Are Orthopedic Hand Surgeons Undercompensated for Time Spent in the Operating Room? A Study of Relative Value Units

Hand ◽  
2022 ◽  
pp. 155894472110643
Author(s):  
Trevor Simcox ◽  
Sakib Safi ◽  
Jacob Becker ◽  
Jason Kreinces ◽  
Adam Wilson
Keyword(s):  
Complication Rate ◽  
Operative Time ◽  
Major Complication ◽  
Hand Surgery ◽  
Reoperation Rate ◽  
Orthopedic Procedures ◽  
Improvement Program ◽  
Relative Value ◽  
American Society ◽  
American Society Of Anesthesiologists

Background: This study aims to investigate whether compensation is equitable among the most commonly performed orthopedic hand surgeries and when compared with general orthopedic procedures. Methods: The National Surgical Quality Improvement Program database was queried for all orthopedic procedures, from 2016 to 2018, performed more than 150 times using Current Procedural Terminology (CPT) codes. Physician work relative value unit (wRVU) data were obtained from the 2020 US Centers for Medicare and Medicaid Services fee schedule. Linear regressions were used to determine whether there was an association among wRVU, operative time, and wRVU per hour (wRVU/h). Reimbursement for hand surgery CPT codes was compared with that of nonhand orthopedic CPT codes. The CPT codes were stratified into quartile cohorts based on mean operative time, major complication rate, mortality rate, American Society of Anesthesiologists class, reoperation rate, and readmission rate. Student t tests were used to compare wRVU/h between cohorts. Results: Forty-two hand CPT codes were identified from 214 orthopedic CPT codes, accounting for 32 333 hand procedures. The median wRVU/h was significantly lower for procedures in the longest operative time quartile compared with the shortest operative time quartile ( P < .001). Compared with hand procedures, nonhand procedures were found to have significantly higher mean operative time ( P < .001), mean complication rate ( P < .001), mean wRVU ( P = .001), and mean wRVU/h ( P = .007). Conclusions: The 2020 Physician wRVU scale does not allocate proportional wRVUs to orthopedic hand procedures with longer mean operative times. There is a decrease in mean reimbursement rate for hand procedures with longer mean operative time. When compared with general orthopedic procedures, hand procedures have a lower mean wRVU/h and complication rate.

scholarly journals Hartmann’s procedure, reversal and rate of stoma-free survival

2018 ◽  
Vol 100 (4) ◽  
pp. 301-307 ◽  
Author(s):  
S Hallam ◽  
BS Mothe ◽  
RMR Tirumulaju
Keyword(s):  
Length Of Stay ◽  
Complication Rate ◽  
Major Complication ◽  
Wound Dehiscence ◽  
Hartmann’S Procedure ◽  
Hartmann's Procedure ◽  
Retrospective Audit ◽  
Audit Period ◽  
American Society ◽  
American Society Of Anesthesiologists

Background Hartmann’s procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy. The timing for reversal of Hartmann’s is not well defined as it is technically challenging and carries a high complication rate. Methods This study is a retrospective audit of all patients who underwent Hartmann’s procedure between 2008 and 2014. Reversal of Hartmann’s rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien–Dindo) including 30-day mortality were recorded. Results Hartmann’s procedure (n = 228) indications were complicated diverticular disease 44% (n = 100), malignancy 32% (n = 74) and other causes 24%, (n = 56). Reversal of Hartmann’s rate was 47% (n = 108). Median age of patients was 58 years (range 21–84 years), American Society of Anesthesiologists grade 2 (range 1–4), length of stay was eight days (range 2–42 days). Median time to reversal of Hartmann’s was 11 months (range 4–96 months). The overall complication rate from reversal of Hartmann’s was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehiscence. Failure of reversal and permanent stoma was less than 1% (n = 2). Thirty-day mortality following Hartmann’s procedure was 7% (n = 15). Where Hartmann’s procedure wass not reversed, for 30% (n = 31) this was the patient’s choice and 70% (n = 74) were either high risk or unfit. Conclusions Hartmann’s procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann’s procedures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann’s procedure in this study.

scholarly journals Predictors of 30-Day Unplanned Readmissions, Complications, and Mortality Following Operative Management of C2 Fractures

