Telephonic follow-up after day case pediatric surgery in an upper middle income country: A pilot study.

BACKGROUND: One third of South African children live in households with no employed adult. Telemedicine may save patients and the strained public health sector significant resources. We aimed to determine the safety and benefits of telephonic post-operative follow-up of patients who presented for day case surgery at CHBAH from 1 January-31 March 2023. METHODS: A prospective descriptive study on patients undergoing day case surgery was performed. Healthy patients greater than 6 years old whose caregivers spoke English and had access to a smartphone were included. Data on the total number of telephonic follow-ups, operative complications, need for in person review, satisfaction with telephonic follow-up, and savings in transport costs and time by avoiding in person follow-up were collected. RESULTS: A total of 38 telephonic follow-ups were performed. Six (15.8%) patients presented for in person review due to the detection of major complications (2, 5.3%), minor complications (2, 5.3%), and parental concern (2, 5.3%) during telephonic follow-up. All caregivers reported being satisfied with telephonic follow-up. Total savings in transport costs were R4452 (US $ 248.45). The majority of patients (29, 76.3%) had at least one unemployed parent. Seven caregivers (18.4%) avoided taking paid leave and 2 (5.3%) unpaid leave from work due to follow-up being performed telephonically. CONCLUSIONS: Innovation is necessary in order to expand access to safe, affordable, and timely care. In this selected group, telephonic follow-up was a safe, acceptable, and cost-effective intervention. The expansion of such a program has the potential for significant savings for patients and the healthcare system.

The effect of a bundle intervention for ambulatory otorhinolaryngology procedures on same-day case cancellation rate and associated costs.

Cancellations within 24 h of planned elective surgical procedures reduce operating theatre efficiency, add unnecessary costs and negatively affect patient experience. We implemented a bundle intervention that aimed to reduce same-day case cancellations. This consisted of communication tools to improve patient engagement and new screening instruments (automated estimation of ASA physical status and case cancellation risk score plus four screening questions) to identify patients in advance (ideally before case booking) who needed comprehensive pre-operative risk stratification. We studied patients scheduled for ambulatory surgery with the otorhinolaryngology service at a single centre from April 2021 to December 2022. Multivariable logistic regression and interrupted time-series analyses were used to analyse the effects of this intervention on case cancellations within 24 h and costs. We analysed 1548 consecutive scheduled cases. Cancellation within 24 h occurred in 114 of 929 (12.3%) cases pre-intervention and 52 of 619 (8.4%) cases post-intervention. The cancellation rate decreased by 2.7% (95%CI 1.6-3.7%, p < 0.01) during the first month, followed by a monthly decrease of 0.2% (95%CI 0.1-0.4%, p < 0.01). This resulted in an estimated $150,200 (£118,755; €138,370) or 35.3% cost saving (p < 0.01). Median (IQR [range]) number of days between case scheduling and day of surgery decreased from 34 (21-61 [0-288]) pre-intervention to 31 (20-51 [1-250]) post-intervention (p < 0.01). Patient engagement via the electronic health record patient portal or text messaging increased from 75.9% at baseline to 90.8% (p < 0.01) post-intervention. The primary reason for case cancellation was patients' missed appointment on the day of surgery, which decreased from 7.2% pre-intervention to 4.5% post-intervention (p = 0.03). An anaesthetist-driven, clinical informatics-based bundle intervention decreases same-day case cancellation rate and associated costs in patients scheduled for ambulatory otorhinolaryngology surgery.

Same day discharge colon surgery: is it financially worth it?

AIM: Same day discharge (SDD) for colorectal surgery shows increasing promise in the era of enhanced recovery after surgery protocols and minimally invasive surgery. It has become increasingly relevant due to the constraints posed by the COVID-19 pandemic. The aim of this study was to compare SDD and postoperative day 1 (POD1) discharge to understand the clinical outcomes and financial impact on factors such as cost, charge, revenue, contribution margin and readmission. METHOD: A retrospective review of colectomies was performed at a single institution over a 2-year period (n = 143). Two populations were identified: SDD (n = 51) and POD1 (n = 92). Patients were selected by International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) and Diagnosis Related Grouper (DRG) codes. RESULTS: There was a statistically significant difference favouring SDD in total hospital cost (p < 0.0001), average direct costs (p < 0.0001) and average charges (p < 0.0016). SDD average hospital costs were $8699 (values in USD throughout) compared with $11 652 for POD 1 (p < 0.0001), and average SDD hospital charges were $85 506 compared with $97 008 for POD1 (p < 0.0016). The net revenue for SDD was $22 319 while for POD1 it was $26 173 (p = 0.14). Upon comparison of contribution margins (SDD $13 620 vs. POD1 $14 522), the difference was not statistically significant (p = 0.73). There were no identified statistically significant differences in operating room time, robotic console time, readmission rates or surgical complications. CONCLUSIONS: Amidst the pandemic-related constraints, we found that SDD was associated with lower hospital costs and comparable contribution margins compared with POD1. Additionally, the study was unable to identify any significant difference between operating time, readmissions, and surgical complications when performing SDD.

