Comparing Costs: Does Extreme Oncoplastic Breast-Conserving Surgery Confer a Cost Benefit When Compared with Mastectomy and Reconstruction?

INTRODUCTION: Extreme oncoplastic breast-conserving surgery (eOBCS) describes the application of OBCS to patients who would otherwise need a mastectomy, and its safety has been previously described. OBJECTIVE: We aimed to compare the costs of eOBCS and mastectomy. METHODS: We reviewed our institutional database to identify breast cancer patients treated surgically from 2018 to 2023. We included patients with a large disease span (≥5 cm) and multifocal/multicentric disease. Patients were grouped by their surgical approach, i.e. eOBCS or mastectomy. The direct costs of care were determined and compared; however, indirect costs were not included. RESULTS: Eighty-six patients met the inclusion criteria, 10 (11.6%) of whom underwent mastectomy and 76 (88.4%) who underwent eOBCS. Six mastectomy patients (60%) had reconstruction and 6 (60%) underwent external beam radiation therapy (EBRT). Reconstructions were completed in a staged fashion, and the mean cost of the index operation (mastectomy and tissue expander) was $17,816. These patients had one to three subsequent surgeries to complete their reconstruction, at a mean cost of $45,904. The mean cost of EBRT was $5542. Thirty-four eOBCS patients (44.7%) underwent 44 margin re-excisions, including 6 (7.9%) who underwent mastectomy. Sixty (78.9%) of the eOBCS patients had EBRT. The mean cost of their index operation was $6345; the mean cost of a re-excision was $3615; the mean cost of their mastectomies with reconstruction was $49,400; and the mean cost of EBRT was $6807. The cost of care for eOBCS patients remained lower than that for mastectomy patients, i.e. $17,318 versus $57,416. CONCLUSION: Mastectomy is associated with a lower cost than eOBCS, which had a low conversion rate compared with mastectomy.

Are we ready for bundled payments for major bowel surgery?

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) recently announced a new voluntary episode payment model for major bowel surgery. The purpose of this study was to examine the financial impact of bundled payments for major bowel surgery. METHODS: An institutional database was retrospectively queried for all patients who underwent major bowel surgery between July 2016 and June 2018. Procedures were categorized using MS-DRG coding: MS-DRG 329 (with MCC, major complications and comorbidity), MS-DRG 330 (with CC, complications and comorbidity), and MS-DRG 331 (without CC/MCC). RESULTS: A total of 745 patients underwent 798 procedures, with mean age 62.1 years and BMI 29.2 kg/m2. The median LOS was 4.0 days, with 12.5% of patients being discharged to a post-acute care facility for an average of 38.5 days. The mean hospital cost was $18,525. The mean payment to a post-acute care facility was $423 per day. The 90-day readmission rate was 8.6% at an average cost of $12,859 per readmission. Patients with major complications and comorbidity (MS-DRG 329) had higher CMS Hierarchical Condition Categories scores, longer LOS, higher costs, more required home health services or post-acute care facilities, and had higher 90-day readmissions. In a fee-for-service model, hospital reimbursements resulted in a negative margin of - 8.2% for MS-DRG 329, - 2.6% for MS-DRG 330, but a positive margin of 2.8% for MS-DRG 331. In a bundled payment model, the hospital would incur a loss of - 13.1%, - 11.1%, and - 1.9% for MS-DRG 329, 330, and 331, respectively. CONCLUSIONS: Patients undergoing major bowel surgery are often a heterogeneous population with varied pre-existing comorbid conditions who require a high level of complex care and utilize greater hospital resources. Further study is needed to identify areas of cost containment without compromising the overall quality of care.

A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair.

