Procedure Volume Research Articles

EGS SO23 - The undifferentiated general surgical take over 10 years: Emergency operating

Abstract Background The aim of this study is to further understand the specific pressures on the department’s operating theatres and capacity, and to identify areas in which we could adapt to facilitate these demands, by reviewing the undifferentiated general surgical admissions in a District General Hospital in July 2013 and July 2023. Method All patients seen by the emergency general surgical team in July 2013 and July 2023 were identified retrospectively. Data was gathered using electronic notes, to analyse admissions and surgeries within 30 days. Patients were excluded if there was insufficient information available. Results 26% (n=102/395) of all patients treated by emergency general surgical teams in July 2013 had surgery within 30 days. This proportion reduced to 23% (134/594) in July 2023, however overall volume has increased by 31%. The proportion of procedures performed on the day of admission has decreased from 10% to 7%. 3% of procedures were performed under local anaesthetic both in 2013 and 2023. Wait from admission to surgery has decreased from 2.84 days (+/-0.6, p=0.02) in 2013, to 1.9 days in 2023 (+/-0.83, p=0.02). Conclusion Although volume of procedures within the same 31-day period has increased throughout the 10 years, the proportion of patients that proceed to intervention has reduced marginally. This is reflected in the increasingly busy emergency operating lists throughout the country, with little change in resources to account for increasing volume. The rising proportion of patients managed conservatively may represent improving medical management of conditions, or more pragmatic management of frail patients.

Abstract 4137165: Changes in Contrast Volume among Patients Undergoing Percutaneous Coronary Intervention: a Report from NCDR CathPCI registry

Background: Acute kidney injury (AKI) is the most common complication after percutaneous coronary intervention (PCI) and can be mitigated by using less iodinated contrast. The National Cardiovascular Data Registry (NCDR) supports quality improvement initiatives by providing quarterly, risk-adjusted, institutional AKI rates. However, it remains uncertain whether these efforts have reduced procedural contrast volume, particularly in high-risk patients. Aims: Examine temporal trends in contrast volume during PCI across different pre-procedural AKI risk strata. Methods: Within the NCDR CathPCI Registry, we identified PCIs performed between April 1, 2018, and December 31, 2022, and examined changes in mean contrast volume over time across different pre-procedural AKI risk strata defined by the validated NCDR AKI risk model. A multivariable hierarchical model, with the physician as a random effect, was constructed to assess the trend in contrast volume use over time. Results: Among 3,126,559 patients undergoing PCI (mean age = 66.8 ± 11.7 years, 69.4% men, and 39.9% elective procedures), contrast volume declined from a mean of 168.1±77.6 ml in Q2 2018 to 149.8±71.2 ml in Q4 2022 ( p < 0.001 for trend) with the trend being consistent across AKI risk strata ( Figure ). After adjusting for patient and pre-procedural characteristics, the contrast volume declined by 18.9 ml (95%CI 19.1 to 18.6, P <0.001) between 2018 and 2022. Despite marked physician variability in mean contrast use, the lowest mean contrast doses were observed in patients at greatest AKI risk (>15%). Conclusions: PCI contrast administration has declined over time, and the average exposure was lowest in patients at highest risk for AKI, suggesting improved efforts to reduce AKI over time.

Abstract 4118804: Use and Clinical Outcomes Associated with Urgent versus Elective Catheter Ablation of Atrial Fibrillation in the United States

