Severe Thyroid Eye Disease in the US: A National Perspective

Abstract Background: Thyroid eye disease (TED) is an unpredictable autoimmune inflammatory disease which can be sight-threatening, debilitating, and disfiguring. The majority of patients have mild, self-limited TED, 20-30% of patients experience moderate/severe disease, and 3-5% may develop sight-threatening disease, such as CON or exposure keratopathy. Surgical intervention is commonly necessary for patients with moderate/severe stable disease or sight-threatening disease, however, there is little data on the prevalence of TED requiring surgical interventions. Objective: To document the number of surgical procedures for thyroid eye disease in the US and evaluate the associated costs of these interventions. Methods: National Ambulatory Surgery Sample (NASS) is the largest ambulatory surgery database, representing approximately 14 million ambulatory surgeries performed annually in a hospital setting in the US. Data from 2,699 hospital-owned facilities located in 31 States and the District of Columbia, approximating a 63-percent stratified sample of U.S. hospital-owned facilities performing selected ambulatory surgeries are available for analyses. Data on clinical procedures and diagnoses, disposition of the patient, expected source of payment, and total charges, as well as geographic, hospital-owned facility, and patient characteristics are collected. For the purposes of this study, TED was identified by concomitantly occurring ICD 10 codes of thyroid disease and ICD-10 codes for eye manifestations of thyroid eye disease. CPT codes were used to identify eye surgeries performed in these patients. The coding algorithms were developed by consensus of three ophthalmic surgeons. Results: In 2018, a total of 1,991 patients with TED required eye surgery, with a national prevalence of 0.6 per 100,000 population. Mean age at surgery was 56.2 years (95% Confidence Interval (CI) 55.3-57.2). Women comprised 73% (1455 women and 536 men) of TED patients who underwent surgery. The average charges for each surgical encounter were $21,875 (95% CI $19,066-$24,684). Total charges for TED surgery in the US totaled over 43.5 million annually. While many patients had private insurance (49.7%), Medicare (31%) and Medicaid (13%) were also significant sources of reimbursement. Of all TED-related surgeries, 93% were conducted in teaching hospitals. Only 0.2% of surgeries were conducted in non-urban rural settings. Conclusion: In the US, severe TED requiring surgery, although uncommon, has significant economic impact. Further research is warranted to better understand the natural history of TED that may inform treatment pathways which may prevent complications needing surgery.

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Medical treatment in thyroid eye disease in 2020

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2020-316051 ◽

2020 ◽

pp. bjophthalmol-2020-316051 ◽

Cited By ~ 1

Author(s):

Jwu Jin Khong ◽

Alan McNab

Keyword(s):

Clinical Trials ◽

T Cells ◽

Cell Surface ◽

Medical Treatment ◽

Severe Disease ◽

Thyroid Eye Disease ◽

Eye Disease ◽

Molecular Pathways ◽

Surface Receptors ◽

Intravenous Corticosteroid

Thyroid eye disease (TED) affects 25% of patients with Graves’ hyperthyroidism, where 1 in 20 patients has active, moderate-to-severe disease that will require medical treatment for reducing TED activity and severity. Intravenous corticosteroid has been the mainstay of treatment for active moderate-to-severe TED. With improved understanding of the pathophysiology of TED, immunotherapy targeting different molecular pathways including T cells, B cells, cytokines and cell surface receptors have been investigated in randomised clinical trials. This review provides an overview of the current advances in medical treatment including teprotumumab, tocilizumab, rituximab and mycophenolate and the indications for their use in the management of active, moderate-to-severe TED.

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Socioeconomic Characteristics of Patients Undergoing Ambulatory Parathyroidectomy and a Comparison of Institutional Charges

The American Surgeon ◽

10.1177/0003134820951479 ◽

2020 ◽

pp. 000313482095147

Author(s):

Ellie A. Moeller ◽

Tamar Walker ◽

Zahra F. Khan ◽

Joshua P. Parreco ◽

Jessica L. Buicko

Keyword(s):

