Abstract Introduction The field of otolaryngology has become the leading specialty in the management of head and neck pathology and trauma. Graduate medical education programs tasked to train military head and neck surgeons within the Department of Defense (DoD) maintain certification by ensuring adequate surgical case volume and training. In recent years, surgical case numbers have declined due to an overall healthy active duty patient population and deployments of residency faculty. As such, a novel initiative between the San Antonio Military Medical Center and the South Texas Veteran’s Healthcare system was developed to provide seamless care among active duty service members, dependents, retirees, and veterans. The goal of this study is to review the impact on Otolaryngology Key Indicator Procedures (KIP), as defined by the Accreditation Council for Graduate Medical Education (ACGME), following integration of a Veterans Affairs health care population into a military otolaryngology residency program. Further, we aim to assess the potential secondary benefits of an integrated health care initiative between the DoD and the Veteran’s Affairs (VA) systems. Materials and Methods Otolaryngology key indicator procedures, as defined by the ACGME, were reviewed at an academic military medical center before and after implementation of an ENT Federal Healthcare Consortium integrating care of VA patients at a military hospital. The surgical scheduling system at our institution was queried for cases within the KIP categories of “Head & Neck” and “Otology” from 2011 to 2015. Results Case data was reviewed from the San Antonio Military Medical Center before (2011–2012) and following integration of VA patient care (2013–2015). A total of 520 “Head & Neck” and 532 “Otology” KIP were performed following development of an ENT Federal Consortium. One hundred and sixty-five KIPs were performed on patients referred from the VA. The range of VA-generated cases contributing to total KIPs for “Head & Neck” and “Otology” ranged from 6.8% to 59.5% and 0% to 18.9% per year. Conclusions The establishment of a Federal Healthcare Consortium and integration of VA patient population provided a tangible and quantifiable increase in otolaryngology KIPs. Development of a training relationship with VA patients is beneficial in reaching outcome-oriented goals for otolaryngology residents. Introduction The field of otolaryngology, once relegated to the management of head and neck infections and their complications in the pre-antibiotic era, has flourished over the past 60 yr. Otolaryngology has since become the leading specialty in the management of head and neck oncology, head and neck trauma, rhinology/skull base surgery, facial reconstruction, airway management, otology, and laryngology. Following World War II, the Veteran’s Affairs (VA) hospital system built many hospitals in close proximity to academic teaching hospitals to take advantage of the specialty care afforded by medical school affiliation and access to faculty and resident physicians.1 Today, VA hospitals contribute to the training of approximately one-third of all U.S. residents each year.2 Affiliations with the VA are viewed positively by the majority of residents and faculty of general surgery, cardiothoracic surgery, and psychiatry residencies.4–6 An analysis of plastic surgery cases between 1998 and 2003 revealed a wide spectrum of caseload generated from the VA patient population with significant increases generated in craniomaxillofacial and head and neck reconstruction cases.7 These cases are of particular interest in otolaryngology residency programs. Although many academic training programs have been intimately involved in the care of veterans through the VA system for decades, the Department of Defense (DoD) medical system, which cares for active duty military members, retirees, and their dependents, has historically been a separate entity from the Department of Veterans Affairs. The divided care systems of the DoD and the VA have resulted in limited access of the veteran patient population to academic military programs. Specifically, the eight military otolaryngology residencies, which graduate up to 15 residents per