Role of Post-Acute Care on Hospital Readmission After High-Risk Surgery.

BACKGROUND: Payment models, including the Hospital Readmissions Reduction Program and bundled payments, place pressures on hospitals to limit readmissions. Against this backdrop, we sought to investigate the association of post-acute care after major surgery and readmission rates. METHODS: We identified patients undergoing high-risk surgery (abdominal aortic aneurysm repair, coronary bypass grafting, aortic valve replacement, carotid endarterectomy, esophagectomy, pancreatectomy, lung resection, and cystectomy) from 2005 to 2010 using the Healthcare Cost and Utilization Project's State Inpatient Database. The primary outcome was readmission rates after major surgery. Secondary outcome was readmission length of stay. RESULTS: We identified 135,523 patients of whom 56,720 (42%) received post-acute care. Patients receiving post-acute care had higher readmission rates than those who were discharged home (16% versus 10%, respectively; P < 0.001). The risk-adjusted readmission length of stay was greatest for patients who received care from a skilled nursing facility, followed by those who received home care, and lowest for those who did not receive post-acute care (7.1 versus 5.4 versus 4.8 d, respectively; P < 0.001). CONCLUSIONS: The use of post-acute care was associated with higher readmission rates and higher readmission lengths of stay. Improving the support of patients in post-acute care settings may help reduce readmissions and readmission intensity.

The comparative effectiveness of quadratus lumborum blocks and paravertebral blocks in radical cystectomy patients.

INTRODUCTION: Multimodal analgesia is an effective way to control pain and limit opioid use after surgery. The quadratus lumborum block and paravertebral block are two regional anesthesia techniques that leverage multimodal analgesia to improve postoperative pain control. We sought to compare the efficacy of these blocks for pain management following radical cystectomy. MATERIALS AND METHODS: We performed a retrospective review of radical cystectomy patients who received bilateral continuous paravertebral blocks (n = 125) or bilateral single shot quadratus lumborum blocks (n = 50) between 2014-2016. The primary outcome was postoperative opiate consumption on day 0. Secondary outcomes included self-reported pain scores and hospital length of stay. RESULTS: Quadratus lumborum block patients had similar opioid use on postoperative day 0 compared with paravertebral block patients (29 mg versus 30 mg, p = 0.90). Pain scores on postoperative day 0 were similar between quadratus lumborum block and paravertebral block groups (4.0 versus 3.8, p = 0.72); however, the paravertebral block group had lower pain scores on days 1-3 compared with the quadratus lumborum block group (all p < 0.05). Hospital length of stay was similar between groups (6.6 days versus 6.2 days, p = 0.41). CONCLUSIONS: There were no differences in opioid consumption among patients receiving bilateral single shot quadratus lumborum blocks and bilateral continuous paravertebral blocks after radical cystectomy. These data suggest that the quadratus lumborum block is a viable alternative for delivering multimodal analgesia in cystectomy patients.

The Changing Roles of Urologists, Radiologists, and Advanced Practice Providers in Uroradiology Procedures.

INTRODUCTION: Urology has seen shifts in the management of many urologic conditions with the advent of noninvasive procedures that rely on multidisciplinary radiological modalities. This study seeks to analyze changes in urologists, radiologists, and advanced practice providers (APPs) performing uroradiology procedures over time. METHODS: The Centers for Medicare & Medicaid Services Physician/Procedure Summary data from 2010 to 2021 were utilized to examine uroradiology Current Procedural Terminology codes billed by urologists, radiologists, and APPs. Percent of total reimbursement and higher volume procedure count (after excluding providers with <11 procedures by per year) by each provider field was calculated and analyzed for changes in distribution from 2010 to 2021. RESULTS: There were significant changes in all procedures when examining procedure reimbursement distribution in 2010 to 2021 (P < .001). During the period, urology saw decreases in reimbursement proportion as large as 28.7% for kidney cryoablation and increases as large as 14.2% for nephrostomy tube removals. Radiology saw the largest decreases in reimbursement proportion with an 18.9% decrease for nephrostograms, while the largest increase was 23.6% for suprapubic tube placements. APPs saw the largest increase in suprapubic tube changes reimbursement proportion, which rose 14.2% from 2010 to 2021. There were significant changes in proportion in all procedures, except for antegrade stent, renal cryoablation, renal biopsy, and renal thermoablation. CONCLUSIONS: Uroradiology procedures have seen shifts in the distribution of which provider type performs each procedure. Most large changes in reimbursement and procedure proportion were shifted between urology and radiology, with APPs seeing smaller changes.