Logistic Regression ◽

Ambulatory Surgery ◽

Private Insurance ◽

High Volume ◽

International Classification Of Diseases ◽

Ambulatory Setting ◽

Multivariate Logistic Regression ◽

White Ethnicity ◽

Classification Of Diseases ◽

Icd 10

Background Parathyroidectomy is frequently performed as ambulatory surgery. This study seeks to characterize the socioeconomic factors that may impact the patient selection for outpatient parathyroidectomy. Methods The 2016 Florida State Inpatient Database (SID) and the 2016 Florida State Ambulatory Surgery Database (SASD) were queried for all patients undergoing parathyroidectomy using the International Classification of Diseases 10 (ICD-10) procedure codes. Univariable comparison and multivariate logistic regression were performed for outpatient versus inpatient parathyroidectomy using all relevant patient and hospital characteristics from the database. Results Seven hundred and sixteen patients underwent parathyroidectomy in Florida in 2016; 322 parathyroidectomies were performed in the ambulatory setting (45.0%). After multivariate logistic regression, patients over age 65 and parathyroidectomies performed at high-volume centers were more likely to be performed at an outpatient center. Those patients who were black, Hispanic, had a Charlson Comorbidity Index ≥3, Medicare, Medicaid, and Self-pay were associated with a decreased likelihood of having an outpatient procedure. Discussion Access to ambulatory parathyroidectomy is more common in patients with private insurance, white ethnicity, and fewer comorbidities.

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Abstract 16782: A Nationwide Look at Hospitalized Patients With COVID-19 - Clinical Features and Key Events

Circulation ◽

10.1161/circ.142.suppl_3.16782 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Monica R Shah ◽

Tanya F Partridge ◽

Xiaoqiang Xue

Keyword(s):

Angiotensin Receptor Blockers ◽

Private Insurance ◽

Resource Planning ◽

Clinical Events ◽

The Us ◽

Icd 10 ◽

Receptor Blockers ◽

Artery Disease ◽

Event Rates ◽

Key Events

Introduction: While there have been single-center and regional reports describing patients with the coronavirus disease 2019 (COVID-19), to date there has not been a national characterization of hospitalized COVID-19 patients (pts) in the US. Hypothesis: To examine baseline features and key clinical events in US hospitalized COVID-19 pts. Methods: We interrogated a verified US medical claims database from Jan to May 2020 (110 million pts; 76% private insurance claims, 21% Medicare claims, 4% Medicaid claims). Using the COVID-19 ICD-10 code (U07.1), we assessed baseline characteristics, medications, and key event rates in hospitalized COVID-19 pts. Results: From Jan to May 2020, we identified 368,365 pts with a diagnosis of COVID-19. Demographics were: age 60 (IQR 46-72); female sex 198,917 (54%). Key comorbidities were: hypertension 111,940 (30%), coronary artery disease 79,398 (22%), diabetes 70,337 (19%), obesity 33,208 (9%), and heart failure 29,556 (8%). Key medications after admission were: hydroxychloroquine 7,656 (2%), azithromycin 15,361 (4%), methylprednisolone 416 (0.1%), dexamethasone 1,873 (0.5%), and ACE inhibitors/angiotensin receptor blockers/sacubitril-valsartan 18,534 (5%). Among COVID-19 pts, 52,443 (14%) were diagnosed with pneumonia. Key clinical events (ICU admission, intubation, ARDS, and the composite) were significantly higher in COVID-19 pts with pneumonia compared to those without pneumonia (Figure). Conclusions: To the best of our knowledge, this is the first national description of hospitalized COVID-19 pts. We observed an equitable distribution by sex, and high rates of cardiometabolic disease. The rates of key clinical events were significantly higher in COVID-19 pts with pneumonia compared to those without pneumonia. This information can be used in a variety of ways - from refining prognosis, resource planning in hospitals, and estimating event rates for COVID-19 clinical trials.

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Trends in Treatment of Active, Moderate-to-Severe Thyroid Eye Disease in the United States

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa140 ◽

2020 ◽

Vol 4 (12) ◽

Author(s):

Yao Wang ◽

Anu Sharma ◽

Lissa Padnick-Silver ◽

Megan Francis-Sedlak ◽

Robert J Holt ◽

...

