HRS/ACC scientific statement: Guiding principles on the performance of intracardiac ablation procedures in ambulatory surgical centers.

HRS/ACC Scientific Statement: Guiding Principles on the Performance of Intracardiac Ablation Procedures in Ambulatory Surgical Centers.

There is an increasing acceptance of conducting minimally invasive transforaminal lumbar interbody fusion (TLIF) in ambulatory surgical centers (ASCs). The Centers for Medicare and Medicaid Services (CMS) introduced the Hospitals Without Walls (HWW) program in March 2020. This program granted hospitals regulatory flexibility to offer services and procedures in nontraditional locations, including ASCs. However, implementation hurdles persist. A survey was sent to 235 surgeons regarding the use of ASCs for performing TLIF surgeries on elderly patients. Multiple-choice questions covering various aspects of TLIF practice preferences, including surgical indications, decision factors for choosing ASCs over hospitals, implementation hurdles, reimbursement concerns, staffing issues, and the impact of CMS rules and regulations on TLIF in ASCs, particularly concerning physician ownership and self-referral conflicts governed by the Stark law, were asked. The survey completion rate was 25.8% (Figure 1). The most common surgical indications for TLIF in ASCs were spondylolisthesis (80%), spinal stenosis (62.5%), and low back pain (47.5%). Most surgeons (78%) believed TLIF could be safely performed in ASCs. Streamlined workflow, lower infection rates, and cost-effectiveness were advantages listed by 58.5% of surgeons. Patient's medical history (75.8%), followed by ASC resources and capabilities (61%) and surgeon preference (61%), were relevant factors. Higher efficiencies at ASCs (14.6%), contractual issues (9.8%), and ownership issues (7.3%) were less relevant to surgeons. About 65.9% of surgeons reported lower reimbursement in ASCs, and 43.9% said it was an implementation hurdle. Lower direct costs were reported by 53.7% of surgeons. Other hurdles included a lack of trained staff (24.4%), inadequate staffing (22.0%), cost overruns (26.8%), high Joint Commission or the Accreditation Association for Ambulatory Health Care credentialing costs, and surgeons feeling uncomfortable performing TLIF in ASCs (22.0%). Only 17.1% listed medical problems as a reason their patient was considered unsuitable for the ASC environment. A majority (53.7%) stated that their ASCs complied with strict Stark requirements by disclosing physician ownership interests. However, 22% of surgeons reported self-referrals under the "In-Office Ancillary Services Exception" allowed by the Stark law. Our survey data show that surgeons' perceptions of current CMS rules and regulations may hinder the transition into the ASC setting because they think the reimbursement is too low and the regulatory burden is too high. ASCs have disproportionally higher initial acquisition and ongoing costs related to staff training and maintenance of the TLIF technology that CMS should consider when determining the appropriate financial remuneration for these complex procedures. ASC offers a viable and attractive option for their TLIF procedure with the advantage of same-day discharge and at-home recovery.

Utilization and Reimbursements of Primary Total Joint Arthroplasty in Ambulatory Surgical Centers: Analysis of Medicare Part A and B Databases

The Centers for Medicare & Medicaid Services (CMS) began reimbursement for percutaneous coronary intervention (PCI) performed in ambulatory surgical centers (ASC) in January 2020. The ability to perform PCI in an ASC has been made possible due to the outcomes data from observational studies and randomized controlled trials supporting same day discharge (SDD) after PCI. In appropriately selected patients for outpatient PCI, clinical outcomes for SDD or routine overnight observation are comparable without any difference in short-term or long-term adverse events. Furthermore, a potential for lower cost of care without a compromise in clinical outcomes exists. These studies provide the framework and justification for performing PCI in an ASC. The Society for Cardiovascular Angiography and Interventions (SCAI) supported this coverage decision provided the quality and safety standards for PCI in an ASC were equivalent to the hospital setting. The current position paper is written to provide guidance for starting a PCI program in an ASC with an emphasis on maintaining quality standards. Regulatory requirements and appropriate standards for the facility, staff and physicians are delineated. The consensus document identified appropriate patients for consideration of PCI in an ASC. The key components of an ongoing quality assurance program are defined and the ethical issues relevant to PCI in an ASC are reviewed.

