Procedure Volume Research Articles

The Sustained Impact of the COVID-19 Pandemic on Vascular Surgical Care Delivery

The coronavirus disease 2019 (COVID-19) pandemic necessitated postponement of vascular surgery procedures nationally. Whether procedure volumes have since recovered remains undefined. Therefore, we sought to quantify changes in procedure volumes and determine whether surgical volume has returned to its prepandemic baseline. We utilized the US Fee-for-Service Medicare 5% National Sample as part of the Department of Veterans Affairs-funded Disrupted Care National Project. We analyzed abdominal aortic aneurysm (AAA) repair for intact aneurysms, carotid endarterectomy (CEA), and major lower extremity amputation (LEA) from 2018 to 2021. Each quarter of 2020 and 2021 was compared to its corresponding prepandemic quarter in 2019. We then performed a subanalysis of these trends by sex, age, and race. We identified 15,921 procedures: 3278 AAA repair, 6399 CEA, and 6244 LEA (Table, Figure). The average percent change during the baseline period from 2018 to 2019 was −4.3% for AAA repair, −8.5% for CEA, and −2.6% for LEA. Compared to Q2 of 2019, Q2 of 2020 demonstrated that AAA repair procedures decreased by 47%, CEA by 40%, and LEA by 14%. While procedures initially rebounded in Q3 of 2020, volumes did not return to their prepandemic baseline, demonstrating a persistent volume reduction (−16% AAA, −22% CEA, and −11% LEA). Thereafter, procedure counts again declined in Q4 of 2021(–42% AAA, −54% CEA, and −41% LEA). Despite the perception that vascular surgical care was singularly disrupted at the outset of the pandemic, there has been a sustained reduction in vascular surgical volume since 2019. Not only have procedure volumes not returned to pre-pandemic baseline, but it also appears that there has been a cumulative incremental impact on overall procedure volume. The impact of these findings on long term population health remain uncertain and necessitate a better understanding of postpandemic care delivery.TableChanges in procedure counts during selected quarters of the pandemic as compared to the baseline prepandemic rateAverage annual percent change (2018-2019)Procedure count Q2 2019Procedure count Q2 2020Percent changeProcedure count Q3 2019Procedure count Q3 2020Percent changeProcedure count Q4 2019Procedure count Q4 2021Percent changeIntact AAA repair−4.3%258137−46.9%221185−16.3%241141−41.5%CEA−8.5%474287−39.5%462360−22.1%423193−54.4%Major LEA−2.6%441381−13.6%423378−10.6%402236−41.3%AAA, Abdominal aortic aneurysm; CEA, carotid endarterectomy; LEA, lower extremity amputation.The baseline pre-pandemic count is defined as the corresponding quarter in 2019. Open table in a new tab

Vascular Surgery Trainees' Experience with Open Lower Extremity Revascularization in an Era of Endovascular-First Therapy

The impact of the adoption of endovascular-first therapies for lower extremity revascularization on vascular trainees’ experience with open bypass is not known. We sought to determine trends in open versus endovascular lower extremity revascularization case volumes among graduating vascular fellows (5+2) and integrated vascular residents (0+5). We reviewed the Accreditation Council for Graduate Medical Education 2012-2021 case log data for graduating vascular surgery fellows (5+2) and integrated residents (0+5). We retrieved the mean number of femoropopliteal and infrapopliteal revascularization procedures carried out by each trainee group, both open and endovascular. The means were plotted against time. A Mann Kendall test was conducted to detect trends in the average number of cases performed by vascular graduates. Between 2012 and 2021, integrated vascular residents graduated with an average of 21.9 femoropopliteal and 22.5 infrapopliteal bypasses which were 4.4 ± 1.4 and 3.0 ± 1.9 more than vascular surgery fellows, respectively. For both trainee groups, the mean number of open procedures—femoropopliteal or infrapopliteal—was consistent over the course of the years with no statistically significant trend observed (Figs 1 and 2). Integrated vascular residents graduated with an average of 47.9 femoropopliteal and 22.7 infrapopliteal endovascular procedures, which were 6.2 ± 2.9 and 3.1 ± 1.7 more than vascular surgery fellows, respectively. We observed a statistically significant increase in the mean number of femoropopliteal and infrapopliteal endovascular procedures in this time period –in both trainee groups. The mean number of femoropopliteal endovascular cases increased by 105.5% (31.1 to 63.9; P < .001) for integrated residents and 110.3% (26.2 to 55.1; P < .001) for vascular fellows. Likewise, the mean number of infrapopliteal endovascular cases increased by 120.3% (14.3 to 31.5; P < .001) for integrated residents and 94.1% (13.6 to 26.4; P < .001) for vascular fellows. The overall case volume of femoropopliteal and infrapopliteal procedures, combining open and endovascular techniques, increased for both trainee groups, which is mainly due a significant increase in peripheral vascular intervention volume. The total case volume of lower extremity revascularization has increased for all vascular trainees but graduates of integrated residency programs have a more robust experience. Despite a significant rise in endovascular case volume, however, the average number of open bypass procedures performed by graduating vascular surgery trainees is not affected and has remained stable.Fig 2Trends in open infrapopliteal bypass revascularization.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Regional variation in patient selection, practice patterns, and outcomes based on techniques for carotid artery revascularization in the Vascular Quality Initiative

