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
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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.

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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.  

​The 2018 Annual Meeting of the AVAS, held May 5-8 2018, at the Fontainebleau Miami Beach, was a resounding success. The program committee, led by Dr. Danny Chu, and the local arrangements committee, led by Dr. Seth Spector, created a memorable program this year. Several fantastic panel sessions were conducted.
 
The first panel session on “Veterans Choice Program (VCP) and value-based care in Veterans Health Administration (VHA): How can vha compete with private sector?” was moderated by Jason Johanning, MD and Ronnie Rosenthal, MD. Carolyn Clancy, MD (Executive-in-Charge, VHA) started the discussion on “Turning challenges into opportunities (2018)”. Vince DeGennaro, MD (Chief of Staff, Miami VA HCS) followed with his talk on “How do you balance VCP vs maintain keeping in-house surgical volume?” The panel concluded with a revelation by Edward Young, MD (Chief, Infection Prevention & control System, Michael E. DeBakey VAMC) on “Veteran/patient perspective, why did you choose to have surgery at VA?”
 
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”. 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”. Nader Massarweh, MD, MPH (Michael E. DeBakey VAMC) finished off the session explaining that “There is no perfect dataset—optimizing your research by linking VA data sources”                       
 
The final session on “Debunking the myth: VHA and innovation-is it possible?”
was moderated by Walter Longo, MD and Mark Wilson, MD, PhD. Joseph Amaral, MD (Vice President Surgical Science Ethicon) initiated the conversation by describing the “Innovation from industry perspective. How may VA partner with industry to achieve innovation?”  Hop Tran, MD (Surgeon Baylor College of Medicine) followed with a description of “The challenge of innovating in the private sector perspective. How may VA partner with private sector to achieve innovation?” Finally, Bill Gunnar, MD (Director VA National Surgery Office) finished the panel off with his explanation of “innovation from VHA perspective. past, present, future of VHA innovations”.
 
Please feel free to peruse the AVAS Newsletter site for summaries of these panel discussion. The approved panel presentation slide decks are available at http://www.vasurgeons.org/resources.html.