The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Randomized Controlled Trial of Awake Transnasal Laser-Assisted Surgery for Benign Laryngeal Lesions.

OBJECTIVE: To compare functional and cost-effectiveness of awake transnasal laser assisted-surgery versus microlaryngeal surgery for benign laryngeal lesions. METHODS: This was a prospective non-inferiority randomized controlled trial conducted from May 2021 to December 2022 at two tertiary referral hospitals in Hong Kong. Patients were block-randomized to receive either awake transnasal laser-assisted surgery or microlaryngeal surgery, with post-operative follow-up in a multidisciplinary voice clinic for 1-year. Primary outcome was Voice Handicap Index (VHI-30). Secondary outcomes included operation time, complications, length of stay, peri-operative discomfort, recurrence, and medical costs. RESULTS: Sixty-one patients were randomized to either awake transnasal laser-assisted surgery (n = 30) and microlaryngeal surgery (n = 31). Both groups had comparable demographics and laryngeal pathologies. Both groups showed significant improvement of VHI-30 score over time and had comparable post-operative VHI-30. Awake transnasal laser-assisted surgery group had a significantly shorter length of stay (0.5 vs. 1 day) and less throat discomfort (2 vs. 4) compared to microlaryngeal surgery group. Intraoperative complications were more common in microlaryngeal surgery group (14.3% vs. 0%). Otherwise, both groups had similar operative time and recurrence rate. Cost-analysis showed a significantly lower hospital cost for awake transnasal laser-assisted surgery (USD 3090) compared to microlaryngeal surgery group (USD 5120). CONCLUSION: Awake transnasal laser-assisted surgery was safe, functionally non-inferior, as measured by VHI-30, to microlaryngeal surgery in managing benign laryngeal lesions, while superior to microlaryngeal surgery in peri-operative discomfort and medical costs. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:3732-3740, 2024.

Economic Implications of Dural Tears in Lumbar Microdiscectomies: A Retrospective, Observational Study.

OBJECTIVE: Dural tears (DTs) are a frequent complication after lumbar spine surgery. We sought to determine the incidence of DTs and the related impact on health care expenditures after lumbar discectomies. METHODS: In this retrospective cohort study, all patients with first-time single-level lumbar discectomies at our institution who underwent minimally invasive surgery from 2015 to 2019 were reviewed. Age, sex, weight, height, body mass index, costs, revenues, length of stay, American Society of Anesthesiologists score, Charlson Comorbidity Index, and operative time (OT) were assessed. Exclusion criteria were age <18 years, previous spine surgery, multiple or traumatic disc herniations, and malignant and infectious diseases. RESULTS: The follow-up time was at least 12 months postoperatively. Of 358 patients identified with lumbar discectomies, 230 met the inclusion criteria. Incidence of DTs was 3.5%. Mean costs (P < 0.001), economic loss (P < 0.01), and OT (P < 0.0001) were found to be significantly higher in the DT group compared with the control group of patients without a DT. The revenues were not statistically different between the 2 groups (P > 0.05). Further analysis of the control group by profit and loss revealed significantly higher body mass index (P < 0.05), length of stay (P < 0.0001), and OT (P < 0.0001) in the loss group. CONCLUSIONS: DTs represent a significant socioeconomic burden in lumbar spine surgery and cause severe secondary complications. The impact of DTs on health care expenses is primarily based on significantly higher OT and a higher mean length of stay.

Smartphone-Based DIY Home Microsurgical Training with 3D Printed Microvascular Clamps and Japanese Noodles.