ObjectiveSignificant regional variation is known with multiple surgical procedures. This study describes regional variation in carotid revascularization within the Vascular Quality Initiative (VQI). MethodsData from the VQI carotid endarterectomy (CEA) and carotid artery stenting (CAS) databases from 2016 to 2021 were used. Nineteen geographic VQI regions were divided into three tertiles based on the average annual volume of carotid procedures performed per region (low-volume: 956 cases [range, 144-1382]; medium-volume: 1533 cases [range, 1432-1589]; and high-volume: 1845 cases [range, 1642-2059]). Patients’ characteristics, indications for carotid revascularization, practice patterns, and outcomes (perioperative and 1-year stroke/death) of different revascularization techniques were compared between these regional groups. Regression models that adjust for known risk factors and allow for random effects at the center level were used. ResultsCEA was the most common revascularization procedure (>60%) across all regional groups. Significant regional variation was observed in the practice of CEA such as variability in the use of shunting, drain placement, stump pressure and electroencephalogram monitoring, intraoperative protamine, and patch angioplasty. For transfemoral CAS, high-volume regions had a higher proportion of asymptomatic patients with <80% stenosis (30.5% vs 27.8%) in addition to higher use of local/regional anesthesia (80.4% vs 76.2%), protamine (16.1% vs 11.8%), and completion angiography (81.6% vs 77.6%) during transfemoral carotid artery stenting (TF-CAS) compared with low-volume regions. For transcarotid artery revascularization (TCAR), high-volume regions were less likely to intervene on asymptomatic patients with <80% stenosis (32.2% vs 35.8%) than low-volume regions. They also had a higher proportion of urgent/emergent procedures (13.6% vs 10.4%) and were more likely to use general anesthesia (92.0% vs 82.1%), completion angiography (67.3% vs 63.0%), and poststent ballooning (48.4% vs 36.8%). For each carotid revascularization technique, no significant differences were noted in perioperative and 1-year outcomes between low-, medium-, and high-volume regions. Finally, there were no significant differences in outcomes between TCAR and CEA across the different regional groups. In all regional groups, TCAR was associated with a 40% reduction in perioperative and 1-year stroke/death compared with TF-CAS. ConclusionsDespite significant variation in clinical practices for the management of carotid disease, no regional variation exists in the overall outcomes of carotid interventions. TCAR and CEA continue to show superior outcomes to TF-CAS across all VQI regional groups.

Association Between Hospital Monopoly Status, Patient Socioeconomic Disadvantage, and Total Joint Arthroplasty Price Disclosure.

