Current Procedural Terminology Research Articles

Progression to Pars Plana Vitrectomy in Patients With Proliferative Diabetic Retinopathy

The Diabetic Retinopathy Clinical Research Network Protocol S suggested that vitrectomy for vitreous hemorrhage (VH) or tractional retinal detachment (TRD) was more common among eyes assigned initially to panretinal photocoagulation (PRP) vs anti-vascular endothelial growth factor (anti-VEGF) for proliferative diabetic retinopathy (PDR). These clinical implications warrant further evaluation in the clinical practice setting. To explore outcomes of PDR treated with PRP monotherapy compared with matched patients treated with anti-VEGF monotherapy. Retrospective cohort study using an aggregated electronic health records research network. Patients with PDR who received PRP or anti-VEGF monotherapy between January and September 2023 were included before propensity score matching. Patients were excluded with 6 or fewer months' follow-up after monotherapy or with a combination of PRP and anti-VEGF. Data were analyzed in September 2023. Patients with new PDR diagnoses stratified by monotherapy with PRP or anti-VEGF agents using Current Procedural Terminology code. Incidence of pars plana vitrectomy (PPV), VH, or TRD. Among 6020 patients (PRP cohort: mean [SD] age, 64.8 [13.4]; 6424 [50.88%] female; 3562 [28.21%] Black, 6180 [48.95%] White, and 2716 [21.51%] unknown race; anti-VEGF cohort: mean [SD] age, 66.1 [13.2]; 5399 [50.52%] male; 2859 [26.75%] Black, 5377 [50.31%] White, and 2382 [22.29%] unknown race) who received treatment, PRP monotherapy was associated with higher rates of PPV when compared with patients treated with anti-VEGF monotherapy at 5 years (RR, 1.18; 95% CI, 1.05-1.36; RD, 1.37%; 95% CI, 0.39%-2.37%; P < .001), with similar associations at 1 and 3 years. PRP monotherapy was associated with higher rates of VH at 5 years (relative risk [RR], 1.72; 95% CI, 1.52-1.95; risk difference [RD], 7.05; 95% CI, 5.41%-8.69%; P < .001) and higher rates of TRD at 5 years (RR, 2.76; 95% CI, 2.26-3.37; RD, 4.25%; 95% CI, 3.45%-5.05%; P < .001), with similar magnitudes of associations at 6 months, 1 year, and 3 years, when compared with patients treated with anti-VEGF monotherapy. These findings support the hypothesis that patients with PDR treated with PRP monotherapy are more likely to develop VH, TRD, and undergo PPV when compared with matched patients treated with anti-VEGF monotherapy. However, given the wide range in relative risk, confounding factors may account for some of the association between PRP vs anti-VEGF monotherapy and outcomes evaluated.

Short-Term Morbidity and Mortality after Distal Femur Open Reduction Internal Fixation in the Geriatric Population.

Distal femur fractures remain a significant cause of morbidity and mortality for elderly patients. There is a lack of large population studies investigating short-term outcomes after distal femur c in elderly patients. The purpose of this study is to assess the incidence of and risk factors for various short-term outcomes after distal femur open reduction internal fixation (ORIF) in the geriatric population. The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database was used to identify all primary distal femur ORIF cases in patients 60+ years old between January 1, 2015 and December 31, 2020 using Current Procedural Terminology (CPT) codes 27511, 27513, and 27514. Demographic, medical, and surgical variables were extracted for all patients. Propensity score matching was used to match cases in the two age groups based on various demographic and medical comorbidity variables. Several 30-day outcome measures were compared between the 60-79-year-old and 80+-year-old groups both before and after matching. Subsequent multivariate logistic regression was used to identify independent risk factors for 30-day outcome measures in the matched cohort. A total of 2913 patients were included in the final cohort: 1711 patients in the 60-79-year-old group and 1202 patients in the 80+-year-old group. Most patients were female (n = 2385; 81.9%). Prior to matching, the older group had a higher incidence of 30-day mortality (1.9% vs. 6.2%), readmission (3.7% vs. 9.7%, p = 0.024), and non-home discharge (74.3% vs. 89.5%, p < 0.001). Additionally, the older group had a higher rate of blood loss requiring transfusion (30.9% vs. 42.3%, p < 0.001) and medical complications (10.4% vs. 16.4%, p < 0.001), including myocardial infarction (0.7% vs. 2.7%, p < 0.001), pneumonia (2.7% vs. 4.6%, p = 0.008), and urinary tract infection (4.1% vs. 6.1%, p = 0.0188). After matching, the older group consistently had a higher incidence of mortality, non-home-discharge, blood loss requiring transfusion, and myocardial infarction. Various independent risk factors were identified for 30-day morbidity and mortality, including American Society of Anesthesiologists (ASA) classification, body mass index (BMI) status, operative duration, and certain medical comorbidities. Geriatric patients undergoing distal femur ORIF are at significant risk for 30-day morbidity and mortality. After matching, octogenarians and older patients specifically are at increased risk for mortality, non-home discharge, and surgical complications compared to patients aged 60-79 years old. Multiple factors, such as BMI status, ASA classification, operative time, and certain medical comorbidities, are independently associated with poor 30-day outcomes.