Ambulatory surgical centers (ASCs) play a considerable role in providing surgical care in the United States. However, compared to hospitals, ASCs may have less oversight and less-well-developed policies for credentialing and privileging. Specialty board certification is one metric for measuring physician competence. What proportion of ASCs currently requires board certification for privileging is unknown. This article examines the relationship between board certification and privileging policies at ASCs in the United States. A telephone survey of privileging personnel among a convenience sample of 139 freestanding ASCs with two or more specialty services was conducted between February and May 2007. Fifty out of 81 eligible ASCs completed the survey, resulting in a cooperation rate of 62 percent. More than half of ASCs surveyed require that surgical specialists (54 percent, N=27), nonsurgical specialists (56 percent, N=22), and non-American Board of Medical Specialties (ABMS) specialists (56 percent, N=24) be board certified at some point during their tenure. Among ASCs that call for board certification during physician tenure, 11 percent (N=3) require surgical specialists, 5 percent (N=1) require nonsurgical specialists, and 12 percent (N=3) require non-ABMS specialists to hold current board certification at the point of initial privileging. Twenty-nine ASCs (59 percent) allow physicians to retain their privileges after certification expires. Ensuring safe medical care necessitates coordination across healthcare organizations and regulatory agencies. Nevertheless, our results indicate that almost half of multispecialty ASCs are not using this measure of physician competence issued by specialty boards as part of their privileging process.

More than 5000 ambulatory surgical centers (ASCs) in the United States participate in the Medicare program. Little is known about infection control practices in ASCs. The Centers for Medicare & Medicaid Services (CMS) piloted an infection control audit tool in a sample of ASC inspections to assess facility adherence to recommended practices. To describe infection control practices in a sample of ASCs. All State Survey Agencies were invited to participate. Seven states volunteered; 3 were selected based on geographic dispersion, number of ASCs each state committed to inspect, and relative cost per inspection. A stratified random sample of ASCs was selected from each state. Sample size was based on the number of inspections each state estimated it could complete between June and October 2008. Sixty-eight ASCs were assessed; 32 in Maryland, 16 in North Carolina, and 20 in Oklahoma. Surveyors from CMS, trained in use of the audit tool, assessed compliance with specific infection control practices. Assessments focused on 5 areas of infection control: hand hygiene, injection safety and medication handling, equipment reprocessing, environmental cleaning, and handling of blood glucose monitoring equipment. Proportion of facilities with lapses in each infection control category. Overall, 46 of 68 ASCs (67.6%; 95% confidence interval [CI], 55.9%-77.9%) had at least 1 lapse in infection control; 12 of 68 ASCs (17.6%; 95% CI, 9.9%-28.1%) had lapses identified in 3 or more of the 5 infection control categories. Common lapses included using single-dose medication vials for more than 1 patient (18/64; 28.1%; 95% CI, 18.2%-40.0%), failing to adhere to recommended practices regarding reprocessing of equipment (19/67; 28.4%; 95% CI, 18.6%-40.0%), and lapses in handling of blood glucose monitoring equipment (25/54; 46.3%; 95% CI, 33.4%-59.6%). Among a sample of US ASCs in 3 states, lapses in infection control were common.

