2019 HSC Section 2 - Practice Management

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Practice Management

Home Study Course

Hsc Home Study Course

Section 2 November 2019

© 2019 American Academy of Otolaryngology—Head and Neck Surgery Foundation Empowering otolaryngologist-head and neck surgeons to deliver the best patient care

THE HOME STUDY COURSE IN OTOLARYNGOLOGY — HEAD AND NECK SURGERY

SECTION 2

Practice Management

November 2019

1999

SECTION FACULTY: Marina Boruk, MD* Johnathan D. McGinn, MD* Daniel Clayburgh, MD Christina M. Gillespie, MD Kellous A. Price, MD, PhD Gopi Shah, MD Betty S. Tsai Do, MD

American Academy of Otolaryngology—Head and Neck Surgery Foundation

Section 2 suggested exam deadline: January 3, 2020 Calendar year 2019 credit required: Submit exam & evaluation by December 31, 2019 Expiration Date: August 6, 2020; CME credit not available after that date

Introduction (Purpose) The Home Study Course is designed to provide relevant and timely clinical information for physicians in training and current practitioners in otolaryngology - head and neck surgery. The course, spanning four sections, allows participants the opportunity to explore current and cutting- edge perspectives within each of the core specialty areas of otolaryngology. The Selected Recent Material represents primary fundamentals, evidence-based research, and state of the art technologies in Practice Management. The scientific literature included in this activity forms the basis of the assessment examination. The number and length of articles selected are limited by editorial production schedules and copyright permission issues and should not be considered an exhaustive compilation of knowledge on congenital and pediatric problems. The Additional Reference Material is provided as an educational supplement to guide individual learning. This material is not included in the course examination and reprints are not provided. Needs Assessment AAO-HNSF’s education activities are designed to improve healthcare provider competence through lifelong learning. The Foundation focuses its education activities on the needs of providers within the specialized scope of practice of otolaryngologists. Emphasis is placed on practice gaps and education needs identified within eight subspecialties. The Home Study Course selects content that addresses these gaps and needs within all subspecialties. Target Audience The primary audience for this activity is physicians and physicians-in-training who specialize in otolaryngology-head and neck surgery. 1. Discuss lack of accurate procedure coding and need for formal education in residency training. 2. Explain how quality metrics can be incorporated into practice and assist in the development of performance measures. 3. Review currently available patient-reported outcome measures for chronic rhinosinusitis and ability to measure quality using questionnaires. 4. Examine faculty diversity and gender gaps in Otolaryngology. 5. Review the history of the Relative Value Scale Update Committee (RUC) and understand the RUC process for update. 6. Describe how physician work is valued. 7. Assess the importance of well-being and become familiar with interventions available to combat physician burnout. 8. Discuss available communication tools for physicians and patients and its role in patient care access. 9. Describe HIPAA compliant communications between providers and handoff practices available during transitions of care. 10. Discuss role of fellowships in otolaryngology and different physician employment models. Outcomes Objectives The participant who has successfully completed this section should be able to:

11. Review equipment infection control in outpatient setting. 12. Examine resident feedback tools in surgical education. 13. Summarize the role of simulation in life-long learning.

Medium Used The Home Study Course is available in electronic or print format. The activity includes a review of outcomes objectives, selected scientific literature, and a self-assessment examination. Method of Physician Participation in the Learning Process The physician learner will read the selected scientific literature, reflect on what they have read, and complete the self-assessment exam. After completing this section, participants should have a greater understanding of Practice Management as it affects otolaryngologists, as well as useful information for clinical application. Accreditation Statement The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit Designation The AAO-HNSF designates this enduring material for 40.0 AMA PRA Category 1 Credit(s) ™. Physicians should claim credit commensurate with the extent of their participation in the activity. ALL PARTICIPANTS must achieve a post-test score of 70% or higher for a passing completion to be recorded and a transcript to be produced. Residents: results will be provided to the Training Program Director. PHYSICIANS ONLY : In order to receive Credit for this activity, a post-test score of 70% or higher is required. Two retest opportunities will automatically be available if a minimum of 70% is not achieved with the first attempt. Disclosure The American Academy of Otolaryngology Head and Neck Surgery/Foundation (AAO-HNS/F) supports fair and unbiased participation of our volunteers in Academy/Foundation activities. All individuals who may be in a position to control an activity’s content must disclose all relevant financial relationships or disclose that no relevant financial relationships exist. All relevant financial relationships with commercial interests 1 that directly impact and/or might conflict with Academy/Foundation activities must be disclosed. Any real or potential conflicts of interest 2 must be identified, managed, and disclosed to the learners. In addition, disclosure must be made of presentations on drugs or devices or uses of drugs or devices that have not been approved by the Food and Drug Administration. This policy is intended to openly identify any potential conflict so that participants in an activity are able to form their own judgments about the presentation. [1] A “Commercial interest” is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. 2 “Conflict of interest” is defined as any real or potential situation that has competing professional or personal interests that would make it difficult to be unbiased. Conflicts of interest occur when an individual has an opportunity to affect education content about products or services of a commercial interest with which they have a financial relationship. A conflict of interest depends on the situation and not on the character of the individual. Estimated time to complete this activity: 40.0 hours

