Y'all, welcome back to another week in my life vlog. I spent the entire weekend at home to get out of this weird funk. I recorded a podcast episode, I'm doing a life reset. Like we're making moves, we're getting out of this. And this week is gonna be a good one. We've got some things going on. Oh, and we have a lot of house updates actually. So my goal this week is to wake up at 6.30 every day and go on a nice little walk every morning before my workout. Because I find that I just feel better. I went on silent walks this week because I was listening to Okay Sis and Maddie was talking about it.  But it's actually really peaceful and it's nice to be like one with my thoughts. It's scary at first, but it gets better. Or like maybe it's just a me thing, but really it was a good experience. So I did that this morning and it's got a little bit of work done. The weather's actually been really nice. So I've been working on my patio, which has just been so fabulous. Lots of things coming. Anyways, today I'm going to work out right now. Then I'm gonna go to Home Depot and I'm gonna get some plants because I wanna put some flowers in my pots. I'm supposed to get a grill at some point this week. And then I also, I think the couch for my studio room is arriving today, which is like really early or so. I can't tell, but I'm pretty sure it's that. Lots of updates, lots of things coming. I'm also gonna be making Ina Gardens new, not new, new to me. Ina Gardens summer pasta, like we are, we're doing the things. We're, this vlog is gonna be the best vlog you guys have seen in a long time. And you're gonna be like, wow, I love kids these vlogs again because something has been going on with me and we're getting out of that. Also, by the way, if y'all are new here, subscribe. It's been a lovely morning here. The weather is beautiful. I might buy a grill, looking at some plants. Okay, this is all looking stunning. And that's been beautiful flowers, spanting soil, grill stuff. I did find a grill, so. Check me out. Okay, I got it all, guys. It was so peaceful. My grill is being picked up later. I'm so excited. Quick break to talk about our sponsor, Centbird. I have loved Centbird for years. If y'all didn't know, Centbird is a fragrance subscription that allows you to try a new or multiple designer fragrances a month for just $17. Each one of these has a 30-day supply, so it's like amazing. Also great for travel. They have over 600 brands to choose from, so they have like Prada, and they have Gucci. I used to always love getting people the juicy on here, so basically all you have to do is twist this to spray. You just open this. This is the actual vial. I have all these different colors. DKNY, I cannot pronounce this correctly, but it's on the screen. Deck of Scarlet, not your girl, which I've been wanting to try. And then Floral Street, Arizona Bloom. It's nice because you're able to try out different fragrances without buying a full bottle, because that's what you have a full bottle.  So with my link, y'all can get 55% off, and a case, which they're so cute. I love this pink one. Thank you to Simford for sponsoring this vlog. Let's get back to the video. Again, don't forget to check it out. QR code, the link's below. Happy shopping. All right guys, there's some people at the household day, but a lot has happened. So I'm gonna give you guys a little update. The rumors are true. I do not have a girl. Okay, I got the next girl, because that is what my mom recommended. The really inexpensive girl. It was five burner. I'm just so excited. I was just on Pinterest looking at recipes of things that I wanna make, but I just feel like this is gonna be the best thing ever. I'm very, very excited. And then as you guys saw, a little high fits. I made a mess over here. Oh, I did get this stuff for grilling. I'm not the tripod, I need to put this stuff away. But these like rubs for different like meat and stuff. And then also a grill spread. But Molly sent me a TikTok saying to not use a grill spray and to use a potato. So I'm gonna try that out. And then I also got this because I feel like I'm gonna be doing a lot of pizza nights and stuff out here when I entertain and that's obviously much needed. I was getting these hung up and then we took them down because they were way too big. And I don't know like, do I go like across this way? Or do we go around? Like how does that work? And I need to get less light. It's like this is too much. Anyways, the flowers are looking so cute. And then the couch has arrived. So ignore the brown things because they look weird right now especially because like the chairs aren't here. They won't even be there. They're gonna be moved. Just ignore them. Like really, I don't need comments, just ignore them. It just looks so cute. Every time I look in this room, I just puts me in such a good mood because I love the wallpaper. Like I'm just obsessed with it. I want a wallpaper like so much more at my house but it doesn't really work at my house. So I think I might wallpaper the guest room just to like have fun project to do eventually. But this couch is from Polly and Bark. It's pretty low to the ground. Like I'll show you guys. But it's actually like really cozy and it's a pretty small couch. Like this room obviously isn't huge and I'm still gonna have a coffee table which I feel like I don't know. You know how a room always looks bigger? Like once you have furniture in it. I'm replacing this with a different like credenza but I kind of feel like we need a smaller coffee table. So I don't know. And then as the chair is coming I also have a rug coming. There's just a lot going on here. This is where I'm gonna be recording the podcast. So it's really cute. And it just like puts me in such a good mood. It's also like the entryway in my house which I don't know if like overtime I'll feel worried about. You know what I mean? I don't know like walking through it every time. But it's gonna also, it's gonna be like an entryway slash podcast room. Like it's only gonna be set up for the podcast when I'm recording the podcast. And then I'm gonna put the stuff away in the closet right there. So that is the plan. Fitz is just the sweetest boy ever lately. He's so needy. Why are you sniffing me? He wants a horse. So anyways, I'm gonna get a little more work done and then I'm going to the movies tonight because I got invited to go see an early screening of The Flash. And my little brother loves movies and he loves like superhero stuff. And also I like that stuff too. So we're going together. That's how I get him to hang out with me. And it's at North Park. So I'm excited. I haven't been to that movie theater in so long but yeah, like guys, ignore this side cause we have a lot going on, but it's just like cozy. It's been a really cozy productive day from home today. Got a lot done around the house and then also got a lot of work done. I do have like random stuff I really just need to clean up and like this is driving me insane but I gotta figure that out. My house is so clean, it just feels good. Okay guys, so I'm supposed to be in the movie right now but like something happened and we went there. They were so rude. Well, only one girl was like the rudest ever. Like, oh my God, but we were supposed to go like we were like sent to the flash movie and then they said they have like no record of that and they are doing all of that but I think I'm like taking them to college or something. I don't know. Long story short, I'm back home. We went to dinner and that is it. I have some stuff for the grill that I got earlier that I showed you guys and took it away. Actually, this is the outside.  Like, do I get a little bucket and keep it in the pantry? Do I get something to store outside? I don't know, like what do people, what do like the grill masters do? Cause I'm trying to be like that, you know what I mean? So anyways, I'm listening. I'm back. I'm listening to Archer X but I think really better than Archer X, okay? Oh, I also ordered this on Amazon. It's just this like barbecue tool set a four piece that I'll definitely be trying out soon. I looked up some recipes and I'm really excited to get on my way and as news ever, skims, my favorite pajamas. These are the ribbed ones. Like two of their pairs of pajamas are the Everday pajamas. And then the skims, cotton rims, like there's just nothing like it. Get, I get a medium in these and they're just like so soft and comfortable. Anyways, they came out in pink. So I got a pink version or a pink pair. Well, I've tried the other skims pajamas and they're like fine, but there's just like nothing that compares to these. Like at all, I will link them. Anyways, the 830. We were gonna go see air, but then my brother was like, I'm just tired. So honestly, that girl's like killed our vibe. Like she was so mean that we were like, oh my God. Like, you know when you're like so excited for your plans and then someone like ruins your night? That's like what happened to us? So I'm like, I don't wanna go anymore because it's like, I can't even describe to you. It was just like, I don't