Artificial disc replacement

Transcription

1 Procedure 231 Clinical PRIVILEGE WHITE PAPER Artificial disc replacement Background Patients who have degenerative disc disease that causes pain and makes it difficult to do everyday activities may find relief through nonsurgical treatment. Those who require alternative treatment methods have two options for back surgery: spinal fusion and artificial disc replacement (ADR). Spinal fusion can be performed in the cervical or lumbar region of the spine and involves fusion of two vertebral sections, which creates one long bone and relieves pain by stopping motion of the discs. On the other hand, ADR is a newer, FDA-approved surgical option that is becoming increasingly popular. A spinal disc has a squishy center surrounded by a tough outer layer that functions like a shock absorber between the vertebrae. If a disc ruptures, it causes squishy tissue to spread and press against nerves. To perform the ADR in the lumbar region, the surgeon accesses the spine from the front, making an incision in the abdomen and exposing the spine by moving abdominal contents out of way. The affected disc is removed and replaced with two metal plates and secured with a plastic bearing in between the plates to allow them to move. Cervical disc replacement also uses an anterior approach, similar to that used for a discectomy and fusion operation. The affected disc is removed completely and the disc space is distracted to its normal height to relieve pressure on the nerves. An artificial disc is then implanted and the patient can usually go home hours after the surgery with minimal activity. Most patients are able to get out of bed and walk around by the evening of the surgery, and typically stay in the hospital for one to two days. There are a few restrictions during the first month of recovery, but patients typically can return to normal activities within six to eight weeks. ADR is not recommended for patients who have had prior spine surgery or disc degeneration at more than one level of the spine. Risks include death, paralysis, spinal cord or nerve damage, and injury to vessels near the disc. A study published in 2009 by researchers at the Washington University School of Medicine indicated ADR works as well and often better than spinal fusion surgery. Perhaps more importantly, those patients who opted for ADR were able to preserve all of their motion. A supplement to Credentialing Resource Center Journal /13

2 The FDA has approved several brands of artificial discs, including the Charite disc (made by DePuy) and ProDisc-L (Synthes) for lumbar replacement, and Prestige (Medtronic), ProDisc -C (Synthes), and Bryan Cervical Disc System (Medtronic) for cervical replacement. For more information, please see the following Clinical Privilege White Papers: General surgery Practice area 161 Neurological surgery Practice area 155 Orthopedic surgery Practice area 159 Involved specialties Orthopedic spine surgeons, medical spine surgeons, neurosurgical spine surgeons, and general surgeons Positions of specialty boards ABSS The American Board of Spine Surgery (ABSS) certifies orthopedic and neurological surgeons who specialize in the field of spine surgery; however, it is not recognized by the American Board of Medical Specialties. To achieve certification through the ABSS, candidates must complete a 12-month spine fellowship and must be board certified by the American Board of Orthopaedic Surgery (ABOS) or the American Board of Neurological Surgery (ABNS). ABSS does not publish specific requirements for ADR. ABOS The ABOS certifies orthopedic surgeons who have completed a minimum of five years of training in an accredited orthopedic residency program; applicants must also pass written and oral examinations. The ABOS does not publish specific requirements for competency in ADR. ABNS The ABNS requires candidates to complete a minimum of 72 months of training in neurosurgery, including a PGY-1 (postgraduate year). At least 42 months of this training must be devoted to core clinical neurosurgery. The ABNS does not publish specific requirements for competency in ADR. ABS The American Board of Surgery (ABS) certifies physicians in general surgery. Candidates must complete a minimum of five years of general surgery residency, with no fewer than 48 weeks of full-time experience in each residency year and at least 54 months of clinical surgical experience. Candidates must also complete 2 A supplement to Credentialing Resource Center Journal /13