November 2019 Section 2 Practice Management Faculty

**Co-Chairs Marina Boruk, MD, Assistant Professor, Director of Rhinology, Department of Otolaryngology-Head and Neck Surgery, SUNY Downstate Medical Center, Brooklyn, New York. Disclosure: No relationships to disclose. Johnathan D. McGinn, MD, Professor, Otolaryngology Head & Neck Surgery, Vice Chair and Residency Program Director, Department of Otolaryngology - Head & Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania. Disclosure: No relationships to disclose. Faculty Daniel Clayburgh, MD, PhD, Associate Professor, Oregon Health and Science University, Portland, Oregon; Otolaryngology Section Chief and Acting Chief of Surgery, Portland Veterans Affairs Health Care System, Portland, Oregon. Disclosure: Honoraria: Intuitive Surgical; Research Funding: AstraZeneca. Kellous A. Price, MD, Assistant Professor, Texas A&M Health Sciences Center; Private Practice, Texas ENT and Allergy, College Station, Texas. Disclosure: No relationships to disclose. Gopi Shah, MD, Assistant Professor, Department of Otolaryngology, Fellowship Director Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas. Disclosure: No relationships to disclose. Betty S. Tsai Do, MD, Assistant Physician, The Permanente Medical Group, Kaiser Permanente, Walnut Creek, Walnut Creek, California. Disclosure: No relationships to disclose. Christina M. Gillespie, MD, Partner, Ocean Otolaryngology, Toms River, NJ. Disclosure: No relationships to disclose.

Planner(s): Linda Lee, AAO─HNSF Education Program Manager Stephanie Wilson, Stephanie Wilson Consulting, LLC; Production Manager Richard V. Smith, MD, chair, AAO-HNSF Education Steering

No relationships to disclose No relationships to disclose

Expert Witness: various legal firms; Royalty: UpToDate No relationships to disclose

Committee

Jeffrey Simons, MD, chair-elect, AAO-HNSF Education Steering

Committee Lance Manning, MD, chair, AAO-HNSF Core

Leadership role: MedEmo.org

Otolaryngology & Practice Management Education Committee

This 2019-20 Home Study Course Section 2 does not include discussion of off-label uses of drugs or devices which have not been approved by the United States Food and Drug Administration.

Disclaimer The information contained in this activity represents the views of those who created it and does not necessarily represent the official view or recommendations of the American Academy of Otolaryngology – Head and Neck Surgery Foundation.

January 3, 2020: Suggested section 2 Exam submission deadline ; course closes August 6, 2020.

Credits required in the 2019 calendar year: Exam and evaluation submission deadline is December 31, 2019, 11:59 PM Eastern time

EVIDENCE BASED MEDICINE The AAO-HNSF Education Advisory Committee approved the assignment of the appropriate level of evidence to support each clinical and/or scientific journal reference used to authenticate a continuing medical education activity. Noted at the end of each reference, the level of evidence is displayed in this format: [EBM Level 3] .

Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001) Level 1

Randomized 1 controlled trials 2 or a systematic review 3 (meta-analysis 4 ) of randomized controlled trials 5 . Prospective (cohort 6 or outcomes) study 7 with an internal control group or a systematic review of prospective, controlled trials. Retrospective (case-control 8 ) study 9 with an internal control group or a systematic review of retrospective, controlled trials. Case series 10 without an internal control group (retrospective reviews; uncontrolled cohort or outcome studies). Expert opinion without explicit critical appraisal, or recommendation based on physiology/bench research.

Level 2

Level 3

Level 4

Level 5

Two additional ratings to be used for articles that do not fall into the above scale. Articles that are informational only can be rated N/A , and articles that are a review of an article can be rated as Review. All definitions adapted from Glossary of Terms, Evidence Based Emergency Medicine at New York Academy of Medicine at www.ebem.org .

1 A technique which gives every patient an equal chance of being assigned to any particular arm of a controlled clinical trial. 2 Any study which compares two groups by virtue of different therapies or exposures fulfills this definition. 3 A formal review of a focused clinical question based on a comprehensive search strategy and structure critical appraisal. 4 A review of a focused clinical question following rigorous methodological criteria and employing statistical techniques to combine data from independently performed studies on that question. 5 A controlled clinical trial in which the study groups are created through randomizations. 6 This design follows a group of patients, called a “cohort”, over time to determine general outcomes as well as outcomes of different subgroups. 7 Any study done forward in time. This is particularly important in studies on therapy, prognosis or harm, where retrospective studies make hidden biases very likely. 8 This might be considered a randomized controlled trial played backwards. People who get sick or have a bad outcome are identified and “matched” with people who did better. Then, the effects of the therapy or harmful

exposure which might have been administered at the start of the trial are evaluated. 9 Any study in which the outcomes have already occurred before the study has begun. 10 This includes single case reports and published case series.

OUTLINE Section 2: Practice Management November 2019

I.

Practice Management A. CPT coding and documentation B. Quality reporting C. Diversity & gender gaps in otolaryngology D. RUC Process

II.

Professionalism A. Physician burnout & wellness B. Emotional intelligence

III.

Communication A. Communication tools for physicians & patients B. Telehealth Systems-Based Practice A. Transitions in care B. HIPAA-compliant communications between providers C. Physician employment models D. Fellowship role in otolaryngology E. Equipment infection control in the outpatient setting

IV.

V.

