The Endangered State of Medicare Reimbursement for Cardiothoracic Surgery: A Call to Action.

Reimbursement for cardiothoracic surgery continues to be threatened with enormous financial cuts ranging from 5% to 10% in recent years. In this policy perspective, we describe the history of reimbursement for cardiothoracic surgery, highlight areas in need of urgent reform, propose possible solutions that Congress and the Executive Branch may enact, and call cardiothoracic surgeons to action on this critical issue. Meaningful engagement of members of The Society of Thoracic Surgeons with their elected representatives is the only way to prevent these cuts.

The Association of Socioeconomic Factors With Outcomes for Coronary Artery Bypass Surgery.

BACKGROUND: Numerous studies have identified the associations of socioeconomic factors with outcomes of cardiac procedures. The majority have focused on easily measured factors like sex, race, and insurance status, or on socioeconomic characteristics of patients' 5-digit zip codes. The impact of more granular census-derived socioeconomic information on outcomes has rarely been studied. METHODS: The independent impact of the Area Deprivation Index (ADI) on short-term mortality and readmissions was tested on patients undergoing isolated coronary artery bypass grafting (CABG) surgery in New York by using it in logistic regression models in conjunction with patient risk factors and typical disparities measures (race, ethnicity, payer). Changes in hospitals' risk-adjusted outcomes and outlier status with the addition of socioeconomic measures were also tested. RESULTS: After adjusting for numerous patient characteristics, patients in the fourth and fifth highest ADI quintiles (most deprived) were more likely to experience in-hospital/30-day mortality after CABG surgery (adjusted odds ratio [AOR] 1.54, 95% confidence interval [CI] 1.08, 2.20; and AOR 1.50, 95% CI 1.02, 2.21), respectively. ADI was not associated with readmissions, but African Americans (AOR 1.49, 95% CI 1.18, 1.87), Hispanics (AOR 1.33, 95% CI 1.06, 1.65) and Medicaid patients (AOR 1.34, 95% CI 1.09, 1.64) were more likely to be readmitted. CONCLUSIONS: Patients with high ADIs are more likely to experience short-term mortality after CABG surgery. African Americans, Hispanics, and Medicaid patients are more likely to experience 30-day readmissions. This information should be taken into account when monitoring patients to reduce adverse events following surgery, and more studies related to ADI are needed to fully understand its implications.

Revascularization for Isolated Proximal Left Anterior Descending Artery Disease.

BACKGROUND: Most studies of patients with isolated proximal left anterior descending (PLAD) coronary artery disease do not include all 3 procedural options: percutaneous coronary intervention (PCI), conventional coronary artery bypass graft (CABG) surgery, or minimally invasive CABG. METHODS: New York's cardiac registries were used to identify patients who underwent revascularization for isolated PLAD disease between January 1, 2010, and November 30, 2016, in New York State. After exclusions, 14,327 patients, of whom 13,115 received PCI, 1001 of whom underwent CABG surgery, and 211 of whom underwent minimally invasive CABG were monitored through the end of 2017 to compare outcomes. Registry data were matched to vital statistics data to obtain deaths occurring after discharge and matched to claims data to obtain subsequent admissions for myocardial infarction and stroke. RESULTS: There were no significant differences in mortality or in mortality/myocardial infarction/stroke after 7 years (with median follow-up times in excess of 4 years) among the 3 procedures after adjusting for differences in patient risk factors. However, conventional CABG surgery was associated with a lower subsequent revascularization rate than PCI (adjusted hazard ratio, 0.45; 95% confidence interval, 0.35-0.58) and minimally invasive CABG surgery (adjusted hazard ratio, 0.46; 95% confidence interval, 0.32-0.66). CONCLUSIONS: Among patients with isolated PLAD disease undergoing any of 3 revascularization options (PCI, conventional CABG surgery, or minimally invasive CABG surgery), conventional CABG surgery was associated with lower subsequent revascularization rates, but there were no differences in mortality or mortality/myocardial infarction/stroke rates.

Association of Anesthesiologist Handovers With Short-term Outcomes for Patients Undergoing Cardiac Surgery.

