Current Procedural Technology Research Articles

Carbon Footprint of Open Carpal Tunnel Release Surgery Performed in the Procedure Room Versus Operating Room Setting

Environmental sustainability is an important issue in health care because of large amounts of greenhouse gases attributable to hospitals. The operating room has been highlighted as one of the highest contributors, prompting several initiatives by organizations focused on the care of hand and upper extremity conditions. This study aimed to quantify and compare the carbon footprint of a common hand surgery in two different surgical settings, the procedure room (PR) and operating room. We hypothesized that open carpal tunnel release (oCTR) will generate a greater environmental impact in the operating room than in the PR. This was a retrospective review of oCTRs performed at a tertiary care medical center. Current procedural technology codes isolated a single cohort of patients who underwent bilateral oCTR, one side performed in the PR and the contralateral side in the operating room. Current published emission conversions were used to calculate carbon footprint at our institution based on energy expenditure necessary for the creation and disposal of waste and sterilization of surgical equipment. Surgery time was combined with heating, ventilation and air conditioning/lighting energy consumption to estimate facility emissions. Fourteen patients had bilateral oCTR surgery performed in both settings. Open CTR performed in the operating room generated 3.7 kg more solid waste than when performed in the PR. In total, emissions from oCTR performed in the operating room generated 32.4 kg CO2, whereas oCTR in the PR emitted 13.0 kg CO2 per surgery. Performing a common hand procedure (oCTR) is more environmentally sustainable in the PR than in the operating room, with a 60% reduction in carbon footprint. Greater effort should be made to perform surgery in the PR instead of the operating room in appropriately indicated patients. Surgical sets should be evaluated for the necessity of included equipment and unnecessary waste.

No Increased Risk of Cerebrovascular Accident With Beach-Chair Versus Lateral Positioning for Shoulder Arthroscopy

To assess the incidence of adverse cerebrovascular events following shoulder arthroscopy in the beach-chair position when compared with the lateral position. Records of 5 shoulder surgeons were searched using Current Procedural Technology codes to identify patients who underwent arthroscopic shoulder surgery in both the beach-chair and lateral positions between 2015 and 2020. Using both Current Procedural Technology codes for cerebrovascular accident (CVA) imaging as well as the International Classification of Diseases, Tenth Revision, codes for CVA and late neurologic sequela, patient charts were analyzed in the 30-day postoperative period. The anesthesiology record also was queried for data regarding the blood pressure management intraoperatively, recording mean arterial pressures (MAPs), and vasopressor administration. Patient demographics, comorbidities, and complications were compared between the 2 cohorts using the Student 2-tailed t-test for continuous variables and χ2 analysis for categorical variables. Significance was set at P < .05. There were 711 patients included in the analysis, with 471 in the beach-chair cohort and 240 in the lateral cohort. Baseline demographics were similar between groups, except for age and American Society of Anesthesiologists physical status classification, with the lateral group being significantly younger (P < .001) and lower American Society of Anesthesiologists physical status classification (P= .001) than the beach-chair group. Mean body mass index, history of CVA, transient ischemic attack, hypertension, and peripheral vascular disease were not significantly different. There were no documented CVAs in either cohort. There was no significant difference in the number of postoperative radiologic scans to evaluate for CVA (P= .77) or neurologic sequelae (P= .48) between groups. The beach-chair cohort had fewer instances of MAP <65 mm Hg, greater mean minimum MAP, but a greater percentage of patients who received blood pressure support. There were no significant differences identified in the incidence of CVA between patients undergoing arthroscopic shoulder surgery in the beach-chair and lateral positions. Level III, retrospective cohort study.