Effect of obesity on short and long-term complications after ankle fracture fixation

Objectives: This study evaluated the relationship between obesity and postoperative complications in patients undergoing ankle open reduction internal fixation (ORIF). Methods: Design: Retrospective cohort study Setting: PearlDiver-Mariner All-Payor Database. Patient Selection Criteria: Patients who underwent ankle ORIF from 2010-2021 and had a minimum 2 year follow-up were identified using CPT, ICD-9, and ICD-10 codes. Outcome Measures and Outcomes: Patients were stratified by Body Mass Index (BMI) into non-obese, obese, morbidly obese, and super-obese groups. Complication rates, including 90-day readmissions, infection, and post-traumatic osteoarthritis, were compared between obesity groups. Patients were additionally compared with a 1:1 matched analysis that controlled for demographics and comorbidities. Results: A total of 160,415 patients undergoing ankle ORIF from 2010 to 2021 were identified. The cohort consisted mostly of females (64.8%) and the average age was 52.5 (SD 18.4). There were higher rates of 90-day readmissions, UTIs, DVT/PE, pneumonia, superficial infections, and acute kidney injuries in patients with increasing levels of obesity (p&lt;0.001). There were increased odds of nonunion and post-traumatic arthritis in the matched analysis at 2 years in the obesity group (OR: 2.36, 95%CI: 1.68 – 3.31, p&lt;0.001; OR: 2.18 95%CI: 1.77 – 2.68, p&lt;0.001, respectively). Conclusion: Postoperative medical complication rates in patients undergoing ankle ORIF, including infection, are higher in obese patients, even in the 1:1 matched analysis that controlled for demographic and comorbidity factors. Rates of nonunion and post-traumatic arthritis were higher in obese patients, as well. As such, it is important for surgeons to provide appropriate education regarding the risks after ankle ORIF in patients with obesity. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Location of Shoulder Glenoid Labral Tears: A Study of 1763 Consecutive Patients.

Anterior shoulder labral tearing has historically been considered the most common location of shoulder labral pathology. Recently, smaller studies have reported that posterior labral involvement may be more common than previously recognized. To examine the location of surgically repaired labral tears by a single surgeon over a consecutive 23-year period. Case series; Level of evidence, 4. A total of 1763 consecutive patients who underwent arthroscopic or open shoulder labral repair by a single seniorsports medicine fellowship-trained orthopaedic surgeon between April 2000 and April 2023 were retrospectively reviewed. Current Procedural Terminology codes were used to identify patients, which included 29806, 29807, 29822, and 29823. Exclusion criteria included isolated shoulder manipulation or glenohumeral joint or labral debridement that did not include repair. Intraoperative glenoid labral tears observed were categorized into 7 broad categories: (1) anterior labral tears, (2) posterior labral tears, (3) superior labral anterior posterior (SLAP) type II tears (A, B, or C), (4) SLAP type V tears, (5) SLAP type VIII tears, or (6) circumferential labral tears (combined SLAP, anterior, and posterior labral tear). Shoulders diagnosed with multiple tear patterns (ie, anterior and posterior) were also noted. During the 23-year period, 1763 patients underwent arthroscopic or open labral repair; they included 1295 male and 468 female patients, ranging in age from 12 to 70 years, with a mean age of 23.2 years and median age of 19 years. Overall, 28.4% of tears involved the anterior labrum, 64.9% involved the posterior labrum, and 59.6% involved the superior labrum. Regarding isolated tears, 9.3% were isolated anterior labral tears, 19.7% were isolated posterior labral tears, 11.5% involved the anterior and posterior labrum, 22.2% were isolated superior (SLAP type II-IV) tears, 3.63% were isolated SLAP type V tears, 29.8% were isolated SLAP type VIII tears, and 4.1% were circumferential tears. Posterior shoulder labral tearing was more common than anterior tearing in a large consecutive series of 1763 patients who underwent surgical repair. This highlights the importance of posterior labral pathology, which sometimes may be overlooked because of more vague complaints, with pain and loss of function being the most common.

Sexually Transmitted Infection and HIV Testing and Diagnosis Among 15- to 44-Year-Old Patients With and Without Opioid Use Disorder.

