Cost minimization in breast conserving surgery: a comparative study of radiofrequency spectroscopy and full cavity shave margins.

BACKGROUND: In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full Cavity Shave (FCS) approach or adding the MarginProbe Radiofrequency Spectroscopy System. OBJECTIVE: We sought to create a functioning Pro-Forma for use by facilities and payers to evaluate and compare the cost savings of implementing FCS or MarginProbe based on personalized variable inputs. METHODS: A decision tree demonstrating three possible surgical pathways, BCS, BCS + FCS, and BCS + MarginProbe was developed with clinical inputs for re-excision rate, mastectomy as 2nd surgery, rate of reconstruction, and rate of 3rd surgery derived by a literature review. A surgical pathway cost formula was created using the decision tree and financial inputs derived by utilizing the nation's largest database of privately billed health insurance claims and Medicare claims data (fairhealth.org). Using the surgical pathway formula and financial inputs, a customizable Pro-Forma was created for immediate cost savings analysis of BCS + FCS and BCS + Marginprobe using variable inputs. Costs are from the perspective of third-party payers. RESULTS: Utilizing MarginProbe to reduce re-excisions for positive margins can be associated with better cost-savings than FCS due to the increased pathology processing costs by using an FCS approach. The reduction in re-excision provided by both FCS and MarginProbe offset their increased expense to various degrees with cost savings of each method improving as baseline re-excisions rates increase, until ultimately each may become cost-neutral or cost-prohibitive when compared to BCS alone. Our data suggest that in the privately insured population, MarginProbe provides a cost-savings over BCS alone when baseline re-excision rates are over 20% and that FCS becomes cost-saving when baseline re-excision rates are over 29%. For Medicare patients, MarginProbe provides a cost-savings when baseline re-excision rates exceed 34%, and FCS becomes cost-saving for re-excision rates over 52%. Our Pro-Forma allows an individual provider or institution to evaluate the cost savings of the FCS approach and/or utilization of the MarginProbe device such that the additional cost or cost-savings of utilizing one or both of these methods can be quickly calculated based on their facility's volume and baseline re-excision rate. CONCLUSIONS: Our data suggest that utilizing either an FCS approach or the MarginProbe radiofrequency spectroscopy system may be a cost-saving solution to reducing the rate of re-excisions depending on a facility or practice's surgical volume and baseline re-excision rate. The degree to which each of these interventions provides an added cost or cost-savings to healthcare payers can be evaluated by utilizing the Pro-Forma outlined herein with customizable variable inputs.

Graft subsidence and reoperation after lateral lumbar interbody fusion: a propensity score-matched and cost analysis of polyetheretherketone versus 3D-printed porous titanium interbodies.

OBJECTIVE: Lumbar interbody cage subsidence has a multifactorial etiology. Cage material, although well studied after transforaminal lumbar interbody fusion, has not been investigated as a contributing factor to subsidence after lateral lumbar interbody fusion (LLIF). In this study the authors compared rates of subsidence and reoperation after LLIF between polyetheretherketone (PEEK) and 3D-printed porous titanium (pTi) in an institutional propensity score-matched and cost analysis. METHODS: This is a retrospective observational cohort analysis of adult patients who underwent LLIF with pTi versus PEEK between 2016 and 2020. Demographic, clinical, and radiographic characteristics were collected. Propensity scores were calculated and 1:1 matching without replacement of surgically treated levels was performed. The primary outcome of interest was subsidence. The Marchi subsidence grade was determined at the time of last follow-up. Chi-square or Fisher's exact tests were used to compare subsidence and reoperation rates between lumbar levels treated with PEEK versus pTi. Modeling and cost analysis were performed using TreeAge Pro Healthcare. RESULTS: The authors identified a total of 192 patients; 137 underwent LLIF with PEEK (212 levels) and 55 had LLIF with pTi (97 levels). After propensity score matching, a total of 97 lumbar levels remained in each treatment group. After matching, there were no statistically significant differences between groups in baseline characteristics. Levels treated with pTi were significantly less likely to exhibit subsidence (any grade) compared to those treated with PEEK (8% vs 27%, p = 0.001). Five (5.2%) levels treated with PEEK required reoperation for subsidence, but only 1 (1.0%) level treated with pTi required reoperation for subsidence (p = 0.12). Given subsidence and revision rates experienced in the cohorts in this study, the pTi interbody device is economically superior to PEEK in a single-level LLIF as long as its cost is at least $1185.94 lower than that of PEEK. CONCLUSIONS: The pTi interbody device was associated with less subsidence, but statistically similar revision rates after LLIF. pTi is potentially a superior economic choice at this study's reported revision rate.

Outcomes following surgery for horizontal strabismus in children of lower socioeconomic backgrounds.

The purpose of this article is to compare alignment outcomes following pediatric strabismus surgery for simple horizontal strabismus in patients with state-based aid, used as a proxy for lower socioeconomic status (SES) with those with private insurance. Medical records of all children treated with horizontal strabismus surgery over a period from 2014-17 were retrospectively reviewed. Medical assistance was used as a proxy for lower SES. Patients were compared to a control population undergoing similar surgery by same surgeons in the same time period. Data points were collected at preoperative and postoperative month 6 visits. Improvement in alignment was the primary outcome variable.  Improvement in fusion, amblyopia, and stereopsis were also examined. Demographic information and compliance with treatment recommendations were recorded. 69 patients met inclusion criteria from a total population of 105 patients; 36 were excluded due to loss to follow-up. This was compared to a control group with private insurance; 34 patients were identified out of a total of 38, 4 patients were lost to follow-up. Overall rate of operative success was 71.0% at POM6. Overall rate of success for control group was 73.5%. The difference failed to be statistically significant (p = 0.37). Race, sex, age at time of surgery, and type of strabismus (esotropia, exotropia) failed to correlate with success rate of surgery. Poor compliance with prescribed treatments (glasses, patching/atropine) in both groups correlated with surgical failure. 68.1% of study patients and 70.6% of control reported good compliance with treatment. We present the first analysis of the impact of SES on strabismus surgery outcomes. Overall surgical success rate in our study population failed to differ significantly from a control population and were comparable to that reported in the literature. We found that compliance with treatment influenced surgical success rates in our study population. The high rate of lost to follow-up in the study population is an important factor influencing our conclusion that no difference exists between our groups.