Risk of hysterectomy at the time of myomectomy: an underestimated surgical risk

To evaluate the risk of hysterectomy at the time of myomectomy, and the associated 30-day postoperative morbidity. Cohort study. Patients who underwent myomectomies identified from the American College of Surgeons' National Surgical Quality Improvement Program from 2010-2021. Current Procedural Technology codes were used to identify myomectomies performed with or without concurrent hysterectomy. Pre-operative characteristics and morbidity outcomes were obtained. Univariate analysis was performed using Chi-Square and Fisher Exact as appropriate. Multivariable logistic regression reported risk factors for individuals undergoing hysterectomy at the time of myomectomy. P values <0.05 were considered statistically significant. A total of 13,213 individuals had a myomectomy. 399 (3.0%) had a hysterectomy performed during myomectomy. Concurrent hysterectomy was most frequently performed (7.1%) with laparoscopic approach, followed by 3.2% and 1.9% with abdominal and hysteroscopic approach, respectively. Age ≥43 years, obesity class II and higher, American Society of Anesthesiologists (ASA) class greater than II, tobacco use, longer operative time (>85 min) and laparoscopic approach significantly elevated the risk of hysterectomy. When adjusting for age, body mass index, race, ASA class, case type, surgical approach, operative time, preoperative transfusion, preoperative hematocrit, and high fibroid burden, increased odds of hysterectomy was noted for White race, longer operative time, ASA class III or higher, obesity, laparoscopic approach and low fibroid burden. Patients who underwent concurrent hysterectomy had longer median length of hospital stay (2 vs 1 day), longer median operative time (161 vs 126 minutes), increased intraoperative/postoperative blood transfusions (14.5 vs 9.0%), higher organ space surgical site infections (1.5 vs 0.5%), and return to surgery (2.0 vs 0.7%) compared to patients who did not (p< 0.05). The risk of a major complication within 30 days of myomectomy was increased for patients who underwent concurrent hysterectomy after adjusting for relevant confounders (adjusted OR 2.4, 95% CI 1.8-3.2). Risk of hysterectomy during a myomectomy is higher than previously reported. Patient age ≥43 years, obesity, White race, ASA class III or higher, longer operative time, and laparoscopic approach were associated with higher odds of hysterectomy. Identification of patients with these risk factors can aid in patient counselling and surgical planning, which may help reduce the unexpectedly high rates of hysterectomy at planned myomectomy.

Emergency thoracic surgery patients have worse risk-adjusted outcomes than non-emergency patients

BackgroundOutcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations. MethodsWe retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005–2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with “emergency status” as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors. ResultsOf 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery. ConclusionPatients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations.

(493) Utilization of Intracavernosal Injection and Penile Ultrasound in the Evaluation of Erectile Dysfunction and Peyronie’s Disease

Abstract Introduction Intracavernosal injections (ICI) and penile duplex Doppler ultrasound (DDUS) play a diagnostic role for patients with erectile dysfunction (ED) and Peyronie’s disease (PD). They can help to identify vascular and anatomical changes that may guide medical and surgical management; however, contemporary utilization rates of ICI and penile DDUS have not recently been described. Here we use a multicenter database to determine utilization of ICI and penile DDUS in patients with ED and PD. Objective To evaluate the rates of ICI and penile DDUS in patients with ED and PD using a global database. Methods TriNetX is a research network of real-time data from 58 Healthcare Organizations globally. Using the International Classification of Diseases Tenth Edition (ICD-10) codes, we queried the network for adult men with ED (N52) being medically treated with phosphodiesterase (PDE)-5 inhibitors from 2002 - 2022. This included sildenafil, tadalafil, vardenafil, and avanafil. Current Procedural Technology (CPT) codes were utilized to identify patients who received penile DDUS (93980, 93981) and penile prosthesis (54400, 54401, 54405). ICD-10 codes were utilized to query the network for those with PD (N48.6) from 2002 – 2022. We then used CPT codes to search within this cohort for those who had ICI (54235) excluding patients that also had penile DDUS (93980, 93981). We separately queried for patients that had penile DDUS (93980, 93981). Finally, we queried for patient who received either evaluation method and had injection therapy (54200), penile plication (54360), or plaque excision +/− grafting (PEG) (54110, 54111, 54112). The analysis was run on June 30, 2022. Results The cohort with ED on a PDE-5 inhibitor in the TriNetX database included 613,323 patients. The cohort had a mean age of 63 +/− 13 years and racial demographics of 18% black and 70% white. 8,540 patients (1.4%) had a penile DDUS and 868 (0.1%) went on to penile prosthesis (Figure 1A). A second study cohort included 46,743 patients with Peyronie’s disease with a mean age of 62 +/− 13 years and racial demographics of 8% black and 73% white. ICI was performed in 2,960 (6.3%) PD patients: 568 (1.2%) then underwent injection therapy, 1,128 (2.4%) penile plication, and 142 (0.3%) PEG (Figure 1B). Penile DDUS was performed in 4,972 (10.7%) patients with PD: 955 (2.0%) then underwent injection treatment, 474 (1.0%) penile plication, and 255 (0.5%) PEG (Figure 1B). Conclusions For ED, penile DDUS is used in a low percentage of evaluations. For PD, penile DDUS is used more commonly than ICI only. After evaluation with penile DDUS, the most common therapy is injection. After an evaluation with ICI only, the most common therapy is penile plication. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast.

Cost and Return on Investment of a Team-Based Palliative Care Program for Parkinson Disease.

