by Kenneth A. Lipshy, MD 
 
The AVAS has proudly sponsored its annual resident and student paper competition for many years. All resident presenters are afforded the opportunity to submit manuscripts to JAMA Surgery for consideration of publication.
 
Winners of the overall Resident/Student competition at the 2019 AVAS Annual meeting were as follows:
 
Best Quickshot ($200)
Shirley Liu
PALLIATIVE CARE IS UNDERUTILIZED AND IMPACTS HEALTHCARE COSTS IN RUPTURED ABDOMINAL AORTIC ANEURYSMS
 
Best Basic Science ($300)
Mia Klein
AN INJECTABLE TISSUE-FACTOR TARGETED NANOFIBER TO SLOW NON-COMPRESSIBLE TORSO HEMORRHAGE
 
Best Medical Student ($200)
Alia Mowery
INCREASED RISK OF HEAD AND NECK CANCER IN AGENT ORANGE EXPOSED VIETNAM ERA VETERANS
 
Best Clinical #1 ($300)
Maren Shipe
INTEGRATING FUNGAL AND CANCER BIOMARKERS IN THE EVALUATION OF INDETERMINATE PULMONARY NODULES
 
Best Clinical #2 ($200)
Benjamin Resio
FUTILE SURGERY? AN ANALYSIS OF EXTREMELY HIGH-RISK SURGERY AT NSQIP HOSPITALS
 
Best Overall ($500)
Nader Zamani
INFLUENCE OF CARDIOVASCULAR DISEASE AND CHRONIC KIDNEY DISEASE ON LONG-TERM MORTALITY FOLLOWING MAJOR OPERATIONS IN A NATIONAL COHORT OF VETERANS
 
In addition, the AVAS proudly sponsors the American College of Surgeons Committee on Trauma Region 13 VA Resident Trauma competition at its annual meeting.

The winners of this year's competition was Dr. Mia Klein, MD, (University of North Carolina) who presented her basic science paper on  AN INJECTABLE TISSUE-FACTOR TARGETED NANOFIBER TO SLOW NON-COMPRESSIBLE TORSO HEMORRHAGE and Dr. Michelle B Mulder, MD (University of, Miami Fl) who presented her clinical paper on DOES FIBRINOLYSIS SHUTDOWN INCREASE MORBIDITY AND MORTALITY IN ADULTS WITH POLYTRAUMA AND BRAIN INJURY? Both resident winners will represent the VA at the ACS COT Military Region 13 Excelsior Society Meeting to be held October 2019 at the ACS Annual Clinical Congress. The winners of that competition will receive transportation to the Annual ACS COT meeting held in March 2020. We encourage AVAS members to remind their staff and affiliates of this opportunity. 

The 2019 Annual Meeting of the AVAS was blessed with several enlightening panel discussions.
The final session (moderated by David Berger, MD and Jason Johanning, MD) was a lesson on “MEASURING ACADEMIC PRODUCTIVITY IN VA”.
 
Eileen Moran, MS (Director, VHA Office of Productivity, Efficiency, and Staffing, ​West Haven, CT) initiated the conversation by providing helpful hints on “MEASURING VA SURGEON PRODUCTIVITY NOW AND IN THE FUTURE “. Dr. Moran reviewed data that most of us were not aware of. The office of productivity is capable of compiling data across the entire VA workforce. Across the board, VA surgeons work an average of 80% clinical FTE. OR case numbers have only risen 20,000 over the past five years. Unique patient workload in surgery has been consistently steady at 1.5M for the past five years and unique encounters in surgery have risen 500K over the past five years. Dr. Moran, discussed that among the reasons for instituting a  productivity model in the first place, one reason was to provide incentives for work, identify barriers to efficient care, identify providers who require assistance, and to distribute work equitably. In theory, by creating a standardized measure, all practices would be on equal ground for that specialty. Surprisingly, for five years over 50% of surgeon RVU’s have been generated in the non-procedural setting. In addition, most of us were surprised to learn that the surgeon workforce has been very stable for the past five years, with the only significant change being that contract and fee provider numbers have steadily declined with a proportionate rise in employed staff. Specialties that have seen the most significant decline in the past five years include neurosurgery, thoracic surgery and general surgery. Gynecology has seen the highest increase. Ophthalmology has generated the highest productivity scores. Dr. Moran concluded by explaining the useful aspects of the SPARQ tool.
 
