for a global surgical package under the PFS. This means that for each surgical procedure, they establish a single payment, which includes payment for all related services typically furnished by the surgeon providing the procedure during the global period. The global surgical package payment rate is based on the work necessary for the typical surgery and related pre and post-operative work. CMS noted that different methodologies have been used in valuing global surgical services and more recently reviewed codes tend to have fewer evaluation and management (E/M) visits in their global periods. They observed that codes reviewed less recently did not appear to have the full work RVUs of each E/M service in the global surgical package, resulting in inconsistent numbers of E/M visits during the post-operative period across families of procedures. Under current policy, a surgeon is not required to document in the medical record what level of E/M visit is provided. CMS believes this practice makes it difficult to determine whether the number and type of visits provided in association with a surgical procedure is appropriate. As a result, CMS requested input in the proposed rule on how best to obtain accurate and current data on E/M services typically furnished as part of a global surgical package. Within the final rule they received a wealth of public feedback regarding methods to verify the number of E/M services provided within the global surgical period. In response, CMS stated it will carefully review and consider all input provided by commenters, and did not finalize any new requirements for tracking or reporting E/M visits associated with the global surgical period for CY 2013. The Agency was clear, however, that it intends to finalize new requirements during CY 2014 rulemaking. Potentially Misvalued Services Under the Fee Schedule Within the final rule, CMS identified 16 Harvard valued codes with annual allowed charges of greater than or equal to $10 million that warrant review as potentially misvalued services. Of these 16 codes, five were already scheduled for RUC review in 2012 and four had been referred to the CPT Editorial Panel. For the remaining codes, CMS stated that they are such low volume codes it may make gathering information on physician work and direct PE inputs difficult via the usual survey method. Given this, CMS encourages use of valid and reliable alternative data source to develop recommended values. Three of these codes had minor Otolaryngology use, including: 66180 Implant eye shunt; 67036 Removal of inner eye fluid; and 67917 Repair eyelid defect. The Academy staff and RUC team will monitor the review process for these procedures and determine if direct Academy involvement is warranted. Validating RVUs of Services Under the Affordable Care Act (ACA), CMS was directed to validate a sampling of RVUs for services. RAND and the Urban Institute will research processes for validating RVUs for potentially misvalued codes under the PFS. CMS notes they will provide additional detail on the validation contracts in future rulemaking. In the past, the Academy has expressed concern about the Agency’s engagement of an outside contractor and strongly urged CMS to be transparent with this process. Therapy Caps and Changes to Reporting Requirements for Therapy Services in 2013 CMS announced the therapy cap amounts for CY 2013, $1,900 for occupational therapy services and $1,900 for combined physical therapy and speech-language pathology services. CMS also finalizes several key changes to reporting requirements associated with the provision of therapy services, including speech-language pathology services, with a test phase starting January 1, 2013, with non-payment enforcement starting on July 1, 2013. For more details on the new reporting requirements, see the Academy’s summary online. Physician Quality Reporting System (PQRS) CMS includes many overarching changes to the PQRS system, with highlights of those potentially affecting Academy members below: Changes to Group Reporting: CMS changes the definition of a “group practice” from 25 or more eligible professionals to two or more eligible