BACKGROUND: The enhanced-view totally extraperitoneal (eTEP) technique has been previously described for Laparoscopic Inguinal Hernia Repair. We present a novel application of the eTEP access technique for the repair of ventral and incisional hernias. METHODS: Retrospective review of consecutive laparoscopic retromuscular hernia repair cases utilizing the eTEP access approach from five hernia centers between August 2015 and October 2016 was conducted. Patient demographics, hernia characteristics, operative details, perioperative complications, and quality of life outcomes utilizing the Carolina's Comfort Scale (CCS) were included in our data analysis. RESULTS: Seventy-nine patients with mean age of 54.9 years, mean BMI of 31.1 kg/m2, and median ASA of 2.0 were included in this analysis. Thirty-four percent of patients had a prior ventral or incisional hernia repair. Average mesh area of 634.4 cm2 was used for an average defect area of 132.1 cm2. Mean operative time, blood loss, and length of hospital stay were 218.9 min, 52.6 mL, and 1.8 days, respectively. There was one conversion to intraperitoneal mesh placement and one conversion to open retromuscular mesh placement. Postoperative complications consisted of seroma (n = 2) and trocar site dehiscence (n = 1). Comparison of mean pre- and postoperative CCS scores found significant improvements in pain (68%, p < 0.007) and movement limitations (87%, p < 0.004) at 6-month follow-up. There were no readmissions within 30 days and one hernia recurrence at mean follow-up of 332 ± 122 days. CONCLUSIONS: Our initial multicenter evaluation of the eTEP access technique for ventral and incisional hernias has found the approach feasible and effective. This novel approach offers flexible port set-up optimal for laparoscopic closure of defects, along with wide mesh coverage in the retromuscular space with minimal transfascial fixation.

The trend toward minimally invasive complex abdominal wall reconstruction: is it worth it?

BACKGROUND: Open abdominal wall reconstruction (AWR) was previously one of the only methods available to treat complex ventral hernias. We set out to identify the impact of laparoscopy and robotics on our AWR program by performing an economic analysis before and after the institution of minimally invasive AWR. METHODS: We retrospectively reviewed inpatient hospital costs and economic factors for a consecutive series of 104 AWR cases that utilized separation of components technique (57 open, 38 laparoscopic, 9 robotic). Patients were placed into two groups by date of procedure. Group 1 (Pre MIS) was July 2012-June 2015 which included 52 open cases. Group 2 (Post MIS) was July 2015-August 2016 which included 52 cases (5 open, 38 laparoscopic, 9 robotic). RESULTS: A total of 104 patients (52 G1 vs. 52 G2) with mean age (54.2 vs. 54.1 years, p = 0.960), BMI (34.7 vs. 32.1 kg/m2, p = 0.059), and ASA score (2.5 vs. 2.3, p = 0.232) were included in this review. Total length of stay (LOS) was significantly shorter for patients in the Post MIS group (5.3 vs. 1.4 days, p < 0.001). Although operating room (OR) supply costs were $1705 higher for the Post MIS group (p = 0.149), total hospital costs were $8628 less when compared to the Pre MIS group (p < 0.001). Multiple linear regressions identified increased BMI (p = 0.021), longer OR times (p = 0.003), and LOS (p < 0.001) as predictors of higher total costs. Factors that were predictive of longer LOS included older patients (p = 0.003) and patients with larger defect areas (p = 0.004). MIS was predictive of shorter hospital stays (p < 0.001). CONCLUSIONS: Despite an increase in operating room supply costs, transition to performing MIS AWR in cases that were previously done through an open approach decreased LOS and translated into significant overall total cost savings.

Evaluation of the Learning Curve When Transitioning From Posterolateral to Direct Anterior Hip Arthroplasty: A Consecutive Series of 1000 Cases.

BACKGROUND: The direct anterior approach (DAA) for primary hip replacement has been gaining more attention and widespread use in recent years. There are a number of published studies evaluating the learning curve when a surgeon changes technique; these studies typically look at complications during the initial cases. This study examines procedure and total operating room (OR) time along with all complications for a surgeon transitioning from the posterolateral approach (PA) to DAA. METHODS: A retrospective review of a single surgeon series of 1000 initial DAA procedures. Total OR time, procedure time, and complications were collected and analyzed. One-way analysis of variance and post hoc least significant difference tests were used for statistical analysis. RESULTS: There was an initial increase in both procedure and OR times compared with the mature PA, by 34% and 30%, respectively. The procedure time became statistically equivalent to the mature PA time after the 400th DAA case, and significantly shorter after the 850th case. The total OR time became statistically equivalent after the 900th DAA case. There were 18 early (<90 days) and 18 late reoperations performed in this series with a nonsignificant trend toward femoral complications occurring early in the series. Minimum follow-up time was 2 years. CONCLUSION: There was an initial increase in both total OR time and procedure time when an experienced surgeon introduced the DAA. By the end of the series, procedure time was significantly shorter and total OR time was equivalent. Complications overall were low and femoral complications decreased with time.

