More from July 2012 - Vol. 31 No. 07
Eugene N. Myers, MD, FRCS, Edin (Hon)
Pavel Dulguerov, MD, PhD, University of Geneva, did a remarkable job organizing the Third International Congress on Salivary Gland Diseases, March 22-23, which was attended by 152 delegates from 33 countries.
The First International Congress took place in Geneva in 2002, and the extremely successful Second Congress in Pittsburgh in 2007. Five years later, there was enough new information for the organizing committee to gather the world’s outstanding specialists who deal with salivary gland function and disorders of the salivary apparatus.
The make-up of both faculty and audience reflected the belief that the symbiotic contributions of clinicians, surgeons, pathologists, immunologists, radiologists, and researchers from different basic science fields make for a stimulating, highly productive way to study salivary gland problems.
The meeting format allowed substantial open discussion after a formal presentation of important new information, as well as panel discussions, numerous free papers, and 22 poster presentations. Yoon-Woo Koh, MD, and his Korean colleagues presented significant new approaches including robot-assisted resection of the submandibular gland via the retroauricular approach.
On the first day, Vincent L. M. Vander Poorten, MD, and Christopher H. Rassekh, MD, moderated a plenary session on pleomorphic adenomas, and featured lecturers, such as Dominique Chevalier, MD; Orlando Guntinas-Lichius, MD; Eugene N. Myers, MD; Chris H. J. Terhaard, MD; and Peter Zbaren, MD.
Pilar Brito-Zeron, MD, Manuel Ramos-Casals, MD, and Athanasios G. Tzioufas, MD, contributed a plenary session on Sjögren syndrome. Drs. Myers and Chevalier moderated the third plenary session on refinements in parotid surgery, with Drs. Dulguerov and Guntinas-Lichius, Francis Marchal, MD, Miguel Quer i Agusti, MD, and Enrico Sesenna, MD.
The second day included sessions on xerostomia, challenging cases of pleomorphic adenoma, and salivary gland cancer with Jorn Bullerdiek, MD, Fernando L. Dias, MD, Silvano DiPalma, MD, Roberto A. Lima, MD, PhD, and Drs. Rassekh, Terhaard, and Vander Porten. Claudio Cernea, MD, gave a special lecture on parotidectomy for skin malignancy.
A thoroughly enjoyable gala dinner with an exceptional menu took place at the Hotel Beau Rivage, one of Geneva’s finest hotels, and was a highlight of the Congress.
First International Sialendoscopy Conference
The First International Sialendoscopy Conference took place March 24-25, with Dr. Marchal as the conference director and Dr. Myers as the honorary president.
For the first time, this conference brought together 106 leading specialists with expertise in sialendoscopy from 48 countries. This followed the unparalleled success of sialendoscopy courses since 2002, in which more than 600 physicians from 54 countries were trained in this new field.
During the ensuing years, the technique has attracted significant interest and popularity worldwide. Building on Dr. Marchal’s pioneering work in Geneva, sialendoscopy has been continuously developed and improved. Using techniques of minimally invasive surgery, which allow for optical exploration of the salivary duct system, it dramatically changed the management of patients with chronic sialadenitis and salivary calculi, saving many patients from removal of their salivary glands.
After Dr. Marchal’s opening address, there followed brief introductory comments about sialendoscopy from many international thought leaders. Dr. Myers gave an interesting and provocative lecture entitled “Sialendoscopy: A Paradigm Shift?” showing remarkable improvements in management of salivary gland inflammatory conditions using sialendoscopy.
Six sessions included a variety of outstanding speakers discussing assessment, sialadenitis, non-sialendoscopy treatments, conservative techniques, issues at the beginning, stones, strictures, and the future.
A gala dinner at the Restaurant du Parc des Eaux Vives, Geneva, climaxed the outstanding social events. Overall, this meeting was highly successful, introducing beginners to fundamentals of sialendoscopy and experts to new concepts. This is the third part of a Bulletin series of instruction courses samplers each month from myriad options to be offered at the AAO-HNSF 2012 Annual Meeting & OTO EXPO in September. One notable course in each of the nine categories will be listed with an excerpt from its objective each month. To read the full course description and to get your first choice of courses, sign up early at www.entnet.org/Annual_Meeting. Make sure to take advantage of the scheduler to review the full listing of courses and to find those of special interest to you.
Business of Medicine/Practice Management
4612-1 Developing a Quality Control Program for Surgeons
Carl H. Snyderman, MD; Erin M. McKean, MD
1:15 pm-2:15 pm, September 12
Quality issues affect all aspects of patient care at all levels of an institution. Benefits of measuring quality include generating data for informed consent, improving surgical care, and providing a marketing advantage. Measurement of quality is now required as part of Medicare Pay for Performance and for Accountable Care Organizations. Indicators of quality can be both tangible (readmission, death, infection, recurrence of disease) and intangible (patient satisfaction, duration of surgery, cosmesis, length of stay, cost, and experience). The government and consumer groups now rank physicians and hospitals on many of these measures. The first step in improving quality is deciding what to measure. Groups such as the American College of Surgeons have established national databases to assist surgeons and hospitals (NSQIP). In industry, there are multiple tools that are used to measure quality that can be applied to surgical practice. The primary goal of such tools is to minimize variation; these tools can be applied to both qualitative and quantitative data. Statistical methods allow the individual surgeon to assess quality measures over time and diagnose and eliminate cases of variation. It is only through a quality improvement program that surgeons can overcome their cognitive biases and improve surgical care.