year or nearly 5% of the total number of otolaryngology graduating residents, have very limited access to VA patients and caseload.3 In an effort to improve GME training, quality of care, military readiness, and cost savings, the ENT Federal Healthcare Consortium (FHC) was developed in 2011 and fully implemented in January 2013. This novel health care policy project integrated care between the San Antonio Military Medical Center (SAMMC) and the South Texas Veterans Healthcare System (STVHCS) and created a seamless health care system providing head and neck care to all federal patients (active duty military, dependents, retirees, and veterans). The impact on GME that resulted from the recent prolonged combat operations and deployments was a major impetus to develop this first FHC.8 Given that the value of VA affiliation on graduate medical education training has been previously demonstrated in other specialties, the purpose of this project is to explore the direct effects of VA integration on an otolaryngology residency training program. Specifically, we aimed to quantify this effect by reviewing the quantity and variety of Otolaryngology Key Indicator Cases (KIPs), as defined by the ACGME generated by an academic partnership between the Veterans Affairs medical system and the San Antonio Military Medical Center. Materials and Methods The project was submitted to the Human Research Protections Office, where a Not-Research determination was made on this program evaluation project based on being a quality improvement initiative. A review of otolaryngology cases relevant to ACGME training requirements was performed and public data from the Department of Surgery regarding access to care and patient outcomes were reviewed as a secondary measure. The surgical scheduling system at the San Antonio Military Medical Center was queried for Otolaryngology Key Indicator Procedures performed before, and following implementation of the ENT FHC, from 2011 to 2012 and 2013 to 2015, respectively. The categories of “Head & Neck” (Parotidectomy, Neck Dissection <all types>, Oral Cavity Resection <Glossectomy>, Thyroid/Parathyroid), and “Otology/Audiology” (Tympanoplasty <all types>, Mastoidectomy <all types>, Stapedectomy/Ossiculoplasty) were used as markers of the academic impact of the VA integration on the BAMC residency program. Utilization data from the Central Operations Department and quality data from the Department of Surgery and National Surgical Quality Improvement Project (NSQIP) was then examined to review patient encounters and access to care. Results Between 2011 and 2015, the Otolaryngology Department at the San Antonio Military Medical Center performed a total of 636 “Head & Neck” KIP cases and 657 “Otology” KIP cases as defined by the ACGME (Table I). Overall, KIP caseload trended positively among the specified categories (Figs 1 and 2). Table I. Key Indicator Procedures 2011–2015 Year Total Patients VA Patients % VA Patients Head and Neck Parotidectomy 2011 13 0 2012 17 0 2013 14 2 14.2 2014 37 22 59.5 2015 31 10 32.3 Neck dissection (all types) 2011 8 0 0 2012 23 0 0 2013 42 17 40.4 2014 53 24 45.2 2015 40 16 40 Oral cavity resec (glossectomy) 2011 1 0 0 2012 0 0 0 2013 8 4 50 2014 6 2 33.3 2015 4 0 0 Thyroid/parathyroidectomy 2011 39 0 0 2012 50 0 0 2013 59 4 6.8 2014 107 10 9.3 2015 84 8 9.5 Otology/audiology Tympanoplasty (all types) 2011 22 0 0 2012 48 0 0 2013 60 2 3.3 2014 101 12 11.9 2015 85 4 4.7 Mastoidectomy (all types) 2011 13 0 0 2012 28 0 0 2013 47 2 4.2 2014 74 12 16.2 2015 58 3 5.2 Stapedectomy/ossiculoplasty 2011 2 0 0 2012 12 0 0 2013 23 0 0 2014 37 7 18.9 2015 47 4 8.5 Year Total Patients VA Patients % VA Patients Head and Neck Parotidectomy 2011 13 0 2012 17 0 2013 14 2 14.2 2014 37 22 59.5 2015 31 10 32.3 Neck dissection (all types) 2011 8 0 0 2012 23 0 0 2013 42 17 40.4 2014 53 24 45.2 2015 40 16 40 Oral cavity resec (glossectomy) 2011 1 0 0 2012 0 0 0 2013 8 4 50 2014 6 2 33.3 2015 4 0 0 Thyroid/parathyroidectomy 2011 39 0 0 2012 50 0 0 2013 59 4 6.8 2014 107 10 9.3 2015 84 8 9.5 Otology/audiology Tympanoplasty (all types) 2011 22 0 0 2012 48 0 0 2013 60 2 3.3 2014 101 12 11.9 2015 85 4 4.7 Mastoidectomy (all types) 2011 13 0 0 2012 28 