Introduction: Catheter ablation of atrial fibrillation (AF) is an increasingly important evidence-based treatment option for select patients. Although typically performed as an outpatient elective procedure, the use and clinical outcomes of AF ablation pursued urgently among inpatients have not been adequately characterized. Hypothesis: Rate of urgent AF ablation, defined as an AF ablation procedure pursued among inpatients hospitalized for a non-procedural indication, has increased over time, and may be associated with worse outcomes. Aims: To describe the use and outcomes of urgent versus elective AF ablation. Methods: Using the NCDR AFib Ablation Registry, patients who underwent AF ablation from 1/1/2016 to 6/30/2023 were stratified according to whether AF ablation was urgent or elective. Logistic regression models were fitted to determine patient and hospital-level factors associated with use of urgent AF ablation. Cochrane-Armitage tests were used to test for trends over time. Unadjusted and adjusted in-hospital event rates were reported. Results: Among 140,051 patients, 2,714 (1.9%) underwent urgent inpatient AF ablation and 137,337 (98.1%) elective ablation. Compared with the elective cohort, those undergoing urgent ablation had higher rates of co-morbid conditions including: diabetes (30.6% vs. 20.4%, P<0.0001), coronary artery disease (30.8% vs. 22.7%, P<0.0001), and heart failure (47.1% vs 20.8%, P<0.0001). Urgent AF ablation was more often used among patients of Black race (OR 1.68; 95% CI: 1.41 – 2.0) and those with AF at the time of the procedure (OR 1.73; 95% CI: 1.36 – 2.20). Higher hospital procedural volume of AF ablations ([per 100 cases] OR 1.22; 95% CI: 1.20 – 1.25) was also associated with higher odds of urgent AF ablation. The use of urgent AF ablation increased from 0.5% in 2016, to 2.0% in 2023 (P<0.0001). Unadjusted event rates for AF-related complications were significantly higher for the urgent cohort (Figure). The adjusted rate of any procedure-related complication was significantly higher in the urgent cohort (urgent 4.9% vs. elective 2.4%, P<0.0001). Conclusions: The rate of urgent inpatient AF ablation has increased over time. Compared with elective AF ablation, after adjustment for patient risk factors, urgent AF ablation is associated with significantly higher rates of procedural complications. Use of urgent, inpatient AF ablation should be carefully considered within clinical contexts and offered to select patients.

Trends in Medicare Reimbursement and Service Volume of Vitreoretinal Procedures: 2000 to 2021.

Purpose: To characterize trends in service volume and inflation-adjusted Medicare reimbursement of vitreoretinal procedures over the past 2 decades. Methods: Medicare Part B National Summary Data Files were accessed to identify the number of allowed services for vitreoretinal procedures. The Medicare Physician Fee Schedule was accessed to identify average annual national reimbursement rates. The Spearman correlation coefficient was used to evaluate time trends for each procedure. All analyses were conducted using Prism 9.5.1 software with 2-sided significance testing and statistical significance set at P ≤ .05. Results: From 2000 to 2021, the 2-tailed Spearman correlation showed that 20 of 38 procedures had statistically significant decreases in service volume over time. Intravitreal injections increased more than 1000-fold, from 2922 in 2000 to 3 444 500 injections in 2021 (ρ = 0.997; P < .001). Panretinal photocoagulation treatments declined from 104 865 to 48 533 procedures (ρ = -0.966; P = .003). Scleral buckling declined from 6502 to 587 procedures (ρ = -0.999; P < .001). Pars plana vitrectomy-associated procedures increased from 71 039 to 95 429 (ρ = 0.691; P < .001). From 2000 to 2021, the 2-tailed Spearman correlation showed that 29 of 38 procedures had statistically significant decreases in reimbursement over time. No procedure had a significant increase in payment. Conclusions: Vitreoretinal practice patterns have changed dramatically over the past 2 decades, with significant declines in inflation-adjusted Medicare reimbursement for most procedures. Awareness of service volume and reimbursement trends is vital to assessing economic viability and patient coverage under the current Medicare payment policies.

High mechanical thrombectomy procedural volume is not a reliable predictor of improved thrombectomy outcomes in patients with acute ischemic stroke in the United States.

The volume of mechanical thrombectomy (MT) performed at hospitals is used as one of the criteria for advanced-level designation for stroke care. Our study sought to determine the relationship between annual MT procedural volume and in-hospital outcomes in acute ischemic stroke patients undergoing MT in the United States. We analyzed the National Inpatient Sample from 2016 to 2020. The hospitals were grouped into quartiles based on the volume of MT procedures performed within the calendar year. We compared the rates of routine discharge/home health care; in-hospital mortality, and post-treatment intracranial hemorrhage (ICH) between the quartiles after adjusting for potential confounders. Patients undergoing MT ranged from 15,395 in quartile 1 to 78,510 MT in quartile 4. There were lower rates of discharge home/self-care of 22.5%, 20.8%, and 20.8% for quartiles 2, 3, and 4, respectively, compared with 34.9% in quartile 1. The odds of ICH increased to 1.81 (p < 0.001), 1.84 (p < 0.001), and 1.98 (p < 0.001) among the quartiles from lowest to highest procedural volumes. The odds of home discharge/self-care decreased to 0.66 (p < 0.001), 0.60 (p < 0.001), and 0.63 (p < 0.001) among the quartiles from lowest to highest procedural volumes. The odds of in-hospital mortality increased to 1.92 (p < 0.001), 1.99 (p < 0.001), and 1.84 (p < 0.001) among the quartiles from lowest to highest procedural volumes. We observed a paradoxical relationship between adverse outcomes and the annual procedural volume of MT at the hospital presumably due to the higher severity of acute ischemic stroke treated at high-volume hospitals.