Practice-Based Learning A. Resident feedback tools B. Role of simulation in life-long learning

T ABLE OF C ONTENTS Selected Recent Materials - Reproduced in this Study Guide

SECTION 2: PRACTICE MANAGEMENT NOVEMBER 2019

ADDITIONAL REFERENCE MATERIAL ……………………………………………………i - iii

I.

Practice Management A. CPT coding and documentation

Balla F, Garwe T, Motghare P, et al. Evaluating coding accuracy in general surgery residents’ Accreditation Council for Graduate Medical Education procedural case logs. J Surg Educ . 2016; 73(6):e59-e63. EBM level 4.........................................................................................................1-5 Summary : The inaccuracy of resident coding logs is evaluated in this article. The barriers to accurate logging include a lack of formal training of procedural coding. Improved communication between residents and attendings is likely to improve accuracy of procedural coding.

Ghaderi KF, Schmidt ST, Drolet BC. Coding and billing in surgical education: a systems-based education program. J Surg Educ . 2017; 74(2):199-202. EBM level 4.......................................6-9

Summary : The article evaluates the effect of didactic coding lessons on a cohort of residents. A small amount of instruction increased coding accuracy during training.

B. Quality reporting Brenner MJ, Chang CWD, Boss EF, et al. Patient safety/quality improvement primer, part I: what PS/QI means to your otolaryngology practice. Otolaryngol Head Neck Surg . 2018; 159(1):3-10. EBM level N/A....................................................................................................10-17 Summary : This article provides an introduction to PS/QI (patient safety/quality improvement) as it pertains to the field of otolaryngology. The authors provide a background about PS/QI history and how it relates to the external agencies such as CMS and AHRQ. The article also discusses how quality metrics are incorporated into practice and how the AAO-HNS has developed clinical practice guidelines to assist in the development of performance measures. Finally, it discusses the ways otolaryngologists can incorporate PS/QI into their practices.

Rathi VK, Metson R, Varvares MA, et al. Bundled payments in otolaryngology: early lessons from Arkansas. Otolaryngol Head Neck Surg . 2018; 159(6):945-947. EBM level N/A.......18-20

Summary : This article summarizes the early implementation of quality metrics into bundled payments in the state of Arkansas, primarily focusing on tonsillectomy and adenoidectomy and how bundled payments impacted the care that was given. It provides some insight into some of the challenges ahead with quality metrics and reimbursement by CMS.

Rudmik L, Hopkins C, Peters A, et al. Patient-reported outcome measures for adult chronic rhinosinusitis: a systematic review and quality assessment. J Allergy Clin Immunol . 2015; 136(6):1532-1540. EBM level 3...............................................................................................21-31 Summary : This article provides an example of how various patient-reported outcome measures are used to assess quality after an intervention for chronic rhinosinusitis. It critically assesses the ability of questionnaires to measure quality. C. Diversity & gender gaps in otolaryngology Abelson JS, Wong NZ, Symer M, et al. Racial and ethnic disparities in promotion and retention of academic surgeons. Am J Surg . 2018; 216(4):678-682. EBM level 4...............................32-36 Summary : Using FAMOUS (Faculty Administrative Management Online User System), a national database of medical school faculty in the US, rates of retention and promotion at 10 years were determined for underrepresented minority academic surgeons between 2003-2006. This study found a lower 10-year promotion rate for black assistant professors across all specialities. The 10-year retention rate for assistant professors was higher for white academic surgeons than for Asian, black, Hispanic, or other minorities. There was no difference in race for promotion or retention at 10 years for associate professors. Lin SY, Francis HW, Minor LB, Eisele DW. Faculty diversity and inclusion program outcomes at an academic otolaryngology department. Laryngoscope . 2016; 126(2):352-356. EBM level 4........................................................................................................................................37-41 Summary : A multi-faceted inclusion and diversity initiative was taken on at an academic otolaryngology department between 2004-2014 to recruit and retain women and underrepresented minorities (URM). Female clinical faculty increased from 5% to 23%, and female basic science faculty increased from 11% to 38%. Women promoted from assistant to associate professor increased from 0 to 8. URM faculty increased from 2 to 4 and full professor from 0 to 1. In 2004, women earned up to 12% less than their male counterparts; there was no salary difference for URM. By the end of the study, salary was equal based on rank and subspecialty training, with no differences by gender or race. D. RUC process Barbieri JS, Nguyen HP, Forman HP, et al. Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Relative Value Scale Update Committee. J Am Acad Dermatol . 2018; 78(4):816-820. EBM level N/A....................................................42-46 Summary : This article explains the history and composition of the Relative Value Scale Update Committee (RUC). The article also describes the RUC update process and addresses some issues such as alternative payment models and global periods.

Jacobs JP, Lahey SJ, Nichols FC, et al. How is physician work valued? Ann Thorac Surg . 2017; 103(2):373-380. EBM level 4...................................................................................................47-54

Summary : This article provides an excellent overview of the history of and process for how physician work is valued.

II. Professionalism

A. Physician burnout & wellness Klevos GA, Ezuddin NS. Burning brightly, not burning out. Physician Leadersh J . 2018; May/June:45-51. EBM level 5..................................................................................................55-61 Summary : This article discusses both individual and organizational interventions to combat burnout. Additionally, it provides suggestions for physician leaders to identify and address burnout among their physician colleagues. Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med . 2017; 177(2):195-205. EBM level 3...............................................................................................................................62-72 Summary : This article summarizes the effectiveness of various types of controlled interventions on burnout. Organization-directed interventions were more effective than physician-directed interventions. While interventions tended to be more effective in physicians with more experience, this was not statistically significant, nor was work setting noted to be a factor.

Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med . 2017; 177(12):1826-1832. EBM level N/A.........................................................73-79

Summary : This article focuses on the cost of replacing physicians in organizations due to burnout and suggests organizational strategies to deal with burnout. It describes the different tiers in improving physician well-being. B. Emotional intelligence Johnson DR. Emotional intelligence as a crucial component to medical education. Int J Med Educ . 2015; 6:179-183. EBM level 4......................................................................................80-84

Summary : This article provides a review of the principles of emotional intelligence and how it should be integrated into medical education.

McKinley SK, Petrusa ER, Fiedeldey-Van Dijk C, et al. A multi-institutional study of the emotional intelligence of resident physicians. Am J Surg . 2015; 209(1):26-33. EBM level 4........................................................................................................................................85-92 Summary : This article evaluates emotional intelligence across different specialties using the Trait Emotional Questionnaire. The implication from the study is that different specialties can benefit from focused emotional intelligence training.

McKinley SK, Phitayakorn R. Emotional intelligence and simulation. Surg Clin North Am . 2015; 95(4):855-867. EBM level 4.........................................................................................93-105

Summary : The authors provide a review of the emotional intelligence literature and the use of simulation to help develop emotional intelligence during training.

III. Communication A. Communication tools for physicians & patients

Lee JL, Choudhry NK, Wu AW, et al. Patient use of email, Facebook, and physician websites to communicate with physicians: a national online survey of retail pharmacy users. J Gen Intern Med . 2016; 31(1):45-51. EBM level 4................................................................................106-112 Summary : A survey was conducted of a cross-section of patients to look at patient behavior and interest in using the internet to contact their physicians. Specifically, use of email and Facebook both were studied. The authors report that 90% of adults in the US use the internet and 72% visit social media sites such as Facebook, with 12% using social media to research health topics. Older patients were less likely to use the internet to contact their physicians. Patients have interest in web-based tools but are not fully utilizing those tools. B. Telehealth Kohlert S, Murphy P, Tse D, et al. Improving access to otolaryngology-head and neck surgery expert advice through eConsultations. Laryngoscope. 2018; 128(2):350-355. EBM level 4....................................................................................................................................113-118 Summary : An eConsult can be an option for a referring provider to access specialists with clinical questions in an asynchronous fashion. The study reviews the eConsult process experience at a Canadian institution, showing the potential benefits of reduced wait times, improved communication between referring and otolaryngology providers, and targeted professional development efforts. Seim NB, Philips RHW, Matrka LA, et al. Developing a synchronous otolaryngology telemedicine clinic: prospective study to assess fidelity and diagnostic concordance. Laryngoscope . 2018; 128(5):1068-1074. EBM level 2.......................................................119-125 Summary : Telemedicine serves to provide remote access to medical care in underserved locations. The authors explore the potential for this technology in otolaryngology, as well as attempt to compare results from a synchronous in-person and telemedicine examination. Murray N, Valdez TA, Hughes AL, Kavanagh KR. Teaching a tracheotomy handoff tool to pediatric first responders. Int J Pediatr Otorhinolaryngol . 2018; 114:120-123. EBM level 4....................................................................................................................................126-129 Summary : The goal of this study was to determine the reliability of teaching and ease of learning the CARE system (Critical Airway Risk Evaluation for difficulty of intubation in pediatric tracheostomy patients) for pediatric otolaryngologists and otolaryngology and pediatric residents. A tutorial was designed to teach the CARE system, as well as an overview on airway anatomy and tracheotomy tubes. An immediate posttest was conducted. There was no difference between pediatric and otolaryngology residents’ airway identifications, and there was substantial interrater reliability among all groups. This may aid in the hand-offs or transitions of care in pediatric tracheostomy patients.

IV. Systems-Based Practice A. Transitions in care

Parent B, LaGrone LN, Albirair MT, et al. Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial. JAMA Surg . 2018; 153(5):464-470. EBM level 1.........................................130-136 Summary : Transitions in care are a defined source of miscommunication that may result in medical errors. The study reviews the use of a standard handoff technique (iPass). In comparison to a run-up control before use of this tool, residents and faculty showed a reduction in perceived poor handoffs, improved confidence in handoffs, better physician satisfaction in handoffs, and a potential reduction in errors. B. HIPAA-compliant communications between providers Sieck CJ, Hefner JL, Schnierle J, et al. The rules of engagement: perspectives on secure messaging from experienced ambulatory patient portal users. JMIR Med Inform . 2017; 5(3):e13. EBM level 4...........................................................................................................................137-147 Summary : This article explores the views of patients concerning communication via secure patient portals. Prior studies have examined implementation of portals; however, this study explores actual use of the portal. Research shows both patients and physicians could benefit from additional training to maximize the benefit of patient portals. C. Physician employment models Harrill WC, Melon DE, Seshul MJ, et al. Contemporary analysis of practicing otolaryngologists. Laryngoscope . 2018; 128(11):2490-2499. EBM level 4.....................................................148-157 Summary : This study is a cross-sectional survey of practicing otolaryngologists in North Carolina and South Carolina in 2016. It found that most otolaryngologists work within large group practices; solo practices are on the decline, while hospital-based employment is growing among younger physicians outside of academic medicine. Neprash HT, Chernew ME, Hicks AL, et al. Association of financial integration between physicians and hospitals with commercial health care prices. JAMA Intern Med . 2015; 175(12):1932-1939. EBM level 3.........................................................................................158-165 Summary : This article examines how the direct employment of physicians by hospitals impacts healthcare costs. The authors found that physician integration with hospitals results in increased outpatient pricing and costs, while inpatient costs and overall healthcare utilization remain stable. Scott KW, Orav EJ, Cutler DM, Jha AK. Changes in hospital-physician affiliations in U.S. hospitals and their effect on quality of care. Ann Intern Med . 2017; 166(1):1-8. EBM level 3....................................................................................................................................166-174 Summary : This article addresses the impact of direct physician employment by hospitals on overall quality of care; the potential for increased quality is a driving force behind policies aimed at increasing direct physician employment. Hospitals that switched to an employment model were compared to peer-matched controls, and no difference was seen between these groups in any of the quality metrics examined.