We have recently incorporated simple modifications of the konjac flour noodle model to enable DIY home microsurgical training by (i) placing a smartphone on a mug to act as a microscope with at least ×3.5-5 magnification, and (ii) rather than cannulating with a 22G needle as described by others, we have found that cannulation with a 23G needle followed by a second pass with an 18G needle will create a lumen (approximately 0.83 mm) without an overly thick and unrealistic "vessel" wall. The current setup, however, did not allow realistic evaluation of anastomotic patency as the noodles became macerated after application of standard microvascular clamps, which also did not facilitate practice of back-wall anastomoses. In order to simulate the actual operative environment as much as possible, we introduced the use of 3D-printed microvascular clamps. These were modified from its previous iteration (suitable for use in silastic and chicken thigh vessels), and video recordings were submitted for internal validation by senior surgeons. A "wet" operative field where the konjac noodle lumen can be distended or collapsed, unlike other nonliving models, was noted by senior surgeons. With the 3D clamps, the noodle could now be flipped over for back-wall anastomosis and allowed patency testing upon completion as it did not become macerated, unlike that from clinical microvascular clamps. The perceived advantages of this model are numerous. Not only does it comply with the 3Rs of simulation-based training, but it can also reduce the associated costs of training by up to a hundred-fold or more when compared to a traditional rat course and potentially be extended to low-middle income countries without routine access to microsurgical training for capacity development. That it can be utilized remotely also bodes well with the current limitations on face-to-face training due to COVID restrictions and lockdowns.

More Laboratory Simulations-Fewer Brain Complications: Prospects from the First Neurosurgery Laboratory in Iraq.

BACKGROUND: The intensive training requirements needed to achieve the requisiste microneurosurgical milestones makes proper training and skill acquisition a challenge to the novice neurosurgeon. This problem is compounded in low- and middle-income nations, where neurosurgery is subject to a myriad of human and financial resource constraints. A temporary solution may be provided by low-cost laboratories that are adaptive to local needs. METHODS: The "HOZ NeuroSurgery LAB" is a nonprofit facility dedicated to microneurosurgery education and skills training. The laboratory, established in June 2015, is housed at the Neurosurgery Teaching Hospital in Baghdad, Iraq. It operates under the motto "More Laboratory Simulation-Fewer Brain Complications.". The fundamental infrastructure of the facility consists of a relatively inexpensive microscope, indigenous locally created training equipment, and animal-based models. RESULTS: Since its inception, this lab has functioned as a hub for resident education and microneurosurgery service, in addition to contributing to the specialty's academic output in the nation. The lab is directly responsible for training 4 vascular neurosurgeons who are currently directing the nation's first organized neurovascular service. Also, it has delivered 53 microneurosurgery skills courses, coordinated 8 student neurosurgery elective cycles with a total of 532 participants, and published approximately 70 research articles. CONCLUSIONS: Our experience may serve as a model for other low- and middle-income countries interested in using the principle of "doing more with less" to overcome some of the challenges associated with microneurosurgery in these parts of the world.

Microdiscectomy Is More Cost-effective Than a 6-Month Nonsurgical Care Regimen for Chronic Radiculopathy.