Functional Outcomes and Accuracy of Patient-Specific Instruments for Total Knee Arthroplasty.

BACKGROUND: Patient-specific instruments (PSIs) were developed to improve mechanical axis alignment for patients undergoing total knee arthroplasty (TKA) as neutral alignment (180°) is a predictor of long-term success. This study examines alignment accuracy and functional outcomes of PSI as compared with standard instruments (SIs). METHODS: We retrospectively reviewed a consecutive series of TKA procedures using PSI. A total of 85 PSI procedures were identified, and these were compared with a matched cohort of 85 TKAs using SI. Intraoperative decision-making, estimated blood loss, efficiency, Knee Society Scores, and postoperative radiographs were evaluated. RESULTS: One hundred and seventy patients with comparable patient demographics were reviewed. Eighty-one percent of the PSI procedures were within target (180 ± 3°) mechanical alignment, while the SI group had 70% of cases within the target plane ( P = .132). Mean target alignment (2.0° PSI vs 2.2° SI, P = .477) was similar between groups. Twenty-seven percent of patients in the PSI group had surgeon-directed intraoperative recuts to improve the perceived coronal alignment. The change in hematocrit was reduced in the PSI group (8.89 vs 7.21, P = .000). Procedure time and total operating room time were equivalent. Knee Society Scores did not differ between groups at 6 months or at 1 year. CONCLUSION: Patient-specific instrumentation decreased change in hematocrit, though coronal alignment and efficiency were equivalent between groups. Surgeons must evaluate cuts intraoperatively to confirm alignment. Functional outcomes are equivalent for PSI and SI groups.

Insulin-Dependent Diabetes Is an Independent Risk Factor for Complications and Readmissions After Total Joint Replacements.

This study examined the risk for postoperative complications, reoperations, and readmissions for patients with insulin-dependent diabetes mellitus (IDDM), patients with non-insulin-dependent diabetes mellitus (NIDDM), and patients without diabetes undergoing total joint replacements (TJRs). The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJRs in 2015. The study identified 78,744 TJRs (84.1% nondiabetic patients, 12.0% NIDDM, and 3.9% IDDM). Multiple logistic regression models identified IDDM as an independent risk factor for increased blood loss, myocardial infarctions, pneumonia, renal insufficiency, urinary tract infections, and readmissions when compared with both NIDDM and nondiabetics. Risk for wound complications and reoperations were comparable between all three groups. IDDM increases the risk for medical complications and readmissions after TJRs. Physicians must counsel patients on the increased risks associated with IDDM before elective surgery and provide appropriate medical support for these patients. (Journal of Surgical Orthopaedic Advances 27(4):294-298, 2018).

Opioid Prescriptions After Total Joint Arthroplasty.

Prescription opioids are commonly prescribed for pain relief after total joint arthroplasty (TJA), yet little is known about the quantity of opioids prescribed after surgery. This study retrospectively reviewed a consecutive series of 1000 TJAs from April 2014 through September 2015. Postoperative opioid prescriptions were quantified using standardized morphine milligram equivalents (MME). Eighty-four percent of total knee arthroplasty (TKA) and 77% of total hip arthroplasty (THA) patients were opioid naïve. The median opioid volume of the first prescription for those undergoing TKA was greater than for those undergoing THA (600 vs. 450 MME), as was the proportion of individuals requiring one or more refills (48% vs. 32%). The total volume of opioids after TKA was also higher than for total hip replacement (870 vs. 525 MME). Patients who were not opioid naïve were prescribed substantially more opioids than their counterparts after TKA (mean 1593 vs. 1064 MME, p < .001) and THA (mean 1031 vs. 663 MME, p < .001). Decreasing opioid use before surgery may decrease total volume of opioid prescriptions after TJA. (Journal of Surgical Orthopaedic Advances 27(3):231-236, 2018).

