IN THIS ISSUE:
MICHIGAN POLLING RESULTS: OVERWHELMING SUPPORT FOR PHYSICIAN SUPERVISION OF ANESTHESIA
F1RSTAnalytics: Real-Time Insight at Your Fingertips
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President Frederick Campbell, M.D. Cedar President-Elect John LaGorio, M.D. Norton Shores Secretary-Treasurer Michael Danic, D.O. Redford Immediate Past President Sam Talsma, M.D. Ann Arbor Communications/ Public Relations Committee Ali Jaffer, M.D. Dominic Monterosso, D.O. Managing Editor Hillary Walilko Cover Photography Courtesy: goodfreephotos.com Contact for advertising information: Hillary Walilko MSA 120 N. Washington Sq., Suite 110A Lansing, MI 48933 Phone: 517.346.5088 Fax: 517.371.1170 email: walilko.h@gcsionline.com The Ventilator is published four times annually by GCSI Association Services. It is funded by the Michigan Society of Anesthesiologists and with advertising revenues. The Michigan Society of Anesthesiologists is a nonprofit, statewide organization.
TAB LE OF C O NT ENT S P R E S I D E N T’ S M E SSAGE ................................................................. 4 DIRECTOR’S REPORT............................................................................ 6 CA LE N D A R O F E V E N TS..................................................7 P O LLI N G R E S U LTS : O VE RW HE L M I N G SUP P O RT F O R P HYSI CI AN A N E S TH E S I O LO GI STS....................................................8 S CI E N TI F I C S E S SI O N RE CAP ......................................... 1 2 MOC NOW HAS AN ASA 4 STATUS .................................................. 14 A REVIEW OF THE EFFICACY OF LIPOSOMAL BUPIVACAINE............................................................. 16 LEGISLATIVE CORNER ........................................................................ 18
INDEX TO ADVERTISERS Anesthesia Business Consultants....................................... IFC Michigan Academy of Anesthesiologist Assistants................5 Paragon Service..................................................................... 11 University of Michigan Health System..................................7
No part of this publication may be reproduced without permission of the publisher and MSA. All article submissions will be considered for publication and accepted at the approval of the Editor and the Communications/Public Relations Committee. We reserve the right to edit submissions for accuracy, clarity, and length.
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3
PRESIDENT’S MESSAGE
Frederick Campbell M.D. President
Spring has arrived in Michigan and the cold and snow are a memory unless you are reading this in the Upper Peninsula!
F
or the Michigan Society of Anesthesiologists, winter’s impending conclusion was highlighted by the MSA Annual Scientific Session in Southfield February 28th. The meeting was held at a new venue and very well attended by registrants as well as exhibitors. We are indebted to the participation of the exhibitors and sponsors whose support makes this enjoyable event possible. The 2015 Scientific Session was eighteenth consecutive meeting planned and conducted by Robert Murray, M.D. who stepped down as Chair of the Continuing Medical Education Committee at the meeting’s conclusion. Bob gave MSA members and meeting participants consistently excellent programs over a sustained period of nearly two decades. This is an admirable contribution to our society and one for which we are all enormously appreciative and grateful. During the Annual Business Meeting at the Scientific Session the President’s Award was presented to Robert Synder, D.O. for his three decades of service to MSA. Dr. Synder earned this recognition by the importance of two meaningful contributions.