Brian R. Smith, MD (VISN 22 Chief Surgical Consultant) followed with his query on “IS STANDARIZED MEASUREMENT OF SURGEON PRODUCTIVITY ACROSS ALL VA'S THE RIGHT APPRAOCH? “. Dr. Smith compared the VA productivity measuring system with that of other institutions. The VA uses work RVU’s and Clinical FTE. Work RVU’s (wRVU) are created thru the summation of RVU’s collected during a provider’s work hours. An entire specialty’s RVU’s are then added to determine the total RVU for that specialty. Clinical FTE are calculated from the labor mapping calculation whereby non-clinical hours are subtracted out. Total Clinical FTE are determined by the sum of the entire Specialty’s Clinical FTE. For the individual and the specialty productivity scores are then created by dividing the wRVU by the clinical FTE. An individual and that specialty can then be compared to the mean productivity score for that specialty in the same facility complexity level. This process relies entirely on that individual being classified in the right specialty (taxonomy) and in the correct mapping of their pay-period workload. Other productivity models rely on clinic wait times, OR wait times, or RVU’s generated per hour or patients seen per hour. Other rely on charges or dollars collected per hour. In the end there was agreement that the system requires a model that incentivizes providers but remains patient centered, easily measurable, and not easily corrupted.
 
Carolyn M Clancy, MD (Deputy Undersecretary for Health, Discovery, Education and Affiliated Networks Department of Veterans Affairs, Washington, DC) pondered the burning question, “CAN VA MAINTAIN ITS TRADITIONAL ACADEMIC MODEL IN THIS DAY AND AGE? “. Dr. Clancy provided an honest opinion on the direction the VA was likely leading in terms of productivity. She acknowledged that the VA compensation model does not coincide with our academic affiliate goal as it does not account for actual academic productivity (teaching and research).  The VA provides an opportunity for young physicians to become researchers. Many simply would not have had that opportunity outside the VA. Dr. Clancy concluded her discussion by reminding us that “we have one foundational service and that is to provide integrated care to our patients” and that “we have a strong foundation”. However, “we do have a lot of opportunity to provide improved care for our veterans”.
 
Mark Wilson, MD PhD ​(Professor and Chief of Surgery, VA ​Pittsburgh Healthcare System ​Acting Director of Surgery, National Surgery Office) concluded with his thoughts on “PRODUCTIVITY AND PERFORMANCE “. Mark Wilson began his discussion by explaining that physicians have mistakenly accepted that productivity (wRVU) is a definitive measure of performance. Productivity measures need to account for time (input) and workload measure generated (output).  Accurate measures should include all input and output measures but for physicians that does not appear to be the case. A more accurate system would not only include time as an input but also support staff and other resources. A fair model would also include the work done doing research and educational activities. The problems identified with most productivity models are that they are assumed to lead to improved performance and identify low performers but they can actually impair production. In the end there must be a balance between motivation, efficiency, customer satisfaction, quality and productivity. The reality is that clinical volume will always be a factor in measuring productivity.

The 2019 Annual Meeting of the AVAS, held April 27-30, 2019, at the Motif Hotel Seattle, WA, was a resounding success. 
The program committee, led by Nader Massarweh, MD, and the local arrangements committee, led by Gale Tang, MD, created a memorable program this year. Several fantastic panel sessions were conducted.

The first panel session on “TO STAY IN VA OR NOT TO STAY? THAT IS THE QUESTION” was moderated by George Sarosi, MD and Seth Spector, MD.

• Kamal Itani, MD (Professor and Chief of Surgery,  VA Boston Health Care System) started the discussion on “WHY I STAYED IN VA”. 
• Melanie Morris, MD (Associate Professor and Chief of General Surgery, Birmingham VA Medical Center) followed with her talk on “HOW AND WHY I SPLIT TIME IN VA” 
• Leigh Neumayer, MD MS (Professor and Chair, University of Arizona) continued with her explanation “WHY I LEFT THE VA”. 
• Todd Rosengart, MD (Professor and Chair, Department of Surgery, Baylor College of Medicine) Concluded with his explanation on “HOW ACADEMIC AFFILIATE CAN SUPPORT VA SURGEONS”.