Decreasing Postanesthesia Care Unit to Floor Transfer Times to Facilitate Short Stay Total Joint Replacements.

PURPOSE: We describe a process for studying and improving baseline postanesthesia care unit (PACU)-to-floor transfer times after total joint replacements. DESIGN: Quality improvement project using lean methodology. METHODS: Phase I of the investigational process involved collection of baseline data. Phase II involved developing targeted solutions to improve throughput. Phase III involved measured project sustainability. FINDINGS: Phase I investigations revealed that patients spent an additional 62 minutes waiting in the PACU after being designated ready for transfer. Five to 16 telephone calls were needed between the PACU and the unit to facilitate each patient transfer. The most common reason for delay was unavailability of the unit nurse who was attending to another patient (58%). Phase II interventions resulted in transfer times decreasing to 13 minutes (79% reduction, P < .001). Phase III recorded sustained transfer times at 30 minutes, a net 52% reduction (P < .001) from baseline. CONCLUSIONS: Lean methodology resulted in the immediate decrease of PACU-to-floor transfer times by 79%, with a 52% sustained improvement. Our methods can also be used to improve efficiencies of care at other institutions.

Primary versus redo paraesophageal hiatal hernia repair: a comparative analysis of operative and quality of life outcomes.

INTRODUCTION: We compared patient outcomes after initial versus redo paraesophageal hernia (PEH) repair at two high-volume GI surgery centers. MATERIALS AND METHODS: Retrospective review analyzed one-year outcomes after initial versus redo elective laparoscopic PEH repair, including wound/non-wound-related complications and quality of life benefits as measured by four validated instruments: reflux symptom index, gastroesophageal reflux disease health-related, laryngopharyngeal reflux, and swallowing scales. RESULTS: Three hundred and seventeen patients (271 initial and 46 redo) underwent laparoscopic PEH repair. Groups differed with respect to age (64.6 vs. 60.2 years, p = 0.027), but were comparable in gender (71.2 vs. 67.4% female, p = 0.596), BMI (29.0 vs. 27.6 kg/m2, p = 0.100), and ASA score (2.3 vs. 2.3 p = 0.666). Redo surgery was more complex with longer mean operative times (112.2 vs. 139.1 min, p < 0.001). Groups did not statistically differ with respect to 30-day wound (0.7 vs. 2.2%, p = 0.363) and non-wound (6.0 vs. 8.7%, p = 0.511)-related complications. After one year of follow-up, QOL analysis revealed that initial versus redo groups significantly benefited from operative intervention. CONCLUSIONS: Although redo PEH repairs are more complex, patients enjoy equivalent operative outcomes and quality of life benefits compared to initial surgery lending support to the significance of surgeon experience and high-volume centers in optimizing outcomes.

Who Is Not a Candidate for a 1-Day Hospital-Based Total Knee Arthroplasty?

BACKGROUND: Short-stay total knee arthroplasty (TKA), defined as a 1-day length of stay (LOS), is feasible in many patients, yet variables identifying who are candidates for a short stay are not well described in literature. With an emphasis on cost-efficiency, we examined preoperative patient characteristics and perioperative hospital factors that correlated with a longer LOS. METHODS: A retrospective review of 381 primary TKAs was performed. Clinical measures differentiating a 1-day LOS group from that of a ≥2-day LOS group were identified. RESULTS: Multiple logistic regression demonstrated older age (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.34-2.77; P < .001), female gender (OR, 4.22; 95% CI, 2.35-7.57; P < .001), American Society of Anesthesiologists score 3 or 4 (OR, 2.00; 95% CI, 1.01-3.95; P = .046), atrial fibrillation (OR, 8.87; 95% CI, 1.81-43.47; P = .007), and prior TKA on the contralateral side (OR, 3.57; 95% CI, 1.27-10.05; P = .016) as significant preoperative characteristics correlating with the ≥2-day LOS group. The most significant hospital perioperative factor associated with longer stays was patients not ambulating on the day of surgery (OR, 4.09; 95% CI, 1.77-9.48; P = .001). Walking 150 ft (93% sensitive, 35% specific) on the day of surgery was predictive of patients in the 1-day LOS group. Hospital costs were US$1873 (P < .001) lower for patients in the 1-day group. CONCLUSION: Shorter stays decrease costs associated with TKA, and more refined predictive models are needed to optimize discharge protocols. Preoperative data help allocate limited healthcare resources toward patients more likely to leave in 1 day, while perioperative data facilitate learning to create a more efficient hospital process.

