Current Procedural Terminology Codes Research Articles

The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair.

In the United States, the use of testosterone therapy has increased over recent years. Anabolic steroid use has been associated with tendon rupture, although there is a paucity of evidence evaluating the risk of biceps tendon injury (BTI) with testosterone therapy. The aim of this study was to quantify the risk of BTI after the initiation of testosterone therapy. This was a retrospective cohort study using the PearlDiver database. Records between 2011 and 2018 were queried to identify patients aged 35-75 years who filled a testosterone prescription for a minimum of 3 months. A control group was created, comprising patients aged 35-75 years who had never filled a prescription for exogenous testosterone. International Classification of Diseases, Ninth Revision, International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes were used to identify patients with distal biceps injuries and those undergoing surgical repair. Three matching processes were completed: one for the overall cohort, one for the cohort comprising only male patients, and one for the cohort comprising only female patients. Each cohort was matched to its control on age, sex, Charlson Comorbidity Index, diabetes, tobacco use, and osteoporosis. Multivariate logistic regression was used to compare rates of distal BTI and subsequent surgical repair in the testosterone groups with their control groups. A total of 776,974 patients had filled a prescription for testosterone for a minimum of 3 consecutive months. In the overall matched analysis between the testosterone and control groups (n=291,610 in both), the mean age of the patients was 53.9 years and 23.1% were women. Within 1 year of filling exogenous testosterone prescriptions for a minimum of 3 consecutive months, 650 patients experienced a distal BTI compared with 159 patients in the control group (odds ratio [OR],4.10; 95% confidence interval [CI], 3.45-4.89; P<.001). At any time after testosterone therapy, patients with testosterone use were more than twice as likely to experience a distal BTI as their matched controls (OR,2.07; 95% CI, 1.94-2.38). Patients who filled prescriptions for testosterone were more likely to undergo surgical repair within a year of the injury compared with the control group. A similar trend was seen in the cohort comprising male patients (OR,1.63; 95% CI, 1.29-2.07). Patients with prior prescription testosterone exposure have an increased rate of BTI and biceps tendon repair compared with patients without such exposure. This finding provides insight into the risk profile of testosterone therapy, and doctors should consider counseling patients about this risk, particularly male patients.

Comparison of Readmission Rates for Same-Day Versus Next-Day Discharge After Benign Vaginal Hysterectomy.

Same-day discharge (SDD) for laparoscopic hysterectomy is shown to be safe and acceptable, but data for vaginal hysterectomy (VH) are lacking. The aim of this study was to compare 30-day readmission rates, timing, and reasons for readmission for SDD versus next-day discharge (NDD) after VH. This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019. Cases of VH with or without prolapse repair were identified by Current Procedural Terminology codes. The primary outcome was 30-day readmissions after SDD versus NDD. Secondary outcomes included reasons for and time to readmission and a subanalysis evaluating 30-day readmissions for those with prolapse repair. Unadjusted and adjusted odds ratios were determined using univariate and multivariate analyses. There were 24,277 women included; 4,073 (16.8%) were SDD. The 30-day readmission rate was low (2.0%; 95% confidence interval [CI], 1.8-2.2%), with no difference in odds of readmission for SDD versus NDD after VH in multivariate analysis (SDD adjusted odds ratio [aOR], 0.9; 95% CI, 0.7-1.2). Results were similar in our subanalysis of VH with prolapse surgery (SDD aOR, 0.94; 95% CI, 0.55-1.62). Median time to readmission was 11 days and did not differ (SDD interquartile range, 5, 16 [range, 0-29] vs NDD, 7, 16 [range, 1-30]; Z = -1.30; P = 0.193). The most common reasons for readmission were bleeding (15.9%), infection (11.6%), bowel obstruction (8.7%), pain (6.8%), and nausea/emesis (6.8%). Same-day discharge after VH did not have an increased odds of 30-day readmission compared with NDD. This study, with preexisting data, supports the practice of SDD after benign VH in low-risk patients.

Comparing sentinel lymphadenectomy and complete lymphadenectomy among obese patients (BMI &gt;30) undergoing minimally invasive hysterectomy for early-stage endometrial cancer: An ACS-NSQIP database study.

e17618 Background: In patients with endometrial cancer, lymph node assessment is used for staging and adjuvant treatment planning. Sentinel lymphadenectomy (SLN) is an acceptable alternative to complete lymphadenectomy due to decreased risk of major complications. As obesity increases in the United States, so does the rate of endometrial cancer. Complete staging may be more challenging in obese patients. Our goal was to evaluate the relative use and complication rates of sentinel versus complete lymphadenectomy among obese patients undergoing minimally invasive hysterectomy (MIH) for early-stage endometrial cancer. Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried for patients diagnosed with stage I to III endometrial carcinoma between 2015 and 2020 who underwent MIH, identified by Current Procedural Terminology (CPT) code. Extent of lymphadenectomy was also identified using CPT codes. Relative utilization of sentinel versus complete lymphadenectomy was evaluated over the study period. Propensity scores were used to control for potential confounders, and complication rates were compared between propensity matched cohorts of sentinel versus complete lymphadenectomy. Major and minor complications were defined by the Clavien-Dindo scale. Results: From 2015 to 2020 a total of 11,844 obese (BMI &gt; 30) patients underwent MIH for stage I to III endometrial cancer. Of these 7,067 (59%) had a lymph node assessment. Sentinel lymphadenectomy was completed in 3,845 patients, and complete lymphadenectomy was completed in 3,222 patients. Over the five-year period, the utilization of SLN increased for obese and non-obese patients. Prior to 2018, complete lymphadenectomy was performed more often. After 2018, SNL was more common. After propensity matching, there was no increased risk of death (OR 0.67, 95% CI 0.06-5.8, p = 1.0), infection (OR 0.86, 95% CI 0.69-1.1, p = 0.20), thrombo-embolic events (OR 0.77, 95% CI 0.51-1.1, p = 0.21), major complications (OR 0.84, 95% CI 0.66-1.1, p 0.15), or minor complications (OR 0.87, 95% CI 0.69-1.1, P = 0.22) in obese patients who underwent SLN compared to complete lymphadenectomy. Conclusions: The average BMI of patients who underwent MIH over the study period was 35. After controlling for comorbidities and other baseline characteristics, there were no significant differences in complication rates between sentinel and complete lymphadenectomy in obese patients. With the adoption of SLN, more patients may be adequately staged, providing more prognostic information and targeted therapies. These results suggest that sentinel lymphadenectomy is a technically feasible and safe staging procedure in obese patients.

