Published: October 24, 2013

How to Advocate to Private Payers for Coverage of Appropriate Services

The Academy receives many requests to help individual members with issues regarding third-party payer coverage of otolaryngology procedures. There are numerous resources available on the Academy’s Practice & Advocacy web pages to help you approach your private payer to advocate for coverage and payment of appropriate services provided to your patient. Due to high priority national policy issues affecting the majority of members, (CMS policy changes, the rolling review of procedures at the AMA RUC for duplicative work, healthcare reform implementation, etc.), the Academy works to address payer coverage issues that affect many members. Based on time and resources available, the Health Policy department and the Academy’s Physician Payment Policy workgroup (3P) may offer assistance for issues affecting many members at the state or national level that have gone through the appeals process and are considered inappropriate based on the Academy’s policy statements and guidelines. Please take the time to first submit your claim and receive a response from the private insurer prior to contacting the Academy’s state otolaryngology society or state medical society to report the issue. Prior to contacting the Academy for any individual assistance, we ask that members try the steps below (also available on our website). Steps to follow to advocate to private payers for coverage of an appropriate service that you furnished: • Appeal the denial or bundling using the Academy’s policy statements, www.entnet.org/Practice/policystatements.cfm; CPT for ENT articles, www.entnet.org/Practice/cptENT.cfm; and Clinical Practice Guidelines, www.entnet.org/Practice/clinicalPracticeguidelines.cfm. • For payer issues you encounter on a state level, we recommend that you contact your state otolaryngology society or state medical society to report the issue, so they may assist you in its resolution. You can access the contact information for your state otolaryngology society at www.entnet.org/Community/BOGSocieties.cfm?View=State. (Log-in is required.) • For issues with payer reimbursement on a national level, contact the Academy’s Health Policy department at Healthpolicy@entnet.org. Once you report the issue, we will research it and determine whether we will follow up with the payer. • Contact our coding hotline at 1-800-584-7773 to assist you with your coding questions prior to submitting your claims. This service is free to AAO-HNS members. Additional Academy Resources Appeal template letters: www.entnet.org/Practice/Appeal-Template-letters.cfm: Sample letters to assist with denials News and updates: www.entnet.org/Practice/News-and-Updates-from-Private-Payers.cfm: Includes important updates on coverage policies for national private payers Other Resources  American Medical Association: (www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/practice-management-center.shtml) The AMA has established a useful third-party payer advocacy department that you can report coverage problems. Association of Otolaryngology Administrators (AOA): (www.oto-online.org) Practice management resources from the AOA. Medical Group Management Association: (www.mgma.com) Practice management resources from the MGMA.

The Academy receives many requests to help individual members with issues regarding third-party payer coverage of otolaryngology procedures. There are numerous resources available on the Academy’s Practice & Advocacy web pages to help you approach your private payer to advocate for coverage and payment of appropriate services provided to your patient.

Due to high priority national policy issues affecting the majority of members, (CMS policy changes, the rolling review of procedures at the AMA RUC for duplicative work, healthcare reform implementation, etc.), the Academy works to address payer coverage issues that affect many members. Based on time and resources available, the Health Policy department and the Academy’s Physician Payment Policy workgroup (3P) may offer assistance for issues affecting many members at the state or national level that have gone through the appeals process and are considered inappropriate based on the Academy’s policy statements and guidelines.

Please take the time to first submit your claim and receive a response from the private insurer prior to contacting the Academy’s state otolaryngology society or state medical society to report the issue. Prior to contacting the Academy for any individual assistance, we ask that members try the steps below (also available on our website).

Steps to follow to advocate to private payers for coverage of an appropriate service that you furnished:

• Appeal the denial or bundling using the Academy’s policy statements, www.entnet.org/Practice/policystatements.cfm; CPT for ENT articles, www.entnet.org/Practice/cptENT.cfm; and Clinical Practice Guidelines, www.entnet.org/Practice/clinicalPracticeguidelines.cfm.
• For payer issues you encounter on a state level, we recommend that you contact your state otolaryngology society or state medical society to report the issue, so they may assist you in its resolution. You can access the contact information for your state otolaryngology society at www.entnet.org/Community/BOGSocieties.cfm?View=State. (Log-in is required.)
• For issues with payer reimbursement on a national level, contact the Academy’s Health Policy department at Healthpolicy@entnet.org. Once you report the issue, we will research it and determine whether we will follow up with the payer.
• Contact our coding hotline at 1-800-584-7773 to assist you with your coding questions prior to submitting your claims. This service is free to AAO-HNS members.

Additional Academy Resources
Appeal template letters: www.entnet.org/Practice/Appeal-Template-letters.cfm: Sample letters to assist with denials

News and updates: www.entnet.org/Practice/News-and-Updates-from-Private-Payers.cfm: Includes important updates on coverage policies for national private payers

Other Resources 
American Medical Association:
(www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/practice-management-center.shtml) The AMA has established a useful third-party payer advocacy department that you can report coverage problems.

Association of Otolaryngology Administrators (AOA): (www.oto-online.org) Practice management resources from the AOA.

Medical Group Management Association: (www.mgma.com) Practice management resources from the MGMA.

More from July 2011 - Vol. 30 No. 07
The Role of Unconscious Bias in the Exam Room
Phyllis B. Bouvier, MD for the Diversity Committee In 1999, Congress requested that the Institute of Medicine assess the extent and source of racial and ethnic disparities and suggest interventional strategies. In 2002, the report, “Unequal Treatment,” confirmed that “racial and ethnic disparities in healthcare are not entirely explained by differences in access, clinical appropriateness, or patient preferences. Disparities exist in the broader historical and contemporary context of social and economic inequality, prejudice, and systemic bias.” Prejudice is an unjustified negative attitude and discriminatory behavior based on a person’s group membership.  Stereotypes are social categories people use in acquiring, processing, and recalling information about those we do not know as individuals. Stereotypes can be cognitive shortcuts, often used when we are short on time. Yet, even when stereotypes are evidence-based, they are likely to lead to disparities when the provider does not take into account the individual’s unique identifiers. Both stereotypes and prejudice are likely to produce negative outcomes. Unconscious (implicit) biases are thoughts that are outside of a person’s conscious awareness. They are habits of the mind, learned over time through repeated personal experience and cultural socialization. These beliefs are highly resistant to conscious change. An individual’s implicit evaluations may differ from their explicit beliefs (those beliefs that are verbalized).  In this situation, a person might hide private thoughts and attitudes from others. Or, a person may not be conscious of the existence of those thoughts and attitudes.  Research indicates that a discordance between a provider’s verbal and non-verbal responses leads to the assumption by the patient that the non-verbal response is indicative of the provider’s true attitude. Current disparity research is focusing less on the technical aspect of care (for instance which test or medication was ordered), and more on the interpersonal aspect of care (for example, expression of bias and cultural competence).  There is a strong relationship between provider interpersonal behavior and patient satisfaction, adherence, utilization, and outcomes. Multiple cultural influences shape a patient’s view toward healthcare, as well as the patient’s past experiences with healthcare providers. Our cultural perspective automatically and unconsciously influences the way we perceive others and behave toward them and in turn this influences the way we interpret their behaviors.  Similarly, the patient brings his own set of expectations, beliefs, and behaviors to the encounter. It is important to find out your own attitude, awareness, and sensitivity to cultural differences. According to research, there is evidence that racial and ethnic minority groups are more likely to perceive bias and lack of cultural competence when seeking treatment in the healthcare system than Caucasian patients, even when controlling for demographic factors, health literacy, self-rated health status, and source of care. The provider may demonstrate the potential for unconscious bias in the questions asked during determination of the appropriateness of treatment. For instance, the provider may believe that the patient’s behavioral characteristics make him more or less appropriate for a particular treatment, service, or procedure.  They may unconsciously confirm this belief/bias through the questions they ask or don’t ask. Project Implicit was developed in 1998 as a virtual laboratory examining the issue of implicit bias with its use of the Implicit Association Test (https://implicit.harvard.edu/). This test can be used to measure those unconscious beliefs that exist outside our awareness and control, and which may be divergent from our conscious beliefs. Findings of this research include: 1. Implicit biases are pervasive. 2. People are unaware of their implicit biases. 3. Implicit biases predict behavior, and those who test higher in implicit bias have been shown to display greater discrimination. 4. People differ in levels of implicit bias, since bias can be affected by your particular group membership, dominance of your group in society, and experiences. Implicit attitudes tend to be resistant to deliberate change, but cognitive biases may not have the same constraints and may be amenable to change. What can you do to rid yourself of an undesirable bias? Experts recommend first creating social conditions that allow new learning experiences. Then, be vigilant since the bias may enter when least expected into your judgments and actions. Consciously create an action plan to compensate for the bias. Focus on patients in terms of their unique qualities rather than as belonging to a certain population. Build a partnership with the patient by acknowledging and understanding his or her cultural diversity, by showing respect for the patient’s health beliefs and practices, and by valuing cross-cultural communication. This type of patient centered care has the goal of eliminating disparities and can lead to what Melanie Tervalon describes as “cultural humility”:  a lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations. References 1. Avey H.  Health Care Providers’ Training, Perceptions, and Practices Regarding Stress and Health outcomes.  Journal of the National Medical Association.  2003; 95(9): 833-845. 2. Banaji M.  The Social Unconscious.  Blackwell handbook of Social Psychology:  Intraindividual Processes.  Ed. Tesser and Schwarz.  2002.  Chapter 7:134-158. 3. Burgess D.  Reducing Racial Bias Among Health Care Providers:  Lessons from Social-Cognitive Psychology.  Society of General Internal Medicine.  2007; 22:882-887. 4. Burgess D.  Why Do Providers Contribute to Disparities and What Can Be Done About It?  J Gen Intern Med.  2004; 19: 1154-1159. 5. Cohen G.  Reducing the Racial Achievement Gap:  A Social-Psychological Intervention.  Science.  2006; 313:1307-1310. 6. Cooper L.  Delving Below the Surface:  Understanding How Race and Ethnicity Influence Relationships in Health Care.  J Gen Intern Med.  2006; 21:S21-27. 7. Johnson RL.  Racial and Ethnic differences in Patient Perceptions of Bias and Cultural Competence in Health Care.  JGIM.  2004; 19: 101-110. 8. Kai J.  Professional Uncertainty and Disempowerment Responding to Ethnic Diversity in Health Care:  A Qualitative Study.  PLoS Medicine.  2007; 4(11):  1766-1776. 9. Nosek B.  Moderators of the Relationship Between Implicit and Explicit Evaluation.  Journal of Experimental Psychology:  General.  2005; 134(4):  565-584. 10. Project Implicit. http://projectimplicit.net/ 11. Tervalon, M. et al.  Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education.  J Health Care Poor Underserved.  1998; 9(2):  117-125. 12. Tucker Smith C., Nosek B.  implicit Association Test. I.B.Weiner & W.E.Craighead (Eds.), Corsini’s Encyclopedia of Psychology, 4th edition (pp.803-804).  Wiley. 13. Van Ryn M.  Paved With Good Intentions:  Do Public Health and Human Service Providers Contribute to Racial/Ethnic Disparities in Health?  American Journal of Public Health.  2003; 93(2):248-255. 14. Washington D.  Transforming Clinical Practice to Eliminate Racial-Ethnic Disparities in Healthcare.  J Gen  Intern Med.  2007; 23(5):685-91.
Imaging Committee: Health Policy, Advocacy, and Quality Updates
Gavin Setzen, MD Chair, Imaging Committee, and Udo Kaja The Imaging Committee continues to educate members on CT imaging policy as well as provide guidance and expert opinion on topics in Quality Improvement. Also, the committee tracks and provides input on government policy and regulations related to imaging, insurance carrier policy, and coverage for imaging services. Recently, the committee has been engaged in various quality and advocacy endeavors, which are detailed below. • Providing feedback on American College of Radiology (ACR) Appropriateness Criteria (www.acr.org/ac.aspx): According to the ACR, “the ACR Appropriateness Criteria® are evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. By employing these guidelines, providers enhance quality of care and contribute to the most efficacious use of radiology.” Expert panels in diagnostic imaging, interventional radiology, and radiation oncology developed the guidelines. Each panel included leaders in radiology and other specialties. (The ACR appointed Brian Nussenbaum, MD, as the AAO-HNSF representative to its Neuro-imaging section.) These criteria are significant because health policy makers, and insurers will most certainly use them to develop coverage policies for imaging services. Also, our patients may use these guidelines as a source of medical information. Initially, Gavin Setzen, MD, chair of the Imaging Committee, reviewed the Appropriateness Criteria (AC) and selected seven that impacted our specialty. They are Headache; Sinonasal Disease; Vertigo and Hearing Loss; Sinusitis (Child); Orbits, Vision, and Visual Loss; Neck Mass/Adenopathy; Cerebrovascular Disease. Next, the Academy’s committees — Allergy, Asthma & Immunology, Equilibrium, Hearing, Pediatric Otolaryngology, Rhinology and Paranasal Sinus, and Skull Base Surgery – were asked to help with expertise in the selected areas that these seven AC covered. Also, the Subspecialty Advisory Committee (SSAC) was notified of the review of the AC to ensure that each of our subspecialties’ perspectives was considered. Through a collaborative and thorough process, the selected committees in conjunction with the Imaging Committee reviewed the AC and concluded whether they were restrictive and/or inappropriate. The committees’ input was delineated in a comment letter. On April 12, the Academy sent its official comments to the ACR, and we are waiting for its response. To view the comment letter, visit: http://www.entnet.org/Practice/Medicareupdates.cfm#IMGHPX. The Academy will continue monitoring development processes for  imaging criteria and other similar guidelines to ensure they adequately reflect current evidence-based medicine and contribute to improved quality and patient safety. • Reviewing the Patient Radiation Dose-Optimization Performance Measurement Set (www.ama-assn.org/resources/doc/cqi/radiation-dose-measurement-set.pdf): The Imaging Committee steadfastly ensures that our specialty’s voice is heard with regard to performance measures. Recently, it reviewed the Patient Radiation Dose Optimization Performance Measurement Set, which was created by the American Board of Medical Specialties (ABMS) and the Physician Consortium for Performance Improvement (PCPI) in collaboration with the American Board of Radiology (ABR) and the ACR. These groups formed a Patient Radiation Dose-Optimization workgroup to identify and define quality measures for implementation into Maintenance of Certification programs. Another reason for developing these measures was to improve health outcomes such as reducing patient harm, excessive radiation risks and exposures, procedural complications, morbidity, etc., for patients undergoing high dose imaging studies. After its review, the committee determined there were seven measures that would possibly impact otolaryngologist—head and neck surgeons. They are (number corresponds to its measure): 1. reporting to a radiation dose index registry 2. utilization of standardized nomenclature for CT imaging description 7. equipment evaluation for pediatric CT imaging protocols 8. utilization of pediatric CT imaging protocols 10. search for prior imaging studies 11. images available for patient follow-up 12. exposure times for procedures using fluoroscopy The committee concluded that these measures were appropriate and do not limit our ability to image our patients, and can increase quality and safety in CT imaging for children and adults. • CME for CT Imaging – Flagging of 2011 Annual Meeting Mini-Seminars and Instruction Courses: In order to fulfill its objective to identify educational activities with CME credits required for CT accreditation purposes, the Imaging Committee will flag miniseminars and instruction courses offered at the 2011 Annual Meeting program. There will be many CT-relevant CME opportunities relating to various anatomic regions of interest in the head and neck region, including paranasal sinus, temporal bone, skull base, and soft tissue imaging (neck) as well. For more information on these and other imaging health policy issues, contact Dr. Setzen at gavinsetzenmd@albanyentandallergy.com or Jenna Kappel at jkappel@entnet.org. Reminder: The Mandatory CT accreditation deadline of January 1, 2012, is rapidly approaching. In order to comply with federal law, and to ensure reimbursement for CT imaging services, apply now for CT accreditation at www.icactl.org.