The Cost of Unnecessary Hospital Days for Medicare Joint Arthroplasty Patients Discharging to Skilled Nursing Facilities.

BACKGROUND: The 72-hour Medicare mandate (3-night stay rule) requires a 3-day inpatient stay for patients discharging to skilled nursing facilities (SNFs). Studies show that 48%-64% of Medicare total joint arthroplasty (TJA) patients are safe for discharge to SNFs on postoperative day (POD) #2. The purpose of this study was to extrapolate the financial impact of the 3-night stay rule. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJAs performed in 2015. Discharge destination was recorded. Institutional cost accounting examined costs for patients discharging on POD #2 vs POD #3. RESULTS: A total of 42,423 TJAs (14,395 total hip arthroplasties [THAs] and 28,028 total knee arthroplasties [TKAs]) were performed in patients over the age of 65 years. Of these patients, 5252 THAs (36.5%) and 12,022 TKAs (42.9%) were discharged from the hospital on POD #3, with 2404 THAs (16.7%) and 5083 TKAs (18.1%) being discharged to SNFs. Institutional cost accounting revealed hospital costs for THA were $2014 more, whereas hospital costs for TKA were $1814 more for a 3-day length of stay when compared with a 2-day length of stay (P < .001). The mean charge per day for an SNF was $486. CONCLUSION: The National Surgical Quality Improvement Program database is a representative sample of all surgeries performed in the United States. Extrapolating our findings to all Medicare TJAs nationally gives an estimated $63 million in annual savings. Medicare mandated, but potentially medically unnecessary inpatient days at a higher level of care increase the total cost for TJAs. Policies regarding minimum stay requirements before discharge should be re-evaluated.

The Impact of Surgical Technique on Patient Reported Outcome Measures and Early Complications After Total Hip Arthroplasty.

BACKGROUND: This study examines patient and surgeon reported outcome measures, complications during index admission, length of stay (LOS), and discharge disposition in a series of total hip replacements (THR) performed via the direct anterior (DA) or posterolateral (PL) approach. METHODS: Five surgeons performed 2698 total hip replacements (1457 DA vs 1241 PL) between January 2010 and June 2015. Complications during index admission were recorded using billing and claims data. Harris Hip Scores (HHS) and Hip disability and Osteoarthritis Outcome Scores (HOOS) were collected in a subset of patients. RESULTS: Patients in the DA group had shorter LOS (2.3 DA vs 2.7 PL days, P < .001) and a larger proportion of patient discharges to home (79.0% DA vs 68.7% PL, P < .001). Surgical (0.75% DA vs 0.73% PL, P = .961) and medical (8.4% DA vs 8.1% PL, P = .766) complications during index admission were equivalent between groups. HHS (n = 462) favored the DA group at an early follow-up (P < .001), but did not differ at 1 year (P = .478). Logistic regression revealed that patients in the DA group were more likely to report no pain, no limp, walk unlimited distances, and climb stairs without the use of the railing at 3- to 6-month follow-up (P < .001). HOOSs were equivalent at all follow-ups regardless of approach. CONCLUSION: Patients in the DA group had shorter LOS and were more likely to be discharged home. The DA group had better HHS at 3- to 6-month follow-up than patients in the PL group, with no difference in medical or surgical complications during index admission.

Incidence, Risk Factors, and Costs for Hospital Returns After Total Joint Arthroplasties.