Changes in Billing and Reimbursement for Urology Office Visits Before and After Medicare Payment Reforms.

INTRODUCTION: The impact of Medicare reimbursement changes on urology office visit reimbursements has not been fully examined. This study aims to analyze the impact of urology office visit Medicare reimbursements from 2010 to 2021, with a focus on 2021 Medicare payment reforms. METHODS: The Centers for Medicare and Medicaid Services Physician/Procedure Summary data from 2010-2021 were utilized to examine office visit CPT (Current Procedural Terminology) new patient visit codes 99201-99205 and established patient visit codes 99211-99215 by urologists. Mean office visit reimbursements (2021 USD), CPT specific reimbursements, and proportion of level of service were compared. RESULTS: The 2021 mean visit reimbursement was $110.95, up from $99.42 in 2020 and $94.44 in 2010 (both P < .001). From 2010 to 2020, all CPT codes, except for 99211, had a decrease in mean reimbursement. From 2020 to 2021, there was an increase in mean reimbursement for CPT codes 99205, 99212-99215 and decreases in 99202, 99204 and 99211 (P < .001). New and established patient urology office visits had significant migration of billing codes from 2010 to 2021 (P < .001). New patient visits were most commonly as 99204, which increased from 47% in 2010 to 65% in 2021 (P < .001). The most commonly billed established patient urology visit was 99213 until 2021 when 99214 became the most common at 46% (P < .001). CONCLUSIONS: Urologists have seen increases in mean reimbursements for office visits both before and after the 2021 Medicare payment reform. Contributing factors consist of increased established patient visit reimbursements despite decreased new patient visit reimbursements, and changes in level of CPT code billings.

The therapeutic efficacy of human adipose tissue-derived mesenchymal stem cells on experimental autoimmune hearing loss in mice.

Autoimmune inner ear disease is characterized by progressive, bilateral although asymmetric, sensorineural hearing loss. Patients with autoimmune inner ear disease had higher frequencies of interferon-γ-producing T cells than did control subjects tested. Human adipose-derived mesenchymal stem cells (hASCs) were recently found to suppress effector T cells and inflammatory responses and therefore have beneficial effects in various autoimmune diseases. The aim of this study was to examine the immunosuppressive activity of hASCs on autoreactive T cells from the experimental autoimmune hearing loss (EAHL) murine model. Female BALB/c mice underwent ß-tubulin immunization to develop EAHL; mice with EAHL were given hASCs or PBS intraperitoneally once a week for 6 consecutive weeks. Auditory brainstem responses were examined over time. The T helper type 1 (Th1)/Th17-mediated autoreactive responses were examined by determining the proliferative response and cytokine profile of splenocytes stimulated with ß-tubulin. The frequency of regulatory T (Treg) cells and their suppressive capacity on autoreactive T cells were also determined. Systemic infusion of hASCs significantly improved hearing function and protected hair cells in established EAHL. The hASCs decreased the proliferation of antigen-specific Th1/Th17 cells and induced the production of anti-inflammatory cytokine interleukin-10 in splenocytes. They also induced the generation of antigen-specific CD4(+) CD25(+) Foxp3(+) Treg cells with the capacity to suppress autoantigen-specific T-cell responses. The experiment demonstrated that hASCs are one of the important regulators of immune tolerance with the capacity to suppress effector T cells and to induce the generation of antigen-specific Treg cells.

