Current Procedural Terminology Codes Research Articles

Abstract B133: Disparities in risk factors for nonalcoholic fatty liver disease (NAFLD) among a racially and ethnically diverse cohort

Abstract Background NAFLD has become the leading cause of chronic liver disease and is an important risk factor for liver cancer. About 25% of the U.S. adult population has NAFLD, with prevalence up to 70% among those with type 2 diabetes. Racial and ethnic disparities in NAFLD show Asian and Hispanic Americans at greater risk. Yet, few studies have examined risk factors and the magnitude of influence of these risk factors for NAFLD in racially and ethnically diverse populations. Methods This cohort included patients ≥ 18 years old who had at least two in-person visits at least one year apart between 2000 and 2017 at Kaiser Permanente Hawai`i, a large, integrated healthcare system. We excluded those who had NAFLD diagnosis at baseline (i.e., first year after the first in-person visit from 2000-2017). From the electronic medical record, we obtained data on sociodemographic (age, sex, race, ethnicity) and behavioral (tobacco use, care utilization) characteristics. We also extracted Current Procedural Terminology codes, International Classification of Diseases (ICD)-9 and -10 codes, prescription orders, vital signs, and laboratory results. We used small-area neighborhood data from the Hawaii Neighborhoods Data System. We ran sequential Cox regression models with outcome of incident NAFLD with age as the time-scale, underlying stratification by baseline year and decile of number of outpatient and ED encounters, and clustering by census tract. We added in variables one-by-one based on the order of influence. This was calculated as the percent difference in effect separately for: 1) sex (men compared to women) and 2) for each race and ethnicity group (compared to non-Hispanic White) from the base model when adding in each covariate separately. Results Of 373,032 patients followed for a median of 5.6 years, 8,994 had a diagnosis of incident NAFLD (2.4%). Variables associated with NAFLD and disparities by sex or race/ethnicity included having hypertension, high triglycerides, lower HDL, smoking, diabetes, overweight or obese body mass index (BMI), limited English proficiency, history of smoking, chronic hepatitis C, or low neighborhood SES. High triglycerides (triglycerides ≥150 mg/dL) had a substantial impact on NAFLD risk by sex; when high triglycerides were accounted for, risk among men compared to women changed from higher (HR=1.28; 95% CI:1.16-1.40) to lower (HR=0.74; 0.60-0.91) risk of NAFLD. Risk factors with the greatest impact on NAFLD risk differed across racial/ethnic groups. Among American Indian/Alaska Native and Hispanic adults, chronic hepatitis C virus infection had the greatest impact on NAFLD risk; among Asian American and Native Hawaiian/Pacific Islander adults, it was diabetes mellitus; and among adults with multiple races or ethnicities, it was BMI. Discussion Our analyses show NAFLD risk factors differ by sex and by race and ethnicity. To reduce NAFLD disparities targeted interventions should address the risk factors that are most salient for each of these groups. Citation Format: Janet N. Chu, Mindy C. DeRouen, Alison J. Canchola, Aly Cortella, Pushkar P. Inamdar, Yihe G. Daida, Scarlett L. Gomez, Hashem El-Serag, Salma Shariff-Marco. Disparities in risk factors for nonalcoholic fatty liver disease (NAFLD) among a racially and ethnically diverse cohort [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B133.

Pathways Linking Post-Traumatic Stress Disorder to Incident Ischemic Heart Disease in Women: Call to Action

BackgroundPost-traumatic stress disorder (PTSD) is associated with increased rates of incident ischemic heart disease (IHD) in women. ObjectivesThe purpose of this study was to determine mechanisms of the PTSD-IHD association in women. MethodsIn this retrospective longitudinal cohort study, data were obtained from electronic health records of all U.S. women veterans who were enrolled in Veterans Health Administration care from January 1, 2000 to December 31, 2017. Propensity score matching was used to match women with PTSD to women without PTSD on age, number of prior Veterans Health Administration visits, and presence of various traditional and nontraditional cardiovascular risk factors at index visit. Cox regression was used to model time until incident IHD diagnosis (ie, coronary artery disease, angina, or myocardial infarction) as a function of PTSD and potential mediating risk factors. Diagnoses of IHD, PTSD, and risk factors were defined by International Classification of Diseases-9th or -10th Revision, and/or Current Procedural Terminology codes. ResultsPTSD was associated with elevated rates of developing each risk factor. Traditional risk factors (hypertension, hyperlipidemia, smoking, diabetes) accounted for 24.2% of the PTSD-IHD association, psychiatric risk factors (eg, depression, anxiety, substance use disorders) accounted for 33.8% of the association, and all 13 risk factors accounted for 48.5% of the association. ConclusionsTraditional IHD risk factors explained a quarter of the PTSD-IHD association in women veterans, and over half of the risk of IHD associated with PTSD remained unexplained even when adjusting for a wide range of risk factors. To be actionable, factors underlying the remaining PTSD-IHD association warrant timely investigation.

Quality ofIntegration ofAir Force Trauma Surgeons Within the Center forSustainment ofTrauma andReadiness Skills, Cincinnati: A Pilot Study.