The association between illicit opioid use and prescription opioid misuse and sexually transmitted infections (STIs) has not been examined recently. Our study aimed to explore differences in STI/HIV care, and delivery of recommended testing and diagnoses among patients with and without opioid use disorder (OUD). Using 2019 MarketScan commercial claims data, we identified 15- to 44-year-old male and female patients, to assess the percentages of STI/HIV diagnoses (using International Classification of Diseases, Tenth Revision, Clinical Modification ) and screening (using Current Procedure Terminology codes) among patients with or without OUD diagnoses codes. We further assessed STI/HIV testing and diagnoses by demographic factors. We identified 24,724 patients with OUD codes among 7.31 million patients. Both STI/HIV testing and diagnoses were significantly ( P < 0.05) higher among patients with OUD codes versus without: testing percentages were 16.81% versus 12.93% for chlamydia, 22.31% versus 16.62% for gonorrhea, 15.26% versus 7.61% for syphilis, and 18.18% versus 7.60% for HIV; diagnoses were 0.80% versus 0.35% for chlamydia, 0.30% versus 0.11% for gonorrhea, 0.23% versus 0.07% for syphilis, and 0.74% versus 0.33% for HIV. Similarly, among 0.53 million 15- to 24-year-old females who received services suggestive of sexual activity, chlamydia testing was significantly ( P < 0.05) higher among patients with OUD codes versus without (59.78% vs. 55.66%). Patients with OUD codes have higher percentages of STI/HIV testing and diagnoses codes compared with those without OUD codes. Clinicians may want to consider a comprehensive multidisciplinary (OUD and STI prevention) approach in patient care and provide recommended STI/HIV screening among patients with OUD if not performed.

Evaluating the risk of return to the operating room across all elective orthopaedic procedures

BackgroundAlthough elective procedures have life-changing potential, all surgeries come with an inherent risk of reoperation. There is a gap in knowledge investigating the risk of reoperation across orthopaedics. We aimed to identify the elective orthopaedic procedures with the highest rate of unplanned reoperation and the reasons for these procedures having such high reoperation rates.MethodsPatients in the NSQIP database were identified using CPT and ICD-10 codes. We isolated 612,815 orthopaedics procedures from 2018 to 2020 and identified the 10 CPT codes with the greatest rate of unplanned return to the operating room. For each index procedure, we identified the ICD-10 codes for the reoperation procedure and categorized them into infection, mechanical failure, fracture, wound disruption, hematoma or seroma, nerve pathology, other, and unspecified.ResultsBelow knee amputation (BKA) (CPT 27880) had the highest reoperation rate of 6.92% (37 of 535 patients). Posterior-approach thoracic (5.86%) or cervical (4.14%) arthrodesis and cervical laminectomy (3.85%), revision total hip arthroplasty (5.23%), conversion to total hip arthroplasty (4.33%), and revision shoulder arthroplasty (4.22%) were among the remaining highest reoperation rates. The overall leading causes of reoperation were infection (30.1%), mechanical failure (21.1%), and hematoma or seroma (9.4%) for the 10 procedures with the highest reoperation rates.ConclusionsThis study successfully identified the elective orthopaedic procedures with the highest 30-day return to OR rates. These include BKA, posterior thoracic and cervical spinal arthrodesis, revision hip arthroplasty, revision total shoulder arthroplasty, and cervical laminectomy. With this data, we can identify areas across orthopaedics in which revising protocols may improve patient outcomes and limit the burden of reoperations on patients and the healthcare system. Future studies should focus on the long-term physical and financial impact that these reoperations may have on patients and hospital systems.Level of clinical evidenceIV.

FIT as a population-based and financially viable method to screen underserved patients for colorectal cancer.

e13516 Background: Temple University Hospital (TUH) created an initiative to increase colorectal cancer (CRC) screening by administering fecal immunochemical tests (FIT) to the underserved population of Philadelphia. We hypothesize that this will increase the percentage of diagnostic colonoscopies performed compared to baseline in our fixed capacity colonoscopy suite and ultimately generate a higher reimbursement per colonoscopy. This potential revenue increase can help fund the infrastructure to administer a large quantity of FIT tests to the community and create a truly equitable population-based approach to CRC screening. Methods: 27,169 colonoscopies and their associated CPT codes from 2017-2022 performed at TUH were analyzed. 16 individual CPT codes were identified and categorized as either screening or diagnostic CPT codes. Reimbursement for each of the CPT codes was determined by the Medicare reimbursement per CPT code and used to determine the average reimbursement per screening CPT code and average reimbursement per diagnostic CPT code. A Monte Carolo simulation model was created using Palisades @Risk software to compare the reimbursements of FIT test prompted vs. non-FIT test prompted colonoscopies over a range of possible distributions of diagnostic CPT codes. Monte Carlo simulations model scenarios that incorporate uncertainties with the objective of providing a distribution of outcomes from the least likely to most likely outcomes. Results: The historical distribution of screening vs. diagnostic CPT codes at TUH is 31% and 69%, respectively, with an average Medicare reimbursement of $2,668 per colonoscopy. We have distributed 292 FIT tests, and 5 FIT test prompted colonoscopies have been completed with 7 associated CPT codes. The preliminary distribution of screening CPT codes vs diagnostic CPT codes is 29% and 71%, respectively, with an average reimbursement of $2,691. Lastly, we used a Monte Carlo simulation to run 10 separate simulations with 5000 iterations each to show the most likely reimbursement rates over a possible distribution of diagnostic colonoscopies (Table). Conclusions: Our preliminary data suggests FIT testing can offer three main benefits: 1) Expansion of the number of patients receiving CRC screening; 2) triage optimization of the fixed capacity colonoscopy suite by performing more diagnostic colonoscopies than screening colonoscopies to diagnose more colorectal pathologies; and 3) funding for a population based FIT testing campaign by utilizing the Medicare reimbursement delta from screening to diagnostic colonoscopies. [Table: see text]