ID: 213146 Trends in Medicare Reimbursement for Deep Brain Stimulation Surgery: 2004-2021

The viability of multidisciplinary movement disorder programs depends heavily on reimbursement for Deep Brain Stimulation (DBS) surgery. Procedures related to DBS include cranial lead insertion, generator placement, microelectrode recording, as well as lead or generator replacements or revisions. These procedures are tied to Current Procedural Terminology (CPT) codes with associated reimbursement rates maintained by the Centers for Medicare and Medicaid Services (CMS). Though not the sole factor in what is ultimately reimbursed to a facility, annual differences in pricing associated with CPT coding can reflect relative changes to reimbursement rates. The purpose of this study was to evaluate trends in Medicare reimbursement for DBS surgery from 2004-2021 when corrected for inflation.

Assessing the marginal costs of radiation therapy and antiestrogen therapy for post-lumpectomy, early-stage breast cancer across Medicaid and Medicare plans.

529 Background: With recent Level I evidence (FAST FORWARD) supporting radiation therapy (RT) duration as short as one week and Level I evidence (CALGB9343) supporting RT omission in favor of antiestrogen endocrine therapy (ET) alone in select patients, the necessity of both RT and ET, adjuvantly, in early-stage breast cancer (BC) has been questioned. Evidence providing granular details on the role of insurance in the aggregate cost of RT and ET is lacking. This project disaggregates costs by insurance plan to increase transparency of out-of-pocket (OOP) cost estimates. Methods: National Comprehensive Cancer Network guidelines were utilized to determine the proper treatments, with FAST FORWARD radiation dose/fractionation (26 Gy in 5 fractions) representing RT. Treatments were identified using Current Procedural Terminology and Healthcare Common Procedure Coding System codes. OOP costs, deductibles, and copay/coinsurance were calculated for Medicaid, Original Medicare, Medigap Plan G, and Medicare Part D Rx. The medicare.gov, medicaid.oh.gov, aarpmedicareplans.com, and cms.gov were used to determine pricing. Price estimates reflect actual costs per insurance plan rather than costs estimated from claims data. All procedures were considered to be performed in an Ohio hospital setting, insurance coverages were based on the zip code 44106, and total expenses were based on all treatments plus a 5-year follow-up (not adjusted for inflation). Results: Treatment charges for ET include medical oncology initial consultation, biannual medical oncology follow-up, baseline bone density study, and Anastrozole cost (5-years). Treatment charges for RT include initial consultation, treatment planning, dosimetry calculations, treatment device, simulation and verification, RT delivery, on-treatment visits, and medical physics consultation. Original Medicare beneficiaries face an OOP cost of 20% for Medicare Part B claims with no cost cap for approved procedures after the deductible. Medications are covered under Medicare Part D with copays. This results in a marginal OOP treatment charge (after 5-year follow-up) of $767.54 for ET alone and $1,416.78 for ET + RT. Medigap Plan G beneficiaries face a marginal OOP charge of $1,225 for both ET alone and ET + RT, assuming the $226 Medicare Plan B deductible is met by the cost of lumpectomy during the year of RT. For Medicaid beneficiaries (assuming all treatments are approved by Medicaid), all expenses are covered without limit, resulting in no OOP expense for either treatment plan. Conclusions: Discussions of adding RT to ET for post-lumpectomy early-stage BC often involves considerations of treatment costs. This model (based on actual cost estimates per insurance plan rather than claims data) can help to enhance cost transparency by comparing expenses between Medicare and Medicaid plans.

Rates of routine cancer screening compared with pre-pandemic levels.