While previous studies have analyzed military surgeon experience within military-civilian partnerships (MCPs), there has never been an assessment of how well military providers are integrated within an MCP. The Center for Sustainment of Trauma and Readiness Skills, Cincinnati supports the Critical Care Air Transport Advanced Course and maintains the clinical skills of its staff by embedding them within the University of Cincinnati Medical Center. We hypothesized that military trauma surgeons are well integrated within University of Cincinnati Medical Center and that they are exposed to a similar range of complex surgical pathophysiology as their civilian partners. After Institutional Review Board approval, Current Procedural Terminology (CPT) codes were abstracted from billing data for trauma surgeons covering University of Cincinnati Hospitals in 2019. The number of trauma resuscitations and patient acuity metrics were abstracted from the Trauma Registry and surgeon Knowledge, Skills, and Abilities clinical activity (KSA-CA) scores were calculated using their CPT codes. Finally, surgeon case distributions were studied by sorting their CPT codes into 23 categories based on procedure type and anatomic location. Appropriate, chi-squared or Mann-Whitney U-tests were used to compare these metrics between the military and civilian surgeon groups and the metrics were normalized by the group's full-time equivalent (FTE) to adjust for varying weeks on service between groups. Data were available for two active duty military and nine civilian staff. The FTEs were significantly lower in the military group: military 0.583-0.583 (median 0.583) vs. civilian 0.625-1.165 (median 1.0), P = 0.04. Per median FTE and surgeon number, both groups performed a similar number of trauma resuscitations (civilian 214 ± 54 vs. military 280 ± 13, P = 0.146) and KSA-CA points (civilian 55,629 ± 25,104 vs. military 36,286 ± 11,267; P = 0.582). Although the civilian surgeons had a higher proportion of hernia repairs (P < 0.001) and laparoscopic procedures (P = 0.006), the CPT code categories most relevant to combat surgery (those relating to solid organ, hollow viscus, cardiac, thoracic, abdominal, and tissue debridement procedures) were similar between the surgeon groups. Finally, patient acuity metrics were similar between groups. This is the first assessment of U.S. Air Force trauma surgeon integration relative to their civilian partners within an MCP. Normalized by FTE, there was no difference between the two groups' trauma experience to include patient acuity metrics and KSA-CA scores. The proportion of CPT codes that was most relevant to expeditionary surgery was similar between the military and civilian partners, thus optimizing the surgical experience for the military trauma surgeons within University of Cincinnati Medical Center. The methods used within this pilot study can be generalized to any American College of Surgeons verified Trauma Center MCP, as standard databases were used.

Incidence and Risk Factors for Revision Within 1 Year of Primary Carpal Tunnel Release.

The annual volume of carpal tunnel release (CTR) in the United States has been estimated to be 577 000 per year. Our objectives were to evaluate the incidence and risk factors for revision CTR within 1 year of primary CTR. We identified all adult patients undergoing primary CTR from October 2015 to September 2019 in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology (CPT) codes. We used the CPT modifier codes to determine laterality of index and revision procedures. We estimated multivariable hierarchical logistic regression models to evaluate risk factors for revision CTR within 1 year. Of the 80 423 primary CTR procedures, 178 (0.22%) underwent a revision CTR within 1 year of the index surgery. The mean (SD) age of the entire cohort was 58.69 (14.43) years, 61.1% were women, 73.2% were non-Hispanic white, 42.9% were covered through private insurance, and 9.5% had diabetes mellitus. Workers' compensation insurance (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.13-2.98, P = .02) and simultaneous bilateral CTR (OR = 14.91, 95% CI, 9.62-23.12, P < .001) were associated with revision CTR within 1 year of the index procedure. No models demonstrated an association between endoscopic technique or surgeon volume and revision CTR. The incidence of revision CTR within 1 year was lower than that previously reported. Patients covered by workers' compensation and those undergoing simultaneous bilateral CTR had higher likelihood of a revision CTR within 1 year, whereas endoscopic technique and surgeon volume were not associated with revision CTR within 1 year.

Trends in orthopaedic surgery resident case volume and the impact of COVID-19 on resident education

IntroductionCOVID-19 had numerous objective and subjective effects on resident physician education. We intended to examine objective changes in orthopedic education that occurred during the COVID pandemic and other trends from 2018 to 2022 by analyzing surgical case logs from Accreditation Counsel for Graduate Medical Education (ACGME) approved American orthopedics programs. We hypothesized that surgical case load during the COVID pandemic would remain similar to pre-pandemic levels and case logs would show a general upward trend. MethodsWe analyzed 3146 resident case-logs from the ACGME national case-log report from academic years (AY) 2018–2022. Surgical cases were classified by their Current Procedural Terminology (CPT) codes and grouped by anatomical location (shoulder, hand, etc.). ResultsFrom AY 18–19 to “peak pandemic” AY 19–20, resident caseloads either had no change or increased in every orthopedic discipline with few exceptions. Residents performed fewer shoulder (p < 0.0001), wrist (p = 0.0023), knee (p < 0.0001) and leg/ankle (p = .0019) arthroscopies in AY 19–20 than AY 18–19. Hip arthroscopy was notably unchanged. Oncology, Spine, and Foot/Toes did not see any change from AY 18–19 to 21–22 while Microsurgeries decreased (p = .0061). There were substantial differences between high volume (90th percentile) residents, and low volume (10th percentile) residents. All other anatomic areas saw significant increases in caseload over those four academic years. Discussion/conclusionCOVID had numerous effects on the orthopedic residency experience, however, any decreases in operative load were small, and largely isolated to the 19–20 AY. Microscopic and arthroscopic surgeries decreased during peak pandemic AY 19–20 when elective surgeries experienced cancellations. This illustrates that these areas of orthopedic education may be supplemented outside of the operating room if similar circumstances arise in the future. Otherwise, resident surgical caseloads continue to rise and show no signs of slowing.