Medicare reimbursement for physician work depends on the estimated time and intensity - which encompasses technical skill, cognitive load, and stress - required to perform services. The Centers for Medicare and Medicaid Services (CMS) quantitatively expresses intensity estimates as compensation rates per unit time. This study aimed to characterize compensation rates under the Medicare Physician Fee Schedule (PFS) for operative procedures commonly performed by otolaryngologists. This study was a retrospective, cross-sectional analysis. This study was a retrospective, cross-sectional analysis of fiscal year 2018 PFS specifications and publicly available Medicare Part B utilization data for the top 100 highest-volume procedures furnished by otolaryngologists to Medicare beneficiaries in inpatient and ambulatory surgical center (ASC) settings between January 1, 2018, and December 31, 2018. Co-primary outcomes were the estimated 1) total compensation rate ($/min) and 2) intraservice (i.e., "skin-to-skin" time) compensation rate ($/min) for each included procedure. The analytic sample included 147 unique procedure types (settings non-mutually exclusive): 82 inpatient procedure types (n = 33,907 procedures) and 95 ASC procedure types (n = 34,765 procedures). In the inpatient setting, median total compensation rate and intraservice compensation rates were $1.50/min (interquartile range [IQR]: $1.19/min-$1.65/min) and $2.27/min (IQR: $1.69/min-$2.68/min), respectively. In the ASC setting, median total compensation rate and intraservice compensation rates were $1.48/min (interquartile range [IQR]: $1.27/min-$1.77/min) and $2.39/min (IQR: $1.82/min-$2.91/min), respectively. At the service line level, volume-weighted total (inpatient: $1.91/min, ASC: $1.90/min) and intraservice (inpatient: $3.84/min, ASC: $3.37/min) compensation rates were highest for rhinologic procedures. Compensation rates under the Medicare PFS varied widely for operative procedures commonly performed by otolaryngologists. NA Laryngoscope, 131:E1785-E1791, 2021.

Getting to Know The ‘Silent Accreditor’

Introduction: Magnetic resonance imaging (MRI) has historically been contraindicated for patients with MRI non-conditional (i.e. legacy) cardiac implantable electronic devices (CIED). Recent trials have demonstrated safety of MRI in legacy CIED patients, with the Center for Medicare & Medicaid Services (CMS) revising MRI coverage to include these patients in 4/2018. We sought to determine the effect of this policy change on MRI utilization for legacy CIED patients with acute ischemic stroke or transient ischemic attack (AIS/TIA) and contemporary use of MRI for these patients. Methods: We performed an interrupted time series analysis of MRI utilization for AIS/TIA patients with the CMS MRI coverage revision for legacy CIED patients serving as the intervention. Using Optum claims data from 1/2012 to 7/2019, we identified AIS/TIA hospitalizations and CIED implantations and interrogations using ICD-9/10 and CPT codes, respectively. The intervention’s effect on MRI utilization for AIS/TIA was determined for patients with and without CIEDs separately. For patients treated after the CMS coverage revision, we used multivariable logistic regression to determine the association between lack of CIED and MRI utilization for AIS/TIA. Results: We identified 417,899 patients hospitalized for AIS/TIA, of which 30,425 patients (7%) had a CIED (CIED patients: age 78.0 ±10.2 years, 45% female; non-CIED patients: age 74.1 ±11.8 years, 55% female). From 2012 to 2019, MRI utilization for AIS/TIA increased from 3% to 20% for CIED patients and 58% to 66% for non-CIED patients. The CMS coverage revision was associated with a 4.2% absolute (25% relative) additional increase in MRI utilization for CIED patients with AIS/TIA. In multivariable regression, non-CIED patients treated after the CMS coverage revision, as compared to CIED patients, were substantially more likely to undergo MRI for AIS/TIA (adjusted OR 6.7, 95% CI: 6.3-7.1, p<0.001). Conclusions: Despite an increase in MRI utilization for AIS/TIA patients with CIEDs attributable to the CMS coverage revision and trials demonstrating safety, a large disparity in use of MRI for AIS/TIA patients with CIEDs persists. Identification and resolution of barriers to appropriate MRI use in AIS/TIA patients with CIEDs are needed.

Defining nurses' ethical practices in the 21st century.

First-in-man implantation of a gold-coated biventricular defibrillator: Difficult differential diagnosis of metal hypersensitivity reaction vs chronic device infection