BACKGROUND: A recent randomized controlled trial (RCT), performed by the authors, comparing early surgical microdiscectomy with 6 months of nonoperative care for chronic lumbar radiculopathy showed that early surgery resulted in improved outcomes. However, estimates of the incremental cost-utility ratio (ICUR), which is often expressed as the cost of gaining one quality-adjusted life year (QALY), of microdiscectomy versus nonsurgical management have varied. Radiculopathy lasting more than 4 months is less likely to improve without surgical intervention and may have a more favorable ICUR than previously reported for acute radiculopathy. QUESTION/PURPOSE: In the setting of chronic radiculopathy caused by lumbar disc herniation, defined as symptoms and/or signs of 4 to 12 months duration, is surgical management more cost-effective than 6 months of nonoperative care from the third-party payer perspective based on a willingness to pay of less than CAD 50,000/QALY? METHODS: A decision analysis model served as the vehicle for the cost-utility analysis. A decision tree was parameterized using data from our single-center RCT that was augmented with institutional microcost data from the Ontario Case Costing Initiative. Bottom-up case costing methodology generates more accurate cost estimates, although institutional costs are known to vary. There were no major surgical cost drivers such as implants or bone graft substitutes, and therefore, the jurisdictional variance would be minimal for tertiary care centers. QALYs derived from the EuroQoL-5D were the health outcome and were derived exclusively from the RCT data, given the paucity of studies evaluating the surgical treatment of lumbar radiculopathy lasting 4 to 12 months. Cost-effectiveness was assessed using the ICUR and a threshold of willingness to pay CAD 50,000 (USD 41,220) per QALY in the base case. Sensitivity analyses were performed to account for the uncertainties within the estimate of cost utility, using both a probabilistic sensitivity analysis and two one-way sensitivity analyses with varying crossover rates after the 6-month nonsurgical treatment had concluded. RESULTS: Early surgical treatment of patients with chronic lumbar radiculopathy (defined as symptoms of 4 to 12 months duration) was cost-effective, in that the cost of one QALY was lower than the CAD 50,000 threshold (note: the purchasing power parity conversion factor between the Canadian dollar (CAD) and the US dollar (USD) for 2019 was 1 USD = 1.213 CAD; therefore, our threshold was USD 41,220). Patients in the early surgical treatment group had higher expected costs (CAD 4118 [95% CI 3429 to 4867]) than those with nonsurgical treatment (CAD 2377 [95% CI 1622 to 3518]), but they had better expected health outcomes (1.48 QALYs [95% CI 1.39 to 1.57] versus 1.30 [95% CI 1.22 to 1.37]). The ICUR was CAD 5822 per QALY gained (95% CI 3029 to 30,461). The 2-year probabilistic sensitivity analysis demonstrated that the likelihood that early surgical treatment was cost-effective was 0.99 at the willingness-to-pay threshold, as did the one-way sensitivity analyses. CONCLUSION: Early surgery is cost-effective compared with nonoperative care in patients who have had chronic sciatica for 4 to 12 months. Decision-makers should ensure adequate funding to allow timely access to surgical care given that it is highly likely that early surgical intervention is potentially cost-effective in single-payer systems. Future work should focus on both the clinical effectiveness of the treatment of chronic radiculopathy and the costs of these treatments from a societal perspective to account for occupational absences and lost patient productivity. Parallel cost-utility analyses are critical so that appropriate decisions about resource allocation can be made. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Variation in Payment per Work Relative Value Unit for Breast Reconstruction and Nonbreast Microsurgical Reconstruction: An All-Payer Claims Database Analysis.

BACKGROUND: Commercial payments for implant-based breast reconstruction have increased within the past decade, whereas reimbursements have stagnated for microsurgical techniques. The physician payment-to-work relative value unit ratio allows for standardization when comparing procedures of differing complexity. This study aimed to characterize payment per work relative value unit for common breast and nonbreast microsurgical procedures. METHODS: The Massachusetts All-Payer Claims Database was queried from 2010 to 2014 for Current Procedural Terminology (CPT) codes related to microsurgical and breast reconstruction. International Classification of Diseases codes were further used to categorize procedures by anatomical region, including head and neck, breast, trunk, and extremities. Physician payments, both commercial and governmental, were aggregated by anatomical region and CPT code. Payment distributions were described with means and medians and compared using statistical tests. RESULTS: Among 3435 commercial claims, distributions of physician payments per work relative value unit for microsurgical and common breast procedures differed only for breast free flaps billed through S codes (p < 0.001). Microsurgical breast procedures (CPT code 19364) had significantly greater median payments per work relative value unit compared to microsurgery of the head and neck, trunk, and upper extremities (p = 0.004). Payment per work relative value unit for common breast and nonbreast microsurgical procedures did not differ significantly among governmental claims (p = 0.103). CONCLUSIONS: Adjustment of physician payments by work relative value units did not show significant variability across common breast procedures, except for S codes, suggesting that payments are mostly driven by differences in work relative value units and individual contractual negotiations. Lower payments per work relative value unit for other regions compared to breast suggests an opportunity for negotiation with commercial payers.

Is Immediate Lymphatic Reconstruction Cost-effective?