know. They were just so mean. Like we were nice. I don't know what's going on. So anyways, still a fun day, really good day. I'm gonna get in bed and read the bright side of the story. Is that I have more time to read, and I've booked up on Wednesday and I need to finish this book anyways. So my God, we're going to Vegas right now or my Vegas group chat is popping off. We're gonna see Kelsey and the Friday before we're going to Billy Carrington it's gonna be a really big weekend. So anyways, oh I also got a Lego set. I know I showed you guys a little, I did a little vlog clip. Probably got a Lego set for Stove. I texted my brother because like we grew up with a stover and all and then I was literally in my car when I was like older, like my parents and I was there, it was just a little bit further away. And my little brother, Cody, was obsessed with Lego. So I texted him and I was like, are they just open a Lego here? And it's like, I want to go in. It's very nostalgic. So we went in and I spent like half of my childhood there with him, he's obsessed with Legos. And we got Sophie Legos because she likes doing Legos with Uncle Cody. So got that. Morning to Abercrombie, do the thing. So anyways, have a fabulous night. And that is that. All right guys, just had a nice morning out on the patio. I'm about to leave for spin class. I've been loving SoulSight lately. I don't know what it is. Actually I do. I really like taking from Ashley. And then I also really like Kayla's class. That's the other class that got me back into it. But when I leave SoulSight though, I'm just in like such a good mood. And it's nice. And I like the playlist. And it's like my other workouts, like weightlifting itself, we like talk through it. So I don't have like time to like zone out necessarily, which I like about weightlifting actually. Like it gets me like more into it. But just having like a good playlist, ah, it's amazing. And I leave in such a good mood. Where's my water? Dang it, I forgot the mirror. Okay, well, we're gonna go get that, but I'm wearing that. That's what it says, like seamless collection, which I wore so much when I moved into this house. It was actually like the only workout set that I was wearing. Oh my God, what is my chest? It was actually the only workout set that I was wearing because I only had like certain clothes or whatever. And it is such a good set. It's so flattering, it's so comfortable. Outdoor voices is priced really well too. I actually really like outdoor voices, but specifically this set. It's like up there. Like I feel like sport body from said active, which I thought it was Skull Flax, I thought it was so much more. And everyone was like, it's actually sport body. So it's actually sport body guys. And then anything near of ours, and then outdoor voices seamless. Like it's just so good. Anyways, I'm gonna listen to some podcasts. I didn't walk this morning because I just wasn't speaking to my soul. It wasn't. And it wasn't even that. Well, I did say it was late until like the night which is fairly, I mean, I finished the auto quiet place book, which is my book club pick. And the controversial take, it wasn't that great. Like everyone was like, oh my God, it's so good. And it just wasn't. Like so many of the comments that they loved it, I did get a few say like it sucked. I'm like, I don't think it sucked. It's just like, I didn't like it until the last 60% of that. And even with that, like, it was good and there were definitely twists that I didn't necessarily see coming. But I wouldn't say it was like amazing. You know what I mean? I am like a thriller queen because I read so many thrillers. So maybe it's that. I don't know. It was fine. It was a good book, but it wasn't like, I'm dying for it. So anyways, we're off. Here we go. I'm home from my workout. It's like 1115. I had some calls and meetings and then I just showered very quickly and got ready and I ordered myself first watch for breakfast. I love first watch. They have these guys, I ate them immediately. It was like bacon, maple vibe. I don't know, bacon. It's really good, like brown sugar. I just ate it and it like hurt my teeth. That's how much sugar I think is on there. So maybe not getting that again because it was a little painful. But anyways, I got a little breakfast wrap. I forgot to make my overnight oats. So I'll do that today. You have no idea what he is doing. Why are you walking like that, bud? What's going on? Bogo and I are gonna go to her physical therapy in a second. I'm gonna eat this breakfast. I just got some books. I got some books in my Kindle and I'm ready to go. I'm like dressed, like really like a true mom. I know you guys are like, how are you wearing this sweater right now on Texas? It's actually really nice out. This sweater, this outfit is for comfort only. This sweater is way too big. It's my favorite people's sweater. Hi Fitz, this is what I mean. Like just so clean. And these are daily drill shorts but I have the wrong size. They don't want to fit. I just have the wrong size I think. And then these shoes are some element. And then I have my dog carrier from Jigs. I wish I had a different color, like a nude but this is me being a mom. Guys, I know I'm wearing a sweater but it is really starting to feel like summer. I might, for very lucky, I'm putting positive energy out into the world. Might be going to the lake house this weekend. My dad got a new lake house but all the lake houses that are within my family, it sounds way busier than it is. My parents are just divorced. They are like Airbnbs. So I'm, anyway, he's got a new one and he just listed it so I'm hoping, I'm gonna hope he gets business. But I'm hoping he gets business after this weekend because I called it if it doesn't get booked this weekend and I'm just praying to God that I end up at the lake this weekend. Seriously, I just need like a summer weekend at the lake. But I'm on my way to the now massage. I'm really excited. I'm getting a scout massage, my first one ever. And I've been really wanting one because I know it's like good for like hair health and hair growth and stuff. They're doing a collab with the way and I love the way and I love the now. So I'm excited to go to the Lord Greenville location. I know they have one, I think I like Preston Center as well and then I know there's a good other one coming. But anyways, I'm excited. I got a lot done. I took a coconut physical therapy, good stuff. Honestly, the physical therapy appointments have been like good for my like productivity because I just have like an hour of time where I just get like everything done that I have been putting off or like just stuff that I need to do on my phone. It's actually pretty productive. So anyways, I'm really excited for this to stop. I've been wanting one so bad. I'm also getting the deep tissue enhancer with it. I'm gonna do a whole TikTok on my experience, but I'm very excited. All right y'all, I just got ready in like 15 minutes. Here's my outfit. I'm actually really into it. I know that probably not everyone will be. So I have my vintage boots on. This is Chris, this is Polly. Pops out to her voices. We're gonna stop so we can't hear Coco anymore. But yeah, my hair is still drying. I'm running out the door. To my workout, I came home. I placed a big order on skims because it's the biannual sale this week. So I'll be doing a skims haul in the future and then I just link them all on my stories. I'm going to. So because you're not following me on Instagram and I'd like to know what I've actually been active like linking my outfits because I find, I feel annoying when I forget in vlogs specifically. And if I forget a vlog link by the way guys, this is why I've forgotten. When I watch back my videos, I do the links during that time. I just forgot to copy and paste the no and put it in the description. So that's on me. Anyways, I'm linking things in real time though on Instagram. So I'm gonna do that later. I'm on my way to Foxtrot. I have a little meeting there, the one on Knox, I love Foxtrot. And then tonight we have book club, Cocoa's another appointment. I just got a lot of work to do around the house. Need to go to the grocery store because I'm gonna start grilling tomorrow which is obviously very exciting for me. I hope that Foxtrot has a breakfast tacos right now because they're so good. I listen to the Jelly Roll podcast or the Jelly Roll on Joe Rogan and listen like Jelly Roll and his wife Bunny deserve the world. I'm obsessed with them. I like watch every single talk she has when you start listening to her podcast. I love them but they are just the best, coolest people that deserve every single thing and more. And like I'm obsessed with them. I can't wait for the documentary to come out. I'm like obsessed. So anyways, I'm gonna be having a fabulous day. Okay y'all, I'm grilling for the first time. So I'm making some zucchini with basil, honey and goat cheese. And then I just got like the lemon salmon from Sprouts to make it like quick and easy. I've only got about like 30 minutes before I've got to head out. But I did get