103. The Impact of COVID-19 restrictions on Open Fracture Emergency Fixation Procedures in eight institutions around South and Southeast Asia

Introduction: Around the time COVID-19 was declared a global pandemic, various restrictions and measures were implemented at all levels to limit disease spread and preserve healthcare capacity. Data is lacking in many low and middle-income countries on how these measures impact healthcare utilization and outcomes. This study aims to determine the impact of COVID-19 restrictions on volumes of the open fracture emergency fixation procedures in South and Southeast Asia. Methods: This was a retrospective cohort study of patients who underwent open fracture fixation from 1 January 2018 to 31 December 2021 at one of 8 institutions in Singapore, Malaysia, Indonesia, India and Vietnam. We compared the weekly volumes, baseline characteristics and outcomes of each procedure across different time periods in each institution defined by different level of COVID-19 restrictions using selected indicators from a city-level and hospital-level response index. Results: A total of 74 (AMH) to 299 (SGH) open fracture fixations were performed over the 4-year period. Weekly volumes decreased significantly at GNRC (p = 1.33 x 10-5), AMH (p = 1.68 x 10-6) and UGH. At UGH there was a drop in the proportion of males during HR1 (66.7%) and HR3 (46.7%) compared to pre-COVID (83.0%) and HR2 (82.4%) (p = 2.02 x 10-4). None of the outcomes were significantly different in any of the institutions. Conclusions: COVID-19 restrictions on the city and hospital level were associated with a decrease in surgical volumes of the open fracture fixation emergency procedures in some of the institutions. There was some suggestion of surgical capacity limitations in UGH and MH175 during periods of more stringent COVID-19 restrictions.

Do Fellowship-educated Military Orthopaedic Oncologists Who Practice in Military Settings Treat a Sufficient Volume of Patients to Maintain Their Oncologic Expertise?

Fellowship-trained orthopaedic oncologists in the US military provide routine clinical care and also must maintain readiness to provide combat casualty care. However, low oncologic procedure volume may hinder the ability of these surgeons to maintain relevant surgical expertise. Other low-volume specialties within the Military Health System (MHS) have established partnerships with neighboring civilian centers to increase procedure volume, but the need for similar partnerships for orthopaedic oncologists has not been examined. The purpose of this study was to characterize the practice patterns of US military fellowship-trained orthopaedic oncologists. We asked the following questions: (1) What are the diagnoses treated by US military fellowship-trained orthopaedic oncologists? (2) What are the procedures performed by US military fellowship-trained orthopaedic oncologists? We queried the Military Data Repository, a centralized repository for healthcare data for all healthcare beneficiaries (active duty, dependents, and retirees) within the Defense Health Agency using the MHS's Management and Reporting Tool for all international common procedure taxonomy (CPT) codes and ICD-9 and ICD-10 codes associated with National Provider Identifier (NPI) numbers of active duty, military fellowship-trained orthopaedic oncologists. Fellowship-trained orthopaedic oncologists were identified by military specialty leaders. Then, we identified all procedures performed by the orthopaedic oncologist based on NPI numbers for fiscal years 2013 to 2022. We stratified the CPT codes by top orthopaedic procedure categories (such as amputation [performed for oncologic and nononcologic reasons], fracture, arthroplasty, oncologic) based on associated ICD codes. These were then tabulated by the most common diagnoses treated. Thirteen percent (796 of 5996) of the diagnoses were oncologic, of which 45% (357 of 796) were malignant. Forty-four percent (158 of 357) of the malignancies were primary and 56% (199 of 357) were secondary; this translates to an average of 2 patients with primary and 2.5 patients with secondary malignancies treated per surgeon per year. During the study period, nine orthopaedic oncologists performed 5996 orthopaedic procedures, or 74 procedures per surgeon per year. Twenty-one percent (1252 of 5996) of the procedures were oncologic; the remaining procedures included 897 arthroplasties, 502 fracture-related, 275 amputations for a nononcologic indication, 204 infections, 142 arthroscopic, and 2724 other procedures. Although military orthopaedic oncologists possess expert skills that are directly translatable to combat casualty care and operational readiness, within MHS hospitals they treat relatively few patients with oncologic diagnoses, and less than one-half of those involve malignancies. Despite postgraduation procedure volume raining stable over the last decade, it is unknown how many new patient visits for oncologic diagnoses and how many corresponding tumor procedures are necessary to maintain competence or build confidence after musculoskeletal oncology fellowship training. It is important to note that there are no military orthopaedic oncology fellowships, and all active duty orthopaedic oncologists undergo training at civilian institutions. Military-civilian partnerships with high-volume cancer centers may enable military orthopaedic oncologists to work at civilian cancer centers to increase their oncologic volume to ensure sustainment of operationally relevant knowledge, skills, and abilities and improve patient care and outcomes.