The second panel appropriately titled the “INSPIRATION SESSION” was moderated by Faisal Bakaeen, MD and Gosta Pettersson, MD

• Frederick Grover, MD (Emeritus Chair, Department of Surgery, University of Colorado) began with his thoughts on “HOW TO INSPIRE THE VA AND HAVE THE VA INSPIRE YOU”.
• Melina Kibbe, MD (Chief of the Department of Surgery University of North Carolina) next provided her thoughts on “A PATH TO THE SURGICAL SUMMIT THROUGH THE VA”.
• Joseph Coselli, MD (Chief, Cardiothoracic Surgery, Baylor College of Medicine) encouraged us further with his heartfelt talk “FROM PERSPIRATION TO INSPIRATION: THE AORTIC LEGEND”. 
• Rachel Ramoni, DMD, ScD (Chief, Research and Development Officer (CRADO) Department of Veterans Affairs) inspired the audience even more with her talk “RESEARCH THAT MAKES A DIFFERENCE”. 

Finally, Houston Surgical Legend, Kenneth Mattox, MD (Professor, Baylor College of Medicine
Chief of Surgery and Chief of Staff, Harris County Hospital) concluded by covering the life of “A VETERAN SURGEON WHO INSPIRED A GENERATION”.

The final session “MEASURING ACADEMIC PRODUCTIVITY IN VA” was moderated by David Berger, MD and Jason Johanning, MD. 
​

• Eileen Moran, MS (Director, VHA Office of Productivity, Efficiency, and Staffing West Haven, CT) initiated the conversation by providing helpful hints on “MEASURING VA SURGEON PRODUCTIVITY NOW AND IN THE FUTURE “.
• Brian R. Smith, MD (VISN 22 Chief Surgical Consultant) followed with his query on “IS STANDARIZED MEASUREMENT OF SURGEON PRODUCTIVITY ACROSS ALL VA'S THE RIGHT APPRAOCH? “
• Carolyn M Clancy, MD (Deputy Undersecretary for Health, Discovery, Education and Affiliated Networks Department of Veterans Affairs, Washington, DC) asked the burning question, “CAN VA MAINTAIN ITS TRADITIONAL ACADEMIC MODEL IN THIS DAY AND AGE?“
• Mark Wilson, MD PhD (Professor and Chief of Surgery, VA Pittsburgh Healthcare System Acting Director of Surgery, National Surgery Office) concluded with his thoughts on “PRODUCTIVITY AND PERFORMANCE “

"Dr. Kevin Pei (Texas Tech University Health Science Center, Lubbock Texas) presented a timely topic titled “Workplace bullying among US surgeons, a national survey of the Society of surgical Chairs”.
​
Dr. Pei explained that "bullying is pervasive in the workplace and other countries have shown that nearly half of surgeons have experienced bullying at work.  Yet workplace bullying is not part of the national conversation about burnout and un-wellness.  There is good evidence that durable change can only come from leadership, so we sought to find out experiences with and perceptions towards bullying among academic surgical leaders.  When we surveyed the influential members of the society of surgical chairs, more than 30% reported having been bullied in the last 6 months and more than 60% reported witnessing bullying in their department.  Respondents largely attributed workplace bullying to strict hierarchy, tradition, and accepted culture.  Most chairs state they have a zero-tolerance policy, yet only half report having a specific policy against workplace bullying.  Workplace bullying is really difficult to handle, one expose noted that many surgeons denied the presence of it and refused to participate in development courses about workplace civility.   I think our study starts the conversation and hopefully sheds some national attention on a worthwhile discussion.  There is a lot of room for collaborative research in workplace civility and more research is needed in efforts to eradicate workplace bullying.”

Thank you Dr. Pei for bringing this timely topic to our attention at our annual meeting. Hopefully this can become a part of a broader panel topic at our upcoming annual meeting.

Kenneth A. Lipshy, MD, FACS and Danny Chu, MD FACS. 
​
​The 2019 Annual Meeting of the AVAS was blessed with several enlightening panel discussions. Our Monday, Lunch panel discussion (moderated by Faisal Bakaeen, MD and Gosta Pettersson, MD) was appropriately titled the “INSPIRATION SESSION”.
 