professionals. Modification of Reporting Periods: CMS allows the continuation of a 6 month reporting period (July 1–Dec. 31) for reporting measures groups via registry in 2013 and 2014 only. Satisfactorily reporting for 2013 and 2014 to avoid penalties in 2015 and 2016: CMS will allow individuals and group practices to report only one PQRS individual measure or one measures group to avoid the 2015 and 2016 penalty adjustment. The penalty adjustment will be a -1.5 percent in 2015 and -2 percent in 2016 and subsequent years. Individual Quality Measures: CMS added 13 new measures for reporting individual quality measures in 2013 and 45 new individual measures for 2014. However, the newly approved “Adult Sinusitis” measures were not included in any of their proposals. Physician Compare CMS finalized lowering the threshold of patients for reporting PQRS quality measures under the group practice reporting option to 20 beginning in 2013. This data is used to compile the published performance rates posted on the Physician Compare website. CMS finalized a policy allowing the reporting of measures that have been developed and collected by specialty societies to be reported on Physician Compare. CMS notes that they have begun to include physician information, such as successful participation in the Medicare E-prescribing (eRx) Incentive Program and PQRS. CMS also plans to publish additional information, a list of which is available in the Academy’s summary available online. Electronic Prescribing (eRx) Incentive Program CMS finalized reducing the minimum group practice size for participation in the eRx incentive program from 25 to two Eligible Professionals (EPs) for 2013. This is consistent with changes to the PQRS program for 2013. Groups of two to 24 EPs who wish to participate must have reassigned their Medicare billing rights to a single TIN to be eligible. CMS reduced the eRx reporting threshold for groups to 75, rather than the proposed 225, meaning groups of 2-24 will have to report the eRx numerator code during a denominator-eligible encounter at least 75 times from January 1 through December 31, 2013. CMS also lowered the 2014 reporting threshold for groups during the six month reporting period to 75. Value-Based Payment Modifier Beginning January 1, 2015, the ACA requires the Secretary to establish a value-based payment modifier (incentive or penalty) to specific physicians and groups of physicians. The incentive or penalty is based on measuring quality of care furnished as compared to cost of that care for Medicare beneficiaries with certain chronic conditions. The agency will begin a three year phase-in of the program that would apply the incentive or penalty (up to potential -1 percent) in 2015 based on 2013 performance for groups of 100 or more providers. CMS proposes that incentives or penalties in 2016 based on 2014 performance for groups of 100 or more providers. The program is voluntary the first two years, but not later than 2017, the value-based payment modifier will apply to all physicians, regardless of group size. Physician Feedback Reporting Program As part of the Value Based Payment Modifier program, the Secretary is required to provide Physician Feedback reports to providers that measure the resources used in providing care to beneficiaries and the quality of care. In 2013, CMS plans to circulate reports to all groups of physicians with 25 or more EPs (based on their TINs) and to individual physicians that satisfactorily reported measures through PQRS in 2012 regarding their performance on 15 administrative claims based measures. Finally, in the fall of 2014, CMS plans to issue reports based on 2013 data that show the amount of the VBP modifier, and the basis for its determination, to groups with 25 or more EPs. CMS will consider issuing reports to groups of less than 25 professionals, as well as individual professionals, in the future. For a more detailed summary on the final requirements for the programs highlighted above, visit the Academy’s CMS Regulations and Comment letter page at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm#CL or email Academy staff at HealthPolicy@entnet.org.