3 a minimum of 750 operative procedures in five years with at least 150 operative procedures in the chief resident year. They must also complete a minimum of 25 cases in surgical critical care. The ABS does not publish requirements for ADR. AOBS The American Osteopathic Board of Surgery (AOBS) certifies osteopathic physicians specializing in general surgery and neurological surgery. AOBS does not publish specific requirements for competency in ADR. AOBOS The American Osteopathic Board of Orthopedic Surgery (AOBOS) offers certification to candidates who complete five years of orthopedic surgery training approved by the American Osteopathic Association (AOA). Candidates must also provide evidence of the performance of at least 200 major orthopedic procedures. The AOBOS does not publish specific requirements for competency in ADR. Positions of societies, academies, colleges, and associations NASS The North American Spine Society (NASS) published Training Recommendations for New Technology, which was last revised in April NASS believes it is essential for physicians to be educated on techniques and complications related to new technology. To that end, NASS developed the following general recommendations before undertaking new technology: Attend to the health and safety of the patient Anticipate and plan for management of attendant risks of the treatment Periodically assess outcomes to refine and expand indications for the procedure accordingly and to assess skill sets Be aware of the availability of a new technology NASS notes that it is not in a position to implement or enforce physician training recommendations and that hospitals should have the final say in establishing credentialing criteria for staff physicians. NASS uses the following criteria in determining technologies for which to develop training requirements: Existing and/or new technologies that are debated or not yet well established (e.g., those with CPT tracking codes) may be considered Technologies that are newly FDA-approved and/or have ongoing investigational device exemption studies Technologies that are reviewed and addressed by NASS New Technology Assessment NASS notes that the American College of Surgeons publishes a number of statements related to emerging technologies, which NASS has used to modify and A supplement to Credentialing Resource Center Journal /13 3

4 create the following advisory recommendations concerning training for new technology: The physician should be in good standing at the hospital Defined education for the use of new technology in clinical settings should include: In-depth knowledge of the relevant disease process and its management. Acquisition of technical skills and familiarity with indications through a defined educational program that includes didactic and practical elements. These skills should be documented as part of a fellowship, post-residency course, or an approved residency. The physician should have experience and knowledge in the management of the disease for which the technology is used. In spine care, patient selection is essential, and physicians should exercise prompt recognition and management of complications by being fully qualified in all aspects of the disease, or have the ability to make referrals if necessary. These qualifications should be reviewed by a local credentialing body whose members have experience with complex spine procedures. Mentoring or proctoring these physicians is encouraged. Other elements of training include: Education that addresses the pros and cons of new technology in comparison with existing methods Sources of content and funding is transparent NASS also published Training Recommendations for New Technology: Lumbar Disc Arthroplasty, which was revised in April This document offers the following specific considerations for ADR: Because the risks of an anterior transperitoneal or retroperitoneal approach are significant, it is recommended that surgeons are well trained and have extensive experience in anterior lumbar interbody fusion (ALIF). If the surgeon does not have experience in this area, he or she should have completed additional instruction in this specific technique. Procedures should be performed in a clinical setting with the ability to do major anterior transperitoneal or retroperitoneal procedures, and deal with intraoperative or postoperative complications if necessary. Surgeons should have knowledge of appropriate treatment options if the procedure fails or must be aborted, including re-do anterior as well as posterior spinal surgical procedures. Experience should be demonstrated with the following competencies: Performance of one to two ALIF procedures on average in each of the preceding 12 months. Proficiency with fluoroscopy. Certification of completion of a lumbar disc arthroplasty course by the manufacturer. A series of mentored operations commensurate with the surgeon s skill and experience with another surgeon accomplished in disc arthroplasty. 4 A supplement to Credentialing Resource Center Journal /13