Frederick Grover, MD ​(Emeritus Chair, Department of Surgery, University of Colorado) began with his thoughts on “HOW TO INSPIRE THE VA AND HAVE THE VA INSPIRE YOU”. Dr. Grover revealed that his exposure to the VA during his residency and his service at the San Diego Naval Hospital motivated him to become a leader in the VA. His continued service in the VA was inspired by the research and inspiration around him to improve the care our Veterans received.
 
Melina Kibbe, MD (Professor and Chair, Department of Surgery, ​University of North Carolina, Chapel Hill) next provided her thoughts on “A PATH TO THE SURGICAL SUMMIT THROUGH THE VA”. Dr. Kibbe revealed that the VA afforded her the opportunity to work full time in the VA (with compressed tour of duty) and part-time at Northwestern University. She expanded on the clinical work she was proudly able to provide to her patients. Following that, her ability to teach future physicians and surgeons motivated her to remain in the VA. Finally, the vast possibilities for funded research in the VA motivated her to become a leader in VA research. Dr. Kibbe concluded that VA surgeons must promote surgical careers in the VA and refute the false ascertains made by many regarding a career in the VA.
 
Houston Surgical Legend, Kenneth L. Mattox, MD (Professor, Baylor College of Medicine
Chief of Surgery and Chief of Staff, Harris County Hospital) gave the audience several important leadership lessons as he talked to the group from the perspective of “A VETERAN SURGEON WHO INSPIRED A GENERATION”. Dr. Mattox reminded us that:

• -All had help getting to where they are now
• -Great leaders in Medicine are great leaders outside the realm of medicine.
• -Take the hard road because it will be more rewarding.
• -Obstructions and Barriers are always present and we should not let them prevent change. Great leaders come from challenge, not an easy route.
• -There’s always room at the top.
• -Thru crisis, great leaders always emerge.
• -Cream always rises to the top
• -Everyone is always a role model to someone who is often unknown to either or both.
• -Leadership and followership traits emerge early in one’s life.
• -Leadership opportunities are typically unexpected, and when they arise, rise to the occasion.
• -Great leaders do not seek recognition or praise.
• -Success knows no work hour restrictions- work while others sleep.
• -Leadership really does not require any talent.
• -There is always a better way.

 
Joseph S. Coselli, MD (Chief, Division of Cardiothoracic Surgery, Baylor College of Medicine) encouraged us further with his heartfelt talk “FROM PERSPIRATION TO INSPIRATION: THE AORTIC LEGEND”. Dr. Coselli inspired us but reminiscing the history of the VA under Dr. Michael E. DeBakey. He reminded us that only via the perseverance of Dr. DeBakey, was there integration of the VA and academic training. He reminded us that great leaders do not always stem from success or accolades and that many leaders face failure and even ridicule and that success comes from perseverance.
 
Finally, Rachel Ramoni, DMD, ScD ​(Chief, Research and Development Officer (CRADO) Department of Veterans Affairs) inspired the audience even more with her talk “RESEARCH THAT MAKES A DIFFERENCE”. Dr. Ramoni reminded us that Surgeons have always been innovators. A surgeon must always be prepared to reconsider differing alternatives to problems they face. She also reminded us that great leaders do not arise alone, and we always need friends and support. We were then reminded of the obligation to provide credit to those who helped us achieve our success.

​The 2019 Annual Meeting of the AVAS was blessed with several enlightening panel discussions.
 
The initial panel discussion (moderated by George Sarosi, MD and Seth Spector, MD) was on “TO STAY IN VA OR NOT TO STAY? THAT IS THE QUESTION”
​
Kamal Itani, MD (Professor and Chief of Surgery, VA Boston Health Care System) started the discussion on “WHY I STAYED IN VA”.  Dr. Itani began our discussion by stating “this was the best career decision I have ever made!”  He pointed out that a career in the VA has provided him continued job satisfaction. Among his reasons for staying with the VA, were that the VA provided a stable environment with a work/life balance that could not be found elsewhere. In addition, he is proud to work for a health care system that provides transcontinental care for our Veterans for life. For him, while the VA provides an excellent environment for mentoring staff/trainees as well as for research opportunities, caring for our Veteran patients provides the ultimate reward. For Dr. Itani, while there may be significant challenges, the rewards clearly outweigh the headaches that intervene. He expressed he has never regretted his decision to stay in the VA.
 