Keyword(s):

United States ◽

Severe Disease ◽

The United States ◽

Thyroid Eye Disease ◽

Eye Disease ◽

Eye Drops ◽

Ocular Surgery ◽

Treatment Practice ◽

Treatment Practices ◽

Orbital Radiation

Abstract Introduction Limited data exist on US referral/management patterns for moderate-to-severe thyroid eye disease (TED), a disabling condition. Methods US ophthalmologists and endocrinologists experienced in treating TED provided medical record data of moderate-to-severe TED patients and information on referral/treatment practices. Data on signs/symptoms, medical/surgical treatments, treatment response, and referral history were collected. Moderate and severe cases were stratified to interrogate treatment/practice differences. Results A total of 181 physicians provided data on 714 patients (49.4 ± 13.6 years old, 65% women, 14% severe disease). Reporting physicians diagnosed 55% of patients themselves and solely managed 37% of cases, with similar referral/comanagement patterns between moderate and severe cases. Topical therapies included lubricating (79%) and glucocorticoid (39%) eye drops. Systemic therapies included oral glucocorticoids (36%), IV glucocorticoids (15%), and rituximab and/or tocilizumab (12%). Few patients underwent orbital radiation (4%) or surgical intervention (4%). IV glucocorticoids (33% vs. 12%), biologics (26% vs. 10%), orbital radiation (11% vs. 3%), and ocular surgery (12% vs. 3%) were used more often in severe versus moderate cases (all P < 0.001). However, severe disease was less responsive to therapy (very responsive to therapy: 28% vs. 49%, P < 0.001). Conclusions Participating physicians were primarily responsible for just over one-half of TED diagnoses, but solely treated <40% of patients. Severe TED was treated more often with surgery and systemic immunologic therapies than moderate disease, but was less likely to respond to treatment. These results reinforce that moderate-to-severe TED is difficult to treat with an unmet medical need in the United States.

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Application of an Artificial Intelligence/Machine Learning Model for Estimating Potential US Prevalence of WHIM Syndrome, a Rare Immunodeficiency, from Insurance Claims Data

Blood ◽

10.1182/blood-2021-148809 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 4305-4305

Author(s):

Cathy Garabedian ◽

Lori Neri ◽

Jan Seng ◽

Graham K Jones ◽

Jonathan Woodring

Keyword(s):

Claims Data ◽

Severe Disease ◽

Control Group ◽

Insurance Claims ◽

Claims Database ◽

Whim Syndrome ◽

The Us ◽

Icd 10 ◽

Insurance Claims Data ◽

History Of

Abstract Introduction: WHIM (Warts, Hypogammaglobulinemia, Infections, and Myelokathexis) syndrome is an inborn error of immunity characterized as a primary immunodeficiency with neutropenia-but the acronym does not reflect the broad spectrum of disease manifestations that patients may experience. A WHIM syndrome diagnosis may be confirmed clinically by the presence of myelokathexis, the retention of white blood cells in the bone marrow, or by identification of a known pathogenic gain-of-function mutation in the CXCR4 gene coding for the CXCR4 receptor. Diagnosis of WHIM syndrome is thought to be frequently missed because of low disease awareness, missed identification of myelokathexis, and lack of routine genetic testing (Al Ustwani O, et al. Br J Haematol. 2014:164;15-23; Dotta L, et al. Curr Mol Med. 2011;11:317-325; Heusinkveld L, et al. Exp Opin Orphan Drugs. 2017;5(10):813-825). The prevalence of WHIM syndrome has never been systematically studied and is unknown. Determination of prevalence via insurance claims data is hindered by the absence of an International Classification of Diseases (ICD)-10 code for WHIM syndrome as well as inconsistent coding for key symptoms of WHIM syndrome, which are variably penetrant. This study applied an artificial intelligence (AI)/machine learning (ML) model to estimate the potential prevalence of WHIM syndrome using a large US insurance claims database. Methods: A deidentified, longitudinal, patient-level US claims database of >300 million lives was used for this study. Thirty-two patients with genetically confirmed WHIM syndrome were identified from the claims database by linking deidentified patients to known physicians and matching clinical and demographic features. Using this group as a positive training class, an AI/ML model was deployed to identify patients with WHIM look-alike clinical phenotypes in the database. Patients were further filtered based on clinical features to generate low (presence of warts, history of infections, and hypogammaglobulinemia) and high (presence of warts, history of infections, and coding associated with immunodeficiency) prevalence estimates; a final prevalence number for the US was projected to account for incomplete coverage of the US population in the claims database. Finally, insurance codes for disease symptoms, treatments, and management were analyzed to investigate the burden of disease in patients identified by the model. Results: The model showed a high predictive value for distinguishing patients with known WHIM syndrome from a random sample of age-matched patients in the database (area under the curve [AUC] of receiver operating characteristic [ROC] plot, >0.99) as well as a control group of patients with ICD-10 codes defining immunodeficiency conditions (AUC of ROC plot, 0.99). The model generated estimates ranging from 1803 (low) to 3718 (high) patients with WHIM look-alike phenotype in the US. Analysis of medical history in the high-estimate WHIM look-alike group revealed symptomatic and severe disease, as evidenced by ≥1 instance of use of granulocyte colony-stimulating factor (41%) or intravenous immunoglobulin (46%) therapy (both <1% in control group), need for respiratory services (82% vs 8% in control group), presence of hearing loss (18% vs 1% in control group), and high annual utilization of emergency (51%) and hospital (44%) services (vs 8% and 1%, respectively, in control group). Conclusions: The methodology used here provides an approach to explore the prevalence of rare diseases that are often mis- or under-diagnosed and are not captured with a unique ICD-10 code. This study estimates a prevalence of 1803 to 3718 WHIM look-alike patients in the US, supporting the possibility that there may be ≤~3700 patients with either diagnosed or undiagnosed WHIM syndrome in the US. An analysis of the medical history of the WHIM look-alike patients revealed a history of symptomatic and severe disease and a high unmet medical need. Since it is not feasible to definitively confirm a WHIM diagnosis in the look-alike group, it is possible that some of these look-alike patients may have diagnosed or undiagnosed WHIM syndrome, while others may have a clinical phenotype consistent with WHIM syndrome without meeting its classic diagnostic criteria. Disclosures Garabedian: X4 Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Neri: X4 Pharmaceuticals: Current Employment. Seng: X4 Pharmaceuticals: Current Employment. Jones: Real Chemistry (Formerly Swoop/IPM): Current Employment, Other: I was paid salary to perform secondary research project work for client "X4" which resulted in this publication.