some work done and I'm just feeling so good. Like I am in just like the best mood this week and I was in such a bad mood last week and I've already said this, but like I'm really just driving. Have Zach Brian playing, blasting. It's only 80 degrees. Like it's feeling great. Guys, this is so good. So I have a video on my TikTok with like the recipe but it's literally just grilled zucchini. I got the zucchini, I cut it, put some salt on, I like patted it down a tongue cause there's so much water in it. And then I brushed it in olive oil, put it on the grill, grilled it, chopped up some basil and then chopped it with goat cheese, honey and basil. It is so good. I also grilled salmon. I'm about to eat that as well. This is great for like an appetizer at a dinner party especially. Like I would do like maybe like five of these and just put them out, but they are so good. This is my outfit of the day. Daily drills. Hey everyone, welcome to another amazing, beautiful day. Ironically, my podcast episode just went live about getting out of the funk but it clearly worked. If you guys have seen this vlog, so go watch it on YouTube and listen to the podcast. I will have it linked. I'm trying to post them as like post on my YouTube channel but I really want it to be more like a vlog cast. You know that's why I'm working on the studio, while we're doing some things. So let me know. I also think I'm gonna need to wash my hair again today. Just thinking out loud here. Anyways, I'm on my way to Pilates right now. And it's a furgy themed class. I am so excited to shine up Pilates. They've been doing a lot of things. I love a themed workout class. Like I'm there. If Soul Cycle especially has so many of them and I'm so excited and oh my God, my favorite class has been booking like crazy. I used to go and get my spot number four every single time, no issue. And then it's so crazy that like the 830 will book and I have to literally be there with my app out as the class is starting to book my spot for the next week. And I finally got my spot today after a couple of weeks and you know what you have like your favorite spot. It's just a very exciting time. Anyways, today I'm just getting some things done. Coco has another appointment. I need to stop at her vet for some meds. And then later I have either one friend or two friends coming over. We're grilling again. We're having like a business meeting with Lauren who owns DeNovo. The store I was at last night. And we're gonna chat all things business. So it's gonna be good. I'm really excited and I'm really excited for this weekend because another day has passed that the book has hasn't booked. So I think it might be mine. Just got back from Coco's acupuncture class or less not lessen appointment, whatever. I made this for the second day. This is just the sprouts like pre marinated lemon whatever salmon they have. I grab a few of those just like through the week because it's easy. I was so hungry when I came back. That's the thing about this meal and grilling it so quick. Then I made the same thing I made yesterday. The recipe is on my Instagram and my TikTok. But it is so good. I'm obsessed with grilling. Like I know I've made two meals, but I'm obsessed. I'm grilling tonight too. Stay tuned, but so good. Also I got this in Martha Stewart's cooking school book. I love like a cookbook or anything like this. I will take these to hair appointments and like dog ear them. And then actually use the recipe I feel like you'll buy cookbooks like I used to in the past and like never actually used the recipes or just used them as like a, not like as actually a comfortable book but like the same vibe of where you get them to like look cute, you know? But now I actually use them all the time and this has like everything that I could need. And I'm obsessed. So I will be going through this. I'm going to link this on my Amazon storefront as well, but I just love it. Also such a good thing to have in my house. I'm cleaning stuff right now. I just unboxed boxes, but I don't really want all these out. Obviously that's not, this is not anything that's staying here. And then I have this like cookbook stand that I love. It's so amazing for cooking, obviously. But yeah, I need to like go through and decide which ones I want to have, which ones I don't. I really like this one by the way, the genius kitchen. I can make an Amazon storefront of my cookbooks. True roots I've used. Yeah, like dog ears and some of it. I don't think I've cooked actually that much from here. But I really like actually having a cookbook because again, it's like less technology in the kitchen I say as I'm filming, but you know what I mean? Like having the cookbook like out here and if not I'll transfer it to a recipe book. Okay, taking a little break and working, but now I'm thinking, they're in prepping for the Ina garden pasta. Like there's some of pasta recipe. I am so excited, I've been wanting to make this all week. So I'm using cherry tomatoes. I know that Ina uses like normal, but on all other recipes, it was like back and forth. So I just chopped up some garlic, and some garlic, and I'm cutting the rest of these tomatoes in half. And then all you do is combine them in a bowl with olive oil for, with like pepper and pepper flakes, salt, olive oil, basil, I think that's it. And you just have it sit in room temperature for four hours. So I'm gonna have that sit as I'm doing the rest of my work today. I'm a friend of mine just coming over tonight for dinner, but we're also like doing work stuff. So she's like helping me brainstorm some stuff. She owns Innova Active. If you guys are in Dallas, you need to go, that's where I went last night. But anyways, I'm just prepping this because we are gonna make these like grilled, caprese, like chicken breast that looks so, oh yeah, that's why I have that tomato. Thank God I didn't chop it up. It looks so good. So this is just gonna be the side. I'm gonna have this like sitting out. I need to put my laundry away. Just been sitting there. If you don't put your laundry away immediately, you just will literally never put your laundry away. Oh, also Coco got sent home with a cart this week, like a wheelchair essentially. So that's something. She's been napping ever since getting back. She gets like really tired because obviously she's just, you know, working out. What are you gonna do? I also had another cup of coffee because for some reason I'm really tired today. I was supposed to close on the town tomorrow, but it's gonna call it. Closing is getting pushed to next week. So gotta figure that one out. Sure, not figure that one out. She's like changing my day tomorrow. Anyways, this is what I have. Then I just chopped up and then I just chopped some basil. I'm gonna put it in this bowl. This bowl I got from, I think at their store. I'm recording an entire solo on dinner parties next week, or tomorrow for next week, but that'll be out already. Imagine you guys see this. Something that's like one of my favorite things in my kitchen. It's just so random. I just have a meaning to mention it. Are these like measuring cups from Anthropology? My mom got me them for Christmas and they are just so much better. Like first off, I love the cups themselves. They're so cute, right? Then they're just better. They're stackable. I don't know other way they're stackable, but just trust me, as far as like saving space, everything, being organized, these are the best I've ever had and I'm obsessed with them. So I guess anyone was on the market for pretty measuring cups. But I think I'm gonna whole thing of all my favorite stuff in my kitchen. Also, I started using Brightland. This week, I love Graza so much. Like obsessed. Started using Brightland, really liked it so far. This is the 100% garlic olive oil. If you ever don't know what to get someone who like maybe has similar inches made for a gift, olive oil is the best gift ever. So random, I'm like really old that that is what I consider exciting, but I'm telling you, it really is. This is my laundry, which took me longer than a minute. I just filmed the Semper sponsorship, as you guys can probably tell. I just like love this stuff. I've been waiting because I didn't wanna lose these because I know I had to film it, but I throw them in my bag. Like that's why these are so convenient and you can like lock it so it doesn't spray. It's just amazing.  