Trends in Ophthalmology Practice Consolidation: 2015-2022.

PURPOSE: To quantify trends in ophthalmology practice consolidation in the United States. DESIGN: A retrospective cross-sectional study. PARTICIPANTS: Providers in the Centers for Medicare and Medicaid Services (CMS) National Downloadable File with a primary specialty designation of ophthalmology. METHODS: We used the CMS database to determine national practice consolidation trends in ophthalmology on individual physician and group practice levels and analyzed by region, sex, and years spent in practice. We used the Cochran-Armitage test to determine the statistical significance of practice size differences between 2015 and 2022. MAIN OUTCOME MEASURES: Temporal practice size trends for physicians and practices in ophthalmology and regional, sex-specific, and age-related trends. RESULTS: Between 2015 and 2022, the number of ophthalmologists decreased from 17 656 to 17 615 (-0.2%), whereas the number of practices decreased from 7149 to 5890 (-18%). The percentage of ophthalmologists in practices of 1 to 2 members decreased from 35% to 28%, whereas those in groups of 50 or more increased from 7% to 11%. The percentage of practices with 1 to 2 members decreased from 75% to 71%, and those with 50 or more increased from 0.2% to 0.4%. Consolidation trends were significant on individual ophthalmologist (P < 0.001) and group practice (P < 0.001) levels. All regions, sexes, and subgroups of years spent in practice demonstrated consolidation (P < 0.001). The Northeast showed the greatest increase in groups of 50 or more physicians (+7%) between 2015 and 2022. Proportionally fewer female than male ophthalmologists were associated with practice sizes of 1 to 2 members in 2015 (29% and 36%, respectively) and 2022 (23% and 30%, respectively). Proportionally fewer ophthalmologists with 0 to 10 years of experience in practice were associated with practice sizes of 1 to 2 members than those with more than 30 years in practice in 2015 (18% and 48%, respectively) and 2022 (14% and 40%, respectively). CONCLUSIONS: Ophthalmology has undergone practice consolidation from 2015 to 2022. A decrease in the proportion of physicians affiliated with smaller practice sizes seems to have occurred. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

National and geographic trends in Medicare reimbursement rates for orthopedic shoulder and upper extremity surgery from 2000 to 2020.

BACKGROUND: There is a paucity of information regarding financial trends in orthopedic upper extremity surgery. If progress is to be made in advancing agreeable reimbursement models, a more comprehensive understanding of these trends is needed. The purpose of this study was to assess national and geographic trends in Medicare reimbursement rates for shoulder and elbow surgical procedures over the past 2 decades. METHODS: The 10 most billed Common Procedural Terminology (CPT) codes for both orthopedic shoulder surgery and elbow/upper arm surgery were determined. Medicare reimbursement data for these CPT codes were compiled between 2000 and 2020 and adjusted for inflation. The percentage change for each procedure and the average change in reimbursement each year were analyzed. Data from 2000, 2010, and 2020 were organized by state. The total percent change in physician fee and the percent change per year were tabulated for each CPT code using inflation-adjusted data and averaged by state. RESULTS: From 2000 to 2020, when corrected for inflation, shoulder and elbow procedures decreased on average by 29.3% and 24.5%, respectively. Shoulder procedures experienced a greater numerical yet statistically insignificant decline in mean reimbursement percent decrease (P = .16), average percent decrease per year (P = .11), a more negative compound annual growth rate (P = .14), and a greater R-squared value as compared with elbow and upper arm procedures. For shoulder procedures, the average percent difference in inflation-adjusted Medicare reimbursement rates from 2000 to 2020 varied from -22.6% in Alaska to -34.1% in Michigan; division data varied from -27.8% in the Mountain Division to -31.2% in the East North Central Division; and region data varied from -28.3% in the West to -30.5% in the Northeast. For elbow and upper arm procedures, the average percent difference in inflation-adjusted Medicare reimbursement rates from 2000 to 2020 varied from -17.6% in Alaska to -29.8% in Michigan; division data varied from -23.0% in the Mountain Division to -26.7% in the East North Central Division; and region data varied from -23.5% in the West to -25.7% in the Northeast. DISCUSSION: Inflation-adjusted Medicare reimbursement in upper extremity surgery has decreased markedly between 2000 and 2020. The degree of decrease varies geographically. If access to quality and sustainable surgical orthopedic care is to persist in the United States, increased awareness of these trends is important. The trends identified in this study can serve to customize regional health care policymaking.