While serving as MSA Secretary-Treasurer, Bob had the vision to recognize a need to support and foster resident physician participation in research, in the MSA, and at the Scientific Session. He was integral to creation of the Michigan Society of Anesthesiologists’ Resident Education and Research Endowment Fund which is ably managed by the Midland Area Community Foundation. Income from this fund provides awards for Resident Research Posters at Annual Scientific Sessions. The continuing presentation of resident research at MSA meetings will be an ongoing reminder of Bob’s accomplishment. Secondly, Dr. Synder epitomizes the grass roots, person-to-person, relationships with lawmakers and politicians that are essential for access to these policy makers. Bob’s relationships have allowed MSA and ASA to take our messages directly to Congressmen and legislators. It was just a few years ago that I, as part of a small MSA delegation including Dr. Synder, was able to sit with the full attention of former Representative Dave Camp, then Chairmen of the powerful House Ways and Means Committee, to talk about access to care, Medicare financing, drug shortages, and patient
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safety. Each of us should strive to emulate Bob Synder’s level of personal involvement in local politics because the relationships developed sustain political access for years. Just as spring brings warmer weather, Michigan’s legislative session is also heating up. Senate Bill 68 is of primary concern to Michigan physicians and patients. This legislation would give certain groups of Advanced Practice Registered Nurses (Certified Nurse Midwives, Certified Nurse Practitioners, Clinical Nurse Specialists-Certified) authority for independent practice- to diagnose, treat, and manage patient illnesses including ordering and interpretation of diagnostic tests and prescription of pharmacologic and nonpharmacologic treatments. The bill provides for funding of grants to APRNs who practice in designated underserved areas. Of concern to the MSA, the law would allow these APRNs to prescribe controlled substances (Schedule 2-5) giving the state more than 6,500 additional sources for narcotic prescriptions that may be misused or abused. Michigan already suffers more than 1,500 deaths annually from drug overdose (more than the number of deaths from motor vehicle accidents and ranking 18th in the United States in 2013), the majority of which are from prescription drugs. Additionally, SB 68 opens the door for the inclusion of Certified Registered Nurse Anesthetists in the APRN groups granted independent practiceeither as an amendment to the current bill or by introduction of a related bill. The future intentions of the legislation’s authors is evidenced by the inclusion of CRNAs on the APRN Task Force SB 68 creates, one function of which is making guidelines for APRN scope of practice. Your MSA is taking proactive steps to maintain the state’s requirement for physician supervision of anesthesia in order to protect Michigan patients who require surgery or management of pain. An example of these actions include the public polling described in this issue of The Ventilator. The poll conducted by a nationally recognized polling company and developed in conjunction with Resch Strategies, sends a strong message to Lansing. Despite use of question language favored by the special interest groups promoting
Spring 2015
independent CRNA practice, Michigan citizens emphatically responded with their preference for physician supervision of anesthesia. As the heat of the season intensifies in Lansing, MSA will keep you informed and will call on every member to participate in the political process by getting our message to your legislators. In the meantime, continue to lead by example in your hospitals and facilities, demonstrate the importance of physician leadership, and … enjoy the warming weather and the sights and sounds of spring! As this issue of the Ventilator goes to press, we have learned the sponsor of SB 68 (Senator Mike Shirkey, R-16th Senate District) has revised the bill in effort to address some of the concerns of Michigan physicians and the Michigan State Medical Society. We wait to see the revised bill and will keep our membership appraised of its implications for Michigan patients and anesthesiologists.
CERTIFIED ANESTHESIOLOGIST ASSISTANTS THE COMMITTED ANESTHESIOLOGIST'S ANESTHETIST
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DIRECTOR’S REPORT
Is SGR Finally Dead,
and What’s Next for Physician Anesthesiologists? Kenneth Elmassian D.O. ASA Director, Michigan Chairman, ASA Committee on Communications
O
n March 26, the U.S. House of Representatives voted 392-37* to permanently repeal the sustainable growth rate (SGR) formula for Medicare physician reimbursement. H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, a bipartisan bill that repeals and replaces SGR would add about $200 billion to the projected Medicare budget over the next 10 years. In addition, the bill extends the Children’s Health Insurance Program [CHIP], as well as funding for community health centers and the National Health Service Corps. CHIP is a federal/state matching program that provides insurance coverage for children from low-income families that earn too much to qualify for Medicaid. As of this writing, the bill’s fate is in the hands of the Senate where there has been a growing consensus to move the legislation across the finish line, but there is no assurance of passage. Some potential stumbling blocks have included Senate Republicans concerned about $70 billion in funding sources for an estimated $200 billion fix…a $130 billion shortfall. On the other side of the aisle, Senate Democrats want to see the CHIP program extended to four years from its current two-year lifespan. All this to say, if the bill does reach President Barack Obama, he has indicated he will sign it. The overwhelming, bipartisan House vote came after years of negotiations and lobbying on behalf of the medical community to eliminate the deeply flawed formula, in which Medicare physician reimbursements were linked to increases in the gross domestic product. In most years, the formula resulted in huge payment cuts for physicians
which would eventually lead to annual cliffhanger moments to avert those cuts with a series of payment “patches” by Congress. In fact, as of April 1st, the SGR formula, if left intact, will impose a 21% cut in Medicare reimbursement. Even though the AMA and many other physician organizations were in full support, the ASA’s position on H.R. 2 was neutral, especially since the bill did not directly address issues specific to anesthesiology payment discrepancies. Regardless, the ASA’s political position in no way diminishes the work Congress and physician advocates have put forward over the past couple of years. That said, if and when the bill passes, the ASA will work with Congress and the Center for Medicare and Medicaid Services [CMS] to improve upon the bill going forward and the opportunities for physician anesthesiologists. SO WHAT DOES THE SGR REPLACEMENT LOOK LIKE? • The measure includes replacing the SGR with an increase of 0.5% in Medicare physician reimbursement starting in July 2015 through December 2015, and then annual 0.5% increases lasting through 2019. •
The measure also consolidates various reporting programs, such as 0 Value-Based Payment Modifiers [VPM] 0 Physician Quality Reporting System [PQRS] 0 Electronic Health Record [EHR] 0 Meaningful Use [MU]
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•
These and other proposed quality measures will be under the umbrella of a new, Merit-based Incentive Payment system [MIPS].