I would love to like shower fully and I really do need to wash my hair and I do need to self tan. But having a friend over from there, so I'm not doing that yet, but I've already said that 15 times. So later I'm not prepping for dinner, getting my things out. This needs about another hour or so, but I'm making the chicken. I'm out of a few things. I need more basil, I really just need a basil plant like here. So that's on the list for this week, but I'm so excited for that. Living for this vibe, like look at this, out there about to start the grill. Gonna drink some wine. I'm trying to get more into wine. I don't know if this is natural. I feel like it isn't, I've just had it forever. But I really do like natural wines. I know I love Aveline. I don't know the other ones I think I need a cork for. Actually, I might try one of those can you go up an edge of wines. Let me see. Good morning, happy Friday guys. I'm going to SoulCycle. I'm having such a good week. I do think we're getting the lake house for this weekend. So that's exciting. I'm making my final plans and recording today. Got a lot of stuff going on. This guy is in my swim cost, and he's staring at me to film myself. So goodbye. Just showered, I got ready into my makeup, but I came home to a package from Califia Farms. Which is my favorite, as you guys know. I literally got iced coffee while I was out. So that was a waste. But, I mean it's not a waste, it's always put to use. I officially have the lake house to begin Marissa and I are going. I think I am going to vlog part of it. Just because I have my niece next week. And I don't have to vlog that much. Jom's also actually coming next week. I know I've said that 15 times, but she really is coming next week. So I gotta prep the gas room and all that stuff.   And for those of you all who've been asking where you get the cookie bread and creamer, cause I know I've heard it's hard to find, but I've never had an issue because it's always at Sprouts and that's where I grocery shop. So I think that maybe Sprouts carries it more often or something, I don't know. But like today, I posted an Instagram story that they were there. So my favorite cold brew or iced coffee. Oh wait, okay. So this is actually iced coffee and this is cold brew. Maybe this is what I love the most. I've got to figure it out cause I don't pay attention to these bottles. I'm more of an iced coffee girl than a cold brew girl, but I drink this all the time and I love it. So I'm wondering if that's it. And then I have the cinnamon roll oat creamer. I have, oh, campfire s'mores. That looks incredible. Like actually incredible. Okay. And then I have Califia Farms. Obviously almond milk creamer. The cookie butter, which is my favorite. It's my favorite, but to be fair, I haven't even tried these two. I'm just so obsessed with the cookie butter creamer. So maybe I'll do a little taste test on TikTok or something. Maybe Marissa and I will do that in the morning. But yeah, I'm really excited. I'm gonna change and then I'm gonna grill for lunch. I have someone coming over who's gonna help me with some stuff this summer and she's gonna help me record some episodes, take some brand photos, all that stuff. And then Marissa and I are gonna record tonight when she comes over. It's a whole thing. I'm having such a good week, guys. Listening to Tanner Swift. Drilling something. I really don't know where I'm gonna put these because I just don't have enough room in my fridge. I'm gonna figure it out. The mushrooms right now are grilling the mushrooms and then just this skewer. Why can't I say that? From, no, from Sprouts. It's literally $2. Amazing, great for hosting. If you end up like being on a time crunch and you get like 10 of these, it's like amazing. All right guys, I'm gonna end today's vlog because I need to like self tan and do all the things and prep for tomorrow. I just filmed and recorded an entire Sella Pockets episode on how I host dinner parties and the room is just getting cuter and cuter. I hope you guys enjoyed this vlog. I love you guys so much and I will talk to you very soon.  So of course they can master it. Like I'm already becoming a girl master but something about grilling is so much easier than cooking because it just automatically tastes better.


I would like to thank the Texas Heart Institute and the School of Refusionists for this kind invitation. It's really my great honor to be here today for this 2020 Perfusion Conference. And why this year is very important is because we honor Terry Crane. Terry worked with non-stop with Dr. Denton Cooley for the School of Refusionists and he made a great contribution over the last 40 years. This is my disclosures. Before we proceed, I would like also to thank Scott Weldon for providing these beautiful illustrations that you are going to see over the next few slides. And also I would like to thank the entire team of perfusionists and sociologists as well as the operating room nurses. In addition, I would really like to thank my partner, teacher and mentor, Dr. Coselli with whom I'm working clinically for the last 12 years. So the talk is related to thoracic aortic aneurysm repair a step-by-step approach. And we're going to divide this talk into two parts. The first part we're going to talk for the proximal ascending repair and the arch repair. And the second part we'll talk for the thoracic abdominal aortic repair. So the proximal aorta can come in different configurations as we see. The aneurysm can be only confined into the aortic root or can be in the mid-ascending aorta with the aortic root being normal or can involve the aortic root as well as the ascending aortic aorta or can be a mega aorta, meaning the ascending aorta is dilated, the arch is dilated as well as the entire thoracic abdominal aorta is dilated. These are the different surgical strategies that we have in our armamentarium when we deal with diseases affecting the ascending aorta, the ascending aorta and the aortic arch. This is the classic what we call marfanoid root where the ascending aorta is normal and the root is the one that is dilated. And in this case, the ascending aorta does not need to be replaced but we replace or repair the aortic root. This is another case where hypothermic circulatory arrest is not required but we replace or we repair the aortic root and we replace the ascending aorta. In this case, a cross-clamp can be placed in the ascending aorta and we carry on with the repair. As we see here, the way that we go on cardiopulmonary bypass is the classic way by cannulating the ascending aorta. Then we give cardioplegia and we put a cross-clamp the way that the cardioplegia is actually our strategy to give anti-grade, a retrograde cardioplegia. Anti-grade cardioplegia is being given direct into the aortic root if there's no aortic insufficiency. In case that there is aortic insufficiency then we open the aorta and we give direct into the osteo of the coronary arteries.  After the so the cross-clamp is placed, the ascending aorta is open and then we replace it with a darkroom graft. We proceed with the distal anastomosis first and then we proceed with the proximal repair. The proximal repair can involve aortic valve replacement, aortic root repair or aortic root replacement depending on the pathology. In case like this one where the ascending aorta as well as the proximal arch is involved then we have to institute a period of circulatory arrest because cross-clamp cannot be placed in this particular situation. So the way that we proceed is first of all we have to establish an arterial inflow for cardiopulmonary bypass. The way that we establish the arterial inflow is via the axillary cannulation or anominal cannulation with an eighth or a 10 millimeter graft. It is our strategy to always use an eighth or a 10 millimeter graft even though across the country there are tick centers that they actually cannulate direct the axillary artery or the anominal artery. So after we establish the arterial inflow, the patient goes on cardiopulmonary bypass and this is just to mention an algorithm that was published in the general thoracic and cardiovascular surgery two years ago where is an algorithm how we decide to proceed with the axillary cannulation versus the anominal cannulation. In case of free-do sternotomy when the cardiac structures are very close into the chest wall, then axillary cannulation is our preferred strategy. In case it is a primary repair, then we proceed in the elective cases, usually the anominal artery cannulation unless the head vessels are very dilated where axillary cannulation is a choice that we use. So like the case that I showed before where the ascending artery needs to be replaced as well as the artery cart, we'll start with anominal or axillary cannulation. Our mean temperature we cool down to 24 degrees. We use what we call moderate hypothermia. According to the ascension to the anominal artery according to the consensus of experts, moderate hypothermia is defined between 20 degrees Celsius to 28 degrees Celsius. And this is our preference to cool down to approximately 23 to 25 degrees Celsius as a mean temperature. Then when the target temperature is approached then we decrease the flows down to 10 to 15 mL per kilo per minute. And the snare is down as you see on the picture over the anominal artery. And we start what we call the anti-grade cerebral perfusion via the right common carotid artery. At that point also we monitor the nears. Then the artery is open and we proceed by placing the second cannula via the left common carotid artery. The flows, as we said, they're 10 to 15 mL per kilo per minute. The cannula that we place into the left common carotid artery is connected via y connector. As we see, the one y is connected into the anominal or the