10573 Background: The COVID-19 pandemic caused significant disruptions to healthcare delivery in the US due to mandatory stay-at-home orders and patient fears about visiting healthcare facilities. A logical consequence, many forms of healthcare use, including cancer screenings, sharply decreased in early 2020. Early studies suggest that cancer screening rebounded through the summer of 2020; however, &gt; 2 years removed from the start of the pandemic, the long-term impact of missed screenings is unknown. The objective of this study was to examine trends in breast, cervical, and colorectal cancer screening from 2017-2022. Methods: This cross-sectional study used the Trilliant Health national all-payer claims database to analyze calendar year quarterly medical claims from Q1 2017- Q2 2022. We limited the study sample to those aged 21-85, the guideline-concordant target populations for the screening procedures. For breast and cervical cancer, we limited our sample to women. Using Current Procedural Terminology (CPT) codes, we calculated the quarterly number of individuals, per 100,000 eligible beneficiaries, who received screening for breast cancer, cervical cancer, and colorectal cancer. Percentage change in screening tests was compared. Results: In total, the analysis included &gt; 300M unique individuals. For breast cancer, the median quarterly rate of pre-pandemic screening mammography was 8013 per 100k beneficiaries, which declined to 4,884 in Q2 of 2020—a 39% decrease. Screening mammography rebounded to pre-pandemic levels by Q3 and Q4 of 2020 but declined to a median rate of 7,314 per 100,000 beneficiaries in Q2 2022, with quarterly deficits ranging from 4-16%. For cervical cancer, the median quarterly rate of pre-pandemic screening was 5,469 per 100k beneficiaries. The rate of cervical cancer screening fell to 3,550 in Q2 of 2020—a 35% decline. By Q3 2020, cervical cancer screening rebounded toward the pre-pandemic median, then progressively declined to 4,557 per 100k beneficiaries by Q2 2022. Over the same time period, colorectal cancer screening decreased from a pre-pandemic median of 3,111 per 100k beneficiaries to 1,731 in Q2 of 2020—a 44% difference. From Q3 2020 to Q1 2022, the quarterly colorectal cancer screening rate remained 10-17% below pre-pandemic levels, but returned to 3,047 per 100k in Q2 2022, only 2% below the pre-pandemic median. Conclusions: Across the three studied cancer types, population-based screening remains below pre-pandemic levels. In agreement with other research, we find that screening quickly rebounded following the initial stages of the pandemic; however, the longer follow-up time reveals that gaps in preventive cancer screening returned and worsened. Underutilization of recommended cancer screenings will likely result in an increase in later-stage initial diagnoses and excess mortality from cancer in the future.

Surgical classification using natural language processing of informed consent forms in spine surgery.

In clinical spine surgery research, manually reviewing surgical forms to categorize patients by their surgical characteristics is a crucial yet time-consuming task. Natural language processing (NLP) is a machine learning tool used to adaptively parse and categorize important features from text. These systems function by training on a large, labeled data set in which feature importance is learned prior to encountering a previously unseen data set. The authors aimed to design an NLP classifier for surgical information that can review consent forms and automatically classify patients by the surgical procedure performed. Thirteen thousand two hundred sixty-eight patients who underwent 15,227 surgeries from January 1, 2012, to December 31, 2022, at a single institution were initially considered for inclusion. From these surgeries, 12,239 consent forms were classified based on the Current Procedural Terminology (CPT) code, categorizing them into 7 of the most frequently performed spine surgeries at this institution. This labeled data set was split 80%/20% into train and test subsets, respectively. The NLP classifier was then trained and the results demonstrated its performance on the test data set using CPT codes to determine accuracy. This NLP surgical classifier had an overall weighted accuracy rate of 91% for sorting consents into correct surgical categories. Anterior cervical discectomy and fusion had the highest positive predictive value (PPV; 96.8%), whereas lumbar microdiscectomy had the lowest PPV in the testing data (85.0%). Sensitivity was highest for lumbar laminectomy and fusion (96.7%) and lowest for the least common operation, cervical posterior foraminotomy (58.3%). Negative predictive value and specificity were > 95% for all surgical categories. Utilizing NLP for text classification drastically improves the efficiency of classifying surgical procedures for research purposes. The ability to quickly classify surgical data can be significantly beneficial to institutions without a large database or substantial data review capabilities, as well as for trainees to track surgical experience, or practicing surgeons to evaluate and analyze their surgical volume. Additionally, the capability to quickly and accurately recognize the type of surgery will facilitate the extraction of new insights from the correlations between surgical interventions and patient outcomes. As the database of surgical information grows from this institution and others in spine surgery, the accuracy, usability, and applications of this model will continue to increase.

Predictors of antimicrobial use in intensive care unit patients

Background: Identification of predictors of antibiotic use can inform targeted antimicrobial stewardship initiatives and can account for sources of bias in before-and-after interventional stewardship studies. To date, no study has identified clinical predictors of antimicrobial use within intensive care units (ICUs), where antimicrobial resistance is most prevalent and problematic. Methods: As part of an ongoing prospective, single-arm, pilot feasibility trial of an ICU diagnostic stewardship intervention, we performed a nested retrospective cohort study to explore associations between patient clinical variables and ICUs antimicrobial use and resistance rates (AURs). We included all patients hospitalized in 3 ICUs (surgical, medical, and cardiac) from 2017 to 2021 at Michigan Medicine, a large, tertiary-care, academic medical center. Data were extracted from the electronic medical record using a structured query. Admission-level data were captured, including patient demographics, medical comorbidities, International Classification of Disease, Tenth Revision (ICD-10) admission diagnoses, as well as calendar day-level data including vital signs, clinical and microbiologic laboratory data, measures of acute severity of illness, ventilator–supplemental oxygen metrics, and procedural interventions using current procedural terminology (CPT) codes. ICU AURs were defined as total antibiotic days of therapy per patient per 100 ICU days. Associations between clinical variables and ICU AURs were calculated as rate ratios (RRs). Multiple imputation using fully conditional specification was performed to create 25 imputation data sets. Negative binomial regression models were constructed for each data set using backward selection. Variables retained in &gt;50% of models were included in a final multivariate model. Results: In total, 15,177 ICU patient admissions were captured. Age, sex assigned at birth, and race did not independently associate with ICU AURs. Comorbidities, medical interventions, admission diagnoses, and laboratory data that independently associated with ICU-AURs are shown in Table 1. The clinical variables most strongly associated with increased ICU-AURs were pneumonia (RR, 1.55; 95% CI, 1.451.64), bacteremia (RR, 1.35; 95% CI, 1.25– 1.46), intraabdominal infection (RR, 1.35; 95% CI, 1.18–1.55), SOFA score (RR, 1.27; 95% CI, 1.14–1.42), abnormal WBC (RR, 1.26; 95% CI, 1.20–1.32), and immunocompromised status (RR, 1.20; 95% CI, 1.10–1.31). Clinical variables most strongly associated with decreased ICU-AURs were cardiac ICU (RR, 0.56; 95% CI, 0.52–0.60), COVID-19 (RR, 0.62; 95% CI, 0.56–0.70), and receipt of an invasive nonsurgical procedure (RR, 0.90; 95% CI, 0.82–0.98). Conclusions: In this single-center retrospective cohort study, several clinical variables were independently associated with ICU-AURs. These results may be used to identify patient subgroups for potentially high-yield ICU-based stewardship interventions and to account for sources of bias in before-and-after studies of ICU-based stewardship interventions.Disclosures: None

