[Congressional Record Volume 144, Number 140 (Thursday, October 8, 1998)]
[Senate]
[Pages S11962-S11964]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




  CONGRATULATIONS TO DR. SHUKRI KHURI OF MASSACHUSETTS WINNER OF THE 
                    BERRY PRIZE IN FEDERAL MEDICINE

  Mr. KENNEDY. Mr. President. It is an honor to call to the attention 
of my colleagues that Dr. Shukri F. Khuri of the Brockton/West Roxbury, 
Massachusetts Veterans Affairs Medical Center, has been awarded the 
1998 Frank Brown Berry Prize in Federal Medicine. This high honor is 
bestowed each year in memory of Dr. Frank Brown Berry, a thoracic 
surgeon and brigadier general who served in both World War I and World 
War II, and who served for seven years as the top medical officer in 
the Department of Defense. The award is presented jointly by U.S. 
Medicine newspaper and the Science Applications International 
Cooperation.
  Dr. Khuri was chosen for this high honor from a large pool of 
nominees by a committee of representatives from the National Institutes 
of Health, the Department of Defense, the Veterans Health 
Administration, and the staff of U.S. Medicine.
  Dr. Khuri received his medical education at the American University 
of Beirut before coming to the United States in 1972. Many of us know 
AUB well as one of the premier institutions of higher education in the 
Middle East, and as one of the strongest bulwarks of American ideals 
and values in that part of the world. Dr. Khuri's recognition as one of 
the leading medical practitioner-scientists in the United States 
reminds us of another important fact about AUB. Many of its graduates--
5,000 distinguished alumni--live here in the United States and make 
major contributions to life and society in America. In fact, Dr Khuri 
serves as President of AUB's Alumni Association of North America.
  Dr. Khuri is now Chief of Surgical Services and Chief of 
Cardiothoracic Surgery at Brockton/West Roxbury VA Medical Center, the 
largest open-heart surgery program in the VA health care system. He 
also serves as the Vice-Chairman of the Department of Surgery at 
Brigham and Women's Hospital and is a Professor of Surgery at the 
Harvard Medical School.
  Dr. Khuri was honored with the Berry Prize for his accomplishments in 
three important areas of medical research and innovation. First, he 
developed a device that monitors on-line myocardial protection during 
open heart surgery, a device which enables surgeons to monitor the 
effect of open heart surgery on the patient and to reduce the chance 
that the surgery will cause irreversible damage. Dr. Khuri's device is 
a major innovation, and it seems likely to become a standard piece of 
equipment in all cardiac surgeries.
  Second, in cooperation with the Navy, Dr. Khuri devised strategies to 
increase the conservation of blood during open-heart surgery. Third, he 
directed the creation of a model system to assess the quality of care 
that patients receive by using risk adjustment outcomes. These 
innovations have significantly affected the practice of medicine in the 
United States.
  I congratulate Dr. Khuri on the Berry Award and for his important 
contributions to American medicine. I ask unanimous consent to insert 
at this point in the Record an article from the August 1998 issue of 
U.S. Medicine, which describes Dr. Khuri's accomplishments in greater 
detail.
  There being no objection, the article was ordered to be printed in 
the Record, as follows:

                 [From the U.S. Medicine, August 1998]

    The Frank Brown Berry Prize for 1998; Cardiac Surgery, Quality 
                               Assessment