axillary artery and the other y is via the cannula that is going into the left common carotid artery. The cannula of choices that we like to use is a nine French prui, but lately over the last year we have switched to the cardiophigia cannula that is a little larger diameter so the resistance is a little less when the flow goes through the left common carotid artery. And this is another representation where you can very well see the y connector with the blood going through the right common carotid artery and then via the other cannula into the left common carotid artery. So after the antegrates, a little perfusion is initiated. Then we proceed with the distal repair, the repair closed into the, by replacing the proximal aortic arch. After the replacement is completed, then the snare, we take the snare off and we start going slowly to full flow. At that point, when we go to full flow, a cross-clamp is placed into the distal, into the doctrine graft and we start rewarming. In case that the pathology is more extensive, then we need to proceed with the total arch replacement. In these cases, the total arch can be done either as an island, a re-implantation or as a double Y graft. When we do it as an island re-implantation, then while we do the anastomosis, the distal anastomosis as well as the island, when we're cooled down to 20 or 24 degrees Celsius and then after the anastomosis is complete, we proceed like the previous repair where a cross-clamp is placed into the doctrine graft and then we proceed with the rest of the proximal repair that can be a repair of the aortic valve or replacement or just a graft into the proximal aorta. In case that the total arch needs to be replaced by using a trifurcated or bifurcated graft, then the sequence can be a little different because after we place the patient on cardiopulmonary bypass, the anastomosis of the subclavian and the carotid can be performed while we're cooling down and then when we reach the target temperature, 23 or 24 degrees Celsius, then we proceed with the circulatory arrest with anti-grade cerebral perfusion. The distal anastomosis as we see here is performed and after the distal anastomosis is performed, the circular, we go back to full flow, a cross-clamp is placed and slowly we start to rewarming. At that point, we have already a cannula that is connected into the side branch as we see in the image and the rest of the body is perfused at that point. So let's switch gears now into the thoracic abdominal aortic aneurysm repair, the step-by-step approach. Of course, as we mentioned before, the pathology is the one that really determines that would be the approach. And these are the different classifications as are classified by Dr. Crawford. We have the extent one aneurysm that is extended from the subclavian down to the level of the visceral vessels, the extent two from the subclavian artery or the way down to the bifurcation, the extent three mid-desending thoracic aorta down to the bifurcation and then the extent four aneurysm that is extended from the around the visceral vessels to the down to the bifurcation. And of course, the repairs are followed. We have extent one repair from the subclavian artery below the level, the other level of the renails, the extent two replacement from the subclavian artery that we place all the way down to the bifurcation, the extent three replacement where we place the mid-desending aorta down to the bifurcation and then the extent four aneurysm replacement where the repair involves the visceral vessels down to the aortic bifurcation. A lot of times we use the term elephant trunk repair. This is when we have already replaced the proximal aorta and at that point we come back a few months later and we replace the thoracic abdominal aorta by connecting the prior graft that we have from proximal repair into the new graft which is used for the second stage repair. In case that the pathology help us is not very extensive, then the vascular techniques can really help us and the second stage can be done with endovascular renaissance repair. Let's go through the steps of the thoracic abdominal repair. First of all, the reason why we treat the thoracic abdominal aneurysm is to prevent death, secondary to rapture. So the patient is placed with the right side down, left side up. We like to use the thoracic abdominal incision via the sixth intercostal and with the space and the patient is placed on left her bypass. The way that we place the patient left her bypass is that we use as an inflow the left inferior pulmonary vein and then as an outflow, as we'll see on the image, the descending thoracic aorta. After the patient is placed on left her bypass, then a cross-clamp is placed distal to the left subclavian artery or sometimes the cross-clamp is placed between the left common carotid and the left subclavian artery. Then the aorta is opened and we proceed with the proximal anastomosis. This proximal anastomosis is performed with the left heart bypass on. Then after the completion of the proximal anastomosis, the left heart bypass is off and the rest of the aorta is open and we identify the visceral vessels. Depending on the situation, sometimes we do perfuse the visceral vessels. As we see on this image, we use the blood of the pump to perfuse the SMA artery as well as the Celiac artery and then we have the circuit, the cold crystaloid or custodial circuit where we give the cold into a cold solution into the left renal and the right renal artery. So we continue with our repair by proceeding with the intercostal left artery patch and then we'll see here in this image where we have the two catheters into this superior mesentery artery and the Celiac artery as well as the cold solution into the left renal and the right renal artery. After the completion of the intercostal patch, in case that we have to proceed like in this image with what we call the tetrafulcated graft where all the visceral vessels are separated anastomosis to each artery, the second, the next step is to proceed with the distal anastomosis. At this case, as we said, the left heart bypass is off, we just give visceral perfusion we use the blood of the pump to produce the SMA as well as the Celiac artery and we use the cold renal solution to give cold renal into the right and the left renal artery during the distal anastomosis. When the distal anastomosis is completed, then the next step, we concentrate into the visceral vessels. At that point, the sequence, we start with the right renal artery. We continue the perfusion into the SMA and the Celiac artery and we continue the cold renal perfusion into the left renal artery. Then the next artery that we re-implant is the SMA and we continue with the Celiac artery. At that point, the patient continues to get renal perfusion via the left renal artery and the last vessel that we anastomost is the left renal artery and then the repair is completed. As we see here, the repair can be actually performed by two ways or by using a tetra-focated graft as we just depicted or by just using the island technique where all the visceral vessels are re-implanted at once. When we use the patch anastomosis, then the sequence can be a little different because the patch anastomosis we actually is completed after we do the intercostal patch and the distal anastomosis is actually at the end. I would like really to thank you for this great invitation. It's a great privilege to be here today and it is my pleasure throughout the years to work with all of you. Thank you and I hope to see you soon.


Historiography, historiography is the study of the methods of historians in developing history as an academic discipline, and by extension is any body of historical work on a particular subject. The historiography of a specific topic covers how historians have studied that topic using particular sources, techniques, and theoretical approaches. Scholars discuss historiography by topic, such as the historiography of the United Kingdom, the historiography of Canada, historiography of the British Empire, the historiography of early Islam, the historiography of China and different approaches and genres, such as political history and social history. Beginning in the 19th century, with the ascent of academic history, there developed a body of historiographic literature. The extent to which historians are influenced by their own groups and loyalties, such as to their nation-state, is a debated question. The research interests of historians change over time, and there has been a shift away from traditional diplomatic, economic, and political history toward newer approaches, especially social and cultural studies. From 1975 to 1995, the proportion of professors of history in American universities identifying with social history increased from 31 to 41 percent, while the proportion of political historians decreased from 40 to 30 percent. In 2007, the 5,723 faculty in the Departments of History at British Universities, 1,644 percent identified themselves with social history and 1,425,25 percent identified themselves with political history.