Forecasting The Impact of the 2023 Current Procedural Terminology Coding Changes On Ventral Hernia Work Relative Value Units. A Cross-Sectional Study

BackgroundIn January 2023, significant changes were implemented to ventral hernia repair Current Procedural Terminology codes, with new codes replacing previous codes. The new codes were assigned a 0-day global period. The impact of these changes on clinical productivity remains unclear. Our objective was to forecast the impact of Current Procedural Terminology changes on ventral hernia-related work relative value units using historical data. MethodsVentral hernia repairs performed between March 2021 and December 2022 on adults by a single surgeon with available 90-day follow-up were retrospectively retrieved from the Abdominal Core Health Quality Collaborative. Demographic, hernia, and operative and postoperative data were collected. The ventral hernia repairs were coded twice using the previous and new Current Procedural Terminology codes, and work relative value units were calculated using both systems. The median work relative value units per case were compared using the Wilcoxon signed-rank test. ResultsA total of 143 ventral hernia repairs were included. The median age was 59 years, and 50% of patients were male. Median hernia width and length were 3.5 and 5.0 cm, respectively. The most common ventral hernia types were incisional 57% and umbilical 33%. Twenty percent of hernias were recurrent, and 99% were elective repairs. 49% of the procedures were open, 30% robotic, and 21% laparoscopic. Component separation was performed in 16%. The median length of stay was 0.0, and the median number of 90-day outpatient postoperative visits was 1.0. The new Current Procedural Terminology coding system was associated with a higher median 90-day work relative value units per case (14.1) than the previous system (13.8) (P = .002). Subset analysis identified statistically higher median 90-day work relative value units per case using the new versus previous Current Procedural Terminology codes for hernias with the largest defect dimension >10 cm (23.3 vs 18.8), umbilical/epigastric/Spigelian hernias (9.2 vs 7.1), recurrent hernias (20.1 vs 17.3) and open ventral hernia repairs (9.8 vs 7.1), all P < .05. Median 90-day work relative value units per case were statistically lower using the new versus previous codes for non-recurrent (11.6 vs 13.8) and incarcerated/strangulated (14.8 vs 14.9) hernias, all P < .05. In the new coding system, postoperative care within 90-days contributed to a median of 1.3 work relative value units per case (9% of total 90-day work relative value units). ConclusionWe forecast that in our practice, the 2023 ventral hernia repair Current Procedural Terminology changes will result in a modest impact on clinical productivity. The impact of these changes on a particular practice depends on surgical practice patterns and ventral hernia case mix.

Risk Factors for Penile Fracture After Intralesional Collagenase Clostridium histolyticum in Peyronie’s Disease

ObjectivesTo evaluate risk factors leading to corporal rupture after Collagenase Clostridium histolyticum (CCh). Peyronie's disease (PD) is a fibrotic condition of the penis characterized by abnormal plaque formation. Intralesional CCh is the only FDA approved medication for PD, however it can lead to corporal rupture, a potential surgical emergency. MethodsWe retrospectively reviewed medical records from Veterans diagnosed with PD who were under treatment with CCh using the Veterans Administration Informatics and Computing Infrastructure (VINCI). Using International Classification of Diseases and Current Procedural Terminology codes, we identified men who suffered a corporal rupture after CCh. Individual charts were reviewed to determine potential risk factors and events leading to corporal rupture. ResultsWe identified 17,647 veterans who were diagnosed with PD, of which 8.7% (1,541) received at least one injection of CCh for PD. Of them, 0.7% (11/1,541) veterans suffered corporal rupture. Within these 11 patients, the median number of CCH injections was 6 with a median initial curvature of 35º. Fracture occurred at a median of 8 days after CCH injection. The majority of fractures were secondary to spontaneous erections or sexual intercourse. Finally, six patients had their fracture repaired surgically while the remaining were managed conservatively. ConclusionsMost fractures occurred within 2 weeks of CCh injections and were associated with sexual intercourse and spontaneous morning erections.