A New Year, a New Congress

January is a month of new beginnings. As such, when the 113th Congress convenes this month it will face many of the same issues, but in a slightly altered environment. Read on to learn more about some of the AAO-HNS federal legislative priorities, and what we can expect in the coming year. Healthcare Reform Although the results of last year’s elections failed to provide a clear outlook for what will be accomplished in the 113th Congress, they did finally confirm that the Affordable Care Act (ACA) is here to stay. It is unlikely that the Republican-controlled U.S. House of Representatives will continue efforts this year to pass legislation fully repealing the ACA. Instead, efforts will shift toward developing legislation designed to modify and/or improve the ACA. In particular, members of the U.S. House will likely renew efforts to repeal individual provisions from the ACA that have lacked popularity within the Chamber. The most notable example is the Independent Payment Advisory Board (IPAB). The IPAB, a brainchild of U.S. Senator Jay Rockefeller (D-WV), which charges an “independent” board with developing recommendations to reduce costs within the Medicare program, has many critics in the House. In addition, the IPAB is widely opposed by various stakeholders, including the AAO-HNS and a vast majority of national physician organizations. In the 112th Congress, legislation (H.R. 452) to repeal the IPAB garnered broad bipartisan support, but closed-door politics prevented the bill from receiving a “stand-alone” floor vote. It is likely that IPAB repeal will remain a top priority in the U.S. House this year. However, while the President and many members of the Senate continue to herald the importance of the IPAB, the overall success of repeal efforts will remain difficult. Scope of Practice The AAO-HNS has long been at odds with the audiology community regarding physician referral requirements within the Medicare program. For years, the American Academy of Audiology (AAA) has sought passage of federal legislation that would provide audiologists with unlimited direct access to Medicare patients without a physician referral. Although the AAO-HNS has, at times, engaged AAA in an effort to negotiate our varying positions, our organizations remain in disagreement on this particular issue. In the 112th Congress, the AAO-HNS was successful in mitigating support for the direct access bill (H.R. 2140). However, strategic changes in the audiology community and developments in the latter part of 2012 have altered our course on this issue and increased the likelihood that direct access will reign as our top specialty-specific priority in the 113th Congress. In November 2012, two direct access-related announcements were made. First, AAA issued a statement publicizing a “study” that claimed providing direct access would result in $240 million in savings to the Medicare system over 10 years. The result of the study, which was commissioned by the AAA, presumes a “preventative savings” and directly contradicts previous reports regarding direct access, including a 2007 report by the Centers for Medicare and Medicaid Services that concluded direct access would actually increase costs for the federal government. In the same week, the Academy of Doctors of Audiology (ADA) announced their “18 By 18” campaign, a comprehensive effort to obtain a “limited license physician” status by amending Title XVIII (18) of the Social Security Act to provide for the treatment of audiologists as “physicians” for purposes of furnishing audiology services under the Medicare program, and to provide for a broadened scope of audiology services available for coverage under the Medicare program. Given passage of the ACA and the President’s subsequent reelection, there is a slightly more favorable environment on Capitol Hill regarding efforts to expand access to nonphysician healthcare providers to help fill “gaps” in care. The AAO-HNS will be aggressive in the 113th Congress to ensure new and returning Members of Congress are well educated in regard to the potential dangers and patient safety concerns associated with direct access. Medicare Physician Payment Overall, Members of Congress continue to support the notion of reforming the Medicare physician payment system. However, efforts to repeal the flawed Sustainable Growth Rate (SGR) formula continue to elude Congress due to the exorbitant cost associated with full repeal. At the time of printing, Congress had not yet acted to avert the 26.5 percent cut in Medicare physician payments scheduled to take effect on January 1, 2013. Since Medicare physician payments continue to cause instability in the Medicare system, it is still possible that substantial reform and/or repeal of the SGR may be included in a broad deficit reduction plan. The physician community, including the AAO-HNS, has put forth principles by which a new system should be based. An optimist could conclude that reform of the system is perhaps more likely to occur in the 113th Congress than in the last several years. Medical Liability Reform The AAO-HNS has long supported comprehensive medical liability reform efforts. However, the politicized nature of the issue has prevented any meaningful progress from being made. In the 113th Congress, discussion regarding medical liability reform may increase due to ongoing efforts to develop a robust deficit reduction plan. However, the focus of reform discussions may shift away from standard “cap” legislation to include a more diverse “menu” of reform mechanisms, perhaps including medical courts, safe harbor exceptions, alternative dispute resolution plans, and further exploration of “disclosure and offer” programs. Graduate Medical Education Funding Due to the heightened fiscal scrutiny anticipated in the 113th Congress, the AAO-HNS expects some Members of Congress and the Administration to continue putting forth proposed reductions in Graduate Medical Education (GME) as a means to reduce costs within the Medicare program. The continued attacks on GME come with some level of irony given well-documented instances of physician shortages across the nation. The AAO-HNS and others in the physician community will continue to aggressively promote the importance of (at least) maintaining existing GME funding levels in the 113th Congress. If you would like more information regarding AAO-HNS federal legislative priorities, please email legfederal@entnet.org. In addition, to receive timely updates on the aforementioned federal issues, as well as state legislative priorities and grassroots programs, AAO-HNS members are encouraged to join the ENT Advocacy Network. To join, email govtaffairs@entnet.org.

ENTPAC As a Resource

ENT PAC, the political action committee of the AAO-HNS, financially supports federal congressional candidates and incumbents who advance the issues important to otolaryngology–head and neck surgery. ENT PAC is a non-partisan, issue-driven entity that serves as your collective voice on Capitol Hill and helps to increase the visibility of the specialty with key policymakers. To learn more about ENT PAC, visit www.entpac.org (log-in with your AAO-HNS ID and password).

Stay Informed: Bookmark the AAO-HNS Legislative and Political Affairs Webpage

Do you want to be one of the first to know the status of healthcare bills moving through Congress or your state? Bookmark the Legislative and Political Affairs webpage today! By visiting the webpage, you can learn more about the issues affecting the specialty, including the flawed Sustainable Growth Rate (SGR) formula, medical liability reform, scope-of-practice battles, Graduate Medical Education (GME) funding, truth-in-advertising initiatives, and efforts to repeal the Independent Payment Advisory Board (IPAB). Visit www.entnet.org/advocacy.