Implementation of palliative care (PC) in neurology settings may improve symptom control and quality of life and reduce acute care admissions. The benefits of team-based PC for patients with Parkinson disease have been established through rigorous evidence standards including randomized controlled trials. However, evidence on implementation costs and return on investment (ROI) is unknown and may guide other providers and systems considering this model of care. We applied time-driven activity-based costing with reimbursable visits calculated using Medicare reimbursement rates in Colorado and current procedural technology codes to 2 outpatient clinics at the University of Colorado Hospital: neurology PC and movement disorders. Per-patient ROI was calculated as the ratio of the incremental difference in financial revenues divided by the incremental difference in investment to expand PC services. The cost per new patient was $154 and $98 for neuropalliative and movement disorders clinics, respectively. Established patient visit costs were $82 and $41 for the neuropalliative care and movement disorders clinics, respectively. The neurology PC clinic had per-patient revenue for new and established visits of $297 and $147, respectively, compared with $203 and $141 for new and established visits, respectively, at the comparator clinic. Based on our assumptions, for every $1 invested in expanding PC services, a projected $1.68 will be recouped by the hospital system for new patient visits, and $0.13 will be recouped for established patient visits. These amounts are context dependent, and a calculator was created to allow other systems to estimate costs and ROI. Our results suggest that in an academic medical setting, both neurology PC and movement disorders clinics provided increased revenue to the health system. Opportunities to improve ROI include efficient allocation of personnel to new and established visits, expanding telemedicine, and other cost offsets for complex patients not estimated in this analysis. ROI may also be greater in health systems that benefit from cost savings such as accountable care organizations. Our approach may be applied to other novel care models. Future research efforts will focus on estimating the continued sustainability of this innovative outpatient care model.

Impact of frailty on 30-day death, stroke, or myocardial infarction in severe carotid stenosis: Endarterectomy versus stenting

ObjectiveCarotid endarterectomy (CEA) and carotid artery stenting (CAS) are used for stroke prevention in patients with carotid stenosis. It remains unclear which surgical approach produces the best outcomes for elderly and frail patients. We investigated the impact of age and frailty on 30-day combined outcomes of death, stroke, and myocardial infarction (MI) in patients who received CEA or CAS for severe symptomatic carotid stenosis. MethodsA retrospective analysis of the NSQIP database identified patients with severe carotid stenosis who received either CEA or CAS between 2015 and 2020 for study inclusion. Frailty was measured by the Modified Frailty Index 5-item (mFI-5), which stratified patients as non-frail (score=0), pre-frail (=1), frail (=2), or severely frail (=3). Age was subdivided into 65 years or younger, 66–84 years, and 85 years or older. The primary outcome was 30-day combined rates of death, stroke, and MI, as analyzed by multivariate logistic regression analyses, adjusted for sex, body mass index, smoking status, anesthetic type, and contralateral carotid stenosis. ResultsA total of 18,074 patients were included in analyses, of which 14,428 received CEA (80 %) and 3646 received CAS (20 %). Mean age was 70.8 and 70.5 years for CEA and CAS, respectively. The rate of combined outcome of death, stroke or MI at 30 days was significantly higher in CEA (3.3 %) than CAS (1.3 %) (χ2 =41.90, p < 0.001). Increasing frailty was associated with higher rates of the primary outcome in CEA patients (χ2 =30.26, p < 0.001) but not CAS (χ2 =6.95, p = 0.07). A 6-component risk score was constructed for the combined outcomes in CEA, which predicted adverse events with 80.7 % accuracy. ConclusionsAge and frailty have a significant impact on the risk of death, stroke, and MI at 30 days in patients with severe, symptomatic carotid stenosis who receive CEA, but not CAS. Non-standard Abbreviations and AcronymsBody mass index (BMI), carotid artery stenting (CAS), carotid endarterectomy (CEA), current procedural technology (CPT), myocardial infarction (MI), modified Frailty Index 5-item (mFI-5), American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

A-224 Relatively Undervalued: Comparing the Work Relative Value Units of Neuropsychological Evaluation to Other Services

Abstract Objective: The work relative value units (wRVUs) assigned to current procedural technology (CPT) codes reflect the time, technical skill, effort, judgment, and stress involved in the procedures. This project compared the work RVUs for CPT codes used by neuropsychologists to codes used by other healthcare providers. Method: CPT codes were collected for evaluation and management (E&amp;M) services (99202 to 99215), psychological evaluation (PE; 90791, 96130/1, 96136/7, 90785), psychotherapy (THER; 90791, 90832 to 90837, 90785), and neuropsychological evaluation (NPE; 96116, 96132/3, 96136/7). The CMS physician fee schedule look-up tool was used to gather the wRVUs for each CPT code. Results: E&amp;M wRVUs vary by complexity from straightforward (0.7-0.93) to highly complex (2.8-3.5) cases. Per unit wRVUs showed a wide range in the other procedure groups: PE (0.45-3.84), THER (1.7-3.84), and NPE (0.45-2.56). PE and NPE codes are comparable except for greater wRVUs for the interview (3.84 versus 1.86). With the complexity modifier, PE and THER wRVUs increase (2.03-4.17). Conclusions: E&amp;M code wRVUs increase with case complexity reflecting greater demands on time, skill, effort, and judgment. Similarly, a modifier to PE and THER codes captures additional effort required for complex cases. In contrast, NPE codes lack a complexity modifier, and NPE wRVUs are lower than those of THER codes, which can be billed by master’s level therapists in many states. It is unclear why wRVUs for NPE are not higher than those for PE given the greater training requirements in neuropsychology and the higher level of specialized knowledge, effort, and technical complexity involved in competent NPE.