Abstract 15616: Decline in Temporal Trends of Medicare Physician Reimbursement for Cardiovascular Procedures

Introduction: Utilization of cardiac procedures are common among Medicare beneficiaries and projected to increase over time. Temporal trends of physician fee reimbursement for CV procedures have not been studied. Methods: Cross-sectional study was conducted for national payment amounts that were extracted from Centers for Medicare &amp; Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool using Current Procedural Terminology (CPT) codes. Study time period ranged from 2013 through 2023. CPT codes were analyzed for coronary (percutaneous coronary intervention, coronary artery bypass graft), valvular (surgical aortic, mitral, tricuspid repair/replacement), and structural (transcatheter aortic valve replacement, mitral transcatheter edge-to-edge repair, left atrial appendage occlusion) procedures. All prices were adjusted for inflation to January 2023 US dollars. Primary outcomes were unadjusted and adjusted mean percentage changes (annual and total over 10-year period) and compound annual growth rates for each CV procedure. Results: From 2013 to 2023, mean total unadjusted percentage changes ranged from -0.54% to -21.78%; which decreased further after adjusting for inflation, ranging from -21.07% to -39.83%. The decline was seen in all studied CV procedures. Annual rates (mean and compound) were -3% for most procedures after adjusting for inflation. Conclusions: Our findings suggest a declining trend in physician reimbursement for CV procedures by Medicare, which may adversely influence access to procedures, affect commercial insurance pricing/coverage, and inform trainees and practicing CV physicians of current financial situation. Emphasis needs to be placed on value-based payment model for sustainable and efficient CV care.

Abstract 17978: Validation of Contemporary Administrative Codes for Identifying Pulmonary Vein Isolation Procedures

Introduction: Use of pulmonary vein isolation (PVI) to treat atrial fibrillation continues to grow. Despite great interest in leveraging administrative data for real-world analyses, contemporary procedural codes for identifying PVI have not been validated. Methods: Inpatient PVIs were identified among US Medicare fee-for-service beneficiaries using Current Procedural Terminology (CPT) code 93656 in the Carrier Line Files. Each patient was cross-matched by procedure date with claims from Medicare Provider Analysis and Review Files (MedPAR), in order to compare CPT claims with International Classification of Diseases-10 th Revision Procedure Coding System (ICD-10 PCS) claims submitted by healthcare facilities to bill for each PVI. We performed the reverse for commonly matched ICD-10-PCS codes, to identify their corresponding CPT-billed procedures. Results: We identified 20,388 inpatient PVIs from 1/2017 to 12/2020, of which 14,468 (71%) were linked to MedPAR by same-day procedure date. Of these, 13,156 (91%) were billed as ICD-10 02583ZZ “ Destruction of Conduction Mechanism, Percutaneous Approach ”, with lower use of other codes. However, the reverse process yielded heterogeneous results: among 75,003 procedures billed as ICD-10 02583ZZ, only 15,691 (21%) matched with CPT 93656 (PVI), as several other procedures were interchangeably billed under this same ICD-10 code (Figure). Conclusions: Compared with CPT codes as a gold standard, the ICD-10-PCS code most commonly associated with CPT-billed PVI procedures actually refers to ablation of the atrio-ventricular junction. Yet this same ICD-10-PCS code also matches with a wide range of other procedures distinct from PVI. We conclude that ICD-10-PCS codes alone are not sensitive or specific for identifying PVI in claims, and cannot be reliably used in isolation for health services research on this important procedure.

Socioeconomic status is associated with greater hazard of post-discharge mortality than race, gender, and ballistic injury mechanism in a young, healthy, orthopedic trauma population

ObjectivesTo explore the utility of legacy demographic factors and ballistic injury mechanism relative to popular markers of socioeconomic status as prognostic indicators of 10-year mortality following hospital discharge in a young, healthy patient population with isolated orthopedic trauma injuries. MethodsA retrospective cohort study was performed to evaluate patients treated at an urban Level I trauma center from January 1, 2003, through December 31, 2016. Current Procedure Terminology (CPT) codes were used to identify upper and lower extremity fracture patients undergoing operative fixation. Exclusion criteria were selected to yield a patient population of isolated extremity trauma in young, otherwise healthy individuals between the ages of 18 and 65 years. Variables collected included injury mechanism, age, race, gender, behavior risk factors, Area Deprivation Index (ADI), and insurance status. The primary outcome was post-discharge mortality, occurring at any point during the study period. ResultsWe identified 2539 patients with operatively treated isolated extremity fractures. The lowest two quartiles of socioeconomic status (SES) were associated with higher hazard of mortality than the highest SES quartile in multivariable analysis (Quartile 3 HR: 2.2, 95% CI: 1.2–4.1, p = 0.01; Quartile 4 HR: 2.2, 95% CI: 1.1–4.3, p = 0.02). Not having private insurance was associated with higher mortality hazard in multivariable analysis (HR 2.0, 95% CI: 1.3–3.2, p = 0.002). The presence of any behavioral risk factor was associated with higher mortality hazard in univariable analysis (HR: 1.8, p < 0.05), but this difference did not reach statistical significance in multivariable analysis (HR: 1.4, 95%: 0.8–2.3, p = 0.20). Injury mechanism (ballistic versus blunt), gender, and race were not associated with increased hazard of mortality (p > 0.20). ConclusionLow SES is associated with a greater hazard of long-term mortality than ballistic injury mechanism, race, gender, and medically diagnosable behavioral risk factors in a young, healthy orthopedic trauma population with isolated extremity injury.