Impacts of Hospital Volume and Patient-Hospital Distances on Outcomes of Older Adults Receiving Percutaneous Microaxial Ventricular Assist Devices for Cardiogenic Shock.

Background: Percutaneous microaxial ventricular assist devices (pVAD) have the potential to reduce mortality of patients with cardiogenic shock (CS). However, the association between the distribution of pVAD-performing centers and outcomes of CS has not been explored. Methods: This observational study included Medicare fee-for-service beneficiaries aged 65-99 years treated with pVAD for CS from 2016 to 2020 and examined the associations between patient outcomes and two exposure variables: hospitals' procedure volumes of pVAD and patient-hospital distances (in quintiles [Qn]). We developed Cox proportional hazard regression for 180-day mortality and heart failure (HF) readmission rates and multivariable logistic regression for in-hospital outcomes, adjusting for patient demographics, comorbidities, concomitant treatments, and hospital characteristics, including CS volume, teaching status, and the ability to perform extracorporeal membrane oxygenation. Results: A total of 6,637 patients with CS underwent pVAD at 1,041 hospitals, with the annualized hospital volume ranging widely from 0.3 to 55.6 cases/year. Patients treated at higher-volume centers experienced lower 180-day mortality compared with patients treated at lower-volume centers (Qn1=reference; Qn2: adjusted hazard ratio [aHR], 0.88; 95% confidence interval [CI], 0.79-0.97; Qn3: aHR, 0.88; 95% CI, 0.79-0.98; Qn4: aHR, 0.88; 95% CI, 0.78-0.99; Qn5: aHR, 0.84; 95% CI, 0.74-0.95; p-for-trend, 0.026), while we found no evidence that patient-hospital distances were associated with mortality (Qn1=reference; Qn2: adjusted hazard ratio [aHR], 0.99; 95% confidence interval [CI], 0.89-1.09; Qn3: aHR, 0.94; 95% CI, 0.85-1.04; Qn4: aHR, 1.01; 95% CI, 0.92-1.11; Qn5: aHR, 0.91; 95% CI, 0.82-1.01; p-for-trend, 0.160). We found no evidence that the hospital volume and patient-hospital distances were associated with in-hospital bleeding, intracranial hemorrhage, or renal replacement therapy initiation. Conclusions: Hospital volume was more strongly associated with mortality than patient-hospital distances, suggesting that rational distribution of pVAD-performing centers while ensuring adequate procedure volumes may optimize patient mortality.

Trends in Medicare Utilization and Reimbursement for Traumatic Brain Injury: 2003–2021

Traumatic brain injury (TBI) is a significant public health issue among Medicare beneficiaries, with many specialties reporting consistent annual decreases in utilization and reimbursement. This study investigates the trends in Medicare utilization and rates of reimbursement for neurosurgical procedures related to TBI from 2003 to 2021, aiming to provide insights into the economic aspects of TBI care. Utilizing the Medicare Part B National Summary Data files, we analyzed 14 neurosurgical procedures over the 18-year period, assessing the changes in procedural volume and mean reimbursement per procedure, adjusted for inflation to the 2021 USD using the Consumer Price Index. From 2003 to 2021, TBI-related neurosurgical interventions showed a total percent change of −15.39% in procedural volume and −3.11% in inflation-adjusted mean reimbursement per procedure. Linear regression analyses indicated a significant downward trend in the overall procedural volume (p &lt; 0.001) but no significant trend in the inflation-adjusted mean reimbursement rates (p = 0.585). Subgroup analyses did not reveal significant changes in the reimbursement rates for decompressive craniotomy/craniectomy, cranioplasty, intracranial pressure management, and traumatic fracture/penetration procedures. Our study indicates a significant decrease in neurosurgical TBI procedural volumes, while reimbursement rates remained stable when adjusted for inflation, highlighting the need for policy adjustments to ensure adequate resources for TBI care.

Procedural Volume and Outcomes After Septal Reduction Therapies in Hypertrophic Obstructive Cardiomyopathy.