Opportunity Awaits: Attend the 2013 BOG Spring Meeting & OTO Advocacy Summit

Don’t miss the opportunity to utilize a rewarding free AAO-HNS member benefit. Plan to attend the 2013 BOG Spring Meeting & OTO Advocacy Summit! The BOG Spring Meeting, scheduled for Sunday, May 5, through Monday, May 6, is a great chance for members to be more involved with the Academy’s Board of Governors and learn more about the BOG committee system by observing such meetings as the BOG Socioeconomic & Grassroots Committee, the BOG Legislative Representatives Committee, and the BOG General Assembly. In addition, BOG meeting attendees have the option to attend workshops on various topics helpful to otolaryngology–head and neck surgery practices, participate in leadership training sessions, hear from keynote speakers, and network with other AAO-HNS members. Following the conclusion of BOG activities, the OTO Advocacy Summit will immediately commence the afternoon of Monday, May 6, and conclude Tuesday, May 7, with pre-scheduled meetings on Capitol Hill. This advocacy-focused meeting provides members with an ideal opportunity to directly lobby the new 113th Congress on behalf of the specialty. Other advocacy activities include an in-depth briefing with insider knowledge on the Academy’s priority legislative issues, including Medicare physician payment, truth in advertising, audiology direct access, GME funding, and comprehensive medical liability reform. AAO-HNS members also will have an opportunity to discuss key strategies to effectively communicate in their Capitol Hill meetings and be equipped with key talking points to fully brief members of Congress and/or Congressional staff on the legislative issues important to the specialty. Finally, attendees will learn more about ENT PAC, the political action committee of the AAO-HNS. ENT PAC is one of the main advocacy resources available to Academy members to help increase the visibility of the specialty with federal legislators and candidates. AAO-HNS members will be briefed on various ENT PAC initiatives that have carried over from 2012, including the Fundraising & State Membership Challenge and our exclusive Leadership Club levels. 2013 Leadership Club members are also invited to attend an exclusive ENT PAC event. Mark your calendars today for the 2013 BOG Spring Meeting & OTO Advocacy Summit—May 5-7, 2013, in Alexandria, VA, and Washington, DC. Online registration for both the BOG Spring Meeting and the OTO Advocacy Summit, a free AAO-HNS member benefit, will open in February 2013. A limited number of travel grants will be available for residents. For additional details, visit http://www.entnet.org/BOG&Summitt.

How a Medical Student’s Cranial Nerve Numbering System Led to Widespread Inaccuracies in Modern Anatomical Illustrations

Eduardo C. Corrales, MD, for the Otolaryngology Historical Society In 1778, Thomas Soemmerring, a 23-year-old medical student in Goettingen, Germany, described in his dissertation the cranial nerve numbering (I–XII), which remains in common use today. His system was based on the rostro-caudal exit points of the nerve roots from the brain. Limited by naked eye observation and poor preservation, errors were made in the rank order. The abducens nerve (VI) actually exits in the groove between the pons and medulla just rostral to the glossopharyngeal nerve (IX) and well caudal to the facial (VII) and audiovestibular nerves (VIII). To further complicate things, modern microscopic observation shows the facial nerve actually exits the pons caudal to the audiovestibular nerve. The weight of authority of this classical numbering system led generation after generation of textbook authors and their illustrators to distort human anatomy to fit with the traditional rank order. Depictions of the ventral surface of the brain and brainstem, with rare exceptions, show the exit order of abducens-facial-auditory-glossopharyngeal rather than the anatomically correct auditory-facial-abducens-glossopharyngeal. For more than 200 years, drawings have been distorted to make anatomy conform to the universally accepted numbering system. Early in medical school, physicians are taught that there is nothing left to be discovered in gross anatomy. The numbering system has been impressed upon beginning medical students, often memorized with the aid of colorful mnemonics, and thus becomes deeply engrained. In a culture that routinely questions the validity of scientific principles, physicians tend not to doubt the correctness of a well established truth such as the numbering of the cranial nerves. While it is always difficult to go against entrenched dogma, it is worth noting that legions of anatomists chose to alter reality rather than rise to this challenge. This article is based on the paper, co-authored by Robert K. Jackler, MD, and Albert Mudry, MD, PhD, and presented by Dr. Corrales at the Otolaryngology Historical Society meeting, September 10, 2012. If you are interested in presenting at the next OHS meeting, Vancouver, BC, Canada, September 30, 2013, email museum@entnet.org.To join the society or renew your membership, please check the box on your Academy dues invoice or email Catherine R. Lincoln, CAE, MA (Oxon) at clincoln@entnet.org or call 1-703-535-3738.

Standards for Trustworthy Clinical Practice Guidelines (CPG)