Oncoplastic breast reduction surgery decreases rates of reoperation with no increased medical risk

The purpose of this study is to compare the oncologic, medical, and surgical outcomes of lumpectomy versus oncoplastic breast reduction surgery (OBRS) on a national scale. A national insurance-based database was queried for patients who had a lumpectomy with or without a same-day breast reduction by Current Procedural Terminology (CPT) codes. Patients were then matched by obesity, body mass index range, age, region, neoadjuvant chemotherapy, and outcomes were compared. There were 421,455 patients in the lumpectomy group and 15,909 patients in the OBRS group. After matching, 15,134 patients were identified in each group. Repeat lumpectomy or subsequent mastectomy was more common in the lumpectomy group (15.2% vs. 12.2%, p<0.001). OBRS patients had higher rates of 90-day surgical complications including dehiscence, infection, fat necrosis, breast abscesses, and antibiotic prescription (p<0.001). Meanwhile, any medical complication was less common in the OBRS group (3.7% vs. 4.5%, p=0.001). Logistic regression revealed that OBRS was associated with decreased odds of repeat lumpectomy (OR=0.71, 95% CI 0.66-0.77, p<0.001) with no significant increased odds of subsequent mastectomy (OR=1.01, 95% CI 0.91-1.11, p=0.914).OBRS was found to be associated with decreased risk for reoperation in the form of lumpectomy without increased likelihood of subsequent mastectomy. Although OBRS was associated with increased wound complications, medical complications were found to occur less frequently. This study endorses increased consideration of OBRS when lumpectomy or OBRS is appropriate.

Changes in the Utilization of Cervicothoracic Injections Between 2010 and 2020.

Descriptive epidemiologic study. To analyze trends and patient characteristics of those undergoing cervicothoracic transforaminal, interlaminar, and facet injections over time. Cervicothoracic transforaminal, interlaminar, and facet injections are considered for varied spinal pathologies. Evolving literature, changing physician preferences, insurance reimbursement policies, and patient factors may influence the utilization of such injections over time. Patients undergoing cervicothoracic transforaminal, interlaminar, and facet injections 2010-2020 were identified in the M151Ortho PearlDiver database using Current Procedural Terminology coding. Patient age, sex, Elixhauser Comorbidity Index, insurance plan (commercial, Medicaid, Medicare), and region of the country where the procedure was performed (Midwest, Northeast, South, and West) were extracted and assessed over study intervals based on prevalence per 100,000 covered lives. Cervicothoracic transforaminal, interlaminar, and facet injections were identified for 195,221 (11.3%), 951,191 (55.2%), and 575,228 (33.4%) patients, respectively. Patient characteristics for each injection type were defined. The annual number of injections performed per 100,000 covered lives decreased during the study period for transforaminal (17.1% decrease) and interlaminar (9.3% decrease) but increased for facet (3.7% increase) injections ( P <0.0001 for each). Stratifying by patient insurance type, administration of transforaminal, interlaminar, and facet injections per 100,000 covered lives was proportionally greatest for commercially insured patients (55%, 50%, and 45%, respectively), and proportionally smallest for Medicaid patients (10%, 13%, and 13%, respectively). Anesthesiology physicians performed the most injections, followed by physical medicine and rehabilitation physicians, with both provider types most frequently performing interlaminar injections, followed by facet and transforaminal injections. Annual cervicothoracic transforaminal and interlaminar injection utilization declined by 17.1% and 9.3% from 2010 to 2020, whereas facet injection administration increased by 3.7% over the same interval. Evolving practice patterns are important to consider in characterizing the overall landscape of spine care.

Gender-affirming hysterectomy in the United States: A comparative outcomes analysis and potential implications for uterine transplantation.

Hysterectomy is a gynecological procedure sometimes performed as part of the gender-affirming process for transgender and gender-expansive patients assigned female at birth. Our goal was to compare surgical outcomes between patients undergoing gender-affirming hysterectomy and patients undergoing hysterectomy for benign menstrual disorders. We then explored the implications of gender-affirming hysterectomy for uterine transplantation. We performed a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2009 through 2018. We identified patients undergoing hysterectomy in the United States based on Current Procedural Terminology code. We used the International Classification of Diseases 9 or 10 codes to identify patients with benign menstrual disorders (non-gender-affirming group) and gender dysphoria (gender-affirming group). We compared patient characteristics and surgical complications. Of the 40,742 patients that met inclusion criteria, 526 (1.3%) patients were individuals with gender dysphoria. Compared to patients who underwent hysterectomy for benign menstrual disorders, gender-affirming patients were younger, were healthier, had a lower prevalence of diabetes, and were more likely to undergo surgery in the outpatient setting, with shorter time to discharge. Complication rates were similar between groups. Logistic regression controlling for the American Society of Anesthesiology classification determined the difference of return to the operating room was not statistically significant (OR 1.082; 95% CI, 0.56-2.10; p = 0.816). Gender-affirming hysterectomy has a safety profile similar to hysterectomy performed for benign menstrual disorders. Researchers should further explore the possibility of uterus donation among these patients as they may be suitable candidates.