2019 ◽  
Vol 10 (2) ◽  
pp. 130-137
Author(s):  
David N. Bernstein ◽  
Caroline Thirukumaran ◽  
Brandon Raudenbush ◽  
Robert W. Molinari ◽  
Emmanuel N. Menga ◽  
...  
Keyword(s):  
Operative Time ◽  
Functional Limitations ◽  
Operative Management ◽  
Unplanned Readmission ◽  
Improvement Program ◽  
Five Factors ◽  
American College Of Surgeons ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Complications And Mortality

Study Design: Retrospective database review. Objectives: To determine factors associated with unplanned readmission, complications, and mortality in patients undergoing operative management for C2 fractures. Methods: The American College of Surgeons–National Surgical Quality Improvement Program (ACS NSQIP) was queried between 2007 and 2014. Unplanned readmission, any complication, and mortality were the outcomes of interest. Bivariate statistics were calculated, and multivariate regression models were estimated. Results: A total of 285 patients were enrolled. Readmission data was available for 199 patients and 11 patients (5.5% of 199 patients) had an unplanned readmission. Overall, 60 patients (21% of 285 patients) had at least 1 complication and 15 patients (5.3% of 285 patients) died. Five factors were associated with complications: transferred from another facility (odds ratio [OR] 3.00, 95% confidence interval [CI]1.51-5.98; P < .01); operative time ≥180 minutes (OR 2.43, 95% CI 1.11-5.36; P = .03); at least 1 patient comorbidity (OR 2.50, 95% CI 1.01-6.18; P < .05); American Society of Anesthesiologists (ASA) class 3 (OR 4.86, 95% CI 1.19-19.88; P = .03); and ASA class 4 (OR 7.24, 95% CI 1.66-31.66; P = .01). The only factor associated with unplanned readmission was having at least one postoperative complication (OR 7.10, 95% CI 1.04-48.59; P < .05), while patients who were partially or totally dependent from a functional standpoint were at increased odds of death (OR 3.98, 95% CI 1.12-14.08; P = .03). Conclusions: Patients with functional limitations have increased odds of death, while patients with postoperative complications have increased odds of unplanned readmission. Being transferred from an outside facility, having an operative time ≥180 minutes, having at least one comorbidity, and being classified as ASA class 3 or 4 increase patient odds of complication.

Assessing Risk of Severe Complications after Endoscopic Transnasal Transsphenoidal Surgery: A Comparison of Frailty, American Society of Anesthesiologists, and Comorbidity Scores

2021 ◽  
Author(s):  
Jordan M. Sukys ◽  
Roy Jiang ◽  
Richard P. Manes
Keyword(s):  
Frailty Index ◽  
Information Criteria ◽  
Improvement Program ◽  
Pituitary Mass ◽  
Complication Risk ◽  
Comorbidity Scores ◽  
Multivariable Regression ◽  
American Society ◽  
Akaike’S Information Criteria ◽  
American Society Of Anesthesiologists

Abstract Objective This study aimed to improve age-independent risk stratification for patients undergoing endoscopic transnasal transsphenoidal (TNTS) approach to pituitary mass resection by investigating the associations between frailty, American Society of Anesthesiologists (ASA), and comorbidity scores with severe complications following TNTS. Design This study is a retrospective review. Setting This review was conducted utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Participants A total of 680 cases of TNTS identified from 2010 to 2013 were included in this study. Main Outcome Measures The modified frailty index (mFI) was calculated to quantify frailty. ASA and Charlson's comorbidity index (CCI) scores were obtained as physiologic status and comorbidity-based prognostic markers. Severe complications were separated into intensive care unit (ICU)-level complications, defined by Clavien–Dindo grade IV (CDIV) criteria, and mortality. Results Overall, 24 CDIV complications (3.5%) and 6 deaths (0.9%) were recorded. Scores for mFI (p = 0.01, R 2 = 0.97) and ASA (p = 0.04., R 2 = 0.87) were significantly correlated with CDIV complications. ASA scores were significantly correlated with mortality (p = 0.03, R 2 = 0.87), as well as independently associated with CDIV complication by multivariable regression models (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.35–6.83, p < 0.01), while mFI was not. CCI was not significantly associated with CDIV complications or mortality. A multivariable regression model incorporating ASA had a lower Akaike's Information Criteria (AIC; 188.55) than a model incorporating mFI (195.99). Conclusion Frailty and physiologic status, as measured by mFI and ASA scores respectively, both correlate with ICU-level complications after TNTS. ASA scores demonstrate greater clinical utility than mFI scores; however, as they are more easily generated, uniquely correlated with mortality and independently associated with ICU-level complication risk on multivariable regression analysis.