Table 1. Standards for Trustworthy Clinical Practice Guidelines (CPG) Standard Institute of Medicine (IOM)1 Guidelines Interational Network2 Methods and Scope The processes by which a CPG is developed and funded should be detailed explicitly and be publicly accessible. A guideline should specify its scope and objective and clearly describe the methods used for development in detail. Conflict of Interest (COI) Prior to selection of the guideline development group (GDG), individuals should declare, in writing, all interests and activities potentially resulting in COI; management of COI includes divestment and exclusions. A guideline should include disclosure of the financial and nonfinancial COIs for members of the GDG and should also describe how any identified conflicts were recorded and resolved. Guideline Development Group (GDG) Composition The GDG should be multidisciplinary and balanced, comprising methodological experts, clinicians, and populations expected to be affected by the CPG; patient and public involvement should be facilitated by including (at least at the time of clinical question formulation and CPG review) a current or former patient and a patient advocate or patient.consumer organization representative in the GDG. A GDG should diverse and relevant stakeholders, such as health professionals, methodologists, experts on a topic, and patients. Evidence Reviews CPG developers should use systematic reviews that meet standards set by the IOM. Guidelines developers should use systematic evidence review methods to identify and evaluate evidence. Decision-making Process Not specified A guideline should describe the process used to reach consensus among the panel members and, if applicable, the sponsoring organization; this process should be established a priority. Recommendation Wording Recommendations should be articulated in a standardized form detailing precisely what the recommended action is an under what circumstances it should be performed; strong recommendations should be worded so that compliance can be evaluated. A guideline recommendation should be clearly stated and based on scientific evidence of benefits, harms, and, if possible, costs. Recommendation Strength Reach recommendation should have a clear description of potential benefits and harms, a summary of relevant available evidence (quality, quantity, consistency), an explanation of the part played by other factors (values, opinion, theory, clinical experience), a rating of the level of confidence in (certainty regarding) the evidence, a description and explanation of any differences of opinion, and a rating of recommendation strength. A guideline should use a rating system to communicate the quality and reliability of both the evidence and the strength of its recommendations. External Review External reviewers should comprise a full spectrum of relevant stakeholders; reviews should be kept confidential; the GDG should consider all reviewer comments and keep a written record of disposition; a draft of the CPG should be made available to the general public for comment. Review by external stakeholders should be conducted before guideline publication. Updating The CPG publication date, date of evidence review, and proposed date for future CPG review should be documented in the CPG; literature should be monitored regularly and the CPG updated when new evidence suggests a need for modification. A guideline should include an expiration date and/or describe the process that the GDG will use to update the recommendations. Financial Support Not stated. A guideline should disclose financial support for the development of the evidence review and guideline recommendations.

Third Edition of AAO-HNSF Guideline Development Manual Published

Henry Nono, MD, International Visiting Scholar, and Susan Cordes, MD, at Moi Teaching and Referral Hospital, Eldoret, Kenya, February 2012.

After All, We Are All Humanitarians

Susan R. Cordes, MD, Vice chair, BOG Legislative Representatives Committee and chair, WIO Section It is human nature to be concerned about the welfare of others, and physicians seem to have a few exclamation points after the humanitarian gene. It sounds like a cliché when people say they want to be a doctor so they can help people, but it’s so true. We went to medical school and made countless personal and financial sacrifices so we could help other people through a profession that is known for altruism and compassion. Ask physicians who go overseas on humanitarian trips why they do it and a common answer is because it reminds them of why they went into medicine in the first place. Stripped of the paperwork, rules, regulations, and bureaucracy that come with practicing medicine in the United States, it is the opportunity to practice medicine at the core of what it is all about—caring for patients. Not every physician who wants to help is ready or able to jump on a plane to a far-away underdeveloped country, but there are many other ways to get involved in humanitarian efforts without ever leaving the office. For instance, the next time you trade in for new equipment, consider asking if the old equipment can be donated to an otolaryngology mission. Old, out-of-date equipment is often state-of-the-art and highly useful in a developing country. If you don’t know someone personally to give the equipment to, the Academy’s humanitarian efforts staff can facilitate getting the equipment to otolaryngologists traveling overseas. Another opportunity to help is through the Millennium Society. Your gift can be designated to benefit humanitarian outreach. Such money is used for a multitude of valuable programs, including grants allowing residents to participate in a mission trip. The benefits gained from your donation are exponential when you fund young, impressionable residents who will likely then participate in humanitarian efforts throughout their careers. Millennium Society gifts can also be used to fund a young otolaryngologist from a developing country to attend the AAO-HNSF Annual Meeting & OTO EXPOSM and gain experience in a U.S. otolaryngology program through the International Visiting Scholarship Program. Additional opportunities exist through Academy involvement. Consider joining the Humanitarian Efforts Committee. In addition to sponsoring miniseminars, this committee reviews resident travel grants, is working on a searchable database, has created disease-specific focus groups to develop best practices in humanitarian otolaryngology, and is involved in a host of other worthwhile activities. See more about the AAO-HNS/F Humanitarian Grant Winners in the March issue. By donating to the ENT PAC and/or attending the BOG Spring Meeting and the OTO Advocacy Summit May 5-7, 2013, we can advocate for the future of our specialty and preserve our ability to participate in humanitarian work. Increasing pressure from the government could threaten our financial ability to take time away from our practices in the United States so we can assist patients and otolaryngologists in less fortunate parts of the world. We must do all we can to preserve the reputation of our profession as honest, compassionate, and ethical in spite of the mischaracterization that occasionally appears in the media or legislative debate. Or, maybe it’s time to take that plunge and go on a mission trip, but it is difficult to know where to begin. Again, the Academy is an excellent resource. The Humanitarian Efforts page of the Academy website includes practical information and opportunities. In every issue of the Bulletin, otolaryngologists recount their experiences and provide a glimpse into the range of opportunities available. Finally, there are numerous otolaryngologists who have been providing humanitarian care in the U.S. and abroad, and a simple email or phone call is sometimes all it takes to get the process underway. That first step can be a difficult one to take, but the results can be amazingly gratifying. As physicians, we are fortunate to provide direct care to people in the course of our daily work; it is truly a gift to have the means, knowledge, and skill to be able to help people in our own communities and around the world. We should be proud of ourselves for using our gift wisely, but with talent comes responsibility. How we respond to that responsibility is what makes us unique individuals, but one thing we all have in common is that, at the end of the day, we are all humanitarians.