•
Physicians will also be incentivized to participate in alternative payment models [APMs] such as accountable care organizations [ACOs]
HOW WILL THE ASA AND PHYSICIAN ANESTHESIOLOGISTS BE INFLUENCED BY THE SGR REPLACEMENT? • As a specialty organization, the ASA will play a meaningful role to advance specialty endorsed quality measures to Medicare, including provisions intended to strengthen and support Qualified Clinical Data registries [QCDRs], such as the Anesthesia Quality Institute’s [AQIs] National Anesthesia Clinical Outcomes Registry [NACOR], as well as gain improvements in the VBM program.
•
There will continue to remain challenges regarding the Meaningful Use program in both the avoidance of penalties, as well as the ability for physician anesthesiologists to participate in its benefits.
•
There will also be opportunities to introduce anesthesiology-related payment models such as the ASA’s Perioperative Surgical Home.
Throughout the anticipated payment transition, the ASA is committed to assisting its membership in this new environment by working with Congress and CMS. No matter what your practice setting, no physician anesthesiologist will escape the ramifications of these changes. For this matter alone, your ASA membership is well worth the continued investment. *Thirteen out of the 14 members of Michigan’s U.S. House members voted in favor of the bill. Justin Amash (R-Grand Rapids) was the only nay from Michigan.
2015 MOCA® Simulation Courses at the University of Michigan Course information and registration available at: http://anes.med.umich.edu/main/programs/moca.html For additional information, contact Dr. Lauryn Rochlen at 734-936-4280 or rochlenl@med.umich.edu. Spring 2015
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MI Pollster Families Show “Overwhelming” Support for Physician Supervision of Anesthesia Stephanie VanKoevering Resch Strategies
A
strong majority of Michigan residents want to have a physician involved in the administration of anesthesia, according to a January 2015 statewide survey.
Pollster Bernie Porn of EPIC-MRA says the poll was conducted in response to legislation introduced in the Michigan Senate last session. The proposed plan would have allowed a nurse anesthetist to administer anesthesia medications without physician involvement. Some expect a similar bill will be introduced during the coming legislative session.
The survey findings showed: 89 percent of respondents prefer physician administration of anesthesia. Only six percent prefer it be administered by a nurse anesthetist acting without supervision.
Porn said the opposition held even after voters heard solid competing arguments.
82 percent believe it is important or essential that a physician supervise the administration of anesthesia care by a nurse anesthetist. By a 69–18 margin, Michigan voters oppose legislative efforts to remove the requirement of physician supervision in anesthesia care, with 51 percent strongly opposed. After hearing the arguments of bill backers, 69 percent continue to oppose the change, with even more residents—52 percent—strongly opposed. Republican voters are generally stronger in their support for the use of a physician anesthetist, but voters in both parties say they would be less likely to vote for a lawmaker that supported SB 180 (Republicans 40 percent less likely, Democrats 33 percent less likely).
“When we shared the bill backers’ own reasons for the change, opposition to the measure actually increased,” Porn said. “This was especially true for independent and younger voters.”