Trends in Surgical Approach for Single-Level Lumbar Fusion Over the Past Decade.

Retrospective Comparative Study. The purpose of this study was to characterize trends in surgical approach for single-level lumbar fusion over the past decade. The number of elective lumbar fusion cases performed is increasing annually. Several different surgical approaches exist for lumbar spinal fusion including novel anterior approaches developed in recent years. With ongoing innovation, trends in the utilization of common surgical approaches in recent years are unclear. A retrospective cohort study was conducted using the PearlDiver database (Fort Wayne, IN). Patients undergoing single-level lumbar fusion between 2010 and 2019 were identified using Current Procedural Technology codes and divided into 4 mutually exclusive cohorts based on surgical approach: (1) anterior-only, (2) anterior approach with posterior instrumentation, (3) posterolateral, and (4) posterior-only interbody. Trend analyses of surgical approach utilization over the last decade were performed with the Cochran-Armitage test to evaluate the 2-tailed null hypothesis that utilization of each surgical approach for single-level lumbar fusion remained constant. A total of 53,234 patients met inclusion criteria and were stratified into 4 cohorts: anterior-only (n=5104), anterior with posterior instrumentation (n=23,515), posterolateral (n=5525), and posterior-only interbody (n=19,090). Trend analysis revealed the utilization of a posterior-only interbody approach significantly decreased from 36.7% to 29.2% ( P <0.001), whereas the utilization of a combined anterior and posterior approach significantly increased from 45.8% to 50.4% ( P <0.001). The utilization of an anterior-only approach also significantly increased from 7.9% to 10.5% ( P <0.001). Utilization of anterior-only and anterior with posterior instrumentation approaches for single-level lumbar fusion have been significantly increasing over the past decade while use of posterior-only interbody approach trended significantly downward. These data may be particularly useful for trainees and spine surgeons as new techniques and technology become available. Level III-retrospective cohort study.

Endoscopy in Infants With Gastrointestinal Bleeding Has Limited Diagnostic or Therapeutic Benefit.

Pediatric gastroenterologists are often consulted to perform diagnostic and therapeutic endoscopy in infants with gastrointestinal bleeding (GIB). The value of endoscopy and risk of complications in this population are not well characterized. We aimed to describe findings and outcomes of infants with GIB who undergo endoscopy. Retrospective, single-center, cohort study of hospitalized infants ≤12 months who underwent esophagogastroduodenoscopy (EGD) and/or colonoscopy/flexible sigmoidoscopy (COL) for GIB. Current procedural technology codes, international classification of diseases codes, and quality control logs identified infants. Fifty-six infants were identified from 2008 to 2019 (51.8% female; mean age 161.6 days). Seven endoscopies identified sources of GIB: gastric ulcers, a duodenal ulcer, gastric angiodysplasia, esophageal varices, and an anastomotic ulcer. Three infants underwent therapeutic interventions of banding/sclerotherapy of esophageal varices and triamcinolone injection of an anastomotic ulcer. Six infants underwent abdominal surgery for GIB or suspected intestinal perforation after endoscopy, where a gastric perforation, jejunal perforation at an anastomotic stricture, necrotizing enterocolitis totalis with perforation, Meckel's diverticulum, and a duodenal ulcer were identified. No source of bleeding was identified surgically in 1 infant with GIB. Respiratory failure, use of vasopressors or octreotide, administration of blood products, and high blood urea nitrogen were associated with increased likelihood of requiring surgery ( P &lt; 0.05 for all). There was limited utility to performing endoscopy in infants ≤12 months old with clinical GIB. Endoscopy in these sick infants carries risk, and 3 infants in this series presented with a gastrointestinal (GI) perforation shortly after the procedure. These limitations and risks should influence clinical decision-making regarding endoscopy in infants with GIB.

