From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that we believe will interest our readers. Today’s post originally appeared on Medicine @ Brown Magazine. Abdul-Kareem Ahmed, MD, provides a poignant depiction of one night as a neurosurgical resident at the University of Maryland. Every patient’s worst moment is Dr. Ahmed’s every day. Read More
From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that we believe will be of interest to our readers. Today’s post originally appeared in MedPage Today on Jan. 21. In the op-ed, neurosurgeons Anthony M. DiGiorgio, DO, MHA, and Praveen V. Mummaneni, MD, MBA discuss the burden of electronic health records (EHR) at their institution, the University of California San Francisco.
Drs. DiGiorgio and Mummaneni audited EHR logs to examine our neurosurgery residents’ work and better understand the benefits and burdens. The results found that on-call residents spent 20 hours logged into the EHR over a single shift. They are detracting from trainees’ educational experience, and health care costs are increasing because of the inefficiencies that come with EHRs.
Drs. DiGiorgio and Mummaneni note that many inefficiencies come from Medicare regulations. For example, the appropriate use criteria program was developed to reduce unnecessary imaging ordered by physicians. Their EHR audit found this added just a few minutes of computer time to the residents’ days. However, there is no evidence that this regulation reduces unnecessary imaging. Many more regulations add a few minutes here and a few minutes there.
Drs. DiGiorgio and Mummaneni state that “it’s death by 10,000 clicks” and urge continued involvement in advocacy to reverse the ever-increasing EHR burden.
Click here to read the full article.
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #EHR.
From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that we believe will be of interest to our readers. Today’s post originally appeared in The American Spectator on Jan. 3. In the op-ed, neurosurgeon Richard Menger, MD, MPA, FAANS and nurses Jessica Murfee, RN, BSN and Erin Roberts, RN, BSN, discuss health care provider burnout from the cumbersome prior authorization process required by insurance companies to perform surgery agreed upon by patient and surgeon.
The time-consuming prior authorization process disregards the patient-physician relationship. It also causes burnout for health care workers, and “Most of the time, it’s an administrative clarification issue, but calling into the insurance abyss is like dialing into a time warp.”
See 2021 AMA prior authorization physician survey
A survey from the American Medical Association noted that, on average, offices spend 13 hours per week on prior authorizations. The article states, “If a higher-level evaluation is needed, either myself or my physician assistant or nurse practitioner will have to get on the line and debate the merits of a neurosurgery with some other type of health representative who is acting on behalf of the insurance company.”
The piece concludes with the authors asking Congress to take action and pass legislation to streamline prior authorization in Medicare Advantage. The Improving Seniors Timely Access to Care Act would require enhanced transparency and streamline authorization in the Medicare Advantage program.
Click here to read the full article.
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #FixPriorAuth.
The Society of Neurological Surgeons (SNS) has established a Neurosurgeon-Scientist Training Program (NSTP) to increase the pool of neurosurgery residents conducting research and to enhance their success rate in becoming independent neurosurgeon-scientists. The NSTP will serve as a formal mentored research program for those neurosurgery residents who are beginning a protected research year or have already completed their protected research year.
The primary goal of this new program is to improve human health by providing participants with the skills, mentorship, education and experience needed to successfully compete for individual research funding (e.g., National Institutes of Health K awards and R01 research grants). Additional research by clinician-scientist neurosurgeons is critical to the fundamental discovery that advances new methods of care and new cures.
A donation of $110,000 by the non-profit StacheStrong provides crucial funding for brain tumor-related grants with the launch of the NSTP. StacheStrong is devoted to raising 
funds and awareness for brain cancer research. Defeating brain cancer and improving the quality of patients’ lives is the mission of StacheStrong.
Click here to read the press release.
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery, @SNS_Neurosurg and @StacheStrong and using the hashtag #BrainCancerResearch.
For patients with aggressive, high-grade gliomas, clinical trials offer access to new experimental therapies studied for their effectiveness. Traditionally, clinical trials have been broken into three phases. Phase 1 clinical trials assess the safety of a new treatment. Phase 2 studies involve more patients and evaluate the efficacy of the treatment. Phase 3 studies are designed to compare the novel treatment to a proven treatment to validate its effectiveness further.