Attending Surgeon Variation in Operative Case Length: An Opportunity for Quality Improvement

2018 ◽  
Vol 84 (10) ◽  
pp. 1595-1599
Author(s):  
Kirollos S. Malek ◽  
Jukes P. Namm ◽  
Carlos A. Garberoglio ◽  
Maheswari Senthil ◽  
Naveen Solomon ◽  
...  
Keyword(s):  
Operative Time ◽  
Resident Training ◽  
Careful Consideration ◽  
Analysis Of Covariance ◽  
Surgical Resident ◽  
Or Efficiency ◽  
American Society ◽  
Case Logs ◽  
American Society Of Anesthesiologists ◽  
The Impact

Balancing resident education with operating room (OR) efficiency, while accommodating different styles of surgical educators and learners, is a challenging task. We sought to evaluate variability in operative time for breast surgery cases. Accreditation Council for Graduate Medical Education case logs of breast operations from 2011 to 2017 for current surgical residents at Loma Linda University were correlated with patient records. The main outcome measure was operative time. Breast cases were assessed as these operations are performed during all postgraduate years (PGY). Breast procedures were grouped according to similarity. Variables analyzed included attending surgeon, PGY level, procedure type, month of operation, and American Society of Anesthesiologists class. Of 606 breast cases reviewed, median overall operative time was 150 minutes (interquartile range 187–927). One-way analysis of covariance demonstrated statistically significant variation in operative time by attending surgeon controlling for covariates (PGY level, procedure, American Society of Anesthesiologists class, and month) ( P = 0.04). With institutional OR costs of $30 per minute, the average difference between slowest and fastest surgeon was $2400 per case [(218–138) minutes 3 $30/min]. Minimizing variability for common procedures performed by surgical educators may enhance OR efficiency. However, the impact of case length on surgical resident training requires careful consideration.

Complications and Outcomes of Chimeric Free Flaps: A Systematic Review

2019 ◽  
Vol 161 (4) ◽  
pp. 568-575 ◽  
Author(s):  
Abhinav R. Ettyreddy ◽  
Collin L. Chen ◽  
Joseph Zenga ◽  
Laura E. Simon ◽  
Patrik Pipkorn
Keyword(s):  
Head And Neck ◽  
Complication Rate ◽  
Operative Time ◽  
Donor Site ◽  
Locally Advanced ◽  
Major Complication ◽  
Free Flaps ◽  
Controlled Vocabulary ◽  
Cochrane Central Register ◽  
Complication Rates

ObjectiveAblations of locally advanced or recurrent head and neck cancer commonly result in large composite orofacial defects. Chimeric flaps represent a unique surgical option for these defects, as they provide diverse tissue types from a single donor site. The purpose of the study was to consolidate the literature on chimeric flaps with regard to postoperative complication rates to help inform surgical decision making.Data SourcesThe librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946), Embase (1947), Scopus (1823), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrails.gov (1997).Review MethodsCandidate articles were independently reviewed by 2 authors familiar with the subject material, and inclusion/exclusion criteria were uniformly applied for article selection. Articles were considered eligible if they included patients who received a single chimeric flap for reconstruction of head and neck defects and if they provided data on complication rates.ResultsA total of 521 chimeric flaps were included in the study. The major complication rate was 22.6%, while the minor complication rate was 14.0%. There were 7 flap deaths noted in the series. Median operative time and harvest time were 15.0 and 2.5 hours, respectively.ConclusionChimeric flaps represent a viable option for reconstruction of complex head and neck defects and have complication rates similar to those of double free flaps and single free flaps with locoregional flap while only modestly increasing total operative time.

scholarly journals Development and validation of a predictive model for American Society of Anesthesiologists Physical Status