Price Transparency for Primary Hip & Knee Arthroplasty: An Overview of the Top 50 US News and World Report Orthopedic Hospitals

BackgroundThe Centers for Medicare and Medicaid Services (CMS) has mandated all hospitals to publish the charges of 300 common procedures to provide price transparency. The aims of our study are to evaluate 50 top orthopedic hospitals to determine compliance with this mandate and to assess the ease of finding cost information for arthroplasty procedures. MethodsThe websites of the top 50 US News and World Report (USNWR) orthopedic hospitals were searched to find publicly accessible procedural charges. Data included the number of clicks to locate pricing documents, number of files provided, and number of data rows pertaining to arthroplasty. Charge data was queried based on Diagnosis related group (DRG) codes (469, 470), Current Procedural Technology (CPT) codes (27130, 27477), and keyword searches (“arthroplasty”, “total hip”, and “total knee”). ResultsForty-four (88%) of the top 50 USNWR Orthopedic institutions had publicly accessible files containing cost information. Thirty three of the 44 institutions provided results with DRG search while less than 10 institutions used CPT and keyword searches. There was an average of 226,190 (range 304-1,121,876) rows of data per file. Average charges varied depending on the use of DRG, CPT or keyword searches ($6,663-$117,072). ConclusionThe majority of compliant hospitals published large data files requiring the use of DRG codes to find cost information with extreme variation in resultant charges provided. These findings underscore the lack of direct patient benefit afforded by the current mandate, as pricing determinations require expert knowledge in medical coding and have a high variability in the reported charges.

Risk of Total Wrist Arthrodesis Following Proximal Row Carpectomy: An Analysis of 1,070 Patients

Proximal row carpectomy (PRC) is a motion-sparing procedure with good patient-reported and clinical outcomes. Although some studies have investigated the risk of conversion to total wrist arthrodesis (TWA) after PRC, additional larger studies evaluating the specific risk factors that lead to failure are required. This study aimed to investigate the patient and procedure factors that are associated with increased risk for conversion to TWA in a large cohort of patients who underwent PRC. The current procedural technology codes identified patients in a National Veteran's Health database undergoing a PRC over a 26-year period. Risk factors of interest comprised age, posterior interosseous nerve neurectomy, wrist arthritis pattern, bilateral surgery, smoking, comorbidities, and preoperative opioid use. The primary outcome was the rate of conversion to TWA. Cox proportional hazard regression was used to create hazard ratios of selected factors for reoperation. There were 1,070 PRCs performed, with a mean follow-up of 79.8 ± 59.6 months. A total of 5.3% (57/1,070) wrists underwent conversion to TWA. Younger age at the time of PRC (<50 years) significantly increased the risk of TWA (hazard ratio, 3.8; 95% confidence interval, 2.2-6.6). With every 1-year increase in age, there was a reduction of 4% (hazard ratio, 0.96; 95% confidence interval: 0.94-0.98) in the hazard of conversion to TWA. No other factors, including concomitant posterior interosseous nerve neurectomy or bilateral PRC, increased the risk of conversion to TWA. Proximal row carpectomy is a motion-preserving salvage procedure with a low rate of conversion to wrist arthrodesis. Younger patient age increases the risk of conversion to arthrodesis, whereas posterior interosseous nerve neurectomy, bilateral PRCs, and comorbidity status do not appear to have an impact on the risk of arthrodesis. Prognostic II.

117EMF Trends in High-Intensity Billing and Visit Complexity of Treat-and-Release Emergency Department Visits in the US, 2006-2018