Facial Plastic and Reconstructive Surgery
2711-1 Open Rhinoplasty: Arming Novices for Success
Edmund A. Pribitkin, MD
3:00 pm-4:00 pm, September 9
This course presents the author’s 18-year experience in teaching resident rhinoplasty in a program where residents actually perform the surgery rather than simply watching the attending physician work. The author’s approach is a distillation of safe techniques enabling residents to learn the procedure while minimizing the attending physician’s stress and maximizing patient outcomes. It proceeds step-by-step through cases and stops everywhere a mishap can occur, explaining how to avoid the mishap in the future and how to correct it in the present. Preoperative planning, patient encounters, and common rhinoplasty scenarios, as well as avoidance and management of postoperative complications are reviewed.
1723-1 Head and Neck Trauma: Lessons of War and Mass Casualties
Joseph Brennan, MD
3:00 pm-4:00 pm, September 9
Great advances in the surgical management of head, facial, and neck trauma have been made during times of military combat and mass casualty treatment. This includes triage of mass casualty victims, management of acute airway injuries and control of bleeding, neck exploration for penetrating neck trauma, and reconstruction of soft tissue and bone injuries. The goal of this instruction course is to educate the otolaryngology community about the state-of-the-art management of specific otolaryngic injuries with emphasis on lessons learned in both Iraq and Afghanistan. The specific trauma topics to be discussed include the following:
Role of otolaryngologist in a mass casualty
Airway management during trauma
Evaluation and treatment of penetrating neck trauma
Reconstruction of bony and soft tissue head and neck trauma
Controversies in the management of head and neck trauma
The civilian practice of otolaryngology-head and neck surgery has benefited greatly from wartime surgical experience with this knowledge improving our ability to care for gunshot wounds, industrial and motor vehicle accidents, and other traumatic injuries in our civilian emergency rooms. With the looming threat of terrorism and mass casualties in the United States, otolaryngologists should be aware of the latest trauma advances.
Head and Neck Surgery
3706-1 Conservation Surgery for Oropharyngeal Cancer
F. Christopher Holsinger, MD; Olivier Laccourreye, MD
3:00 pm-4:00 pm, September 11
Both transoral and transcervical surgical approaches preserving the external framework of the upper aerodigestive tract without sacrificing critical neurologic and muscular structures. As such, conservation surgery for oropharyngeal cancer provides functional organ preservation and excellent oncologic outcomes. Yet radiation therapy (alone or with concomitant chemotherapy) has evolved as the primary treatment modality for oropharyngeal cancer (OC). However, the recent rise of HPV-associated OC has ushered in a new era. Patients present at a much earlier age and, as such, may be at greater risk for the long-term side effects of XRT and chemoradiation.
3825-1 Endoscopic Microsurgical Techniques for Laryngeal Disease
Mark S. Courey, MD; Katherine C. Yung, MD
4:15 pm-5:15 pm, September 11
Hoarseness, voice change, is due to alterations in laryngeal vibration. Both neoplastic and non-neoplastic laryngeal diseases change laryngeal histology, which then hampers vibratory patterns and impairs the laryngeal vocal output. This course will briefly review normal laryngeal histology and the changes created by laryngeal diseases. With an understanding of these changes, case presentations will be used to demonstrate endoscopic microsurgical techniques using cold steel and laser instrumentation. At the completion of this course the participants will possess an understanding of these contemporary techniques and be able to apply them in their clinical practice. The course will discuss the instrumentation requirements for endoscopic exposure and microscopic visualization. To a limited extent the preoperative and postoperative management will also be presented.
1720-2 Chronic Otitis Media: Ear Surgery
Derald E. Brackmann, MD; William M. Luxford, MD
3:00 pm-5:00 pm, September 9
This course details the techniques used at the House Ear Clinic for the management of chronic otitis media. The course content varies from year to year. Topics that may be included are the office management of the draining ear and a discussion of the indication for surgery. The clinic favors the outer surface graft technique and the intact canal wall procedure for management of the mastoid in most cases of cholesteatoma. The clinic does not hesitate to perform canal wall down procedures, however, and the presenters may discuss any of these operations. Finally, management of complications of chronic otitis media may be discussed. This course is illustrated by slides and videotapes of surgical procedures and supplemented by handouts on the subject.