Appeal Letter Template for Septoplasty
In response to the denials some members have received for CPT code 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), the Physician Payment Policy workgroup (3P) has drafted an appeal template letter that members may use to appeal these denials. This appeal template letter is also available at www.entnet.org/Practice/Appeal-Template-letters.cfm.This letter is generic and acts only as a guide to help you construct your appeal letter. You should use your company letterhead/logo and fill in the blanks and header information. Please remove the sections in the template letter that do not apply to your denial. We recommend that you also submit any other relevant supporting documents such as medical notes, operative reports, clinical indicators, etc. If you receive a denial for a septoplasty from United Healthcare, report this denial and the denial reason to healthpolicy@entnet.org or 1-703-535-3727. We encourage members to write us with relevant topics of interest in health policy and practice management. Please email us at healthpolicy@entnet.org. [Date] [Insurer Name] [Insurer Address] Re: Patient: [Name] Policy Number: Group Number: Claim Number: Date of Service: Dear [Medical Director]: Please consider this letter a formal request for reconsideration of a denial received for a septoplasty on [Patient’s Name] on [Date of Service] by [Name of Physician]. The [claim] [pre-certification] for the [septoplasty] was billed with CPT© code 30520 – Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft. If the pre-certification or the claim was denied because the patient’s condition was not chronic for more than two months or the patient did not have recurrent acute sinusitis, then you may include the text below in your template letter:  I disagree with [insurer name]’s denial of the septoplasty based on your logic that the [Patient Name]’s condition was not chronic for over two months or that [s/he] did not have recurrent sinusitis. According to current medical practice, it is more clinically appropriate to document nasal obstruction that persists despite reasonable medical therapy (e.g., four to eight weeks). As a result, I believe that [insurer name]’s denial of this procedure is not justifiable. If the pre-certification or the claim was denied because you did not include a photograph of the external nose, then you may include the text below in your template letter: I disagree with [insurer name]’s denial of this septoplasty as medically unnecessary for [Patient Name] because I did not include a photograph of the patient’s external nose. Photographs will often not show a clinically significant septal deviation; only caudal deviations will be evident and photos generally demonstrate external nasal deformities. As such, I believe that [insurer name]’s denial of this procedure is not justifiable. If the pre-certification or the claim was denied because you noted that the patient has a posterior septal deviation,  which causes a physiologic functional impairment, then you may include the text below in your template letter: Septoplasty corrects deformities of the partition between the two sides of the nose. I am enclosing the previously submitted claim [or pre-certification request], the Explanation of Benefits and operative notes. Please reprocess this [claim] [pre-certification] for the payment of CPT code 30520.  If you require additional information, please contact me at [Phone number]. Thank you for your prompt action. Sincerely, [Physician Name, MD] Enclosures: [insert number of enclosures] cc:  [Patient’s Name]
PSQI Mini-Program at the 2011 AAO-HNS Annual Meeting & OTO EXPO
Developed under the guidance of David W. Roberson, MD, Children’s Hospital Boston, and Rahul K. Shah, MD, assistant professor, Children’s National Medical Center, co-chairs of the PSQI Committee. Otolaryngologists must be prepared as payers, government, consumers, and medical/surgical Boards all increase their demand for documentation that we are measuring performance and taking steps to make improvement when necessary. This mini-program will include sessions focused on making patient safety a national priority, advancing programs that support clinicians and patients, and techniques for understanding and reducing medical malpractice risk. Tuesday, September 13, 2011 8 – 8:50 a.m. Miniseminar: Applying PSQI: Metrics and Moree Moderator: Rahul K. Shah, MD Presenters: Lee D. Eisenberg, MD, MPH; Brian Nussenbaum, MD; Scharukh Jalisi, MD 9 – 9:50 a.m. What’s New in Quality Improvement and What to Prepare For Moderator: Brian Nussenbaum, MD Presenter: Matthew A. Kienstra, MD 10 – 11:50 a.m. Apology and Disclosure Moderator: David W. Roberson, MD Presenters: Robert Hanscom, JD; David B. Troxel, MD; Linda Kenney; and Doug Wojcieszak
Quality, Research, Metrics, and You
Rahul K. Shah, MD George Washington University School of Medicine Children’s National Medical Center, Washington, DC There is a continuum in the patient safety and quality improvement area that essentially involves quality improvement initiatives, research to build on initiatives, metrics to measure outcomes with the interventions and benchmark, and ultimately measurement of the initiative’s impact on the end users — the patient and the physician. Reviewing the recent history of patient safety and quality improvement in otolaryngology reveals an interesting progression along this spectrum. The early literature focused on what was wrong with the system with suggestions to ameliorate latent systems defects. The next iteration has involved attempts to produce tightly focused patient safety and quality improvement studies using research methodology, paradigms, and statistical measures. David W. Roberson, MD, co-chair of the Patient Safety and Quality Improvement (PSQI) committee, and a national thought leader in this arena, often explains that quality improvement initiatives are distinctly different from basic science studies in terms of the significance of the burden of proof needed to show demonstrable differences. In other words, a great quality improvement initiative may not necessarily need a robust statistical significance to pass the basic litmus test of, “is this good for the patient/physician/system, etc.” An excellent and well-known example of this is that we do not need a randomized, double-blinded study to show that using a parachute when sky-diving improves outcomes. Of course, that example is an exaggeration of Dr. Roberson’s point – that basic science and quality improvement have different research end-points. With this caveat, we have seen a trend in the literature, within the body of surgery, and specifically for otolaryngology that quality improvement initiatives are now becoming more robust. The most beneficial result of the application of statistical tests and measures is that the initiatives are more readily accepted by physicians. Surgeons are accustomed to reading and interpreting literature with such statistics and now have come to expect such from many of our journals. The infusion of these measures into quality improvement initiatives has resulted in adoption of the findings much more readily than before. Most recently, the Joint Commission and other regulatory bodies have been ensuring that hospitals follow the Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) recommendations. These are excellent initiatives. However, their success and ultimately validity depends on the input. For example, to recite the well-known adage – garbage in, garbage out. I have spoken with more than a dozen hospitals and otolaryngology programs representing the community and academic setting, and the common sentiment is that many of the metrics that we propose are basic and do not differentiate or facilitate stratification among otolaryngologists. My fear is that if we do not produce robust metrics that allow such and are created, vetted, and adopted by us, then others (regulatory or insurance bodies) will use their vast databases to produce metrics or measures. We will then be forced to follow OPPE guidelines set by others and controlled by others – not the physicians. Hence we see the continuum from quality improvement initiatives morphing toward studies with application of research methodologies, which will result in data that can be used for setting and creating metrics to help demonstrate the quality of care that we provide to our patients while preserving the autonomy of our practices. The programming at the Annual Meeting attempts to cover this changing trend by having topics on apology and disclosure, quality/research in patient safety/QI, and how to make the transition to putting the literature to work in the form of metrics for maintenance of certification and hospital regulatory obligations. It has been excellent to see how the programming has evolved over the past years. This year’s programming should allow otolaryngologists to be updated on how to continue to provide care and contribute to this continuum of patient safety and quality improvement. We encourage members to write us with any topic of interest. We will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names.  Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
Are You an ENT PAC Member?
U.S. AAO-HNS members who make contributions to ENT PAC prior to August 1, 2011, will be recognized on the  acclaimed “Donor Wall” displayed proudly during the AAO-HNSF Annual Meeting & OTO EXPO in San Francisco. To make a contribution, visit the ENT PAC website at www.entnet.org/entpac (AAO-HNS log-in required) or contact staff at entpac@entnet.org. *Contributions to ENT PAC are not deductible as charitable contributions for federal income tax purposes. Contributions are voluntary, and all members of the American Academy of Otolaryngology—Head and Neck Surgery have the right to refuse to contribute without reprisal. Federal law prohibits ENT PAC from accepting contributions from foreign nationals. By law, if your contributions are made using a personal check or credit card, ENT PAC may use your contribution only to support candidates in federal elections. All corporate contributions to ENT PAC will be used for educational and administrative fees of ENT PAC, and other activities permissible under federal law. Federal law requires ENT PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year.
AAO-HNS Mid-Year Legislative Update
Time flies when you’re tracking multiple legislative efforts. During the first half of 2011, the AAO-HNS Government Affairs team has worked hard to help advance and/or monitor the Academy’s legislative priorities on the federal and state levels. Here is an update regarding the issues impacting the specialty this year. On Capitol Hill, health-related issues remain a high priority and have generally only been rivaled in 2011 by national budget and debt negotiations. The new Republican majority in the U.S. House of Representatives and the accompanying large freshmen class of legislators has resulted in a vastly different legislative atmosphere. To that end, the Government Affairs team has increased its efforts to educate Members of Congress about the issues important to the AAO-HNS via regular email updates, additional in-person meetings, and press statements when applicable. Across the country, each of the nation’s 50 state legislatures convened this year. By July only eight states will remain in regular session, as most will have adjourned for the year. At the time of printing, 128,086 state-based bills had been introduced in the United States in 2011. The AAO-HNS is monitoring more than 571 bills at the state level, including holdover bills from 2010. Of those, there are 35 state legislative bills that have been identified as being of particular importance to the AAO-HNS. We have provided state otolaryngology leaders with customized tracking reports, notifications, and alerts for these legislative bills of interest. Federal Legislative Efforts Medicare Physician Payment Reform: Following a year of heightened payment instability and multiple short-term “fixes,” U.S. House of Representatives Speaker John Boehner  (R-OH) clearly identified Medicare physician payment reform as a priority for the first session of the 112th Congress. In February, the AAO-HNS was among a small group of physician organizations invited to discuss possible payment reform options to accompany an assumed full repeal of the Sustainable Growth Rate (SGR) formula. The AAO-HNS also submitted an official response to the House Energy and Commerce Committee in April, following a bipartisan request for input regarding Medicare physician payment reform. If Congress fails to enact payment reform legislation this year, physicians will face a payment cut of nearly 30 percent on January 1, 2012. Repeal of Independent Payment Advisory Board (IPAB): Now that we are more than one year beyond passage of the Affordable Care Act (ACA), health-related organizations, including the AAO-HNS, have been working with Members of Congress to identify provisions in the new law that are particularly egregious in relation to the delivery of healthcare. Specifically, there is broad support across the health industry to repeal the ACA-mandated creation of the IPAB. The IPAB, an unelected, unaccountable body of individuals appointed solely by the President and charged with creating Medicare payment policy, usurps the rightful authority of our elected officials to create and shape Medicare policy. By limiting Congressional authority, IPAB essentially eliminates the transparency of hearings, debate, and the meaningful opportunity of stakeholder input. Furthermore, fewer than half of the IPAB members can be healthcare providers, and none are permitted to be practicing physicians or be otherwise employed. In January, U.S. Rep. Phil Roe, MD (R-TN) introduced H.R. 452: “Medicare Decisions Accountability Act of 2011.” The AAO-HNS strongly supports H.R. 452, and its Senate companion bill (S. 668) and has been working to identify co-sponsors and increase support for this legislation. At press date, the bipartisan bill had 144 co-sponsors. Medical Liability Reform: The nation’s current medical liability system places patients in jeopardy of losing their access to vital healthcare services. With affordable and adequate medical liability insurance becoming difficult to find, physicians are retiring early, limiting their practices, or moving to states with less costly premiums. For this reason, and many others, the AAO-HNS continues to advocate for passage of comprehensive medical liability reform legislation. In January, U.S. Rep. Phil Gingrey, MD (R-GA) introduced H.R. 5: “Help Efficient, Accessible, Low-cost, Timely Healthcare, (HEALTH) Act of 2011.” This act includes comprehensive reforms designed to fairly compensate those harmed by the negligent actions of their healthcare providers, while still preserving patient access to quality healthcare. Thus far, H.R. 5 has 134 cosponsors and bipartisan support in the U.S. House of Representatives. The House Judiciary and Energy and Commerce Committees completed their work on the bill, and floor action on the legislation is imminent. The HEALTH Act also has been introduced in the U.S. Senate (S. 1099), but there has been no additional legislative activity in 2011. Audiology Direct Access Legislation: The AAO-HNS strongly believes a physician-led hearing healthcare team with coordination of services is the best approach for providing the highest quality care to patients. In past years, the audiology community has pursued unlimited direct access to Medicare patients without a physician referral. The AAO-HNS has repeatedly opposed such legislative efforts due to significant patient safety concerns. Although audiologists play a critical role in providing quality hearing healthcare, their desire to diagnose hearing disorders independently transcends their level of training and expertise. On June 3, U.S. Rep. Mike Ross (D-AR) introduced H.R. 2140: “Medicare Hearing Healthcare Enhancement Act of 2011.” Following introduction of H.R. 2140, the AAO-HNS resumed efforts to prevent advancement of the bill and educate Members of Congress, especially freshmen, of the dangers associated with unlimited direct access. Clarity and Transparency in Healthcare Advertisements: Advocates for “transparency” in patient communications, including the AAO-HNS, argue that clear and accurate information empowers patients with an improved understanding of the healthcare system.  Currently, there is little transparency associated with the most fundamental and important component of healthcare delivery – the many health professionals who interface with patients every day. To help ensure patients are fully educated about the background and training of various medical providers, the “Healthcare Truth and Transparency Act of 2011” (H.R. 451) was introduced by U.S. Reps. John Sullivan (R-OK) and David Scott (D-GA) on January 26, 2011. The AAO-HNS strongly supports H.R. 451 and has been working with other physician groups to educate Members of Congress about the merits of this legislation. State Legislative Efforts Scope of Practice: The AAO-HNS believes it is appropriate for non-physician providers to seek updates to statutes and regulations relating to their defined scope of practice to reflect advances in education and training. However, the AAO-HNS strongly opposes state legislation that would inappropriately expand the scope of practice of non-physician providers beyond their skills. Enabling non-physician providers to independently diagnose, treat, or manage medical disorders could adversely affect the quality of patient care. This year, the AAO-HNS has advocated to modify and/or defeat several potentially harmful bills that would inappropriately expand the scope of practice of non-physician professionals. In South Dakota, the AAO-HNS successfully opposed a bill regulating the practice of speech-language pathology. The bill, as proposed, would have inappropriately expanded  the scope of practice for speech-language pathologists to allow them to diagnose, manage, and treat. The bill passed the House, but was tabled in a Senate committee. Similarly, the West Virginia legislature was considering a scope-of-practice expansion bill for speech-language pathologists and audiologists. The AAO-HNS worked closely with the state medical association to highlight concerns as the bill moved through the legislative process. Although the bill passed the House, the Senate committee declined to move it forward prior to the end of their legislative session. Companion bills in New York sought to permit non-physician oral and maxillofacial surgeons to perform elective surgeries in the oral and maxillofacial regions if granted hospital privileges. The AAO-HNS worked as a coalition with other national organizations to defeat this legislation. Taxes on Medical Procedures: Each year, there is a re-emergence of proposals to tax medical procedures, and in light of extensive state budget shortfalls, this year has been no exception. The Stop Medical Taxes Coalition – a coalition of national, state, and local organizations, of which the AAO-HNS is a member – asserts that the taxation of medical procedures is unfair for patients and is a “slippery slope” toward the taxation of other medical services. In Connecticut, a 6.25-percent cosmetic medical procedures tax was included in the Governor’s budget proposal. The AAO-HNS and other Coalition members submitted written testimony to the Connecticut legislature in opposition to the proposed tax. However, Gov. Dan Malloy ultimately signed the budget in May with the cosmetic tax provision included. The Washington House was considering a sales and use tax on cosmetic procedures to fund the maintenance of basic health program enrollment. The bill failed to clear the House by the “cross-over” date, so the legislation is dead for 2011. New Jersey has re-introduced a bill to repeal the 6-percent tax currently imposed on cosmetic procedures. The tax would be reduced by 2 percent each year, for three years, ending with a 0-percent tax rate. In Texas, the legislature considered taxing elective cosmetic procedures, but did not provide the tax rate in the legislation. Hearing Aid Services: The coverage of, sale, and dispensing of hearing aids is an issue considered by several states in various forms each year. In New York, the AAO-HNS worked closely with the Patient Access to Hearing Aids (PAHA) Coalition to pass a bill that would attempt to expand patients’ access to hearing aid services by striking an archaic law prohibiting physicians from deriving a profit on hearing aid sales. This year, the PAHA Coalition attained introduction of companion bills in both the Senate and Assembly. Several states considered bills to require insurers to cover the cost of or expand benefits for hearing aids and/or cochlear implants, including California, Hawaii, Illinois, Kansas, Maryland, Massachusetts, Minnesota, New Hampshire, New York, Tennessee, and Vermont. Several states also considered bills that would provide a tax credit and/or exemption for hearing aids, including Arizona, Arkansas, Florida, Michigan, and Oklahoma. Tobacco Use and Smoking Cessation: The AAO-HNS supports legislation and regulations that will help to reduce the use of tobacco products and exposure to secondhand smoke in order to promote healthy environments and lifestyles for the public. This year thus far, bills have been introduced in 14 states seeking to strengthen existing smoking ban laws — Alabama, California, Connecticut, Indiana, Iowa, Maryland, Massachusetts, Michigan, Mississippi, New Jersey, Oklahoma, South Carolina, West Virginia, and Wyoming. A number of states considered proposals to mandate insurance coverage and/or benefits for tobacco cessation, including California, Connecticut, Hawaii, Massachusetts, Mississippi, New York, and Washington. Two states, Hawaii and Illinois, had proposed legislation to exempt certain establishments from a smoking ban if they pay a fee to become licensed as exempt. Truth in Advertising: With the emergence of clinical doctorate programs for non-physician providers, which has led to many degree holders referring to themselves as “doctors,” there is growing confusion within the patient population about the level of training and education of their healthcare providers. In 2011, truth-in-advertising bills were introduced in California, Colorado, Idaho, Massachusetts, New York, and Wyoming. In Colorado, there was a proposed bill that failed to progress beyond committee. The bill would have required practitioners to wear photo ID badges that stated their type of license. Practitioners also would have been responsible for communicating to their patients if care was being provided by someone other than a medical doctor or doctor of osteopathic medicine. The Massachusetts legislature is currently considering a bill that would add the term “oral physician” for dentists’ scope of practice and for compliance with the state’s current truth-in-advertising requirements. Medical Liability Reform: In 2011, there are 22 states considering various tort reform measures, including those related to affidavits of merit, alternative reforms, caps on non-economic damages, defensive medicine issues, expert witnesses, health courts, or pre-trial screening panels. Those that considered enacting or modifying caps on non-economic damage awards in medical liability cases include Connecticut, Hawaii, New Jersey, Virginia, Wisconsin, and Wyoming. For more information about AAO-HNS legislative priorities and/or activities, visit the Legislative and Political Affairs website at www.entnet.org/advocacy or contact legfederal@entnet.org regarding federal legislative issues and legstate@entnet.org for state legislation inquiries. If you would like to receive timely updates regarding AAO-HNS legislative priorities and efforts, join the ENT Advocacy Network by emailing govtaffairs@entnet.org.