BACKGROUND: Complete handover of anesthesia care to a second anesthesiologist has been demonstrated to be associated with worse short-term adverse outcomes among cardiac surgery patients, but little information from multi-institutional studies is available. METHODS: New York's cardiac surgery registry was used to identify patients who underwent cardiac surgery in New York between 2010 and 2016 with and without complete handovers of anesthesia care. A retrospective observational study with inverse probability treatment weighting (IPTW) based on the propensity score was used to adjust for differences in preoperative patient characteristics while comparing differences in the primary outcome (in-hospital/30 day mortality), major complications in the index admission or within 30 days of the index surgery, readmissions within 30 days, and length of stay. RESULTS: A total of 8.5% of the 103,102 cardiac surgery procedures involved complete handovers. After adjustment, there was a difference between patients with and without handovers in the primary outcome (2.86% vs 2.48%, adjusted risk ratio [ARR] = 1.15 [1.01-1.31]). There was no difference in readmissions within 30 days (13.7% vs 14.4%, ARR = 0.95 [0.90-1.00]), and the differences in complications and length of stay were not clinically meaningful (adjusted differences of <10%). CONCLUSIONS: Cardiac surgery patients in New York who had complete anesthesia handovers experienced higher short-term mortality rates, but there were no meaningful differences in other outcomes. Unnecessary handovers should be carefully monitored.

Hybrid Coronary Revascularization Versus Conventional Coronary Artery Bypass Surgery: Utilization and Comparative Outcomes.

BACKGROUND: Hybrid coronary revascularization (HCR) treats multivessel coronary artery disease by combining a minimally invasive surgical approach to the left anterior descending artery with percutaneous coronary intervention for non-left anterior descending diseased coronary arteries. The objective of this study is to compare HCR and conventional coronary artery bypass graft (CABG) surgery medium-term outcomes. METHODS: Data from multivessel disease patients in New York's cardiac surgery and percutaneous coronary intervention registries in 2010 to 2016 were used to compare mortality and repeat revascularization rates for HCR and conventional CABG after using propensity matching to reduce selection bias. RESULTS: There was a total of 303 HCR (0.80%) patients and 37 556 conventional CABG patients after exclusions. After propensity matching, the respective median follow-up times were 3.72 years and 3.76 years. There was no difference between HCR and conventional CABG in survival at 6 years (80.9% versus 85.8%%, adjusted hazard ratio, 1.44 [0.90-2.31]), but HCR had higher mortality excluding deaths during the first year (adjusted hazard ratio, 1.88 [1.10-3.23]). Conventional CABG patients were more likely to be free from repeat revascularization at 6 years than HCR patients (88.2% versus 76.6%; hazard ratio, 2.22 [1.44-3.42]). CONCLUSIONS: HCR is rarely performed for patients with multivessel coronary artery disease. HCR and conventional CABG had no different 6-year mortality rates, but HCR had higher mortality after 1 year and higher rates of subsequent revascularization that were caused by both the need for repeat revascularization in the left anterior descending artery where minimally invasive CABG was performed, and in the coronary arteries where percutaneous coronary intervention was performed. Graphic Abstract: A graphic abstract is available for this article.

Out-of-Hospital 30-day Deaths After Cardiac Surgery Are Often Underreported.

BACKGROUND: Operative mortality (in-hospital during the index admission or within 30 days of the procedure after discharge) is commonly used as a quality of care measure for public reporting of cardiac surgery outcomes, but the ability to capture out-of-hospital deaths accurately remains undetermined. The objective of the study was to estimate the impact of incomplete reporting of out-of-hospital deaths on hospital risk-adjusted mortality and outlier status. METHODS: New York State's 2014 to 2016 cardiac registry data were used to compare the capture of 30-day postprocedure deaths after discharge with and without the use of national and state-level vital statistics data for all 54,442 patients undergoing isolated coronary artery bypass graft, cardiac valve surgery, or both. Hospital risk-adjusted operative mortality rates and mortality outliers were compared based on statistical models that were developed with and without the use of vital statistics data. RESULTS: Thirty-day deaths postprocedure after discharge ranged from 10% to 39% of all operative deaths among cardiac surgical procedures. More than 30% of these deaths were missing without vital statistics confirmation for 7 of the 10 cardiac procedures examined, and more than 40% were missing for 5 of the procedures examined. When vital statistics data were used to confirm 30-day postprocedure deaths after discharge, an additional high outlier for valve surgery was identified. CONCLUSIONS: Operative mortality after cardiac surgery is often underreported owing to a considerable percentage of out-of-hospital cardiac surgery deaths that are missed by reporting centers. This can adversely affect the assessment of hospital risk-adjusted mortality in public reports.