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A Guide to Coding and Billing for the Audiological Management of Patients Receiving Ototoxic Medical Treatments

Perspectives of the ASHA Special Interest Groups ◽

10.1044/2019_pers-sig8-2018-0028 ◽

2019 ◽

Vol 4 (5) ◽

pp. 936-946

Author(s):

Dawn Konrad-Martin ◽

Neela Swanson ◽

Angela Garinis

Keyword(s):

Otoacoustic Emissions ◽

Best Practice ◽

Private Insurance ◽

Monitoring Program ◽

Current Method ◽

International Classification Of Diseases ◽

Ethical Practice ◽

Party Payer ◽

High Frequency Audiometry ◽

Icd 10

Purpose Improved medical care leading to increased survivorship among patients with cancer and infectious diseases has created a need for ototoxicity monitoring programs nationwide. The goal of this report is to promote effective and standardized coding and 3rd-party payer billing practices for the audiological management of symptomatic ototoxicity. Method The approach was to compile the relevant International Classification of Diseases, 10th Revision (ICD-10-CM) codes and Current Procedural Terminology (CPT; American Medical Association) codes and explain their use for obtaining reimbursement from Medicare, Medicaid, and private insurance. Results Each claim submitted to a payer for reimbursement of ototoxicity monitoring must include both ICD-10-CM codes to report the patient's diagnosis and CPT codes to report the services provided by the audiologist. Results address the general 3rd-party payer guidelines for ototoxicity monitoring and ICD-10-CM and CPT coding principles and provide illustrative examples. There is no “stand-alone” CPT code for high-frequency audiometry, an important test for ototoxicity monitoring. The current method of adding a –22 modifier to a standard audiometry code and then submitting a letter rationalizing why the test was done has inconsistent outcomes and is time intensive for the clinician. Similarly, some clinicians report difficulty getting reimbursed for detailed otoacoustic emissions testing in the context of ototoxicity monitoring. Conclusions Ethical practice, not reimbursement, must guide clinical practice. However, appropriate billing and coding resulting in 3rd-party reimbursement for audiology services rendered is critical for maintaining an effective ototoxicity monitoring program. Many 3rd-party payers reimburse for these services. For any CPT code, payment patterns vary widely within and across 3rd-party payers. Standardizing coding and billing practices as well as advocacy including letters from audiology national organizations may be necessary to help resolve these issues of coding and coverage in order to support best practice recommendations for ototoxicity monitoring.

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