5 ISASS This could be fulfilled by a fellowship-trained spinal surgeon with extensive experience in disc arthroplasty. The International Society for the Advancement of Spine Surgery (ISASS) ( formally the Spine Arthroplasty Society) published Position Statement: Cervical Total Disc Arthroplasty in 2009, which states that total disc arthroplasty (TDA) is an acceptable, proven alternative to anterior cervical discectomy and fusion in the treatment of symptomatic cervical disc disease. The position statement cites studies that show TDA in the cervical spine preserves motion better than spinal fusion with good clinical results. However, it does not address privileging or competency requirements for ADR. AOA The AOA publishes Basic Standards for Residency Training in Surgery and Surgical Subspecialties, revised in July These standards include r equirements for general vascular surgery and neurological surgery. General surgery residencies must be five years long with a focus on management of patients with severe and complex illnesses and major injuries, along with experience with evolving advanced diagnostic, therapeutic, and interventional measures. Each resident must complete a minimum of 750 major surgical procedures as a surgeon or first assistant. Neurology surgical residencies must be six years long, encompassing disorders of the nervous system; disorders of the brain, meninges, and skull; and disorders of the spinal cord, meninges, and vertebral column, including disorders that may require treatment by fusion, instrumentation, or endovascular techniques. Residents should perform a minimum of 400 major neurosurgical procedures, including spinal procedures of a sufficient number and variety using modern techniques. The AOA also published Basic Standards for Residency Training in Orthopedic Surgery, updated in July Residencies should be five years long and include a minimum of 250 major orthopedic surgical cases yearly in years two through five. The first year should include three months or rotations of electives in a number of areas, including the spine. In years two through five, residents should serve a three-month rotation in orthopedic spine or log 50 spine cases. While both of these documents provide guidelines for spinal procedures, neither contains specific information with regards to ADR. ACGME The Accreditation Council for Graduate Medical Education (ACGME) publishes Program Requirements for Graduate Medical Education in Neurological Surgery, updated in September Neurological surgery programs should be six years A supplement to Credentialing Resource Center Journal /13 5

6 long, with an additional 12 months of research or advanced training in some cases. Residents should receive instruction in the basic neurosciences, competently perform neurosurgical operative procedures, and participate in management and surgical care to include the full spectrum of neurosurgical disorders. The ACGME also publishes Program Requirements for Graduate Medical Education in Orthopaedic Surgery, updated in July Residencies should be five years long and include instruction in the basic medical sciences, including diagnosis, treatment, and management of clinical disorders. Residents should demonstrate knowledge of those areas appropriate to orthopedic surgery and each resident s experience should include surgery of the spine, including disc surgery, spinal trauma, and spinal deformities. Each graduating resident must log between 1,000 and 3,000 procedures. Additionally, the ACGME publishes Program Requirements for Graduate Medical Education in Orthpaedic Surgery of the Spine, revised in September Orthopedic spine surgery fellowships should be 12 months long and focus on spinal column diseases, disorders, and injuries, along with treatment through medical, physical, and surgical methods. Resident education should include developing a treatment plan to manage patients with traumatic, congenital, developmental, infectious, metabolic, degenerative, and rheumatologic disorders of the spine. Technical training should ensure fellows are able to perform skillfully the procedures required to practice the subspecialty to treat a wide variety of problems in various spinal regions. Finally, ACGME publishes Program Requirements for Graduate Medical Education in General Surgery, updated in July General surgery residencies are five years long, with 54 months dedicated to clinical assignments in surgery with documented experience in emergency care and surgical critical care. Residents must complete a minimum of 750 procedures, including a minimum of 150 in their last year as chief resident. Residents should complete rotations in essential content areas including the abdomen and its contents; the alimentary tract; skin, soft tissues, and breast; endocrine surgery; head and neck surgery; pediatric surgery; surgical critical care; surgical oncology; trauma and nonoperative trauma; and the vascular system. Positions of subject matter experts Jeffrey M. Spivak, MD New York City ADR should be performed by trained spine surgeons with a background in orthopedic surgery or neurosurgery who have also completed a course in cervical or lumbar ADR through a disc manufacturer, says Jeffrey M. Spivak, MD, director of the Spine Center at the NYU Hospital for Joint Diseases and assistant professor in the Department of Orthopaedic Surgery at the NYU School of Medicine in New York. 6 A supplement to Credentialing Resource Center Journal /13