What Patients Say About Their Orthopaedic Hand and Wrist Surgeons: A Qualitative Analysis of Negative Reviews on Yelp.

Background Patients often turn to online reviews as a source of information to inform their decisions regarding care. Existing literature has analyzed factors associated with positive online patient ratings among hand and wrist surgeons. However, there is limited in-depth analysis of factors associated with low patient satisfaction for hand and wrist surgeons. The focus of this study is to examine and characterize extremely negative reviews of hand and wrist surgeons on Yelp.com. Methods A search was performed using the keywords "hand surgery" on Yelp.com for eight major metropolitan areas including Washington DC, Dallas, New York, Phoenix, Los Angeles, San Francisco, Boston, and Seattle. Only single-star reviews (out of a possible 5 stars) of hand and wrist surgeons were included. The complaints in the 1-star reviews were then categorized into clinical and nonclinical categories. Result A total of 233 single-star reviews were included for analysis, which resulted in 468 total complaints. Of these complaints, 81 (18.8%) were clinically related and 351 (81.3%) were nonclinical in nature. The most common clinical complaints were for complication (24 complaints, 6%), misdiagnosis (16 complaints, 4%), unclear treatment plan (16 complaints, 4%), and uncontrolled pain (15 complaints, 3%). The most common nonclinical complaints were for physician bedside manner (93 complaints, 22%), financially related (80 complaints, 19%), unprofessional nonclinical staff (61 complaints, 14%), and wait time (46 complaints, 11%). The difference in the number of complaints for surgical and nonsurgical patients was statistically significant ( p < 0.05) for complication and uncontrolled pain. Clinical Relevance Patient satisfaction is dependent on a multitude of clinical and nonclinical factors. An awareness of online physician ratings is essential for hand and wrist surgeons to maintain and improve patient care and patient satisfaction. We believe the results of our study could be used to further improve the quality of care provided by hand and wrist surgeons.

Utilization and reimbursement trends of osteopathic manipulative treatment for Medicare patients: 2000-2019.

CONTEXT: Osteopathic manipulative treatment (OMT) has been established as a beneficial and noninvasive treatment option for multiple conditions. With the total number of osteopathic providers tripling and the subsequent increase in osteopathic physician representation, we would expect the clinical use of OMT to increase accordingly. OBJECTIVES: To that end, we evaluated the utilization and reimbursement of OMT services among Medicare beneficiaries. METHODS: Current procedural terminology (CPT) codes 98925 to 98929 were accessed from the Center for Medicare and Medicaid Services (CMS) from 2000 to 2019. These codes indicate OMT treatment, 98925 (1-2 body regions treated), 98926 (3-4 body regions treated), 98927 (5-6 body regions treated), 98928 (7-8 body regions treated), and 98929 (9-10 body regions treated). Monetary reimbursement from Medicare was adjusted for inflation, and total code volume was scaled to codes per 10,000 beneficiaries to account for the increase in Medicare enrollment. RESULTS: Overall OMT utilization declined between 2000 and 2019 by 24.5%. A significant downward trend in the utilization of CPT codes for OMT involving fewer body regions (98925-98927) was observed, and was contrasted by a slight upward trend in the use of codes for more body regions (98928, 98929). The adjusted sum reimbursement of all codes decreased by 23.2%. Lower value codes showed a higher rate of decline, whereas higher value codes changed less dramatically. CONCLUSIONS: We conjecture that lower remuneration for OMT has disincentivized physicians financially and may have contributed to the overall decline in OMT utilization among Medicare patients, along with a decreased number of residencies offering specific training in OMT, and increased billing complexity. In considering the upward trend of higher-value code usage, it is possible that some physicians are increasing the comprehensiveness of their physical assessment and associated OMT to reduce the overall financial impact of reimbursement cuts.

