Trend of ambulatory benign prostatic obstruction surgeries during COVID-19 pandemic.

INTRODUCTION: Benign prostatic obstruction (BPO) is one of the most common causes of male lower urinary tract symptoms. Some institutions routinely perform BPO surgeries in ambulatory setting, while others elect for overnight hospitalization. With the COVID-19 pandemic limiting resources and hospital space for elective surgery, we investigated the time trend of ambulatory BPO procedures performed around the COVID-19 outbreak. METHODS: We identified BPO surgeries from the California State Inpatient and State Ambulatory Surgery Databases between 2018 and 2020. Our primary outcome was the proportion of procedures performed in ambulatory settings with a length of stay of zero days. Univariable and multivariable analyses were performed to analyze factors associated with ambulatory surgery around the COVID-19 outbreak. Spline regression with a knot at the pandemic outbreak was performed to compare time trends pre- and post-pandemic. RESULTS: Among 37,148 patients who underwent BPO procedures, 30,067 (80.9%) were ambulatory. Before COVID-19, 80.1% BPO procedures were performed ambulatory, which increased to 83.4% after COVID-19 outbreak (p < 0.001). In multivariable model, BPO procedures performed after COVID-19 outbreak were 1.26 times more likely to be ambulatory (OR 1.26, 95% CI 1.14-1.40, p < 0.0001). Spline curve analysis indicated significantly different trend of change pre- and post-pandemic (p = 0.006). CONCLUSIONS: We observed a rising trend of BPO surgeries performed in ambulatory setting post-pandemic. It remains to be seen if the observed ambulatory transition remains as we continue to recover from the pandemic.

Trends in inpatient versus outpatient upper extremity fracture surgery from 2008 to 2021 and their implications for equitable access: a retrospective cohort study.

PURPOSE: The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery. METHODS: Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management. RESULTS: From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures. CONCLUSION: There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care.

Shifting paradigms in endoscopic sinus surgery: a comprehensive analysis from Japan's national database.

BACKGROUND: In 2013, Japan established a standardized classification system for categorizing endoscopic sinus surgery (ESS) into types I-V, yet no evaluation has been conducted thereof. OBJECTIVE: We assessed the ESS trends and status in Japan, focusing on outpatient and inpatient surgeries. MATERIAL AND METHODS: This descriptive retrospective cohort study used Japan's National Database of Health Insurance Claims and Specific Health Checkups between 2014 and 2021. The distribution of ESS types I-V and outpatient and inpatient surgeries was analysed, along with age groups and regional differences, focusing on ESS type III. RESULTS: Overall, 427,813 ESS procedures were performed, with types III and IV being most common. Outpatient ESS type III increased substantially compared to inpatient surgeries. Younger individuals favoured outpatient ESS type III over inpatient surgeries, with substantial regional variations across prefectures. CONCLUSIONS AND SIGNIFICANCE: The adoption of a standardized ESS classification in Japan has facilitated a detailed understanding of surgical trends. The shift toward outpatient surgeries, especially for type III ESS, aligns with global trends toward minimally invasive procedures and reflects changing patient preferences and healthcare delivery practices. Consequently, continuous monitoring and research are crucial for adapting surgical practices to the evolving healthcare needs and patient expectations.

National Long-Term Trends in Postoperative Opioid Prescribing in Ambulatory Urology Procedures.