How Postoperative Infection Affects Reoperations after Implant-based Breast Reconstruction: A National Claims Analysis of Abandonment of Reconstruction.

We conducted a retrospective cohort study using Optum's de-identifed Clinformatics Data Mart Database to analyze women undergoing implant breast reconstruction from 2003 to 2019. Unplanned reoperations were identified via Current Procedural Terminology (CPT) codes. Outcomes were analyzed via multivariate linear regression with Poisson distribution to determine statistical significance at P < 0.00625 (Bonferroni correction). In our national claims-based dataset, post-IBR infection rate was 8.53%. Subsequently, 31.2% patients had an implant removed, 6.9% had an implant replaced, 3.6% underwent autologous salvage, and 20.7% discontinued further reconstruction. Patients with a postoperative infection were significantly associated with increased incidence rate of total reoperations (IRR, 3.11; 95% CI, 2.92-3.31; P < 0.001) and total hospital length of stay (IRR, 1.55; 95% CI, 1.48-1.63; P < 0.001). Postoperative infections were associated with significantly increased odds of abandoning reconstruction (OR, 2.92; 95% CI, 0.081-0.11; P < 0.001). Unplanned reoperations impact patients and healthcare systems. This national, claims-level study shows that post-IBR infection was associated with a 3.11× and 1.55× increase in the incidence rate of unplanned reoperations and length of stay. Post-IBR infection was associated with 2.92× increased odds of abandoning further reconstruction after implant removal.

Real-world analysis of commercially insured and Medicare Advantage patients with advanced cancer and rates of molecular testing.

6633 Background: Guideline-recommended molecular testing has become essential for biomarker-guided clinical decision making, particularly for patients with advanced (adv) disease. Several biomarkers have indications that are tumor type-agnostic (starting with MSI in 2017, NTRK in 2018, TMB in 2020, and RET and BRAF in 2022). Biomarker testing is covered by insurers, both Medicare (covers comprehensive genomic profiling [CGP] and non-CGP panels) and commercial (at least non-CGP). This study aimed to understand utilization of biomarker testing across tumor types. Methods: This retrospective analysis used de-identified administrative claims from Optum Labs Data Warehouse. Adult Commercial (COM) and Medicare Advantage (MA) enrollees diagnosed with any 1 of 6 adv cancer types from 1/2018 to 8/2021 were identified; the date of the first claim indicating adv cancer was the index date. Continuous enrollment for 12 months prior to (baseline), and ≥6 months post-index date, unless they died (follow-up) was required. Biomarker testing was captured using Current Procedural Terminology (CPT) codes indicating CGP (&gt; 50 gene panels), non-CGP (at most 5-50 gene panels), or CPT code 81479 (unlisted molecular pathology procedure) during the study period. The primary analysis evaluates testing in the follow-up only, with secondary analyses evaluating testing including the baseline (to account for testing prior to the index date). Results: We identified 16,931 breast (BC), 16,838 non-small cell lung (NSCLC), 8,755 colorectal (CRC), 4,244 pancreatic (PC), 2,610 ovarian (OC), and 1,231 gastric (GC) adv cancer patients meeting study criteria. Overall biomarker testing rates in the follow-up period were: 37% NSCLC, 19% BC, 41% CRC, 35% PC, 51% OC, 35% GC. The Table shows testing rates by cancer, insurance type, and panel size during follow-up. Testing rates were lower among MA patients compared to COM patients. Even considering baseline and follow-up periods, overall biomarker testing rates were low, and lower among MA compared to COM : 48% NSCLC (53% COM, 47% MA), 27% BC (34% COM, 22% BC), 56% OC (61% COM, 53% MA),42% PC (53% COM, 38% MA), 47% CRC (56% COM, 42% MA), 41% GC (54% COM, 35% MA). Conclusions: Considering guideline recommendations, rates of biomarker testing across tumor types are far from optimal despite insurance coverage for testing. Identification of barriers to biomarker testing and interventions to overcome these are needed to improve adherence to biomarker testing guidelines. [Table: see text]

Bacterial Burden, Not Local Immune Response, Differs Between Acute and Chronic Peri-Prosthetic Joint Infections.