0 0 2013 47 2 4.2 2014 74 12 16.2 2015 58 3 5.2 Stapedectomy/ossiculoplasty 2011 2 0 0 2012 12 0 0 2013 23 0 0 2014 37 7 18.9 2015 47 4 8.5 Table I. Key Indicator Procedures 2011–2015 Year Total Patients VA Patients % VA Patients Head and Neck Parotidectomy 2011 13 0 2012 17 0 2013 14 2 14.2 2014 37 22 59.5 2015 31 10 32.3 Neck dissection (all types) 2011 8 0 0 2012 23 0 0 2013 42 17 40.4 2014 53 24 45.2 2015 40 16 40 Oral cavity resec (glossectomy) 2011 1 0 0 2012 0 0 0 2013 8 4 50 2014 6 2 33.3 2015 4 0 0 Thyroid/parathyroidectomy 2011 39 0 0 2012 50 0 0 2013 59 4 6.8 2014 107 10 9.3 2015 84 8 9.5 Otology/audiology Tympanoplasty (all types) 2011 22 0 0 2012 48 0 0 2013 60 2 3.3 2014 101 12 11.9 2015 85 4 4.7 Mastoidectomy (all types) 2011 13 0 0 2012 28 0 0 2013 47 2 4.2 2014 74 12 16.2 2015 58 3 5.2 Stapedectomy/ossiculoplasty 2011 2 0 0 2012 12 0 0 2013 23 0 0 2014 37 7 18.9 2015 47 4 8.5 Year Total Patients VA Patients % VA Patients Head and Neck Parotidectomy 2011 13 0 2012 17 0 2013 14 2 14.2 2014 37 22 59.5 2015 31 10 32.3 Neck dissection (all types) 2011 8 0 0 2012 23 0 0 2013 42 17 40.4 2014 53 24 45.2 2015 40 16 40 Oral cavity resec (glossectomy) 2011 1 0 0 2012 0 0 0 2013 8 4 50 2014 6 2 33.3 2015 4 0 0 Thyroid/parathyroidectomy 2011 39 0 0 2012 50 0 0 2013 59 4 6.8 2014 107 10 9.3 2015 84 8 9.5 Otology/audiology Tympanoplasty (all types) 2011 22 0 0 2012 48 0 0 2013 60 2 3.3 2014 101 12 11.9 2015 85 4 4.7 Mastoidectomy (all types) 2011 13 0 0 2012 28 0 0 2013 47 2 4.2 2014 74 12 16.2 2015 58 3 5.2 Stapedectomy/ossiculoplasty 2011 2 0 0 2012 12 0 0 2013 23 0 0 2014 37 7 18.9 2015 47 4 8.5 Figure 1. View largeDownload slide Head and neck cases. Figure 1. View largeDownload slide Head and neck cases. Figure 2. View largeDownload slide Otology cases. Figure 2. View largeDownload slide Otology cases. Following the implementation of the ENT FHC in 2013, otolaryngology residents performed a total of 520 “Head & Neck” and 532 “Otology” cases. Within the category of “Head and Neck,” 19.2–27.2% of all KIP cases were performed on VA patients (Fig. 1). Parotidectomy and neck dissection revealed a robust increase in caseload, with VA patients accounting for 14.2–59.5% and 40–45.2% of cases, respectively. Within the category “Otology,” 3.3–18.9% of all KIP cases were generated from the VA population. The largest proportion of VA patients contributing to Otology cases was found in 2014, accounting for 11.9% of tympanoplasty, 16.2% of mastoidectomy, and 18.9% of stapedectomy/ossiculoplasty of KIPs (Fig. 2). In 2015, 2 yr after initiation of the FHC, BAMC was able to provide STVHCS patients with 1,087 outpatient visits resulting in 207 surgical cases from 599 VA patients. This contributed to a 7% increase in total outpatient visits and 10% increase in total surgeries performed. With respect to access to care, non-VA patients, on average, were seen at 19 d after their initial consult was placed. VA patients were seen at an average of 23 d after their consult was placed, with the 4-d difference resulting from the VA system consult review process required before the consult was sent to clinic schedulers. National Surgical Quality Improvement Program data provided by the SAMMC Department of Surgery demonstrated that the quality of ENT FHC care was “exemplary” or “as expected” in all categories examined when compared with other participating health care institutions. Discussion The Accreditation Council for Graduate Medical Education (ACGME) serves as a national governing body responsible for the accreditation of MD residency training programs within the United States.9 In 1999, the ACGME introduced the Outcomes Project, designed to focus on ways to quantifiably measure educational goals and outcomes. This contrasted efforts before 2002, in which residency program accreditation was based on the ability of a program to educate residents through process-oriented education. Following the implementation of the Outcomes Project, residency training and program accreditation became based on a series of measurable outcomes to assess competency.9 One facet of the outcome-oriented educational model is a focus on resident case logs and, more recently, key indicator case