BACKGROUND: Unplanned hospital returns after total joint arthroplasty (TJA) reduce any cost savings in a bundled reimbursement model. We examine the incidence, risk factors, and costs for unplanned emergency department (ED) visits and readmissions within 30 days of index TJA. METHODS: We retrospectively reviewed a consecutive series of 655 TJAs (382 total knee arthroplasty and 273 total hip arthroplasty) performed between April 2014 and March 2015. Preoperative diagnosis was osteoarthritis of the hip or knee (97%) or avascular necrosis of the hip (3%). Hospital costs were recorded for each ED visit and readmission episode. RESULTS: Of the 655 TJAs reviewed, 55 (8.4%) returned to the hospital. Of these hospital returns, 35 patients (5.3%) returned for a total of 36 unplanned ED visits whereas the remaining 20 patients (3.1%) presented 22 readmissions within 30 days of index TJA. The 2 most common reasons for unplanned ED visits were postoperative pain/swelling (36%) and medication-related side effects (22%). Avascular necrosis of the hip was a significant risk factor for an unplanned ED visit (7.27 odds ratio [OR], 95% confidence interval [CI] 1.67-31.61, P = .008). Multiple logistic regression analysis revealed the following risk factors for readmission: body mass index (1.10 OR, 95% CI 1.02-1.78, P = .013), comorbidity >2 (2.07 OR, 95% CI 1.06-6.95, P = .037), and prior total knee arthroplasty (2.61 OR, 95% CI 1.01-6.72, P = .047). Ambulating on the day of surgery trended toward a lower risk for readmission (0.13 OR, 95% CI 0.02-1.10, P = .061). The 2 most common reasons for readmission were ileus (23%) and cellulitis (18%). The total cost associated with unplanned ED visits were $15,427 whereas costs of readmissions totaled $142,654. CONCLUSION: Unplanned ED visits and readmissions in the forthcoming bundled payments reimbursement model will reduce cost savings from rapid recovery protocols for TJA. Identifying and mitigating preventable causes of unplanned visits and readmissions will be critical to improving care and controlling costs.

Predictors of Hospital Length of Stay in an Enhanced Recovery After Surgery Program for Primary Total Hip Arthroplasty.

BACKGROUND: Shorter length of stay (LOS) for total hip arthroplasty (THA) is becoming standard, yet variables identifying candidates for a 1-day discharge in an enhanced recovery after surgery program are not well defined. With growing emphasis on cost-efficiency and bundled care for THA, this study looked to identify variables that correlated with LOS. METHODS: A retrospective chart review was performed for 273 primary THAs, from April 2014 to January 2015. Clinical measures differentiating a 1-day LOS cohort from that of a LOS longer than 1 day were identified. Direct medical costs were calculated for services billed during hospitalization. RESULTS: Logistic regression identified the following preoperative patient characteristics to correlate with an LOS >1 day: older age (odds ratio [OR]: 1.06, P < .001), increased body mass index (OR: 1.06, P = .005), female gender (OR: 1.76, P = .031), American Society of Anesthesiologists score 3 or 4 (OR: 1.84, P = .029), and coronary artery disease (OR: 3.90, P = .013). After adjusting for age, body mass index, and gender, the following perioperative variables led to an LOS ≥2 days: general anesthesia (OR: 2.24, P = .007), longer operative time (OR: 1.04, P < .001), and increased blood loss (OR: 1.01, P = .001). Postoperatively, not ambulating on the day of surgery strongly correlated with an LOS ≥2 days (OR: 3.9, P < .001). Hospital costs were approximately $2900 higher for a 2-day LOS. CONCLUSION: With growing emphasis on cost-efficiency, studying the association of clinical factors with LOS is necessary to develop a preoperative and perioperative predictive risk stratification model that may be used to help optimize discharge protocols for patients in an enhanced recovery after surgery program.

Early Experiences With Bundled Payments for Care Improvement for Major Bowel Surgery.