Expanding Access for New York’s Hearing-Impaired Patients
Gavin Setzen, MD President, NY State Society of Otolaryngology—Head & Neck Surgery Immediate Past-Chair, Board of Governors, AAO-HNS New York state law currently prohibits physicians who conduct hearing loss evaluations from selling hearing aids for a profit. This includes selling them for a reasonable price that would cover necessary costs and expenses associated with providing this important treatment option to the estimated 1.85 million New Yorkers who have hearing loss. The New York State Society of Otolaryngology—Head & Neck Surgery (NYSSO) has been actively working during the past several years to change this antiquated law. NYSSO engaged all stakeholders and formed the Patient Access to Hearing Aids (PAHA) Coalition to seek adoption of legislation that would strike this outdated law. The PAHA Coalition includes the AAO-HNS and NYSSO, along with the Medical Society of the State of New York (MSSNY), the American Medical Association (AMA), the American Osteopathic Association, the American Osteopathic Colleges of Ophthalmology and Otolaryngology—Head and Neck Surgery, and the American Otological Society, among others. Opponents to our Coalition efforts maintain that physicians should not “benefit financially from the sale of products that they order or prescribe.” However, audiologists and hearing aid dispensers are able to provide this service without limitations. These “profits” help cover the cost of overhead expenses, testing and equipment, follow-up appointments, and making instrument adjustments or addressing individual patient problems. These expenses are typically bundled into the consumer’s cost of the hearing aid. Without being able to charge for such reasonable and necessary expenses, and recovering only the wholesale price of the hearing aid, physicians cannot afford to offer hearing aids, despite hearing aid dispensing being within the scope of practice of otolaryngology—head and neck surgeons and of audiologists who work with them. In reality, the current system is advantageous for independent audiologists and hearing instrument specialists as the law essentially creates a mandatory referral system. The July 2009 issue of Consumer Reports, “Hear Well in a Noisy World: Hearing Aids, Hearing Protection & More,” reinforced what otolaryngology has been asserting all along: The best provider for hearing aids is a medical office headed by an ENT physician, with an audiologist on staff to fit and dispense hearing aids. There are several reasons cited for this recommendation, including higher marks than other providers from patients for thoroughness in evaluating hearing loss, and the ability of the otolaryngologist to rule out medical conditions and remove cerumen prior to the hearing test. Essentially, when otolaryngologists and audiologists work together, this model ensures that all patients get the right care from the right professional. We believe patients are ill-served by the current New York law, which is anti-consumer and monopolistic. For the patient, convenience and continuity of care are negatively impacted, possibly preventing certain individuals from taking that extra step to obtain a hearing aid, especially those who are older or are already hesitant due to stigma, cost, or fear. PAHA Lobby Day The PAHA Lobby Day activities, held March 15, 2011, were coordinated by our talented AAO-HNS Government Affairs team in conjunction with MSSNY – an excellent collaborative relationship that has strengthened over the last few years. One goal of the PAHA Lobby Day was to educate legislators on the facts surrounding this critical issue and to rebuff the incorrect assertions being made by organized audiology and the hearing aid dealers. Another goal was to secure additional sponsors for Assembly Bill 1739 and Senate Bills 3788 and 5164, and to garner additional support from other key legislators. Involvement by many otolaryngologists in New York with the PAHA Coalition effort has included writing letters to legislators, obtaining support from patients and colleagues (including audiologists), meeting with legislators (prior to Lobby Day), and ultimately attending the PAHA Lobby Day at the State Capitol in Albany, N.Y. In addition to 18 otolaryngologist attendees, we had two audiologists and Rebecca J. Patchin, MD, a member of the AMA Board of Trustees, flown in from California by the AMA. There were also four members of the MSSNY Legislative & Regulatory Affairs department lobbying on our behalf. A briefing was held for all attendees at the start of the PAHA Lobby Day in which all of the materials were reviewed and a strategy for the meetings was discussed. Overall, there were 22 legislative meetings with members of the Assembly Higher Education and Senate Consumer Protection Committees. Packages were provided for each legislator that included various letters of support, organizational position statements, “talking points,” and the Consumer Reports article. Afterward, a debriefing session was held, action points were developed, and PAHA Coalition conference calls were scheduled so the lobbying effort could continue. In addition, letters were sent to all legislators thanking them, briefly summarizing the key points, and asking them to co-sponsor legislation (A. 1739/S. 5164 and S. 3788.) The PAHA Coalition activities did not end there. We continued to press the issue through the spring with ongoing advocacy efforts, including a press conference and political fundraising events. In addition, our support for A. 1739/S. 5164 and S. 3788 was included in the advocacy materials for the New York Coalition of Specialty Care Physicians’ Lobby Day in Albany on May 10, 2011. While ultimately we were unable to secure passage of the legislation in 2011, we will continue to push for fair laws that ensure patients have access to needed hearing health services. This must remain a priority for all otolaryngologist—head and neck surgeons, regardless of subspecialty. For more information on the PAHA Coalition and our legislative efforts, visit www.entnet.org/Practice/members/PAHA.cfm.
The History of Otolaryngology— Head and Neck Surgery
Michael S. Benninger, MD Chairman, Head and Neck Institute Cleveland Clinic The history of the journal Otolaryngology—Head and Neck Surgery in many ways is a reflection of the history of the American Academy of Otolaryngology—Head and Neck Surgery. The first efforts to publish material from the meetings of the American Academy of Ophthalmology and Oto-Laryngology began in 1896 and 1897 when papers from the meeting were officially bound together as transactions of the meeting. In 1898, the American Journal of Ophthalmology and The Laryngoscope were designated the official journals of the Academy. After the articles were published in their respective journals, they were bound for each specialty and distributed to the members. In 1903, the first hard cover volume of the “Transactions,” or Transactions of the American Academy of Ophthalmology and Otolaryngology, were given to each member, including both ophthalmology and otolaryngology articles. The Transactions became the main published educational material for the Academy for over half a century. A single yearly volume was published until 1941, when it was expanded to six issues a year. In 1975, the Transactions were separated to provide a journal for each specialty. In 1977, Mansfield F.W. Smith, MD, MS, became the editor of the otolaryngology Transactions, and in 1978, the official name of the journal was changed to Otolaryngology. Dr. Smith helped to oversee the transition from a transaction format to one where articles from the meeting were submitted to a formal, peer-reviewed national and international journal for printing. In 1979, the journal title was expanded to Otolaryngology and Head and Neck Surgery. In 1981, as the Academy changed its name, the journal dropped the first “and” and added a hyphen, changing the name to Otolaryngology—Head and Neck Surgery, the name that has persisted to this day. The early responsibility of publishing the journal was through the Academy offices in Rochester, MN, but this was transferred to the C.V. Mosby Company in 1982. The original journal was eight issues a year. Six were composed of scientific articles and the other two were instruction and scientific programs for the annual meeting. In 1985, Bruce W. Pearson, MD, became editor of the journal. During his six-year term as editor, the journal grew to 12 issues a year, increasing the number of pages by 50 percent and doubling the number of articles published per year. During his tenure, corporate sponsorship grew, allowing for complimentary copies to be sent to residents in training. J. Gail Neely, MD, assumed the role of editor in 1991. He continued to expand the journal, instituted a more rigorous review process, and established an executive editorial board. These efforts enhanced both the quality and the international recognition ofOtolaryngology-Head and Neck Surgery as one of the premier otolaryngology journals in the world. The fourth editor was G. Richard Holt, MD. His meticulous approach to peer-review and his insightful editorials further strengthened the quality of the journal. During this time, C.V. Mosby was purchased by Elsevier, which led to a change in the more formal submission and publication processes. Because of the rapid growth in international submissions, Dr. Holt created a second International Editorial Office, under the guidance of the international editor, Eugene N. Myers, MD. In 2000, Dr. Holt became the executive vice president of the American Academy of Otolaryngology—Head and Neck Surgery, shortening his term as editor to three years rather than the customary six years. My term as editor began in 2000. The following few years were tumultuous ones. A major step for the journal was to permanently move the editorial offices to the Academy headquarters in Alexandria, VA. Until that time, the editorial offices would move with the offices of the editor-in-chief. With the ready communication afforded by the Internet, it was no longer necessary to have the editor and the editorial offices in the same location. This also reduced the downtime for the transfer of material and manuscripts between offices during the editor transition. A Mission Statement was developed to refine the objectives of the journal: “The mission of Otolaryngology—Head and Neck Surgery is to publish contemporary, ethical, clinically relevant information in otolaryngology, head and neck surgery (ear, nose, throat, head, and neck disorders) that can be used by otolaryngologists, clinicians, scientists, and specialists to improve patient care and public health.” The two most significant events were also the result of the growth of the Internet. The first was the transition from paper submissions to online submissions, with Otolaryngology—Head and Neck Surgery being one of the first otolaryngology journals to fully make this transition. The second was in large part the result of online submissions, with a dramatic increase in the number of submissions to 1,300 per year by the beginning of 2006. To meet this demand, the journal was expanded to publish 12 issues containing scientific papers, and supplements with the scientific and instruction programs were added. During this transition, the entire process of submission, review, acceptance, and publication changed over a short time, revolutionizing journal publishing. Policies and procedures were formally adopted related to a number of key publishing issues, and we focused many editorials on the ethics of research and publishing. We also began publishing the level of evidence in the abstracts of each article. In 2003, Byron (Ron) J. Bailey, MD, editor of The Laryngoscope, and I pulled together the editors of the American otolaryngology journals to meet twice a year to discuss mutual issues related to publishing and ethical concerns. This meeting continues to this day, providing a forum for many levels of editorial discussion. In 2006, Richard M. Rosenfeld, MD, PhD, became the sixth Editor of Otolaryngology-Head and Neck Surgery. His background in evidence-based medicine and review are ideal for identifying the highest quality of evidence in otolaryngology literature. The monthly review of “Extracts from The Cochrane Library” has given the readers exposure to cutting-edge evidence as it relates to our specialty. His clever editorials provide insight into the nuances of publishing and medicine in a way that is both instructional and entertaining. He has also overseen the transition to a new publisher, Sage Publications, seamlessly and without a misstep. Otolaryngology-Head and Neck Surgery and Transactions before it have provided the highest quality, ethical articles in otolaryngology to a world audience. Among the journal contributors who make this achievement possible are editorial board members, reviewers, authors, sponsors, and most importantly, readers. The value these contributors provide is immeasurable. The journal also accepts a wide range of article types, from systematic reviews to original research to case reports, making it the “journal of choice” for manuscript submissions from otolaryngologists at all levels of their careers. When this was brought up to the Board of Directors of the American Academy of Otolaryngology—Head and Neck Surgery, it was determined that more than 50 percent of the Board at that time had published their first papers in the journal. In 1991, Dr. Neely’s first editorial was titled, “Upon the Shoulders of Giants,” recognizing the contributions of the people who were responsible for this remarkable journal. His comments reflect the unique contributions that those individuals and Otolaryngology-Head and Neck Surgery have made to our specialty, and I am proud to have been a part of it. Otolaryngology-Head and Neck Surgery Editors: Mansfied F.W. Smith, MD, MS 1977-1984 Bruce W. Pearson, MD 1985-1990 J. Gail Neely, MD1991-1996 G. Richard Holt, MD 1997-1999 Michael S. Benninger, MD  2000-2006 Richard M. Rosenfeld, MD. MPH 2006- Some of the information presented was taken from: Pratt LR, Goldstein JC, Bryan SA, Hill TS. A Century of Excellence: A 100th Anniversary History of the American Academy of Otolaryngology—Head and Neck Surgery and Its Predecessor Organizations. 1996.