Mini: We conducted a cost-utility analysis to evaluate the cost and quality of life of patients undergoing axillary lymph node dissection (ALND) and ALND with regional lymph node radiation (RLNR), with and without lymphatic microsurgical preventive healing approach (LYMPHA), in a node-positive breast cancer population. We found that the addition of LYMPHA to both ALND or ALND with RLNR is more cost-effective. Objective: This manuscript is the first to employ rigorous methodological criteria to critically appraise a surgical preventative technique for breast cancer-related lymphedema from a cost-utility standpoint. Summary of Background Data: Breast cancer-related lymphedema is a well-documented complication of breast cancer survivors in the US. In this study, we conduct a cost-utility analysis to evaluate the cost-effectiveness of the LYMPHA. Methods: Lymphedema rates after each of the following surgical options: (1) ALND, (2) ALND + LYMPHA, (3) ALND + RLNR, (4) ALND + RLNR + LYMPHA were extracted from a recently published meta-analysis. Procedural costs were calculated using Medicare reimbursement rates. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years (QALYs). A decision tree was generated and incremental cost-utility ratios (ICUR) were calculated. Multiple sensitivity analyses were performed to evaluate our findings. Results: ALND with LYMPHA was more cost-effective with an ICUR of $1587.73/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 1.35 QALY justified an increased incremental cost of $2140. Similarly, the addition of LYMPHA to ALND with RLNR was more cost-effective with an ICUR of $699.84/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 2.98 QALY justified a higher incremental cost of $2085.00. Conclusions: Our study supports that the addition of LYMPHA to both ALND or ALND with RLNR is the more cost-effective treatment option.

Percutaneous Transforaminal Endoscopic Discectomy Versus Open Microdiscectomy for Lumbar Disc Herniation: A Systematic Review and Meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To give a systematic overview of effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) compared with open microdiscectomy (OM) in the treatment of lumbar disk herniation (LDH). SUMMARY OF BACKGROUND DATA: The current standard procedure for the treatment of sciatica caused by LDH, is OM. PTED is an alternative surgical technique which is thought to be less invasive. It is unclear if PTED has comparable outcomes compared with OM. METHODS: Multiple online databases were systematically searched up to April 2020 for randomized controlled trials and prospective studies comparing PTED with OM for LDH. Primary outcomes were leg pain and functional status. Pooled effect estimates were calculated for the primary outcomes only and presented as standard mean differences (SMD) with their 95% confidence intervals (CI) at short (1-day postoperative), intermediate (3-6 months), and long-term (12 months). RESULTS: We identified 2276 citations, of which eventually 14 studies were included. There was substantial heterogeneity in effects on leg pain at short term. There is moderate quality evidence suggesting no difference in leg pain at intermediate (SMD 0.05, 95% CI -0.10-0.21) and long-term follow-up (SMD 0.11, 95% CI -0.30-0.53). Only one study measured functional status at short-term and reported no differences. There is moderate quality evidence suggesting no difference in functional status at intermediate (SMD -0.09, 95% CI -0.24-0.07) and long-term (SMD -0.11, 95% CI -0.45-0.24). CONCLUSION: There is moderate quality evidence suggesting no difference in leg pain or functional status at intermediate and long-term follow-up between PTED and OM in the treatment of LDH. High quality, robust studies reporting on clinical outcomes and cost-effectiveness on the long term are lacking.Level of Evidence: 2.

Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample.

BACKGROUND: In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms. METHODS: The National Inpatient Sample years 2010 - 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS. RESULTS: A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 - 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 - 24.34) for patients with > 1 complication. CONCLUSIONS: Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.

An economic analysis of prophylactic lymphovenous anastomosis among breast cancer patients receiving mastectomy with axillary lymph node dissection.