Preoperative COVID-19 Infection Increases Risk for 60-Day Complications Following Total Shoulder Arthroplasty: A Propensity-Matched Analysis

Total shoulder arthroplasty (TSA) is an effective treatment for a wide range of shoulder pathologies. Literature investigating the impact of COVID-19 diagnosis on outcomes following TSA is limited. The objective of this study was to perform a retrospective multi-institutional database analysis to investigate the association between preoperative COVID-19 diagnosis and 60-day complications following TSA. We queried the TriNetX database using Current Procedural Terminology (CPT) and the International Classification of Diseases, Tenth Revision (ICD-10) codes for patients who underwent a TSA from January 1, 2018 to July 1, 2023. Patients were categorized by those who had and those who did not have a diagnosis of COVID-19 within 30 days prior to surgery. The cohorts were matched based on age, gender, ethnicity, race, and past medical history. Chi-square analysis was performed to determine the relationship between COVID-19 diagnosis and 60-day postoperative complications including pneumonia, sepsis, emergency department (ED) visit, hospital admission, mortality, periprosthetic fracture, superficial wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), acute myocardial infarction (MI), and revision surgery. The search results identified a total 63,768 patients who met study criteria. Of these patients, 7,118 (11.08%) were diagnosed with COVID-19 within 30 days prior to their TSA procedure. Propensity score matching resulted in 6,982 patients in each of the two cohorts. Patients with a recent COVID-19 diagnosis prior to surgery had 1.96 (P = 0.0005) times the odds of sepsis, 1.42 (P = 0.0032) times the odds of superficial wound infections, 1.42 (P < 0.0001) times the odds of DVT, 1.52 (P = 0.0001) times the odds of PE, 1.10 (P = 0.0249) and 1.79 (P < 0.0001) times the odds of ED visits and hospital admissions, respectively, and 3.10 (P < 0.0001) and 2.87 (P < 0.0001) times the odds of periprosthetic fracture and revision surgery within 60 days of TSA. Our study suggests an increased risk of sepsis, ED visits, hospital admissions, periprosthetic fracture, superficial wound infection, DVT, PE, and revision surgery in TSA patients with a recent COVID-19 diagnosis. There may be significant benefit to closer monitoring and greater preventive measures to reduce the occurrence of postoperative complications in this setting. In addition, patients may benefit from postponing elective TSA procedures in the setting of a recent COVID-19 infection.

Compliance with Centers for Medicare &amp; Medicaid Services (CMS) 2021 price transparency requirements among proton therapy centers.

e23034 Background: Since 2019, the Centers for Medicare &amp; Medicaid Services (CMS) has required hospitals to publish gross charges for all goods and services provided. In 2021, CMS amended this requirement to include publishing standard charge files, which include cash and payer-negotiated prices for all goods and services provided. This was enacted in an attempt to reduce healthcare prices by reducing information asymmetry and generating competition among both insurers and hospitals. Since complex proton therapy is one of the most expensive modalities of cancer treatment, we aimed to determine proton therapy center compliance with CMS price transparency requirements. Methods: We searched for online standard charge files for the 44 proton therapy centers in the United States. To assess compliance with the nine CMS price transparency criteria, we obtained prices for proton therapy using keyword searches and billing code 77525, the CPT code for the per fraction technical charge billed for complex proton treatment delivery. Results: Out of 44 operating proton therapy centers, 5 (11.4%) are free-standing private practice centers that are not affiliated with a hospital system, and thus not required to publish standard charge files per CMS policy. Of the 39 centers required to publish, 39 (100%) published their standard charge files free of charge with appropriately named files, thus meeting Criteria 1-3. Twenty-seven (69.2%) centers met Criteria 4 by including data on complex proton therapy (CPT code 77525) and Criteria 5a by including the gross charge for the service. One (2.6%) center partially met Criteria 4. Seventeen (43.6%) centers included negotiated prices for commercial insurers, thus meeting Criteria 5b, while 3 (7.7%) partially met this criterion. Twenty-two (56.4%) centers met Criteria 5c and 5d by including the deidentified minimum and maximum negotiated commercial prices, respectively. Twenty-six (66.7%) centers met Criteria 5e by listing the cash price for complex proton therapy, which is typically paid out-of-pocket by patients. One (2.6%) center partially met Criteria 5c-e. In total, 17 (43.6%) out of 39 proton therapy centers were in complete compliance with the 2021 CMS price transparency requirements. Conclusions: In summary, 17 out of 39 eligible proton centers were fully compliant with the 2021 CMS price transparency requirements in regard to complex proton radiation therapy. This suggests that deficiencies exist among hospital compliance and the CMS review process used to identify non-compliance. Future directions are aimed at expanding this analysis to include evaluation of proton center compliance with other billing codes, such as simple and intermediate proton treatment delivery. [Table: see text]

Post-Tonsillectomy Bleeding and Analgesic Use Before and After the FDA Boxed Warning Against Codeine.