Mentorship and Networking in Otolaryngology
Sarah K. Wise, MD Assistant Professor of Otolaryngology—Head and Neck Surgery Emory University, Atlanta, GA for the Women in Otolaryngology Section At some point in our careers, most of us have had mentors who were vital to our professional development. In those individuals, we found the necessary encouragement, support, and guidance to facilitate growth and advancement. Many of us have also served as mentors. Mentorship is an important and useful tool that can serve us well as physicians, regardless of our career stage. Further, one-on-one mentorship often leads to development of an individual’s broader professional network. Mentoring Mentoring is strongly desired by physicians early in their careers. A 2001 survey of women in medical school faculty positions indicated that departmental mentoring for academic career development was in the top three highest ranked needs.1  Similarly, a recent interview study of 40 medical students, residents, and faculty members found “role models and mentors” to be among the five most common themes discussed.2 A preliminary questionnaire was distributed at the Women in Otolaryngology luncheon during the 2010 AAO-HNSF Annual Meeting & OTO EXPO in Boston. This questionnaire included questions about mentoring needs and attitudes.  Of 140 respondents, only 28 percent reported having a mentoring program in their current practice setting. Less than half of people who responded (46 percent) reported being part of a mentoring program in the past, yet 80 percent of those who had previously participated in a mentoring program found it helpful. Further, 91 percent stated that they would like to be part of a mentoring program in the future, with 56 percent indicating that they would be interested in having a mentor and 39 percent interested in serving as a mentor. The issues indicated as most important in a mentoring program included career development in the academic setting, pay and benefits negotiation, work-life balance, and career development in the community practice setting. Based on these preliminary WIO questionnaire results, a more in-depth survey is being designed to further investigate mentoring needs, with the ultimate goal of developing a mentoring network through the WIO Section. Developing a meaningful mentor-mentee relationship is an active process that requires time and dedication. In the busy lives of physicians, cultivating this relationship will require effort in the beginning, but ultimately, the rewards can be tremendous. When searching for a mentor, young physicians may initially seek out extremely prestigious and accomplished individuals. However, those who desire mentorship should be aware that simply standing in the vicinity of a Nobel Laureate does not impart the wisdom and experience to ensure a similar career path. Regardless of the career stage, prestige, and other commitments, a potential mentor must have the desire, interest, and time to devote to developing the mentor-mentee relationship. White, et al., (2009) and Cohen (1995) describe six behavioral functions in the context of the mentor role. First, the relationship emphasis fosters trust and honesty between the mentor and mentee. The information emphasis then allows the mentor to learn about the mentee’s interests, plans, desires, and goals. Next, the facilitative focus encourages the mentee to explore alternative options and different views.  During the confrontive focus, the mentor challenges the mentee’s explanations, actions, or decisions. The mentor model allows the mentor to share personal experiences and promotes the mentee taking suitable risks for career advancement. The final behavioral function is to stimulate the students’ vision of their future, including setting and meeting goals in personal and professional realms. It is clear from these various mentor functions that a strong relationship of trust is required between mentor and mentee.  Further, the mentee will not benefit from the relationship if the mentor is simply agreeable in all contexts. The mentor must provide proper and useful critiques, clear guidance, and thoughtful encouragement to the mentee to ensure the best chance of success from the relationship. White, et al., (2009) specifically emphasize the nurturing aspects of the mentor-mentee relationship. The goal is to develop the self-efficacy of the mentee. This is best accomplished by adopting a “power with” teacher-learner interaction, in contrast to the typical “power over” teacher-learner power structure of most medical education experiences. Nurturing teachers often make ideal mentors. It is important to note, though, that nurturing characteristics can be developed over time. Formal mentoring programs or informal mentoring relationships may fulfill an individual’s mentoring needs. Formal mentoring programs typically assist in pairing mentors and mentees. These programs may also provide mentor training, as well as objectives and structured evaluations of the mentoring process. However, formal mentoring processes also necessitate funding and administrative support. An informal mentoring relationship often requires the mentee to seek out an appropriate mentor through self-motivation and determination. Formal mentor training and evaluations do not typically exist in an informal mentoring relationship. However, due to identification and selection of the mentor by the mentee, a match that meets the true needs of the mentee may be more likely.3 Networking For physicians or young professionals early in their careers, establishing a mentoring relationship often leads to development of a broader professional network. Mentors are frequently instrumental in introducing mentees to colleagues and other professionals. However, even if a professional network is not facilitated by a mentor, networks can be extremely valuable to physicians at any stage in their career. Based upon adjustments in the healthcare environment and medical education, Baker et al (2010) have suggested a network approach for faculty and professional development. Citing reasons such as shifting from inpatient to ambulatory care focus, increasing numbers of learners, societal expectations, and new concepts in educational theory, these authors advocate a structured network to link faculty and physicians who are often geographically separated. Key aspects of developing this network included establishing a favorable environment, creating a vision, recruiting crucial leaders, growing the collaborative network, building social capital, developing legitimacy, and maintaining flexibility. Whether an individual is part of a structured or spontaneous professional or personal network, certain things remain the same. The individuals within a network typically uphold a unified vision, which helps guide the goals and interactions of its members.  Larger networks frequently contain people at various stages in their careers.  Within the network, less experienced members have the opportunity to seek advice from those with more experience. Those further along in their career may engage more junior members with tasks that will ultimately lead to the advancement of the junior person. Finally, personal connections developed within a network provide innumerable resources for its members. Within the American Academy of Otolaryngology—Head and Neck Surgery, its sections and committees, and various subspecialty societies, we are repeatedly presented with opportunities for both structured and informal networking. Both junior and senior members of these networks are encouraged to extend their questions, skills, advice, and contributions to other members of the network and beyond. As otolaryngologists, we are fortunate to be surrounded by bright, motivated, and accomplished individuals at all levels. This gives us extraordinary resources for professional and personal development through mentoring and networking. Regardless of career stage, mentoring and networking hold numerous benefits for all persons involved. The opportunities for mentoring and networking in otolaryngology are abundant and will likely grow even more in the future. In this vein, the WIO section is initiating the process of creating a mentoring program with the goal of matching mentors and mentees with similar goals from the mentorship experience. References 1. McGuire LK, Bergen MR, Polan ML. Career advancement for women faculty in a U.S. school of medicine: Perceived needs. Academic Medicine 2004;79:319-25. 2. O’Sullivan PS, Niehaus B, Lockspeiser TA, Irby DM. Becoming an academic doctor: Perceptions of scholarly careers. Medical Education 2009;43:335-41. 3. White HK, Buhr GT, and Pinheiro SO. Mentoring: A key strategy to prepare the next generation of physicians to care for an aging America. J Amer Geriatr Soc 2009;57:1270-77. 1. Cohen NH. The principles of adult mentoring scale. In: Galbraith MW, Cohen NH, eds. Mentoring: New Strategies and Challenges. San Francisco: Josey-Bass 1995, Misc: pp. 15-32. 5. Baker L, Reeves S, Egan-Lee E, Leslie K, and Silver I. The ties that bind: A network approach to creating a programme in faculty development. Medical Education 2010;44:132-9.
sleep
Polysomnography Guideline Summary
Peter S. Roland, MD, Richard M. Rosenfeld, MD, MPH, Lee J. Brooks, MD, Norman R. Friedman, MD, DABSM, Jacqueline Jones, MD, Tae W. Kim, MD, Siobhan Kuhar, MD, PhD, DABSM, Ron B. Mitchell, MD, Michael D. Seidman MD, Stephen H. Sheldon, DO, Stephanie Jones, BS, and Peter Robertson, MPA Corresponding Author: Peter S. Roland, MD, Professor & Chairman, University of Texas–Southwestern, Department of Surgery, Department of Otolaryngology The AAO-HNSF Guideline Development Task Force supported the development of the new Polysomnography Guideline that will be published in the July supplement of Otolaryngology—Head and Neck Surgery. This issue with the supplement is on its way to you and can be viewed online at www.otojournal.org. This following summary of “talking points” for physicians is purposely written in plain language that oversimplifies the guideline findings. The intent of this offering is to alert members to the availability of this new multidisciplinary guide so that the complexities of the problem and its treatment can be fully described and understood. The summary gives you an introduction to the topic, the purpose behind the guidelines, and action statements with related evidence profiles. A specially crafted version of the talking points is available to use in your community or with local press on our website atwww.entnet.org/aboutus/PressRoom.cfm (login required). Talking Points Executive Summary Clinical Practice Guideline: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children Polysomnography (PSG), commonly referred to as a “sleep study,” is presently the gold standard for diagnosing and quantifying sleep-disordered breathing (SDB) in children.1,2 SDB affects approximately 12 percent of children with manifestations ranging from simple snoring to potentially serious conditions including sleep apnea.3 SDB is also the most common indication for tonsillectomy with or without adenoidectomy in the United States.4,5 Since more than 530,000 tonsillectomies are performed annually on children under the age of 15 years, primarily for SDB, clear and actionable guidance on optimal use of PSG is strongly needed.6 This guideline is intended to assist otolaryngologists—head and neck surgeons in making evidence-based decisions regarding PSG in children aged 2 to 18 years with a clinical diagnosis of SDB who are candidates for tonsillectomy and may benefit from PSG prior to surgery. The following definitions are used: • Polysomnography (PSG) is the electrographic recording of simultaneous physiologic variables during sleep and is currently considered the gold standard for objectively assessing sleep disorders. Physiologic parameters typically measured include gas exchange, respiratory effort, airflow, snoring, sleep stage, body position, limb movement, and heart rhythm. PSG may be performed in a sleep laboratory with continuous attendance as defined below.7 • Sleep disordered breathing (SDB) is characterized by an abnormal respiratory pattern during sleep, and includes snoring, mouth breathing, and pauses in breathing. SDB encompasses a spectrum of disorders that increase in severity from snoring to obstructive sleep apnea. For example, obstructive sleep apnea (OSA) is diagnosed when SDB is accompanied by an abnormal PSG with obstructive events. • Tonsillectomy is defined as a surgical procedure with or without adenoidectomy that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. For clarity, the term “tonsillectomy” is used instead of “adenotonsillectomy” in this guideline, recognizing that often, but not always, the adenoid is removed concurrently with the tonsils. A discussion on the merits of intracapsular vs. complete tonsillectomy is beyond the scope of this guideline. Although PSG can help guide medical decision-making, assess surgical candidacy, and optimize perioperative monitoring after tonsillectomy, the test is time-consuming and often not readily available.5 Additional obstacles to testing include lack of consensus on what constitutes an abnormal study and access to a qualified sleep center and specialist to obtain and to interpret the results. Consequently, less than 10 percent of children undergo PSG prior to tonsillectomy, even though a clinical diagnosis of SDB in children is known to be a poor predictor of disease severity.5,8 The decision to proceed with PSG is, therefore, often at the discretion of the physician or caregiver.5 There is increasing interest in portable monitoring (PM) devices, instead of formal PSG to assess children with SDB. For the purposes of this guideline, the term PM is used to refer to home monitoring performed without a technologist present. PM devices will typically measure at least four physiologic parameters, including two respiratory variables (i.e., respiratory effort and airflow), a cardiac variable (i.e., heart rate or electrocardiogram), and arterial oxygen saturation via pulse oximetry. In contrast, PSG includes seven or more channels of monitoring and evaluates sleep stages. Guideline Scope and Purpose The primary purpose of this guideline is to provide evidence-based recommendations for PSG prior to tonsillectomy in children aged 2 to 18 years with SDB as the primary indication for surgery. The target audience is otolaryngologists in any practice setting where a child would be evaluated. Although the guideline was developed with input from other specialties, the intent is to provide guidance specifically for otolaryngologists—head and neck surgeons. Additional goals are to highlight the evidence for obtaining PSG in special populations or in children who have modifiable risk factors. A guideline is necessary, given the evidence of practice variation between practitioners and in the literature. The guideline does not apply to children under age 2 years or over 18 years of age, to those who have already undergone tonsillectomy, to children having adenoidectomy alone, or to children who are being considered for continuous positive airway pressure (CPAP) or other surgical therapy for SDB. The guideline is intended to focus on a limited number of quality improvement opportunities, deemed most important by the working group, and is not intended to be a comprehensive, general guide for prescribing PSG for tonsillectomy candidates and patients with SDB. In this context, the purpose is to define actions that could be taken by otolaryngologists to deliver quality care. Conversely, statements in this guideline are not intended to limit or restrict care provided by clinicians based on assessment of individual patients. Statement 1. Indications for PSG Before performing tonsillectomy, the clinician should refer children with SDB for PSG if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses.  Recommendation based on observational studies with a preponderance of benefit over harm. Evidence Profile for Statement 1: PSG for SDB with Comorbidity • Aggregate evidence quality: Grade C, observational studies; one systematic review of observational studies on obesity • Benefit: PSG confirms indications and appropriateness of surgery, helps plan perioperative management, provides a baseline for postoperative PSG, and defines severity of sleep disturbance • Harm: None • Cost: procedural cost; indirect cost of missed work • Benefits-harm assessment: Preponderance of benefit over harm • Value judgments: Knowledge gained through PSG can assist in diagnosing those children with significant SDB; belief that PSG can improve surgical outcomes through improved perioperative planning. • Role of patient preferences: Limited • Intentional vagueness: The panel decided to use the broad categories of neuromuscular disorders and craniofacial anomalies, rather than a comprehensive list of diseases and syndromes, to emphasize the need for individualized assessment. • Exclusions: None • Policy level: Recommendation Statement 2. Advocating for PSG The clinician should advocate for PSG prior to tonsillectomy for SDB in children without any of the comorbidities listed in Statement #1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of SDB. Recommendation based on observational and case-control studies with a preponderance of benefit over harm. Evidence Profile for Statement 2: Advocating for PSG • Aggregate evidence quality: Grade C, observational and case-control studies • Benefit: Selection of appropriate candidates for tonsillectomy • Harm: None • Cost: Time spent counseling the patient or family; financial implications to the family and insurance industry; time commitment for the study and follow-up • Benefit-Harm assessment: Preponderance of benefit over harm • Value judgments: Based upon expert consensus, there are circumstances in which PSG will improve diagnostic certainty and help inform surgical decisions. • Intentional vagueness: The panel decided to “advocate for” PSG rather than to “recommend” PSG in these circumstances to avoid setting a legal standard for care and to recognize the role for individualized decisions based on needs of the child and caregiver(s). Further, the word “uncertain” is used in the statement to encompass a variety of circumstances regarding the need for tonsillectomy that include, but are not limited to, disagreement among clinicians or caregivers, questions about the severity of SDB or validity of the SDB diagnosis, or any other situation where the additional information provided by PSG would facilitate shared decisions. • Role of patient preferences: Limited role in advocating; significant role in deciding whether or not to proceed with PSG • Exclusions: None Statement 3. Communication with Anesthesiologist Clinicians should communicate PSG results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with SDB. Recommendation based on observational studies with a preponderance of benefit over harm. Evidence profile for Statement 3: Communication with anesthesiologist • Aggregate evidence quality: Grade C observational studies and Grade D panel consensus • Benefit: Improve communication, provide information to the anesthesiologist that may alter perioperative management, reduce perioperative morbidity • Harm: None • Cost: None • Benefit-Harm assessment: Preponderance of benefit over harm • Value judgments: Promoting a team approach to patient care will result in improved patient outcomes. • Intentional vagueness: None • Role of patient preferences: None • Exclusions: None Statement 4. Inpatient Admission for Children with OSA Documented in Results of PSG Clinicians should admit children with OSA documented in results of PSG for inpatient, overnight monitoring after tonsillectomy, if they are under age 3 years or have severe OSA (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80 percent, or both).  