INTRODUCTION: With more than 60% of urological procedures performed in ambulatory settings, it is imperative to understand the current trends in postoperative narcotic prescriptions and their adherence to the guidelines. We studied postoperative opioid-prescribing patterns after selected common urology ambulatory procedures. METHODS: A retrospective cohort was derived from a 10% random sample of enrollees within the IQVIA PharMetrics Plus for Academics database from 2015 to 2021. Patient-level baseline characteristics were collected in the year preceding the index date. Descriptive and bivariate analyses were used to compare patient characteristics from opioid and nonopioid cohorts and those who utilized opioids ≤ 7 days and > 7 days postprocedurally. Trends of opioid and nonopioid use were also investigated and compared. RESULTS: Between 2015 to 2021, 17,817 patients underwent urological ambulatory procedures, of which the majority (90.9%) were endoscopic procedures. Of those, 4077 (22%) were prescribed opioids and 978 (5.4%) patients were given prescription nonopioid (ie, ketorolac) medication. From 2015 to 2021, there was an overall decrease in prescription of opioids from 32% to 19%. The acute fulfillment (within 7 days of the procedure) of opioids had notably declined; however, there is a slight increase in the fulfillment of opioids beyond 7 days. CONCLUSIONS: Within the 7-day postsurgical period after ambulatory procedures, narcotic prescribing habits among urologists are congruent with current initiatives to reduce narcotic use in the setting of the opioid pandemic. However, beyond the 7-day postsurgical period, further guidelines are needed to guide narcotic prescribing habits.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review.

PURPOSE OF REVIEW: To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures. RECENT FINDINGS: Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Vasectomy: An increasingly common procedure in France.

OBJECTIVES: To analyze the evolutionary trends concerning vasectomy over the last 8 years in order to better understand the situation and identify measures to be implemented to develop this activity. METHODS: The number of vasectomy procedures performed between 2015 and 2022 was extracted from the Open CCAM file compiled from the national database of the Programme de médicalisation du système d'informations français (PMSI). RESULTS: Over the period 2015-2022, the number of vasectomy procedures increased from 3743 in 2015 to 29,890 in 2022. This increase was observed in all French metropolitan and overseas regions. The number of minimally invasive vasectomies (notably without scalpel) rose sharply, from 313 to 7760. Almost all vasectomies were performed during outpatient hospitalization (0 nights), with fewer than 300 acts reported/year in outpatient care. CONCLUSION: In France, vasectomy is becoming an increasingly frequent contraceptive method. This analysis is in line with recent surveys carried out in France, and tends to prove that more and more couples of childbearing age are in favour of sharing the contraceptive burden.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data.

INTRODUCTION: Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty. METHODS: Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes. RESULTS: A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time ( P < 0.001). DISCUSSION: TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued. LEVEL OF EVIDENCE: Level III, therapeutic retrospective cohort study.

Total Hip and Total Knee Arthroplasty Outpatient Case Volume During the 2020 COVID-19 Pandemic in New York and California.

BACKGROUND: Inpatient total hip and total knee arthroplasty were substantially impacted by the SARS-CoV-2 (COVID-19) pandemic. We sought to characterize the transition of total joint arthroplasty (TJA) to the outpatient setting in 2 large state health systems during this pandemic. METHODS: Adult patients who underwent primary elective TJA between January 1, 2016 and December 31, 2020 were retrospectively reviewed using the New York Statewide Planning and Research Cooperative System and California Department of Health Care Access and Information datasets. Yearly inpatient and outpatient case volumes and patient demographics, including age, sex, race, and payer coverage, were recorded. Continuous and categorical variables were compared using descriptive statistics. Significance was set at P < .05. RESULTS: In New York during 2020, TJA volume decreased 16% because 22,742 fewer inpatient TJAs were performed. Much of this lost volume (46.6%) was offset by a 166% increase in outpatient TJA. In California during 2020, TJA volume decreased 20% because 34,114 fewer inpatient TJAs were performed. Much of this lost volume (37%) was offset by a 47% increase in outpatient TJA. CONCLUSIONS: This present study demonstrates a marked increase in the proportion of TJA being performed on an outpatient basis in both California and New York. In both states, despite a decrease in overall TJA volume in 2020, outpatient TJA volume increased markedly. LEVEL OF EVIDENCE: Therapeutic Level IV, Retrospective Cohort Study.

Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme.

We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2-18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05-1.24). Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories. We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.

Patients, procedures, and PPE: Safe office-based anesthesia recommendations in the COVID-19 era.