BACKGROUND: Bundled Payment (BP) models are becoming more common in surgery. We share our early experiences with Bundled Payments for Care Improvement for major bowel surgery. METHODS: Patients undergoing major bowel surgery between January and October 2021 were identified using Medicare Severity-Diagnosis Related Group (MS-DRG) codes. Major drivers of cost in a BP model are reported and compared to the Fee-For-Service (FFS) payment model. RESULTS: A total of 202 cases (173 FFS vs 29 BP) were analyzed. The mean BP cost per Clinical Episode was $28,340. Eleven patients (38%) in the BP model had costs greater than the Target Price. The drivers of cost in the BP model were 59% acute care facility, 17% physician services, 9% post-acute care facilities, 8% other, and 7% readmissions. Clinical Episode of care costs varied considerably by MS-DRG case complexity. Robotic surgery increased costs by 35% (mean increase $3724, P < .01). The 90-day readmission rate was 17% for a mean cost of $11,332 per readmission. Three patients (10%) were discharged to a skilled nursing facility at an average cost of $11,009, while fifteen patients (52%) received home health services at a mean cost of $2947. Acute care facility costs were similar in the BP vs FFS groups (mean difference $1333, P = .22). CONCLUSIONS: Patients undergoing major bowel surgery are a heterogeneous population. Physicians are ideally positioned to deliver high-value, patient-centered care and are crucial to the success of a BP model. The post-acute care setting is a key component of improving efficiency and quality of care.

Socially vulnerable patients are more likely to fail outpatient management of symptomatic cholelithiasis.

BACKGROUND: Symptomatic cholelithiasis is a common surgical problem, with many patients requiring multiple gallstone-related emergency department (ED) visits before cholecystectomy. The Social Vulnerability Index (SVI) identifies vulnerable patient populations. This study aimed to assess the association between social vulnerability and outpatient management of symptomatic cholelithiasis. METHODS: Patients with symptomatic cholelithiasis-related ED visits were identified within our health system from 2016 to 2022. Clinical outcomes data were merged with SVI census track data, which consist of 4 SVI subthemes (socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation). Multivariate analysis was used for statistical analysis. RESULTS: A total of 47,292 patients presented to the ED with symptomatic cholelithiasis, of which 6103 patients (13.3 %) resided in vulnerable census tract regions. Of these patients, 13,795 (29.2 %) underwent immediate cholecystectomy with a mean time to surgery of 35.1 h, 8250 (17.4 %) underwent elective cholecystectomy at a mean of 40.6 days from the initial ED visit, and 2924 (6.2 %) failed outpatient management and returned 1.26 times (range, 1-11) to the ED with recurrent biliary-related pain. Multivariate analysis found social vulnerability subthemes of socioeconomic status (odds ratio [OR], 1.29; 95 % CI, 1.09-1.52) and racial and ethnic minority status (OR, 2.41; 95 % CI, 2.05-2.83) to be associated with failure of outpatient management of symptomatic cholelithiasis. CONCLUSION: Socially vulnerable patients are more likely to return to the ED with symptomatic cholelithiasis. Policies to support this vulnerable population in the outpatient setting with timely follow-up and elective cholecystectomy can help reduce delays in care and overutilization of ED resources.

Analysis of 10-year trends in Medicare Physician Fee Schedule payments in surgery.