D. Fellowship role in otolaryngology Wilson MN, Vila PM, Cohen DS, et al. The pursuit of otolaryngology subspecialty fellowships. Otolaryngol Head Neck Surg . 2016; 154(6):1027-1033. EBM level 4...............................175-181 Summary : Data from the AAO-HNS annual survey of residents and fellows from 2008-2014 was examined to determine factors that influence interest in fellowship training. A total of 2,422 residents were surveyed. In this time period, senior residents were less interested in fellowship training than junior residents. Age, educational debt, and practice setting preferences predicted interest in fellowship training; gender did not. E. Equipment infection control in the outpatient setting Sowerby LJ, Rudmik L. The cost of being clean: a cost analysis of nasopharyngoscope reprocessing techniques. Laryngoscope . 2018; 128(1):64-71. EBM level 2......................182-189 Yalamanchi P, Yu J, Chandler L, Mirza N. High-level disinfection of otorhinolaryngology clinical instruments: an evaluation of the efficacy and cost-effectiveness of instrument storage. Otolaryngol Head Neck Surg . 2018; 158(1):163-166. EBM level 2...................................190-193 Summary : The article compares positive culture rates of otolaryngology clinic instruments between sterilization and peel-packing and high-level disinfection and cohabitation in cabinet drawers. The study showed no difference in positive culture rates in these two groups, despite the much higher cost of individual peel-packed processing. Gunderson K, Sullivan S, Warner-Hillard C, et al. Examining the impact of using the SIMPL application on feedback in surgical education. J Surg Educ . 2018; 75(6):e246-e254. EBM level 2....................................................................................................................................194-202 Summary : This article demonstrates the effectiveness of a simple smartphone-based app to provide feedback to surgical residents. This method was shown to be equally effective to in-person feedback, and may provide a useful alternative to formalized in-person feedback. Summary : This is an excellent review of techniques for providing feedback to residents and other learners. Although this article comes from the pathology literature, the strategies and techniques discussed here are widely applicable in all medical fields. B. Role of simulation in life-long learning Roberts J, Sawyer T, Foubare D, et al. Simulation to assist in the selection process of new airway equipment in a children's hospital. Cureus . 2015; 7(9):e331. EBM level 4.......................210-215 Summary : Simulation techniques may be employed in the selection of new equipment for medical practice. This study looks at the decision regarding new laryngoscope purchases facility-wide via blinded simulation use of the tools with stakeholders before choosing the new equipment. Jug R, Jiang XS, Bean SM. Giving and receiving effective feedback: a review article and how-to guide. Arch Pathol Lab Med . 2019; 143(2):244-250. EBM level 4...................................203-209 Summary : The article focuses on multiple available techniques for processing nasopharyngoscopes in the office setting, with a focus on cost analysis among the techniques.

V. Practice-Based Learning A. Resident feedback tools

Smith ME, Navaratnam A, Jablenska L, et al. A randomized controlled trial of simulation-based training for ear, nose, and throat emergencies. Laryngoscope . 2015; 125(8):1816-1821. EBM level 1....................................................................................................................................216-221 Summary : The study employs a control group of lecture-only trainees versus a group of trainees receiving both lecture and simulation training with blinded facilitator assessment on otolaryngology emergencies. The group using simulation performed better and had a more positive view of the training as compared to controls. Weinger MB, Banarjee A, Burden AR, et al. Simulation-based assessment of the management of critical events by board-certified anesthesiologists. Anesthesiology . 2017; 127:475-489. EBM level 4....................................................................................................................................222-236 Summary : Anesthesia has used simulation for board-certification and maintenance of certification for several years. While from outside the otolaryngology literature, this study looks at the potential benefits of simulation assessment of high-stakes events in practicing providers.

ADDITIONAL REFERENCES SECTION 2, November 2019

Bekelis K, McGirt MJ, Parker SL, et al. The present and future of quality measures and public reporting in neurosurgery. Neurosurg Focus . 2015; 39(6):E3.

Beswick DM, Vashi A, Song Y, et al. Consultation via telemedicine and access to operative care for patients with head and neck cancer in a Veterans Health Administration population. Head Neck . 2016; 38(6):925-929.