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Seshadri C. Mudumbai ◽  
Suzann Pershing ◽  
Thomas Bowe ◽  
Robin N. Kamal ◽  
Erika D. Sears ◽  
...  
Keyword(s):  
Predictive Validity ◽  
Research Quality ◽  
Multinomial Regression ◽  
Physical Status ◽  
Improvement Program ◽  
Variable Model ◽  
Preoperative Status ◽  
American Society ◽  
Key Indicators ◽  
American Society Of Anesthesiologists

Abstract Background The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes. Methods Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator. Results Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/− 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ Conclusions Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

scholarly journals The Paisley Pattern Breast Reduction

2019 ◽  
Vol 27 (2) ◽  
pp. 189-194
Author(s):  
Devra B. Becker
Keyword(s):  
Chart Review ◽  
Operative Time ◽  
Breast Reduction ◽  
Proof Of Concept ◽  
Flap Necrosis ◽  
Institutional Review ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Wise Pattern

Background: Skin resection patterns inform the shape and scars after breast reduction. The 2 most commonly performed skin resection patterns, the Wise pattern and vertical pattern, each have limitations. The most common challenge is addressing excess lateral skin while avoiding medial scars. The Paisley Pattern breast reduction addresses this by incorporating lateral dogear excision in the skin resection design. Methods: Thirty consecutive patients received a Paisley Pattern breast reduction. After institutional review board approval, a chart review was performed to evaluate resection weight, operative time, American Society of Anesthesiologists class, flap necrosis, and seroma. Results: Operative times were comparable to published times for the Wise and vertical pattern techniques. No patients had lateral flap necrosis, and no patients required a return to the operating room during the follow-up period. One patient developed a unilateral seroma that was drained by interventional radiology. Conclusions: This report of a novel skin resection design demonstrates a proof of concept that the skin resection pattern can be performed safely in a wide variety of patients. Although there is a learning curve to the technique to prevent over-resection laterally, it provides efficient and aesthetically acceptable alternative to the Wise and vertical skin resection patterns for both large and small reductions.

Postoperative Complications Predict 30-Day Readmission in Geriatric General Surgery Patients

2017 ◽  
Vol 83 (4) ◽  
pp. 365-370 ◽  
Author(s):  
James D. Dieterich ◽  
Celia M. Divino
Keyword(s):  
Venous Thromboembolism ◽  
General Surgery ◽  
Cox Regression ◽  
Operation Time ◽  
Unplanned Readmission ◽  
Improvement Program ◽  
Vein Thrombosis ◽  
American Society ◽  
Patient Readmissions ◽  
American Society Of Anesthesiologists

The Affordable Care Act has placed unplanned patient readmissions under more scrutiny than ever. Geriatric patients, in particular, suffer a disproportionate amount of complications from any kind of hospitalization, including readmissions. This study seeks to identify risk factors in this population that predispose them to an unplanned readmission within 30 days after index surgery. The National Surgical Quality Improvement Program database was used to select patients 65 years and older, who underwent general surgery procedures in 2012. Patient demographics, comorbidities, complications, and readmissions were analyzed. A Cox regression survivorship model was used for multivariate analysis. A total of 7712 patients were reviewed; 617 patients (8.0%) had an unplanned readmission within 30 days of their operation. Cox regression revealed five different independent predictors of unplanned readmission within 30 days. They are age [P = 0.009, hazard ratio (HR) = 1.016, 95% confidence interval (CI) = 1.01–1.03], American Society of Anesthesiologists Class >2 (P = 0.037, HR = 1.22, CI = 1.024–1.475), operation time (minutes) (P = 0.001, HR = 1.001, CI = 1.00–1.002), any complication (P = 0.03, HR = 1.449, CI = 1.33–1.852), and deep vein thrombosis (P = 0.03, HR = 1.87, CI = 1.31–3.85). Using Cox regression to adjust for patient length of stay, age, American Society of Anesthesiologists class, any complication, operation time, and venous thromboembolism all independently increased the rate of unplanned readmissions. Patients who suffer any complication or a venous thromboembolism postoperatively are at a particularly high risk of readmission. These patients should be targeted for increased inpatient monitoring and included in preventable readmission programs after discharge.

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