The aim of this study was to investigate the trends in post-tonsillectomy analgesic utility and incidence of post-tonsillectomy hemorrhage before and after the 2013 FDA Boxed Warning against codeine use after pediatric tonsillectomy. A retrospective study was conducted using TriNetX. A search for patients up to 18 years from 2008 to 2022 within the US Collaborative Network identified 15,648,542 subjects. CPT and ICD-10 codes were used to identify children who experienced post-tonsillectomy hemorrhage within 14 days of a tonsillectomy. Analgesics given within 14 days of tonsillectomy were tabulated annually from 2008 to 2022, including codeine, ibuprofen, acetaminophen, oxycodone, ketorolac, and hydrocodone. Bleeding percentage and analgesic utility were grouped into events before and after 2013. Mean age at tonsillectomy was 5.6 years (SD = 3.0). Before 2013, the median percentage of children who experienced postoperative bleeding was 1.8% with 0.73% returning to the OR for bleeding control. After 2013, the median percentage of children who experienced postoperative bleeding was 2.4% (p = 0.029), and 0.99% returned to the OR (p = 0.008). Use of post-tonsillectomy codeine fell from 10.4% to 0.5% (p = 0.003) whereas ibuprofen rose from 2.0% to 63.9% (p = <0.001), acetaminophen from 42.8% to 77.2% (p = <0.001), ketorolac from 1.2% to 9.2% (p = <0.001), and oxycodone from 2.0% to 30.9% (p = <0.001). No change was detected in use of hydrocodone. Analgesics used post-tonsillectomy in children have changed since the FDA Boxed Warning against codeine. There has been a small but statistically significant increase in post-tonsillectomy bleeding. IV Laryngoscope, 2024.

Association of COVID-19 Vaccination With Changes in Smell and Taste.

Since the introduction of vaccines for severe acute respiratory syndrome coronavirus 2in the United States, there has been significant vaccine hesitancy, in part due to fear of adverse effects. We sought to investigate the rates of smell and taste changes after COVID-19 vaccination compared to other common vaccines. Our study cohort included individuals identified by Current Procedural Terminology code in the TriNetX database receiving the COVID-19 first series, COVID-19 booster, influenza, tetanus, diphtheria, pertussis (TDAP), or pneumococcal vaccines between December 15, 2020, and August 15, 2023. After 1:1 propensity score matching, postvaccination incidence of disturbance of smell and taste was significantly less likely after COVID-19 first series vaccine compared to influenza (odds ratios, OR: 0.27 [95% confidence interval, CI: 0.20-0.36]), TDAP (OR: 0.35 [95% CI: 0.26-0.47]), and pneumococcal vaccines (OR: 0.17 [95% CI: 0.09-0.32]). Similarly, incidence of disturbance of smell and taste was significantly less likely after COVID-19 booster vaccine compared to the influenza (OR: 0.60 [95% CI: 0.48-0.76]), TDAP (OR: 0.63 [95% CI: 0.47-0.85]), and pneumococcal vaccines (OR: 0.44 [95% CI: 0.28-0.68]). This study builds upon the literature demonstrating the safety of COVID-19 vaccination.

Factors associated with increased 30-day re-operation risk in anterior cruciate ligament reconstruction

BackgroundRevision surgery following isolated anterior cruciate ligament reconstruction (ACLR) has often focused on mid- to long-term revisions due to re-rupture, while short-term 30-day revision is a rare, but underappreciated entity. This study aims to characterize incidence and risk factors for reoperations following isolated ACLR. MethodsThis is a retrospective case-control analysis of the American College of Surgeons National Surgical Quality Improvement Program Database (NSQIP) database from 2005 to 2017. Current Procedural Terminology codes were used to identify elective isolated ACLR patients. Patients undergoing reoperations were analyzed using bivariate analysis against their respective perioperative variables. Multivariate stepwise logistic regression was used to identify independent risk factors for reoperations after ACLR. Results12,790 patients were included in the study. 37.0% of patients were female. Mean age was 32.2+/-10.7 years and mean body mass index (BMI) was 27.8+/-6.5 kg/m2, with 28.9% of patients with BMI > 30. The most frequently reported reason for reoperation based on CPT and ICD-9/10 codes was postoperative infection (0.5%). Overall reoperation rate was approximately 0.5%. Multivariate analysis identified operative time >1.5 h (OR 2.6 [95% CI; 1.5–4.4]), dependent functional status (OR 14.0 [1.4–141.6]), and adjunctive anesthesia (OR 2.4 [95% CI; 1.1–5.0]) as independent risk factors for reoperation. Female sex was a protective factor against reoperations (OR 0.6 [0.3–0.98]). ConclusionPrimary, isolated ACLR is associated with extremely low rates of short-term reoperations. Operative time >1.5 h, dependent functional status, and adjunctive anesthesia were independent risk factors for reoperation and female sex was a protective factor against reoperation. Level of EvidenceLevel III. Retrospective cohort study.