To characterize the number of treat-and-release ED visits in the US from 2006 to 2018 by their physician services evaluation and management codes (level of service), and to characterize how risk-adjusted likelihood of high-intensity billing in 2018 compares to 2006. This is an observational analysis of the Nationwide Emergency Department Sample from the AHRQ Healthcare Cost and Utilization Project in 2006 and 2018. We included all treat-and-release ED visits (not resulting in admission to the same hospital) for adult patients, excluding visits with disposition against medical advice, left without being seen, or death in ED. Current Procedural Technology (CPT) codes for these visits were available for evaluation and management codes level of service. Consistent with prior work, we defined ED visits with level of service 5 (CPT 99285) or critical care (CPT 99291/99292) as high-intensity billing. We defined diagnostic categories using Clinical Classification Software, developed by AHRQ to provide meaningful groupings of diagnoses. The top ten modal diagnosis categories, as well as primary payer (Medicare, Medicaid, private insurance, self-pay), sex, and age were utilized in subsequent modeling. The outcome was high-intensity visit rate, utilizing survey weights for nationally-representative estimates, in 2006 and 2018. We report both the unadjusted ratio of high-intensity billing rate for 2018 as compared to 2006 and the risk-adjusted observed:expected ratio for high-intensity billing in 2018. We constructed a logistic regression model using 2006 data with the following covariates: disposition (discharged, transfer, home healthcare), age, sex, primary payer, and diagnosis category amongst the ten modal categories. In order to generate risk-adjusted observed:expected ratio in 2018, we divided the observed rate with that predicted for high- intensity billing using the above logistic regression model and inputted 2018 data. In 2006 there were an estimated 79,515,535 treat-and-release ED visits nationwide meeting sample criteria, of which 4,773,046 ED visits (6.0%) were classified as high-intensity. By 2018, there were 96, 739, 780 such visits nationwide of which 17,172,884 (17.7%) were classified as high-intensity. The unadjusted ratio of the high intensity billing rate in 2018 as compared to 2006 was 2.95. In logistical regression analysis using data from 2006, increasing age, transfer to a short-term hospital, Medicare, Medicaid, abdominal pain, and lower respiratory diseases were associated with greater likelihood of high-intensity visitation. The observed high-intensity billing rate in 2018, 17.7%, was slightly higher than that expected based on the model, 15.3%, yielding an observed:expected ratio of 1.15. High-intensity billing for treat-and-release ED visits had increased in the period from 2006 to 2018. Several patient-level factors predict high-intensity billing, and accounting for these factors given observed trends in ED case-mix such as increased visitation by older adults, those insured by public programs, evolution of the ED as an acute diagnostic certain, results in fairly modest differences in risk-adjusted billing rates. Policymakers must consider the increasingly complex needs of patients receiving outpatient services when designing payment policies.

Trends of Utilization and 90-Day Complication Rates for Computer-Assisted Navigation and Robotic Assistance for Total Knee Arthroplasty in the United States From 2010 to 2018.

BackgroundComputer-assisted navigation (CAN) and robotic assistance (RA) for total knee arthroplasty (TKA) are gaining in popularity. The purpose of this study is to update the literature on United States technology-assisted TKA trends of national utilization, regional utilization, and 90-day complication rates requiring readmission.MethodsPatients who underwent primary, elective TKA between 2010 and 2018 were retrospectively identified in the PearlDiver All Payer Claims Database (PearlDiver Technologies Inc.). TKAs were classified as conventional, CAN, or RA based on International Classification of Diseases nineth or tenth revision and Current Procedural Technology codes. Annual rates and regional trends of each type of TKA were reported. Ninety-day complications requiring readmission for each group were captured. Multivariable logistic regression was used to identify odds ratios (OR) for all-cause readmission based on TKA modality.ResultsOf the 1,307,411 elective TKAs performed from 2010 to 2018, 92.8% were conventional, and 7.7% were technology-assisted (95.2% CAN and 4.9% RA). RA-TKA had the greatest increase in utilization (+2204%). The Western region had the highest utilization of technologies for TKA, while the Midwestern region had the lowest. Ninety-day postoperative complications requiring readmission were highest for conventional TKA and lowest for RA-TKA. RA-TKA (OR 0.68; 97.5% confidence interval 0.56-0.83, P < .001) and CAN-TKA (OR 0.93; 97.5% confidence interval 0.88-0.97, P < .05) had significantly lower odds of all-cause 90-day complications requiring readmission than conventional TKA.ConclusionUtilization of RA-TKA and CAN-TKA continues to rise across the United States. The use of these technologies is associated with a lower OR of readmission within 90 days postoperatively.

Early aseptic reoperation after shoulder arthroplasty increases risk of subsequent prosthetic joint infection.

BackgroundDespite the success of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), the clinical course of some patients necessitates operative intervention in the acute postoperative period. In this study, we evaluate the risk of subsequent prosthetic joint infection (PJI) in patients who undergo an aseptic reoperation within 90 days of primary shoulder arthroplasty.MethodA retrospective review of patients with primary TSA and RSA was performed using a commercially available national database (PearlDiver Inc., Fort Wayne, IN, USA). Queries were performed with use of International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Technology codes. Patients were divided into cohorts based on undergoing aseptic reoperation, reoperation for PJI, or no reoperations within 90 days of index procedure. Primary outcome was subsequent PJI within 1 year of index procedure. Observed PJI rates were compared using chi-square analysis. Risk factors for PJI were compared using logistic regression.ResultsFrom 2010 to 2018, a total of 96,648 patients underwent primary shoulder arthroplasty: 46,810 underwent TSA and 49,838 underwent RSA. The rate of aseptic reoperation within 90 days was 0.72% and 1.5% in the TSA and RSA cohorts, respectively. At 1 year postoperatively, patients who underwent an aseptic reoperation within 90 days had an elevated risk of subsequent PJI compared with the overall rate of PJI in the TSA (3.54% vs. 0.75%; P < .001) and RSA (3.08% vs. 0.73%; P < .001) cohorts. On multivariate logistic regression analysis, aseptic reoperation within 90 days was identified as a significant risk factor for subsequent PJI in the TSA cohort (odds ratio, 14.19; P < .001) and RSA cohort (odds ratio, 8.38; P < .001). The most common indication for aseptic reoperation was postoperative prosthetic joint instability in both the TSA (31%) and RSA (49%) cohorts.ConclusionAseptic reoperation within 90 days of primary TSA or primary RSA was associated with a notably increased risk of subsequent PJI.