Septal myectomy and alcohol septal ablation (ASA) are septal reduction therapies for patients with symptomatic obstructive hypertrophic cardiomyopathy. Operator and hospital volume may influence outcomes, but contemporary data on this relationship are limited. This retrospective cohort study used data from the Vizient Clinical Data Base (2016-2022). Patients with undergoing septal myectomy and ASA were identified using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and stratified into low-, medium-, and high-volume groups based on annualized operator and hospital volumes. The outcomes were 30-day in-hospital mortality and 90-day readmission, analyzed using multivariable adjusted logistic and Cox models. Among 5725 patients with hypertrophic cardiomyopathy (3990 septal myectomy; 1735 ASA), most operators and hospitals performed <10 procedures annually. For septal myectomy, low-volume operators were associated with higher odds of 30-day mortality (adjusted odds ratio [aOR], 1.86 [95% CI, 1.11-3.15]) and greater risk for 90-day readmission (aOR, 1.51 [95% CI, 1.22-1.88]), and medium-volume operators had higher odds of 30-day mortality (aOR, 1.93 [95% CI, 1.05-3.55]). Medium-volume hospitals had higher 30-day mortality (aOR, 2.29 [95% CI, 1.32-3.99]), with low-volume hospitals showing greater risk for 90-day readmission (aOR, 1.60 [95% CI, 1.14-2.23]). For ASA, low- and medium-volume operators had increased 30-day mortality (aOR, 2.99 [95% CI, 1.15-7.75] and aOR, 3.86 [95% CI, 1.30-11.46]), but the risk of 90-day readmission was similar. Hospital volumes did not significantly impact outcomes for ASA. Low operator and hospital volumes were associated with worse outcomes for septal reduction therapies, emphasizing the need to refer patients with hypertrophic cardiomyopathy to high-volume centers with experienced operators.

Comparing Traditional and Newer Glaucoma Procedures by Physician Experience and Practice Location in the United States.

Analysis of CMS Physician Payment data found that physician certification year, degree of urbanization, and estimated income by zip code were significant in predicting the proportion of traditional glaucoma procedures performed by each provider in the United States. The prevalence of microinvasive glaucoma surgery (MIGS) compared to traditional procedures has been increasing in glaucoma management. It is important to understand whether the uptake of new glaucoma procedures is associated with aspects of the physician practice. In this cross-sectional study, data on glaucoma procedure distribution, degree of urbanization and physician certification in the United States were extracted from the 2019 Centers for Medicare & Medicaid Services (CMS) Physician Payment and American Board of Ophthalmology databases. The distribution of traditional and MIGS procedure numbers for metropolitan versus non-metropolitan providers were visualized with boxplots and statistically compared using Mann-Whitney U tests. We used two-dimensional histograms and regression analyses to assess the relationship between certification year and volume of traditional versus MIGS procedures. A multivariable linear regression model was created using certification year, rural-urban commuting area (RUCA) code, and estimated income by practice zip code to predict the number and proportion of each type of glaucoma procedure. This study included 2625 providers from the CMS physician payment data who performed only traditional procedures (n=370), MIGS procedures (n=1727), or both procedure types (n=528) in 2019. The median number of MIGS procedures performed by each provider was greater in non-metropolitan areas (31 vs. 29, P=0.015) while the proportion of traditional procedures performed by each provider was greater in metropolitan areas (0.24 vs. 0.08, P<0.001). Regression analysis showed a positive relationship between certification year and the proportion of traditional procedures performed by each provider (P<0.001). Multivariable regression models found that certification year, RUCA code, and estimated income of practice location were all significant predictors (P<0.02) of the proportion of traditional procedures performed by each provider. In the United States, physicians in metropolitan areas and more recent certification years are more likely to perform a larger proportion of traditional procedures. This finding suggests that the distribution of glaucoma procedure types is related to physician factors such as degree of urbanization and duration of practice. More research is needed to better understand how such differences affect patient access and outcomes.

Center-Related Variation in Hospitalization Cost for Patients Undergoing Percutaneous Left Atrial Appendage Occlusion

BackgroundThe commercial use of percutaneous left atrial appendage occlusion with the Watchman device is increasing in the United States. The purpose of this study was to evaluate center-related variation in total hospital costs for Watchman device implantation and identify factors associated with high hospital costs at a national level. MethodsAll adults undergoing elective left atrial appendage occlusion with Watchman were identified in the 2016-2018 National Inpatient Database. Mixed models were used to evaluate the impact of center on total hospital costs, adjusting for patient and center characteristics and length of stay. ResultsA total of 30,175 patients underwent Watchman device implantation at a median cost of $24,500 and demonstrated significant variability across admissions (interdecile range, $13,900-37,000). Nearly 13% of the variability in patient-level costs was related to the center performing the procedure rather than patient factors. Higher-volume centers had lower total costs and demonstrated lesser total cost variation. Centers with low procedural volume, occurrence of procedural complications, congestive heart failure, and length of stay were independent predictors of a high-cost hospitalization. Though complications were associated with increased expenditure, they did not explain the observed cost variation related to the center. ConclusionsA significant proportion of variation in total hospital cost was attributable to the center performing the procedure. Addressing variability of Watchman-related costs is necessary to achieve high-quality value-based care.