Multiple Versus Single Arterial Coronary Bypass Graft Surgery for Multivessel Disease.

BACKGROUND: Despite recent guideline statements, there is still wide practice variation in the use of multiple arterial grafts (MAGs) versus single arterial grafts (SAGs) for patients with multivessel disease undergoing coronary artery bypass graft surgery. This may be related to differences in findings between observational and randomized controlled studies. OBJECTIVES: This study sought to compare intermediate-term MAG and SAG outcomes with enhanced matching to reduce selection bias. METHODS: New York's cardiac registry identified 63,402 multivessel disease patients undergoing coronary artery bypass graft surgery between January 1, 2005, and December 31, 2014, to compare outcomes (median follow-up 6.5 years) for patients receiving SAGs and MAGs. SAG and MAG patients were propensity matched using 38 baseline characteristics to reduce selection bias. The primary endpoint was mortality, and secondary endpoints included repeat revascularization and a composite endpoint of mortality, acute myocardial infarction, and stroke. RESULTS: Before matching, 20% of procedures employed MAG. At 1 year, there was no mortality difference between matched MAG and SAG patients (2.4% vs. 2.2%, adjusted hazard ratio [AHR]: 1.11; 95% confidence interval [CI]: 0.93 to 1.32). At 7 years, MAG patients had lower mortality (12.7% vs. 14.3%, AHR: 0.86; 95% CI: 0.79 to 0.93), a lower composite outcome (20.2% vs. 22.8%, AHR: 0.88; 95% CI: 0.83 to 0.93), and a lower repeat revascularization rate (11.7% vs. 14.6%, AHR: 0.80; 95% CI: 0.74 to 0.87). At 7 years, the subgroups for which MAG did not have a lower mortality rate included patients with off-pump surgery, 2-vessel disease with right coronary artery disease, recent acute myocardial infarction, renal dysfunction, and patient ≥70 years of age. CONCLUSIONS: Mortality and the composite outcome were similar between MAG and SAG patients at 1 year, but lower for MAG after 7 years. Patients of higher volume MAG surgeons experienced lower MAG mortality.

Usefulness of Circulating Caspase-3 p17 and Caspase-1 p20 Peptides and Cardiac Troponin 1 During Cardioplegia to Gauge Myocardial Preservation.

Evidence is accumulating that cardiac apoptosis occurs and contributes to myocyte cell death during myocardial ischemia. Cardioplegia, defined as the temporary cessation of cardiac activity during cardiac surgery, is a clinically controlled condition with myocardial ischemia and reperfusion. Our goal was to determine whether the apoptotic biomarker caspase-3 p17 is elevated in the coronary sinus (CS) during cardioplegia and if any elevations were reflected in the peripheral venous (PV) blood. Levels of the necrotic biomarker cardiac troponin I (cTnI) and the inflammatory marker caspase-1 p20 were also quantified in CS and PV. Blood was drawn before and at the end of cardioplegia in PV and CS and levels of p20, p17, and cTnI were measured. cTnI, p20, and p17 PV levels were significantly elevated compared with the control population before and at the end of cardioplegia. PV levels of all 3 markers increased after cardioplegia. CS levels were higher than PV levels for all 3 markers at both time points. Our data are consistent with the occurrence of cardiac apoptosis and inflammation during cardioplegia, in addition to necrosis. The heart-derived markers contributed to the peripheral levels and suggest that measurement of PV biomarker concentrations can be used to gauge cardiac preservation.

Mitral valve repair versus replacement for patients with preserved left ventricular function without heart failure symptoms.