Bhattacharyya N. Involvement of physician extenders in ambulatory otolaryngology practice. Laryngoscope . 2012; 122(5):1010-1013.

Childers R, Lipsett PA, Pawlik TM. Informed consent and the surgeon. J Am Coll Surg . 2009; 208(4):627-634.

Cochran A, Elder WB. A model of disruptive surgeon behavior in the perioperative environment. J Am Coll Surg . 2014; 219(3):390-398.

Cook DA, Blachman MJ, West CP, Wittich CM. Physician attitudes about maintenance of certification: a cross-specialty national survey. Mayo Clin Proc . 2016; 91(10):1336-1345.

DesRoaches CM, Rao SR, Fromson JA, et al. Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA . 2010; 304(2):187-193.

Fletcher AM, Pagedar N, Smith RJ. Factors correlating with burnout in practicing otolaryngologists. Otolaryngol Head Neck Surg . 2012; 146(2):234-239.

Grogan MJ, Knechtges P. The disruptive physician: a legal perspective. Acad Radiol . 2013; 20(9):1069- 1073.

Hasan H, Ali F, Barker P, et al. Evaluating handoffs in the context of a communication framework. Surgery . 2017; 161(3):861-868.

Hirsch JA, Leslie-Mazwi TM, Nicola GN, et al. Current procedural terminology; a primer. J Neurointerv Surg . 2015; 7(4):309-312.

Hirsch JA, Silva E 3rd, Nicola GN, et al. The RUC: a primer for neurointerventionalists. J Neurointerv Surg . 2014; 6(1):61-64.

Hughes CA, McMenamin P, Mehta V, et al. Otolaryngology workforce analysis. Laryngoscope . 2016; 126 Suppl 9:S5-S11.

Irizarry T, DeVito Dabbs A, Curran CR. Patient portals and patient engagement: a state of the science review. J Med Internet Res . 2015; 17(6) e148.

Kraft SA, Constantine M, Magnus D, et al. A randomized study of multimedia informational aids for research on medical practices: implications for informed consent. Clin Trials . 2017; 14(1):94-102.

i

Lawrason Hughes A, Murray N, Valdez TA, et al. Development of the Connecticut Airway Risk Evaluation (CARE) system to improve handoff communication in pediatric patients with tracheotomy. JAMA Otolaryngol Head Neck Surg . 2014; 140(1):29-33.

Lee SH, Phan PH, Dorman T, et al. Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture. BMC Health Serv Res . 2016; 16:254.

McCool RR, Davies L. Where does telemedicine fit into otolaryngology? An assessment of telemedicine eligibility among otolaryngology diagnoses. Otolaryngol Head Neck Surg . 2018; 158(4):641-644.

Miller P, Mosley K. Physician reimbursement: from fee-for-service to MACRA, MIPS and APMs. J Med Pract Manage . 2016; 31(5):266-269.

Nellis JC, Eisele DW, Francis HW, et al. Impact of a mentored student clerkship on underrepresented minority diversity in otolaryngology-head and neck surgery. Laryngoscope . 2016; 126(12):2684-2688.

Norris B, Harris T, Stringer S. Effective use of physician extenders in an outpatient otolaryngology setting. Laryngoscope . 2011; 121(11):2317-2321.

Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systemic review and meta-analysis. Syst Rev . 2014; 3:56.

Overton AR, Lowry AC. Conflict management: difficult conversations with difficult people. Clin Colon Rectal Surg . 2013; 26(4):259-264.

Pianosi K, Gorodzinsky AY, Chorney JM, et al. Informed consent in pediatric otolaryngology: what risks and benefits do parents recall? Otolaryngol Head Neck Surg . 2016; 155(2):332-339.

Przybylo JA, Wang A, Loftus P, et al. Smarter hospital communication: secure smartphone text messaging improves provider satisfaction and perception of efficacy, workflow. J Hosp Med. 2014; 9(9):573-578.

Richter JP, McAlearney AS, Pennell ML. The influence of organizational factors on patient safety: examining successful handoffs in health care. Health Care Manage Rev . 2016; 41(1):32-41.

Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg . 2013; 258(6):856-871.

Shams A, Ahmed M, Scalzitti NJ, et al. How does TeamSTEPPS affect operating room efficiency? Otolaryngol Head Neck Surg . 2016; 154(2):355-358.

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Reprinted by permission of J Surg Educ. 2016; 73(6):e59-e63.

2016 APDS SPRING MEETING

Evaluating Coding Accuracy in General Surgery Residents ’ Accreditation Council for Graduate Medical Education Procedural Case Logs

Fadi Balla, MD, Tabitha Garwe, PhD, Prasenjeet Motghare, MS, Tessa Stamile, MD, Jennifer Kim, MD, Heidi Mahnken, MSIV, and Jason Lees, MD

Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) case log captures resident operative experience based on Current Procedural Termi- nology (CPT) codes and is used to track operative experience during residency. With increasing emphasis on resident operative experiences, coding is more important than ever. It has been shown in other surgical specialties at similar institutions that the residents ’ ACGME case log may not accurately re fl ect their operative experience. What barriers may in fl uence this remains unclear. As the only objective measure of resident operative experience, an accurate case log is paramount in representing one ’ s operative experience. This study aims to determine the accuracy of procedural coding by general surgical residents at a single institution. METHODS: Data were collected from 2 consecutive grad- uating classes of surgical residents ’ ACGME case logs from 2008 to 2014. A total of 5799 entries from 7 residents were collected. The CPT codes entered by residents were com- pared to departmental billing records submitted by the attending surgeon for each procedure. Assigned CPT codes by institutional American Academy of Professional Coders certi fi ed abstract coders were considered the “ gold standard. ” A total of 4356 (75.12%) of 5799 entries were identi fi ed in billing records. Excel 2010 and SAS 9.3 were used for analysis. In the event of multiple codes for the same patient, any match between resident codes and billing record codes was considered a “ correct ” entry. A 4-question survey was distributed to all current general surgical residents at our institution for feedback on coding habits, limitations to

accurate coding, and opinions on ACGME case log repre- sentation of their operative experience. RESULTS: All 7 residents had a low percentage of correctly entered CPT codes. The overall accuracy proportion for all residents was 52.82% (range: 43.32%-60.07%). Only 1 resident showed signi fi cant improvement in accuracy during his/her training (p ¼ 0.0043). The survey response rate was 100%. Survey results indicated that inability to fi nd the precise code within the ACGME search interface and unfamiliarity with available CPT codes were by far the most common perceived barriers to accuracy. Survey results also indicated that most residents (74%) believe that they code accurately most of the time and agree that their case log would accurately represent their operative experience (66.6%). CONCLUSION: This is the fi rst study to evaluate correct- ness of residents ’ ACGME case logs in general surgery. The degree of inaccuracy found here necessitates further inves- tigation into the etiology of these discrepancies. Instruction on coding practices should also bene fi t the residents after graduation. Optimizing communication among attend- ings and residents, improving ACGME coding search inter- face, and implementing consistent coding practices could improve accuracy giving a more realistic view of residents ’ operative experience. ( J Surg Ed 73:e59-e63. Published by Elsevier Inc on behalf of the Association of Program Directors in Surgery) KEY WORDS: coding, coding accuracy, ACGME, ACGME case log, general surgery residency, graduate medical education, operative experience, CPT coding COMPETENCIES: Professionalism, Interpersonal and Communication Skills, Practice-Based Learning and Improvement, Systems-Based Practice

Correspondence : Inquiries to Fadi Balla, MD, Department of Surgery, University of Oklahoma Health Sciences Center, 941 S.L. Young Blvd, Oklahoma City, OK 73104; e-mail: fadiballa@gmail.com

Journal of Surgical Education

Published by Elsevier Inc on behalf of the Association of Program Directors in Surgery

1931-7204/$30.00 http://dx.doi.org/10.1016/j.jsurg.2016.07.017

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TABLE 1. Number of Procedures and Proportion Correctly Coded (in Parentheses) by Resident and Postgraduate Year

Total

Number of matched procedures ( N ¼ 4356)

PGY1 PGY2 PGY3 PGY4 PGY5 p Value †

Resident ID

1 2 3 4 5 6 7

669 561 765 604 622 584 551

40 (63) 107 (57) 264 (58) 92 (51) 166 (60) 0.6806 385 (58) 67 (42) 243 (45) 58 (28) 133 (47) 0.1306 243 (43.32) 94 (49) 264 (58) 163 (50) 201 (56) 0.2204 411 (53.73) 1 (100) 52 (58) 167 (50) 167 (47) 217 (56) 0.2825 313 (51.82) 78 (32) 135 (50) 194 (51) 175 (52) 0.0043 * 295 (47.43) 29 (76) 199 (58) 195 (53) 161 (53) 0.1057 326 (55.82) 38 (63) 191 (58) 178 (61) 144 (62) 0.8379 331 (60.07) 60 (45) 43 (44) 40 (30) 0 (0) 0 (0)

(), proportion correctly coded. *p o 0.05. † Based on the Cochrane Armitrage Trend test.

INTRODUCTION The surgical resident ’ s procedural case log serves as the only procedural-based objective interresidency comparative metric. With the American Board of Surgery ’ s increasing emphasis on standardized outcomes for graduating resi- dents, accurate coding is more important than ever. Furthermore, an inaccurate case log may misrepresent a resident ’ s exposure to given necessary technical skills required to obtain pro fi ciency. It has been shown in other surgical specialties at similar institutions that the residents ’ ACGME case log may not accurately re fl ect their true operative experience. 1 Additionally, reports from the Council of Orthopaedic Residency Directors found discrepancies between resident and faculty coding for cases. 1 Inconsistent coding practices have been implicated in large variability between minimum, mean, and maximum resident case numbers in otorhinolaryngology residents. 2 These studies may suggest that the overall body of surgical residents ’ case log entries may be inaccurate to a certain degree. Throughout residency, this system is used to electronically log cases a resident performs, assists, or teaches a given procedure. These cases are logged using Current Procedural Terminology (CPT) codes which are the most widely used medical terminology between physicians and other parties. Although the ACGME case log cannot show competence for a procedure, it does represent operative experience, and this has been shown to correlate with con fi dence in practice after training 3 and comfort level with a given procedure. 4 Previous studies have investigated the role of interven- tions aimed at improving resident record keeping in the Accreditation Council for Graduate Medical Education (ACGME) case log and found that these improve accuracy of ACGME case log reports, especially among junior residents. 5 This shows an excellent opportunity for resident education in coding. However, the degree to which residents are inaccurate is uncertain. Senior residents have been shown to be more accurate than junior residents but further investigation is needed. 5 The purpose of our study was to investigate the accuracy of procedural coding by general surgery residents at a single institution using the

ACGME case log system as well as describe the factors associated with challenges in coding to preserve the integrity of the ACGME resident case log system and residents ’ surgical experience.