requirements. Case logs were developed as a measure of a resident’s surgical competency through the reporting of all procedures completed and their role in each case.10 Rosenburg and Franzese examined case log data, including minimum, maximum, and mean case numbers, in a 2012 study.11 They analyzed resident national data reports from ACGME resident case log system performed from 2004 to 2010 and found large differences between the mean and minimum numbers of both uncommon and common procedures. Some residents graduated without documentation of otherwise common procedures.11 This study highlighted the need for absolute minimums for all procedures before graduating from otolaryngology residency program.11 In 2013, a minimum number of key indicator cases were established by the ACGME and beginning in 2014, graduating residents were required to meet all minimum requirements.12 Academic affiliations with the VA medical system have been viewed positively by the majority of residents and faculty across a spectrum of medical specialties. Bakaeen et al. reported survey results to include 76% of respondents’ opinion that the operating room experience at the VA afforded more autonomy and hand-on experience for cardiothoracic surgery trainees.4 Robinson et al. reported survey results with respect to perceptions of general surgery training and the Veterans Affairs hospital system. Of particular interest was the finding that 91% of general surgery program chairs found VA affiliation valuable for training; however, only 62% of program respondents were integrated with VA care.6 With respect to case volume, Poteet et al. reported that ACGME minimum requirements were reached during respective VA rotations alone within multiple subsets of general surgery training to include surgical oncology, endocrine, colorectal, hepatobiliary, transplant, gastrointestinal laparoscopy, and elective/emergency general surgery.5 Ravin et al. reviewed the role of Veterans Affairs health care on plastic surgery residency requirements with similar positive results. Plastic surgery cases between 1998 and 2003 were examined revealing 1,655 operative cases supporting the training mission of plastic surgery to include extremity/trunk, breast/cosmetic, head/neck, hand, and craniomaxillofacial cases. Interestingly, head and neck cases were the largest subset and provided training in free tissue transfer and local reconstruction.7 The Department of Defense medical system provides residency training for United States Army, Navy, and Air Force officers and graduates between 12 and 15 otolaryngology residents per year.8 Despite fluctuations in otolaryngology faculty throughout the Iraq and Afghanistan wars, with 26 faculty members deployed from their respective training facilities between 2001 and 2010, military otolaryngology resident caseload has remained comparable with national averages.8 Although overall caseload and board pass rates remained on par with civilian counterparts, a specific downtrend in Head & Neck cases was noted from 2005 to 2010.8 This trend was primarily due to deferrals of Medicare eligible patients to civilian practice and, to a lesser extent, the deployment of otolaryngology teaching faculty. Consequently, clinical rotations at outside facilities became important to attain appropriate case numbers and efforts to recapture lost patient populations were initiated. One such effort was the development of the ENT FHC, a collaboration between the San Antonio Military Medical Center and the STVHCS. The proposed advantages of a FHC are improved GME training, improved quality of patient care, timely patient care delivery, federal government cost savings, and enhanced military readiness. The SAMMC otolaryngology department officially merged with the STVHCS otolaryngology department in 2011 and then implemented the ENT FHC in early 2013. Before the FHC, the VA had 2.5 full-time equivalent ENT staff members and could only provide rhinology, facial plastics, and otology specialization. Partnering with SAMMC, there are now more than 20 ENT staff members who provide subspecialty care in the following areas: laryngology, head and neck oncology, pediatric otolaryngology, general otolaryngology, otology/neuro-otology, facial