Comparing Relative Value Units among Shoulder Arthroplasty, Hemiarthroplasty, and ORIF for Proximal Humerus Fractures in the Elderly: Which is Most Worth Your Time?

Relative value units (RVUs) are assigned to Current Procedural Technology (CPT) codes and give relative economic values to the services physicians provide. This study compared the RVU reimbursements for the surgical options of proximal humerus fractures in the elderly, which include arthroplasty (reverse [RSA] and total [TSA]), hemiarthroplasty (HA), and open reduction and internal fixation (ORIF). Using the National Surgical Quality Improvement Program, a total of 1,437 patients of at least 65 years of age with proximal humerus fractures between 2008 and 2016 were identified. Of those, 259 underwent RSA/TSA (CPT code 23472), 418 underwent HA (CPT codes 23470 and 23616), and 760 underwent ORIF (CPT code 23615). Univariate analysis compared RVU per minute, reimbursement rate, and the average annual revenue across cohorts based on respective operative times. RSA/TSA generated a mean RVU per minute of 0.197 (SD 0.078; 95%CI [0.188, 0.207]), which was significantly greater than the mean RVU per minute for 23470 HA (0.156; SD 0.057; 95%CI [0.148, 0.163]), 23616 HA (0.166; SD 0.065; 95%CI [0.005, 0.156]), and ORIF (0.135; SD 0.048; 95%CI [0.132, 0.138]; P<0.001). This converted to respective reimbursement rates of $6.97/min (SD 2.78; 95%CI [6.63, 7.31]), $5.48/min (SD 2.05; 95%CI [5.22, 5.74]), $5.83/min (SD 2.28; 95%CI [5.49, 6.16]) and $4.74/min (SD 1.69; 95%CI [4.62, 4.87]). After extrapolation, respective average annual revenues were $580,386, $456,633, $475,077, and $395,608. RSA/TSA provides significantly greater reimbursement rates compared to HA and ORIF. Orthopaedic surgeons can use this information to optimize daily procedural cost-effectiveness in their practices.

Return-On-Investment for Billable Pharmacist-Provided Services in the Primary Care Setting

Background: Pharmacists are increasingly fulfilling roles on primary care teams, yet business models for pharmacist services in these settings have not been optimized. This study describes how an ambulatory care pharmacy department implemented various billing methods to generate revenue for pharmacist services. Objectives: (1) Describe pharmacist-delivered billable and non-billable services; and (2) Assess the impact of various billing methods on the return-on-investment (ROI) for billable services. Methods: This study was conducted from September 2016 to August 2017 in Virginia. Pharmacist time spent performing billable encounters using current procedural technology (CPT) codes (e.g., incident-to a physician, annual wellness visits) was calculated. Encounters eligible for the hospital-based facility (G0463) and chronic care management (CCM) codes were considered to be potentially billable services. The ROI was calculated for billable and potentially billable services. Results: A total of 948.3 hours (0.46 full-time equivalents (FTE)), 17% of all clinical services, were billed using CPT codes. This resulted in a total revenue of $173,638.66. Missed revenue from not billing for the G0463 and CCM codes was $68,268.37. The cost of pharmacist services for 0.46 FTE was $78,613.08, resulting in a ROI for billed pharmacist services of 1.2:1. The ROI increased to 1.6:1 when considering potentially billable services. Conclusion: It is feasible to have a positive ROI for billable pharmacist services. To achieve a sustainable business model, there must be a high volume of billable services. G0463 and CCM codes are often underutilized, yet represent significant opportunities in revenue for pharmacist services and should be pursued.