3621-1 Pediatric Airway 101
Robin T. Cotton, MD
1:45 pm-2:45 pm, September 11
A fundamental knowledge of the pediatric airway, including adequate assessment and basic airway management skills is an essential component of pediatric otolaryngology. This course seeks to provide a simple overview of basic management of the pediatric airway. This will include assessment of the pediatric airway, from office flexible endoscopy, through the techniques of rigid bronchoscopy of the neonatal and pediatric airway. Diagnosis of common conditions including laryngomalacia and vocal cord paralysis, as well as assessment of subglottic stenosis, laryngeal clefts, and complete tracheal rings will be covered. Operative management of laryngomalacia, as well as neonatal and pediatric tracheotomy will be discussed, as will the difficult intubation and foreign body management. The minimal desirable equipment for pediatric airway assessment and management will be covered.
1715-2 Gussack Memorial: Avoiding Bad Results in Sinus Surgery
Martin J. Citardi, MD; Christopher T. Melroy, MD; Scott M. Graham, MD
3:00 pm-5:00 pm, September 9
This course presents the causes of recurrent/persistent rhinosinusitis and poor surgical results/outcomes after endoscopic sinus surgery by addressing the theory and technique of functional endoscopic sinus surgery (FESS). The review of cases in which surgery has failed can provide important information about appropriate treatment strategies. Inadequate initial surgical management may precipitate worsening or persistent disease. The discussion will include the surgical management of the middle turbinate, the maxillary ostium, the frontal recess, and the sphenoethmoid recess. Specific cases that illustrate appropriate surgical management in these areas will be discussed. Instrumentation, including the microdebrider and image-guided surgery, will be presented. Principles of postoperative management will be emphasized. The philosophy of FESS incorporates a comprehensive understanding of pre-existing medical conditions that may contribute to sinusitis. Immunological issues, antimicrobial resistance, sinusitis caused by enteric gram-negative organisms, fungal sinusitis, and nasal polyposis will also be addressed. Strategies for the incorporation of innovative treatments, such as topical antibiotic regimens, will be described. The major complications of FESS will be presented. Specific recommendations for the intraoperative management and prevention of these complications will be made. Review of clinical cases will serve to illustrate critical points.
3627-2 Integrating Oral Appliances into Your Sleep Apnea Practice
Ofer Jacobowitz, MD, PhD; Alan J. Chernick, DDS; Tod C. Huntley, MD; Christopher J. Lettieri, MD
1:45-3:45 pm, September 11
Comprehensive management of OSA requires a personalized approach. Non-adherence to CPAP and fear of surgery are common among OSA patients. Oral appliance therapy is recognized as an effective treatment for OSA and can be employed as a primary treatment modality or following a suboptimal surgical or CPAP outcome. In order to integrate this modality into the sleep apnea practice, otolaryngologists should acquire the requisite conceptual understanding and practical skills. What are the indications and contraindications for oral appliances? What is their mechanism of action? What are the relevant features for patient assessment? How is appliance fitting and titration performed? What are the relevant features of the informed consent for this modality, especially for otolaryngologists? What are the problems and complications of oral appliance therapy? How do you get reimbursed for your work? This course will use lecture and a hands-on session where participants will practice taking impressions and bite registrations. The participants will benefit from instruction by experts in the field of dental sleep medicine. Since 1896, the AAO-HNSF Annual Meeting & OTO EXPO has provided an opportunity for thousands of practitioners in otolaryngology-head and neck surgery to learn the latest evidence-based medicine and clinical practices, and explore hundreds of products and services displayed in the OTO EXPO. This is the largest international meeting of otolaryngologists and attracts the best and brightest in our field. Medical students, residents, and fellows-in-training can benefit from the tremendous opportunities designed especially for them at the annual meeting. This article discusses what will be available in September for this key audience in Washington, DC.
The annual meeting is the premier source of education for otolaryngologists in training, offering a comprehensive collection of the latest advances in otolaryngology with more than 400 poster presentations, more than 80 miniseminars, and more than 300 instruction courses. In addition to a wealth of scientific presentations and education programs, the annual meeting offers a variety of AAO-HNSF programming to encourage medical student, resident, and fellow-in-training involvement in AAO-HNSF activities.
For starters, residents, medical students, and fellows-in-training will save nearly 50 percent off the member price of registration if registered before August 3. The savings began with the early registration deadline with 70 percent off the member rate, if registered by June 22. Verification of resident, student, and/or fellow-in-training status must be submitted during the registration process to take advantage of the savings.
This Discounted Registration Fee Includes the Following:
Access to all Scientific Sessions and Honorary Guest Lectures
Entrance to the OTO EXPO
The opportunity to review the latest scientific research in the poster area
Access to the complimentary shuttle service to and from most official AAO-HNSF hotels and the Walter E. Washington Convention Center
Entrance to the Opening Ceremony and President’s Reception
The annual meeting can be an overwhelming experience for a new attendee. Don’t miss the First-Time Attendees’ orientation from 5:30-6:15 pm on Saturday, September 8. This event will help you discover how to get the most from the annual meeting and will connect you with other newcomers right from the start. You will have an opportunity to participate in small group discussions led by Academy leaders and staff. Academy leaders facilitate special roundtable discussions, including discussion for Spanish-speaking visitors.