plastics, sleep medicine, craniofacial/skull base, and rhinology. VA beneficiaries are now able to receive fellowship-trained care in every subspecialty area within ENT in an academic setting at the DoD facility, who previously may have been sent to community partners for care. With the implementation of the ENT FHC in 2013, surgical cases were prescreened by VA providers for acuity and routed to the DoD facility for higher level care. As noted, analysis of 2015 data revealed that the Veterans Affairs population contributed to a 10% increase in total surgeries performed and a 7% increase in total outpatient visits. The surgical yield for VA outpatient visits is significantly higher than for DoD visits, with one out of every three VA patients referred to SAMMC resulting in a surgical case as compared with one out of every 8–10 DOD patients. The availability and quality of care through the ENT FHC described above is of specific relevance given the recent highlight on VA access to care.13 Efforts have been made across government health care to address these concerns. This issue brought to light the importance of health care professionals providing on-time quality care to veterans, which the ENT FHC provides. Review of key indicator cases preceding and following development of the ENT Federal Consortium clearly demonstrated the quantifiable benefit of the VA health system to DoD resident education. Within the two categories of KIPs for otolaryngology residency training examined, VA integration provided a robust increase in these critically important case numbers. Parotidectomy and neck dissection provided the largest increase in case numbers, with VA patients comprising up to 59% of total parotidectomies and up to 45% of total neck dissections. The authors and the senior military head and neck surgery staff believe that these complex VA head and neck cases best prepare staff and residents for wartime operations and combat surgery. Improved access to this specific patient population has significantly improved readiness for DoD ENT surgeons. Interestingly, as can be gleaned from the data, case variability year-to-year, specifically in the scope of thyroid/parathyroid and oral cavity resection (glossectomy), revealed unexpected data trends. Thyroid/parathyroid case numbers increased dramatically beginning in 2014, more so than would be expected from VA integration alone. Although many factors may have been occurring at this time, we attribute a concerted effort made by our otolaryngology staff with endocrinology colleagues to enhance referral patterns as a contributing factor. Furthermore, documented oral cavity resection (glossectomy) case numbers are less than expected from the senior author’s experience. These case numbers may have been lost to capture due to coding by ancillary staff as procedures other than glossectomy, such as wide local excision due to unfamiliarity of case coding in the electronic surgical scheduling system by ancillary staff. Interestingly, in 2013, 50% of oral cavity resections (4 of 8) were referred from the VA, and these four patients resulted in higher level reconstructions (two pectoralis flaps, two radial forearm free flaps), which support the overall academic and readiness benefits. The authors acknowledge the limitations of our project insofar as our conclusions are drawn from retrospective review of electronic surgical case documentation. This relies on accurate and reliable description of cases performed and subsequent input into the scheduling system. Furthermore, case numbers from the year 2013 and data analysis from this time point may be affected by the transition in cases being performed at SAMMC versus the STVHCS and the novelty of documenting beneficiary status into the electronic scheduling system at that time. The project focus is centered on only two of the four ACGME KIP categories: “Head & Neck” and “Otology.” The decision to exclude “Facial Plastics Reconstructive Surgery” and “General/Pediatric” categories was made due to expected challenges in accurate data collection and analysis. Specifically, FPRS cases and coding may be skewed due to intraoperative reconstructive decisions, which would not