OBJECTIVE: The purposes of this study are to compare outcomes of mitral valve repair (MV-repair) and mitral valve replacement for patients with severe mitral regurgitation with preserved ventricular function and no congestive heart failure (CHF) symptoms and to examine variations in surgeon choice of procedure and outcomes by surgeon volume. METHODS: In total, 2259 consecutive patients in 42 New York State hospitals with the characteristics mentioned previously who underwent mitral valve repair (1801, 79.7%) or replacement between January 1, 2008, and December 31, 2014, were identified from a mandatory statewide clinical registry. Propensity-matching was used to compare mortality and competing risk analyses were used to compare nonfatal outcomes. Median follow-up was 4.0 years. The use of mitral repair and risk-adjusted mortality for surgery were also examined as a function of individual surgeon mitral case volume. RESULTS: Propensity-matched patients who underwent MV-repair experienced a significantly lower mortality rate at 4 years (3.5% vs 12.1%, P < .001). Greater-volume surgeons were more likely to perform MV-repairs (92% vs 84%, 74%, and 69% in lower volume quartiles, respectively). No significant differences in mortality were observed among volume quartiles. CONCLUSIONS: Patients with chronic severe primary mitral valve regurgitation with preserved ventricular function and no CHF symptoms who underwent MV-repair experienced lower mortality and no different reoperation, CHF, or stroke readmission rates than patients who underwent replacement. Greater-volume surgeons were more likely than their lower volume counterparts to choose mitral repair. Repair should be considered as the surgical option for these patients whenever possible.

Advancing the Legislative Priorities of Cardiothoracic Surgeons: The Society of Thoracic Surgeons Political Action Committee.

In the late 1990s, several federal government health policy decisions threatened the viability of thoracic surgery as a specialty. To respond to such decisions, active participation in political processes was given extremely high priority by the Executive Committee of The Society of Thoracic Surgeons (STS). Creation of the STS Political Action Committee (STS-PAC) in 1997 was a part of the platform of participation. The purpose of the STS-PAC is to enhance the Society's voice and stature in health care policymaking. Although the STS-PAC receives voluntary contributions from STS members, on average, only 10% of STS members contribute to the STS-PAC. For the 2015-2016 election cycle, there were 542 contributors to the STS-PAC totaling $273,000. An annual contribution of $100 from every STS member would put the STS-PAC into the top 10 for medical PACs (whereas currently it is ranked 22nd of 28 in the group of physician and dental association PACs). Despite the relatively small dollar amount the STS-PAC directs, its strategic disbursement of these dollars has yielded impressive results. For example, the STS-PAC was able to use its influence to effectively stop the Centers for Medicare and Medicaid Services from implementing a potentially calamitous rule that would effectively end traditional global surgical payments. Other advocacy successes include providing guidance to the Centers for Medicare and Medicaid Services in developing the national coverage determination for transcatheter aortic valve replacement and structuring its complex reimbursement schedule, and ensuring that a provision was included in the bill that would give the STS National Database access to claims data. The STS-PAC is a principal component of the STS' advocacy armamentarium. Despite the many successes of the STS-PAC, with even modest contributions by more STS members, the STS-PAC could become a leading medical PAC, and would give the STS an even stronger presence and voice in Washington, DC. Clearly, contributing to the STS-PAC provides STS members the opportunity to have a voice and an impact on health policy and the care of their patients.

How Is Physician Work Valued?

Strategies to value physician work continue to evolve. The Society of Thoracic Surgeons and The Society of Thoracic Surgeons National Database have an increasingly important role in this evolution. An understanding of the Current Procedural Terminology (CPT) system (American Medical Association [AMA], Chicago, IL) and the Relative Value Scale Update Committee (RUC) is necessary to comprehend how physician work is valued. In 1965, with the dawn of increasingly complex medical care, immense innovation, and the rollout of Medicare, the need for a common language describing medical services and procedures was recognized as being of critical importance. In 1966, the AMA, in cooperation with multiple major medical specialty societies, developed the CPT system, which is a coding system for the description of medical procedures and medical services. The RUC was created by the AMA in response to the passage of the Omnibus Budget Reconciliation Act of 1989, legislation of the United States of America Federal government that mandated that the Centers for Medicare & Medicaid Services adopt a relative value methodology for Medicare physician payment. The role of the RUC is to develop relative value recommendations for the Centers for Medicare & Medicaid Services. These recommendations include relative value recommendations for new procedures or services and also updates to relative value recommendations for previously valued procedures or services. These recommendations pertain to all physician work delivered to Medicare beneficiaries and propose relative values for all physician services, including updates to those based on the original resource-based relative value scale developed by Hsaio and colleagues. In so doing, widely differing work and services provided can be reviewed and comparisons of their relative value (to each other) can be established. The resource-based relative value scale assigns value to physician services using relative value units (RVUs), which consist of three components: work RVU, practice expense RVU, and malpractice RVU, also known as professional liability insurance RVU. The Centers for Medicare & Medicaid Services retains the final decision-making authority on the RVUs associated with each procedure or service. The purpose of this article is to discuss the role that the CPT codes and the RUC play in the valuation of physician work and to provide an example of how the methodology for valuation of physician work continues to evolve.