Clinical and Laboratory Indications for Serum Protein Electrophoresis Testing in US Veterans: A Retrospective Cohort Study

Introduction: Serum Protein Electrophoresis (SPEP) is a frequently ordered diagnostic test when there is suspicion of plasma cell dyscrasia, based on clinical or laboratory abnormalities. This study describes the demographic characteristics of US Veterans who underwent SPEP testing, evaluates the distribution of clinical and laboratory abnormalities, and their influence on SPEP test ordering by Veteran Health Administration (VHA) providers. Methods: The study employed a retrospective cohort design utilizing national data from the VHA. We included Veterans aged 50-65 years who had a total protein test performed at any time. Veterans who were dually enrolled in VHA and Medicare were excluded because of the unavailability of laboratory data in Medicare. An ordered SPEP was defined by Current Procedural Terminology codes of 84165 or 83883. Multivariable logistic regression was performed to examine the association of SPEP testing with clinical and laboratory indications, including, chronic kidney disease, anemia, pathologic fractures, vertebral fracture, neuropathy, total protein level, hypercalcemia, and body mass index, as well as sociodemographic factors, including, race, sex, socioeconomic status, and geographic location. The clinical and laboratory indications were selected based on literature review and clinicians' input. For patients who received SPEP testing, data on these indications within one year before their initial SPEP test were used. For patients who did not receive SPEP testing, these indications were collected within one year of their most recent total protein test. Result: Between 1999 and 2022, 294,640 Veterans were identified, with 17,035 (5.78%) undergoing SPEP testing. Veterans who had SPEP testing were mostly male (77%), White (51%), and frequently obese (BMI&amp;gt;30 kg/m 2) (42%). In addition, 17% of these Veterans who had SPEP testing had neuropathy, 15% had anemia, 11% had chronic kidney disease, 4% had a total protein level &amp;gt; 8.5gm/dL, and 2% had hypercalcemia. Only 0.5% had pathologic fractures and 0.5% had vertebral fractures. VHA providers ordered SPEP tests more often in African American Veterans than White Veterans (OR 1.34, 95% CI 1.29-1.39), and less often in underweight (BMI &amp;lt; 18.5 kg/m 2) Veterans compared to normal-weight (18.5-24.9 kg/m 2) Veterans (OR 0.55, 95% CI 0.40-0.74). SPEP testing was more likely in Veterans having total protein level &amp;gt;8.5gm/dL (OR 3.87, 95% CI 3.47-4.32), vertebral fracture (OR 3.44, 95% CI 2.47-4.81), anemia (OR 3.26, 95% CI 3.06-3.48), hypercalcemia (OR 3.04, 95% CI 2.53-3.65), neuropathy (OR 2.55, 95% CI 2.43-2.69), pathologic fracture OR 2.38, 95% CI 2.38-1.52), and chronic kidney disease (OR 1.97, 95% CI 1.81-2.14) compared to Veterans without the respective indication. Conclusions: VHA providers were likely to order a SPEP for protein level &amp;gt;8.5gm/dL, vertebral fracture, anemia, hypercalcemia, neuropathy, pathologic fracture, and chronic kidney disease. Obesity and demographic factors such as African American race were also associated with SPEP testing. Further research is needed to evaluate the combined influence of these factors on SPEP testing, as well as factors that lead clinicians to order multiple SPEP tests prior to the diagnosis of plasma cell dyscrasias.

NATIONWIDE DEMOGRAPHIC DISPARITIES IN UNITED STATES EMERGENCY DEPARTMENT VISITS IN PATIENTS WITH RHEGMATOGENOUS RETINAL DETACHMENT.

Within the evolving landscape of healthcare in the United States (US), delineating the demographic nuances and financial implications of emergent conditions, such as rhegmatogenous retinal detachment (RRD), is paramount. This study seeks to analyze the demographic and hospital billing amount/cost of service disparities in RRD visits to emergency departments (EDs) nationwide. We conducted a retrospective, cross-sectional, population-based study using International Classification of Diseases, 10th revision , and Current Procedural Terminology codes in the 2016 to 2019 Nationwide Emergency Department Sample databases to identify RRD visits. The analysis included demographics, hospital billing amount, and cost of service of RRD ED management. A total of 12,492 RRD encounters were identified with men constituting 64% and a prominent age group being 50 to 64 years (49.3%). Most patients (90%) were managed in metropolitan teaching hospitals, predominantly in the southern U.S. region (56.1%). Private insurance covered 45% of patients. Same-day RRD repair odds increased in November and December. Whites had a higher likelihood for same-day treatment. Hospital billing amount rose from $23,600 in 2016 to $30,354 in 2019, with stable mean total cost of service. Rhegmatogenous retinal detachment ED visit incidence did not show seasonal variation ( P = 0.819). Most patients with RRD in U.S, EDs were middle-aged men, with Whites more likely to receive same-day repair. There was no sex bias observed in same-day repair decision-making. Although hospital billing amount increased over the study period, total cost of service remained stable. The incidence of RRD ED visits showed no seasonal variation.