Recommendation based on observational studies with a preponderance of benefit over harm. Evidence Profile for Statement 4: Impact of PSG on Postoperative Monitoring • Aggregate evidence quality: Grade C, observational studies on age; diagnostic studies, guidelines, and panel consensus on what constitutes a severely abnormal PSG • Benefit: PSG can help determine the appropriate setting for recovery after tonsillectomy that would allow prompt detection and management of respiratory complications among high-risk children. • Harm: Unnecessary admission of children who do not have respiratory complications; occupying a hospital bed that might be better utilized; risk of iatrogenic injury (infection, parenteral narcotics causing respiratory depression, hyponatremia from hypotonic IV fluids, etc.); reduced “family-centered care” during recovery process • Cost: Hospital admission; cost of monitoring • Benefit-Harm assessment: Preponderance of benefit over harm • Value judgments: Despite the lack of consistent data on what constitutes severe OSA on PSG, the panel decided some criteria, based on consensus, should be provided to guide clinical decisions; perception by the panel that inpatient admission after tonsillectomy is underutilized for children with abnormal PSG and that obstacles exist in the healthcare system for pre-certifying inpatient admission, even when appropriate. • Intentional vagueness: None • Role of patient preferences: Limited • Exclusions: None Statement 5. Unattended PSG with Portable Monitoring Device In children for whom PSG is indicated to assess SDB prior to tonsillectomy, clinicians should obtain laboratory-based PSG, when available. Recommendation based on diagnostic studies with limitations and a preponderance of benefit over harm. Evidence Profile for Statement 5: Unattended PSG with PM Device • Aggregate evidence quality: Grade C, one small diagnostic study in children and extrapolation from diagnostic studies and guidelines for adults • Benefit: Avoid inaccurate results or misdiagnosis of OSA because of limitations in the precision and accuracy of currently used PM devices • Harm: Potential for delays in testing based on access to PSG and availability of child-friendly test facilities • Cost: Procedure-related direct cost • Benefit-Harm assessment: Preponderance of benefit over harm • Value judgments: The panel chose to emphasize accuracy of test results over convenience of testing. The term “when available” was used to acknowledge that although home studies have limitations there may be circumstances when the caregivers express a strong preference for home-based testing or when access to laboratory-based PSG is limited by geography, scheduling conflicts, or insurance restrictions. • Intentional vagueness: None • Role of patient preferences: Some role for patient preference in deciding whether or not a PM device would be an acceptable alternative to PSG • Exclusions: None. Author’s Institutions Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical School, Dallas, TX Department of Otolaryngology, SUNY Downstate Medical Center and Long Island College Hospital, Brooklyn, NY Department of Pediatrics, Pulmonary Division, The Children’s Hospital of Philadelphia, PA Children’s Sleep Medicine Laboratory, The Children’s Hospital, Aurora, CO Department of Otolaryngology, New York Hospital Cornell ENT, NY Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, MD Albany Regional Sleep Disorders Center, Albany ENT and Allergy Services, Albany, NY Department of Otolaryngology, Cardinal Glennon Children’s Medical Center, St. Louis, MO Department of Otolaryngology, Henry Ford Medical Center, West Bloomfield, MI Sleep Medicine Center, Northwestern University Feinberg School of Medicine, Chicago, IL Department of Research and Quality Improvement, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, VA References 1. Society AT. Standards and indications for cardiopulmonary sleep studies in children. American Journal Respir Crit Care Med. Feb 1996;153(2):866-878. 2. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. Apr 2002;109(4):704-712. 3. Ali NJ, Pitson DJ, Stradling JR. Snoring, sleep disturbance, and behaviour in 4-5 year olds. Arch Dis Child. Mar 1993;68(3):360-366. 4. Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol. Mar 1990;99(3 Pt 1):187-191. 5. Mitchell RB, Pereira KD, Friedman NR. Sleep-disordered breathing in children: survey of current practice. Laryngoscope. Jun 2006;116(6):956-958. 6. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. Jan 28 2009(11):1-25. 7. Practice parameters for the use of portable recording in the assessment of obstructive sleep apnea. Standards of Practice Committee of the American Sleep Disorders Association. Sleep. Jun 1994;17(4):372-377. 8. Brietzke SE, Katz ES, Roberson DW. Can history and physical examination reliably diagnose pediatric obstructive sleep apnea/hypopnea syndrome? A systematic review of the literature. Otolaryngol Head Neck Surg. Dec 2004;131(6):827-832.
Susan R. Cordes, MD Board of Governors Member-at-Large
Research, Competencies, and the Art of Medicine
In the realm of medical education, there is significant emphasis on the competencies. Most practicing otolaryngologists were trained before establishment of the competencies, but the Accreditation Council for Graduate Medical Education (ACGME) now expects resident physicians to be trained and evaluated in each of the following: • Medical Knowledge • Patient Care • Interpersonal and Communication Skills • Professionalism • Systems-Based Practice • Problem-Based Learning and Improvement These are the areas established by the ACGME that make a competent physician, and research runs through all of them. Whether you are in a private practice setting, academics, or a resident in training, research has and will continue to impact your practice. It is not difficult to see how research adds to medical knowledge and improves patient care; otolaryngologists incorporate research into daily practice. Each advancement in our specialty is the product of research. Underlying each diagnostic and therapeutic practice, there is a wealth of knowledge accumulated during the history of our specialty from the performance of research. The novel concepts and cutting-edge research of today often become the accepted practices of tomorrow, thereby improving patient care. But what does research have to do with interpersonal and communication skills or professionalism? Communication with patients is a key component of the physician-patient relationship, and recruiting patients into a research study requires discussing the project with the patient. The research consent process can be as in depth as explaining a surgical procedure, but like any form of communication, it deepens the relationship between the patient and physician. Research also involves communicating with other physicians and healthcare providers as part of the research and patient care team and ultimately communicating results to colleagues at meetings and in the literature. Professionalism can be difficult to define, but the ACGME definition includes compassion, integrity, respect, accountability, sensitivity, and “responsiveness to patient needs that supersedes self-interest.” Though less structured than a definition per se, the concept of professionalism can be likened to an internal compass that guides one to “do the right thing.” Professionalism sets us apart as physicians. Research stems from the quest for knowledge and the desire to improve patient care and well being, and it is at the core of what makes us professionals. We respond to that innate drive by advancing otolaryngology knowledge through research. Systems-based practice requires knowledge of practice and delivery systems, cost-effective healthcare, advocating for quality patient care, and partnering with others in the healthcare system. Advances in medical knowledge obtained through research allow us to practice the best and most effective care. What better way to advocate for quality patient care than discover best practices through research? And certainly research is needed to determine the most cost-effective care practices. Problem-based learning and improvement (PBLI) requires physicians to analyze their practices and apply evidence to improve care. It includes using information technology to access and manage information for educational purposes, and it also includes educating others. Conducting and presenting research and attending research conferences allow us to actively engage in PBLI. Research presentations are thought-provoking and keep us up to date on the evolution of our specialty. In addition to the annual meeting, there are numerous regional and national meetings that showcase the work of talented colleagues. And how about attending the research day at your alma mater or local residency training program? You will likely be impressed with what the residents are doing, and your presence at such events means a lot to the residents and the attending faculty. You don’t have to don a lab coat and grab a pipette to be involved in research. Clinical research is extremely valuable and can be done in any kind of practice. Check Education and Research Academy website pages, www.entnet.org, to find studies open to recruitment as well as information about the CORE Grant Program. Sure, there is work involved in getting your study approved and up and running, but it is an excellent opportunity to collaborate with your otolaryngology colleagues for assistance, and it is well worth it when you see your work published. You also can contribute by reviewing for a journal in our specialty. And research doesn’t happen without financial support. Consider donating to the AAO-HNSF Millennium Society for Research/Quality or donate to your alma mater training program or local otolaryngology training program to support the research of resident trainees and our colleagues in academics. Consider it an investment in the future of otolaryngology—head and neck surgery. Sir William Osler said, “The practice of medicine is an art based on science.” In spite of financial and political pressures, we as otolaryngologists will continue to support research. This is a fundamental aspect of being competent physicians and professionals.
David R. Nielsen, MD, AAO-HNS/F EVP/CEO
ACOs: Pros and Cons for the Otolaryngologist
On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS) and other Federal agencies released four documents relating to implementation of Section 3022 of the Affordable Care Act (ACA), which mandates the establishment of a new Medicare Shared Savings Program by January 1, 2012. The regulation on Accountable Care Organizations (ACOs) is a complex rule that is likely to change. Currently, it does not offer much guidance regarding how otolaryngologists will be integrated, and whether an otolaryngologist would even find it desirable to align with an ACO. An ACO is a practitioner/provider network under common governance that enters into a three-year (renewable) agreement with CMS to be held accountable for some of the cost and quality of care for a group of assigned Medicare beneficiaries. The ACO shares in some of the savings and absorbs some of the costs (in excess of certain thresholds) of providing Part A and Part B services to the assigned Medicare population, as compared with a benchmark determined by CMS. The amount of shared savings/losses depends on the ACO’s size, the model selected, and performance on quality measures. The CMS ACO model makes primary care providers (PCP) central to the program. Beneficiary assignment is based on the PCP from whom a Medicare beneficiary receives the plurality of his or her primary care services. Actual patient assignment is determined retrospectively based on who received care from the ACO and patients may opt in and out to obtain care. A PCP must be exclusive to one ACO, but specialists, such as otolaryngologists, can participate in multiple ACOs. An ACO may include specialists, but must include PCPs and be composed of at least 5,000 Medicare beneficiaries to be approved by CMS. In many cases, a patient may have minimal contact with an ACO PCP and yet may be considered an ACO patient, for whom the ACO is accountable in terms of care cost and quality. Conversely, an ACO specialist may provide numerous primary care services to a patient, and the patient may still not be considered an ACO patient. The patient assignment rule has the potential to effect referral to specialists. However, ACOs will need specialist participation and cooperation to achieve reduction of healthcare costs. To qualify as an ACO, the ACO must have in place (or create) a governing body representing all participants, including hospitals and physicians. To ensure clinical integration, a full-time medical director must be employed by the ACO and a quality assurance committee must be in place. Otolaryngologists may participate in ACOs as owners/members or as participating physicians. There are several pros and cons to participating in an ACO as owner/member: Pros • Potential shared savings • Provides a “seat at the table” in determining ACO policies and procedures • May decrease the likelihood of lost referrals Cons • Time commitment required • Liability risk for potential losses • May be required to sign exclusive contract The proposed rule provides for two “tracks” of possible shared savings. Within the one-sided model, the ACO accepts downside risk (i.e., the risk that the costs of caring for the assigned Medicare beneficiaries will be greater than the applicable threshold) only in Year 3 of the contract, but shares in only 50 percent of the savings. In the two-sided model, the ACO accepts downside risk during all three years of the ACO’s contract with CMS and is eligible for 60 percent of the savings share. The one-sided model is geared toward small physician practices and startup ACOs, not ACOs that have already been in existence, where less risk is involved. However, the one-sided ACO is eligible for less shared savings. Both models require reporting on quality measures. ACOs must report on 65 proposed quality measures across five key domains. ACOs that do not meet quality performance thresholds for all measures would not be eligible for shared savings, regardless of how much costs were reduced. In general, there is a lack of specialty measures and no quality measures unique to otolaryngology among the proposed list of measures. However, there are measures that are relevant to otolaryngology practice used by other physician groups, such as peri-operative and smoking cessation measures. CMS anticipates establishment and approval of 75 to100 ACOs over the next three years, which most likely means only large groups that are already in ACOs will qualify for the program and will slow adoption. The way the proposed requirements are currently written makes participation unattractive for small physician practices. The average upfront cost in the Physician Group Practice Demonstration (ACO predecessor) was $1.7 million. The Academy suggests that members become fully informed before signing contracts of participation. Efforts in the private market are also occurring around the provision of accountable care throughout the country so otolaryngologists need to be aware of what is happening in their local communities. The awareness and engagement will allow you to be an active participant and have a seat at the table if and when the time is right for partnering with ACOs.
J. Regan Thomas, MD, AAO-HNS/F President
Learning, Doing, and Expanding Our Horizons
I am delighted to present an overview of the work of the AAO-HNSF on Research and Quality and Patient Safety. The sophistication of the specialty, our world, our communication, and our technology has allowed an integration of learning to take place as we are more and more able to access knowledge and understanding across the former barriers of time, space, and culture. This concept will be celebrated during our annual meeting’s opening ceremony through the theme this year, “The Changing Face of Otolaryngology.” In “Our World Is Flat” by Thomas Freidman, the New York Times columnist alludes to the perceptual shift in the world where divisions of history and geography are increasingly irrelevant—our traditional modes are giving way to flow of one discipline to another. For us, the practice of medicine is improved by adding “doing” to learning curriculums, by connecting research to our medical practices, by advocating for better quality medical care for the patient. A New Guideline in our Journal The July issue of Otolaryngology—Head and Neck Surgery offers a new multidisciplinary guideline supplement, Clinical Practice Guideline: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children, by Peter S. Roland, MD; Richard M. Rosenfeld, MD, MPH; Lee J. Brooks, MD; Norman R. Friedman, MD, DABSM; Jacqueline Jones, MD; Tae W. Kim, MD; Siobhan Kuhar, MD, PhD, DABS; Ron B. Mitchell, MD; Michael D. Seidman MD; Stephen H. Sheldon, DO; Stephanie Jones, BS; and Peter Robertson, MPA. To help you understand the value of the full article, read the overview for physicians in this Bulletin but make sure to seek the whole article in this month’s journal.  To further expand your reading, a 10-minute podcast with several guideline authors is also available at www.entnet.org/Practice/ClinicalPracticeGuidelines.cfm. Bulletin Online Gets a Makeover Last month, AAO-HNSF unveiled its new and improved online Bulletin. The updated landing page features 2011 issues, starting with a pictorial thumbnail of each cover. Behind each thumbnail, you will find the compendium of that issue’s articles, as delivered in print. With each online issue, you will find the feature focus, such as May’s highlights for the AAO-HNSF Annual Meeting & OTO EXPO, as well as the customary departments — Academy News, Legislative and Political Advocacy, Regulatory Advocacy & Business of Medicine, and Our Community. As you open each monthly issue, you will find a quick list of article headlines accompanied by a brief lead-in to each article. Mindful of your busy schedules, this approach allows you to quickly scan an issue for articles of interest. Likewise, you can use the search function in the right-hand navigation column to track down articles or subjects that are of the most interest you. One caveat: As this new online landing page is ramping up, the search function applies to 2011 issues only. In order to access the search function for articles prior to 2011, you will need to go to www.entnet.org/bulletin/bulletinarchive.cfm. All of the URLs you find in the print edition are automatically linked in each online article for your convenience. They appear in red and a simple click will take you to that address. This functionality allows you to quickly tap additional information as referenced in each article. Finally, at the heart of the otolaryngology business of medicine is sharing our learning. You will notice the share functionality at the top of each article, which allows you to quickly and easily “share” or forward an article of value. Underneath each headline, you will note the sampling of social networking icons. The first five linked icons – Twitter, Facebook, LinkedIN, Digg, and Delicious – are the most popular social networking sites today. You can use those links to share or you can send a personalized email by clicking on the small envelope icon. The final icon in the series allows you to access other less common social networking sites, such as Blogger, Corkboard, and Bebo. I hope you find these added elements and ways of accessing knowledge beneficial for your learning, doing and expanding within your practice.