Characterizing Extremely Negative Reviews of Ophthalmologists on Yelp.Com.

PURPOSE: To perform a retrospective characterization of one-star reviews of ophthalmologists on Yelp.com and to increase understanding of patient complaints on Yelp.com. METHODS: A search was performed for reviews on Yelp.com using the keyword "ophthalmologist" for the top 8 most population-dense metropolitan areas in the United States. One-star reviews were collected and classified as procedural or nonprocedural. Complaints were also categorized as clinical, nonclinical, or both. Clinical complaints cited issues such as complications, reoperations, uncontrolled pain, misdiagnosis, unclear treatment plan, etc. Nonclinical complaints included comments such as physician bedside manner, other staff interpersonal manner, wait time, brevity of appointment time, etc. RESULTS: 5,532 total reviews were assessed, of which 477 (9%) one-star reviews were included in the study for analysis. These reviews amounted to 1,120 distinct complaints. 287 (26%) were clinical in nature and 833 (74%) were nonclinical. Technical incompetence or error (50: 4%), unsatisfactory results (46: 4%), and complications (43: 4%) represented the most common clinical complaints while office staff interpersonal manner (182: 16%), wait time (174: 16%), and physician interpersonal manner (141: 13%) were the most common nonclinical complaints. Refractive surgery was the most frequently mentioned subspecialty (89: 8%). Patients undergoing an ophthalmic procedure (surgery, injection, etc.) wrote 64 reviews that resulted in 193 (17%) complaints. Nonprocedural patients wrote 413 reviews that resulted in 927 (83%) complaints. Compared with procedural reviews, nonprocedural reviews were less likely to include a clinical complaint (rate ratio, 0.3: P < .001). DISCUSSION: The majority of one-star reviews of ophthalmologists included in this study were nonclinical. Complaints referencing a procedural episode were more likely to include a clinical component in the review. In the era of intense medical consumerism and increased physician and health care institution competition for patient acquisition and retention, the characterization of excessively negative reviews allows identification of potential areas of concern for patients that use online review sites such as Yelp.com.

The Majority of Complaints About Orthopedic Sports Surgeons on Yelp Are Nonclinical.

PURPOSE: To examine and characterize extremely negative Yelp reviews of orthopedic sports surgeons in the United States. METHODS: A search for reviews was performed using the keywords "Orthopedic Sports Medicine" on Yelp.com for 8 major metropolitan areas. Single-star reviews were isolated for analysis, and individual complaints were then categorized as clinical or nonclinical. The reviews were classified as surgical or nonsurgical. RESULTS: A total of 11,033 reviews were surveyed. Of these, 1,045 (9.5%) were identified as 1-star, and 289 were ultimately included in the study. These reviews encompassed 566 total complaints, 133 (23%) of which were clinical, and 433 (77%) of which were nonclinical in nature. The most common clinical complaints concerned complications (32 complaints; 6%), misdiagnosis (29 complaints; 5%), and uncontrolled pain (21 complaints; 4%). The most common nonclinical complaints concerned physicians' bedside manner (120 complaints; 21%), unprofessional staff (98 complaints; 17%), and finances (78 complaints; 14%). Patients who had undergone surgery wrote 47 reviews that resulted in 114 complaints (20.5% of total complaints), whereas nonsurgical patients were responsible for 242 reviews and a total of 452 complaints (81.3% of total complaints). The difference in the number of complaints by patients after surgery and patients without surgery was statistically significant (P < 0.05) for all categories except for uncontrolled pain, delay in care, bedside manner of midlevel staff, and facilities. CONCLUSION: Our study of extremely negative Yelp reviews found that 77% of negative complaints were nonclinical in nature. The most common clinical complaints were complications, misdiagnoses and uncontrolled pain. Only 16% of 1-star reviews were from surgical patients. CLINICAL RELEVANCE: Patients use online review platforms when choosing surgeons. A comprehensive understanding of factors affecting patient satisfaction and dissatisfaction is needed. The results of our study could be used to guide future quality-improvement measures and to assist surgeons in maintaining favorable online reputations.