In recent years, healthcare institutions and regulatory bodies have enacted cost transparency mandates for routine interventions such as total hip arthroplasty and total knee arthroplasty. However, disclosure rates remain low. This study examined the effect of financial characteristics of hospitals and the socioeconomic status of patients on price disclosure. Hospitals conducting total hip arthroplasty/total knee arthroplasty, their quality ratings, and procedural volumes were identified using the Leapfrog Hospital Survey and linked to procedure-specific prices. Financial performance and the Area Deprivation Index (ADI) were used to correlate disclosure rates with hospital and patient characteristics. Hospital financial, operational, and patient summary statistics were compared by price-disclosure status using two-sample t -tests for continuous variables and Pearson chi-square test for categorical variables. The association between total joint arthroplasty price disclosure and hospital ADI was further evaluated using modified Poisson regression. A total of 1,425 hospitals certified by the Centers for Medicare & Medicaid Services were identified in the United States. 50.5% (n = 721) of hospitals had no published payer-specific price information. Hospitals in an area of higher socioeconomic disadvantage were more likely to disclose prices of total joint arthroplasty (incidence rate ratio = 0.966, 95% CI: 0.937 to 0.995, P = 0.024). Hospitals that were considered monopolies or were for-profit were less likely to disclose prices (IRR = 1.15, 95% CI: 1.030 to 1.280, P = 0.01; IRR = 1.256, 95% CI: 0.986 to 1.526, P = 0.038, respectively). When accounting for both ADI and monopoly status, hospitals with patients who had a higher ADI were more likely to disclose costs for a total joint arthroplasty, whereas for-profit hospitals or hospitals considered monopolies in their HSA were less likely to disclose prices. For nonmonopoly hospitals, a higher ADI correlated with a higher likelihood of price disclosure. However, for monopoly hospitals, there was no significant association between ADI and price disclosure. II.

P296 WHAT IF CARDIAC SURGEONS PERFORM TRANS–CATHETER AORTIC VALVE INTERVENTIONS?

Abstract Background and aim Aim of this study is to present the results of our aortic valve interventions program embedding surgical (SAVR) and trans–catheter treatment, both in the hands of cardiac surgeons. Methods Data of patients who had isolated aortic valve interventions during the period 2016–2022 were reviewed. SAVR was performed mainly through a minimally invasive approach . TAVI included either TF or TA access procedures, all performed in a cardiac surgery theatre with fluoroscopy equipment. Results During the study period, 1435 patients underwent isolated aortic valve intervention: 1022 surgical AVR (665 mini AVR, 357 FS) and 413 TAVI (333 TF and 80 TA). TAVI were introduced during 2018 and gained a wider application over the years with the progressive adoption of awake procedures and fully percutaneous access (Figure 1). The global volume of aortic valve procedures increased of 38% comparing the full–years 2021 with 2018 (295 vs 213 cases). Multivariable logistic regression showed that TAVI was significantly associated with increased age, female gender, a higher rate of comorbidities and lower LVEF. Overall in–hospital mortality was 0.6% – mini AVR 0.3%, FS 0.3%, TF TAVI 1% and TA TAVI 3%. Permanent neurologic injury was recorded in 0.7% of the patients. Permanent PM implantation was higher after TAVI (87/413 vs 32/1022 patients who had surgical AVR). Conclusions TAVI procedures can be safely performed by cardiac surgeons. The expertise in both surgical and trans–catheter treatment translated in the possibility of treating aortic valve disease in a higher volume of patients including older and comorbid patients with excellent early results.

Systematic Review and Cost-Consequence Analysis of Ambu aScope 5 Broncho Compared with Reusable Flexible Bronchoscopes: Insights from Two US University Hospitals and an Academic Institution.

The aim of this study was to perform a systematic review, meta-analysis and cost-consequence analysis of the single-use bronchoscope, Ambu aScopeTM 5 Broncho, in relation to reusable flexible bronchoscopes (RFB) available within three high procedure volume university hospitals and academic institutions in the USA. The primary outcome was incremental cost and the secondary outcome was incremental cross-infection risk of use for both the single-use flexible bronchoscope (SUFB) and RFBs. Cost estimates included capital, repair, and reprocessing costs derived from a prospective observational micro-costing approach within three large university hospitals and academic institutions. All costs were valued in 2022 US dollars (USD). A meta-analysis based on literature covering cross-contamination and infection from 2010 to 2020 investigated cross-infection risk following bronchoscopy procedures with RFBs. Capital costs were discounted at 3% over 5-8 years. All parameters were evaluated using both univariate deterministic and probabilistic sensitivity analyses. In high-volume hospitals, RFBs were cost minimizing compared to SUFBs. Probabilistic sensitivity analysis showed that RFBs were cost saving in 88% of iterations. Univariate analyses illustrated sensitivity of the base-case result to the procedure volume. Data from sensitivity analyses suggest that the two interventions are cost neutral at a break-even point of 756 procedures per year or 46 procedures per bronchoscope per year. Assuming equivalent clinical performance, single-use flexible bronchoscopes are not cost minimizing when including the costs associated with cross-infection in high-volume US university hospitals and academic institutions. Overall, the benefits of conversion from RFBs to SUFBs are dependent on the annual procedure volume of individual hospitals, expected cross-infection risk, and purchase price of the aScope 5 Broncho.