METHODS This was a retrospective descriptive study using data collected from 2 consecutive graduating classes totaling 7 surgical residents ’ ACGME case logs from 2008 to 2014 at a single institution. The CPT codes entered by residents into the ACGME resident case log system were compared to depart- mental billing records submitted by the attending surgeon for each procedure by matching codes based on the medical record number and date of procedure. The matching was done using Microsoft Excel 2010 ’ s “ v-lookup ” function. The case logs records were saved by our institution from ACGME case log entry website queries after the residents had graduated and were the fi nalized logs of their resident operative experience. Assigned CPT codes by institutional American Academy of Professional Coders certi fi ed abstract coders were considered the “ gold standard. ” In the event that there were multiple codes eligible for billing in the same procedure, any match between resident codes and billing record codes was considered a “ correct ” entry. Analysis of accuracy proportion for each resident between postgraduate year (PGY) 1 to 5 years was performed and is represented by the p value in Table 1 . A 4-question survey was distributed to all current general surgical residents (PGY 1-5) at our institution for feedback on coding habits, limitations to accurate coding, and opinions on ACGME case log representation of their operative experience ( Table 2 ). Of 27 current general surgical residents at the time of distribution, all of them completed the questionnaire. The survey was not administered to the graduated residents, and that the survey results should not be used to explain the coding results directly but rather by inference. Proportions were used to summarize the data. Trends were evaluated using the Cochran-Armitage Trend Test. All analyses were performed using SAS (SAS 9.3, SAS Institute, Cary, NC).

Journal of Surgical Education Volume 73/Number 6 November/December 2016

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TABLE 2. Survey Results of all Current General Surgical Residents at OUHSC to Identify Coding Habits, Limitations to Accurate Coding on ACGME Case Log Entry

n /response proportion (%) ( n ¼ 27)

Survey questions

Response

What are the biggest challenges to accurately coding procedures using the ACGME case log system? (check all that apply)

Unsure about operative role in the case Unsure exactly what procedure was performed Unfamiliarity with available codes in the ACGME CPT directory Unable to fi nd precise code on the ACGME search interface Lack of formal education on procedural coding Delay in entering case codes

4 (15) 2 (7) 16 (59) 6 (22) 23 (85) 10 (37) 1 (4) 5 (19) 5 (19) 5 (19) 9 (33) 2 (7) 2 (7)

How often do you input your procedural codes into the ACGME case log system?

After each case

Daily

Multiple times per week Multiple times per month

Monthly

Less frequently than monthly

What is your perception of your own procedural coding accuracy using the ACGME case log system?

I believe I correctly code the procedure performed ALL the time I believe I correctly code the procedure performed MOST of the time I believe I correctly code the procedure performed SOME of the time I believe I RARELY code the procedure performed correctly I believe I NEVER code the procedure performed correctly

20 (74)

4 (15)

1 (4)

0 (0)

“ I believe that at the end of my residency training, my ACGME case log will accurately represent my operative experience. ”

Strongly agree

3 (11) 18 (67) 4 (15)

Agree Neutral Disagree

2 (7) 0 (0)

Strongly disagree

current general surgery residents (27/27). Survey results indicated that inability to fi nd the precise code within the ACGME search interface and unfamiliarity with available CPT codes were by far the most common perceived barriers to accuracy (85.19% and 59.26%, respectively). Survey results also indicated that most residents (74.07%) believe they code accurately most of the time and agree that their case log would accurately represent their operative experi- ence (66.6%). Furthermore, the results from questions regarding coding habits show that the highest proportion of respondents (33%) log cases only once a month. The remaining respondents reported input frequency of “ daily, ” “ multiple times per week, ” and “ multiple times per month ” as the next most frequent responses (18.5% for all). DISCUSSION A number of potential factors in fl uence case log accuracy, which makes capturing the actual surgical procedures challenging. When looking at each individual resident, we found at best a 60% accuracy proportion over the course of

This study was approved by the University of Oklahoma Health Sciences Center Institutional Review Board.

RESULTS A total of 5799 entries from 7 residents were retrieved from the ACGME case log system. Of these, 1443 (25%) entries could not be matched to the billing database. The following results summarize the remaining 4356 entries that were successfully matched. Table 1 summarizes coding accuracy by surgery residents. In general, the number of procedures performed by all 7 residents increased with increasing PGY ( r ¼ 0.88, p o 0.0001). For all residents, the coding accuracy ranged from low to modest; the overall accuracy proportion for all residents was 52.82% (range: 43.32%- 60.07%). Only 1 resident showed signi fi cant improvement in accuracy during his/her training (p ¼ 0.0043); however, this may have been a result of his or her ’ s PGY1 coding accuracy being disproportionately much lower than all the other residents. Table 2 summarizes the results from our 4-question survey distributed to all current general surgery residents at our institution. The survey response rate was 100% of all

Journal of Surgical Education Volume 73/Number 6 November/December 2016

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