Risk of Infectious Endophthalmitis From a Resident-Performed Intravitreal Injection

This work assesses the safety of resident-performed intravitreal injections by comparing the incidence of postinjection endophthalmitis associated with residents vs surgical retina attendings. In this retrospective noninferiority cohort study, the Current Procedural Technology code for an intravitreal injection was used to identify patients from July 1, 2015, to October 31, 2018, at a single-center Veterans Affairs hospital where patients receive intravitreal injections from attending vitreoretinal surgeons and residents. The medical record for each injection was reviewed for the training level of the proceduralist, indication, medication, and laterality. The main outcome was the incidence of postinjection endophthalmitis occurring within 30 days of an intravitreal injection, which was confirmed by at least 2 medical-record reviewers. In this cohort of 593 patients, most were male (97.0%), and the average age was 70.3 years (±10.8 years). Of the 6934 injections given, 3877 (55.9%) were performed by residents and 3057 (44.1%) by attendings. Of the 5 cases of endophthalmitis identified, 3 were associated with a resident-performed injection in his or her fourth year of postgraduate training. The difference (0.012%; 95% CI, -0.168% to 0.169%) in the incidence of postinjection endophthalmitis between residents (0.077%) and attendings (0.065%) did not cross the predetermined noninferiority limit (0.200%). At our teaching clinic, resident-performed injections were not associated with an elevated risk of endophthalmitis when compared with attending-performed injections. Under varying levels of supervision, residents appeared to demonstrate appropriate sterile injection technique.

Maintaining access to maternal fetal medicine care by telemedicine during a global pandemic

Objective This study aims to compare a conventional medical treatment model with a telehealth platform for Maternal Fetal Medicine (MFM) outpatient care during the global novel coronavirus pandemic. Methods In this study, we described the process of converting our MFM clinic from a conventional medical treatment model to a telemedicine platform. We compared clinical productivity between the two models. Outcomes were analysed using standard statistical tests. Results We suffered three symptomatic COVID-19 infections among our clinical providers and staff prior to the conversion, compared with none after the conversion. We had a significant decrease in patient visits following the conversion (53.35 visits per day versus 40.3 visits per day, p < 0.0001). However, our average daily patient visits per full-time equivalent (FTE) were only marginally reduced (11.1 visit per FTE versus 7.6 visits per FTE, p < 0.0001), resulting in a relative decrease in adjusted work relative value units (6987 versus 5440). There was an increase in more basic follow-up ultrasound procedures, complexity (current procedural technology [CPT] code 76816 (10.7% versus 19.5%, relative risk [RR] 1.81, 95% CI 1.60–2.05, p < 0.0001)) over comprehensive follow-up ultrasound procedures, CPT code 76805 (17.2% versus 7.8%, RR 0.46, 95% CI 0.39–0.53, p < 0.0001) after conversion. Despite similar proportions of new consults, there was an increase in the proportion of follow-up visits and medical decision-making complexity evaluation and management CPT codes (e.g. 99214/99215) after the conversion (17.2% versus 24.6%, RR 1.43, 95% CI 1.26–163, p < 0.0001). There were no differences between amniocentesis procedures performed between the two time periods (0.3% versus 0.2%, p = 0.5805). Conclusion The rapid conversion of an MFM platform from convention medical treatment to telemedicine platform in response to the novel coronavirus pandemic resulted in protection of healthcare personnel and MFM patients, with only a modest decrease in clinical productivity during the initial roll-out. Due to the ongoing threat from the novel coronavirus-19, an MFM telemedicine platform is a practicable and innovative solution and merits the continued support of CMS and health care administrators.

Panniculectomy at the time of bariatric surgery: a propensity score-matched analysis of outcomes in the MBSAQIP database.

Body contouring in the postbariatric surgery patient improves quality of life and daily function. To determine the risk profile of panniculectomy when performed in select patients at the time of bariatric surgery. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating centers. We examined the MBSAQIP database (2016-2017), in which data on 379,544 bariatric surgeries are reported. Concurrent panniculectomy procedures were identified by Current Procedural Technology (CPT) codes. Patient characteristics and in-hospital as well as 30-day complications were compared between the body contouring group and propensity score-matched bariatric surgery controls. One hundred twenty-four patients met inclusion criteria and were matched to 248 controls. An infra-umbilical panniculectomy was performed in the majority of patients (n = 94, 75.8%). Most patients received an open rather than laparoscopic bariatric surgery (n = 87, 70.2%). There were no statistically significant differences between 30-day mortality (1.9%), wound complications (11.5%), readmission (12.5%) and reoperation (5.8%) between the 2 groups (P > .05). Wound complications occurred in 11.5% of patients and were associated with prolonged hospital stay (odds ratio 4.65, 95% confidence interval 1.99-10.86, P < .001) and a body mass index (BMI) > 50 (odds ratio 3.19, 95% confidence interval 1.02-9.96, P = .046). In select patients, panniculectomy at the time of bariatric surgery was not associated with increased in-hospital or 30-day adverse outcomes compared with matched bariatric surgery controls. This procedure may be performed in select patients, with awareness that revision surgery may be needed once weight loss stabilizes.