Medicare Reimbursement Rates and Utilization Trends in Sacroiliac Joint Fusion.

Sacroiliac joint (SIJ) fusion is a surgical treatment option for SIJ pathology in select patients who have failed conservative management. More recently, minimally invasive surgical (MIS) techniques have been developed. This study aimed to determine the trends in procedure volume and reimbursement rates for SIJ fusion. Publicly available Medicare databases were assessed using the National Summary Data Files for 2010 to 2020. Files were organized according to current procedural terminology (CPT) codes. CPT codes specific to open and MIS SI joint fusion (27279 and 27280) were identified and tracked. To track surgeon reimbursements, the CMS Medicare Physician Fee Schedule Look-Up Tool was used to extract facility prices. Descriptive statistics and linear regression were used to evaluate trends in procedure volume, utilization, and reimbursement rates. Compound annual growth rates were calculated, and discrepancies in inflation were corrected for using the Consumer Price Index. A total of 33,963 SIJ fusions were conducted in the Medicare population between 2010 and 2020, with an overall increase in procedure volume of 2,350.9% from 318 cases in 2010 to 7,794 in 2020. Since the introduction of the 27279 CPT code in 2015, 8,806 cases (31.5%) have been open and 19,120 (68.5%) have been MIS. Surgeon reimbursement for open fusions increased nominally by 42.8% (inflation-adjusted increase of 20%) from $998 in 2010 to $1,425 in 2020. Meanwhile, reimbursement for MIS fusion experienced a nominal increase of 58.4% (inflation-adjusted increase of 44.9%) from $582 in 2015 to $922 in 2020. SIJ fusion volume in the Medicare population has increased substantially in the past 10 years, with MIS SIJ fusion accounting for most of the procedures since the introduction of the 27279 CPT code in 2015. Reimbursement rates for surgeons have also increased for both open and MIS procedures, even after adjusting for inflation.

Hospital Procedural Volume and Clinical Outcomes Following Septal Reduction Therapy in Obstructive Hypertrophic Cardiomyopathy.

Background Prior national data showed a substantial in-hospital mortality in septal myectomy (SM) with an inverse volume-outcomes relationship. This study sought to assess the contemporary outcomes of septal reduction therapy and volume-outcome relationship in obstructive hypertrophic cardiomyopathy. Methods and Results All septal reduction therapy admissions between 2010 to 2019 in the United States were analyzed using the National Readmission Databases. Hospitals were stratified into tertiles of low-, medium-, and high-volume based on annualized procedural volume of alcohol septal ablation and SM. Of 19 007 patients with obstructive hypertrophic cardiomyopathy who underwent septal reduction therapy, 12 065 (63%) had SM. Two-thirds of hospitals performed ≤5 SM or alcohol septal ablation annually. In all SM encounters, 482 patients (4.0%) died in-hospital post-SM. In-hospital mortality was <1% in 1505 (88.4%) hospitals, 1% to 10% in 30 (1.8%) hospitals, and ≥10% in 167 (9.8%) hospitals. There were 63 (3.7%) hospitals (averaging 2.2 SM cases/year) with 100% in-hospital mortality. Post-SM (in low-, medium-, and high-volume centers, respectively), in-hospital mortality (5.7% versus 3.9% versus 2.4%, P=0.003; adjusted odds ratio [aOR], 2.86 [95% CI, 1.70-4.80], P=0.001), adverse in-hospital events (21.30% versus 18.0% versus 12.6%, P=0.001; aOR, 1.88 [95% CI, 1.45-2.43], P=0.001), and 30-day readmission (17.1% versus 12.9% versus 9.7%, P=0.001; adjusted hazard ratio, 1.53 [95% CI, 1.27-1.96], P=0.001) were significantly higher in low- versus high-volume hospitals. For alcohol septal ablation, the incidence of in-hospital death and all other outcomes did not differ by hospital volume. Conclusions In-hospital SM mortality was 4% with an inverse volume-mortality relationship. Mortality post-alcohol septal ablation was similar across all volume tertiles. Morbidity associated with SM was substantial across all volume tertiles.