While most clinical trials for high-grade glioma patients study systemically administered chemotherapies managed by a neuro-oncologist, some high-grade glioma clinical trials are now surgically based. In these trials, tumor surgery plays more than its usual cytoreductive role. Examples of surgically based clinical trials include:
The first example of obtaining biological information through the surgery consists of phase 0-like “window of opportunity” clinical trials, first in human studies in which a small number of patients are given a drug for a few days before surgery. Blood is drawn regularly before and during the surgery to obtain pharmacokinetic and pharmacodynamic information, which helps determine how quickly a steady-state concentration of the drug within the tumor is achieved under the prescribed dosing regimen. Cerebrospinal fluid is obtained during surgery to determine whether the agent’s intracranial penetration achieves a steady state after a similar time as occurs systemically. Tumor tissue is analyzed to measure drug levels in the enhancing versus non-enhancing tumor, with levels often 3-4 times higher in the former than the latter, underscoring the difficulty of treating the non-enhancing tumor with systemic chemotherapy. Tumor tissue can also be analyzed for levels of the drug’s target protein and its downstream mediators to determine whether the drug affects the intended target in tumor tissue.
The second example of surgically based clinical trials typically involves immunotherapies in which a vaccine is developed from tumor tissue. The vaccine can be peptide-based — in which an immunostimulatory peptide-like heat shock protein is combined with tumor peptides — or a cellular vaccine in which immune cells like dendritic cells taken from the patient are primed with tumor peptides and then returned to the patient to provide antitumor immunity.
The third example involves the surgical administration of cellular, viral or pharmacologic therapies. These can be delivered into craniotomy walls after resection or directly into the tumor without resection. The advantages of delivering the therapy into craniotomy walls include combining the benefit of cytoreductive surgery with the therapeutic injection. In contrast, the disadvantages of delivering the therapy into the craniotomy walls include the reflux of the agents back into the resection cavity. Needle delivery into the tumor avoids reflux into the resection cavity, but reflux up the injection tract or adjacent cavities from previous surgery must be accounted for. The lack of cytoreductive surgery means needle delivery may be best for smaller focal tumors. Needle delivery into the tumor can be accomplished via direct needle delivery or convection-enhanced delivery involving infusion through a catheter along a pressure gradient over hours or days.
Neurosurgeons play a critical role in designing and developing surgically based clinical trials for high-grade glioma patients. Many of these trials have developed from neurosurgeon-scientists’ basic science research in laboratories using preclinical animal models. There is hope that these trials will lead to discoveries that meaningfully impact the prognosis of patients diagnosed with high-grade gliomas in the future.
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.
Manish K. Aghi, MD, PhD, FAANS
UCSF Dept. of Neurological Surgery
San Francisco, Calif.
The Medicare physician payment system is on an unsustainable path that has failed to keep up with inflation over the years, threatening patient access to care. The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) are actively engaged in preventing steep Medicare payment cuts and preserving patient access to care through the Surgical Care Coalition. The coalition is in year three of its campaign to stop these cuts and implement lasting changes to the physician payment and quality improvement systems.
On Jan. 1, 2023, neurosurgeons face a minimum 8.5% Medicare payment cut, including a nearly 4.5% cut for all Medicare Physician Fee Schedule services and a 4% Statutory Pay-As-You-Go Act cut, triggered due to new federal spending. After successfully protecting patients’ timely access to quality surgical care in 2020 and 2021 by securing Congressional action to mitigate proposed cuts to Medicare, the coalition is fighting against similar cuts proposed for 2023. The AANS and the CNS are also working with Congress on long-term solutions to fix these broken systems. To that end, we submitted detailed comments in response to a Congressional request for information.
The people who the proposed cuts will most impact are our patients. Every day, neurosurgeons take care of some of the sickest patients who face painful and life-threatening neurologic conditions. Alexander A. Khalessi, MD, FAANS, John K. Ratliff, MD, FAANS and Maya A. Babu, MD, FAANS, share their experiences as neurosurgeons and how the cuts will impact neurosurgical practices and their patients. The videos are available as follows:
Patients Deserve Timely, Quality Care
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @SurgeonsCare.
From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that may be of interest to our readers. Today’s post originally appeared on AL.com on Nov. 1, titled “Why is it hard for grandma to see her doctor?” In the op-ed, Richard Menger, MD, MPA, assistant professor of neurosurgery and political science at the University of South Alabama in Mobile, Ala., discusses how steep Medicare physician payment cuts scheduled to go into effect on Jan. 1, 2023, are not a good prescription for a healthy physician workforce.
The average physician will receive 8.5% less for providing the same services they did last year. While adjusting for inflation, Medicare payments to physicians have declined 22% from 2001-2021. According to Dr. Menger, “The people most impacted by these cuts will be our Medicare patients. In the backdrop of inflation, practices will not be able to sustain themselves by treating Medicare patients.” Dr. Menger concludes by stating that this puts seniors at risk for reduced access to care.
Click here to read the full article.
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery.