Guideline for Guidelines

One of the most important advances the Academy has made to improve healthcare outcomes and fulfill its mission to empower physicians to provide the best healthcare has been the successful development and implementation of a process for creating relevant, valid, otolaryngology-specific evidence-based guidelines. Our published methodology, which has been cited by the Institute of Medicine (IOM) and the Council of Medical Specialty Societies (CMSS) in their work on guidelines, is just receiving its third revision and will be published this month as a supplement in our journal Otolaryngology–Head and Neck Surgery. The Academy first published its guideline methodology in the journal in October 2006, followed by an advanced and updated version in June 2009. Since the first issue, the Academy has been successfully building guidelines, applying them to quality improvement through performance measurement, and providing members and other practitioners with better tools to improve patient care. As Academy members and staff have presented at multi-disciplinary meetings on quality improvement, evidence-based medicine, and performance measures thoughout the years, we have frequently made copies of our methodology available to other specialties, international participants, and even allied health provider groups. Our approach was highly regarded and the number of copies was always insufficient to meet the demand. Over time, we have been complimented and cited for the principles contained therein that are essential to effective use of guidelines for improving care. In 2008, the U.S. Congress passed the Medicare Improvements for Patients and Providers Act (MIPPA), which required the IOM to undertake a study of guideline development and to make recommendations for better application of medical knowledge to improve patient care. The IOM committee’s work in response to the MIPPA was published in March of 2011, outlining eight standards for creating rigorous, trustworthy clinical practice guidelines (CPGs). The report, “Clinical Practice Guidelines We Can Trust,” called upon the Agency for Healthcare Research and Quality (AHRQ) to engage in demonstrations of the application of these standards to assess their validity and reliability. If you have not read it, at least a cursory review of these standards is important to understand the true value of guidelines—not as “cookbook medicine” or a prescriptive mandate for care; but as a useful tool for all physicians who daily face difficult decisions and uncertainty in their care of each patient. These standards can be found on the IOM’s website at www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspx and a short summary of the development of the IOM report is at www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx. During the course of the committee’s deliberations, its chair, Sheldon Greenfield, MD, expressed to Norman Kahn, MD, CEO of the Council of Medical Specialty Societies, his hope that the CMSS would engage its member societies (which represent nearly 750,000 specialist physicians in the United States) in creating their own statement of best practices for implementing these standards so that all guidelines developed could be relied upon to represent the best available care recommendations. CMSS took this charge seriously and assigned the CPG Component Group, which it convened to draft a white paper that would serve as a guide on which societies could model their methodology for CPG development. After nearly 18 months of collaboration and work this “guideline for guidelines” was presented in November 2012, and approved by the Council. The Academy’s Board of Directors voted to support this document and recognized that it mirrors most of the carefully crafted elements of our published methodology. It is well worth noting that both the IOM and the CMSS received input and testimony during their work from otolaryngologists and both entities cited the Academy’s published methods in their reports. As you read Otolaryngology–Head and Neck Surgery this month, I urge every Academy member to read the supplement on guideline methodology and become familiar with the motivation behind, and the purpose for, developing and implementing guidelines. Reference to the appropriate uses of guidelines and their limitations is made within the document. Key elements, such as including multiple specialties and perspectives in guideline development, transparency, avoiding and managing conflicts of interest, articulating strength of recommendations, and extensive external review are all critical to achieving the goal of effectively using guidelines to apply the best available evidence to patient care and achieving the best outcomes. I extend my personal thanks to the tireless volunteers on our Guidelines Development Task Force, reviewing committees, specialty societies, and staff who have built such a strong culture of quality improvement.