7 Before gaining experience with ADR, all spine surgeons should be proficient with anterior cervical discectomy and fusion surgery (for those focusing on the cervical region), or anterior interbody fusion in the lumbar region. Orthopedic surgeons typically receive most of this training in spine surgery during a spine fellowship, whereas neurosurgeons usually receive sufficient training in fusion surgery during their residency. That s where they learn those basic procedures, but they should have also had experience as an attending themselves before going ahead with artificial disc replacements, Spivak says. Although there isn t a specific number that determines proficiency in spinal fusion procedures, Spivak estimates a minimum of 10 for each procedure (anterior cervical discectomy and anterior interbody fusion) would likely indicate a level of proficiency. Once spine surgeons are proficient with fusion surgery, they need to attend a manufacturer-sponsored, FDA-approved training course. Spivak has been teaching for Synthes, which makes ProDisc artificial discs, for the last five years. There are separate courses for cervical and lumbar procedures, since each requires a unique approach. Surgeons can take courses in both cervical and lumbar procedures, although cervical surgeries are currently favored due to surgeon preference and because payers are more apt to approve cervical disc replacement, Spivak says. Those courses have a didactic component, a component where we view a taped surgery, and then we go ahead and use the instruments in a cadaver to perform the procedure and the placement of the device itself, he says. Once they have completed the course, surgeons are deemed competent to perform the procedure on their own. In some instances, during a surgeon s first case, a regional technical specialist from the manufacturer will be in attendance to offer suggestions. In terms of reprivileging, there is no published annual number of ADR cases that surgeons must complete to maintain competency, especially since the number of cases each year can vary depending on the number of patients they see who would benefit from the procedures, as well as the number of cases that are approved by insurance companies. Instead, some hospitals set a minimum caseload for the combined number of fusion and ADR procedures since fusion surgeries incorporate the complicated process of accessing the spine to perform surgery, Spivak says. If the hospital said you need to do 20 anterior fusion or disc replacements a year, that would be reasonable, even if 18 are fusions and two are disc replacements, he says. A supplement to Credentialing Resource Center Journal /13 7

8 Richard Guyer, MD Plano, Texas ADR is performed exclusively by fellowship-trained orthopedic spine surgeons and neurosurgeons who have additional training from spinal disc manufacturers, says Richard Guyer, MD, cofounder and fellowship director at the Texas Back Institute in Plano and associate clinical professor of orthopedics at the University of Texas Southwestern in Houston. Surgeons need to receive specific training to perform ADR in the cervical and lumbar regions of the spine. Prior to receiving that training they need to have experience with anterior cervical fusion in the cervical region and anterior interbody fusion in the lumbar region. Spine surgeons typically gain that experience during their fellowship training. They should have done at least 10, but most of these people that go to these courses are interested in doing the artificial disc replacement and have a lot of experience with fusions, Guyer says. There are multiple manufacturers that provide required training for cervical disc replacement, but Synthes is the only FDA-approved company that provides training for lumbar disc replacement. This training includes didactic and observations sessions, followed by hands-on training with cadavers. Surgeons who complete the course are subsequently certified by the manufacturer to perform ADR. Although there is not specific number of ADR procedures required to be considered competent, Guyer recommends that surgeons perform at least six procedures proctored by an experienced surgeon. A guy that has done 1,000 anterior cervical fusions probably doesn t need to be proctored as much, but I think the lumbar region in particular is a little more finicky and I think it would be good to have someone who has experience with them initially, he says. Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for ADR. However, the CMS Conditions of Participation (CoP) define a requirement for a criteria-based privileging process in (c)(6) stating, The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. 8 A supplement to Credentialing Resource Center Journal /13

9 482.12(a)(6) states, The governing body must assure that the medical staff bylaws describe the privileging pro cess. The process articulated in the bylaws, rules or regula tions must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers: Individual character Individual competence Individual training Individual experience Individual judgment The governing body must ensure that the hospital s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners. Specific privileges must reflect activi ties that the majority of prac titioners in that category can perform competently and that the hospital can support. Privileges are not granted for tasks, procedures, or activities that are not conducted within the hospital, regardless of the practitioner s ability to perform them. Each practitioner must be individually evaluated for requested privileges. It can not be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. The individual practitioner s ability to perform each task, activity, or privilege must be individually assessed. CMS also requires that the organization have a process to ensure that practitioners granted privileges are work ing within the scope of those privileges. CMS CoPs include the need for a periodic appraisal of practitioners appointed to the medical staff/granted medical staff privileges ( [a][1]). In the absence of a state law that establishes a time frame for the periodic appraisal, CMS recommends that an appraisal be conducted at least every 24 months. The purpose of the periodic appraisal is to determine whether clinical privileges or membership should be continued, discontinued, revised, or otherwise changed. The Joint Commission The Joint Commission has no formal position concerning the delineation of privileges for ADR. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS ). A supplement to Credentialing Resource Center Journal /13 9