Robotic-assisted surgery for prostatectomy – does the diffusion of robotic systems contribute to treatment centralization and influence patients’ hospital choice?

BackgroundBetween 2008 and 2018, the share of robotic-assisted surgeries (RAS) for radical prostatectomies (RPEs) has increased from 3 to 46% in Germany. Firstly, we investigate if this diffusion of RAS has contributed to RPE treatment centralization. Secondly, we analyze if a hospital’s use of an RAS system influenced patients’ hospital choice.MethodsTo analyze RPE treatment centralization, we use (bi-) annual hospital data from 2006 to 2018 for all German hospitals in a panel-data fixed effect model. For investigating RAS systems’ influence on patients’ hospital choice, we use patient level data of 4614 RPE patients treated in 2015. Employing a random utility choice model, we estimate the influence of RAS as well as specialization and quality on patients’ marginal utilities and their according willingness to travel.ResultsDespite a slight decrease in RPEs between 2006 and 2018, hospitals that invested in an RAS system could increase their case volumes significantly (+ 82% compared to hospitals that did not invest) contributing to treatment centralization. Moreover, patients are willing to travel longer for hospitals offering RAS (+ 22% than average travel time) and for specialization (+ 13% for certified prostate cancer treatment centers, + 9% for higher procedure volume). The influence of outcome quality and service quality on patients’ hospital choice is insignificant or negligible.ConclusionsIn conclusion, centralization is partly driven by (very) high-volume hospitals’ investment in RAS systems and patient preferences. While outcome quality might improve due to centralization and according specialization, evidence for a direct positive influence of RAS on RPE outcomes still is ambiguous. Patients have been voting with their feet, but research yet has to catch up.

A 6-year nationwide population-based study on the current status of gastric endoscopic resection in Korea using administrative data

Gastric endoscopic resection (ER) is widely performed in Korea. This study aimed to investigate the overall status of gastric ER in Korea. We enrolled ESD or EMR cases performed for gastric cancer and adenoma from 2012 to 2017 by searching the NHIS database. The annual trend of gastric ER and the clinical characteristics were investigated. Institutions were classified into very high-, high-, low-, and very low volume centers (VHVC, HVC, LVC, and VLVC) by the procedure numbers, and institutional types, regional distributions, and medical resources were investigated accordingly. There were 175,370 ER cases during the study period, with an increasing trend over time. The average annual ESD procedure numbers were 3.9, 54.5, 249.5, and 540.3 cases in 131 VLVCs, 119 LVCs, 24 HVCs, and 12 VHVCs, respectively. Among ESD-performing institutions, 44.8% were located in the Seoul Capital Area. The distribution of medical resources showed a positive correlation with the procedural volume. Similar tendencies were also demonstrated in EMR, with some differences in hospital types and regional distribution. Gastric ER and ESD are increasing in Korea. There was a significant variance in the number of ER procedures and the distribution of types, regions, and medical resources according to the procedural volume.

PO-03-237 PERCUTANEOUS LEFT ATRIAL APPENDAGE OCCLUSION AND PERIPROCEDURAL OUTCOMES TREND IN THE UNITED STATES: AN INSIGHT FROM NATIONWIDE READMISSION DATABASE 2016-2019

The watchman device is the first percutaneous left atrial appendage closure device (pLAAC) indicated in patients with non-valvular AF who cannot tolerate anticoagulation. Our study aims to assess the national trend of utilization of percutaneous left atrial appendage closure device (pLAAC) in atrial fibrillation (AF) patients and determine risk factors and predictors associated with periprocedural morbidity and mortality. Using the National Readmission Database (NRD) database between January 2016 to December 2019, patients with AF who underwent pLAAC evaluated for complications and mortality. Logistic/multivariate regression and Cox regression were used. A total of 54,903 procedures were identified from 2016-2019, mean age 75.91± 7.74, and 76.34 ± 7.42 for the years 2016 and 2019 respectively, 58.23% were male. The total volume of procedures across the board increased consistently each year being 4671 in 2016, 9389 in 2017, 12,698 in 2018, and 25,361 in 2019. Procedures were done in patients with higher number of chronic comorbidities including Prior myocardial infarction (MI), percutaneous coronary intervention, coronary artery disease, heart failure, hypertension, valvular disease, anemia, obesity, chronic lung disease, chronic kidney disease, diabetes, and obstructive sleep apnea (P<0.001). The rate of complications showed a trend toward reduction from 8.2% in 2016 to 7.1% in 2019 (Ptrend=0.006). Bleeding-related complications were significantly reduced for the year 2019 compared with 2016 (4.7% vs 5.5% respectively, Ptrend=0.024). This was primarily driven by fewer hemorrhagic strokes, major bleeds, and blood transfusion procedures. Hospitals with a higher volume of procedures had decreased mortality rates (aOR:0.89, CI0.85-0.93, P<0.0001). Mortality rates did not differ between different years (0.2%). This large NRD study shows there is an inverse relationship between hospital volume and odds of mortality for pLAAC procedures. The number of patients with chronic comorbidities undergoing pLAAC is increasing. Complication rates have been consistently decreasing. Despite this, there was no significant change in mortality.