Assessing out-of-pocket cost differences in treatment for Medicare-eligible patients with favorable prognosis early-stage Hodgkin lymphoma.

15 Background: In the treatment of favorable Hodgkin Lymphoma (HL), Level 1 evidence comparing combined modality therapy (CMT) with chemotherapy alone has persistently demonstrated that obviating radiation therapy (RT) worsens recurrence rates despite no significant overall survival difference. As there remains limited evidence on the granularity of the impact of insurance on HL treatment, this project disaggregates costs by insurance plans to enhance the transparency of out-of-pocket (OOP) cost estimations in Medicaid and/or Medicare-eligible (age 65+) patients. Methods: National Comprehensive Cancer Network guidelines were queried to assess the appropriate therapy for HL. Following initial adriamycin/bleomycin/vinblastine/dacarbazine (ABVD) chemotherapy x 2 cycles with Deauville 1-2 response on PET scan, CMT was defined as involved site RT (20 Gy / 10 fractions), while chemotherapy alone was defined as an additional ABVD x 2. Current Procedural Terminology and Healthcare Common Procedure Coding System codes identified treatments. OOP expenditures, deductibles, and copay/coinsurance were computed for Medicaid, Original Medicare, and Medigap Plan G plans via medicare.gov, medicaid.oh.gov, and cms.gov. Price estimates (from actual prices per insurance plan rather than claims data predictions) assume an Ohio hospital location (zip code = 44106) for all treatments. Total costs were calculated based on all treatments plus a 5-year follow-up (not adjusted for inflation). Treatment charges for chemotherapy alone include initial medical oncology office visit, cost of ABVD x 4, and infusion costs for 4 cycles. Additional treatment charges for CMT include initial radiation oncology consultation, treatment planning, dosimetry calculations, treatment device, simulation and verification, RT delivery, on-treatment visits, medical physics consultation, and annual TSH labs. Results: With Original Medicare plans, patients are faced with an OOP cost of 20% for Medicare Part B claims with no cost cap for approved procedures after the deductible. As such, patients are faced with a total 6-year charge of $1,928.95 for chemotherapy alone, and $2,385.28 for CMT. Under Medigap Plan G, patients encounter an OOP charge of $1,151.14 for chemotherapy alone and $1,176.34 for CMT. Medicaid beneficiaries (assuming all treatments are approved by Medicaid) face no OOP expenses for both treatment plans, as all expenses are covered without limit. Conclusions: By comparing OOP costs between Medicare and Medicaid plans, this model improves cost transparency in the treatment of favorable early-stage HL. Our findings indicate that omitting RT in favor of chemotherapy alone yields a cost savings of 2-24% at a 5-year follow-up. Further studies are required to assess whether these savings compensate for the inferior outcomes achieved by omitting RT in this patient population.

Financial Impact of Imaging Examination Site of Service in the Medicare Population.

The financial sustainability of the US healthcare system is a growing concern in an environment of declining reimbursement and rising costs. Variable Centers for Medicare and Medicaid (CMS) reimbursement and denial rates for specific imaging examinations exist across sites of service, adding complexity to financial planning for healthcare organizations. Understanding the financial implications of site of service in existing CMS reimbursement for imaging may be of strategic importance for organizations going forward. Current Procedural Terminology (CPT) codes were obtained for common cross-sectional imaging examinations using the 2022 CMS Medicare Physician Fee Schedule. Using reimbursement rates with historical volumes and denial rates, a simulation was created to estimate the overall reimbursement of paired hospital outpatient departments (HOPD) and free-standing office (FSO) sites. A baseline simulation was performed with random allocation of imaging examinations between sites of service, and an optimized simulation was performed to estimate the maximum financial impact of targeted allocation between sites. These simulations were performed for paired CT and MR scanners separately. For CT, the baseline simulation estimated annual average reimbursement for combined HOPD and FSO was $3.25M. Reimbursement increased to $3.51M after optimized reallocation of studies between sites of service, resulting in an expected gain of $260,162 for a set of paired HOPD and FSO scanners. For MR, the same approach resulted in baseline reimbursement of $2.51M, increasing to $2.60M upon reallocation between sites for an expected gain of $87,532. Assuming a stable cost of service delivery, this approach would result in improved margins of 8% for CT and 3.5% for MR. There were 28 CT and 19 MRI daily patient imaging appointments at each respective HOPD and FSO scanners, unchanged between baseline and optimized cases. Differences in reimbursement rates between sites were the dominant driver of increased margins at low denial rates, although denial rates became dominant at values greater than 50%. Given CMS payment and denial rate variability, optimally allocating imaging studies between sites of service may improve reimbursement for the same services delivered. Although financial incentives exist for site allocation, such decisions should require physician input to assess safety and appropriate level of care. This work contributes to an understanding of financial incentives of existing reimbursement policy and may guide future policy design towards high value care.

Association of Emergency Department Evaluation With Public Insurance Use and Treatment Delays for ACL Injury.