Background: Conducting gram stains in peri-prosthetic joint infections (PJI) is known to have poor sensitivity. However, the aims of this study were to use gram stain results of acute and chronic PJI to determine differences with respect to bacterial burden and levels of local innate immunologic response. Patients and Methods: Patients with acute and chronic PJI from January 1, 2016 and December 31, 2020 were identified by use of Current Procedural Terminology codes. Manual review of medical records for infecting organisms and gram stain results for stained bacteria and for local tissue inflammation (amount of polymorphonuclear leukocytes seen on high powered microscopic fields) were recorded. Statistical comparisons between acute (n = 70) and chronic (n = 134) PJI were analyzed with respect to gram stain sensitivity and amount of local tissue inflammation. Results: The ability to identify stained bacteria was statistically significantly higher in the acute cohort (61.4%) than the chronic cohort (9.7%; p < 0.0001). Interestingly, the amount of local inflammation was similar for acute and chronic PJI except in the subgroup analysis with chronic polymicrobial (p = 0.0229) and chronic culture negative (p = 0.0001) PJI. Conclusions: This study shows that both acute and chronic PJI had similar levels of local inflammation seen on gram stains, despite higher bacterial burdens in acute infections. This suggests that innate immune responses, and thus likelihood of infection eradication, is not solely dependent on bacterial burden. These findings should spearhead further research evaluating the different immunologic responses that occur in acute and chronic PJI to improve diagnostics, therapeutics, and infection-free implant survival.

The Long-term Incidence and Quality of Life Outcomes Associated With Treatment-Related Toxicities of External Beam Radiotherapy for Prostate Cancer

To assess the long-term incidence of treatment-related toxicities and quality of life (QOL) outcomes associated with toxicity after external beam radiotherapy (EBRT) for prostate cancer. We identified all men who had EBRT between 1994 and 2017 from Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a longitudinal, nationwide prostate cancer registry. CaPSURE was queried for patient-reported and International Classification of Diseases-9/10 and Current Procedural Terminology codes. The Medical Outcomes Studies Short Form 36 and the University of California, Los Angeles Prostate Cancer Index were used to provide measures of general health, sexual, urinary, and bowel function. Repeated measures mixed models were used to determine QOL change after onset of toxicity. From a total of 15,332, 1744 (11.4%) men had EBRT. The median follow-up was 7.9years (interquartile range [IQR] 4.3-12.7). The median time to onset of any toxicity including urinary pad usage in 265 (15.4% at 8years) men was 4.3years (IQR 1.8-8.0). The most frequent toxicity was hemorrhagic cystitis (104, 5.9% at 8years) after a median of 3.7years (1.3-7.8), gastrointestinal (48, 2.7% at 8years) after a median of 4.2years (IQR 1.3-7.8), followed by urethral stricture (47, 2.4% at 8years) after a median of 3.7years (IQR 1.9-9.1). Repeated measures mixed models found that onset of hemorrhagic cystitis was associated with change in general health over time. EBRT for prostate cancer is associated with distinct treatment-related toxicities which can occur many years after treatment and can affect QOL. These results may help men understand the long-term implications of treatment decisions.

Association of HIV Infection and Incident Abdominal Aortic Aneurysm Among 143 001 Veterans.

People with HIV (PWH) have an increased risk of cardiovascular disease. Previous cross-sectional data suggest there is a higher prevalence of abdominal aortic aneurysm (AAA) in PWH than in those without HIV. Whether PWH have an increased risk of incident AAA compared with those without HIV is unknown. We analyzed data among participants without prevalent AAA from the Veterans Aging Cohort Study, a prospective, observational, longitudinal cohort of veterans with HIV matched 1:2 with veterans without HIV infection. We calculated AAA rates by HIV status and assessed the association between HIV infection and incident AAA using Cox proportional hazards models. We defined AAA using the International Classification of Diseases, 9th or 10th revision, or Current Procedural Terminology codes and adjusted all models for demographic characteristics, cardiovascular disease risk factors, and substance use. Secondary analyses examined the association between time-varying CD4+ T-cell count or HIV viral load and incident AAA. Among 143 001 participants (43 766 with HIV), over a median follow-up of 8.7 years, there were 2431 incident AAA events (26.4% among PWH). Rates of incident AAA per 1000 person-years were similar among PWH (2.0 [95% CI, 1.9-2.2]) and people without HIV (2.2 [95% CI, 2.1-2.3]). There was no evidence that HIV infection increased the risk of incident AAA compared with no HIV infection (adjusted hazard ratio, 1.02 [95% CI, 0.92-1.13]). In adjusted analyses with time-varying CD4+ T-cell counts or HIV viral load, PWH with CD4+ T-cell counts <200 cells/mm3 (adjusted hazard ratio, 1.29 [95% CI, 1.02-1.65]) or HIV viral load ≥500 copies/mL (adjusted hazard ratio, 1.29 [95% CI, 1.09-1.52]) had an increased risk of AAA compared with those without HIV. HIV infection is associated with an increased risk of AAA among those with low CD4+ T-cell counts or elevated HIV viral load over time.

The Impact of Preoperative Myelopathy on Postoperative Outcomes among Anterior Cervical Discectomy and Fusion Procedures in the Nonelderly Adult Population: A Propensity-Score Matched Study.