Sgwrs, mae'n gwybod i'r ffordd i chi'n gweld, fel'i ddechreu y peir yw'r ysgwrthfawr, lle'r llwysawr ar y FNH. Felly, mae'n gweld y ffrifio cyflwyng CMTP a'r SHEI. Mae'r rhai o dda'r ffyrdd i'r ysgwrthfawr yw'r wyf. Felly, mae'n gwybod i'ch gweld i'r ysgwrthfawr, gweithio mewn dfodol i'n bwysig a'r byw yn ddechrau'r bydd hynny yn dweud o'r cyfrifio o'r ddechrau. Felly, y gallai y syniad bwysig hwnnw? Felly, mae'n bwysig hwnnw yn ddweud o ddweud o'r ddweud o'r ddweud o'r ddweud o'r gweithlidol genomig a'n ddweud o'r genomig ar hyn, a'n ddweud yma. As I's been talking about a lot over the past day, this coverage is contingent on demonstrating clinical utility. For a lot of these tests, there is insufficient evidence of clinical utility to persuade payers that these are things that are clearly worth testing. So there are questions about who should be paying for the test, who should be what research needs to be done in order for clinical utility to be demonstrated. i'r ddweud ymwneud, ychydig i'r ddweud ymwneud. A'r ddweud yw'r ddweud yw'r ddweud, mae'n gyntaf i'r hyn o'r cymryd yn berthynasol. Felly, rwy'n meddwl gennymig yma, yn y Cwgogol, ond rwy'n fawr i'r ddweud yw'r ddweud y ddweud yma ychydig i'r hyn o'r ddweud yw'r hyn o'r ddweud i'r ddweud i'r ddweud i'r ddweud. Ie, mae'r cwestiynau o'r cwestiynau yw'r cyfnod o'r wneud, ond ni'n gwneud i ni i'r LHGRI i ddim ni'n ganddo i ddim ni'n ganddo i'r cyfrifiadau o'r ganwraethio'r cyfrifiadau a'r gwneud i ni'n gwneud i LHGRI. Yn ymwysg yw yma yn yr hyn ychydig i chi ddweud yma yng Nghaerfer, What are the endpoints that influence coverage decisions by health insurance issuers? Is it just clinical utility or is other health efficiencies like length of hospitalisation and so on? Given that so many of these tests don't have clear clinical utility, are there innovative ways in which payment is being done and patients are receiving tests in the absence of that clear data? So, after the workshop we had a subsequent call with Sean Tunis and his colleagues at the Centre for Medical Technology Policy, and that was the origins of this workshop that was held in October. So, as I was mentioning, several members of the Genomic Medicine Working Group were there. There were also a number of payers we had representative from Wellpoint, some from Palmetto GBA, which is a Medicare contractor. As someone mentioned yesterday, CMS was also there. A number of test developers were also represented, myriad, genomic health, Everson genetics. Wean Currie was there representing the CDC. Eric and Laura and Jean, a number of NHGRI staff were there, and a key group that I missed off unfortunately on this slide is the Centre for Medical Technology Policy, the group that we work with. So, we decided to focus, to structure the workshop on four test cases. Some of these are a little different in the details, but some of these are instances where there is limited evidence of clinical utility of a test, but where an insurer is nevertheless willing to pay, and patients are getting access to the test. The first one is the one that I think it was Mark mentioned yesterday. In 2009, CMS announced that they were going to, for pharmacogenomic testing for warfarin, they were going to start a coverage with evidence development policy. What that means is that they are willing to cover warfarin testing, but only if a patient is in a clinical trial. Jeff Roche presented from CMS, and then we had a representative of Everson genetics who is funding a clinical trial to look at the impact of warfarin testing on hospitalisations of severe clinical events. They are expecting that research to come out at the end of this year. We also had a couple of representatives from Genomic Health who talked about their performance-based risk sharing agreement they had with United Healthcare with regard to Oncotype DX coverage. They weren't at liberty to give us all the details of the exact agreement between them, but it was related to the collection of the data to see if the use of Oncotype DX would reduce referrals for chemotherapy. Then a couple of former colleagues of MedCo talked about a partnership that they had with the Mayo Clinic, again where they were looking at what the effect was warfarin testing. Lastly, a little bit of a different one, I'm sure many of you will have heard about Palmetto GBA's initiative they started. Last year, the Moldex program, one of the challenges that this Medicare contractor reported as having was that they were getting bills from labs and they really had a limited understanding of what exactly it was they were paying for. So they would get a bill from one lab for $150, another bill from another lab for $650, and to them it looked like they were paying for the same test. So to address this, they started this program where if you want to be reimbursed for a particular test you have to let Palmetto know exactly what it is that you're doing, what the analytical validity is, what the clinical validity is, what the clinical utility is, and then they make a decision as to whether they think it's reasonable and necessary for the Medicare population that they are responsible for. So we considered all these examples and were discussing whether these could be models for broader application, whether there are others that could do similar kinds of things, and to listen to some of the emerging themes. So these were some of the things that came out. One thing that's apparent is that there's little consensus. We can't think of all payers as being the same and the United Health example, they were interested in referral to chemotherapy. I don't know that that would particularly fit with CMS because CMS says they strictly look at patient outcomes, those are the kind of barometers they look at. So in answering the question, what is it that insurers want to see in order to determine whether something has validity or value, it's a complex question to answer. It was apparent that from the examples and from the discussion that payers are willing to consider evidence other than randomised clinical trials. The Palmetto representative Becky Turner was clarifying that they certainly, that's the gold standard, but they are willing to consider other evidence and whether a test has clinical utility or not. We also discussed Medicare statutory limitations. So Medicare can't pay for preventive services. Medicare can't pay for confirmation of a diagnosis as opposed to making a diagnosis. And I think this is something we need to think about because if Medicare is often used by other payers as a reference point, and if they're not paying for genomics-based services because it doesn't make sense for their population or it doesn't fit within the statute within which they operate, then there might be something we might want to think about how other payers may not also adopt for that reason. There was a discussion about who is responsible for funding this evidence base. It was quite clear from some of the payers that they don't think that that's their job. You bring them the evidence when you think you can justify this is something they need to pay for. And also, as was alluded to yesterday, it was apparent that there are some complications when it comes to sharing of patient data between a provider of health insurance and a test developer. So we came up with a few action items, some of which are no underway. The first was to write a white paper summarising some of these case studies thinking it might not be apparent to everyone that these are options, these are ways in which things are being done to get around the clinical utility problem. And also to summarise some of those emerging themes. We're going to conduct a policy analysis on data sharing what the issues are. Of course, Hipper is an issue Pearl mentioned yesterday about some state laws. There may be other things, so that'll be, we're going to get going on that next month. Mark's going to be leading an effort on research on physician ordering of tests. So one of the points that came up was that no matter how good the clinical utility is, if it's not being ordered appropriately or interpreted appropriately by physicians, then of course that clinical utility is very much limited. And then another point that was made, there were so many of these tests with so little clinical utility perhaps you ought to think about how to prioritise these. And lastly, there was the discussion about how much of an investment it is to do clinical utility research. So there was some kind of an idea of, if there might be some way in which provides some kind of infrastructure by which this could happen. So the white paper is an early draft, is ongoing that the second and the third were just starting working on those, the fourth and the fifth haven't started yet. So if you want to, I've tried to summarise everything that was in the workshop, but if you want to read in more detail, you go to that URL and it'll give you a more in-depth summary of the workshop. So I was also asked to come up with one or two ideas as to what might be next steps for things to think about. So these are completely unveted, they're just things under my head, so take them as you will. But it struck me that perhaps one of the things we want to do is to talk to some of the decision makers who really are responsible for determining what gets covered, who gets covered and how, whether it's actuaries, underwriters, to truly try to understand things from their point of view. Something else that struck me is that we often talk about the lack of coverage, but we rarely do we specify which tests we think really ought to be covered right now and which to have clear clinical utility but where health insurance issuers aren't picking them up. So I think that it would be interesting to discuss which tests should be covered right now and which tests might be appropriate for this coverage with evidence development kind of model