Total knee arthroplasty reimbursement is declining overall and at a marginally faster rate amongst female orthopaedic surgeons: A Medicare analysis

BackgroundWhile the prevalence of total knee arthroplasty (TKA) is increasing, reimbursement is declining. The purpose of this study was to determine how surgeon gender influences procedure volume, reimbursement, practice style, and patient demographics for TKAs nationally and regionally between 2013 and 2021. MethodsThe Medicare Physician and Other Practitioners database was queried from 2013 to 2021 for procedure volume, TKA reimbursement, surgeon characteristics, and patient demographics for any surgeon who performed at least ten primary TKAs per year. Statistical tests were conducted to analyze differences based on surgeon gender, geography, and year. ResultsOf the 2,415,802 TKAs performed between 2013 and 2021, 1.5 % were billed by female surgeons. The number of TKAs performed annually increased by 29.1 % for female surgeons and decreased by 2.6 % for male surgeons. Between 2013 and 2021, reimbursement for TKAs decreased by 23.9 % for male surgeons and 26.2 % for female surgeons. In 2021, male surgeons were reimbursed $1017 per TKA while female surgeons were reimbursed $964 (p = 0.049). Male surgeons performed more TKAs annually in 2021 (Male: 39.3, Female: 30.9, p < 0.001), more total billable services (Male: 4148.0, Female: 2719.3, p < 0.001), and more unique billable services (Male: 70.7, Female: 55.3, p < 0.001) than female surgeons. ConclusionsFemale representation among surgeons who perform TKAs is increasing nationally. However, male surgeons treat more patients, perform more total billable services, and perform more unique billable services than female surgeons. TKA reimbursement is decreasing at a faster rate for female surgeons than male surgeons, although this is likely due to geographical differences.

Invited Commentary: Transcarotid Artery Revascularization: Short Learning Curve but Low Procedural Volume Still Predicts Higher Morbidity.

Invited Commentary: Transcarotid Artery Revascularization: Short Learning Curve but Low Procedural Volume Still Predicts Higher Morbidity.

Endocrine surgery fellowship is necessary for competent endocrine surgical practice: perspectives from Australia and New Zealand.

Currently pathways to practice in endocrine surgery vary based on location and surgical training programme. International data highlights the impact of surgeon volume on outcomes, and the importance of understanding the learning curve in developing minimum training competencies. This study aims to explore how surgeons obtain competence in endocrine surgery in Australia and New Zealand, and perceptions around competence and scope of practice. A web-based survey was distributed to fellows practicing endocrine surgery. Participants were invited to complete a semi-structured interview to explore key themes around competence. Thematic analysis was performed. Responses from 87 surgeons, with 30% practicing primarily in a regional or rural area, showed 94% emphasized post-fellowship training to be competent in endocrine surgery. Median primary operator procedural volume learning curves were 50 thyroid, 30 parathyroid and 20 laparoscopic adrenalectomy procedures. Semi-structured interviews with 12 participants identified four major themes: (1) learning opportunities during general surgical education and training programmes alone are insufficient for consultant-level competence; (2) the importance of sufficient training to develop clinical decision-making, insight and judgement to appropriately select patients in the management of endocrine disease; (3) expected standards of clinical and technical performance are independent of practice location or context; (4) the importance of multi-disciplinary teams for complex cases including advanced cancers. Practicing endocrine surgeons acknowledge formal fellowship training is required to achieve competence across technical and non-technical domains. The definition of competence and expectations regarding technical outcomes are independent of practice location or context.

Comparison of utility and organizational impact of reusable and single-use rhinolaryngoscopes in a tertiary otorhinolaryngology department.