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OREBM Mini-Program at the 2011 AAO-HNSF Annual Meeting & OTO EXPO
Monday, September 12, 2011 10:30 a.m. – 11:50 a.m. Mini-seminar: Evidence-Based Approach to Treating Chronic Rhinosinusitis Moderator: Greg E. Davis, MD, MPH Presenters: Timothy L. Smith, MD, MPH; Bradley F. Marple, MD; Richard R. Orlandi, MD 8 a.m. – 9:20 a.m. Mini-seminar: Landmark Randomized Clinical Trials in Otolaryngology Moderator: Scott E. Brietzke, MD, MPH Presenters: Debra G. Weinberger, MD; Greg Davis, MD, MPH; Seth R. Schwartz, MD, MPH Wednesday, September 14, 2011 10:30 a.m. – 11:50 a.m. Mini-seminar: Outcomes Research: Past, Present, and Future Moderator: Michael G. Stewart, MD, MPH Presenters: Jay F. Piccirillo, MD; Richard E. Gilklich, MD; Timothy L. Smith, MD, MPH; Bevan Yueh, MD, MPH; Richard M. Rosenfeld, MD, MPH; Amy Y. Chen, MD, MPH
EBP and Otolaryngology: Where Are We Now? Where Are We Going?
The integration of evidence-based medicine into everyday clinical practice, now termed evidence-based practice (EBP), aims to synthesize patient information, current evidence, and clinical experience to decrease variations in patient care and improve patient outcomes.1,2 As the complexity of medical decision-making increases, access to data and current evidence is imperative to determine the best course of action for each patient. The Outcomes Research and Evidence Based Medicine (OREBM) Committee of the American Academy of Otolaryngology—Head and Neck Surgery exists to assist the otolaryngologist in this quest for high-quality evidence and data to guide one’s practice. Its formal stated charge is: “To serve as a repository of expertise on health services research and evidence-based medicine, including outcomes and effectiveness research generally and specifically in otolaryngology—head and neck surgery; to advise and support other Academy and Foundation committees on outcomes and clinical effectiveness; to liaison with the Quality Improvement Committee on research aspects of the development of clinical practice guidelines; to develop and maintain educational material, instruction courses, and Annual Meeting mini-seminars in these areas, including an Outcomes Primer; and to develop and maintain a prioritized list of project areas suitable for research on outcomes and clinical effectiveness.” With this charge in mind, the OREBM aims to: 1) highlight relevant, current research data that can assist the otolaryngologist with patient decision-making and 2) guide research efforts into clinical areas that will most benefit our specialty based on identified gaps in evidence and emerging clinical importance. Where Are We Now? Table 1 provides a brief glimpse into our progress as a specialty in the publication of EBP supportive articles over the past several years. This is not meant to be an exhaustive search but rather presents a few indicators of our progress. The rapidly increasing numbers of EBP supportive publications in otolaryngology demonstrate clearly that our specialty has embraced the need to publish data that support the pursuit of evidence-based practice. Table 1: Evidence-Based Medicine Publications for Otolaryngology by Decade Decade Number of Randomized Clinical Trials Published Number of Meta-Analyses Published Number of Clinical Practice Guidelines Published 1980-1989 55 2 0 1990-1999 356 26 8 2000-2009 678 108 31 Note: Numbers obtained by searching PUBMED with limits by study type, by decade, with keyword search term of “otolaryngology.” Randomized clinical trials (RCTs) represent the highest level of clinical evidence available, with less potential for systematic bias. Not all clinical questions can be addressed with an RCT, but a well-designed and executed RCT can directly compare treatment options and produce results to potentially change and improve patient management. The OREBM Committee will present a mini-seminar at this year’s annual meeting discussing the key, landmark RCTs in otolaryngology in the last several years. If attending the meeting in San Francisco this fall, plan on joining us for this informative, high-yield session, as well as other mini-seminar sessions on the history of outcomes research in otolaryngology, EBP in rhinology, and EBP in sleep surgery supported by the committee. A meta-analysis (MA) is a qualitative and quantitative assessment of currently available data on a clinical topic. It is especially useful in the development of an EBP as it can provide a summation of the key data that are currently available and allows a practitioner to access those data efficiently to guide decision-making, rather than locating, reading, and analyzing multiple individual studies on their own. Table 2: Recently PublishedClinical Practice Guidelines Clinical Practice Guideline Topic Year Published Acute Otitis Externa (AOE) 2006 Adult Sinusitis 2007 Impacted Cerumen 2008 Benign Paroxysmal Positional Vertigo 2008 Hoarseness (Dysphonia) 2009 Nasal Valve Compromise 2010 Tonsillectomy in Children 2011 Polysomnography forSleep-Disordered Breathing Prior to Tonsillectomy in Children 2011 Clinical practice guidelines (CPGs) represent the most user-friendly tool to develop an EBP, as they are the summation of the review of currently available data on a topic by a group of experts presented as a series of clinical management recommendations. Each clinical practice guideline represents the end-product of a large amount work and discussion. Our specialty as a whole is extremely fortunate that the leadership of the American Academy of Otolaryngology has so thoroughly embraced the challenge of producing clinical practice guidelines for the benefit of all otolaryngologists. A list of recently completed guidelines is shown in Table 2. Where Do We Go From Here? Our specialty has made steady, committed progress in the pursuit and development of the tools to guide an EBP. However, when on a long journey, it is always wise to pause at times and consider the direction you are headed and the destinations ahead. In the pursuit of an EBP, where do we head from here? The OREBM Committee as a group has spent considerable time pondering this question for otolaryngology as a specialty. We have made it our task to reflect on our own practices and consider which areas are in most need of future data (i.e., “evidence gaps”) to help improve evidence-based clinical decision-making. We developed a selected list of prioritized, current areas for future study that are listed in Table 3. Note that only some areas of otolaryngology are listed. We are well represented currently with pediatric otolaryngologists, rhinologists, laryngologists, and sleep surgeons on the committee. We are in need of more neuro-otologists, head and neck surgeons, and facial plastic surgeons to join us. If this is your area of expertise, please consider participation in the OREBM Committee. In addition to pondering evidence gaps, the OREBM Committee has been considering and attempting to identify clinical areas that may benefit from compiling and critically analyzing the currently available data in the form of a systematic review or meta-analysis. These efforts may lead to future studies and/or help sharply develop clinical areas where true evidence gaps lie. The completion of a high-quality Table 3:  Possible Prioritized Evidence Gaps Subspecialty Evidence Gap PediatricOtolaryngology 1. Diagnosis and management of residual obstructive sleep apnea after adenotonsillectomy to include use of sleep endoscopy and cine MRI 2. Management of otitis media with effusion diagnosed in neonates within neonatal hearing screening programs 3. Use of imaging in evaluation of hearing loss in children – MRI versus CT 4. Benefits of proton pump inhibitor therapy in neonates with laryngomalacia/stridor 5. Use of balloon dilation in the management of pediatric subglottic stenosis Rhinology 1. Standardization of maximal medical therapy for chronic rhinosinusitis 2. Accuracy of diagnosis of chronic rhinosinusitis in the primary care setting, e.g., family practice, internal medicine 3. Development of a chronic rhinosinusitis treatment data registry 4. Role of bioflims in chronic rhinosinusitis Laryngology 1. Long-term compliance and benefits of voice therapy 2. Effectiveness of antibiotic therapy in the setting of acute laryngitis 3. Determination of which hoarse patients benefit the most from proton pump inhibitor therapy 4. Efficacy of neurontin, elavil, and/or lyrica in treating chronic cough 5. Utility of voice rest of after vocal surgery Sleep Surgery 1. Outcomes for nasal (and pharyngeal) surgery in improving long-term CPAP compliance 2. Benefit of turbinoplasty in addition to adenotonsillectomy for management of pediatric obstructive sleep apnea 3. Use of home sleep testing in a sleep surgical practice 4. Outcomes for medical and surgical treatments for treatment of socially bothersome primary snoring 5. Development of a sleep surgery data registry meta-analysis is not a simple task. Some committee members were selected after an academy-wide competitive search for sponsorship to attend the International Cochrane Colloquium Meeting in October 2011. This meeting will include training in advanced meta-analysis techniques. The expectation of receiving this support is a resulting submission of a completed meta-analysis for publication in the Otolaryngology—Head and Neck Surgery journal. Thus, academy members can expect to see more and more high-quality meta-analyses in our journal in the future. Our specialty is fortunate that our Academy not only recognizes the importance of EBP but is willing to support it. The OREBM Committee has several ongoing and recently completed studies targeting what is believed to be important evidence gaps. Table 4 on page 33 lists and provides a brief update on the status of these projects.  As the committee strives to identify key evidence gaps, it is the goal that future projects of the committee and research sponsored by the Academy CORE grants will translate to a continually improving evidence basis on which to guide clinical decision-making. In conclusion, we hope you agree it is a worthy goal to develop a strong evidence basis to your practice for the benefit of current and future patients. It is the goal of the OREBM committee to continually support this pursuit for the otolaryngologist with educational endeavors, research activities, and emphasis of targeted areas within our specialty that are most in need of investigation to build an otolaryngology EBP. Table 4: Status Reports on the Ongoing Studies of the OREBM Committee Study PrincipalInvestigator Open to Enrollment Status Parent Response to Ear Disease in Children with and without Tubes (PREDICT) Quality of Life Research Study Judith E. C. Lieu, MDWashington University SOM St Louis, MO Yes The study is 64% to our goal of 1000 complete (physician and patient) records. 1,896 sets of forms have been sent out to our 23 participating sites. Of those, 1,138 physician forms (60%) and 696 patient forms (37%) have been returned to the AAO-HNSF for data entry. TALC (Treatment of Advanced Laryngeal Cancer) Study Bevan Yueh, MD, MPHUniversity of Minnesota Minneapolis, MN Yes As of February 2011, the study had enrolled 48 patients.Mean age = 60.5 Gender = 39 Male and 9 Female Treatment Group = 30 Laryngectomy and 18 Chemoradiation Studying Life Effects and Effectiveness of Palatopharyngoplasty (SLEEP) Edward M. Weaver, MD, MPHUniversity of Washington Seattle, WA No Results PublishedStudying Life Effects & Effectiveness of Palatopharyngoplasty (SLEEP) Study: Subjective Outcomes of Isolated Uvulopalatopharyngoplasty. Weaver EM, Woodson BT, Yueh B, Smith T, Stewart MG, Hannley M, Schulz K, Patel MM, Witsell D; the SLEEP Study Investigators. Otolaryngol Head Neck Surg. 2011 Apr; 144(4):623-631. Epub 2011 Feb 10.
JosephClarke
Residents join the CORE Study Section
For the third year, the CORE Study Section accepted residents as part of this year’s review. The AAO-HNSF received 27 applications to fill six coveted positions (two on each of the subcommittees). Residents represented 15 percent of the Study Section this year. Joseph C. Clarke, MD Third-year resident, University of Iowa Hospitals & Clinics, Iowa City, IA “Participating in the CORE study section as a resident reviewer was a fine introduction to grant critiquing and it expanded my perspective on proposal writing. Peering behind the curtain of the grant review process was invaluable and will no doubt strengthen my future grantsmanship. It was a pleasure to work with such a strong group of researchers and physician scientists in our field.”   Joseph E. Hall, MD Third-year resident, Vanderbilt University, Nashville, TN “I greatly appreciated the opportunity to serve as a resident CORE grant reviewer. I was honored to be selected for this position by the AAO-HNSF and I thoroughly enjoyed my experience. This opportunity immerses residents in the grant reviewing process with leaders in the field of otolaryngology. This experience certainly allows residents to improve skills associated with research study design, manuscript writing, and grant submission in preparation for a career in academic otolaryngology.”   Rick F. Nelson, MD, PhD Third-year resident, University of Iowa Hospitals & Clinics, Iowa City, IA “Participating in the CORE grant review process was educational and a great way to meet fellow surgeon-scientists. Reading, critiquing, and discussing grants helped me recognize the more salient features of  successful grant applications. I am grateful for this opportunity the CORE provided me and I would recommend this experience to any aspiring surgeon-scientist.”   Justin H. Turner, MD Fifth-year resident, Johns Hopkins University School of Medicine, Baltimore, MD “It was a privilege to serve as a resident member of the CORE grant study section. I had submitted grant applications to different funding organizations in the past, but being a part of the CORE study section helped me to finally understand the elements of a successful grant application. The opportunity to be a part of the critiquing and evaluation process was a remarkably enlightening experience. Being a part of the study section also afforded me the chance to personally examine some of the cutting-edge research that is ongoing in our profession. Residents with an interest in research should strongly consider this opportunity.”   Nancy P. Judd, MD Third-year resident, Washington University School of Medicine, St. Louis, MO “I would like to thank AAO-HNSF for the honor of participating in the CORE grant study section. This wonderful experience offered great insight into both the details of the grant-writing process as well as the dedication of our field to promoting innovative, exciting, and well-derived research projects. This is an invaluable opportunity that I would recommend to all residents interested in a career in academic otolaryngology.”   Waleed M. Abuzeid, MD Third-year resident, University of Michigan, Ann Arbor, MI  “The CORE grant review process is an invaluable educational experience.The opportunity to constructively evaluate grants alongside leaders in our field, all of whom have a proven track record in research, allows those so inclined to facilitate progress in otolaryngology. From a more practical standpoint, this opportunity has equipped me with a much deeper understanding of the critical components that constitute a well-written grant and, by extension, enhanced my own grantsmanship. It was truly an honor to serve on the AAO-HNSF CORE Study Section and I would strongly encourage participation from those interested in personally and collectively advancing the state-of-the-art.”