10 In the introduction for MS , The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission introduces MS by stating, The organized medical staff is respon sible for planning and implementing a privileging process. It goes on to state that this process typically includes: Developing and approving a pro cedures list Processing the application Evaluating applicant-specific information Submitting recommendations to the governing body for applicant-specific delineated privileges Notifying the applicant, relevant personnel, and, as required by law, external entities of the privi leging decision Monitoring the use of privileges and quality-of-care issues MS further states, The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an objective, evidence-based process. The EPs for standard MS include several requirements as follows: The need for all licensed independent practitioners who provide care, treatment, and services to have a current license, certification, or registration, as required by law and regulation Established criteria as recommended by the organized medical staff and approved by the governing body with specific evaluation of current licensure and/or certification, specific relevant training, evidence of physical ability, professional practice review data from the applicant s current organization, peer and/or faculty recommendation, and a review of the practitioner s performance within the hospital (for renewal of privileges) Consistent application of criteria A clearly defined (documented) procedure for processing clinical privilege requests that is approved by the organized medical staff Documentation and confirmation of the applicant s statement that no health problems exist that would affect his or her ability to perform privileges requested A query of the NPDB for initial privileges, renewal of privileges, and when a new privilege is requested Written peer recommendations that address the practitioner s current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism A list of specific challenges or concerns that the organized medical staff must evaluate prior to recommending privileges (MS , EP 9) A process to determine whether there is sufficient clinical performance information to make a decision related to privileges 10 A supplement to Credentialing Resource Center Journal /13

11 A decision (action) on the completed application for privileges that occurs within the time period specified in the organization s medical staff bylaws Information regarding any changes to practitioners clinical privileges, updated as they occur The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS ). In the EPs for standard MS , The Joint Commission states that the information review and analysis process is clearly defined and that the decision process must be timely. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The criteria must be consistently applied and directly relate to the quality of care, treatment, and services. Ultimately, the governing body or delegated governing body has the final authority for granting, renewing, or denying clinical privileges. Privileges may not be granted for a period beyond two years. Criteria that determine a practitioner s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested are consistently evaluated. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS ). In the EPs for MS , The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. HFAP The Healthcare Facilities Accreditation Program (HFAP) has no formal position concerning the delineation of privileges for ADR. The bylaws must include the criteria for determining the privileges to be granted to the individual practitioners and the procedure for applying the criteria to individuals requesting privileges ( ). Privileges are granted based on the medical staff s review of an individual practitioner s qualifications and its recommendation regarding that individual practitioner to the governing body. A supplement to Credentialing Resource Center Journal /13 11

12 It is also required that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. Privileges must be granted within the capabilities of the facility. For example, if an organization is not capable of performing open-heart surgery, no physician should be granted that privilege. In the explanation for standard related to membership selection criteria, HFAP states, Basic criteria listed in the bylaws, or the credentials manual, include the items listed in this standard. (Emphasis is placed on training and competence in the requested privileges.) The bylaws also define the mechanisms by which the clinical departments, if applicable, or the medical staff as a whole establish criteria for specific privilege delineation. Periodic appraisals of the suitability for membership and clinical privileges is required to determine whether the individual practitioner s clinical privileges should be approved, continued, discontinued, revised, or otherwise changed ( ). The appraisals are to be conducted at least every 24 months. The medical staff is accountable to the governing body for the quality of medical care provided, and quality assessment and performance improvement ( ) information must be used in the process of evaluating and acting on re- privileging and reappointment requests from members and other credentialed staff. DNV DNV has no formal position concerning the delineation of privileges for ADR. MS.12 Standard Requirement (SR) #1 states, The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges. The governing body shall ensure that under no circumstances is medical staff membership or professional privileges in the organization dependent solely upon certification, fellowship, or membership in a specialty body or society. Regarding the Medical Staff Standards related to Clinical Privileges (MS.12), DNV requires specific provisions within the medical staff bylaws for: The consideration of automatic suspension of clinical privileges in the following circumstances: revocation/restriction of licensure; revocation, suspension, or probation of a DEA license; failure to maintain professional liability insurance as specified; and noncompliance with written medical record delinquency/deficiency requirements Immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner s Medicare/Medicaid status Fair hearing and appeal 12 A supplement to Credentialing Resource Center Journal /13