“If lawmakers who are tempted to consider this measure may want to think twice,” Porn said. “A vote for this concept is really going against the grain of public opinion.”
“Clearly if the legislature were to pass this proposal, it would fly in the face of overwhelming public opinion,” Porn said. “Roughly nine of every 10 voters prefer to have a physician directly administer or supervise anesthesia procedures.”
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As introduced in the last term, Senate Bill 180 would have removed physician supervision of anesthesia care in operating rooms, making nurses solely responsible for planning and administering anesthesia care. Under a similar measure, not only would nurses be handling the administration of every anesthetic from light sedation through drug-induced comas, they would also be responsible for responding to any serious problems or emergencies that may arise.
“These arguments didn’t seem to resonate with the people we polled,” Porn said. “The results couldn’t be any clearer.”
Proposal backers say the bill would not threaten patient safety, and could help build efficiency in today’s health care system. They argue that current law requires every health care provider to adhere to the same system for anesthesia administration regardless of size or location. They further allege that physician supervision of anesthesia is obsolete and immaterial to patient outcomes.
These findings may reflect personal experiences with anesthesia risks and outcomes. Surgery patients may have existing medical conditions and/or unknown drug allergies that can cause unanticipated problems during surgery. Moreover, anesthesia risks are significant for even the healthiest patient, depending on how they are administered. Injections close to nerves or the spinal cord, for instance, carry risks that are
Porn noted that 71 percent of respondents who have received or had a family member receive anesthesia care in the past wanted a physician administering anesthesia care if needed again. Only nine percent would prefer a nurse anesthetist.
Michigan residents understand how important physician anesthesiologists are for patients’ health and safety. According to a poll conducted in January 2015 by EPIC / MRA:
n
89 percent of respondents prefer a physician directly administer or supervise the administration of anesthesia care. Only 6 percent prefer it be administered by a nurse anesthetist acting without supervision.
n
82 percent believe it is important or essential that a physician supervise the administration of anesthesia care by nurse anesthetists.
n
71 percent who have received or had a family member receive anesthesia care in the past would want a physician administering anesthesia care if needed again. Only 9 percent would prefer future anesthesia be administered by a nurse anesthetist.
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substantial, even life-threatening. Opponents to the proposal say physician anesthesiologists have typically at least 12 years of training, whereas nurse anesthetists have just half that amount. They further contend that fees for physician-administered anesthesia vs. nurseadministered anesthesia are the same, eliminating any cost benefit. They also note that physician anesthesiologists prevent more than six avoidable deaths for every 1,000 patients who encounter a complication.
Republican-led Legislature will have to consider these outcomes very carefully as they decide whether to advance a measure like this.”
“The survey outcomes were roughly consistent among all the subgroups—Republicans, Democrats, men, women, younger and older voters,” Porn said. “The strongest opposition, however, came from Republicans. The current
Families are rejecting special interest attempts to remove the requirement that physicians participate in the administration of anesthesia care. Oppose
n
By a 69-18 margin, residents oppose any effort in Lansing to remove the requirement of physician supervision in anesthesia care, with 51 percent strongly opposed.
Oppose
n
When pollsters shared the CRNA’s own arguments for removing physician supervision, residents still don’t buy it. 69 percent continue to oppose the move, with even more residents— 52 percent— strongly opposed! Strongly Support
n
Only 5 percent of residents would strongly support a law to end physician supervision.
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Spring 2015
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SCIENTIFIC SESSION RECAP
2015 Jensen Memorial Lecturer and ASA First Vice President Jeffrey Plagenhoef, M.D. with MSA Board Members.
T
he Michigan Society of Anesthesiologists held its 60th Annual Scientific Session & Annual Meeting on February 28th at the Westin – Southfield. We were honored to have had American Society of Anesthesiologist First Vice-President, Jeffrey Plagenhoef, M.D. (a Michigan native) as the speaker for the Jensen Memorial Lecture. Other session topics included: • Everything You Need to Know About MOCA Lauryn R. Rochlen, M.D. • The Impact of Anesthetics on the Developing Brain: Known Unknowns Sulpicio G. Soriano, III, M.D. • The Airway Approach Algorithm: What would Andy (Ovassapian) say? William Rosenblatt, M.D. • Controversies in Central Line Insertion Avery Tung, M.D., FCCM • Frail, Feeble or Fit? The Oldest Old: What should we do differently for the geriatric patient undergoing anesthesia? Sheila Ryan Barnett, M.D.
