The Cost Effectiveness of Implementation of a Postoperative Endocrinopathy Management Protocol after Resection of Pituitary Adenomas.

Purpose After developing a protocol for evaluating, diagnosing, and treating postoperative endocrinopathy both during the hospitalization and during the immediate discharge period following resection of pituitary adenomas, we sought to assess the impact of this protocol on quality outcomes. Methods An IRB-exempt, quality improvement initiated, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective comparison of a pre-and-post-protocol cohort of all patients undergoing endoscopic endonasal resection of pituitary adenomas at NYU Langone Medical Center from January 2013 to December 2018. Demographic characteristics of the patients and their tumors with their postoperative outcomes were recorded. Quality outcomes regarding number of laboratory studies sent, rate of diabetes insipidus, length of stay, and readmission rate were also recorded. Statistical analysis was performed between the pre- and post-protocol groups. Results There was a significant reduction in laboratory studies sent per patient (55.66 vs. 18.82, p <0.001). This corresponded with an overall cost reduction in laboratory studies of $255.95 per patient. There was a decrease in the overall number of patients treated with DDAVP (21.4% in the pre-protocol group vs. 8.9% in the post-protocol group, p = 0.04). All post-protocol patients requiring DDAVP at discharge were identified by 48 hours. There was no significant change in length of stay or need for hydrocortisone supplementation postoperatively between the two groups. Length of stay was driven mostly by need for reoperation during initial hospitalization. There was no significant change in the rate of 30-day readmission. Conclusion Implementation of a postoperative management protocol results in a more efficient diagnosis and management of endocrinopathy after pituitary adenoma surgery which translates to decreased cost.

Rhinology Medicare reimbursements have not been keeping up with inflation.

BACKGROUND: Studies have suggested that physicians are steadily being paid less per Medicare service over time based on inflation-adjusted dollars. The objective of this study was to determine whether this phenomenon was true for rhinologic procedures. METHODS: This study was a retrospective analysis of the 2000-2021 Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule investigating fees for in-office endoscopies (Current Procedural Terminology [CPT] codes 31231-31238), in-office balloon ostial dilation (CPTs 31295-31298), in-facility low-relative value unit (RVU) surgeries (<10 work RVUs [wRVUs]; CPTs 31239-31288 and 61782), and in-facility high-RVU surgeries (>10 wRVUs; CPTs 31290-31294). Total number of and reimbursements for these services was obtained from yearly National Part B Summary Datafiles. RESULTS: Between 2000 and 2021, adjusted reimbursements for low- and high-wRVU rhinologic surgeries decreased by 50.0% and 36.1%, respectively. The average compound annual growth rate (CAGR) decrease was 3.3% and 2.1%, respectively. Excluding a 48.3% unadjusted reimbursement increase between 2000 and 2004, endoscopies saw an adjusted reimbursement decrease of 29.4% from 2004 onward, an average CAGR of -2.1%. From 2011 onward, balloon ostial dilations saw a decrease in adjusted reimbursement of 43.8%, an average CAGR of -6.0%. Nevertheless, after inflation adjustment, National Part B data reveal that Medicare paid more, in total, for these procedures in 2019 than in 2000 due to increasing utilization. CONCLUSION: Medicare reimbursements are complex, adjusted yearly, and undergo constant federal scrutiny due to the increasing costs of health care. These results suggest that, in terms of real dollars, rhinologic procedures have seen a large gradual decrease in Medicare reimbursement, which is important information for policymakers and surgeons alike.

Laryngopharyngeal reflux: Comparing improvements in reflux symptom index with reflux finding score.