BACKGROUND AND OBJECTIVES: Prophylactic lymphovenous anastomosis (LVA) has been shown to decrease the incidence of postoperative lymphedema among patients receiving mastectomy with axillary lymph node dissection (ALND). However, the economic impact of this intervention on overall healthcare costs has not been adequately studied and insurance reimbursement for lymphedema treatment is limited resulting in substantial out-of-pocket patient expenses. METHODS: We performed a cost-minimization decision analysis from the societal perspective to assess two different patient scenarios: (a) mastectomy with ALND alone, (b) mastectomy with ALND and prophylactic LVA. RESULTS: The annual cost of lymphedema-related care is estimated to be $5,691.88 ($3,160.52 direct, $2,531.36 indirect). If all patients undergoing mastectomy with ALND undergo prophylactic LVA, the average expected lifetime cost per patient in the entire population (whether or not they develop lymphedema) is approximately $6,295.61, compared to $13,942.26 if no patients in the same population receive prophylactic LVA. CONCLUSIONS: Prophylactic LVA is economically preferred over mastectomy and ALND alone from a cost minimization perspective, and results in an average of $7,646.65 (45.2%) cost saving per patient over the course of their lifetime.

Costs and Complications Associated With Resection of Supratentorial Tumors With and Without the Operative Microscope in the United States.

BACKGROUND: The operative microscope, a commonly used tool in neurosurgery, is critical in many supratentorial tumor cases. However, use of operating microscope for supratentorial tumor varies by surgeon. OBJECTIVES: To assess complication rates, readmissions, and costs associated with operative microscope use in supratentorial resections. METHODS: A retrospective analysis was conducted using a national administrative database to identify patients with glioma or brain metastases who underwent supratentorial resection between 2007 and 2016. Univariate and multivariate analyses were used to assess 30-day complications, readmissions, and costs between patients who underwent resection with and without use of microscope. RESULTS: The cohort included 12,058 glioma patients and 5433 metastasis patients. Rates of microscope use varied by state from 19.0% to 68.6%. Microscope use was associated with $5228.90 in additional costs of index hospitalization among glioma patients (P <0.001), and $2824.00 among metastasis patients (P <0.001). Rates of intraoperative cerebral edema were lower among the microscope cohort than among the nonmicroscope cohort (P <0.027). Microscope use was associated with a slight reduction in 30-day rates of neurological complications (14.7% vs. 16.7%, P = 0.048), specifically in nonspecific cerebrovascular complications. There were no differences in rates of other complications, readmissions, or 30-day postoperative costs. CONCLUSIONS: Use of operative microscope for supratentorial resections varies by state and is associated with higher cost of surgery. Microscope use may be associated with lower rates of intraoperative cerebral edema and some cerebrovascular complications, but is not associated with significant differences in other complications, readmissions, or 30-day costs.

A Propensity Score-Matched Comparison of Readmission Rates Associated With Microsurgical Clipping and Endovascular Treatment of Ruptured Intracranial Aneurysms.

BACKGROUND: In the treatment of aneurysmal subarachnoid hemorrhage (aSAH), microsurgical clipping, and endovascular therapy (EVT) with coiling are modalities for securing the ruptured aneurysm. Little data is available regarding associated readmission rates. We sought to determine whether readmission rates differed according to treatment modality for ruptured intracranial aneurysms. METHODS: The Nationwide Readmissions Database (NRD) was used to identify adults who experienced aSAH and underwent clipping or EVT. Primary outcomes of interest were the incidences of 30- and 90-day readmissions (30dRA, 90dRA). Propensity score matching was used to generate matched pairs based on age, comorbidities, hospital volume, and hemorrhage severity. RESULTS: We identified 13,623 and 11,160 patients who were eligible for 30dRA and 90dRA analyses, respectively. Among the patients eligible for 30dRA and 90dRA, we created 4282 and 3518 propensity score-matched pairs, respectively. There was no difference in the incidence of 30dRA (12.4% for clipping versus 11.2% for EVT; P = .094). However, 90dRA occurred more frequently after clipping (22.5%) compared to EVT (19.7%; P = .003). Clipping was associated with poor outcome after 30dRA (odds ratio [OR] = 1.51, 95% confidence interval [CI] 1.21-1.88, P < .001) and after 90dRA (OR = 1.60, 95% CI 1.34-1.91, P = .001). Mean duration to readmission and cost of readmission did not vary, but clipping was associated with longer lengths of stay during readmission. CONCLUSIONS: Microsurgical clipping of ruptured aneurysms is associated with a greater incidence of 90dRA, but not 30dRA, compared to EVT. Poor outcomes after readmission are more common following clipping.