Once again, residents submitted posters for our Annual Resident Poster Session. Eleven posters were submitted from Residency programs across the state. First place went to M.J. Romnek, M.D. from Beaumont for Evaluating the Need for Modified NPO Status in Patients with Gastric Bands. Wayne State University Medical Student Karima AlWakya took second place for Standardized Handoff Perioperative Protocol: Patient Outcome Study. And in third place was Lisa Colosimo, D.O. from Henry Ford Hospital for Voluntary Reporting of Anesthesia Adverse Events Increases with Novel Electronic Event Reporting System. Congratulations to our winners! Our Annual Meeting saw the election of MSA Directors, ASA Delegates and Alternate Delegates. The recipient of this year’s President’s Award was Robert Snyder, D.O., of Midland. Thanks once again to our sponsors: Anesthesia Business Consultants and the American Society of Anesthesiologists
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J udges and attendees list e n t o p re se n t at ion s d urin g t h e A n n u a l R e s i d e n t P o s t e r S e s s i o n .
MSA Pr esident Dr. Frede ric k C a mpbe l l pre se n t s Dr. Rober t Sny der with the 2 0 1 5 P re sid e n t ’s Award .
Drs. Downs, Snyder and Kuzel volunteer at the A S A PA C b o o t h .
C ME C h air, Dr. Ro ber t M urra y a d d re sse s t h e g roup.
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Maintenance of Certification Eric L. Larson, MD Grand Rapids, MI
Now Has an ASA 4 Status
I
t appears the tide has turned inexorably against the American Board of Medical Specialties, and its insistence that the specialty medical boards implement time-limited board certification. The initiation of Maintenance of Certification (MOC) has created so much ire and resistance amongst physicians that the battle is now being reported in the lay press (Newsweek 3/11/2015: MOC Goes Mainstream: The Ugly Civil War in American Medicine & Wall Street Journal 7/21/2014: Doctors Upset Over Skills Review.) Resistance to MOC began percolating in 2011 with internists, concerned that their ABIM recertification test was having an increasingly higher fail rate, requiring retesting and paying additional fees. This investigation led the ABIM to admit that the fail rate was increasing, with their solution being to increase testing frequency and add practice module requirements at more frequent intervals to guarantee quality with their physicians. This ‘ramping’ up of requirements led a few internists to dive into the financial reports of the ABIM and that is when things got interesting.
last year, forcing them to participate in MOC. What finally infuriated the internists was that the ABIM did not require any actual work or testing for those previously grandfathered to meet MOC requirements - just cash. That was the final straw and a petition circulated quickly which gathered over 10,000 signatures to halt the MOC process. The ABIM again refused to change or to reevaluate their MOC process. This year Dr. Paul Teirstein, chief cardiologist at Scripps Clinic, along with other academic faculty from Harvard, Mayo Clinic, Dartmouth, Cedars-Sinai, Columbia, UMass, NYU formed a competing board certification organization: the National Board of Physicians and Surgeons (NBPAS). Instead of continued testing, practice modules, simulators, and studies to maintain certification, the NBPAS requires diplomates to pass their initial ABMS board examination, hold an unrestricted state medical license, and complete 50 hours of CME every two years. Essentially, it is what the original board certification stated - one is a consultant for life.
The physician citizen investigators discovered that the ABIM went from a $7M/year enterprise in 2007 to $23M in 2013. In that time, executive pay exploded with board members making six and seven figure salaries. The ABIM paid for executive spouse first class air travel and bought a Manhattan condo complete with limo service for officers, all the while increasing the cost and steps involved in their MOC process.
Immediately after the formation of the NBPAS, the ABIM sent a letter to all internists saying that it was suspending a number of its MOC activities to review and verify their effectiveness. Other specialty boards under the same pressure from physician grassroots responded defiantly with a form letter stating that they were committed to quality and would look over their requirements closely but were leaving them unchanged.