Melanie Morris, MD (Associate Professor and Chief of General Surgery, Birmingham VA Medical Center) followed with her talk on “HOW AND WHY I SPLIT TIME IN VA”. Dr. Morris explained her story regarding her decision to split her time between the VA and University of Alabama. She expressed that she experiences several advantages including the ability to provide highly specialized clinical care designed at the academic affiliate for her Veteran patients. In addition, she felt that the leadership opportunities at the VA have expanded her potential in the academic setting. She reminded everyone of the challenges of meeting part-time provider VA mandates, but, in spite of those obstacles, she is satisfied with her decision to split time.
 
Leigh Neumayer, MD MS ​(Professor and Chair, University of Arizona) continued with her explanation “WHY I LEFT THE VA”. Dr. Neumayer began by explaining that when she was employed by the VA she found working for the VA very advantageous. Among those reasons were the incredible opportunities to help our Veteran patients, research opportunities, and teaching opportunities. She reminded us of the lesser known potential for research funding for cooperative studies as well as additional educational opportunities. Among the reasons for Dr. Neumayer’s departure from the VA were the gradual increase in unaddressed infrastructure concerns, her interest in expanding her focus on women’s healthcare, the academic opportunities that required full time commitments, and the difficulty in providing call coverage for two different institutions.
 
Todd Rosengart, MD (Professor and Chair, ​​Department of Surgery, Baylor College of Medicine) concluded with his explanation on “HOW ACADEMIC AFFILIATE CAN SUPPORT”. Dr. Rosengart outlined the following six steps in partnering with the VA: creating a culture of cooperativity, defining expectations, facilitating the partnership, promoting the partnership, reinforcing the partnership and continued reassessment of achievements or failures/obstacles.
He explained that there is a constant balance between success and managing hallenges faced in academic surgery (constant competing demands, funding challenges, and burnout challenges). He explained the first step in creating a cooperative culture is to break down the silos. To be successful you must partner with your staff and your VA partners to define the expectations of the partnership. To foster, this partnership, you must build a foundation for innovative programs. Part of this foundation requires stakeholders to address the RVU compensation concerns of those who work for the VA as well as conduct research. Following this, Dr. Rosengart expounded on methods for promotion and reassessment. He highlighted the need for continued social media and CME outreach.
 
We sincerely appreciate the surgeons who took the time out of their busy schedule to participate in the enlightening panel discussion.

The AVAS has proudly sponsored its annual resident and student paper competition for several years. At the 2018 AVAS Annual meeting residents and students presented 29 full presentations and 38 quickshots. All resident presenters are afforded the opportunity to submit manuscripts to JAMA Surgery for consideration of publication.
 
Winners of the overall Resident/Student competition at the 2018 AVAS Annual meeting were as follows:
 
The Best Overall Abstract Presentation ($500) was won by Mr. Dewan (medical student) for his presentation on “Nationwide trends and outcomes of cardiovascular surgery in patients with opioid disorders.” (Cleveland Clinic Foundation, Case Western University School of Medicine, VA Pittsburgh Healthcare System)
 
Dr. Resio (resident) won the 1st place ($250) award for a Full Oral Abstract Presentation on “Multi-institutional assessment of the impact of risk prediction on operative decision making.”
West Haven VA Medical Center and Yale University School of Medicine
 
Dr. Tricarico (PhD fellow) won the 2nd place ($200) award for a presentation on “Flow rate and pressure estimation toolbox for TEVAR patients.” North Florida/South Georgia Veterans Health Service, University of Florida
 
Dr. Eidelson (resident) was one of the 1st place tie winners ($150) for a Quickshot Abstract presentation on “Endotoxemia after penetrating or burn trauma.”  University of Miami/Ryder Trauma Center, Miami VA Medical Center
​
Dr. Polcz (resident) was the other winner of the 1st place tie winner ($150) for a Quickshot presentation on “Reducing benign lung resection by integrating an interventional pulmonology program with a thoracic surgery department.” Vanderbilt University Medical Center, VA Tennessee Valley Healthcare System
 