PO-02-195 ADJUNCTIVE VEIN OF MARSHALL ETHANOL ABLATION FOR ATRIAL FIBRILLATION: SINGLE CENTER EXPERIENCE AND PROCEDURAL LEARNING CURVE

Retrograde ethanol infusion into the vein of Marshall (EI-VOM) has been demonstrated to be an effective adjunct to pulmonary vein isolation (PVI) for ablation of atrial fibrillation (AF). This study sought to assess the temporal change in procedural volume and associated success rate of VOM ethanol ablation. All patients undergoing PVI with EI-VOM at The Ohio State University Wexner Medical Center from January 2021 to November 2022 were included. Procedural success was defined as successful retrograde infusion of ethanol into the vein of Marshall followed the development of a characteristic distribution of low voltage scar in a semicircular pattern around the left inferior pulmonary vein on high-density electroanatomical mapping. The scar was adjudicated by two blinded high-volume operators. The primary endpoint was procedural success over 6-month intervals. Statistical significance was assessed via Fisher's exact test. 201 patients underwent attempted EI-VOM. Patient characteristics were notable for age 65.2 ± 9.0 years, 56 (28%) females, body mass index 33.1 ± 7.3 kg/m2, left ventricular ejection fraction 52.3 ± 11.3%, and CHA2DS2-VASc 2.9 ± 1.5. 113 (56%) patients had non-paroxysmal AF. 173 (86%) patients had failed antiarrhythmic drugs, 113 (56%) patients had a prior cardioversion, and 105 (52%) patients had a prior catheter ablation for AF. Over 23 months, procedural volume increased from an average of 2 cases/month to 12 cases/month, and the procedural success rate increased from 33% to 68% (p=0.020). Figure 1 demonstrates the case volume and procedural learning curve over time. Notable complications included 1 (0.5%) case of cardiac tamponade requiring pericardiocentesis. VOM ethanol ablation is associated with a significant learning curve, and procedural success rate significantly improves with increased case volume.

Variability in Emergency Department Procedure Rates and Distributions in a Regional Health System: A Cross-Sectional Observational Study.

Procedural competency is essential to the practice of emergency medicine. However, there are limited data quantifying emergency department procedural volumes to inform the work of educators and credentialing bodies. In this study, we characterize procedural scope and volume in a regional health care system and compare rates between practice settings and over time. Cross-sectional data were acquired from electronic medical records of a regional health care system from March 2017 through February 2022. Nonspecific entries, esoteric procedures, and nonprocedural clinical skills were excluded. Procedural rates were compared: (1) between academic and community hospitals, (2) across study years, and (3) across seasons. Analyses were repeated for pediatric encounters, and with study year 4 removed to assess the influence of the first year of the coronavirus disease 2019 pandemic on results. There were 131,976 instances of 40 qualifying procedures in 1,979,935 unique visits across 9 EDs. Several high-acuity procedures had similar rates in academic and community settings, including cardiac pacing, cricothyrotomy, and lateral canthotomy. Year-over-year procedural rates were stable or increasing for most procedures, with a notable exception of lumbar puncture. Most procedures did not have significant seasonal variation, and most findings were stable when study year 4 was removed from the analysis. All procedures were performed in all settings and rates of several emergent procedures were similar in both settings, underscoring the importance of broad procedural competence for all emergency physicians. Educators and credentialing organizations can use these data to inform decisions regarding curriculum design and certification requirements.

Relationship between Total Expenditure on Cosmetic Procedures in the United States and NASDAQ 100 Index.