Prominent members within the medicine community called for transparency, studies, MOC reform, and a reduction in fees. These complaints fell on deaf ears, as the ABIM instead eliminated grandfathered status of all internists
However, when faced with an alternative that requires extensive testing and busywork that often does not reflect how we practice and costs between $6,000 – $10,000 per ten years versus one that costs less than $1,000 and is designed around
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individualized CME of the physician’s choosing, it is hard to imagine that the ABIM or any of the other specialty societies like the ABA will survive the physician backlash. It is mostly true that the ABA has not committed such gross fiscal malfeasance as the ABIM, but the fact remains that it ratcheted up the requirements for certification without proof that they would improve care nor did the ABA acquire consensus with its diplomates in general. Already there is discussion at the national ASA level questioning why the ASA has been complicit in the ABA’s actions. With a hassle-free and economical alternative in NBPAS it is now only a matter of time before the ABA loses all its diplomates unless it eliminates all of its expensive and time consuming requirements.
boards. They know that no other profession retests its diplomates and nullifies their years of training. Their friends who are attorneys do not retake the Bar exam and accountants don’t retake the CPA exam despite an ever changing legal system and tax code. In our evidence based practice of medicine, physicians will no longer accept jumping through increasingly expensive hoops in an era of downward reimbursements, pressure from competitors in the anesthesia market, and no proof of efficacy. MOCA definitely qualifies as ASA 4 status and I suspect we will know whether it achieves ASA 5 status later this year. Disclosure: Dr. Eric Larson successfully completed his first ten year cycle of MOCA last year.
An online petition calling for an end to MOCA just eclipsed one thousand signatures as of the writing of this article and petitions now exist for virtually every medical specialty. Physicians are no longer accepting the dictates from their specialty
CALENDAR OF EVENTS
2015 May 1
Michigan Surgical Quality Collaborative Meeting Livonia, MI May 4 – 6
ASA Legislative Conference Washington D.C. June 10
MSA Board Meeting Lansing, MI
Spring 2015
June 26 – 28
ASA Perioperative Surgical Home Conference Huntington Beach, CA September 17
MSA Board Meeting Lansing, MI September 24 – 25
Michigan Surgical Quality Collaborative Conference Livonia, MI Visit www.mymsahq.org for current events and training opportunities.
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A Review of the Efficacy
of Liposomal Bupivacaine (Exparel®) Philip Fanapour, M.D.a and Lebron Cooper, M.D.b Henry Ford Hospital Department of Anesthesiology Detroit, MI
L
iposomal bupivacaine has received growing attention in the medical community for providing prolonged analgesia at the site of wound infiltration. It is routinely used by a large number of surgical facilities for this purpose. Its method of action is thought to be through the slow release of bupivacaine by a liposomal drug delivery technology at the site of infiltration, enabling a prolonged local anesthetic effect. Researchers at Henry Ford Hospital examined two randomized controlled trials, pivotal to the FDA approved indications of liposomal bupivacaine for post-op analgesia in bunionectomy and hemorrhoidectomy, as well as a critical review that further analyzed these data. Our review of this literature brings into question the efficacy of liposomal bupivacaine in providing prolonged analgesia and an opioid-sparing effect.
post-op, and a greater percentage of pain free patients at several time points (2, 4, 8, and 48 hours) post-op. Also, there were fewer patients requiring first opioid use, and less total opioids consumed through 24 hours post-op. In 2014, Hadley and Dine revisited and analyzed these data, and they showed lower mean PI scores through only 24 hours (Table 1) and decreased opioid consumption through only 12 hours postop (Table 2).3 Likewise, a statistical review of this study by the FDA’s Center of Drug Evaluation and Research4 disagreed with the conclusions of Golf, et al, and included the following comments: • •
In 2011, Gorfine and colleagues demonstrated superiority of liposomal bupivacaine over placebo in patients undergoing hemorrhoidectomy. From 0-72 hours post-op, there were lower NRS-AUC (numeric rating scale-area under the curve) pain intensity (PI) scores, lower total opioid use, and a greater percentage of opioid-free patients.1 That same year, Golf and colleagues demonstrated superiority of liposomal bupivacaine over placebo in patients undergoing bunionectomy.2 There were lower NRS-AUC PI scores through 36 hours
• •
•
24 hours post-surgery…mean PI scores for all patients increased from mild, score between 1 and 3, to moderate, score between 4 and 7. After eight hours post-surgery, regardless of the method, there was no longer a significant difference in the percentage of patients that were pain free. The median time to first use of rescue (opioid) was 5 and 7 hours for the placebo and Exparel groups, respectively… When I examined the mean total amount of morphine equivalents (mg) used through 72 hours post-surgery, there was not a significant difference...” Exparel did not seem effective at controlling postoperative pain associated with bunionectomy.