Section for Residents and Fellows-in-Training
The Section for Residents and Fellows (SRF) General Assembly, taking place from 2:30 pm-4:30 pm, Monday, September 10, is the business meeting of the SRF Section. The agenda will feature presentations from Academy leaders, a keynote speaker, section elections, the presentation of the 2012 SRF survey results, resolutions, and the presentation of awards. As a medical student, resident, and fellow-in-training this is an ideal venue to meet colleagues and have a voice in AAO-HNSF initiatives and activities.
Monday, September 10, is Residents Day with activities specifically planned for you. We encourage you to take advantage of this opportunity and make plans now to attend.
6th Annual Academic Bowl
Another entertaining and informative event at the annual meeting is the Academic Bowl. Now in its sixth year, the contest pits four resident teams against each other in a clinically oriented test of knowledge. The 2012 Academic Bowl teams are from Otolaryngology Residency Programs at Eastern Virginia Medical School, Southern Illinois University, Loma Linda University, and Henry Ford Hospital. Everyone in attendance also gets to participate through an audience response system. The Academic Bowl will take place at 10:30 am Sunday, September 9.
Special Education Opportunities
Medical students, residents, and fellows-in-training can receive free admission to many of the instruction courses at the meeting. Check in at the Member Resident Instruction Course Booth at the Walter E. Washington Convention Center each morning for free tickets to some of the most popular instruction courses. Seats have been reserved for member residents of the AAO-HNSF on a first-come, first-served basis.
The Tuesday morning scientifc miniseminar program will be geared toward residents, fellows, and young physicians. It includes three miniseminars that focus on interviewing for a position, setting up or running a practice, and tips for balancing personal life with the demands of a physician.
During “Interviewing: What to Ask and How,” physicians who are starting or changing careers will be exposed to mock interviews, learn successful interview tips, and discover important questions that physicians should expect during the interview. The “Top 10 Business Mistakes I Have Made in Practice” miniseminar focuses on what is often not discussed in practice management—the mistakes made in setting up and running a practice. It features four otolaryngologists who have all formed their own practices in different stages of their careers. They will discuss errors they made along the way, including poor job selection, improper choice of partners, errors in forming professional relationships, isolation of referring physicians, and failed business ventures. “Finding Balance in a Surgical Career” will conclude the program. Physicians face extraordinary demands on their time and need to learn how to balance the demands of careers and family, while also allowing time to cultivate personal interests. During this interactive miniseminar, fellow otolaryngologists will share practical techniques and pearls regarding time management and work-life balance. The panel will include both private and academic otolaryngologists who manage busy practices and make substantial contributions to their institutions and specialty societies while maintaining strong relationships with their friends and families, and pursuing interests outside of medicine.
There will be something for everyone at the annual meeting. All medical students, residents, or fellows-in-training should strongly consider attending this year’s conference. The opportunities for learning, networking, and leading abound within the Academy. Miniprogram: Sleep Medicine
This is part of a Bulletin series of course samplers from the myriad options to be offered at the 2012 AAO-HNSF Annual Meeting & OTO EXPO in September. To read the full course description and to get your first choice of courses, sign up early at www.entnet.org/Annual_Meeting. Make sure to take advantage of the scheduler to review the full listing of courses and find those of special interest to you.
This year’s Basic & Translational Research miniprogram will focus on sleep medicine. The program, developed by Edward M. Weaver, MD, MPH, chair; Scott E. Brietzke, MD, MPH, co-chair; and Pell Ann Wardrop, MD, co-chair, seeks to cover a broad spectrum of topics relevant to sleep apnea and surgical treatment, with a focus on research topics and data. The topics range from basic science relevant to understanding the upper airway pathology (miniseminar no. 1), to data on emerging surgical treatments (miniseminar no. 2), to research that influences policies relevant to sleep surgery (miniseminar no. 3).
The miniprogram will highlight major advances in the field of sleep apnea research relevant to surgery and the important areas in need of deeper understanding at each level, from bench to policy development.
The guest speakers are leaders in the field of sleep medicine. The 2012 Neel Distinguished Research Lecturer, Allan I. Pack, MBChB, PhD, was selected to complement the three miniseminars. Dr. Pack is a world-renowned expert in the field and a dynamic speaker. His lecture will provide an overview on genetics in the context of OSA, sharing both experience and data from a large genetics study he is leading in Iceland, an area that provides unique advantages for genetics studies.
Atul Malhotra, MD, is the director of the Sleep Program at Harvard’s Brigham & Women’s Hospital and an international leader on normal upper airway physiology and sleep apnea airway pathophysiology. While otolaryngologists are expert in assessing the anatomical features of the upper airway, most otolaryngologists do not as well understand the physiological basis of upper airway collapse during sleep.