Impact of Physician Payments on Microvascular Breast Reconstruction: An All-Payer Claim Database Analysis.

BACKGROUND: Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction. METHODS: The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality. RESULTS: Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001). CONCLUSIONS: Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Manual small incision cataract surgery.

PURPOSE OF REVIEW: To review various techniques of manual small incision cataract surgery (MSICS), updates on training residents and fellows, and cost-effectiveness of the surgery. RECENT FINDINGS: Recent population studies estimate that there are 53 million people blind worldwide from cataracts, up from previous figures. This is in part because of population growth and increased life expectancy worldwide. MSICS continues to play a significant role in addressing cataract burden and there is an increasing need to train surgeons in the technique. In response to this need, several modules and rubrics have been developed to assist in the training process. SUMMARY: MSICS has been refined over recent decades with overall outcomes comparable to phacoemulsification (phaco) in certain settings. MSICS cost and efficiency advantages support its ongoing essential role in addressing global cataract blindness.

A structured pathway for accelerated postoperative recovery reduces hospital stay and cost of care following microvascular breast reconstruction without increased complications.

INTRODUCTION: Accelerated recovery protocols have proved effective in many surgical procedures but are infrequently applied in breast reconstruction. In this study, we evaluate the impact of a structured pathway for accelerated postoperative recovery in patients undergoing microvascular breast reconstruction at a high-volume center. METHODS: We describe our care pathway for patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our center. We compared length of stay (LOS), complication rates, readmission rates, and cost of inpatient care before (pre-protocol (Pre-P)) and after (post-protocol (Post-P)) the implementation of the protocol. RESULTS: Patients in the Post-P group (n = 198) had a significant reduction in mean LOS as compared to those in the Pre-P (n = 183) group (3.6 +/- 0.85 vs. 4.7 +/-1.04 days, p = 0.006). There was no significant difference in the rates of major (Pre-P 16.9% vs. Post-P 14.7%, p = 0.71) or minor (Pre-P 21.3% vs. 17.1%, p = 0.22) postoperative complications between groups. The readmission rates were also similar (Pre-P 6.5% vs. Post-P 4.5, p = 0.69). Implementation of the protocol resulted in a significant reduction in the mean cost of in-patient care. CONCLUSION: A simple protocol for accelerated and streamlined postoperative recovery effectively reduces LOS and patient care costs following DIEP flap breast reconstruction without compromising patient safety.

[Profitability of reconstructive microsurgery: position paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels]. / Wirtschaftlichkeit der rekonstruktiven Mikrochirurgie: Positionspapier der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie ­ (DAM).

The profitability of medical treatment has gained increasing importance in health politics and likewise has become a considerable part of a microsurgeon's daily practice. The resulting cost pressure leads to microsurgeons having to justify their often complex and expensive treatments against hospital providers and health insurances. In this position paper of the German Speaking Group for Microsurgery of Peripheral Nerves and Vessels, we analyze the current status of profitability of microsurgical extremity and breast reconstruction, and its impact on choice of therapy and residency training. We specifically highlight the available literature, that shows often reduced long-term treatment costs after microsurgical reconstruction in comparison to cheaper initial treatments. The statements are based on a consensus workshop on the 40th meeting of the DAM in Lugano, Switzerland.

The Role of Low-Cost Microsurgical Training Models and Experience with Exercises Based on a Bovine Heart.