Flexible rhinolaryngoscopes are an important tool in otolaryngology. In recent years, single-use rhinolaryngoscopes (SURLs), which have been developed as an alternative to reusable scopes (RRLs), offer various advantages including less risk of contamination and elimination of the need for cleaning and reprocessing between procedures. This study aimed to compare procedure efficiency, organizational impact, and economic impact between SURLs and RRLs used for elective procedures conducted outside the otorhinolaryngology department in the hospital environment. In this randomized prospective study, either type of endoscope was tested by on-call otolaryngologists over a total of twelve weeks. The organizational impact was investigated using a quantitative research design. All categories of stakeholders responded to specific surveys based on profession; these included doctors (n = 13), those in managerial positions (n = 3), and other healthcare staff including technicians and nurses (n = 11). A micro-costing approach was used to evaluate resource utilization and cost of services. The trial was uploaded to clinicaltrials.gov (ID number: NCT0519821, https://clinicaltrials.gov/study/NCT05198219?intr=rhinolaryngo&rank=1). Overall, 14 and 12 procedures were performed using the SURLs and RRLs, respectively. No significant differences were observed between the endoscopes in terms of procedure duration, reported image quality, or maneuverability. The SURLs were significantly superior in terms of four organizational impact parameters, namely, modes of cooperation and communication, vigilance and monitoring methods, working conditions and safety, and logistics. The estimated per-procedure cost of the RRLs was SEK 536 (€ 34,68). The cost and effectiveness of RRLs and SURLs is influenced by the healthcare setting, procedure volume, and duration of device use. The adoption of SURLs can improve safety, streamline processes, and potentially reduce the risk of disease transmission.

Differences in Primary Total Shoulder Arthroplasty Volume, Reimbursement, Practice Styles, and Patient Populations Based on Surgeon Gender: A Temporal Analysis

BackgroundOrthopedic surgery has previously been shown to have a shortage of female physicians and a gender pay gap. However, this has not been thoroughly evaluated in the setting of shoulder surgery. The primary purpose of this study was to evaluate differences in total shoulder arthroplasty (TSA) volume, reimbursement, surgeon billing practices, and patient populations between male and female surgeons from 2013 to 2021. MethodsThe Medicare Physician and Other Practitioners database, a publicly available dataset that includes 100% of services billed to Medicare Part B was utilized. The database was queried for all billing episodes of Current Procedural Terminology (CPT) code 23472, which encompasses both anatomic and reverse primary TSA. Procedural volume, average inflation-adjusted reimbursement per TSA, physician billing information, and the patient demographics of each surgeon who performed TSAs were collected. Welch’s t-test and Kruskal-Wallis were utilized to compare male and female surgeons each year between 2013 and 2021. ResultsBetween 2013 and 2021, the proportion of TSAs performed by female surgeons nationally increased from 1.8% to 2.9% (+1.1%). This increase was greatest in the Northeast (2.0% to 6.1%), while a decrease was seen in the Midwest (1.9% to 1.6%). In 2021, there was no significant difference between male and female surgeons in the average inflation-adjusted reimbursement per TSA ($1,144.00 vs $1,143.00, p=0.792) and the average number of TSAs performed per surgeon (26.6 vs 23.1, p=0.105). Female TSA surgeons, on average, had less Medicare beneficiaries (348 vs 462, p<0.001), performed fewer annual services (1,817 vs 3,630, p<0.001), and performed fewer unique services (60 vs 76, p<0.001) compared to male surgeons. A higher proportion of female surgeon’s patient populations were non-White (24% vs 22%, p=0.028), female (61% vs 59%, p=0.001), and dual enrolled Medicare-Medicaid patients (13% vs 10%, p<0.001). However, there was no difference in the average patient complexity between male and female TSA surgeons based on hierarchical condition category (HCC) score (1.0783 vs 1.0732, p=0.228). ConclusionFemale representation within TSA surgery is increasing nationally, with the greatest representation in the Northeast and West and the lowest representation in the South and Midwest. Although female TSA surgeons perform a similar number of TSAs, receive comparable reimbursement per TSA, and have a similarly complex patient population as their male counterparts, they perform significantly fewer total and unique billable services annually. Additionally, female TSA surgeons tend to see more non-White, women, and dual Medicare-Medicaid enrolled patients.