       Name: Shukri F. Khuri, M.D.
       Title: Chief of Surgical Services and Chief of 
     Cardiothoracic Surgery, Brockton-West Roxbury VA Medical 
     Center; Vice Chairman, Department of Surgery, Brigham and 
     Women's Hospital; Professor of Surgery, Harvard Medical 
     School.
       Summary Of Accomplishment: Three disparate areas of 
     achievement:
       Directing the creation of a model system to assess quality 
     of care using risk adjustment outcomes.
       Developing a device that monitors online myocardial 
     protection during open heart surgery.
       Through a collaboration with the Navy, devising strategies 
     to better conserve blood during cardiac surgery.
       Path To Accomplishment.
       Research-Clinical Link: Dr. Khuri chairs the largest open 
     heart surgery program in the health care system, and his 
     medical contributions promise to have a far-reaching impact 
     on medicine.
       A native of Palestine, Dr. Khuri received his medical 
     degree with distinction from the American University of 
     Beirut in Lebanon. Following his residency there, he received 
     further training in the 1970s at Johns Hopkins University and 
     at the Mayo Clinic.
       Today, his curriculum vitae reads like a book.
       When he first arrived in the U.S. in 1972, he relates, his 
     intention was to return to Lebanon eventually, but 
     unfortunately it was 1976 and the strife there was at its 
     height. He could not think of returning.
       Harvard University recruited Dr. Khuri to come to West 
     Roxbury VAMC. Again, he planned to stay only a few years, but 
     instead has remained for 22 years.
       The West Roxbury VAMC has the oldest and the largest open 
     heart surgery program in the VA system and have been 
     designated by the agency as a Center of Excellence in cardiac 
     surgery, West Roxbury VAMC proudly states.
       ``I've been chief of cardiac surgery [at West Roxbury] 
     since 1977,'' he relates, emphasizing that one of the 
     facility's major strengths is offering the ability to combine 
     investigative research with clinical practice.
       ``I feel we can only improve the way we deliver care by 
     simultaneously conducting practical research that will answer 
     the frustrations that we meet in our daily work. VA is an 
     ideal environment that allowed me to combine both research as 
     well as clinical care.''
       For example, shortly after arriving he was allowed to 
     pursue his interest in medical informatics. The result was 
     the first automated ICU in the VA system. Subsequently, he 
     chaired the surgery SIUG (Special Interest User Group), and 
     was instrumental in developing software that is in current 
     use in all VA surgical services.
       pH In Heart Surgery: Almost all his achievements, Dr. Khuri 
     explains, ``have been bome out of some frustration with 
     certain limitations of our current clinical efforts.''
       During open heart procedures, cardiac surgeons must cross-
     clamp the aorta and totally interrupt the blood supply to the 
     heart in order to arrest it. However, to avoid irreversible 
     tissue damage to the heart, they also must employ myocardial 
     protection techniques, comprised of administering solutions 
     to the heart. Without such fluids, he explains, surgeon would 
     be able to safely cut off the blood flow to the hear only for 
     15 to 20 minutes.
       This is not enough time; cardiac surgery takes a lot 
     longer, he emphasizes.
       ``What was frustrating to me was that when we arrested the 
     heart, we had no way of assessing how well we were protecting 
     the heart during this period. There is no way today of 
     knowing while you are operating on the heart how well you are 
     protecting it from irreversible damage.
       ``This is why we felt it was important in our research to 
     try to come up with a methodology or a technology that would 
     allow us, in an online manner, to monitor the adequacy of the 
     protection of the heart,'' he explains.
       Based on animal experiments, which he had conducted to the 
     John's Hopkins Hospital and West Roxbury. Dr. Khuri proposed 
     in 1983 a novel approach monitoring myocardial tissue and 
     acid-balance as a valuable way to evaluate how successfully 
     the surgeons were protecting the heart during surgery. In a 
     large series of basic animal experiments, which he 
     subsequently conducted both at the West Roxbury VAMC and the 
     NMR Magnel Laboratory at MIT, Dr. Khuri demonstrated that the 
     rise in myocardial tissue hydrogen ion concentration (or fall 
     in myocardial tissue pH, measured with a glass electrode 
     which he had developed in conjunction with Vascular 
     Technology, Inc., based in Chelmsford, Mass., provided an 
     accurate metabolic measure of the magnitude of regional 
     myocardial ischemia (i.e., the damage caused by the lack of 
     adequate nutritive supply).
       The electrode which he developed for this purpose is made 
     of special 1 mm in diameter pH-sensitive glass containing 
     silver-silver chloride. Although the full 10 mm length of the 
     electrode is inserted perpendicularly into the heart muscles, 
     is sensing surface is limited to its distal 4 mm tip, 
     allowing assessment of the acid-base balance of the deeper 
     and more vulnerable tissues of the heart.
       The most recent prototype of the electrode also allows for 
     the simultaneous measurement of the temperature of the 
     tissues at the