Utilization of an emergency department (ED) visit for anterior cruciate ligament (ACL) injury is associated with high cost and diagnostic unreliability. Patients initially evaluated at an ED for an ACL injury would be more likely to be from a lower income quartile, use public insurance, and experience a delay in treatment. Cohort study; Level of evidence, 3. Patients in the Rhode Island All Payers Claims Database who underwent ACL reconstruction (ACLR) between 2012 and 2021 were identified using the Current Procedure Terminology (CPT) code 29888. Patients were stratified into 2 cohorts based on CPT codes for ED or in-office services within 1 year of ACLR. A chi-square analysis was used to test for differences between cohorts in patient and surgical characteristics. Multivariable linear and logistic regression were used to determine how ED evaluation affected timing and outcome variables. While adjusting for patient and operative characteristics, patients in the ED cohort were more likely to have Medicaid (29% vs 12.5%; P < .001) and be in the lowest income quartile (44.6% vs 32.1%; P < .001). ED visit and Medicaid status were associated with increased time to (1) diagnostic magnetic resonance imaging, adding 7.97 days on average (95% CI, 4.14-11.79 days; P < .001) and 8.40 days (95% CI, 3.44-13.37 days; P = .001), respectively; and (2) surgery, adding 20.30 days (95% CI, 14.10-26.49 days; P < .001) and 12.88 days (95% CI, 5.15-20.60 days; P = .001), respectively. Patients >40 years who were evaluated in the ED were 2.5 times more likely to require subsequent ACLR (odds ratio, 2.50 [95% CI, 1.01-6.21]; P = .049). In this study, patients who visited the ED within 1 year before ACLR were more likely to have a lower income, public insurance, increased time to diagnostic imaging, and increased time to surgery, as well as decreased postoperative physical therapy use and increased subsequent ACLR rates in the 40-49 years age-group.

Digital musculoskeletal program is associated with decreased joint replacement rates.

To compare 12-month total knee arthroplasty (TKA) and total hip arthroplasty (THA) rates for digital musculoskeletal (MSK) program members vs patients who received traditional care for knee or hip osteoarthritis (OA). Retrospective, longitudinal study with propensity score-matched comparison group that used commercial medical claims data representing more than 100million commercially insured lives. Study participants with hip OA (M16.x) or knee OA (M17.x) International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were identified in the medical claims database. Digital MSK program members were identified using record linkage tokens. The comparison group had hip- or knee-related physical therapy identified via ICD-10-CM and Current Procedural Terminology codes. Respectively in each knee and hip OA group, digital members were matched to control group patients with similar demographics, comorbidities, and baseline MSK-related medical care use. TKA and THA at 12 months post participation were compared. In the knee OA group, 739 of 56,634 control group patients were matched to 739 digital members. At 12months, 3.79% of digital members and 14.21% of control group patients had TKA (difference, 10.42%; P < .001). In the hip OA group, 141 of 20,819 control group patients were matched to 141 digital members. At 12 months, 16.31% of digital members and 32.62% of control group patients had THA (difference, 16.31%; P = .001). These findings suggest that patients who participated in a digital MSK program to manage OA have lower rates of total joint arthroplasty in the 12 months afterenrollment.

Real-World Continuous EEG Utilization and Outcomes in Hospitalized Patients With Acute Cerebrovascular Diseases.

Continuous electroencephalography (cEEG) is recommended for hospitalized patients with cerebrovascular diseases and suspected seizures or unexplained neurologic decline. We sought to (1) identify areas of practice variation in cEEG utilization, (2) determine predictors of cEEG utilization, (3) evaluate whether cEEG utilization is associated with outcomes in patients with cerebrovascular diseases. This cohort study of the Premier Healthcare Database (2014-2020), included hospitalized patients age >18 years with cerebrovascular diseases (identified by ICD codes). Continuous electroencephalography was identified by International Classification of Diseases (ICD)/Current Procedural Terminology (CPT) codes. Multivariable lasso logistic regression was used to identify predictors of cEEG utilization and in-hospital mortality. Propensity score-matched analysis was performed to determine the relation between cEEG use and mortality. 1,179,471 admissions were included; 16,777 (1.4%) underwent cEEG. Total number of cEEGs increased by 364% over 5 years (average 32%/year). On multivariable analysis, top five predictors of cEEG use included seizure diagnosis, hospitals with >500 beds, regions Northeast and South, and anesthetic use. Top predictors of mortality included use of mechanical ventilation, vasopressors, anesthetics, antiseizure medications, and age. Propensity analysis showed that cEEG was associated with lower in-hospital mortality (Average Treatment Effect -0.015 [95% confidence interval -0.028 to -0.003], Odds ratio 0.746 [95% confidence interval, 0.618-0.900]). There has been a national increase in cEEG utilization for hospitalized patients with cerebrovascular diseases, with practice variation. cEEG utilization was associated with lower in-hospital mortality. Larger comparative studies of cEEG-guided treatments are indicated to inform best practices, guide policy changes for increased access, and create guidelines on triaging and transferring patients to centers with cEEG capability.