Thank you to the 2011 CORE Study Section
The AAO-HNSF, CORE societies, partnering foundations, and sponsors would like to formally thank the 2010 CORE Study Section for their commitment to ensuring that research grants are awarded to the most meritorious grant applications. They provide written critiques to each applicant to assist our young investigators with strengthening their grant-writing skills and encouraging them to continue to pursue their research careers in otolaryngology–head and neck surgery. Waleed M. Abuzeid, MD Oliver F. Adunka, MD Kenneth W. Altman, MD, PhD Brandon G. Bentz, MD Jay O. Boyle, MD Rakeash K. Chandra, MD Alan G.Cheng, MD Joseph C. Clarke, MD Noam A. Cohen, MD, PhD Marion E. Couch, MD, PhD Jayme R. Dowdall, MD David R. Friedland, MD, PhD Susan L. Garetz, MD Ann M. Gillenwater, MD Nira A. Goldstein, MD Gayle M. Gordillo, MD Christine G. Gourin, MD Neil D. Gross, MD Samuel P. Gubbels, MD Joseph E. Hall, MD Marlan R. Hansen, MD Alexander T. Hillel, MD Keiko Hirose, MD Michael E. Hoffer, MD Eric H. Holbrook, MD Timothy E. Hullar, MD Cliff R. Hume, MD, PhD Lisa Michelle Ishii, MD Akira Ishiyama, MD Scharukh Jalisi, MD Mark J. Jameson, MD, PhD Romaine F. Johnson, MD Nancy P. Judd, MD Benjamin L. Judson, MD Seungwon Kim, MD Young J. Kim, MD, PhD Stephen Y. Lai, MD, PhD Andrew Lane, MD Paul L. Leong, MD Judith E. C. Lieu, MD Jeffrey C. Liu, MD Lawrence R. Lustig, MD Tomoko Makishima, MD, PhD Eduardo Mendez, MD Suzette K. Miklua, MD Jeffrey S. Moyer, MD Rick F. Nelson, MD, PhD Anh T. Nguyen Huynh, MD, PhD Richard R. Orlandi, MD Albert H. Park, MD Maria T. Pena, MD Jay F. Piccirillo, MD David Poetker, MD Melissa A. Pynnonen, MD Vicente A. Resto, MD, PhD Claus-peter Richter, MD, PhD Peter S. Roland, MD Eben L. Rosenthal, MD Rodney J. Schlosser, MD Cecelia E. Schmalbach, MD Duane Sewell, MD Carol G. Shores, MD, PhD Andrew Sikora, MD, PhD Bhuvanesh Singh, MD, PhD Matthew E. Spector, MD Maie St. John, MD, PhD Michael E. Stadler, MD John B. Sunwoo, MD Jonathan Y. Ting, MD Travis T. Tollefson, MD Justin H. Turner, MD Andrea Vambutas, MD Steven J. Wang, MD Sarah K. Wise, MD Charles R. Woodard, MD Bradford A. Woodworth, MD Adam M. Zanation, MD   Contact Stephanie Jones at sjones@entnet.org to join this prestigious group.
CORE Grant Program
Important Dates August 2011 2012 CORE Funding Opportunity Announcements released/proposalCENTRAL opens December 15, 2011 Deadline: Letters of Intent January 16, 2012 Deadline: Full Applications March 13-24, 2012 2012 CORE Study Section Review of Applications May-June 2012 2012 Grantees Announced The Centralized Otolaryngology Research Efforts (CORE) grant program societies and foundations have awarded more than 400 research grants, totaling more than $6 million since the program’s inception. The CORE grants program aims to: unify the research application and review process; encourage young investigators to pursue research in otolaryngology; and serve as an interim step that may eventually channel efforts for important NIH funding opportunities. In conjunction with the AAO-HNSF, societies, foundations, and sponsors are involved in funding one- to two-year non-renewable grants ranging from $5,000 to $70,000. This year the CORE Study Section reviewed 151 applications. Applicants were seeking $2,310,922 in research funding. The 2011 Study Section subcommittees included:  Head and Neck Surgery, chaired by Jay O. Boyle, MD; Otology, chaired by Lawrence R. Lustig, MD; and General Otolaryngology, chaired by Richard R. Orlandi, MD. After many years of service as the chair of the Otology subcommittee, Dr. Lustig has stepped down and passed the reins to David R. Friedland, MD, PhD. The AAO-HNSF and the CORE societies and foundations thank Dr. Lustig for his commitment to the program. The 2011 CORE leadership (including the boards and councils of all participating societies) have approved a portfolio of 38 grants totaling $630,067. 2011 Research Awards CeremonyThe 2011 Research Awards Ceremony will be held from 10:30 a.m. to noon, Wednesday, September 14, 2011, at the 2011 AAO-HNS/F Annual Meeting & OTO Expo in San Francisco, CA. All the 2011 CORE Grantees will be recognized.   Congratulations to the 2011 CORE Grantees The Alcon Foundation AAO-HNSF/The Alcon Foundation Resident Research Grant Candice C. Colby, MD Emory University School of Medicine, Atlanta, GA Genetic Assay of Newborns Who Fail Auditory Physiologic Screening ($12,500)   Thanks to CORE Grant SupportersTo establish an endowed CORE grant, contact Development@entnet.org or 703-535-3714.The AAO-HNSF Percy Memorial Research Award. Established in 1990, the AAO-HNSF Percy Memorial Research Award was established by Leslie Bernstein, MD, DDS, in memory of A. Edward Percy, Jr., MD. This generous grant provides vital funding for research projects in any area within the scope of otolaryngology—head and neck surgery. Dr. Bernstein is applauded for this act of generosity that will continue to facilitate new research in otolaryngology while also providing a great source of honor to his colleague, Dr. Percy.The ANS/AAO-HNSF Herbert Silverstein, MD, Otology and Neurotology Research Award. Established in 1999, the ANS/AAO-HNSF Herbert Silverstein Otology and Neurotology Research Award was established by Herbert Silverstein, MD, and receives additional support from the American Neurotology Society (ANS) and the AAO-HNSF. This grant supports clinical or translational research projects focused on diseases, disorders, or conditions of the peripheral or central auditory and/or vestibular system by new full-time academic surgeons. Dr. Silverstein’s significant gift ensures that the CORE grant program will continue to foster advances in this important area of patient care. The AAO-HNSF Rande H. Lazar, MD Health Services Research Grant. Established in 2002, the AAO-HNSF Rande H. Lazar, MD, Health Services Research Grant was endowed by Rande H. Lazar, MD, to inspire investigation of health services and socioeconomic issues by young physicians. The grant represents the first time an individual in the AAO-HNS has provided this level of funding in support of a sustained effort to gather socioeconomic data for otolaryngology and promotes increased participation by otolaryngologists in the rapidly expanding area of health services research. The first $10,000 CORE grant was awarded in 2008 (awarded every other year). We look forward to the continuation of new research in this area for many years thanks to Dr. Lazar’s stellar display of philanthropy. AAO-HNSF Resident Research Grant supported by The Alcon Foundation. In 2009, The Alcon Foundation generously committed its support to award an annual CORE grant for a period of five years. The purpose of this grant is to stimulate original resident research with a preference for grants related to pediatric otolaryngology and to promote the discovery and development of innovative treatments. Resident Research Grant sponsored by The Oticon Foundation. In 2010, The Oticon Foundation generously committed its support to award an annual CORE grant for a period of five years. Oticon is the oldest hearing aid manufacturer in the world and in keeping in line with the Foundation’s commitment to support the needs of hearing impaired people, this grant will be used to establish a new CORE grant for research in otology with the goal of generating vital new research about hearing loss and otology. Resident Research Grant sponsored by Olympus. Olympus has generously supported the AAO-HNS/F Annual Meeting & OTO Expo and the resident/medical student paper prizes for many years. To continue their support of our young investigators, in 2010 the resident/medical student paper prizes were sunsetted and the Olympus sponsorship dollars were redirected in support of a resident research grant.   Education and Research Foundation for the American Academy of Facial Plastics and Reconstructive Surgery (AAFPRS) AAFPRS Leslie Bernstein Grant Robin W. Lindsay, MD National Naval Medical Center, Bethesda, MD Development of Comparative Effectiveness Tools in Facial Paralysis ($24,798) AAFPRS Leslie Bernstein Investigator Development Grant J. Regan Thomas, MD The Board of Trustees of the University of Illinois, Chicago, IL Experimental Studies on Photo Aging in the Mouse model ($25,000) AAFPRS Leslie Bernstein Resident Research Grant Sang Woo Kim, MD Massachusetts Eye and Ear Infirmary, Boston, MA Histologic Changes Following Sensory Neuroprotection of Facial Musculature ($5,000) American Academy of Otolaryngology — Head and Neck Surgery Foundation (AAO-HNSF) AAO-HNSF Resident Research Grant Marsha S. Reuther, MD The Regents of the University of California, San Diego, CA Hypoxia-modulated tissue engineering of human nasal septum ($10,000) Arnaud F. Bewley, MD The Trustees of the University of Pennsylvania, Philadelphia, PA Defining cetuximab’s impact on HNSCC subpopulation dynamics and invasiveness ($10,000) Anton M. Kushnaryov, MD The Regents of the University of California, San Diego, CA Rabbit Nasal Defect Model and Repair with Autogenous Engineered Septal Cartilage ($10,000) Jeffrey Phillips, MD CFF Care Center Louisiana State University Health Sciences, Shreveport, LA Curcumin inhibits UV radiation-induced cutaneous squamous cell carcinoma in vivo ($10,000) Javad A. Sajan, MD University of Minnesota – Twin Cities, Minneapolis, MN Validated Assessment Tools for Reconstructing Facial Defects in Simulation ($9,893) Marcus M. Monroe, MD Oregon Health & Science University, Portland, OR Functional and Clinical Significance of Lgr6 Expression in Head and Neck Cancer ($10,000) Jennifer Yoon Lee, MD University of Pennsylvania, Philadelphia, PA Novel Murine Model of Granulation Tissue in Laryngotracheal Stenosis ($10,000) Daniel R. Clayburgh, MD, PhD Oregon Health & Science University, Portland, OR Changes in gene expression in metastatic cutaneous squamous cell carcinoma ($9,900) Bryan K. Ward, MD Johns Hopkins University School of Medicine, Baltimore, MD Diabetes and Inner Ear Vestibular Dysfunction ($10,000) Baishakhi Choudhury, MD The University of North Carolina, Chapel Hill, NC The Treatment of Otitis Media with Effusion using CpG Oligodeoxynucleotides ($10,000) Joshua R. Mitchell, MD Vanderbilt University Medical Center, Nashville, TN Biochemical basis for early vs. delayed vocal fold mobilization after microflap ($10,000) Nathan Jowett, MD McGill University, Montreal, Québec Osseointegration Following Ultrafast Laser Ablation Osteotomy ($9,976) AAO-HNSF Maureen Hannley Research Training Award No meritorious applications received AAO-HNSF Percy Memorial Research Award Alexis Donneys, MD The Regents of the University of Michigan, Ann Arbor, MI A Combined Approach for Managing Mandibular Non-Unions After Radionecrosis ($20,000) Christine G. Gourin, MD Johns Hopkins University School of Medicine, Baltimore, MD The Effect of Volume on Long-Term Outcomes and Costs of Head and Neck Cancer ($25,000) Pamela C. Roehm, MD, PhD New York University School of Medicine, New York, NY Injuries and Mechanisms Causing HSV1 Reactivation in Peripheral Neurons ($25,000) Kenneth H. Lee, MD, PhD UT Southwestern Medical Center, Dallas, TX Enhanced Cochlear Implant Signal Transfer With Carbon Nanotube Coated Electrodes ($25,000) AAO-HNSF Health Services Research Grant No meritorious applications received American Head and Neck Society (AHNS) AHNS Pilot Grant Waleed M. Abuzeid, MD The Regents of the University of Michigan, Ann Arbor, MI STAT3 inhibition for the treatment of head and neck cancer ($10,000) Sunshine M. Dwojak, MD Massachusetts Eye and Ear Infirmary, Boston, MA Outcomes among American Indians in South Dakota with Squamous Cell Carcinoma ($10,000) AHNS Alando J. Ballantyne Resident Research Pilot Grant Jonathan R. George, MPH, MD The Regents of the University of California, San Francisco, CA Case-control study of a novel head and neck squamous cell carcinoma biomarker ($10,000) AHNS/AAO-HNSF Young Investigator Combined Award Natalya Chernichenko, MD Memorial Sloan-Kettering Cancer Center, New York, NY The Role of Rho Family Proteins in Perineural Invasion by Cancer Cells ($40,000) Paul M. Weinberger, MD Medical College of Georgia, Augusta, GA Minimally invasive multiplexed assays for the detection of thyroid cancer ($40,000) AHNS/AAO-HNSF Surgeon Scientist Combined Award No meritorious applications received American Hearing Research Foundation (AHRF) AHRF Wiley H. Harrison Memorial Research Award Tara D. Rachakonda, MD Washington University School of Medicine, St. Louis, MO Validity, discriminative ability and sensitivity to change of the HEAR-QL ($25,000) The American Laryngological, Rhinological and Otological Society, Inc., aka The Triological Society The Triological Career Development Awards Ronna Hertzano, MD, PhD University of Maryland, Baltimore, MD Cell type-specific genome-wide mapping of protein-DNA interactions in the ear ($39,820) Bruce K. Tan, MD Northwestern University Feinberg School of Medicine, Chicago, IL The Role of Autoimmunity in Chronic Sinusitis with Nasal Polyps ($39,875) American Rhinology Society (ARS) ARS New Investigator Award Holly Boyer, MD University of Minnesota – Twin Cities, Minneapolis, MN Office-sclerotherapy for epistaxis due to hereditary hemorrhagic telangiectasia ($25,000) ARS Resident Research Grants Nicholas C. Sorrel, MD The University of Texas Health Science Center, Houston, TX Manuka Honey for Management of CRS – an in vitro and in vivo Analysis ($8,000) Samuel L. Oyer, MD Medical University of South Carolina, Charleston, SC Inflammatory role of fibroblasts in chronic rhinosinusitis ($8,000) American Society of Pediatric Otolaryngology (ASPO) ASPO Research Grant Marci Lesperance, MD The Regents of the University of Michigan, Ann Arbor, MI Development of a cost-effective algorithm for evaluation of genetic hearing loss ($25,000) Joseph Haddad, Jr., MD Columbia University Medical Center, New York, NY Identification of Genes Associated with Familial Non-syndromic Cleft Lip/Palate ($20,000) Deafness Research Foundation (DRF) DRF Centurion Clinical Research Award Grant James E. Saunders, MD Trustees of Dartmouth College, Lebanon, NH Genetic Hearing Loss in Remote Nicaraguan Families ($10,000) Olympus Olympus/AAO-HNSF Resident Research Grant Robbi A. Kupfer, MD The Regents of the University of Michigan, Ann Arbor, MI Spontaneous laryngeal reinnervation following recurrent laryngeal nerve injury ($10,000) The Oticon Foundation The Oticon Foundation/AAO-HNSF Resident Research Grant Yu-Lan Mary Ying, MD Baylor College of Medicine, Houston, TX Role of Sirt3 in Hearing Preservation ($11,000) The Plastic Surgery Foundation (PSF) PSF/AAO-HNSF Combined Grant Iram N. Ahmad, MD The University of Iowa, Iowa City, IA Role of p75NTR and Merlin in Schwann Cell Response Following Facial Nerve Injury ($25,000)
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Basic and Translational Research Mini-Program at the 2011 AAO-HNSF Annual Meeting & OTO EXPO
The topic of this year’s Basic and Translational Research program is Pediatrics. In 2008, the focus was Otology, 2009 Rhinology, and 2010 Facial Plastics. The goal of the mini-program is to start at the basic science level of a disease, walk through the steps of how this produces disease, and review the strategies currently in development to treat the disease. This year’s program was developed under the guidance of Joseph E. Kerschner, MD, and John S. Rhee, MD, MPH. Monday, September 12, 2011  8 – 8:50 a.m. Miniseminar: Otitis Media: Evidence-Based Reviews to Change Practice  Moderator: Martin J. Burton, MA, DM, FRCS Presenters: Richard M. Rosenfeld, MD, MPH; Anne G.M. Schilder, MD, PhD 9 – 9:50 a.m. Miniseminar: Genetics in Otolaryngology: Translational Research Moderator: Marci Lesperance, MD Presenters: Stephen B. Gruber, MD, PhD, MPH; Christina L. Runge, PhD 10 – 10:55 a.m. Miniseminar: From Bench to Bedside: Updates in Pediatric Obstructive Sleep Apnea Moderator: Stacey L. Ishman, MD, MPH Presenters: Rakesh Bhattacharjee, MD; Susan Garetz, MD 11 – 11:55 a.m. Miniseminar: Biofilms in Otolaryngology: What Does This Mean to the Clinician?  Moderator: Craig S. Derkay, MD Presenters: J. Christopher Post, MD, PhD, MSS; J. William Costerton, PhD; David H. Darrow, MD, DDS Wednesday, September 14, 2011  9:30 – 10:30 a.m. 2011 Neel Distinguished Research Lecture Biofilms in Health and Disease: The Human Host and its Microbiomes Presenter: J. Christopher Post, MD, PhD, MSS
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Clinical Practice Guidelines and Consensus Statements at the 2011 AAO-HNSF Annual Meeting & OTO EXPO
Monday, September 12, 2011 9:30 – 10:20 a.m. Clinical Consensus Statement: Appropriate Use of CT for Paranasal Sinus Disease Moderator: Gavin Setzen, MD Presenters: Berrylin J. Ferguson, MD, Joseph Han, MD, John S. Rhee, MD, MPH 9:30 – 10:20 a.m. Clinical Practice Guideline: Polysomnography before Tonsillectomy in Children Moderator: Peter S. Roland, MD Presenters: Richard M. Rosenfeld, MD, MPH, Ron B. Mitchell, MD, Norman R. Friedman, MD, DABSM Wednesday, September 14, 2011 9 – 10:20 a.m. Clinical Practice Guideline: Sudden Hearing Loss Moderator: Robert J. Stachler, MD Presenters: Sujana S. Chandrasekhar, MD, Sanford M. Archer, MD, Richard M. Rosenfeld, MD, MPH, Seth R. Schwartz, MD, MPH
AAO-HNSF Clinical Practice Guidelines