Content and Functionality of United States Medical School Websites.

Introduction Most medical school applicants use the internet as a source of information when applying for medical school. Previous analyses have evaluated residency and fellowship websites; however, an in-depth analysis of medical school websites is lacking. Methods We evaluated 192 United States (US) medical school websites for presence or absence of 39 items relevant to medical school applicants. Items fell into seven general categories: curriculum, research, demographics of incoming class, admissions information, faculty, financial aid, and social. Results Of the 192 websites evaluated (152 allopathic and 40 osteopathic schools), websites contained a mean of 23 items (59%) with a standard deviation of 4.2 items. Conclusion Our study examining US medical school websites revealed a lack of online information for medical school applicants. As medical school interviews transition to being online during the COVID-19 pandemic, the importance of the medical school website to applicants becomes increasingly crucial. The information contained in our study could be used to improve the functionality and quality of information on medical school websites, which could help both applicants and the medical schools themselves.

Exposure to second-hand cigarette smoke exacerbates the progression of osteoarthritis in a surgical induced murine model.

Osteoarthritis (OA), formerly understood to be a result of passive wear, is now known to be associated with chronic inflammation. Cigarette smoking promotes systemic inflammation and has been implicated in increased joint OA incidence in some studies, though the recent observational data on the association are contradictory. We hypothesize that second-hand smoke (SHS) treatment will increase the incidence of OA in a mouse model that has been subjected to a surgical destabilization of the medial meniscus (DMM). To test this hypothesis, we applied either SHS treatment or room air (RA) to mice for 28 days post-DMM surgery. Histopathology findings indicated that the knees of SHS mice exhibited more severe OA than their control counterparts. Increased expression of matrix metalloprotease-13 (MMP-13), an important extracellular protease known to degrade articular cartilage, and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), an intracellular effector of inflammatory pathways, were observed in the SHS group. These findings provide greater understanding and evidence for a detrimental role of cigarette smoke on OA progression and systemic inflammation.

Topical Application of Wogonin Provides a Novel Treatment of Knee Osteoarthritis.

Osteoarthritis (OA) is a degenerative joint disease characterized by inflammatory degradation of articular cartilage and subchondral bone. Wogonin, a compound extracted from the plant Scutellaria baicalensis (colloquially known as skullcap), has previously been shown to have direct anti-inflammatory and antioxidative properties. We examined the pain-reducing, anti-inflammatory, and chondroprotective effects of wogonin when applied as a topical cream. We validated the efficacy of delivering wogonin transdermally in a cream using pig ear skin in a Franz diffusion system. Using a surgical mouse model, we examined the severity and progression of OA with and without the topical application of wogonin. Using a running wheel to track activity, we found that mice with wogonin treatment were statistically more active than mice receiving vehicle treatment. OA progression was analyzed using modified Mankin and OARSI scoring and direct quantification of cyst-like lesions at the chondro-osseus junction; in each instance we observed a statistically significant attenuation of OA severity among mice treated with wogonin compared to the vehicle treatment. Immunohistochemistry revealed a significant decrease in protein expression of transforming growth factor ß1 (TGF-ß1), high temperature receptor A1 (HTRA1), matrix metalloprotease 13 (MMP-13) and NF-κB in wogonin-treated mice, further bolstering the cartilage morphology assessments in the form of a decrease in inflammatory and OA biomarkers.