13 The Interpretive Guidelines also state that core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined. DNV also requires a mechanism (outlined in the bylaws) to ensure that all individuals provide services only within the scope of privileges granted (MS.12, SR.4). Clinical privileges (and appointments or reappointments) are for a period as defined by state law or, if permitted by state law, not to exceed three years (MS.12, SR.2). Individual practitioner performance data must be measured, utilized, and evaluated as a part of the decision-making for appointment and reappointment. Although not specifically stated, this would apply to the individual practitioner s respective delineation of privilege requests. CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this procedure. Minimum threshold criteria for requesting privileges in ADR Basic education: MD or DO Minimal formal training: Successful completion of an ACGME- or AOA-accredited residency in surgery, neurological surgery, or orthopedic surgery, and/or successful completion of an accredited fellowship in orthopedic surgery of the spine, and/or completion of resident training and experience deemed by the American College of Spine Surgery to be equivalent to a 12-month approved spine fellowship program, and/or current certification by the ABSS. Required current experience: At least 20 procedures involving surgery of the spine, reflective of the scope of privileges requested, within the last 12 months or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months. References If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced. Minimum threshold criteria for requesting privileges in lumbar disc arthroplasty Applicants must demonstrate current competence and evidence of anterior lumbar interbody fusion experience (the performance, on average, of one or two such procedures in each of the preceding 12 months and evidence of the performance of at least [n] lumbar disc arthroplasty procedures in the past 12 months) or completion of training in the past 12 months. A supplement to Credentialing Resource Center Journal /13 13

14 Minimum threshold criteria for requesting privileges in cervical disc arthroplasty Applicants must demonstrate successful completion of an ACGME- or AOAaccredited spine fellowship or completion of an ACGME- or AOA-accredited residency training program in surgery, neurological surgery, or orthopedic surgery that included extensive experience in disc arthroplasty and a series of mentored operations with another surgeon accomplished in disc arthroplasty and completion of a cervical disc arthroplasty course by the offering technology company, as well as demonstrated current competence and evidence of at least 10 cervical disc arthroplasty procedures in the past 12 months or completion of training in the past 12 months. Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. Candidates for reappointment must demonstrate current competence and evidence of the performance of at least 20 lumbar or cervical disc arthroplasty procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes. Proficiency with fluoroscopy is required for both the initial applicant and for renewal of privileges. In addition, continuing education related to ADR should be required. For more information Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: Fax: Website: American Board of Spine Surgery 1350 Broadway, 17th Floor, Suite 1705 New York, NY Telephone: Fax: Website: American Board of Neurological Surgery 245 Amity Road #208 Woodbridge, CT Telephone: Fax: Website: 14 A supplement to Credentialing Resource Center Journal /13

15 American Board of Orthopaedic Surgery 400 Silver Cedar Court Chapel Hill, NC Telephone: Fax: Website: American Board of Surgery 1617 John F. Kennedy Boulevard, Suite 860 Philadelphia, PA Telephone: Fax: Website: American Osteopathic Association 142 East Ontario Street Chicago, IL Telephone: or Fax: Website: American Osteopathic Board of Orthopedic Surgery 800 Military Street, Suite 307 Port Huron, MI Telephone: Website: American Osteopathic Board of Surgery 4764 Fishburg Road, Suite F Huber Heights, OH Telephone: or Fax: Website: Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: Website: DNV Accreditation, Inc. 400 Techne Center Drive, Suite 350 Milford, OH Telephone: Website: A supplement to Credentialing Resource Center Journal /13 15

16 Healthcare Facilities Accreditation Program 142 East Ontario Street Chicago, IL Telephone: Website: International Society for the Advancement of Spine Surgery 2323 Cheshire Drive, Suite 101 Aurora, IL Telephone: or Fax: Website: North American Spine Society 7075 Veterans Blvd. Burr Ridge, IL Telephone: Fax: Website: The Joint Commission One Renaissance Blvd. Oakbrook Terrace, IL Telephone: Fax: Website: Editorial Advisory Board Clinical Privilege White Papers Associate Editorial Director Todd Hutlock Managing Editor Katrina Gravel William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, Ga. Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, Texas Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, Calif. Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, Ariz. Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, Mo. Sally J. Pelletier, CPCS, CPMSM Director of Credentialing Services The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Danvers, Mass. The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2013 HCPro, Inc., Danvers, MA A supplement to Credentialing Resource Center Journal /13