Planning for Relevance

No matter what we call it, the beginning of a new year is a natural time to renew commitments and revise our goals. And, as discussed in this column previously, the AAO-HNS/F begins this year with new guidance from its leaders who gathered in December to revise and renew our strategic plan. In preparation, we sent Board Members and other AAO-HNS/F leaders various materials for the strategic planning event, including the 2011 book, Race for Relevance: 5 Radical Changes for Associations. We based this year’s strategic planning on a system described by the book’s authors, Harrison Coerver and Mary Byers, CAE. The importance of being increasingly relevant to our Members had been brought to my attention as part of training for association presidents-elect and their CEOs. And, I believe this book to be a very useful and powerful assessment vehicle. Both authors present impressive knowledge of association management. Harrison Coerver is president of Harrison Coerver & Associates, a management consulting firm that specializes in strategy and planning for trade associations, professional societies, and other tax-exempt membership organizations. In the last 25 years, he has consulted with more than 1,200 associations on strategy, planning, governance, and management. His colleague, Mary Byers, is a former association executive, consultant, and professional speaker who specializes in facilitating strategic planning and organization-focused events. Together they have more than 40 years of experience working with associations. In their work, the authors researched emerging changes in the association environment and presented convincing case studies. Their book targets what associations need to be aware of to continue to provide member value in the future. Why Radical Change? Harrison Coerver, who agreed to facilitate our strategic planning sessions, and his co-author, make a strong case for bold changes that will be needed to sustain our organization now and in the future. In fact, the authors attest that while it was a given in the past for professionals to support their societies, renewing their membership yearly, volunteering within the society on boards, committees, and task forces, such loyalty has been severely constrained by changes in our world. The authors outlined three areas of environmental shift so basic that they shook up our economy and changed our society. They further pointed out that most of these changes evolved from advances in technology. Specifically, the things that have changed in all of our lives involve “Time” available and the pace of change, the “Expectations for Value,” the “Market Structure” in its consolidation and specialization, “Competition” from specialized sources, the “Generational Differences,” and a sea change in the nature of competition. What We Have Done Already and How We’ve Moved Forward Governance and Value—efficient, flexible, and relevant Fortunately, our Academy and Foundation have seen this shift coming and we have worked during the past several years to make some of the changes that will address the needs of our new age. These included assessing and reworking our governance systems and researching our value offerings with members. However, radical change requires more from us. And so we asked our leaders to read the book prior to our meeting. That book provided the foundation to make our strategic planning even more successful and our time more effective, efficient, and satisfying. We also asked them to complete and return a strategic planning matrix that addressed the “Related to Mission and Vision” and the “Competitive Advantage” areas. And they did. When we came together in December, the AAO-HNS/F leaders rated 36 programs for: their importance related to our mission and vision, and for their relative competitive advantage. It was not easy, especially when hard choices resulted in some assumptions not being realized, but with gratitude and respect for all of my colleagues’ efforts, I can say we reached a consensus for moving forward. The 2014 Plan As I write, our expert staff enthusiastically takes on the responsibility for moving the plan forward, transitioning our efforts to action plans and budgets. Tactics are being assigned and measureables set. In March, our boards will receive a draft of the budget for the plan that will be finalized during their May meeting and offered to you as the FY 2014 Budget in the June Bulletin. I hope you can see the determination and respect for each of you that your leaders bring to these activities. We act for you who care so deeply for our specialty and our patients’ health.