[[Page S11963]]

     same site of electrode insertion. The electrode is attached 
     to a computerized monitor which corrects for the changes in 
     temperature and provides online readings of both the pH and 
     the hydrogen ion concentration in the heart.
       Dr. Khuri's research group conducted animal studies which 
     also demonstrated the utility of the electrode and monitor to 
     measure regional pH changes in tissues other than the hearts, 
     specifically in transposed musculocutaneous flaps and the 
     intestinal wall.
       The first myocardial pH measurements in man were reported 
     by Dr. Khuri's group in 1983. Since then, his group has 
     measured pH in more than 600 patients undergoing cardiac 
     surgery. Based on the observations, a new concept of ``pH-
     Guided Myocardial Management'' has been formulated by Dr. 
     Khuri and his group.
       FDA approval for the Khuri pH Electrode and Monitor was 
     obtained in 1987. At that time, however, ``we were reluctant 
     to distribute it nationwide, mainly because there was a lot 
     more that we needed to understand about myocardial tissue pH 
     and what it meant. Most importantly, the thing that really 
     took a great deal of time after we developed the technology 
     was to figure out what maneuvers to employ to maintain normal 
     pH levels in the heart and to reverse a fall in pH.
       ``That was the key question that we addressed in our 
     clinical and laboratory studies since 1987,'' Dr. Khuri 
     explains.
       The final results of these studies was the development of a 
     set of maneuvers that formed the basis of pH-Guided 
     Myocardial Management.
       ``The underlying hypotheses behind all of this, which we 
     ultimately have verified, is that acidosis, particularly when 
     severe is bad for the heart.'' So if a surgeon can prevent 
     myocardial acidosis during surgery chances are it will 
     improve the protection of the heart and ultimately improve 
     the outcome of the patients.
       Dr. Khuri is optimistic that the impact of pH-guided 
     myocardial management will be two-fold: surgeons will improve 
     on the adequacy to protect the heart and therefore improve 
     the outcomes of these patients, and also they will have a 
     tool which allows them to assess, in coronary bypass 
     operations exactly how well they have improved the blood 
     supply to the heart.
       His data are very compelling and have been shared with 
     leading experts, who ``feel that it is a very promising and 
     valuable tool in cardiac surgery,'' he relates. One leading 
     expert has compared it to the now standard Swan-Ganz catheter 
     developed some 30 years ago. The monitor, which he emphasizes 
     has no known dangers or ``downside.'' might one day become a 
     routine piece of cardiac surgery equipment.
       Once it becomes widely available commercially he is 
     confident the Veterans Health Administration will make it a 
     standard operating room device. ``The VA [medical] 
     facilities, particularly in cardiac surgery, have a wonderful 
     tract record in the use of innovative technology from the 
     pacemaker onwards'' he relates. Once the device is available 
     commercially, then ``I'm almost certain that it would be 
     applied within the VA.''
       ``But these things do take time. There are many skeptics 
     out there'' he notes. ``There are many surgeons who believe 
     they already know how to protect the heart and do not need 
     anything new.''
       Defeating The Bleeding: In 1983, Dr Khuri formed a 
     collaboration with colleagues at the Naval Blood Research 
     Laboratory (NBRL) in Boston. ``one of the most outstanding 
     naval research institutes in the country,.'' to tackle 
     another frustration of cardiac surgeons--unavoidable bleeding 
     following open heart surgery.
       All cardiac surgeons, he explains, are seeking methods to 
     decrease this bleeding which sometimes can be substantial. 
     Through ``a very fruitful collaboration'' with Dr. C. Robert 
     Valeri and his team at the NBRL, Dr. Khuri has gained a 
     better understanding of this postoperative bleeding.
       Through his years of research trying to alleviate this 
     frustration, he has come to understand the exact role of the 
     platelets in bleeding diatheses and has identified a host of 
     factors associated with the platelet which resulted in 
     platelet-dysfunction during cardiopulmonary bypass. These 
     include hypothermia, heparinia, and hemodilution.
       In addition,``we have demonstrated, for the first time, the 
     value of using frozen platelets as an alternative to using 
     fresh platelets'' and have shown, ``I think unequivocally 
     that you can use heparin-coated circuits with low-dose 
     heparin to a big advantage during cardiopulmonary bypass.''
       ``We are advocating a compendium of techniques and 
     maneuvers that, in our hands at least, have decreased the 
     magnitude of postoperative bleeding'' by almost 80 percent, 
     he relates.
       ``Our blood loss postoperatively now is really minimal in 
     these patients.'' His unit has not taken a patient back to 
     the operating room for bleeding in several months, a step 
     which was commonplace previously.
       Part of the technique he advocates is the use of heparin-
     coated circuits with low-dose heparin, which decreases the 
     need for heparin and protamine during cardiopulmonary bypass. 
     Not many institutions are using this technique--including VHA 
     facilities, he points out.
       The cardiac surgery unit at Boston University, where the 
     technique also is used, he states, ``has had just as dramatic 
     an experience in reducing their blood loss as we have here.''