Assessing Private Equity Involvement in Ophthalmology: Parallels with the Past, Concerns for the Future

PurposeTo discuss the history and current state of private equity in ophthalmology and explore potential implications for ophthalmology practices, physicians, and patients. DesignPerspective. MethodsReview of selected articles in ophthalmology and non-ophthalmology medical literature and commentary based on the authors’ experiences. ResultsInvestment in ophthalmology appeals to private equity firms because of high procedural volumes, fragmented private practices, opportunities for real estate ownership, and an aging population in need of eye care. As a result, acquisition of private practices by large private equity companies has swelled since 2015. Metropolitan areas and practices that possess ambulatory surgical centers or a high proportion of retina surgeons receive the greatest investment. However, little objective data exists regarding the benefits of this trend. Initial research suggests that private equity ownership may negatively impact patient care through greater costs, shorter appointments, and fewer Medicare/Medicaid patients seen. Skeptics of private equity also highlight concerns that include financial risk falling primarily on the acquired practice itself, a short-term business approach that rewards profit maximization, and the erosion of physician autonomy. Furthermore, young ophthalmologists express reservations about working for private equity firms. 78% of trainees indicated they would not consider employment by a private equity owned practice and 81.4% of vitreoretinal fellows voiced concerns about autonomy and job security. Proposed legislation aimed at limiting private equity acquisitions is currently under review at the statewide level, adding additional uncertainty to the future of private equity involvement in ophthalmology. ConclusionAlthough investment by private equity offers potential financial rewards and operational improvements for practices, it also raises significant concerns reminiscent of those experienced by physician practice management companies in the 1990s. Nonanecdotal data is needed to assess the benefits and future of private equity involvement in ophthalmology.

Less Is More: Dissecting Trauma Centers by Procedural Volume.

This study aims to examine the relationship between procedural volume and annual trauma volume (ATV) of ACS Level I trauma centers (TC). Although ATV is a hard criterion for TC verification, importance of procedural interventions as a potential quality indicator is understudied. Patients managed at ACS level I TCs were identified from ACS-TQIP 2017-2021. TCs were identified using facility keys and stratified into quartiles based on ATV into low, low-medium, medium-high, and high volume. TCs were also stratified into tertiles [low (LV), medium (MV), high (HV)] based on procedural volume by assessing annual number of laparotomies, thoracotomies, craniotomies/craniectomies, angioembolizations, vascular repairs, and long bone fixations performed at each center. The Cohen κ statistic was used to assess concordance between ATV and procedural volume. A total of 182 Level I TCs were identified: 76 low, 47 low-medium, 35 high-medium, and 24 high volume. Long bone fixation, laparotomy, and craniotomy/craniectomy were the most performed procedures with a median of 65, 59, and 46 cases/center/year, respectively. Overall, 31% of HV laparotomy centers, 31% of HV thoracotomy centers, 22% of HV craniotomy/craniectomy centers, 22% of HV vascular repair centers, 32% of HV long bone fixation centers, and 33% of HV angioembolization centers contributed to the overall number of low-medium and low-volume TCs. The Cohen κ statistic demonstrated poor concordance between ATV and procedural volumes for all procedures (overall procedural volume-κ=0.378, laparotomy-κ=0.270, thoracotomy-κ=0.202, craniotomy/craniectomy-κ=0.394, vascular repair-κ=0.298, long bone fixation-κ=0.277, angioembolization-κ=0.286). ATV does not reflect the procedural interventions performed. Combination of procedural and ATV may provide a more accurate picture of the clinical experience at any given TC. Level III.

Which factors influence the decision of hospitals to provide procedures on an outpatient basis? –Mixed-methods evidence from Germany

Shifting care from the resource-intensive inpatient setting to the more economically efficient outpatient sector is being promoted internationally by policymakers. Financial incentives are a major focus of such efforts because low levels of hospital outpatient care are attributed to differences in payment for inpatient and outpatient services. In Germany, however, there is significant variation in the extent to which hospitals provide outpatient care despite a uniform payment system. Therefore, other factors must be influencing German hospitals’ strategic decisions whether to offer outpatient care. While most research has focused on specific procedures or lacks empirical support, our study provides a comprehensive analysis of the factors beyond financial incentives that influence the provision of hospital outpatient services in Germany. We employed a mixed-methods approach, first contacting health care experts with in-depth knowledge of the hospital outpatient landscape to identify possible influencing factors and then conducting a comprehensive quantitative analysis of all German hospitals. Our findings suggest that policymakers seeking to promote hospital outpatient care should consider a broad range of factors. We found that a hospital's service mix, size, procedure volume, and emergency care infrastructure significantly affected the proportion of outpatient services it offered. Strategic hospital planning emphasizing specialization and adherence to minimum volume standards might therefore be a valuable policy tool. Our analysis also highlights the importance of demographic and socioeconomic factors, such as the regional share of single-person households, suggesting that a comprehensive policy framework should account for broader population characteristics and not just elements directly related to hospital care.