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DISCUSSION: Liposomal bupivacaine has received attention for providing prolonged analgesia up to 72 hours. However, after literature review, such evidence appears lacking. In comparison to placebo, its effectiveness in controlling pain appears to be limited to 24 hours. Additionally, opioid sparing effect is short-lived (~12 hours). Considering the cost compared to other local anesthetics, its analgesic properties appear to be marginally beneficial. Finally, studies comparing it to traditional long-acting local anesthetics in equivalent doses that demonstrate superiority are lacking. Further studies are needed to determine whether or not the limited benefits of this medication outweigh the costs to the health system. SOURCES: 1 Gorfine SR, Onel E, et al. Bupivacaine extendedrelease liposome injection for prolonged postsurgical analgesia in patients undergoing hemorrhoidectomy: a multicenter, randomized, double-blind, placebo-controlled trial. Diseases of the Colon & Rectum. 2011;54(12):1552-1559.
Spring 2015
Golf M, Daniels SE, et al. A phase 3, randomized, placebo-controlled trial of DepoFoam® bupivacaine (extended-release bupivacaine local analgesic) in bunionectomy. Adv Ther. 2011; 28(9):776-788. 3 Hadley and Dine. Where is the Evidence? A Critical Review of Bias in the Reporting of Clinical Data for Exparel: A Liposomal Bupivacaine Formulation. J Clinic Res Bioeth 2014, 5:4 2
Petullo D, Price D Statistical Review and Evaluation, Clinical Studies: NDA 22-496/0000. Exparel™ (extended release bupivacaine). US Department of Health and Human Services, Food and Drug Administration. October 28, 2011. http://www.accessdata.fda.gov/drugsatfda_docs/ nda/2011/022496Orig1s000StatR.pdf, accessed March 5, 2014.
4
Dr. Fanapour is a current CA-3 anesthesiology resident at Henry Ford Hospital, Detroit b Dr. Cooper is a Professor of Anesthesiology, Wayne State University and Senior Staff Anesthesiologist at Henry Ford Hospital, Detroit a
17
LEGISLATIVE CORNER
SOME NEW FACES ON THE SENATE AND HOUSE HEALTH POLICY COMMITTEES
A
s with the case with the beginning of many new sessions, there have been some changes to the committee assignments from previous years. In the area of health policy, the 201516 session brings several new faces to these committees of jurisdiction. On the State Senate side, Senator Mike Shirkey (R-Clarklake) is the new chairman of the Health Policy Committee and Senator Joe Hune (R-Hamburg) is the new vice chair of the committee. Former chairman, Senator Jim Marleau (R-Lake Orion) remains a member of the policy committee, but will now also be chairing the Senate Appropriations Subcommittee on Department of Community Health (DCH). For the State House, former Vice Chair, Representative Mike Callton (R-Nashville) is the new chair of House Health Policy and Representative Henry Vaupel (R-Fowlerville) is the new Vice Chair. Representative Rob VerHeulen (R-Walker) is the chair of the House Appropriations Subcommittee on DCH and he is also a member of the policy committee. Your team of MSA and GCSI has been doing outreach to many members of the Senate and House Health Policy Committees, with an emphasis on introducing new committee members to the MSA and discussing issues of concern, particularly the supervision of nurse anesthetists (see related story). Senate Health Policy Committee members: Senators Mike Shirkey (R-Clarklake)-Chair Joe Hune (R-Hamburg)-Vice Chair Margaret O’Brien (R-Portage) Jim Marleau (R-Lake Orion) Rick Jones (R-Grand Ledge)
Legislative Corner is a regular feature, written by Marcia Hune, Governmental Consultant Services, Inc.