Retrospective cohort study. Anterior cervical discectomy and fusion (ACDF) is a common surgical intervention for patients diagnosed with cervical degenerative diseases with or without myelopathy. A thorough understanding of outcomes in patients with and without myelopathy undergoing ACDF is required because of the widespread utilization of ACDF for these indications. Non-ACDF approaches achieved inferior outcomes in certain myelopathic cases. Studies have compared patient outcomes across procedures, but few have compared outcomes concerning myelopathic versus nonmyelopathic cohorts. The MarketScan database was queried from 2007 to 2016 to identify adult patients who were ≤65 years old, and underwent ACDF using the international classification of diseases 9th version and current procedural terminology codes. Nearest neighbor propensity-score matching was employed to balance patient demographics and operative characteristics between myelopathic and nonmyelopathic cohorts. Of 107,480 patients who met the inclusion criteria, 29,152 (27.1%) were diagnosed with myelopathy. At baseline, the median age of patients with myelopathy was higher (52 years vs. 50 years, p <0.001), and they had a higher comorbidity burden (mean Charlson comorbidity index, 1.92 vs. 1.58; p <0.001) than patients without myelopathy. Patients with myelopathy were more likely to undergo surgical revision at 2 years (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.54-1.73) or are readmitted within 90 days (OR, 1.27; 95% CI, 1.20-1.34). After patient cohorts were matched, patients with myelopathy remained at elevated risk for reoperation at 2 years (OR, 1.55; 95% CI, 1.44-1.67) and postoperative dysphagia (2.78% vs. 1.68%, p <0.001) compared to patients without myelopathy. We found inferior postoperative outcomes at baseline for patients with myelopathy undergoing ACDF compared to patients without myelopathy. Patients with myelopathy remained at significantly greater risk for reoperation and readmission after balancing potential confounding variables across cohorts, and these differences in outcomes were largely driven by patients with myelopathy undergoing 1-2 level fusions.

Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis

There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization. This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy. We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated. There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001). This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

Women Have a Lower Rate of Abdominal Aortic Aneurysm Repair and Higher Long-term Aortic-related Mortality Compared With Men in a Population-based Study

Increased mortality has been reported after open or endovascular repair of abdominal aortic aneurysms (AAAs) in women. Our aim was to evaluate the natural history and outcomes of AAAs in women at a population level. A population-based cohort study was conducted (1980-2017) of all patients with AAA based on identification using International Classification of Diseases, 9th or 10th Revision and Current Procedural Terminology codes. The gender-specific incidences of AAAs were initially calculated. Medical records were reviewed to confirm diagnosis and identify late events and clinical reasons for opting against repair. Survival analysis for overall and aortic mortality was performed and stratified based on gender and repair status. There were 1537 patients with AAAs; 381 (25%) were female. The incidence of AAA in women was 4.5 times lower than men (23 vs 105 per 100,000 person-years). Compared with men, women were diagnosed at an older age (80 vs 73 years, P < .001), with smaller initial aneurysm size (4 vs 4.3 cm, P < .001). In 99 of 1537 patients, the initial presentation was with rupture (male:female; 79:20); 14 ruptured AAAs were <5.5 cm, 10 of 14 in women. Median follow-up was 18 years. AAA repair was less frequent in women (26% vs 41%, P < .001); with no change after availability of endovascular repair (16% vs 20%, P = .2), women had similar 30-day mortality from AAA repair (4% vs 5%, P = .5). However, on Kaplan-Meier analysis, aortic and all-cause mortality at 10 and 20 years were highest in women who did not undergo repair of their AAA (NRF, hazard ratio: 3, 95% confidence interval: 1.8-4.5, P < .001) as compared with all men and women who underwent repair (Table). This cumulative incidence of aortic-related death remained significantly higher in NRF when analyzed with non-aortic-related deaths as a competing risk, 15% vs 5%-8% in the other groups. All patients with aortic-related death (both women and men) had refused repair because of older age and risk from comorbidities, except in 2 females with rupture of 4.8 and 5.5 cm AAAs while awaiting repair. AAAs are diagnosed in women almost a decade later than men. In this study, mortality after AAA repair was not inferior in women compared with men; however, the incidence of repair was significantly lower in women. Based on the findings of threefold greater long-term aortic-related mortality in women not undergoing AAA repair, it may be advisable to consider repair in women earlier at a smaller AAA size.

Optimising vitrectomy operation note coding with machine learning.

The accurate encoding of operation notes is essential for activity-based funding and workforce planning. The aim of this project was to evaluate the procedural coding accuracy of vitrectomy and to develop machine learning, natural language processing (NLP) models that may assist with this task. This retrospective cohort study involved vitrectomy operation notes between a 21-month period at the Royal Adelaide Hospital. Coding of procedures were based on the Medicare Benefits Schedule (MBS)-the Australian equivalent to the Current Procedural Terminology (CPT®) codes used in the United States. Manual encoding was conducted for all procedures and reviewed by two vitreoretinal consultants. XGBoost, random forest and logistic regression models were developed for classification experiments. A cost-based analysis was subsequently conducted. There were a total of 1724 procedures with individual codes performed within 617 vitrectomy operation notes totalling $1 528 086.60 after manual review. A total of 1147 (66.5%) codes were missed in the original coding that amounted to $736 539.20 (48.2%). Our XGBoost model had the highest classification accuracy (94.6%) in the multi-label classification for the five most common procedures. The XGBoost model was the most successful model in identifying operation notes with two or more missing codes with an AUC of 0.87 (95% CI 0.80-0.92). Machine learning has been successful in the classification of vitrectomy operation note encoding. We recommend a combined human and machine learning approach to clinical coding as automation may facilitate more accurate reimbursement and enable surgeons to prioritise higher quality clinical care.