The growth of office-based surgery (OBS) has been due to ease of scheduling and convenience for patients; office-based anesthesia safety continues to be well supported in the literature. In 2020, the Coronavirus Disease 19 (COVID-19) has resulted in dramatic shifts in healthcare, especially in the office-based setting. The goal of closing the economy was to flatten the curve, impacting office-based and ambulatory practices. Reopening of the economy and the return to ambulatory surgery and OBS and procedures have created a challenge due to COVID-19 and the infectious disease precautions that must be taken. Patients may be more apt to return to the outpatient setting to avoid the hospital, especially with the resurgence of COVID-19 cases locally, nationally, and worldwide. This review provides algorithms for screening and testing patients, selecting patients for procedures, choosing appropriate procedures, and selecting suitable personal protective equipment in this unprecedented period.

The effect of the COVID-19 pandemic on non-elective otolaryngology admissions and a positive change in clinical practice.

As the COVID-19 pandemic progressed across the UK and Northern Ireland in March 2020, our otolaryngology department began to make preparations and changes in practice to accommodate for potentially large numbers of patients with COVID-19 related respiratory illness in the hospital. We retrospectively reviewed the number of non-elective admissions to our department between the months of January and May in 2019 and 2020. A significant reduction in admissions of up to 94% during the months of the pandemic was observed. Our practice shifted to manage patients with epistaxis and peritonsillar abscess on an outpatient basis, and while prospectively collecting data on this, we did not observe any significant adverse events. We view this as a positive learning point and change in our practice as a result of the COVID-19 pandemic.

Recent Trends in Medicare Utilization and Reimbursement for Orthopaedic Procedures Performed at Ambulatory Surgery Centers.

BACKGROUND: As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017. METHODS: This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization. RESULTS: A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South. CONCLUSIONS: This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.

Utilizing Outpatient Pelvic Reconstructive Surgery in the Era of the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic has created a significant strain on the medical system, creating resource scarcity. We sought to demonstrate the reduction in hospital room utilization after implementation of outpatient pelvic reconstructive surgery. METHODS: We included all minimally invasive reconstructive surgical procedures in this retrospective cohort study within a large managed care organization of 4.5 million members (2008-2018). We queried the system-wide medical record for Current Procedural Terminology (CPT), International Classification of Diseases, Ninth Revision (ICD-9), and International Classification of Diseases, Tenth Revision (ICD-10) codes for all included procedures and patient perioperative data. Categorical variables were compared using χ2 test for categorical variables and the Kruskal-Wallis test for continuous variables. RESULTS: Of the 13,445 patients undergoing pelvic reconstructive surgery, 5,506 were discharged the same day, whereas 7,939 were discharged the next day. Over the 10-year period, patients without hysterectomy had outpatient surgery rates increase from 31.2% to 76.4% (+45.2%), whereas those with hysterectomy increased from 3% to 56.4% (+53.4%). Hospital room utilization decreased by 45,200 room days/100,000 reconstructive procedures without hysterectomy and 53,400 room days/100,000 reconstructive procedures with hysterectomy. When compared to 2008, in 2018 after more widespread adoption of outpatient elective surgery, for the 738 patients undergoing surgery without hysterectomy, 334 less room days were used, whereas 335 less room days were used among the 640 patients who had a surgical procedure with hysterectomy. CONCLUSIONS: The implementation of outpatient pelvic reconstructive procedures leads to a significant reduction in hospital room utilization. Same-day discharge decreases hospital resource utilization, therefore improving hospital access, which may be essential for the delivery of routine care during times of resource scarcity such as the COVID-19 pandemic.

Exploring the rapid expansion of office-based laboratories and peripheral vascular interventions across the United States.

OBJECTIVE: To characterize the relationship between office-based laboratory (OBL) use and Medicare payments for peripheral vascular interventions (PVI). METHODS: Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty, stent placement, and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level. RESULTS: Between 2014 and 2017, 2641 providers performed 308,247 procedures. The mean payment for OBL stent placement in 2017 was $4383.39, and mean payment for OBL atherectomy was $13,079.63. The change in the mean payment amount varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. The change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R2 = 0.40; P < .001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R2 = 0.85; P < .001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (P < .001). CONCLUSIONS: A rapid shift into the office setting for PVIs occurred within some HRRs, which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL use and, in particular atherectomy, to better align the policy with its intended goals.