The authors analyzed annual cosmetic procedure statistics from the American Society of Plastic Surgeons for 2005-2020 against economic indices, including major US stock market indices [NASDAQ 100, S&P 500, Dow Jones Industrial Average (DJIA), Russell 2000 indices from the New York Stock Exchange, gross domestic product (GDP)], median income of US citizens, and the US population from the Federal Reserve Bank of St. Louis. Pearson correlation coefficient and multiple regression analysis were used for the statistical analysis. Total expenditure on cosmetic surgery and minimally invasive procedures (TECP) has more than doubled since 2005 to 2020. TECP revealed statistically significant correlations with all other indicators. TECP had the greatest correlation with DJIA (r = 0.952, P < 0.001). In the multiple regression analysis, the increase in TECP led to the rise of the NASDAQ 100 index (adjusted R2 was 0.790, P < 0.001). There was a statistically significant correlation between the TECP in USA and the major indices of the US stock market. In particular, the increase in TECP led to the rise of the NASDAQ 100 index.

How I do it: the endoscopic endonasal transclival approach for clipping of the ruptured vertebral artery aneurysm.

Vertebral artery aneurysms account for less than 5% of all cerebral aneurysms. They have a high risk of rupture and are associated with threatening clinical outcomes compared with anterior circulation aneurysms. The endoscopic endonasal transclival approach (EETA) was used. During the temporary clipping, the neck of the aneurysm was dissected, and a permanent clip was applied. The repair of the skull base defect was carried out with the nasoseptal mucoperiosteal flap on the vascular pedicle. The EETA is a feasible alternative for the clipping of the medially located ruptured vertebral artery aneurysm. EETA can be recommended for centers with a large volume of cerebrovascular and endoscopic neurosurgical procedures.

AUTHOR REPLY

We appreciate the editorial comments as well as the opportunity to respond. We acknowledge the limitations inherent to public Medicare data, including censoring of surgeons with a low volume of procedures, and inability to capture some procedures done at a low volume. However, we were able to capture volume of more common RLS procedures and include surgeons with >10 cases per year allowing for evaluation of surgeons with more regular and substantive robotic practices. Furthermore, the power and accessibility of the dataset allowed us to approach the novel question of female surgeon involvement in RLS in a meaningful and prompt way.

PO-02-048 U.S. TRENDS IN THE HIGH-VOLUME MEDICARE CARDIAC IMPLANTABLE ELECTRONIC DEVICE EXTRACTION WORKFORCE, 2013-2020

Extraction of cardiac implantable electronic devices (CIEDs) is a complex potentially life-saving procedure performed by a subset of specially trained cardiac electrophysiologists and surgeons. Approximately 60% of US CIED extraction procedures occur in Medicare beneficiaries. High volume CIED extractors (HVE) have superior outcomes and the Heart Rhythm Society recommends a minimum of 15 CIED extractions/extractor/year to maintain competence. To examine nationwide trends in the Medicare CIED HVE workforce and CIED extraction volume in the US. Using data from the Medicare Provider Utilization and Payment Database (MPUPD) we identified all extractors who used an individual transvenous CIED extraction procedure code (CPT 33234, 33235, 33244) >10 times in any year from 2013-2020. The number, demographics, and location of these HVEs were trended over the study period. There were an average of 1621 CIED extractions performed annually by 74 HVEs over the study period. Only 5% (n=3) of HVEs were women (Figure Panel A). During the 8-year period, the number of HVEs in the MPUPD as well as the total number of CIED extraction procedures performed by HVEs decreased by 60% (Figure Panel A, C). The proportion of women HVEs remained unchanged (Figure Panel A). In 2020, fewer than 50% of states had a HVE and only 2 states had a woman HVE (Figure Panel B). The median procedural volume between represented men and women HVEs was similar. A minority of cardiac electrophysiologists and surgeons perform a high volume of CIED extractions and the number of HVEs is declining, leading to a growing disparity of geographic availability. Future study is needed to determine whether fewer CIED extractions are being performed or a greater proportion of CIED extractions are being performed by lower volume extractors.

PO-02-028 NEGATIVE EFFECTS OF COVID-19 ON THE IMPLANTATION RATE OF CARDIAC RESYNCHRONIZATION THERAPY WITH DEFIBRILLATOR DEVICE.