Clinical Predictors of Pathologically Positive Temporal Artery Biopsy

Temporal arteritis (TA) can present with a wide spectrum of symptoms and lab findings, including temporal headaches, vision changes, jaw or tongue claudication, fevers, and elevated serum inflammatory markers. Here, we review a large series of patients who have undergone temporal artery biopsies. A retrospective review of all patients who underwent temporal artery biopsies within our health system from January 2005 to January 2022 was performed. Patients were selected using the Current Procedural Terminology code for temporal artery biopsy (37609). Chart review was performed to determine demographic, clinical, laboratory, and operative characteristics, as well as pathologic outcome. The primary outcome was the final pathology result of the biopsy. Patients with non-diagnostic pathology reports were excluded from the study. Variables that met a P-value < .1 in univariate analysis were included in the final multivariable logistic regression analysis. A separate sensitivity analysis was performed on a cohort with complete lab data. We identified 613 patients who underwent temporal artery biopsies across three hospitals within our health system from January 2005 to January 2022. The average age of the cohort was 73.2 ± 11.2 years. The majority of the patients, 70.5% (n = 430), were female. The most common presenting symptom was a headache, which was present in 254 (41.4%) of patients. Older age (>65), white race, lower body mass index (BMI), presence of jaw claudication, lack of blurry vision, elevated erythrocyte sedimentation rate, elevated C-reactive protein, elevated platelet count, and longer biopsy length were associated with a positive biopsy on univariate analysis (P < .05) (Table I). Specimen length did not differ significantly between groups with positive and negative pathology, nor by bilateral versus unilateral biopsy or surgeon specialty. On multivariate analysis, the presence of jaw claudication (odds ratio [OR], 3.69; P < .001) was associated with a positive biopsy. Black race was associated with a lower odds of a positive biopsy (OR, 0.27; P < .001). On sensitivity analysis, erythrocyte sedimentation rate levels above 40 were significantly associated with increased odds of a positive biopsy (OR, 7.53; P = .009). Platelet counts of 401 to 600 (OR, 7.60; P < .001) and above 600 (OR, 7.15; P = .006) were also significantly associated with a positive biopsy. Clinical and patient features including the symptom of jaw claudication, elevated erythrocyte sedimentation rate, elevated platelet count, and white race are associated with positive temporal artery biopsy. Further work is needed to determine who benefits most from this procedure.TablePatient characteristics and biopsy outcomesTotalNegative biopsy resultPositive biopsy resultP-valueN = 613n = 523n = 90Age, years <5011 (1.8)10 (1.9)1 (1.1).009 50-64109 (17.8)103 (19.7)6 (6.7) 65-79313 (51.1)266 (50.9)47 (52.2) 80+180 (29.4)144 (27.5)36 (40.0)Sex Female430 (70.5)374 (71.8)56 (62.9).090 Male180 (29.5)147 (28.2)33 (37.1)Race/ethnicity White322 (52.8)250 (48.1)72 (80.0)<.001 Black229 (37.5)216 (41.5)13 (14.4) Other/unknown59 (9.7)54 (10.4)5 (5.6)BMI Underweight (BMI <18.5)11 (1.8)7 (1.3)4 (4.4)<.001 Healthy (18.5 ≤ BMI < 25)168 (27.4)123 (23.5)45 (50.0) Overweight (25 ≤ BMI < 30)172 (28.1)150 (28.7)22 (24.4) Obese (BMI ≥30)262 (42.7)243 (46.5)19 (21.1)Preoperative steroid use Yes392 (68.7)330 (67.8)62 (73.8).27Preoperative aspirin use Yes254 (45.3)218 (45.5)36 (43.9).79Past medical history of other rheumatic disease Yes147 (25.2)130 (26.1)17 (20.2).26History of polymyalgia rheumatica Yes62 (26.6)53 (26.4)9 (28.1).83Bruit Yes3 (0.5)3 (0.6)0 (0.0).47Fever Yes41 (6.7)32 (6.1)9 (10.0).17Headache Yes254 (41.4)216 (41.3)38 (42.2).87Tenderness Yes130 (21.2)111 (21.2)19 (21.1).98Bilateral tenderness Yes26 (4.2)19 (3.6)7 (7.8).072Jaw claudication Yes95 (15.6)64 (12.3)31 (34.8)<.001Tongue claudication Yes0 (0.0)0 (0.0)0 (0.0)Blurry vision Yes111 (18.1)102 (19.5)9 (10.0).030Double vision Yes18 (2.9)13 (2.5)5 (5.6).11Tinnitus Yes6 (1.0)5 (1.0)1 (1.1).89Erythrocyte sedimentation rate at diagnosis <2050 (9.4)48 (10.6)2 (2.5).008 20-4059 (11.1)55 (12.1)4 (5.1) 40+423 (79.5)350 (77.3)73 (92.4)C-reactive protein at diagnosis <3140 (33.5)128 (36.1)12 (19.0)<.001 3-1083 (19.9)68 (19.2)15 (23.8) 11-2060 (14.4)58 (16.3)2 (3.2) 20+135 (32.3)101 (28.5)34 (54.0)Platelet count at diagnosis <200112 (20.5)104 (22.3)8 (9.9)<.001 200-400356 (65.1)314 (67.4)42 (51.9) 401-60063 (11.5)38 (8.2)25 (30.9) 601-800+16 (2.9)10 (2.1)6 (7.4)Alk-Phos (continuous)93.1 (65.9)92.9 (66.8)94.2 (62.1).90White blood cells (continuous)11.0 (17.8)10.8 (19.0)11.6 (8.1).71Longest length of biopsy specimen, cm (continuous)1.9 (0.9)1.9 (0.9)2.1 (1.0).057Boldface P indicates P-value < .1, used in multivariate analysis.Data are presented as number (%) or mean (standard deviation). Open table in a new tab

