Medicare procedural costs in ambulatory surgery centers versus hospital outpatient departments for spine surgeries.

OBJECTIVE: Multiple studies have demonstrated the safety of outpatient spine surgery, with reports of equivalent to improved patient outcomes compared with inpatient procedures. This has resulted in the increased use of outpatient surgery over time. However, there remains a paucity of literature evaluating the difference in costs between ambulatory surgery center (ASC)- and hospital outpatient department (HOPD)-based procedures for Medicare beneficiaries. METHODS: Publicly available data from Centers for Medicare & Medicaid Services were accessed via the Medicare Procedure Price Lookup tool. Current Procedural Terminology (CPT) codes were used to identify spine-specific procedures approved for the outpatient setting by CMS. Procedures were grouped into decompression (cervical, thoracic, and lumbar), fusion/instrumentation (cervical, lumbar, and sacroiliac), and kyphoplasty/vertebroplasty cohorts, as well as an overall cohort. Data regarding total costs, facility fees, surgeon reimbursement, Medicare payments, and patient copayments were extracted for each procedure. Descriptive statistics were used to calculate means and standard deviations. Differences between ASC- and HOPD-associated costs were analyzed using the Mann-Whitney U-test. RESULTS: Twenty-one individual CPT codes approved by Medicare for the ASC and/or HOPD setting were identified. Decompression procedures were associated with a significantly lower total cost ($4183 ± $411.07 vs $7583.67 ± $410.89, p < 0.001), facility fees ($2998 ± $0 vs $6397 ± $0, p < 0.001), Medicare payments ($3345.75 ± $328.80 vs $6064.75 ± $328.80, p < 0.001), and patient payments ($835.58 ± $82.13 vs $1515.58 ± $82.13, p < 0.001) in ASCs compared with HOPDs. Fusion/instrumentation procedures had significantly lower facility fees ($10,436.6 ± $2347.51 vs $14,161 ± $2147.07, p = 0.044) and Medicare payments ($9501.2 ± $1732.42 vs $13,757 ± $2037.58, p = 0.009) in ASCs, as well as a trend toward lower total costs ($11,876.8 ± $2165.22 vs $15,601.2 ± $2016.06, p = 0.076). Patient payments in the HOPD setting were significantly lower in the fusion/instrumentation cohort ($1843.6 ± $73.42 vs $2374.4 ± $433.48, p = 0.009). In the kyphoplasty/vertebroplasty cohort, there was no statistically significant difference between ASCs and HOPDs, despite lower overall costs in the ASC for all variables. Surgeon fees were the same regardless of setting for all procedures (p > 0.99). When combining decompression, fusion/instrumentation, and kyphoplasty/vertebroplasty CPT codes into a single cohort, ASC setting was associated with significant cost savings in total cost, facility fees, Medicare payments, and patient payments. CONCLUSIONS: In general, performing spine surgeries in ASCs is associated with cost savings compared with HOPDs. This was demonstrated for decompression and fusion/instrumentation, and kyphoplasty/vertebroplasty Medicare-approved outpatient procedures.

Radiolucent implants in orthopedic oncology.

Radiolucent implants in have demonstrated promising results for both extremity and spine oncologic procedures. However, questions persist about whether the superiority in surveillance imaging justify the increased cost and technical challenges. In this review, we present the current body of literature for the use of radiolucent implants in musculoskeletal oncology, with a focus on implant complications, including screw loosening, breakage, malposition, and loss of reduction. We also discuss clinical outcomes, technical considerations, and postoperative radiotherapy.

U2AF2 binds IL7R exon 6 ectopically and represses its inclusion.

Interleukin 7 receptor α-chain is crucial for the development and maintenance of T cells and is genetically associated with autoimmune disorders including multiple sclerosis (MS), a demyelinating disease of the CNS. Exon 6 of IL7R encodes for the transmembrane domain of the receptor and is regulated by alternative splicing: inclusion or skipping of IL7R exon 6 results in membrane-bound or soluble IL7R isoforms, respectively. We previously identified a SNP (rs6897932) in IL7R exon 6, strongly associated with MS risk and showed that the risk allele (C) increases skipping of the exon, resulting in elevated levels of sIL7R. This has important pathological consequences as elevated levels of sIL7R has been shown to exacerbate the disease in the experimental autoimmune encephalomyelitis mouse model of MS. Understanding the regulation of exon 6 splicing provides important mechanistic insights into the pathogenesis of MS. Here we report two mechanisms by which IL7R exon 6 is controlled. First, a competition between PTBP1 and U2AF2 at the polypyrimidine tract (PPT) of intron 5, and second, an unexpected U2AF2-mediated assembly of spicing factors in the exon. We noted the presence of a branchpoint sequence (BPS) (TACTAAT or TACTAAC) within exon 6, which is stronger with the C allele. We also noted that the BPS is followed by a PPT and conjectured that silencing could be mediated by the binding of U2AF2 to that tract. In support of this model, we show that evolutionary conservation of the exonic PPT correlates well with the degree of alternative splicing of exon 6 in two non-human primate species and that U2AF2 binding to this PPT recruits U2 snRNP components to the exon. These observations provide the first explanation for the stronger silencing of IL7R exon 6 with the disease associated C allele at rs6897932.