Nelson Powell, MD, DDS, is clinical professor of sleep medicine at Stanford University and is a pioneer of sleep surgery and sleep research. Dr. Powell will speak on a new area of research using computational fluid dynamics to understand airflow and its potential adverse effects on the airway tissues in normal and sleep apnea patients. Dr. Powell’s presentation will complement the presentation by Leila Kheirandish-Gozal, MD, associate professor of pediatrics at the University of Chicago, who will speak on upper airway tissue damage, i.e., neuropathy, as a pathogenetic mechanism for OSA.
Innovations in surgical treatment of OSA include modification and refinements of existing techniques, topics covered in instruction courses annually at the AAO-HNSF Annual Meeting & OTO Expo. Promising new innovations also include using new technologies, new approaches, and newly invented devices to address upper airway collapse during sleep.
Robotic approaches for pharyngeal surgery are being tested for OSA, and early data on this approach will be presented during the second miniseminar, along with three hypoglossal nerve stimulation devices, which are in various stages of human testing and show early promise as a tool to treat tongue-base obstruction in OSA. A review of the latest available data for this approach will be presented. Other new devices and approaches will also be covered, some with more data than others. Thus, this miniseminar serves to review data on the latest cutting-edge technologies being tested to treat OSA surgically.
The third and final miniseminar will discuss recently published reviews of sleep surgery that focus on sleep testing outcomes, review data on sleep surgery outcomes, and present new data on cost-effectiveness of sleep surgery. Several reviews and guidelines for the treatment of OSA have been published in the last few years. The reviews and criticisms of surgical treatment outcomes have focused largely on inadequate cure rates of OSA as measured by the apnea-hypopnea index. This miniseminar reviews the state of the sleep surgery literature and policy, and it looks forward to data and models that may help dictate future policy for the role of sleep surgery.
Sleep Apnea—From Bench to Bedside and Beyond
8 am–9:20 am Tuesday, September 11
Obstructive Sleep Apnea Pathophysiology
Moderator: Edward M. Weaver, MD, MPH
Upper airway physiology and OSA pathophysiology, Atul Malhotra, MD;
Upper airway neuropathy in the pathogenesis of OSA, Leila Kheirandish-Gozal, MD;
Computer modeling of the upper airway in normals and OSA, Nelson B. Powell, DDS, MD.
Novel Sleep Apnea Surgical Treatments
9:30 am–10:20 am
Moderator: Scott E. Brietzke, MD, MPH
Robotic sleep surgery, Erica R. Thaler, MD;
Hypoglossal nerve stimulators, Eric J. Kezirian, MD, MPH;
Novel surgical treatments under development, B. Tucker Woodson, MD.
Sleep Surgery Treatment Outcomes & Policy
10:30 am–11:50 am
Moderator: Pell Ann Wardrop, MD
Systematic reviews and guidelines, Ofer Jacobowitz, MD, PhD;
Sleep surgery treatment outcomes, Edward M. Weaver, MD, MPH;
Cost-effectiveness of uvulopalatopharyngoplasty, Jonathan R. Skirko, MD. by Matt Brown, Special to the Bulletin
The Bulletin asked some of the Academy’s leaders a few questions regarding what goes into getting the most of the Annual Meeting & OTO EXPO. They were kind enough to share what works for them and what doesn’t. Here’s what they had to say:
Liana Puscas, MD
American Medical Association (AMA) Delegation Chair Liana Puscas, MD, said the best thing to do before attending the meeting is to look through the courses being offered, decide what looks interesting, and make sure to sign up early.
“The popular sessions tend to sell out,” she said. “I certainly plan my meeting by picking out specific sessions and themes. In terms of mornings, which are free, I think it is important to go through and choose the themes you are interested in to organize your experience and I think you need to do a bit of preparation.”
Dr. Puscas said it is also important not to miss the advance registration deadline.
“If you know you are going to the meeting, go ahead and sign up, because the difference between the two options is pretty significant…there is a substantial difference in savings—so if you know you’re going to go, you should just sign up,” she said.
Dr. Puscas said planning ahead is key to having a great meeting.
“There is a lot of great stuff in the program and you have to decide what you want to experience,” she said. “People should also look at the activities that are available in the city the meeting is in. So when you are planning your travel, add a few days to your schedule that will allow you to enjoy that city. That adds to the overall experience and allows you to mix in some fun with all of that work.”
Lauren Zaretsky, MD
Lauren Zaretsky, MD, chair, Ethics Committee, said the first thing she does prior to the annual meeting every year is join the Millennium Society.
“It is one of the highlights of the meeting to be able to catch up with people from around the country,” she said. “The Millennium lounge adds to the whole annual meeting experience. It is the place you can catch up with everybody you haven’t seen since last year.”
In preparation for the annual meeting, Dr. Zaretsky said she likes to review the whole calendar, look at all of the instruction courses and presentations and make sure to highlight the things she is interested in. From there, she said she coordinates those items with all of the committee meetings she needs to attend.