Coronavirus-19 (COVID-19) pandemic drastically changed the landscape of the US medical system. Total surgical procedure volume declined across all specialties, primarily in elective procedures. Multiple task forces promoted the cancellation of nonurgent elective procedures, including the implantation of a Cardiac Resynchronization Therapy Defibrillator (CRT-D) in stable patients during the pandemic. The effect of COVID-19 on the rate of CRT-D implantation is poorly understood. We aim to explore the impact of the COVID-19 pandemic on CRT-D insertion rates, along with negative outcomes related to delays in care. We conducted a retrospective analysis using the National Inpatient Sample (NIS) database for patient encounters involving the insertion of CRT-D between 2017 & 2020. Variables were identified using their ICD-10 codes. Admissions were included if the patient was at least 18 years of age, presenting for a non-elective admission, had a primary diagnosis of hypertensive heart disease, hypertensive heart, and chronic kidney disease, or heart failure (ICD-10 codes I11, I13, I50), and underwent insertion of a CRT-D (ICD-10 code 0JH**9*). Between 2017 and 2020, CRT-D devices were inserted during 23,635 admissions. On average, 6,198 devices were implanted yearly from 2017 to 2019, with only 5,040 being implanted in 2020. CRT-D implant rates dropped below their previous 3-year average in every region of the US during 2020 (Figure 1). Additionally, the highest average death rate at 13.89%, but this difference was statistically insignificant (adjusted Wald test p=0.767), and COVID-19 was not associated with an increased risk of inpatient mortality (OR 0.22, 95% CI 0.03-1.82, p=0.162). Blacks were disproportionately affected by a reduction in CRT-D procedures for this demographic in 2020 as compared to other races. COVID-19 pandemic has affected all facets of the healthcare system, especially surgical volume rates. Consistent with many other procedures, CRT-D procedures significantly decreased in 2020 following multiple task force recommendations to postpone nonurgent procedures in the setting of rampant COVID-19 infections. To our knowledge, this is the first retrospective study highlighting the trend of decreased rates of CRT-D implantation as a response to the COVID-19 pandemic.

Characterizing the Practices of Canadian Orthopedic Surgeons in the Management of patients With Anterior Glenohumeral Instability.

To determine the practice patterns of Canadian orthopedic surgeons in the management of patients with anterior glenohumeral instability (AGHI). Cross-sectional survey. Canada. Canadian orthopedic surgeons with membership in the Canadian Orthopedic Association or Canadian Shoulder and Elbow Surgeon group who had managed at least 1 patient with AGHI in the previous year. A survey including demographics and questions on the management of patients with AGHI was completed. Statistical comparisons (χ 2 ) were completed with responses stratified using the instability severity index score (ISIS) in practice, years of practice, and surgical volumes. Summary statistics were compiled, and response frequencies were considered for consensus (75%). Case series responses were stratified on use of the ISIS in practice, years of experience, and annual procedure volumes (χ 2 , P < 0.05). Eighty orthopedic surgeons responded, with consensus on areas of diagnostic workup of AGHI, nonoperative management, and operative techniques. There was no consensus on indications for soft tissue and bony augmentation or postoperative management. There was no difference in practices based on the use of ISIS, years in practice, or surgical volumes. Canadian orthopedic surgeons manage AGHI consistently with consensus achieved in preoperative diagnostics and operative techniques, although debate remains as to the indications for soft tissue and bony augmentation procedures.

A long short-term memory model for forecasting the surgical case volumes at a hospital

Surgical procedures are the primary source of expenditures and revenues for hospitals. Accurate forecasts of the volume of surgical cases enable hospitals to efficiently deliver high-quality care to patients. We propose an algorithm to forecast the expected volume of surgical procedures using multivariate time-series data. This algorithm uses feature engineering techniques to determine factors that affect the volume of surgical cases, such as the number of available providers, federal holidays, weather conditions, etc. These features are incorporated in a long short-term memory (LSTM) network to predict the number of surgical procedures in the upcoming week. The hyperparameters of this model are tuned via grid search and Bayesian optimization techniques. We develop and verify the model using historical data of daily case volume from 2014 to 2020 at an academic hospital in North America. The proposed model is validated using data from 2021. The results show that the proposed model can make accurate predictions six weeks in advance, and the average = 0.855, RMSE = 2.017, MAE = 1.104. These results demonstrate the benefits of incorporating additional features to improve the model’s predictive power for time series forecasting.