Insulin Dependence Negatively Impacts Outcomes in Anterior Cervical Discectomy with Fusions: A Ten-Year Retrospective Analysis

Background ContextAlthough anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing diabetic patient population, there is a paucity of literature focusing on insulin-dependence as a risk-factor for post-operative ACDF complications. PurposeTo evaluate the differential impact of insulin dependence on perioperative outcomes including total length of stay, surgical, and medical complications within thirty days following ACDF. Study Design/SettingA retrospective cohort, large multicenter database study. Patient SampleThe American College of Surgeons National Surgical Quality Improvement Program database was queried to retrospectively identify patients who had undergone ACDF between 2011 and 2021 using the Current Procedural Terminology code 22551. Outcome MeasuresPerioperative surgical and medical complications. MethodsThe study population was divided into three groups 1) insulin-dependent diabetes mellitus (IDDM), 2) insulin-independent diabetes mellitus (NIDDM), and 3) no diabetes mellitus (non-DM). One-way analysis of variance for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the three groups. Multivariable logistic regression analysis assessed the effect of diabetes mellitus status on post-operative medical and surgical outcomes. ResultsA total of 85,758 ACDF procedures were identified between 2011 and 2021, of which 5,178 were IDDM, 9,652 were NIDDM, and 70,982 were non-DM. The rates of surgical and medical complication varied between the three groups. IDDM patients had the highest rates of at least one medical complication (6.1%). Only IDDM increased the risk for medical complications (OR: 1.320, 95% CI [1.144-1.518]) and extended hospital length of stay (LOS) (OR: 1.244, 95% CI [1.071-1.441]) following a multivariate logistic regression analysis. ConclusionPatients with IDDM were at an increased risk for postoperative medical complications and extended hospital LOS. Personalized postoperative management, guided by risk assessment is indicated for this population. These findings can be used to improve risk stratification and informed consent for DM patients who are insulin dependent.

Impact of Anti-Discrimination Legislation on Access to Gender-affirming Care: A Commercial Claims Analysis

ObjectivesTo examine the temporal relationship between the anti-discrimination rules of the Affordable Care Act, which took full effect in 2017, and the incidence of commercial claims for gender-affirming care, as well as cost sharing for these services. MethodsWe used a previously described algorithm to define a cohort of gender diverse adults in the MarketScan® Commercial Claims and Encounters Database. Claims for gender-affirming medical and surgical care were identified using International Classification of Diseases and Current Procedural Terminology codes plus pharmacy data; the annual incidence of surgical claims was calculated. Interrupted time series analyses were used to evaluate the temporal relationship between claims and anti-discrimination legislation. Claims data was also used to evaluate the patient contribution towards services. ResultsThere were 70,733 gender diverse adults included in the study and 36,702 (51.9%) of them filed claims for gender-affirming care. The incidence of persons with claims for gender-affirming surgery increased from 0.002% in 2009 to 0.012% in 2021. Interrupted time series analyses demonstrated a greater year-to-year increase for claims after anti-discrimination policy influences took effect. This change was greatest for transmasculine chest procedures. The median lifetime net payment for gender-affirming surgery was $12,429.10 and cost sharing was $1,019.20 (8.6%). ConclusionsCommercial claims for gender-affirming surgery increased temporally with respect to implementation of anti-discrimination legislation and cost-sharing was reasonably low. However, many gender diverse persons did not have claims for gender-affirming care, which may indicate continued out-of-pocket payment for these services.

Cardiovascular risk in anti-VEGF treatment of neovascular age-related macular degeneration

ObjectiveAssess 5-year all-cause mortality (ACM), hemorrhagic stroke, ischemic stroke, and myocardial infarction (MI) risks in nAMD patients receiving anti-VEGF injections compared with controls. DesignPopulation-based retrospective cohort study using a U.S. federated health research network, containing de-identified data of 96 million patients from 1/1/2003 to 3/6/2023. ParticipantsnAMD Patients with anti-VEGF injections. Controls included nAMD patients without anti-VEGF injections, non-exudative AMD patients, and patients without AMD. MethodsPatients were identified using nAMD ICD-10 and anti-VEGF CPT codes and matched for age, sex, and comorbidities. Five-year relative risk of ACM (RR1), hemorrhagic stroke (RR2), ischemic stroke (RR3), and MI (RR4) in nAMD patients receiving anti-VEGF injections were calculated. ResultsA total of 27,609 nAMD patients (mean diagnosis age [SD], [78.2 (10.3)]) received anti-VEGF injections; 769 nAMD patients without injections (75.8 [12.2]), 27,599 non-exudative AMD patients (78.2 [10.3]), and 21,902 no-AMD patients (76.1 [10.5]) were identified. After matching, nAMD patients receiving injections did not show increased risk versus nAMD patients without injections (RR1, 0.66; 95% CI [0.53, 0.82]), (RR2, 1.00 [0.42, 2.38]), (RR3, 1.70 [0.92,3.13]), (RR4, 0.63 [0.33, 1.18]). No increased risk was found compared to non-exudative AMD patients (RR1, 0.99 [0.95, 1.03]), (RR2, 0.94 [0.83,1.07]), (RR3, 1.04 [0.96, 1.12]), (RR4, 0.99 [0.91, 1.08]). Increased risk for ACM was observed versus no-AMD patients (RR1, 1.21 [1.15, 1.27]), but no other differences were found (RR2, 0.81 [0.70, 0.93]), (RR3, 1.00 [0.92, 1.09]), (RR4, 0.986 [0.90, 1.09]). ConclusionAnti-VEGF injections were not associated with major cardiovascular events in nAMD patients over 5 years.