BACKGROUND: Medicare expenditures have steadily increased over the decades, and yet Medicare Physician Fee Schedule payments for individual services have declined. We examine trends in Medicare Physician Fee Schedule payments for office visits, inpatient visits, and surgical procedures. METHODS: The Medicare Physician Fee Schedule Look-Up Tool was queried for payment data for office visits, inpatient visits, and surgical procedures between 2013 and 2023. All data were adjusted for inflation using the Consumer Price Index. Trends in payments were calculated for 5 common procedures in each surgical specialty. Trends in aggregate national health expenditures were compared to Medicare Physician Fee Schedule payments for physician services from 2013 to 2021. RESULTS: The Consumer Price Index increased by 29.3% from 2013 to 2023. Inflation-adjusted per-visit Medicare Physician Fee Schedule payments decreased by 12.2% for outpatient office visits, 19.1% for inpatient visits, and 22.8% for surgical procedures from 2013 to 2023. This varied by surgical specialty: vascular (-25.8%), endocrine (-22.0%), general surgery (-27.0%), thoracic (-19.2%), surgical oncology (-22.1%), breast (-22.4%), urology (-2.2%), neurosurgery (-22.8%), obstetrics/gynecology (-19.9%), and orthopedics (-24.7%). Adjusted for inflation, national health expenditures increased by 33.9% for physician services from 2013 to 2021. In comparison, Medicare Physician Fee Schedule payments over the same time period 2013 to 2021 increased by 1.3% for outpatient office visits but decreased by 10.6% for inpatient visits and 9.8% for surgical procedures. CONCLUSION: Controlling rising national health expenditures is important and necessary, but 10 years of declining Medicare Physician Fee Schedule payments on a per-procedure basis in surgery would suggest that this strategy alone may not achieve those goals and could ultimately threaten access to quality surgical care. Surgeons must advocate for permanent payment reforms.

Male Breast Cancer With Dual BRCA2 and BRIP1 Deleterious Gene Mutations.

Background: Male breast cancer remains relatively underexplored in the medical literature. At present, male patients with breast cancer follow the same treatment guidelines as female patients with breast cancer, principally because of similar outcomes with treatment. However, this practice should not preclude generating evidence for male breast cancer surveillance, diagnosis, and management. BRCA2 gene mutations are associated with an increased risk of male breast cancer, along with lesser-known gene mutations that could also increase this risk, such as mutations of the BRIP1 gene. This case report presents a male patient with dual BRCA2 and BRIP1 deleterious gene mutations. To our knowledge, this combination has not been reported in the medical literature to date. Case Report: A 53-year-old male presented with a palpable symptomatic mass underneath the right nipple-areolar complex. Biopsies confirmed a poorly differentiated, infiltrating ductal carcinoma that was estrogen and progesterone receptor positive and human epidermal growth factor receptor-2 negative. The patient underwent a left modified radical mastectomy, with a right prophylactic simple mastectomy. Postoperatively, he underwent adjuvant chemotherapy and endocrine therapy. Conclusion: This novel case of genetically based male breast cancer with dual deleterious gene mutations provides insight into current treatment recommendations and the subtle differences between male breast cancer and female breast cancer. Engaging in discussions surrounding such rare cases not only raises awareness of male breast cancer but also indicates the need for further research aimed at establishing evidence-based management strategies for male patients with breast cancer.

Impact of Frailty Upon Surgical Decision-Making for Left-Sided Colon Cancer.

Background: Frailty is characterized by reduced physiologic reserve, and for patients with colon cancer, frailty is associated with increased morbidity after resection. One commonly cited reason for performing an end colostomy vs a primary anastomosis in left-sided colon cancer is the belief that frail patients do not have the physiologic reserve to withstand the morbidity associated with an anastomotic leak. We explored the impact of frailty on the type of operation performed in patients with left-sided colon cancer. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program for patients with colon cancer who underwent a left-sided colectomy from 2016 to 2018. Patients were categorized using the modified 5-item frailty index. Multivariate regression was used to identify independent predictors of complications and type of operation performed. Results: Of 17,461 patients, 20.7% were considered frail. Frail patients received an end colostomy more often than nonfrail patients (11.3% vs 9.6%, P=0.01). On multivariate analysis, frailty was a significant predictor for total medical complications (odds ratio [OR] 1.45, 95% CI 1.29-1.63) and readmission (OR 1.53, 95% CI 1.32-1.77) but was not independently associated with organ space surgical site infections or reoperation. Frailty was independently associated with receiving an end colostomy vs a primary anastomosis (OR 1.23, 95% CI 1.06-1.44), but an end colostomy did not decrease the risk of reoperation or organ space surgical site infections. Conclusion: Frail patients with left-sided colon cancer are more likely to receive an end colostomy, but an end colostomy does not lower the risk of reoperation or organ space surgical site infections. Based on these results, frailty alone should not prompt the decision to perform an end colostomy, but further studies are needed to guide surgical decision-making in this understudied population.