Utilization and 1-Year Mortality for Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement in New York Patients With Aortic Stenosis: 2011 to 2012.

OBJECTIVES: The purpose of this study was to investigate changes in the use of transcatheter aortic valve replacement (TAVR) relative to surgical aortic valve replacement (SAVR) and to examine relative 1-year TAVR and SAVR outcomes in 2011 to 2012 in a population-based setting. BACKGROUND: TAVR has become a popular option for patients with severe aortic stenosis, particularly for higher-risk patients. METHODS: New York's Cardiac Surgery Reporting System was used to identify TAVR and SAVR volumes and to propensity match TAVR and SAVR patients using numerous patient risk factors contained in the registry to compare 1-year mortality rates. Mortality rates were also compared for different levels of patient risk. RESULTS: The total number of aortic valve replacement patients increased from 2,291 in 2011 to 2,899 in 2012, an increase of 27%. The volume of SAVR patients increased by 7.1% from 1,994 to 2,135 and the volume of TAVR patients increased 157% from 297 to 764. The percentage of SAVR patients that were at higher risk (≥3% New York State [NYS] score, equivalent to a Society of Thoracic Surgeons score of about 8%) decreased from 27% to 23%, and the percentage of TAVR patients that were at higher risk decreased from 83% to 76%. There was no significant difference in 1-year mortality between TAVR and SAVR patients (15.6% vs. 13.1%; hazard ratio [HR]: 1.30 [95% confidence interval (CI): 0.89 to 1.92]). There were no differences among patients with NYS score <3% (12.5% vs. 10.2%; HR: 1.42 [95% CI: 0.68 to 2.97]) or among patients with NYS score ≥3% (17.1% vs. 14.5%; HR: 1.27 [95% CI: 0.81 to 1.98]). CONCLUSIONS: TAVR has assumed a much larger share of all aortic valve replacements for severe aortic stenosis, and the average level of pre-procedural risk has decreased substantially. There are no differences between 1-year mortality rates for TAVR and SAVR patients.

Thirty-Day Readmissions After Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis in New York State.

BACKGROUND: Several studies have compared short-term and medium-term mortality rates for patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR), but no studies have compared short-term readmission rates for the 2 procedures. METHODS AND RESULTS: New York's Cardiac Surgery Reporting System was used to propensity match 617 TAVI and 1981 SAVR patients using numerous patient risk factors contained in the registry. The 389 propensity-matched pairs were then used to analyze differences in readmission rates between the 2 groups. TAVI and SAVR readmission rates were also compared for patients with a history of congestive heart failure and for patients aged ≥80. Also, reasons for readmission for TAVI and SAVR patients were examined and compared. Readmission rates were not statistically different for all propensity-matched TAVI and SAVR patients (respective rates, 18.8% and 19.3%; P=0.86). After further adjustment using a logistic regression model, there was still no significant difference (adjusted odds ratio, 0.97; 95% confidence interval [0.68-1.39]). For patients aged ≥80, the 30-day readmission rates were 19.9% and 22.0% (P=0.59), and when further adjusted using the logistic regression model, adjusted odds ratio=0.89 (0.55-1.45). For patients with a history of congestive heart failure, the respective rates were 22.8% and 20.4% (P=0.56), and with further adjustment, adjusted odds ratio became 1.15 (0.72-1.82). CONCLUSIONS: There are no statistically significant differences between TAVI and SAVR patients in short-term readmission rates.