       Part of this work has been published, and one paper 
     explaining his work on cryopreserved platelets has been 
     accepted for publication in the Journal of Thoracic and 
     Cardiovascular Surgery, which he hopes will add ``academic 
     credibility'' to his strategy. Dr. Khuri suspects that, 
     following publication, a number of institutions will adopt 
     these procedures to reduce bleeding.
       Again, in describing the medical community's reaction, he 
     explains that it often takes time for professionals to adapt 
     a new method or theory. ``It's exciting in a way that we are 
     at the cutting edge, but it's also disappointing that it 
     takes time to get this thing to people.''
       Science is cautiously slow, he concedes.
       National Outcome Assessment: Dr. Khuri, as chief of 
     surgery, has found another frustration to consume his time.
       ``I am someone that believes very, very strongly that VA 
     results have always been excellent in surgery. We have very 
     good surgical centers at the Veterans Health Administration, 
     particularly those that are affiliated with major 
     institutions,'' he asserts, noting that he is a full 
     professor at Harvard Medical School and all his staff have 
     academic appointments at Harvard.
       Unfortunately, the VA has been often criticized for having 
     high mortality rates after surgery. In fact, in the mid '80s, 
     ``a very concentrated attack'' by the media attempted to 
     ``discredit'' VA by publishing surgical outcomes, which 
     various periodicals claimed were evidence of higher mortality 
     rates than in the private sector.
       ``I felt very frustrated by this,'' he relates. ``We were 
     all convinced we were doing a good job and that our results 
     were the same as [his affiliated hospital at] the Brigham.''
       The difference, he points out, is that VA patients are 
     sicker patients and therefore are at higher risk of dying as 
     a result of surgery. ``No one would dispute this,'' he 
     stresses.
       This debate over higher VA mortality rates reached a climax 
     in 1986, Dr. Khuri relates, prompting Congress to pass a 
     mandate that VA must report its surgical outcomes in 
     comparison to national averages and risk-adjusted for the 
     patients' severity of illnesses. VA also was to report to 
     Congress every two years on how it addressed this mandate.
       In 1987, VA asked him to chair a committee to fulfill this 
     task. ``It became very evident to us when we met as a group 
     that the congressional mandate was untenable because there 
     were no national standards for surgical outcomes anywhere in 
     the world.'' There were no models for risk-adjusted outcomes 
     either.
       Dr. Khuri's committee advised VA to explain to Congress the 
     lack of national standards and pointed out that the agency 
     was in the unique position not only to develop these national 
     standards, but also to develop risk-adjusted outcomes with 
     which it could compare one VA medical facility to another and 
     to the private sector.
       It took almost three years to convince VA to make this 
     claim to Congress and to agree to fund an initiative to 
     address these issues.
       The committee he chaired put together a study to examine 
     the unadjusted outcomes in the VA surgical services. In 1991, 
     it launched the National VA Surgical Risk Study in 44 VA 
     medical centers and assigned clinical nurses to collect 
     preoperative, intraoperative, and outcomes data--both deaths 
     and complications on all major operations.
       From the inception of the study, an advisory board 
     comprised of leading outside experts advised the study how to 
     proceed and conduct analyses. Dr. Khuri also recruited Dr. 
     Jennifer Daley, an expert in health science research, as his 
     co-chair of the risk study. The results of this prospective 
     analysis ultimately lead to the development of national 
     models that allowed VA to report its outcomes adjusted for 
     the severity of illness of its patients.
       O/E Ratio: An assessment system was developed that enabled 
     a particular surgical service to calculate the expected 
     mortality or complications rate for patients undergoing 
     surgery over a certain period of time in that hospital, based 
     on the preoperative severity of their illnesses.
       Then using the observed mortality rate for the same period, 
     an observed to expected ration, or ``O/E Ratio'' could be 
     generated, he explains.
       If the observed ratio is much higher than that expected, 
     based on the severity of the illness of the patients, he 
     explains, the assumption is that there are other factors that 
     have contributed to the high mortality rate of that 
     population, probably related to the quality of care in that 
     institution.
       A study was performed to validate the O/E Ratio as a 
     measure of quality of care, and by January 1995, ``we had 
     developed for the first time models that would allow for risk 
     adjustment, not only in cardiac surgery, but in almost every 
     major field of non-cardiac surgery.''
       VA recognized the value of this as a way to continuously 
     monitor the quality of surgical care, Dr. Khuri notes.
       ``The VA leadership was insightful enough to go along with 
     our recommendation that the models that had been developed 
     should be applied to all the VA's that were doing surgery.'' 
     The result was the National Surgical Quality Improvement 
     Program (NSQIP), which Dr. Khuri chairs and which basically 
     expanded the methodology employed in the National VA Surgical 
     Risk Study of all 123 VA medical centers performing surgery.