PURPOSE: The objective of this study was to determine the correlation of reported symptom improvement in laryngopharyngeal reflux (LPR) with physical findings on laryngoscopic examination following medical therapy. MATERIALS AND METHODS: This IRB-approved, retrospective, single-institution study included all patients who were diagnosed and medically treated for LPR from Jan. 1, 2015-October 21st, 2019. Only patients who received at least six weeks of treatment with a proton pump inhibitor and those with pre- and post-treatment Reflux Symptom Index; RSI (n = 91) and Reflux Finding Score; RFS (n = 33) were included in the study. RESULTS: A total of 91 patients were included in the analysis (61.54% female). There was a 19.99% improvement in total RSI (p = 0.0034) and a 25.20% improvement in total RFS (p = 0.0011) following at least six weeks of treatment (average = 253 ± 213 SD days). RSI symptoms were significantly decreased between pre- and post-treatment for hoarseness (p = 0.0005), clearing of the throat (p = 0.0066), excess throat mucus or postnasal drip (p = 0.0004), troublesome cough (p = 0.0231), and heartburn/chest pain (p = 0.0053). RFS demonstrated a statistically significant decrease in only subglottic edema (p < 0.0001) and ventricular obliteration (p = 0.0295). Pearson's correlation test did not demonstrate a relationship between RSI and RFS in the pre- and post-treatment analyses alone, but did demonstrate a statistically significant relationship when analyzed across all captured pre and post data (r = 0.265, p = 0.006). CONCLUSIONS: RSI and RFS are complimentary to one another when assessing for treatment response, but improvement in RSI does not correlate with that in RFS.

Combined Therapy of Ventricular Assist Device and Membrane Oxygenator for Profound Acute Cardiopulmonary Failure.

Short-term ventricular assist devices (ST-VADs) have been effective in treating the patients with refractory cardiogenic shock. Membrane oxygenators (MOs) can be added to the circuit for concomitant, profound refractory hypoxia. This study reports the outcomes of combined therapy in this portion of patients. This is a retrospective review of 166 patients who received an ST-biventricular assist device (BiVAD) or right ventricular assist device (RVAD) for cardiogenic shock between November 2007 and November 2014. An MO was added to the RVAD for profound hypoxia refractory to maximized ventilation. Patients were divided into two groups: 33 with (MO-VAD [MV]) and 133 without (VAD only [VO]) an MO. Survival to discharge and adverse events were compared between groups. More MV than VO patients were intubated (93.9% vs. 59.4%; p < 0.001) and on veno-arterial extracorporeal membrane oxygenator (VA-ECMO) (72.7% vs. 19.5%; p < 0.001) before implantation. Survival to discharge (51.5% MV vs. 52.6% VO; p = 0.515) and 1 year survival (54.4% MV vs. 48.6% VO; p = 0.955) were not significantly different. MV patients had more prolonged intubation (69.7% vs. 37.6%; p < 0.001), tracheostomies (39.4% vs. 16.5%; p = 0.008), and a higher risk for bleeding (p = 0.037). Patients suffering from cardiogenic shock with refractory hypoxia requiring combined ST-VAD and MO therapy appear to achieve similar mid-term survival despite increased risk for early complications.

Feasibility of smaller arterial cannulas in venoarterial extracorporeal membrane oxygenation.

OBJECTIVES: To facilitate venoarterial extracorporeal membrane oxygenation (ECMO) insertion for cardiogenic shock, we recently adopted a strategy of using a 15F arterial cannula in all patients, rather than 1 designed to maximize flow. We aimed to compare the clinical outcomes of these 2 strategies. METHODS: In this retrospective study, 101 consecutive patients supported with ECMO via femoral cannulation between March 2007 and March 2013 were divided into 2 groups: Group L (17F-24F arterial cannula to accommodate full flow [ie, cardiac index of 2.5 L/m(2)/min]; n = 51) and Group S (15F arterial cannula; n = 50). The primary outcomes of interest were patients' overall status at 24 hours of support and cannulation-related adverse events. RESULTS: There were no significant differences in patient demographics, etiology of cardiogenic shock, or severity of illness before ECMO initiation between the 2 groups. Group L had significantly higher ECMO flow than Group S (flow index at 24 hours: 2.2 ± 0.7 vs 1.7 ± 0.3 L/m(2)/min; P < .001). However, there was no significant difference in use of vasoactive medication/hemodynamic parameters/laboratory parameters. Group L had higher incidence of cannulation-related adverse events (35% vs 22% in Group S [P = .14]), particularly in cannulation site bleeding (28% vs 10% [P = .03]). Thirty-day survival was 55% in Group L versus 52% in Group S (P = .77). Bleeding complication occurred in 53% in Group L versus 32% in Group S (P = .03). CONCLUSIONS: Compared with the use of larger cannulas, ECMO with a 15F arterial cannula appears to provide comparable clinical support with reduced bleeding complications.