Oral, Head, and Neck Cancer Facts

Oral, Head, and Neck Cancer Facts www.OHANCAW.com What is OHANCAW? Oral, Head, and Neck Cancer Awareness Week© (OHANCAW©) is a weeklong series of events that aims to educate the p ublic about these potentially life-threatening, but eminently treatable cancers and to promote prevention, screening, and early detection. OHANCAW is highlighted by the free screenings and related activites at participating medical centers across the country. The screenings are quick, painless, and designed to advance early diagnosis, which can lead to better outcomes, OHANCAW is sponsored by the Head and Neck Center Alliance (HNCA). When is OHANCAW? The 16th annual Oral Head and Neck Cancer Awareness Week is April 14-20, 2013. The primary focus of our media efforts will be directed toward awareness activities occuring during this week, but HNCA is encouraging all supporters to pick a week during the year that works best for their group to host a free screening event. For more information, go to www.headandneck.org, email info@ohancaw.com or call 866-792-4622. Oral Cancer Facts Oral cancer is cancer that arises in the head or neck region, including the nasal cavity, sinuses, lips, mouth, thyroid glands, salvary glands, throat, or larynx (voice box). According to the American Cancer Society, an estimated 52,610 new cases of cancer of the oral cavity and throat, and an estimated 11,500 deaths from these cancers were expected in 2012. Signs and Symptoms Most oral cancers arise on the lips, tongue, or the floor of the mouth. They also may occur inside of your cheeks, on your gums, or on the roof of your mouth. Other head and neck canceres arise from the voice box or throat. Some signs and symptoms include: A sore in your mouth that doesn’t heal or that increases in size. Persistent pain in your mouth Lumps or white or red patches inside your mouth Difficulty chewing or swallowing or moving your tongue Soreness in your throat or feeling that something is caught in your throat Changes in your voice A lump in your neck Risk Factors Tobacco (including smokeless tobacco) and alcohol use are the most important risk factors for oral, head, and heck cancers, particularly those of the tongue, mouth, throat, and voice box. Eight-five percent of head and neck cancers are linked to tobacco use. People who use both tobacco and alcohol are at greater risk for developing these cancers than people who use either tobacco or alcohol alone. (Source: National Cancer Institute). Anyone can develop thyroid cancers, although a family history or exposure to radiation is often a factor. Salivary gland cancers do not seem to be associated with any particular cause. Human Papillomavirus (HPV) and Oral Cancer Researchers have attributed the increase of head and neck cancer incidence in young adults, a group traditionally at low risk, to the human-papillomavirs (HPV), a cancer-causing virus that can be transmitted through oral sex. Many studies support that oropharyngeal cancers – those affecting the tonsils, back of the mouth (throat), and base of the tongue – have been on the rise since the mid-1980’s. and currently 50 percent to 70 percent of these cases are caused by HPV infection. Many studies show that patients with HPV-positive oropharyngeal cancers are more responsive to treatment and have better survival rates then HPV-negative patients. Courtesy of the Head and Neck Cancer Alliance at www.ohancaw.com.

Take Part in Oral, Head, and Neck Cancer Awareness Week

The 16th Annual Oral, Head, and Neck Cancer Awareness Week© (OHANCAW©) is scheduled for April 14-20, 2013. Sponsored by the Head and Neck Cancer Alliance, OHANCAW is a weeklong series of events promoting awareness of this life-threatening, but treatable (if caught early) disease, highlighted by a day of free oral cancer screenings at medical offices, centers, and institutions throughout the country. All members can participate by conducting a free screening at their medical practice, clinic, hospital, or university. The Alliance supports screening sites by providing free materials, including posters, T-shirts, and media kits, to help set up and promote the activity. For more details, and to register to organize a free screening in your area, visit www.OHANCAW.com.

Patient Outreach: 10 Minutes That Could Save Your Life

Patient Outreach: 10 Minutes That Could Save Your Life Just because you can’t feel it, doesn’t mean it isn’t there. Just ask the more than 50,000 Americans who were diagnosed with cancers of the head and neck last year. Unfortunately, many Americans do not recognize the symptoms of these life-threatening diseases, which include cancers of the oral cavity, larynx, and pharynx, and by the time they are diagnosed, for some, it’s too late. Oral, head, and neck cancers claim nearly 12,000 lives each year. However, there is hope. If diagnosed early, these cancers can be more easily treated without significant complications, and the chances of survival greatly increase. Who Should Get Tested? Every adult should get tested. Tobacco and alcohol users traditionally have been considered the populations at greatest risk for these cancers. However, oral cancer cases are on the rise in younger adults who do not smoke, and recent research indicates this development is due partly to the increase of the human papillomavirus (HPV) virus, a cancer-causing infection that can be transmitted by oral sex. HPV-related oral cancers are more difficult to detect because these cancers usually occur on the back of the tongue or on the tonsils, providing even more reason to get screened regularly. What are the Potential Warning Signs of Oral Cancers? The signs and symptoms of oral cancer often go unnoticed. However, there are a few visible signs associated with these cancers that require immediate attention, including: A sore in your mouth that doesn’t heal or that increases in size Persistent pain in your mouth Lumps or white or red patches inside your mouth Difficulty chewing or swallowing or moving your tongue Soreness in your throat or feeling that something is caught in your throat Changes in your voice A lump in your neck Why Should I Get Screened? If the above stats weren’t reason enough, know that the screening is quick, painless, and free, and it’s right around the corner. Given the current state of the economy and rising healthcare costs, take advantage of the opportunity to benefit from this preventive health measure at no charge by taking 10 minutes to do something that could save your life. Early diagnosis and treatment improves outcomes and chances of survival, particularly for individuals with HPV-related oral cancers. If you have any of the above warning signs, do not wait for the free screenings. Seek medical attention immediately.

2012 Committee Highlights