Dr. Staton (resident) won the 2nd place ($100) Quickshot presentation on “Neurophysiological changes impacting hand function after arteriovenous hemodialysis placement.” Malcom Randall VA Medical Center, University of Florida, Gainesville
 
The best Medical Student Presentation ($100) was won by Ms. Huntress (medical student)
for her presentation on “Wound severity score in patients with critical limb ischemia and tissue loss undergoing tibial revascularization with coronary drug-eluting stents.” Yale University School of Medicine, VA Connecticut Healthcare System
 
In addition, the AVAS proudly sponsors the American College of Surgeons Committee on Trauma Region 13 VA Resident Trauma competition at its annual meeting. The winner of this year's competition was Dr. Sarah Eidelson, MD who presented her paper on Endotoxemia after penetrating or burn Trauma (see below for full list of competing presenters*). Dr. Eidelson will represent the VA at the ACS COT Military Region 13 Excelsior Society Meeting to be held October 2018 at the ACS Annual Clinical Congress. The winners of that competition will receive transportation to the Annual ACSCOT meeting held in March 2019. We encourage AVAS members to remind their staff and affiliates of this opportunity.
 
 
*The full list of eligible competing Trauma Competition papers is as follows.
 
ENDOTOXEMIA AFTER PENETRATING OR BURN TRAUMA
Eidelson SA*, Mulder MB, Madiraju SK, Karcutskie CA, Rattan R, Schulman CI, Namias N, Proctor KG
University of Miami/Ryder Trauma Center
 
EFFECTS OF PACKED RED BLOOD CELLS AND FRESH FROZEN PLASMA TRANSFUSION ON VENOUS THROMBOEMBOLISM RISK AFTER TRAUMA
Karcutskie CA*, Mundra LS, Meizoso JP, Ray JJ, Eidelson SA, Schulman CI, Ginzburg E, Namias N, Proctor KG
Ryder Trauma Center, Dewitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
 
DIFFERENCE IN VENOUS THROMBOEMBOLISM RISK AFTER NONOPERATIVE MANAGEMENT OF BLUNT SPLEEN VS. LIVER TRAUMA
Karcutskie CA*, Mundra LS, Meizoso JP, Ray JJ, Eidelson SA,  Rao K, Teisch LF, Schulman CI, Namias N, Procto KG
Ryder Trauma Center, Dewitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
 
POTENTIAL NEW VARIABLES TO QUANTITATE STRESS IN FORWARD SURGICAL TEAMS
Mulder MB*, Eidelson SA, Madiraju SK, Gross KR, Buzzelli MD, Batchinsky A, Convertino VA, Howard JT, Schulman CI, Namias N, Proctor KG
Dewitt Daughtry Dept of Surgery and Army Trauma Training Department, University of Miami Miller School of Medicine, Miami, FL; Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, Fort Sam Houston, TX

The 2018 Annual Meeting of the AVAS was blessed with several enlightening panel discussions.
The second panel session on “Nuts and bolts of vha data warehouse outcomes research: what do i need to be successful? “was moderated by Panos Kougias, MD and George Sarosi, MD.
 
Laura Graham, PhD (HSR&D fellow Center for implementation to Innovation, Palo Alto VA HCS) began the educational discussion by describing the “Medication/pharmacy database”. Dr Graham explained that of the four sources of pharmacy data (Corporate Data Warehouse (CDW), Pharmacy Benefits Management (PBM), Pharmacy Managerial Cost Accounting Ntional Data Extract (MCA NDE) and Non-VA meds) the CDW has the most granular information on prescriptions. She noted that the database structure can be challenging to work with. The CDW has information on inpatient and outpatient medications. The PBM has data on prescriptions dispensed within the VA since 1999. MCA-NDE has pharmacy costs and workload for inpatient and outpatient VHA. Non-VA meds data is entirely reliant on the medication reconciliation process so dates are not exact. Dr. Graham concluded by providing the audience with several data resource links.
 
Daniel E Hall, MD, (Surgeon and Core investigator, Center for health equity research and promotion VA Pittsburgh HCS) next explained his experience and lessons in “Working with local and national VASQIP data for quality improvement”. Dr Hall explained that the VASQIP database has high quality data including outcomes beyond 30 days. He explained that the data contains useful information in several surgical specialties. Dr. Hall outlined the data access process. Dr. Hall explained that if National data is sought for research purposes then the National Data System (NDS) and Data Access Request Tracker (DART) are useful tools.He reminded us that if the purpose is soley for quality improvement we can access our local data through the Surgical quality nurse. If the goal is for the performance of research then an IRB would be required. He defined research as a systematic investigation designed to develop or contribute to generalizable knowlege. To further expand on the various components determining whether a project was purely for QI as opposed to research, Dr. Hall explained the details found in handbook 1058.05. He explained that any learning activity can be published in a peer reviewed journal. If you have identified a problem, clinical champions, cooperation with administrative leadership and collected data for QI purposes then you can always submit an IRB for conducting research later on.
 
Nader Massarweh, MD, MPH (VA HSR&D Center for Innovations Effectiveness and Safety, Michael E. DeBakey VAMC) finished off the session explaining that “There is no perfect dataset—optimizing your research by linking VA data sources”. Dr. Massarweh explained to the audience that the CDW is the national central repository of VA data (clinical EHR and administrative data).  The data warehouse obtains data from multiple VHA sources that then allows one to query for desired subsets (i.e. diabetes, OEF/OIF etc).  Dr. Massarweh, proceeded to provide the audience with a detailed description of observational research designs and sources. He explained the important considerations regarding External validity and Internal validity. The audience was provided a detailed synopsis of the potential for bias (the achilles heel of observational research) and two methods to address bias- statistical methodology and study design. Dr. Massarweh explained linking data sources using common variables across different data sources- administrative/operational data, surveys, EHR, Financial, quality improvement, CMS and cancer registry. He then went on to explain several examples of how to put a study together looking at the primary cohort, VASQIP and CDW. Finally, he explained that VA data can support a robust, informative and impactful observational and comparative effectiveness research enterprise. In addition, linkage of VA data sources is a useful and available research technique to provide more robust observational research data.

​
AVAS 2016 Karl Storz Research Award Winner: Dr. Ryan Thomas
 
​The Association of VA Surgeons 2016 Karl Storz Award was presented to Dr. Ryan M. Thomas in 2016. His research has finally been completed and he presented his findings at the meeting in 2018.
 
Dr. Ryan M. Thomas is the Section Chief of General Surgery at the North Florida/South Georgia VAMC and Assistant Professor of Surgery at the University of Florida. He has a basic science research focus on the role of the microbiome in pancreatic cancer development. He received the Karl Storz research award for his investigation entitled “Role of Gram Negative Bacterial Lipopolysaccharide in CXCR4-mediated Pancreatic Carcinogenesis”.

Dr. Thomas previously demonstrated the role of the microbiota in pancreatic carcinogenesis and sought to investigate the role of lipopolysaccharide (LPS), produced by Gram negative bacteria, with accelerating this processes through the CXCR4 chemokine receptor, a known regulator of pancreatic cancer. His data demonstrate that in a subset of pancreatic cancer cells, LPS can alter the expression of CXCR4 but likely is not responsible to accelerating pancreatic carcinogenesis alone. He and his group concluded that microbial-mediated pancreatic carcinogenesis is likely secondary to non-LPS factors. 

As a result of this award, Dr. Thomas has secured additional funding from the University of Florida Cancer Center and the American Cancer Society for his ongoing investigations.

The 2018 Annual Meeting of the AVAS was blessed with several enlightening panel discussions.
The initial panel discussion (moderated by Jason Johanning, MD and Ronnie Rosenthal, MD)
was on “Veterans Choice Program (VCP) and value-based care in Veterans Health Administration (VHA): how can VHA compete with private sector?“
 
Carolyn Clancy, MD (Executive-in-Charge, VHA) led the panel with her discussion on “What are the goals of VCP from the central office perspective? how can VA compete with private sector to deliver high-quality subspecialty surgical care?“ Dr. Clancy discussed the challenges faced in the VA. She noted that we should not allow these challenges to overshadow the potential greatness to be gained by the VA system. These challenges include:

• Bureaucratic system
• Duplications of functions and system of workarounds
• Numerous uncoordinated initiatives
• Inconsistent roles and responsibilities management/ leadership transitions
• Weak governance structure with little decision-making authority

 
Dr. Clancy conceded that VHA headquarters should help facilities bypass these barriers. She explained that the Network should decide which services must the VA provide and which we should divert to the community. This discussion was a constant reminder that the VA must strive to be a Veteran driven system of care that focuses on the following:

• Leverage of technology and tools
• Provision of care without boundaries
• Provision of seamless care coordination
• Provision of care when needed
• Empowerment of veterans in their own care
• Delivery of Whole Health.