Bringing New Technologies to Market: Hurdles and Solutions

BACKGROUND AND OBJECTIVE:Accreditation is usually a voluntary program in which trained external peer reviewers evaluate a healthcare organization's compliance and compare it with pre-established performance standards. The aim of this study was to evaluate the impact of accreditation programs on the quality of healthcare servicesMETHODS:We did a systematic review of the literature to evaluate the impact of accreditation programs on the quality of healthcare services. Several databases were systematically searched, including Medline, Embase, Healthstar, and Cinhal.RESULTS:Twenty-six studies evaluating the impact of accreditation were identified. The majority of the studies showed general accreditation for acute myocardial infarction (AMI), trauma, ambulatory surgical care, infection control and pain management; and subspecialty accreditation programs to significantly improve the process of care provided by healthcare services by improving the structure and organization of healthcare facilities. Several studies showed that general accreditation programs significantly improve clinical outcomes and the quality of care of these clinical conditions and showed a significant positive impact of subspecialty accreditation programs in improving clinical outcomes in different subspecialties, including sleep medicine, chest pain management and trauma management.CONCLUSIONS:There is consistent evidence that shows that accreditation programs improve the process of care provided by healthcare services. There is considerable evidence to show that accreditation programs improve clinical outcomes of a wide spectrum of clinical conditions. Accreditation programs should be supported as a tool to improve the quality of healthcare services.

INTRODUCTION: Interspinous process devices (IPDs) are a popular less invasive treatment option for lumbar degenerative disease. Studies suggest they may yield initial symptomatic relief but are not better than traditional surgery in improving function or quality of life and may increase reoperation and costs. Ideal indications remain contested. METHODS: Centers for Medicare and Medicaid Services Physician/Supplier Procedure Summary data sets (2017-2020) were queried by CPT codes for lumbar interlaminar/interspinous process stabilization/distraction devices without fusion. Utilization rates were normalized per 10,000 lumbar fusions. RESULTS: IPD utilization increased by 329% from 2017-2020. Percutaneous IPD utilization increased to 31.8 (+1,267%), while open procedures decreased to 4.4 (-27%). Pain management/anesthesia placed the majority of IPDs and increased utilization the most (27.4, +1,387%). Physical medicine and rehabilitation (PM&R) had the second-highest rate of utilization (3.5, +1,492%). Neurosurgery (2.3, -15%) and orthopedics (0.7, -63%) decreased utilization. Ambulatory surgical centers (ASCs) increased utilization the most (25.8, +907%). Outpatient procedures increased (9.2, +162%), while inpatient procedures decreased (1.2, -49%). IPD reimbursements decreased to $400 (-44.6%), with decreasing trends in percutaneous ($364, -28.6%) and open placement ($776, -6.8%). Reimbursements were highest for orthopedics ($800, +0.6%) and lowest for pain management/anesthesiology ($362, -26.7%). Reimbursements decreased across all settings, especially outpatient (-48.8%) and inpatient (-35.9%). CONCLUSIONS: Despite uncertainty of indications for IPDs, utilization increased by 329% when normalized to lumbar fusions to account for changes in disease prevalence. IPDs are increasingly placed by PM&R and pain management in ASCs and outpatient settings. Utilization does not seem to be driven by reimbursement rates. It is unknown how the rapid increase in IPDs has affected clinical outcomes. Given the magnitude of increased utilization and limited data on the safety and efficacy of IPDs, closer examination of indications is warranted.

BackgroundCuraçao is a Dutch Caribbean island with a relatively high aging population, a high prevalence of chronic diseases and a health care system that is driven by cost-containment. In 2009 the development of a new value-based health care (VBHC) system was initiated on the island, and a key role was identified for the St. Elisabeth Hospital as a (model) platform for implementing this initiative. We therefore decided to investigate for the requirements needed to build a health care environment that is conducive for change and capable of facilitating the smooth migration of existent services into an effective and sustainable VBHC system.FindingsOur findings revealed that our chosen approach was well accepted by the stakeholders. We discovered that in order to achieve a new value based health care system based on a reliable and well-organized system, the competencies of health care providers and the quality of the health care system needs to be assured. For this, extra focus needs to be given to improving service and manpower development both during and after formal training.ConclusionsIn order to achieve a VBHC system in a resource-limited environment, the standard of physicians’ competencies and of the health care system need to be guaranteed. The quality of the educational process needs to be maintained and safeguarded within an integrated health care delivery system that offers support to all care delivery and teaching institutions within the community. Finally, collaborative efforts with international medical institutions are recommended.