and I use that broadly. And then of that it would certainly be interesting to look at what is covered by, what currently is covered. And lastly I think one of the longer term goals of what HGRI is, think about how we could either fund research or partner with others in research. Lastly I just want to flag a number of other issues that are out there which weren't really addressed by the workshop but are certainly within the realm of coverage and reimbursement and the question is whether NHGRI would want to take a lead role on this, whether we want to partner, whether it's just something we want to monitor and be aware of. The first is that Jeff Roche of CMS said quite clearly that if there was an application for instance of whole genome sequencing that fit their definition of reasonable and necessary for the Medicare population that's something they would definitely entertain so it might be worth thinking about whether there's a case that could be made for something like that. I don't understand things from their point of view, recognising of course, as I was saying before, the central role of Medicare. Then there are some of these other things that are going on, some of the interest to the AMAs and CMS is the adoption of new CPT codes that's going to allow better tracking of which tests are being done. And there was discussion at the workshop in parallel to that. There's a lot of enthusiasm for the Moldex initiative and there are questions whether this is just something that's happening within the California and the other states within the purview of parallel to GBA in that Medicare contract area where this is something that should be a national programme. For the genetic councillors, the most important coverage and reimbursement issue is direct billing of course. Something that I thought might be interesting to look at. We know the FDA now has over 100 drugs where on the label it has some kind of genetic, some kind of pharmacogenomic indication. And given that there is great concern about how physicians are misusing the tests or misinterpreting the tests, it might be interesting to look at some of those and to ask whether we think that they are really clear as to what the use of the test and what the use in helping administer the drug is. Lastly, a couple of things with the Affordable Care Act, the exchanges kick in in 2014 and one of the pieces of that is that each state is coming up with defining what are the essential health care benefits that need to be covered in order to be in the exchanges. The question is, do we think there's anything within genomics that meets that bar? And similarly, the recommendations of the US preventive services task force have been elevated, I think, to a new height with the passage of the Affordable Care Act. And so there are requirements if there's, if there's an A or B recommendation from the task force, there are requirements for health insurers to follow that recommendation and coverage decisions. So the question is whether we think there's anything within genomics that we would want them to consider. So those are just some ideas. So I'd like to thank Mark and Jean, who are on endless planning calls for the workshop. I know Mark enjoyed them particularly, as well as Laura and then Laura Coons, who is instrumentals now, who's a fellow in our office currently in Louise Slaughter's office and gone to the hill now, as well as the CMTP staff who are instrumental. So with that, hopefully I've tried to give an overview, but there are many of you there. So Mark, Jean, or whoever else might want to mention one or two things that I've skipped over or missed. Just to make the observation that those four examples dealt with really serious clinical problems. Two with Warfren. If a patient started on Warfren, it's my understanding that a quarter of them are in an ER within a period of time with either clots or bleeding. So that's a serious problem. Another one is whether a woman with breast cancer has to get chemotherapy or not. And then the other one had to do with the correct approach to lung cancer with targeted therapy. So somehow out of the mix, they chose really important clinical questions. So let's start with Jeff and then Mark and then Bruce. I have two questions. The first is could you clarify whether there was an explicit commitment from the payers to actually fund research on clinical utility, or is that an aspirational goal for the group? I would say it was more correct to say there was a specific commitment not to do so. We only had a few representatives there, but I think from the few that we had, I think they don't see it as their job. If you want to go to them and justify why you think your test needs to be covered, then they will consider it and they will look at the literature, but they are not going to a priori go out there and do the research themselves in order to determine whether they ought to cover the test. That was certainly what I heard anyway. But I think one of the things that was discussed was the idea of could there be innovations in coverage design that could somehow facilitate a collection of the data around certain key questions that the payers wanted answered. So for example, the United Healthcare Scenario, they were reasonably convinced that Oncotype DX was useful and had utility based on the evidence, but they were not convinced that clinicians would actually use the information to change care. What they were concerned about was that they were going to pay several hundred dollars for a test, and everybody was going to get chemotherapy anyway. So the way they set that up was to say, we will give you a target and if you can demonstrate to us that this does in fact change the care in some predefined, and we didn't get all the details about how this was set up because that was done under a proprietary situation, we will pay you for the test. So they worked directly with the test provider to collect data, so the test provider actually contacted all the clinicians that ordered the test after the test results were given and then collected data on whether or not chemotherapy was given. And they actually then hit the target that United had set in conjunction with them and they were reimbursed for the test. So it was that sort of idea which is that no, they don't want to pay for research because that's not really what their job is, but they're not necessarily averse to thinking about different ways of using their benefit structure to encourage collection of data that they think is key to making decisions. And I mentioned yesterday, I did follow up since well points headquartered in Chicago, I did follow up with well point representative and they are very anxious in partnering with us to provide data that may be useful. So I think as a first step we should really make sure we take them up on that offer. Yeah, so the data, one of the things that we found particularly in the Mayo MedCo study was the idea that there are data sources out there, in this case a pharmacy benefit manager that has a lot of data that could potentially be used to answer research questions and that there was willingness, I think under certain conditions to be able to share some of those data to be able to again answer specific questions. So it's just for us to think about other places to look for the data that we're interested in. Yeah, that could be incredibly valuable outcomes measures for some of our initiatives. So my second question may be, it's a brief answer, but did you have a chance to explore how they are thinking about covering clinical genome sequencing? We've heard. We didn't talk about it. I mean, I think that's the fair thing. We really talked about these four use cases and innovative designs so we did not get into the space of saying, here's what's coming down the road and really spend much time talking about that. I think oncology is an excellent area to look at and first of all in regard the genomic health, it's several thousand dollars, not several hundred. That sounds like a lot, but it's not because oncology payers are reimbursing ten thousand dollars a month or more for treatment regimens and back you could say diagnostics are a drop in the bucket of the national problem regarding oncology costs and so I think it would be very useful to analyze the entire oncology model. The other thing to keep in mind is that you may be talking to CMS regarding national policy, but the local coverage decisions are rampant and there are, I won't say hundreds, but there are many companies out there that have seduced the local provider into making a local coverage decision for a laboratory which then allows them to, of course, receive samples from anywhere in the country and bypass national policy. So I think you need to really look carefully not just at national policy, but at all the local coverage decisions regarding oncology testing, not just genomics, but there's a lot of companies out there selling chemotherapy testing, things like that and often these tests are ordered by providers who don't know what to do because the patient has progressed on all evidence-based regimens and so they're looking for some justification to give more treatment and add more costs and so they order a test of no proven value and then they give more therapies that add more costs of no value and so this is a real mess and I'd be happy to work with you guys on this. Yeah, we, actually that did come up and we did talk about that and one of the use cases was that a demonstration project that CMS funded to have a clearinghouse of all laboratory tests to try and get around some of these local coverage decision issues, but that is a topic that we are going to be discussing in the workgroup that I'm going to be running and I'll sign you up. Okay, so that teaches you to say the same thing around here. Bruce. I think one of the issues that distresses some payers and hospitals like is the tendency to