“I usually go through multiple times—sometimes by topic—but I usually look for the new courses so I am able to get a flavor of the new information out there,” she said. “I do the same with miniseminars, incorporating things that are new into my schedule.”
“I use the Bulletin program in conjunction with the website and whittle it down, then I merge everything together, all the while making sure I keep in mind there needs to be time to catch up with colleagues,” Dr. Zaretsky said. “I also stay as close to the convention center as possible, which means I try to register as early as possible so I avoid all the running back and forth.”
Dr. Zaretsky said she also makes dinner plans with colleagues months in advance.
“I have to make sure I have my dinner plans arranged well ahead of time because the people I want to make sure to see are generally in high demand and this is the only opportunity to see many of them each year,” she said. “I’m also looking forward to going to Washington, DC, because it is such a terrific city, so I need to figure those plans out ahead of time, too.”
Duane J. Taylor, MD
Diversity Committee Chair Duane J. Taylor, MD, said he gets the most out of the annual meeting by planning ahead.
“I also look for the courses and miniseminars that interest me most and provide a variety of perspectives on evaluation and management of otolaryngologic disorders,” he said.
Dr. Taylor said the annual meeting also offers the opportunity for face-to-face question-and-answer opportunities, and dialogue with colleagues.
“I would also encourage Bulletin readers to take the opportunity when attending the meeting to find out firsthand about the Academy’s various committees and leadership opportunities,” he said. “Most of the committees are open and you can get a flavor for what it might be like to be a part of a particular group that interests you.”
Dr. Taylor said he would encourage members who have been to “more than a few” meetings to make sure they attend some course, meeting, or seminar that is different from what they have attended before.
“Our Academy has so many things to offer attendees at the annual meeting,” he said. “Take the time while you are at the meeting to find out about them. Lastly, enjoy the collegiality of known colleagues, take the time to meet new ones, and interact with the residents, because they appreciate it.” On May 7, the Academy submitted comments to the Centers for Medicare and Medicaid Services (CMS) regarding the proposed rule for “Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2.” The Academy expressed its support for adopting robust and applicable electronic health records (EHRs) into practices to improve quality of care and enhance patient safety, but cautioned that stringent program requirements with high satisfaction thresholds will hinder health information technology (HIT) adoption.
While the Academy supports a staged approach to the EHR meaningful use incentive program, it believes this approach must take into account the current technological realities and the additional financial and administrative costs that will be incurred by physicians to meet all of the program requirements. Our letter focused on the proposed Menu Set of Measures and Objectives and the proposed Options for reporting Clinical Quality Measures (CQMs).
Menu Set: Measures and Objectives
CMS proposed 17 core objectives and five menu objectives that Eligible Professionals (EPs) must meet, or qualify for an exemption. EPs must meet all 17 core objectives and three out of five menu objectives. The Academy expressed concerns about many of these core and menu objectives. Often, the objectives set incredibly high thresholds that would be difficult for physicians to meet and attest to for successful meaningful use. Specific concerns were raised by the Academy about several specific core objectives including: Computerized Physician Order Entry (CPOE) requirements; electronic prescribing; incorporating clinical lab-test results into EHR as structured data; providing patients with electronic access to their health information and providing clinical summaries for patients; and medication reconciliation.
In the proposed rule, CMS included a measure for CPOE for more than 60 percent of medication, laboratory, and radiology orders made by a licensed professional. The Academy recommended that CMS remove the laboratory and radiology requirements during the EHR reporting period and decrease the proposed threshold for medication orders to require only one laboratory and one radiology order be entered electronically. The rule also proposed an increase in the requirement of orders transmitted as e-prescriptions, which the Academy does not support. Another requirement proposed was the incorporation of lab test results into EHRs. Although the Academy is supportive of the idea, it believes this requirement forces practices to purchase costly lab interfaces in order to meet meaningful use requirements.
The proposed rule also requires physicians to provide clinical summaries within 24 hours and to provide patients the ability to view their health information within four days of the information being available to the practice. The Academy believes patients should have access to information online, but the “24-hour and four day” time limits are arbitrary and fail to recognize that physician practices are not typically open 24 hours a day. In addition, this requirement fails to appreciate that some information should be provided to patients only during a face-to-face encounter.
Clinical Quality Measures
In the proposed rule, CMS includes two reporting options for consideration for CY 2014, Option 1 and Option 2. Option 1 includes two alternatives: 1a and 1b; however, only one method will be finalized. In Option 1a, EPs would report 12 CQMs from those listed in Table 8 of the proposed rule, including at least one measure from each of the six domains. These domains include the following:
Patient and family engagement;
Population and public health;
Efficient use of healthcare resources; and
The proposal for Option 1b includes EPs who would report 11 “core” CQM listed in Table 6, plus one “menu” CQM. Option 2 would allow Medicare EPs who submit and satisfactorily report Physician Quality Reporting System (PQRS) measures under the PQRS EHR reporting option, using certified EHR technology, to satisfy their CQM reporting requirement under the Medicare EHR incentive program.