be listed on the scheduling system (i.e., local flaps/grafts) as well as loss of documented cases performed in an outpatient setting (i.e., Mohs reconstruction). General/pediatric category was primarily excluded from study due to patient age demographics from the VA system. However, an unreported increase in laryngology cases was noted. Future quality improvement initiatives are needed to assess the impact of VA affiliation on FPRS and general category KIPs. The authors also note that an inherent feature of incorporating any new patient population into a surgical practice affords a potential increase in caseload. However, the goal of this project is to support the notion that access to the VA population not only increases general and more common otolaryngology procedures, but those specific cases outlined by the ACGME as requisite for adequate and complete GME training. Conclusions The establishment of a FHC via integration of a Veterans Affairs patient population with a DoD otolaryngology residency program provided a tangible and quantifiable increase in otolaryngology Key Indicator Procedures. Affiliation and collaboration between the VA Health System and an active duty military residency training program have demonstrated significant benefits for both patients and graduate medical education at our institution. In addition, the increased exposure of staff and residents to complex VA head and neck cases improves readiness for combat operations and better prepares these military surgeons to care for our wounded. References 1 Calhoun KH, David WE, Templer JW: Otolaryngology residency training: resurgence of the specialty. Otolaryngol Clin North Am 2007; 40( 6): 1195– 201. Google Scholar CrossRef Search ADS PubMed 2 Sherrier RH, Chang BK, Rawson JV, et al. : The role of the VA in Academic radiology: a report of the ACR’s committee on governmental and regulatory affairs in academic radiology. J Am Coll Radiol 2012; 9( 8): 564– 70. Google Scholar CrossRef Search ADS PubMed 3 National Resident Matching Program, Results and Data: 2016 Main Residency Match . Washington, DC, National Resident Matching Program, 2016. 4 Bakaeen FG, Stephens EH, Chu D, et al. : Perceptions regarding cardiothoracic surgical training at Veteran’s Affairs hospitals. J Thorac Cardiovasc Surg 2011; 141: 1107– 13. Google Scholar CrossRef Search ADS PubMed 5 Poteet S, Tarpley M, Tarpley JL, et al. : Veterans Affairs general surgery service: the last bastion of integrated specialty care. Am J Surg 2011; 202( 5): 507– 10. Google Scholar CrossRef Search ADS PubMed 6 Robinson CN, Freischlag J, Brunicardi FC, et al. : The VA is critical to academic development. Am J Surg 2010; 200: 628– 31. Google Scholar CrossRef Search ADS PubMed 7 Ravin AG, Gottlieb NB, Wang HT, et al. : Effect of the Veterans Affairs Medical System on Plastic surgery residency training. Plast Reconstr Surg 2006; 117( 2): 656– 60. Google Scholar CrossRef Search ADS PubMed 8 Scalzitti N, Brennan J, Bothwell N, et al. : Military otolaryngology resident case numbers and board passing rates during the Afghanistan and Iraq wars. Otolaryngol Head Neck Surg 2014; 150( 5): 787– 91. Google Scholar CrossRef Search ADS PubMed 9 Marple BF: Competency-based resident education. Otolaryngol Clin N Am 2007; 40: 1215– 25. Google Scholar CrossRef Search ADS 10 Review Committee for Otolaryngology ACGME. “Case Log Coding Guidelines.” ACGME. Nov, 2015. Web. 15 Aug 2016. 11 Rosenberg TL, Franzese CB: Extremes in otolaryngology resident surgical case numbers. Otolaryngol Head Neck Surg 2012; 147( 2): 261– 70. Google Scholar CrossRef Search ADS PubMed 12 Review Committee for Otolaryngology ACGME. “Required Minimum Number of Key Indicator Procedures for Graduating Residents. ACGME. Apr, 2013. Web. 1 Aug 2016. 13 Bronstein S, Griffin D “A fatal wait: Veterans languish and die on a VA hospital’s secret list”. CNN Investigations. CNN. 23 Apr 2014. Web. 1 Aug 2016. Author notes The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, the Department of Defense, or the U.S. Government Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.
Military Medicine – Oxford University Press
Published: May 9, 2018
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