Comparison of standard charges for complex proton therapy among Medicare Prospective Payment System (PPS) –exempt and –non-exempt cancer centers.

e23039 Background: Proton therapy is one of the most expensive treatment modalities offered to cancer patients, and only 44 proton therapy centers are operational in the U.S. Of those, 5 are Medicare Prospective Payment System (PPS)-exempt and are reimbursed based on their reported costs rather than predetermined prices. These PPS-exempt cancer centers set their adjusted payment rates to reflect the expense required for providing specialized care. We hypothesized that PPS-exempt centers would have higher rates for complex proton therapy delivery compared to non-exempt centers. Methods: We obtained online standard charge files for 44 proton therapy centers in the U.S. We used the CPT code 77525, the per fraction technical charge billed for complex proton treatment delivery, to extract the gross price (base charge for service), de-identified minimum and maximum negotiated price (lowest/highest charge negotiated with third-party payers), and cash price (charge for cash payment of service) per fraction of complex proton therapy. Prices were compared between PPS-exempt and non-exempt proton therapy centers using Wilcoxon/Kruskal Wallis test with a p-value &lt; 0.05 considered significant. Results: Of the 44 proton therapy centers, 39 (88.6%) had publicly available standard charge files, and 5 (11.4%) are private practice not required to provide a standard charge file. Five of the 39 (12.8%) centers are PPS-exempt, and the remaining 34 (87.2%) are PPS non-exempt. Four (80%) PPS-exempt centers had their gross price, minimum and maximum negotiated price, and cash price available in their standard charge file for CPT 77525, while 23 (67.6%) PPS non-exempt centers had their gross price and cash price listed and 19 (55.9%) had the minimum and maximum price available. The median gross charge per fraction for complex proton treatment delivery was $8,035.25 (IQR $7,022.00-$9,427.50) at PPS-exempt versus $6,434.00 (IQR $5,213.00-$12,350.00) at PPS non-exempt centers. The median minimum price was $656.47 (IQR $178.04-$1,353.23) at PPS-exempt versus $1,294.70 (IQR $734.20-$2,267.46) at PPS non-exempt centers. The median maximum price was $8,120.10 (IQR $5,576.40-$11,529.86) at PPS-exempt versus $5,814.00 (IQR $4,830.00-$9,524.70) at PPS non-exempt centers. The median cash price was $5,360.65 (IQR $2,979.51-$6,897.08) at PPS-exempt versus $4,170.40 (IQR $2,828.00-$5,640.00) at PPS non-exempt centers. Conclusions: In summary, 80% of PPS-exempt and 67.6% of PPS non-exempt centers had publicly available standard charge files. Median charges for PPS-exempt centers are higher for gross charge, maximum price, and cash price, however did not meet statistical significance. [Table: see text]

Capturing anatomy in computed tomography scans for genital pathology.

In this cross-sectional study,we aimed to characterize how frequently the anatomy of interest (AOI) was excluded when evaluating genital pathology using the current CT pelvis protocol recommended by the American College of Radiology and evaluate how AOI exclusion affects patient management. We retrospectively reviewed medical records, using diagnosis and CPT codes, of patients admitted with genital pathology who obtained a CT scan at our institution from July 1, 2020-April 30, 2023. Baseline patient demographics were included. Data about each index CT scan (scan obtained at our institution) were recorded and assessed for exclusion of the AOI. Statistical analysis was performed to determine the rate of AOI exclusion and to compare patient management between patients with AOI excluded versus those without AOI exclusion. 113 presentations for genital pathology included an index CT scan and were included for analysis. Patients were primarily men (98%) with a mean age of 53.1 years (SD 13.9). The most common diagnoses were Fournier's gangrene (35%), scrotal abscess (22%) and unspecified infection (19%). 26/113 scans (23%) did not capture the entire AOI. When the AOI was missed during the index scan, there was a higher rate of obtaining additional scans (38% vs. 21%), but a similar rate of intervention (77% vs. 63%) when compared to index scans that captured the entire AOI.35 scans (31%) had protocol-extending instructions;index scans that captured the entire AOI were more likely to have specific protocol-extending instructions(38% vs. 8% p < 0.01). Creating a specific CT protocol for genital pathology could decrease the amount of inappropriate irradiation and improve AOI capture rates without relying on specific request for protocol deviation.