BACKGROUND: Microscopic training is essential for development of neurosurgical skills. A range of models is reported in the literature for this purpose, including live animals, exvivo, and synthetic material. Among the factors involved in selection and development of a training station, cost is a decisive one. METHODS: We present a low-cost model to practice microvascular anastomoses using a bovine heart and an artificial perfusion system. We also present a brief review of laboratory models for microsurgical training, focusing on the costs and reproducibility of the different options. RESULTS: Exvivo models are a great bridging point between nonbiologic and living animal training models. These models have major similarities to human vessels, such as lumen size and malleability of the arteries. The bovine heart model allowed the residents to gain confidence in handling vascular tissue in a microscopic environment. CONCLUSIONS: Although these models do not resemble anatomic landmarks in the human brain, the bovine heart model allowed the residents to gain confidence in handling vascular tissue in a microscopic environment.

Effects of Anesthesia Protocol on Perioperative Outcomes and Costs of Lumbar Microdiscectomies.

AIM: To compare the effects of spinal anesthesia (SA) and general anesthesia (GA) in lumbar microdiscectomy in terms of their costeffectiveness, and perioperative outcomes. MATERIAL AND METHODS: We randomly allocated 100 consecutive patients who were scheduled to undergo elective lumbar microdiscectomy, into either SA or GA groups. We recorded and evaluated various parameters, including demographic aspects, body mass index (BMI), perioperative hemodynamics, time elapsed from operating room (OR) entry until incision, operative time, time elapsed from application of the surgical dressing to exiting OR, blood loss, post anesthetic care unit (PACU) time, preoperative and postoperative pain scores, postoperative analgesic requirements, first mobilization time, first oral intake, the length of hospital stay, time to return to work, and perioperative anesthetic costs. The patients, anesthesiologists, and neurosurgeons were handed a questionnaire before discharge to determine their satisfaction with the procedure. RESULTS: Several variables were found to be better in the SA group: the mean arterial pressure and heart rate changes were significantly lower, and the time elapsed from OR entry until incision, operative time, time elapsed from application of the surgical dressing to exiting OR, PACU time, the length of hospital stay, and time to return to work were shorter; furthermore, the postoperative pain scores, the analgesic requirements, the intraoperative blood loss, and the cost of anesthesia were all lower. Moreover the first mobilization and oral intake occurred earlier; and most significantly, the satisfaction of the patients and surgeons was higher in the SA group. Furthermore, we encountered no complications. CONCLUSION: Based on our results, we conclude that SA is reliable and clinically successful procedure in lumbar microdiscectomy.

Low-Cost Stereoscopic Recordings of Neurologic Surgery Operative Microscopy for Anatomic Laboratory Training.

OBJECTIVE: Stereoscopic video recordings of operative microscopy during neuroanatomic dissections are an important component of surgical training and research in well-financed medical schools and teaching hospitals. However, the high cost of the latest operative microscopes with integrated video recording equipment can be a limiting factor in their worldwide use. The aim of the present work is to provide a simple low-cost 3-dimensional (3D) stereoscopic operative microscope recording system that can be used even in economically and resource-limited locations. This is achieved by using readily available smartphones, smartphone accessories, and computer software. METHODS: Stereoscopic recording is accomplished by attaching and aligning matched or similar smartphones to the eyepieces of an operative microscope using readily available smartphone mounting connectors. Video recordings from the smartphones are then transferred to a personal computer and processed with a video-editing software to generate stereoscopic movies that are viewed on a smartphone using virtual-reality glasses. RESULTS: The setup time to mount and align the smartphone cameras typically requires 15-30 minutes. Video image quality and 3D depth presentation is more than sufficient for surgical training and research purposes. The implementation cost ranges from $1,315-$7,066, or much less if smartphones and a computer are already available. CONCLUSIONS: The 3D video system demonstrated herein can be implemented on any type of operative microscope, including older units for which commercial stereo recording systems are not available. The system and method presented herein can be readily and affordably implemented in low-budget environments for clinical training and research.