(325) The Role of Advanced Practice Providers Who Treat Men’s Health Urologic Conditions: An Analysis of Medicare and Commercial Claims in the United States

Abstract Introduction The role of advanced practice providers (APPs) had expanded in the recent years according to the AUA. This increase of APPs had been endorsed by AUA to offset the increasing burden on the urologist workforce. Moreover, contemporary literature on the involvement of APPs in men’s-specific disease conditions is lacking. Objective We aim to clarify the role of APPs for publicly and privately insured patients in the treatment of mens’ urologic conditions commonly encountered in Men’s Health Clinics. Methods Medicare and commercial insurance claims from the Physician/Supplier Procedure Summary and IBM® MarketScan® Commercial Database, were queried for procedures submitted by APPs between 2010 and 2020. Common urologic conditions were identified using Current Procedural Terminology codes and grouped into six categories: overactive bladder (OAB), testicular hypofunction, erectile dysfunction (ED) and Peyronie’s disease (PD), benign prostatic hyperplasia (BPH), genital warts, and scrotal pain. The proportion of procedures submitted by APPs was calculated for each year and category. Results The proportion of claims submitted by APPs treating OAB, genital warts, and testicular hypofunction rose steadily from 2010 to 2020. Proportion of submitted service counts under OAB, genital warts and testicular hypofunction increased approximately 5, 8, and 4-fold among the privately insured compared to 3, 6, and 10-fold among the publicly insured (Figures 1 and 2). For BPH, ED and PD, and scrotal pain the proportion of APPs in both the MarketScan and Medicare groups was higher in 2020 than 2010, but with less dramatic and stable growth rates compared to other procedures. The proportions of APPs for all conditions were higher in the Medicare group compared to the MarketScan group. The Medicare data captured more year to year fluctuations in the proportion of claims submitted by APPs per condition than that of the MarketScan data. Conclusions APPs play a critical role in urologic care and can help address impending physician workforce shortages in urology, specifically in men’s health. The role of APPs in men’s urologic health, particularly OAB, testicular hypofunction, and genital warts, is increasing for both privately and publicly insured patient populations. Further research on implementation and utilization of APPs, as well as the health outcomes of such workforce modifications, is warranted. Disclosure No

(482) Patients Receiving Urologic Implants Taking Sodium-Glucose Co-Transporter 2 Inhibitors, a Global, Propensity-Score Matched Analysis

Abstract Introduction Sodium-glucose co-transporter 2 inhibitors (SGLT2i) prevent the reabsorption of glucose and facilitate its excretion in urine. These medications are a newer treatment for Type 2 Diabetes Mellitus patients and have also been associated with positive cardiorenal effects. Patients taking these medications are at a hypothetical increased risk of urinary tract infections given the mechanism of action. Objective We questioned whether patients taking SGLT2i would be at an increased risk of genitourinary device infection or failure. As these medications are newer and without widespread use, we sought to utilize the power of a multinational database to generate a sufficient sample size to generate our answer. Methods TriNetX is a collaborative research enterprise which collects real-time data from almost 89 million patients located in 58 healthcare organizations across the globe and analyzes patient data from 20 years back to present (2002-2022). We queried TriNetX for all adult male patients undergoing Artificial Urinary Sphincter (AUS) or Inflatable Penile Prosthesis (IPP). For each implant, we separated patients into two cohorts defined by those taking an SGLT2i within 1 year before and/or after surgery and those not taking this class of medications. Cohorts and outcomes were defined using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-10) codes. We used the impact of Age, Race, Ethnicity, Body Mass Index, diabetes (DM) smoking history, history of radiation, and history of prostatectomy to generate propensity score matching (PSM). Our primary outcome was need for re-intervention (revision, removal, or replacement surgery) at any point after implantation based on CPT codes. Secondary outcomes included infection rate and overall device complication rate, including infections based on ICD-10 codes. Analytics were performed via TriNetX on demographic data which calculated Risk Ratios and were run on June 14th, 2022 Results In total, there were 8864 patients who underwent IPP and 4272 who underwent AUS (Table 1). After PSM, there were 292 patients in each IPP cohort and 74 patients in each AUS cohort. After matching for IPP and AUS, patients were similar ages (60.6 vs 60.6 years and 67.9 vs 67.8 years) with similar comorbidity profiles. The average Hemoglobin A1c level was 8.0 vs 7.4% (p&amp;lt;0.01) for IPP and 7.9% vs 7.3% (p=0.13) for AUS. Patients with an IPP on an SGLT2i were at a lower risk of overall complication (RR 0.60, p=0.02). There was no difference for AUS and risk of complication. There was no difference for either implant on risk of infection or need for second procedures for both AUS and IPP. Conclusions Patients taking SGLT2is may be safely offered urologic implants. To our knowledge, this is the first study to evaluate this class of medications in this patient population. There may be a difference in overall risk of complication for patients on SGLT2is getting an IPP, however there are similar rates of infection and re-intervention. These newer medications remain incompletely studied but the data supports their use in patients interested in implants. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast.