Update on SAAAVE Act

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Vascular Crises Prevention In the Hinterland
New Hampshire Chapter ACS Bretton Woods,
NH November 10, 2007
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• Crises
• Surgical Crises
• Socioeconomic Crises
• ACS Crises
• Prevention
• AAA screening

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Medicare Physicians Fee Schedule Conversion Factor
Dollars paid for 1 RVU 2000 36.61 2001
38.26 2002 36.20 2003 36.78 2004
37.34 2005 37.90 2006 37.90 2007
37.90 2008 34.0682
If Congress pulls rabbit out of hat again in
late December, CF could be anywhere from
34.07 to 37.90, unlikely more.
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Office Physician Payment with Work Adjustor

• In 2008, Physician Payment will be
• 34.07 x 0.8806 x MD work RVUs MD PE RVUs MD
  malpractice RVUs

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• Surgical Crises
• What to Hold?
• What to Ship?
• How to Ship?

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• What to Hold?
• Surgical Resources
• Hospital Resources
• Diabetic Foot
• Cold Leg
• Ruptured AAA

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Ruptured AAA The Least Known Cause of Death
14th most common COD in men in U.S.
9,000 15,000 American Deaths per year MINIMUM
Actual may be as many as 30,000
Gillum, J Clin Epidemiol 1995, CDC 2004
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Is AAA Rupture Rate Stable? Going Down?
Going Up?
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AAA Rupture Rate per 100,000
Sweden - UK
Standardized for Population Age Very High Autopsy
Rate
Drott et al, Br J Surg, 1992
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Hospital Deaths from AAA, Scotland
Best et al, Br J Surg, 2003
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Are We Getting Better at Fixing Ruptured AAAs?
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Operative Mortality Ruptured AAA
Meta Analysis 1950 - 2000
48
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55.
Brown et al, Br J Surg, 2002
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Outcome of Ruptured AAA
50 Operative Mortality 85 Overall Mortality
Survived Operation 15
Died Despite Operation 15
Died Without Operation 70
Bengtsson et al, J Vasc Surg, 1993
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Mortality of AAA Rupture 85 Mortality of
Elective AAA repair 1-5 Clinical Goal Find
AAAs prior to rupture treat those at risk for
rupture
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How Are AAAs Detected?

• 243 patients underwent elective AAA repair
• AAA detected by
• Physical examination 38
• Incidental abdominal imaging 62
• 23 were not detectable on exam even with the
  diagnosis was known
• In obese patients, 2/3 were not detectable

Chervu et al, Surgery, 1995
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Is Physical Exam Any Good?

• Physical Exam detection in patients with known
  AAAs
• 3-3.9 cm 29
• 4-4.9 cm 50
• gt 5 cm 75
• Conclusion Ability to detect AAA by physical
  exam is poor.

Lederle et al, Arch Intern Med, 1998
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What is Best Screening Test for AAA?

• Ultrasound
• Least expensive
• Non-invasive
• Accurate
• CT
• More expensive, radiation, IV contrast
• More precise delineation of anatomy

Jaakola et al, Eur J Vasc Endovas Surg, 1996
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Does Ultrasound AAA Screening Save Lives?
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Multicentre Aneurysm Screening Study
Mortality Reduced 42 after 4 years 53 Reduction
in those who attended screening
AAA-Related Mortality
- Ashton et al, Lancet 2002
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AAA Ultrasound Screening Saves Lives

• 6 large European trials
• gt125,000 patients, multiple countries
• Mostly men, 50-65 years old
• 74-84 accepted screening invitation
• After 4-10 years follow-up
• 45-49 decrease rupture
• 21-68 decrease in AAA mortality

- Lederle, Ann Int Med 2003
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AAA Screening Programs in U.S.
Free to Patient

• American Vascular Association
• Aneurysm Outreach Inc
• Legs for Life
• Medtronic CWP

• Commercial
• Life Line Screening, Inc
• Up to 17 other private ventures

Government Sponsored NONE
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American Vascular Association National Screening
Program
P lt 0.0001
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If AAA screening is this good, why doesnt
Medicare pay for it?
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• Each Medicare screening benefit requires an Act
  of Congress
• Glaucoma
• Prostate cancer
• Colorectal cancer
• Bone mass measurement
• Mammograms for breast cancer
• Pap smear / pelvic exam

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National Aneurysm Alliance
Created in 2004 Mission Create a Medicare
Screening Benefit for Americans at risk for
death from ruptured AAA
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National Aneurysm Alliance Members
Professional Societies Society for Vascular
Surgery American College of Surgeons American
Society of Echocardiography Society of
Interventional Radiology Soc Diagnostic Medical
Sonography Soc for Vascular Ultrasound ARDMS Ne
w England Society for Vasc Surg Southern
Association for Vasc Surg
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National Aneurysm Alliance Members
Foundations American Vascular
Association Aneurysm Outreach Inc Vascular
Disease Foundation
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National Aneurysm Alliance Members
Industrial Partners Boston Scientific Cardiomems
Cook W.L. Gore JJ Cordis Medical Metrx
Solutions Medtronic NEMA Philips Siemans Sono
site
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SAAAVE Bill Introduced June 23, 2004

• Screen AAA Very Efficiently
• One-time ultrasound AAA Screening
• for Medicare beneficiaries at risk
• Bipartisan, Bicameral Support

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Senator Jim Bunning R KY Primary Senate Sponsor
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Senator Chris Dodd D CT Primary Senate Sponsor
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2004 Primary House Sponsors Congressman Jim
Greenwood (R PA) Congressman Gene Green (D TX)
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The Real Work of getting a Bill Passed
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SAAAVE Act Progress
9 Senate / 18 House Co-Sponsors in 04 108th
Congress closed without passage Fresh Start in
2005 with 109th Congress Reintroduced Feb 05
S390 / HR 827 Member by Member recruiting renewed
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2005 Primary Congressional Sponsors Senate Jim
Bunning R KY Chris Dodd D CT House John
Shimkus R IL Ron Lewis R KY Gene Green D TX
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Media Attention
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Wall Street Journal Aortic
Aneurysms Kill Quietly A Death Sentence You
Can Avoid Artery Flaw Is Fixable if Found,
Often a Killer, Lacks a Constituency Knowledg
e Gap Medical Illnesses Tom Burton Kevin
Helliker win Pulitzer Prize
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Grassroots Efforts

• Screening Events
• Screen the Hill
• Multiple District Screenings
• House and Senate Members
• PAY ATTENTION to letters

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How Does Congress Distinguish Competing Health
Initiatives? Enter the U.S. Preventive
Services Task Force
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What is The United States Preventive Services
Task Force? www.preventiveservices.ahrq.gov Ind
ependent panel of experts in primary care
and prevention that systematically reviews
evidence of effectiveness develops
recommendations for clinical preventive
services.
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Chronology of USPSTF AAA Screening 1996 -
insufficient data to recommend for or against
AAA screening 2003 decision to reexamine AAA
screening 2005 New recommendation favoring
AAA screening in men at risk
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Current US Preventive Services Task Force
Recommendations
Ann Intern Med 2005 142 198-202
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USPSTF Recommendations for AAA Screen Good
evidence for screening men age 65 to 75 who have
ever smoked!! Task Force also noted more
harms than potential benefits for screening
women for AAA
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2005 Senate Co-sponsors Evan Bayh (D-IN) Thad
Cochran (R-MS) Norm Coleman (R-MN) Jon Corzine
(D-NJ) Mark Dayton (D-MN) Mike Dewine
(R-OH) Elizabeth Dole (R-NC) Richard Durbin
(D-IL) James Jeffords (I-VT) Edward Kennedy
(D-MA) Patty Murray (D-WA) Barack Obama (D-IL)
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2005 Energy and Commerce Committee
Co-sponsors Charles Bass (R-NH)
Michael Bilirakis (R-FL) Mary Bono (R-CA)
Steve Buyer (R-IN) Eliot Engel (D-NY)
Anna Eshoo (D-CA) Michael Ferguson (R-NJ)
Paul Gillmor (R-OH) Jay Inslee (D-WA)
Chip Pickering (R-MS) Edward Whitfield (R-KY)
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2005 Ways and Means Committee
Co-sponsors Dave Camp (R-MI) Eric Cantor
(R-VA) Kenny Hulshof (R-MO) J.D. Hayworth
(R-AZ) Sam Johnson (R-TX) Jim McDermott
(D-WA) Jim Ramstad (R-MN) Clay Shaw (R-FL)
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Additional 2005 House co-sponsors Dale Kildee
(D-MI) Barbara Lee (D-CA) Solomon Ortiz
(D-TX) Bill Pascrell (D-NJ) Donald Payne
(D-NJ) Steven Rothman (D-NJ) Pete Sessions
(R-TX) Mark Souder (R-IN)
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SAAAVE Passed by the Senate!! November 3,
2005 Amendment Introduced by Senator Rick
Santorum R PA
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SAAAVE Passed by the House!! SAAAVE added
to Deficit Reduction Act passed by
House December, 2005
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SAAAVE Act signed by President Bush
February 8, 2006
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What Are Details of SAAAVE?
When Started Jan 2007 Who Men and Women with
family history of AAA Men who have smoked
gt100 cigarettes Limited to new Medicare
beneficiaries Linked to Welcome to Medicare
Physical
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Plans for 2008
Un-do Linkage Welcome to Medicare Educate
PCPs Educate Patients Find the AAAs / SAVE some
lives Learn More About Prevalence - Women
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Thank You!!