encourage what I guess could be described as shotgun testing or bundling of tests. Don't include in this genomic sequencing but there are many examples where a clinical question is phrased in a sufficiently vague way that where a $500 test could have answered the question instead a $10,000 test gets sent looking at every possible gene that could ever be imagined to be involved in that phenotype even though some are much more probable than others and I think that actually at least in my institution has actually given genetic testing a bad name in general because the perception is genetic tests cost $10,000 a shot without realizing that in fact if you break them down and use clinical judgment you can often do them for much less so I guess in a way it broadly comes under the heading of clinical utility but I think it is a kind of a mountain within that area that needs to be addressed specifically. This is the utilization management issue and again that will be under the purview of our group the appropriate ordering of tests and as I mentioned yesterday the ARUP white paper that came out showed that in their portfolio $30,000 to $36,000 a month of testing was being ordered inappropriately and there is no disagreement around anyone that there's any worth to doing inappropriate testing but the challenges Derek alluded to in the presentation was that because of coding issues and other things it's almost impossible for the payers to actually do effective utilization review either on the front or the back end and so this is going to be the area about could we in fact develop some solutions that would be able to address this problem so that is high in everybody's priority list because we all recognize that this is just pure and simple waste. There's no impact on patient care except to the possibility that we're going to lead to more expenditures and as Mark pointed out inappropriate therapy so yeah, we want to get rid of that. I've got several in the queue here and we're relatively short so I think I'll just kind of keep going but I'll add you to the list. Gail. So several issues that are big obstacles clinically right now are pre-authorizations and the need to test relatives in order to efficiently care for the patient in front of you and those relatives may not benefit from that test or they may be deceased and we may be working with a repository or a tissue sample and I didn't see you see those on your list of other and I wondered if either of those was getting bandwidth I know we had one insurer who used to if a medical geneticist ordered a test that we didn't need to pre-auth that and they actually got rid of that policy. No, that's not something I had thought about as I was generating the list but I did realize as I put the list together I started thinking of more so I think there were certainly that wasn't supposed to be an exhaustive list it was more like jotting down some of the other things that perhaps we should start to think about perhaps that should be, we should add that one. Yeah and that falls within I'm not trying to characterize the workgroup that I'm going to be leading as the be all and end all of the questions to this point have directly impacted on what the meeting actually flagged as a huge problem which is the appropriate utilization so that will be a major focus. Cathy. Was there any discussion about the first of all I had two questions any discussion about coverage of interpretation or was it really about specifically the test itself? We didn't really get too much into coverage of interpretation it was more about whether tests, whether specifically because of the nature of the case studies it was more about specifically whether the tests are being covered but obviously that's an an additional issue. Although the United Genomic Health use case really was about interpretation because it was asking the question are clinicians using the information to avoid chemotherapy so even though the interpretation was not formally measured it was indirectly measured looking at utilization. Okay and then my second question was there any further discussion about clinical utility and the lines between that and personal utility or social utility in the sense or was it and what the value can be of those genetic tests based on those definitions or was it strictly discussion around clear cut clinical well I'm not sure what that is either but clinical utility To the extent that we all agree on exactly what clinical utility is it was more on the latter there was little discussion of personal utility what benefits someone might get out of personally of understanding stuff about their genome and again it was obviously focused on what health insurance issuers are going to be prepared to pay for. I just want to say that in addition to coverage there are benefits packages that you know so I think having the employers the large employer groups involved they may be another source of data and I think their opinions and their understanding of this would be helpful and you know they're they're often driving what the insurers are are doing. I also just wanted to comment I am the ACMG representative to the Blue Cross Blue Shield Association Medical Advisory Panel and I have you know we're allowed to submit you know ideas for future topics so I have submitted you know whole genome or I shouldn't say whole but genome exon sequencing. You can say whatever you want. So I'm sure that will be discussed probably more as an informational piece and then maybe ultimately to kind of look at whatever evidence does exist so in our deliberations it usually is completely evidence based because we usually focus on technologies that are controversial and evidence is key. I think the employer piece is a good one it was something that definitely came up the challenge of course is that it's harder to find the you know what might be considered a representative employer. I have one I mean I think the person you might consider is Helen Darling She represents I can't remember her official title but she's on the Medical Advisory Panel at Blue Cross Blue Shield. Helen Darling If it's any of your contact information I'll invite her to be a part. That would be great. Thank you. Kate. As of today Medicare just released a document for public comment about reimbursement for multi analytical panels for cancer testing which includes cancer sequencing, type arrays and all of that they're actually looking for public comment in the next six to eight weeks we were contacted by the head of Medicare for our 14 states or 12 states or something like that and they're so we're coordinating actually an effort it's a weird sort of set of states but nonetheless we're recording a set of efforts that are actually going to come back with documents to support multi analytical testing for cancer biomarkers so I just want to make sure that everybody's aware that in fact now is the time to look at what the Medicare guidelines are for somatic panel and sequencing because they're just available for public comment and they want people to get together in each of the Medicare regions and comment from the institutions Kate could you make arrangements to send that link around to the group you could send it either to Ian or to Richard and we'll distribute it so that everybody has a chance to get that that would be great David I wanted to follow up on what Bruce had said there was the discussion of the coordinating committee or the society of societies I know we're not allowed to use that term anymore this would be a very good topic for that coordinating committee because if they're talking about guidelines or the concept of developing guidelines in order to convince insurers that you're acting responsibly if the societies started telling their members these are good ways to use molecular testing that sort of benefits everybody it's better medical care per Bruce and it's less money per the insurance companies and it's responsible for the societies thank you I think we've got time for one more I think you have the last word God makes me nervous two thoughts one I would like to endorse Derek's idea of really trying to put some data behind what tests it is we think should be covered right now and what should be considered with more data and somehow marry that to yesterday all of the surveys I was impressed by the fact that there was this universal the orderers not having a clue as to what is covered and it would be interesting to know what are they ordering are they ordering in the category of what we think should be covered or are they ordering the wackos so I think somehow to get more feather out more data in both of those categories may inform the process okay thank you that's a good point and we'll see if we might be able to to do it the challenge as I've mentioned before is that because of the current coding system the way that we would traditionally collect data is difficult to do because all we see are the procedural CPT codes for molecular diagnostics and we can't tell exactly what test was done and so whether you're in an individual institution and want to know what your doc's ordering or whether you're looking at it on a more broad perspective it's very difficult and even though there are some now modifiers that have been added the use of those has been sporadic although the demonstration project that was part of the presentations there for their region there was a requirement that the bill as submitted had to have the modifiers so they actually were able to use that to understand specifically what test was ordered and do some utilization but that was really the first group that had larger, broader data and that was still pretty early in its stages so this has been a problem that we've been discussing in the coverage and reimbursement realm before I was on SACGHS and working actually back to SACGT and we still haven't come up with a great solution. Great. Terry are you