 
She also reminded the group that in many aspects the VA is ahead of the Healthcare game. We are way ahead of the world in terms of what we can do remotely. The VA has been outperforming the private sector in most indicators for some time now. Our challenge for our veterans is that they had previously been serving well outlined missions. In addition, they learn the cardinal principal that you always take care of your buddy. However, in the outside world, life is not so well organized. It is difficult for veterans to adjust to a world that is not well organized.
Dr. Clancy outlined the Priorities of the VA as Follows:

• Greater choice for Veterans through an integrated High Performing Network
• Quality and Safety
• Improving patient experience.

 
She concluded that in the end we must remember that the drivers for customer service are really the communication between doctors and nurses.
 
Dr. Vince DeGennaro, MD (Chief of Staff Miami VA HCS, surgeon) followed with his discussion on “how do you balance VCP vs maintain keeping in-house surgical volume?“ Dr. DeGenanaro began his talk by reminding the audience that “Any captain can captain the seas when things are calm but it takes a REAL captain to lead the ship when things are rough.” Dr. DeGennaro noted that community care will remain an essential component of Veteran care. To do this we need to improve Veterans’ choice of community providers in meeting their needs. We need to simplify veteran eligibility with a focus on Veterans’ needs. We need to consolidate community care programs and add convenient care benefits with timely payment strategies. We must also permit medical record sharing in the network. Perhaps most importantly per Dr. DeGennaro was the need to address clinical staff shortages through expansion of GME and improve VA hiring and retention. Dr. DeGenarro discussed that measuring patient experience is not as simple as we attempt to make it sound. The experience is entirely graded by the patients’ expectations. He noted that the “secret of change is to focus all of your energy NOT on Fighting the old BUT on building the new.” He explained that our focus should be on customer service. He noted that those who do not make customer service a priority will have responsibility to bear. Transparency will be vital for us to survive. The need to remember our internal customers was emphasized – including the strengthening of the Primary care-Specialty Care alliance. Dr. DeGenarro reminded everyone of the scarcity of surgeons across the US. He explained that the shape of the future will be a group practice with APRNS with an MD assigned for consultation. There should be a specialist traveling to those smaller sites once a month at minimum. He emphasized that the MD lectures to Primary care providers monthly on case studies is vital. Complex care would then be deferred to the hub. He concluded by reminding us that “however beautiful the strategy, you should occasionally look at the results” because “we are often not measuring what we think we are measuring”.
 
Edward J. Young, M.D. (Professor, Baylor College of Medicine and Chief, Infection Prevention & Control, Michael E. DeBakey VA Medical Center, Houston, TX) discussed “Why I choose VA care”.  Dr. Young is in a unique position (as a veteran, former Chief of Staff and currently practicing infectious diseases physician) to explain why one would choose to obtain care at the VA.  Dr. Young reviewed Hollywood’s depiction of VA hospitals, noting that three of five films  cited depicted a positive picture whereas in the remainder, the VA was portrayed negatively, sometimes virulently negative. Dr. Young presented an unofficial survey of the attitudes of some of his clinic patients regarding their reasons for choosing VA care. Camaraderie outnumbered lack of insurance or reputation of VA by most respondents. Next, he reviewed a 2010 HSR&D report comparing the quality of care in VA and non-VA settings. Among 17 reports comparing surgical specialties, 9 reported no difference, 3 reported better outcomes by VA and 5 reported worse outcomes by VA. When more recent publications were reviewed, VA surgical outcomes were comparable to or better than the private sector in most areas studied. In fact, the outcome of heart surgeries and vascular procedures performed in the VA were statistically superior to non-VA facilities.  Possible reasons for superior performance included VA’s investment in electronic health records (1970s), performance measures (NSQUIP 1980s and SAIL 1990s), and embedded teaching and research programs.