Administering human adipose-derived mesenchymal stem cells to prevent and treat experimental arthritis.

Rheumatoid arthritis is a chronic autoimmune disease and affecting approximately 1% of the population. Human adipose-derived mesenchymal stem cells (hASCs) were recently found to suppress effector T cell and inflammatory responses and, thus, to have beneficial effects in various autoimmune diseases. In this study, we examined whether hASCs could play a protective and/or therapeutic role in collagen-induced arthritis (CIA). We showed that hASCs both prevented and treated CIA by significantly reducing the incidence and severity of experimental arthritis. We further demonstrated that treatment with hASCs inhibited the production of various inflammatory mediators, decreased antigen-specific Th1/Th17 cell expansion, and induced the production of anti-inflammatory cytokine interleukin-10. Moreover, hASCs could induce the generation of antigen-specific Treg cells with the capacity to suppress collagen-specific T cell responses.

Gender Gap in Industry Relationships and Scholarly Impact Among Academic Urologists in the United States.

OBJECTIVES: To examine the distribution of industry payments to male and female academic urologists and the relationship between industry funding, academic rank, and scholarly impact. MATERIAL AND METHODS: Academic urologists from 131 programs with publicly available websites were compiled. Gender, rank, fellowship training, and scholarly impact metrics were recorded. Data from the 2016 Centers for Medicare and Medicaid Services Open Payments database were paired with faculty names. Comparisons were made using Fisher's Exact, Wilcoxon Rank Sum, and Spearman's Rank-Order tests. Multivariable logistic regression modeling identified predictors of receiving payments in the top quintile. RESULTS: Among 1,657 academic urologists, males comprised 84%. While there were no gender differences in the number of urologists listed in the Open Payments Database, males received more total funding (P < .001) and higher median general payments per capita (P < .03). Males also received higher proportions of research funding (P = .002), speaker fees (P = .03), education fees (P = .03) and higher median consulting fees (P = .003). Overall, males had higher scholarly impact (P < .001), which correlated with total industry payments (rho = 0.27, P < .001). Predictors of accepting the top quintile payments include male gender, associate professorship and H-index score ≥10. CONCLUSION: Most academic urologists accepted at least one industry payment in 2016, but males received more funding than females. There is a positive correlation between total industry payments, H-index, and total publications. More research is needed to understand why gender and scholarly productivity are associated with higher payouts. This is another important area that may influence career advancement and compensation for female urologists.

Strong Conflict of Interest Policies are not Associated With Decreased Industry Payments to Academic Urology Departments.

OBJECTIVE: To identify whether institutions with strong conflicts of interest (COI) policies receive less industry payments than those with weaker policies. While industry-physician interactions can have collaborative benefits, financial COI can undermine preservation of the integrity of professional judgment and public trust. To address this concern, academic institutions have adopted COI policies. It is unclear whether the strength of COI policy correlates with industry payments in urology. MATERIALS AND METHODS: 131 US academic urology programs were surveyed on their COI policies, and graded according to the American Medical Student Association (AMSA) criteria. Strength of COI policy was compared against industry payments in the Center for Medicare and Medicaid Services Open Payments database. RESULTS: Fifty-seven programs responded to the survey, for a total response rate of 44%. There was no difference between COI policy groups on total hospital payments (P = .05), total department payments (P = .28), or dollars per payment (P = .57). On correlation analysis, there was a weak but statistically nonsignificant correlation between AMSA Industry Policy Survey Score and Open Payments payments (ρ = -0.14, P = .32). CONCLUSION: Strength of conflicts of interest policy in academic urology did not correlate to industry payments within the Open Payments database. Establishment of strong COI policy may create offsetting factors that mitigate the intended effects of the policy. Further studies will be required to develop the evidence base for policy design and implementation across various specialties.