[[Page S11964]]

       The program uses 88 full-time nurses to collect data on all 
     major surgery in the VA, which is transmitted to the program 
     database in Chicago. The ``very rich database'' contains more 
     than 500,000 cases, he relates, and generates annually a 
     detailed report for each surgical service at the VA.
       The program has published more than 17 publications about 
     the NSQIP data and, within the coming year the program will 
     be accessed through the Internet.
       VHA had certain advantages as it implemented the outcome 
     assessment program, he explains. First, the agency's uniform 
     clinical and administrative database and software program--
     the Decentralized Hospital Computer Program, now known as 
     VISTA--has permitted the NSQIP to access a consistent 
     surgical scheduling module and operating room log in every 
     VAMC to identify all operations performed in operating rooms 
     throughout the country and to centralize the data so that the 
     surgical nurse reviewers enter uniform data.
       However, the NSQIP risk models and outcomes may have a few 
     limitations, he cautions, because they may not be 
     generalizable to populations dissimilar to veterans. Further, 
     to reduce the data collection burden for the nurse reviewers, 
     operation- and subspecialty-specific patient risk factors are 
     not collected for non-cardiac surgery.
       A final limitation, Dr. Khuri notes, is that the outcomes 
     measured in the NSQIP currently are restricted to the adverse 
     occurrences of postsurgical mortality and morbidity, and 
     length of stay.
       ``There is a lot of interest now, not just among the VA 
     surgeons, but among the surgical community outside of VA.'' 
     Dr. Khuri contends, especially with modern medicine's current 
     emphasis on managed care and cost containment.
       ``VA has completely adopted this,'' Dr. Khuri proudly 
     notes, and ``it is leading the world in the use of risk-
     adjusted outcomes.
       ``We think that the NSQIP is providing models that are 
     leading the way towards the qualification of quality of 
     surgery and the ability to compare the quality of care at 
     various institutions using risk adjusted outcomes,'' Dr. 
     Khuri declares.
       Results of the National VA Surgical Risk Study were 
     published as to lead three articles in the October 1997 issue 
     of the Journal of the American College of Surgeons, and a 
     full description of the NSQIP will be published in the 
     upcoming October issue of the Annals of Surgery.

                          ____________________