The Academy supports having options 1 and 2 to allow otolaryngologists to participate in the program, while it continues to develop specific clinical quality measures. Having the two options allows flexibility. Of the two Option 1 reporting options, Option 1a (12 measures, reporting at least one measure across the six domains) is preferable as it would allow more members to participate rather than submitting zero denominators. The Academy also encouraged CMS to consider a third option where EPs would report six CQMs, including at least two clinically relevant measures from any, not each, of the six domains. This is a more feasible option that would help ensure EPs can identify measures specific to their specialty.
Along with its comment letter, the Academy also signed on to two additional letters drafted by the American Medical Association and the American College of Surgeons. In these letters, the signed organizations expressed their desire to work with CMS on the adoption of EHR and Meaningful Use, but outlined concerns related to the stringent requirements necessary to meet Meaningful Use that could exclude specialists, such as otolaryngologists. The Academy signed onto these letters to reiterate common concerns across specialties regarding the proposed rule, but where there is any ambiguity, its comments take precedence.
You can see the entire letter to CMS at http://www.entnet.org/Practice/ONC.cfm. Questions about EHR, Meaningful Use, or the proposed rule for Stage 2 should be directed to the Health Policy Unit at firstname.lastname@example.org. Every day the Academy receives member inquiries and notifications regarding claim denials and payment policy issues that arise when seeking payment for otolaryngology procedures from private insurers and Medicare. In response, the Academy has established policy that we follow when we receive inquiries about private payer denials to determine whether the matter is a local or state issue, or a national issue that the Academy Physician Payment Policy (3P) workgroup would need to investigate further. We have found that many times there is a better outcome when a local issue is addressed by the local AAO-HNS physician members who work directly with the payer’s Medical Director on issue resolution.
The Academy has resources available to members, including the coding hotline, information accessible on the Academy’s Practice and Advocacy websites, appeal template letters, clinical indicators, and policy statements to help members obtain appropriate payment for various otolaryngology procedures. The Academy’s Health Policy team closely monitors and tracks private payer policies and Medicare Administrative Contractor (MAC) policies affecting members. Although the Academy cannot represent physician members individually on each issue with payers, we believe the established policy provides beneficial assistance to members having problems with getting claims paid and we appreciate being notified of any problems you are encountering so we can track the issue and provide any additional assistance possible.
To further assist members, the Academy has outlined the following recommended steps for members when you encounter difficulties obtaining payment for your services:
Contact the Academy’s coding hotline to ensure that the service was billed appropriately (e.g., appropriate modifiers used with appropriate CPT codes). The Coding Hotline is available 9 am-6 pm EST at 1-800-584-7773. This service is an Academy membership benefit (please have your member ID available when calling).
Consult the Academy website for various resources to assist with an appeal for a specific service. Some helpful resources include:
Clinical Indicators: http://www.entnet.org/Practice/clinicalIndicators.cfm
CPT for ENT articles: www.entnet.org/Practice/cptENT.cfm
Clinical Practice Guidelines: http://www.entnet.org/Practice/clinicalPracticeguidelines.cfm
Appeal Template Letters: http://www.entnet.org/Practice/Appeal-Template-letters.cfm
Policy Statements: http://www.entnet.org/Practice/policystatements.cfm
For payer issues at the state level, we recommend you contact your state otolaryngology society or state medical society to report the issue. They may be able to provide a better idea of how widespread an issue is among providers in the area. You can access contact information for several state otolaryngology societies at http://www.entnet.org/Community/BOGSocieties.cfm?View=State (Login required). For issues with private payers we also recommend members initially attempt to work directly with the payer’s medical director to obtain more information on their policies and the rationale for denying the initial claim. To do so, members should access the carrier or third party payer’s website, logging in as a provider, and search for the policy relevant to your geographic jurisdiction.
For Medicare payment issues, we often recommend you contact the Medicare Administrative Contractor’s (MAC) medical director directly, and contact your regional MAC’s Carrier Advisory Committee (CAC) representative. Currently, there is an ENT CAC representative designated to each state within a MAC jurisdiction (15 geographic regions nationwide). Each representative acts as a liaison between Medicare contractors and state specialty societies. For more information on the CAC representative nomination process, or for local CAC representative contact information, email Health Policy email@example.com.
The Academy encourages members to take full advantage of available appeals processes when encountering denied claims. Even in cases where you may feel no progress is made, it is important to exhaust your right to appeal in order to gather pertinent information necessary for the Academy to understand the issue. Once you take these recommended steps and a service continues to be inappropriately denied, the Health Policy team may request additional information, including a copy of the applicable policy (this includes denial letters, national or local coverage policies, or any other documentation the payer has provided you during your appeals process, with patient HIPAA information redacted from any materials you provide to the Academy), so staff and 3P can try to determine the root cause of the payer’s denial.
Then 3P will determine how widespread your specific issue is and whether additional advocacy efforts are required.