Coming Soon: Sinusitis Measures  The Foundation has been working with the AMA Physician Consortium for Performance Improvement (PCPI) on the development of a comprehensive measurement set on sinusitis with underuse and overuse as a component. In addition, there is a measure on patient-reported outcomes reported through a validated questionnaire. The Foundation’s Adult Sinusitis guideline is the basis for the work. The workgroup is co-chaired by Richard M. Rosenfeld, MD, MPH, and William Golden, MD, a primary care physician, with five Foundation members as representatives on the workgroup. The first workgroup meeting was in November 2010, and the measures should be finalized in late summer. There will be an opportunity for public comment through PCPI in July. Once the measures are finalized, they will be sent to the National Quality Forum for endorsement. The measure set will provide an additional opportunity for otolaryngologists to participate in CMS’ quality initiatives, such as the Physician Quality Reporting System and expand upon the existing Otitis Media measures. The intent is for the measures to be included in 2013 PQRS and Stage 2 Meaningful Use. The AAO-HNSF develops clinical practice guidelines and clinical consensus statements to support evidence-based decisions in patient care for its members, the wider clinical community, and the general public. The Foundation developed and published its first guideline in 2006 and has since published at least one new guideline each year. This year, the Foundation will develop and publish two guidelines: Indications for Polysomnography for Sleep-Disorder Breathing Prior to Tonsillectomy in Children and Sudden Hearing Loss and a consensus statement — CT Imaging Indications for Paranasal Sinus Disease. Each will be presented as a mini-seminar during the AAO-HNSF 2011 Annual Meeting & OTO EXPO in San Francisco. In addition, a second consensus statement on Tracheostomy Care has begun development and is expected to be completed by winter 2011. Guideline Development Guidelines are developed using an explicit and transparent a priori protocol for creating actionable statements based on the strength of supporting evidence and the associated balance of benefit and harm. The Foundation’s methodology is outlined in the Clinical Practice Guideline Development Manual, which is available on the Foundation’s website. Guideline development occurs over a 12-month period and the development panel includes a variety of stakeholders representing multiple specialties and subspecialties and consumers. The guideline panel convenes twice in person over a 12-month period, with three conference calls scheduled in between. A final draft of the guideline is distributed for peer review, both internally and externally, and sent for Board approval prior to submission to the journal where the guideline undergoes the traditional peer review by journal editors prior to publication. Guidelines are published in Otolaryngology —Head and Neck Surgery as supplements.  Additionally, copies of each guideline are made freely available via the Foundation’s website or on the National Guidelines Clearinghouse website www.guideline.gov. Guideline Development Task Force (GDTF) The GDTF is comprised of Foundation leadership representatives from multiple specialty and subspecialty societies and has been established to review and prioritize topics submitted for guideline development. The group meets biannually at the Foundation’s headquarters and reviews guideline development progress and prioritizes upcoming work products. Additionally, the GDTF produces a newsletter that highlights the group’s activities and provides updates on guideline development.  Recent editions of the GDTF newsletter are available on the Foundation’s website. Future Guideline Development The Foundation maintains awareness of ongoing progress in the field of guideline development. As such, the Foundation’s guideline development manual is reviewed and updated on a periodic basis to reflect the most up-to-date methodological techniques. Furthermore, the Foundation has just started its second year of collaboration with Richard N. Shiffman, MD, MCIS, and the Yale Center for Medical Informatics as part of the Guidelines into Decision Support (GLIDES) project sponsored by the Agency for Healthcare Research and Quality (AHRQ). The objective of the GLIDES project is the development, implementation, and evaluation of demonstration sub-projects that advance the understanding of how best to incorporate clinical decision support (CDS) into the delivery of healthcare. The project explores how the translation of clinical knowledge into CDS can be routinely applied in practice, and taken to scale, to improve the quality of healthcare delivery in the U.S. As part of this collaboration, over the past year, the Sudden Hearing Loss guideline panel pilot-tested Bridgewiz (an action-statement development tool) and eGLIA (a guideline-implementability appraisal tool). On March 23, the Institute of Medicine (IOM) released two consensus reports, Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust. These reports were produced following a congressional mandate in the Medicare Improvement for Patients and Providers Act of 2008 for two independent studies: one to develop standards for conducting systematic reviews and the other to develop standards for trustworthy clinical practice guidelines. The IOM report, Clinical Practice Guidelines We Can Trust, highlighted eight standards for developing rigorous and trustworthy clinical practice guidelines. The Foundation has reviewed each report and believes that the current AAO-HNSF guideline development methodology, to a large extent, meets the eight standards. However, we recognize that the Foundation’s methodology needs to reflect current best practices. AAO-HNS/F staff attended the May 10 Implementation Workshop on Standards for Systematic Reviews and Clinical Practice Guidelines held by the IOM in Washington, DC. The workshop included presentations and panel discussions on the reports’ standards and recommendations, including an invited presentation by Richard M. Rosenfeld, MD, MPH, the current GDTF chair. The goals of the workshops were to provide an opportunity for stakeholders to learn about, react to, and discuss the IOM reports; identify what actions stakeholders need to take to implement the standards; and highlight what barriers exist to implementation and promote stakeholder collaboration to implementing the recommended standards. AAO-HNS/F staff will work with the GDTF, Dr. Rosenfeld and chair-elect, Seth R. Schwartz, MD, MPH, to develop a strategy for moving forward based on these new recommendations. For more information, contact the Research and Quality Improvement business unit, quality@entnet.org. Copies of the Foundation’s guidelines, the guideline development manual, and information on the GDTF are available on the Foundation’s website at www.entnet.org/Practice/ClinicalPracticeGuidelines.cfm.
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CHEER: Providing a Working Foundation for Expedient Research and Translation
Kris Schulz, MPH, Debara L. Tucci, MD, MS,  and David L. Witsell, MD, MHS “Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe ” …Those who sponsor, perform, and regulate therapeutic research need to find ways of making trials much simpler and much larger. Otherwise, the next 50 years of randomized evidence will not fulfill the promise of 50 years ago, when a properly randomized clinical trial was first published, transforming medical research by its method of generating unbiased answers to many therapeutic questions.” — Richard Peto Statistician, tobacco and cancer Oxford Clinical Trials Service Unit  Creating Healthcare Excellence through Education and Research (CHEER) is a community-based research network currently funded by a National Institute on Deafness and Other Communication Disorders (NIDCD) R21/33 infrastructure grant, entering its fifth and final year of initial funding. (www.cheerresearch.org). The mission of the network is to become the national resource for practice-based clinical research in hearing and communicative sciences. In practical terms, CHEER provides the necessary infrastructure to accelerate clinical research in order to improve patient outcomes. The focus of CHEER is research education. By standardizing Research Coordinator education, sites are “at the ready” to participate, patients are protected and safe, and the integrity of gathered data is assured and maintained. David L. Witsell, MD, MHS, Duke University Medical Center, is the overall grant principal investigator (PI). Kris Schulz, MPH, chief research officer at the AAO-HNS/F, serves in a project leadership role for the grant including the fostering of relationships with AAO-HNSF members for site recruitment. Duke serves as the coordinating center for the network, which relies on a hub-and-spoke concept with five academic hub sites serving to mentor community sites. Community sites range from private practices of all sizes through academic sites without highly formalized research infrastructure. The five academic hubs and their associated PIs are: Duke, Debara L. Tucci, MD, MS; Massachusetts Eye and Ear Infirmary, Steven D. Rauch, MD; University of Michigan, Steven A. Telian, MD; University of Texas – Southwestern, Peter S. Roland, MD; and Oregon Health & Science University, Anh T. Nguyen-Huynh, MD, PhD. A Coordinator Advisory Board, consisting of coordinators from academic and community sites, was developed to ensure the coordinator’s voice is represented and that the practicality of proposed research projects is vetted among all site types and experience levels. This board was developed as it became clear that the coordinator was the crucial component to ensuring the day-to-day commitment of the practice to CHEER and the promotion of its studies and activities. The benefits of community-based research networks to expedient and translatable research include generalizability and representativeness of research findings; answering questions of importance to providers and the community-at-large; expanding the field of clinician-scientists and research coordinators; and facilitating the process of research translation.1 This last point is paramount, as many proven effective treatments do not become incorporated into everyday care.2 As quantified in one study, only 14 percent of findings from research filter into practice, and for those that do, it takes an average of 17 years.3 In its five years, CHEER has gone from a concept on paper to a network of 26 academic and community research sites throughout the country, 22 of which met higher level criteria (based on training, project participation, and annual conference attendance) established for “active sites.” We have sites in 16 states: Arizona, California, Illinois, Indiana, Kentucky, Maryland, Massachusetts, Michigan, North Carolina, New Jersey, New York, Oregon, Pennsylvania, South Carolina, Texas, and Washington. Highlights from the last year include: The Otology Data Collection (ODC) Project was launched in March 2010 and ran through November 2010 as a proof-of-concept initiative testing the network’s readiness to deploy a study. Approximately 1,500 patients were recruited across the sites in this highly successful study focusing on tinnitus and dizziness, both major areas in need of treatment guidance. Patients filled out validated questionnaires and background information for the appropriate condition(s) and physicians filled out an accompanying worksheet on exam and clinical information. A snapshot of this data is provided above. Since the first CHEER publication (Tucci DL, Schulz K, Witsell DL. Building a national research network for clinical investigations in otology and neurotology. Otol Neurotol. 2010 Feb; 31 (2): 190-5.), a second CHEER manuscript on network progress was accepted for publication in March 2011, and a third CHEER manuscript (on the ODC project) was submitted in March 2011. A grant focusing on tinnitus (developed from the CHEER Expert Panel on tinnitus) was submitted last year. Although not funded in the initial submission, it did qualify for resubmission, which is under way. A grant focusing on migrainous vertigo (a result of the CHEER Expert Panel on dizziness) is in development. A poster presentation on the successes of and lessons learned from CHEER was accepted and presented at the Association for Research in Otolaryngology Winter Meeting in February 2011. CHEER continues to host its Annual CHEER Coordinator’s Conference each August at the AAO-HNS/F offices where CHEER site research coordinators attend two days of research training, networking, and mentorship. The online Clinical Scholars program was revamped through CHEER and is a resource for any interested AAO-HNSF member. CHEER submitted an R24 limited competition “renewal grant” in March. The networking aspect of the CHEER Coordinator’s Conference allows for informal conversations, relationship building, and mentorship. CHEER benefits the AAO-HNS/F and its members through its ability to bring more private and community physicians into research. Ultimately the activities and projects, published manuscripts, and grants CHEER has submitted are relevant to both comparative effectiveness research and expedient and relevant research translation, all of which were top priorities indicated by the leadership representing members during the AAO-HNS/F strategic planning. For more information on CHEER, contact Kris Schulz at kschulz@entnet.org. References 1. Zerhouni EA. “Translational research: moving discovery to practice” Clin Pharmacol Ther 2007; 81:126Y8. 2. IOM report “Crossing the Quality Chasm” 3. Balas E et al. “Managing Clinical Knowledge for Healthcare Improvement. Yearbook of Medical Informatics 2000: Patient Centered Systems, Stuttgart, Germany: Schattauer; 2000
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SCAHPS: Status of the AAO-HNSF Pilot Project
By Kris Schulz, MPH and Jean Brereton, MBA The Surgical Consumer Assessment of Healthcare Providers and Systems (SCAHPS®) is a standardized tool sponsored by the American College of Surgeons and the Surgical Quality Alliance that asks consumers and patients to report on and evaluate their experiences and satisfaction with their surgical care. The survey covers topics such as communication skills of providers (surgeon and anesthesiologist) and front-office staff and assesses all phases of the surgery (pre-, intra-, post-operative) for inpatient and outpatient settings. The SCAHPS consists of 45 items: • 12 items about care before surgery • 11 items about care during surgery (including eight items about anesthesiology) • Nine items about care after surgery • Two items about office staff during visits • One item rating the surgeon • One eligibility item • Nine “About You” items Health plans, insurers, and specialty boards may use the data from the SCAHPS for quality improvement activities and other financial incentive programs. Specifically, beginning in 2011, the American Board of Otolaryngology will require assessment of the interpersonal and communication skills of the surgeon using the SCAHPS or an equivalent survey. Given that this is a new tool and there is lack of data on implementing this type of survey and assessing its value, the AAO-HNSF Board of Directors leadership supported the development of this pilot project to: 1. Describe the tool itself and the utility of the scores that assess physician-patient communication to improvement, and 2. Describe the feasibility and challenges of implementing a patient experience survey in busy academic and private otolaryngology—head and neck surgery practices. A copy of the AHRQ Surgical SCAHPS survey can be downloaded at: www.cahps.ahrq.gov/content/products/PDF/Surgical_Eng.doc. Project Status  Survey data collection, which is conducted through Dynamic Clinical Systems, a third-party vendor for data security and credibility reasons, began last August and continued through May. Four sites are participating in the pilot – two academic medical centers and two private practice sites. An interim analysis based on 135 completed surveys was performed earlier this year on data collected through November 2010 and aggregate summary reports with blinded surgeon level information were sent to all participants to begin familiarizing the surgeons with the composite scoring process. At press time, there were 281 surveys completed across four sites and 12 surgeons, with one month remaining in the data collection process. When the final analysis occurs at the conclusion of data collection, the data will be used to develop a manuscript detailing the challenges and lessons learned from the logistical aspect of implementing a patient experience survey, and summary level findings from the responses. Depending on sample sizes, comparisons and correlations will be explored on items such as procedure type and patient demographics. The individual sites and surgeons that participated will also receive data to assist with determining benchmark physicians in key areas or survey composites from which to potentially learn approach, technique, and best practices for improvement opportunities. An example of one of the composites from the survey as reported on in the interim analysis is provided at right.