Complications and feasibility analysis of ambulatory surgery for gynecological diseases in China.

ABSTRACT: The Chinese government is attaching great importance to the development of ambulatory surgery in order to optimize the healthcare system in China. The study aims to examine the complications and quality indicators of patients who underwent gynecological ambulatory surgery at a tertiary hospital in China.This was a retrospective study of patients who underwent ambulatory surgery between July and September 2019 at the Department of Gynecology of the First Affiliated Hospital of Shandong First Medical University. The patients were followed by phone at 30 days after discharge. The postoperative complications, mortality, unplanned re-operation, delayed discharge, unplanned re-hospitalization, and patient satisfaction were collected. The patients who underwent conventional hysteroscopic resection of uterine lesions during the same period were collected as controls for the economics analysis.A total of 392 patients who underwent ambulatory gynecological surgery were included. Fifteen patients had postoperative complications, and the total complication rate was 3.8% (15/392). Eight (8/392, 2.0%) patients had delayed discharge. There were no unplanned re-operations and deaths. There were two (2/392, 0.5%) cases of unplanned re-hospitalization. At 30 days after discharge, two patients were dissatisfied, and 390 cases were satisfied, for an overall satisfaction rate of 99.5%. Compared with conventional hysteroscopic resection of uterine lesions, ambulatory hysteroscopic surgery had a shorter hospital stay and lower total costs (P < .05) but similar surgery-related costs.Ambulatory gynecological surgery is feasible in China, with an acceptable complication profile and obvious economic and social benefits. Nevertheless, hospital management shall be reinforced.

The Impact of Preoperative Depression on Patient Satisfaction With Spine Surgeons in the Outpatient Setting.

STUDY DESIGN: Retrospective review. OBJECTIVE: The aim of this study was to examine the association between preoperative depression and patient satisfaction in the outpatient spine clinic after lumbar surgery. SUMMARY OF BACKGROUND DATA: The Clinician and Group Assessment of Healthcare Providers and Systems (CG-CAHPS) survey is used to measure patient experience in the outpatient setting. CG-CAHPS scores may be used by health systems in physician incentive programs and quality improvement initiatives or by prospective patients when selecting spine surgeons. Although preoperative depression has been shown to predict poor patient-reported outcomes and less satisfaction with the inpatient experience following lumbar surgery, its impact on patient experience with spine surgeons in the outpatient setting remains unclear. METHODS: Patients who underwent lumbar surgery and completed the CG-CAHPS survey at postoperative follow-up with their spine surgeon between 2009 and 2017 were included. Data were collected on patient demographics, Patient Health Questionnaire 9 (PHQ-9) scores, and Patient-Reported Outcome Measurement Information System Global Health Physical Health (PROMIS-GPH) subscores. Patients with preoperative PHQ-9 scores ≥10 (moderate-to-severe depression) were included in the depressed cohort. The association between preoperative depression and top-box satisfaction ratings on several dimensions of the CG-CAHPS survey was examined. RESULTS: Of the 419 patients included in this study, 72 met criteria for preoperative depression. Depressed patients were less likely to provide top-box satisfaction ratings on CG-CAHPS metrics pertaining to physician communication and overall provider rating (OPR). Even after controlling for patient-level covariates, our multivariate analysis revealed that depressed patients had lower odds of reporting top-box OPR (odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.06-0.63, P = 0.007), feeling that their spine surgeon provided understandable explanations (OR: 0.32, 95% CI: 0.11-0.91, P = 0.032), and feeling that their spine surgeon provided understandable responses to their questions or concerns (OR: 0.19, 95% CI: 0.06-0.63, P = 0.007). CONCLUSION: Preoperative depression is independently associated with lower OPR and satisfaction with spine surgeon communication in the outpatient setting after lumbar surgery.Level of Evidence: 3.