If you believe services are being inappropriately denied by a private payer, or your MAC, and have exhausted all appeal options to rectify payment; please email the Health Policy team at firstname.lastname@example.org. Richard W. Waguespack, MD; Michael Setzen, MD; Jenna Kappel; and Joseph Cody
During the last year, the Physician Payment Policy Workgroup (3P), supported by Health Policy staff, has been tirelessly working with insurers to advocate for changes to restrictive policies that limit the use of a balloon as a tool in a standard approach to sinus ostial dilation procedures. Private payers like Blue Cross Blue Shield Association (BCBSA), Humana, and HealthNow developed policies that designate stand-alone ostial dilation as “Investigative/Not Medically Necessary.” The Academy strongly disagrees with these policies and believes that the use of a balloon is acceptable and an appropriate therapeutic option for selected patients with sinusitis.
In early 2011, 3P and Academy staff began conversations with the national medical director from BCBSA regarding its balloon sinus ostial dilation draft reference medical policy. In all of these communications, the Academy expressed disagreement with the classification of balloon sinus ostial dilation as “Investigational/Not Medically Necessary” and provided evidence supporting the safety and effectiveness of the procedure. These communications included a letter from Academy Executive Vice President and CEO David R. Nielsen, MD, responding to the draft reference medical policy and a conference call with members from 3P and Academy staff on the final reference policy. Despite these efforts, BCBSA decided to keep the “Investigational/Not Medically Necessary” designation until future studies could meet the research criteria necessary for the policy to be changed. The Academy has continued to communicate with Blue Cross Blue Shield to provide additional evidence and advocate for a change in its policy at the national level.
At the local level, Gavin Setzen, MD, a member of the Academy’s Board of Directors who serves on the Medical Management Clinical Committee for Blue Shield Northeastern New York (BSNENY, also known as HealthNow, representing roughly 500,000 people in New York), advocated for review and removal of the “experimental” and “not medically necessary” designation in the policy for balloon sinus ostial dilation surgery. During the March meeting of the Medical Management Clinical Committee, HealthNow reviewed its policy and in light of the new research presented by Dr. Setzen and others, and decided to change the designation to “medically necessary.” In the new policy, effective May 1, HealthNow will now consider the use of a catheter-based inflatable device (balloon ostial dilation) in the treatment of medically refractory chronic sinusitis as medically necessary when used as a minimally invasive alternative to endoscopic sinus surgery. The policy also states when balloon ostial dilation is performed in conjunction with a medically necessary functional endoscopic sinus surgery (FESS) in the same sinus, balloon ostial dilation is considered to be not medically necessary as it would be an integral part of FESS, and therefore, not be separately payable.
In April, the Academy delivered comments to Humana regarding its balloon dilation policy. Humana’s policy designated standalone balloon ostial dilations as “Investigational/Not Medically Necessary,” therefore limiting physician choice. In the letter sent to Humana, the Academy expressed disagreement with the policy designating stand-alone ostial dilations as “Investigational/Not Medically Necessary,” and provided evidence showing the widespread use and clinical experience of the procedure. The letter also sought to clarify which patient populations are appropriate for balloon dilations. In response to comments submitted by the Academy, Humana amended its policy and now supports physician choice when treating chronic sinusitis. The updated policy allows the use of balloon ostial dilation as a standalone and as a hybrid procedure when deemed clinically appropriate by the surgeon.
In addition to these changes, multiple other plans across the country have reviewed and changed their policies. Wellmark and Blue Cross Blue Shield Montana both now allow a hybrid approach and allow the use of a balloon catheter in FESS. Blue Cross Blue Shield Louisiana, CGS Medicare, Blue Cross Blue Shield North Dakota, Blue Cross Blue Shield Wyoming, Healthcare Service Corporation (Blue Cross insurer for IL, TX, NM, and OK), Blue Cross Blue Shield Western New York, and Network Health Plan now all allow the standalone use of a balloon catheter as an alternative to FESS. With these changes, the policies of roughly 194 million people now cover balloon dilation only procedures.
These policy changes show how important it is for Academy members to advocate at the local level. It is important to nurture good relationships with medical directors and decision makers, become involved in the committee structures, and be well prepared to present a cogent argument supported by clinical data. “Persistence beats resistance” in most cases, according to Dr. Setzen. In the meantime, the Academy will continue to advocate for physician choice and changes to policies in order to allow the use of a balloon.
If you are denied the use of a balloon, please forward information, indicating whether the full session is being denied and in what setting the procedure is being denied, to email@example.com so we can continue to track these problems. Please also let us know if your local BCBSA plan is covering and paying for balloon sinus ostial dilation. The Academy has developed a template letter for members to utilize to appeal denials, which can be found at http://www.entnet.org/Practice/Appeal-Template-letters.cfm. Stay tuned to “The News” and our Private Payer page at http://www.entnet.org/Practice/News-and-Updates-from-Private-Payers.cfm for updates on additonal Academy advocacy efforts.