Jim Stamas (R-Midland) David Robertson (R-Grand Blanc) Curtis Hertel Jr. (D-East Lansing)-Minority Vice Chair David Knezek (D-Dearborn Heights) Hoon-Yung Hopgood (D-Taylor) House Health Policy Committee members: Representatives Mike Callton (R-Nashville)-Chair Henry Vaupel (R-Fowlerville)-Vice Chair John Bizon (R-Battle Creek) Lee Chatfield (R-Levering) Kathy Crawford (R-Novi) Daniela Garcia (R-Holland) Joe Graves (R-Linden) Tom Hooker (R-Byron Center) Holly Hughes (R-Montague) Klint Kesto (R-Commerce Twp.) Jim Tedder (R-Clarkston) Rob VerHeulen (R-Walker) Ken Yonker (R-Caledonia) George Darany (D-Dearborn)-Minority Vice Chair Winnie Brinks (D-Grand Rapids) Tom Cochran (D-Mason) Erika Geiss (D-Taylor) Frank Liberati (D-Allen Park) Sheldon Neeley (D-Flint) Phil Phelps (D-Flushing) Robert Wittenberg (D-Oak Park)
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LEGISLATION REMOVING PHYSICIAN SUPERVISION OF NURSE ANESTHETISTS
Last session, one of the major bills we actively opposed was legislation removing the physician supervision requirement for nurse anesthetists. That particular legislation, Senate Bill 180, was introduced by Sen. Mike Green (R-Mayville) and referred to the Senate Health Policy Committee. The bill amended the Public Health Code to expand the definition of the “practice of nursing” to include “the administration of anesthesia by a registered professional nurse who holds a specialty certification as a nurse anesthetist”, essentially removing the requirement of physician supervision of nurse anesthetists. Senate Bill 180 was up in Senate Health Policy Committee for testimony only in the fall of 2013, and since several senators on the committee expressed concern over the idea of removing physician supervision at the risk of patient safety, the bill was not brought up again during that session. Throughout 2014, we remained concerned that a member of the House of Representatives would introduce companion legislation on the issue, and the threat existed also that an amendment could be added to another bill amending the Public Health Code to include the issue of removing physician supervision of nurse anesthetists. Since the start of the new session in 2015, MSA members and GCSI have been speaking with the members of both the House and Senate Committees on Health Policy to again express our concern with any proposal that would seek to remove the supervision of nurse anesthetists. While there has not been any legislation yet introduced on this topic, we wanted to ensure that the new committee members, as well as the returning ones, are educated about the issue. GCSI and your MSA Legislative Committee will continue to work hard in advocating on behalf of anesthesiologists and physician supervision in regard to this potential legislation.
Spring 2015
LEGISLATION TO EXPAND THE SCOPE OF CERTAIN ADVANCED PRACTICE NURSES
Another issue that was of concern last session was Senate Bill 2, sponsored by former Sen. Mark Jansen (R-Grand Rapids), which provided for an expansion of scope for certain advanced practice registered nurses (APRNs). The bill also included certified nurse midwives, certified nurse practitioners, and clinical nurse specialistscertified. The legislation had passed the full Senate and was before the House Health Policy Committee; however it was not considered prior to the end of the lame duck session. This session, Sen. Mike Shirkey (R-Clarklake), who is the new chair of the Senate Health Policy Committee, has introduced a similar bill on the APRN issue and it is now Senate Bill 68. While there are a number of concerns with Senate Bill 68 as introduced, one that has been expressed specifically by the MSA is the provision in the bill which would authorize a licensed APRN to prescribe and administer nonscheduled prescription drugs and Schedule 2 through 5 controlled substances if he or she met certain criteria. The Senate Health Policy Committee met three times to take testimony on Senate Bill 68 so far this year, and Chairman Shirkey has expressed his interest in wanting to report a bill possibly prior to the summer recess in June. Sen. Shirkey has been working with the Michigan State Medical Society (MSMS) and the MSA on our concerns with the legislation, as well as the concerns of other physician groups, and substitute language continues to be worked on that will require APRNs to be part of a Patient Care Team led by a physician. GCSI continues to work diligently to be the eyes, ears, and representatives of the Michigan Society of Anesthesiologists in Lansing, as we advocate for policies that ensure the safety of patients. If members have questions, please do not hesitate to contact us at hune.m@gcsionline.com.
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