Comparison of intermediate-term outcomes of coronary artery bypass grafting versus drug-eluting stents for patients ≥75 years of age.

Several randomized controlled trials and observational studies have compared outcomes of percutaneous coronary interventions (PCIs) with drug-eluting stents (DESs) and coronary artery bypass grafting (CABG), but they have not thoroughly investigated the relative difference in outcomes for patients aged ≥75 years. In this study, a total of 3,864 patients receiving DES and CABG (1,932 CABG-DES pairs) with multivessel coronary disease were propensity matched using multiple patient risk factors and were compared with respect to 3 outcomes (mortality, stroke/myocardial infarction [MI]/mortality, and repeat revascularization) at 2.5 years with a mean follow-up of 18 months. The mortality rates (DES/CABG hazard ratio 1.06, 95% confidence interval 0.87 to 1.30) and the stroke/MI/mortality rates (DES/CABG hazard ratio 1.15, 95% confidence interval 0.97 to 1.38) for the 2 procedures were not significantly different. Repeat revascularization rates were significantly higher for patients who received DESs. In conclusion, older patients experienced similar mortality and stroke/MI/mortality rates for CABG and PCI with DES, although repeat revascularization rates were higher for patients undergoing PCI with DES.

Long-term mortality of coronary artery bypass graft surgery and stenting with drug-eluting stents.

BACKGROUND: Few studies have examined differences in long-term mortality between coronary artery bypass graft surgery and stenting with drug-eluting stents (DES) for multivessel disease without left main coronary artery stenosis. This study compares the risks of long-term mortality between these 2 procedures during a follow-up of up to 5 years. METHODS: Patients who underwent isolated bypass surgery (n=13,212) and stenting with DES (n=20,161) between October 2003 and December 2005 in New York State were followed for their vital status through 2008. To control for treatment selection bias, bypass and stenting patients were matched on age, number of diseased coronary vessels, presence of proximal or nonproximal left anterior descending (LAD) artery disease, and propensity of undergoing bypass surgery. Five-year survival rates for the 2 procedures were compared and hazard ratios for death of bypass surgery compared with stenting were obtained. RESULTS: The respective 5-year survival rates in the 8,121 pairs of matched bypass and stenting patients were 80.4% and 73.6% (p<0.001), and the risk of death after bypass surgery was 29% lower than for stenting (hazard ratio = 0.71, 95% confidence interval: 0.67 to 0.77, p<0.001). Significantly lower risks of death for bypass surgery were observed in patients with LAD artery disease but not in patients without LAD artery disease. Significantly lower risks of death for bypass surgery were also found in all patient subgroups defined by the presence of selected baseline risk factors. CONCLUSIONS: Bypass surgery is associated with lower risk of death than stenting with DES for multivessel disease without left main stenosis.

Risk score for predicting in-hospital/30-day mortality for patients undergoing valve and valve/coronary artery bypass graft surgery.

BACKGROUND: Risk scores are simplified linear formulas for predicting mortality or other adverse outcomes at the bedside without personal digital assistants or calculators. Although risk scores are available for valve surgery, they do not predict short-term mortality (within 30 days of surgery) after hospital discharge. METHODS: New York's Cardiac Surgery Reporting System 2007 to 2009 data were matched to vital statistics data to identify valve surgery with and without concomitant coronary artery bypass graft (CABG) surgery deaths occurring in the index admission or within 30 days after the procedure in any location. Risk scores were created to easily predict these outcomes by modifying more complicated logistic regression models. RESULTS: There were 13,455 isolated valve surgery patients and 8,373 valve/CABG surgery patients in the study. The respective in-hospital/30-day mortality rates were 4.03% and 6.60%. There are 11 risk factors comprising the isolated valve surgery score, with risk factor scores ranging from 1 to 8, and the highest observed total score is 28. There are 14 risk factors comprising the valve/CABG surgery score, with risk factor scores ranging from 1 to 6, and the highest observed total score is 19. The scores accurately predicted mortality in 2007 to 2009 as well as in 2004 to 2006, and were strongly correlated with complications and length of stay. CONCLUSIONS: The risk scores that were developed provide quick and accurate estimates of patients' chances of short-term mortality after cardiac valve surgery.