The Effect of Extracorporeal Membrane Oxygenation in Patients With Multiple Orthopaedic Injuries.

Extracorporeal membrane oxygenation (ECMO) plays a vital role in providing life support for patients with reversible cardiac or respiratory failure. Given the high rate of complications and difficulties associated with caring for ECMO patients, the goal of this study was to compare outcomes of orthopaedic surgery in polytrauma patients who received ECMO with similar patients who have not. This will help elucidate the timing and type of fixation that should be considered in patients on ECMO. A retrospective cohort was collected from the electronic medical record of two level I trauma centers over an 8-year period (2015 to 2022) using Current Procedural Terminology codes. Patients were matched with a similar counterpart not requiring ECMO based on sex, age, American Society of Anesthesiologists score, body mass index, injury severity score, and fracture characteristics. Outcomes measured included length of stay, number of revisions, time to definitive fixation, infection, amputation, revision surgery to promote bone healing, implant failure, bleeding requiring return to the operating room, and mortality. Thirty-two patients comprised our ECMO cohort with a patient-matched control group. The ECMO cohort had an increased length of stay (40 versus 17.5 days, P = 0.001), number of amputations (7 versus 0, P = 0.011), and mortality rate (19% versus 0%, P = 0.024). When comparing patients placed on ECMO before definitive fixation and after definitive fixation, the group placed on ECMO before definitive fixation had significantly longer time to definitive fixation than the group placed on ECMO after fixation (14 versus 2.0 days, P < 0.001). ECMO is a lifesaving measure for trauma patients with cardiopulmonary issues but can complicate fracture care. Although it is not associated with an increase in revision surgery rates, ECMO was associated with prolonged hospital stay and delays in definitive fracture surgery when initiated before definitive fixation. III.

Replicating Current Procedural Terminology code assignment of rhinology operative notes using machine learning

AbstractObjectivesDocumentation and billing are important and time‐consuming parts of an otolaryngologist's work. Given advancements in machine learning (ML), we evaluated the ability of ML algorithms to use operative notes to classify rhinology procedures by Current Procedural Terminology (CPT®) code. We aimed to assess the potential for ML to replicate rhinologists' completion of their administrative tasks.Study DesignRetrospective cohort study.SettingUrban tertiary hospital.MethodsA total of 594 operative notes from rhinological procedures across six CPT codes performed from 3/2017 to 4/2022 were collected from 22 otolaryngologists. Text was preprocessed and then vectorized using CountVectorizer (CV), term frequency‐inverse document frequency, and Word2Vec. The Decision Tree, Support Vector Machine, Logistic Regression and Naïve Bayes (NB) algorithms were used to train and test models on operative notes. Model‐classified CPT codes were compared to codes assigned by operating surgeons. Model performance was evaluated by area under the receiver operating characteristic curve (ROC‐AUC), precision, recall, and F1‐score.ResultsPerformance varied across vectorizers and ML algorithms. Across all performance metrics, CV and NB was most overall the best combination of vectorizer and ML algorithm across CPT codes and produced the single best AUC, 0.984.ConclusionsIn otolaryngology applications, the performance of basic ML algorithms varies depending on the context in which they are used. All algorithms demonstrated their ability to classify CPT codes well as well as the potential for using ML to replicate rhinologists' completion of their administrative tasks.

Impact of a History of COVID-19 Infection on Postoperative Outcomes for Free Flap Patients.

Objectives: This study examines the impact of a history of coronavirus disease 2019 (COVID-19) infection on patients' outcomes after microvascular free flap surgery and to examine the recommendations on when to perform microvascular surgery after a COVID-19 infection. Methods: A retrospective chart review using the TriNetX database was completed on March 5, 2023. Two cohorts were created: (1) patients who had a positive COVID-19 diagnosis within 1 year before microvascular free flap surgery, and (2) patients with no history of COVID-19 who underwent free flap surgery. Current Procedural Terminology codes were used to identify procedures and International Classification of Diseases-10 codes were used to identify outcomes. Results: There was a total of 31,505 patients who underwent microvascular free flap surgery, 500 of whom had a diagnosis of COVID-19 within 1 year of free flap surgery and 31,005 without history of COVID-19. There was increased risk of sepsis, surgical site infection (SSI), generalized infection, gangrene, dehiscence, hematoma, seroma, intensive care unit admission, and death in patients who underwent free flap surgery within a year of COVID-19 infection. After propensity score matching, there were 498 patients in both groups. Increased risk remained for SSI and gangrene in patients with a history of COVID-19 after matching. When comparing surgical timing between 0 to 2 months after COVID-19 infection and 2 to 12 months after COVID-19 infection, there were no significant differences between groups. Conclusions: After propensity score matching, patients with a history of COVID-19 infection were at increased risk for SSI and gangrene. However, many flap surgeries cannot be delayed. This study may help counsel patients regarding the possible complications after surgery and provide a heightened awareness in the surgical team of a possible increase in infectious complications in this population. Additional studies should investigate optimal timing of free flap surgery after COVID-19 infection and ways to mitigate the risk of infectious complications.