Safety and Outcome Measures of Ankle Open Reduction and Internal Fixation in an Ambulatory Surgical Center.

The transition of traditionally hospital-based orthopedic procedures to the ambulatory surgery center setting provides many benefits from a patient care and financial perspective. Specifically, closed ankle fractures can potentially be managed at such centers without needing hospitalization. Adding to the paucity of data, this study describes the safety, cost, and outcomes of patients undergoing ankle fracture repair in an ambulatory surgery center. A retrospective chart review of 100 patients who underwent ankle fracture open reduction and internal fixation from a single ambulatory surgery center by 1 surgeon were reviewed. Demographic data, surgical characteristics including operating time and cost were collected. Short- and long-term complications, as well as, reoperation rates were reported and functional outcomes were described. Of the 100 patients, 59% were female and the overall average age was 50 ± 16 years. The average cost per case was $8,709.63 ± 6,360.18. The short-term complication rate was 16%, with surgical site infection reported as the most common complication. No postoperative hospital admissions were reported. Planned and unplanned hardware removal was performed in 7% and 5% of patients, respectively. The delayed union rate was 13%, in which 86% shared a history of smoking. Smoking history was the only statistically significant predictor of prolonged bone healing (p = .002). This investigation demonstrates low complications rates for surgeries performed in a surgery center when compared to historical rates of those procedures performed in the hospital. These results suggest that ambulatory surgery center-based ankle fracture repair does not increase complications while may decrease overall cost when compared to ankle ORIF in a hospital setting.

Major ambulatory surgery among US adults with inflammatory bowel disease, 2017.

BACKGROUND: Patients with inflammatory bowel disease (IBD) have higher health services use than those without IBD. We investigated patient and hospital characteristics of major ambulatory surgery encounters for Crohn's disease (CD) or ulcerative colitis (UC) vs non-IBD patients. METHODS: We conducted a cross-sectional study using 2017 Nationwide Ambulatory Surgery Sample. Major ambulatory surgery encounters among patients aged ≥18 years with CD (n = 20,635) or UC (n = 9,894) were compared to 9.4 million encounters among non-IBD patients. Weighted percentages of patient characteristics (age, sex, median household income, primary payers, patient location, selected comorbidities, discharge destination, type of surgeries) and hospital-related characteristics (hospital size, ownership, location and teaching status, region) were compared by IBD status (CD, UC, and no IBD). Linear regression was used to estimate mean total charges, controlling for these characteristics. RESULTS: Compared with non-IBD patients, IBD patients were more likely to have private insurance, reside in urban areas and higher income zip codes, and undergo surgeries in hospitals that were private not-for-profit, urban teaching, and in the Northeast. Gastrointestinal surgeries were more common among IBD patients. Some comorbidities associated with increased risk of surgical complications were more prevalent among IBD patients. Total charges were 9% lower for CD patients aged <65 years (Median: $16,462 vs $18,106) and 6% higher for UC patients aged ≥65 years (Median: $16,909 vs $15,218) compared to their non-IBD patient counterparts. CONCLUSIONS: Differences in characteristics of major ambulatory surgery encounters by IBD status may identify opportunities for efficient resource allocation and positive surgical outcomes among IBD patients.

Long-run growth of ambulatory surgery centers 1990-2015 and Medicare payment policy.

OBJECTIVE: To examine long-run growth in the ambulatory surgery center (ASC) industry and potential factors influencing its trajectory. DATA SOURCES: National data for all Medicare-certified ASCs (1990-2015) and outpatient discharge records from the state of Florida in 2007. STUDY DESIGN: We documented the number of ASCs in the United States over time and decomposed the trend into underlying ASC market entry and exit behavior. We then examined the plausibility of 2008 Medicare payment reforms to influence the trend changes. DATA EXTRACTION METHODS: Data on ASC openings and closures are obtained from the Centers for Medicare and Medicaid Services Provider of Service files. Secondary data on ASC volume in Florida are obtained from the Florida Agency for Health Care Administration. PRINCIPAL FINDINGS: The number of ASCs in the United States grew 5%-10% annually between 1990 and 2007 but by 1% or less beginning in 2008. This change coincided with substantive reductions in Medicare payments for key ASC services. The annual number of new ASCs was as much as 50% lower following the payment change. CONCLUSIONS: ASCs are an important competitor for outpatient services, but growth has slowed dramatically. Sharp changes in new ASC entry align with less generous Medicare fees.

Safety and Cost-Effectiveness of Outpatient Surgery in Acute Burn Care.

Outpatient burn surgery is increasingly used in acute burn care. Reports of its safety and efficacy are limited. This study aims to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our center's experience. This was a single-center, retrospective cohort study of consecutive patients who underwent outpatient burn surgery requiring split-thickness skin graft or dermal regenerative template from January 2010 to December 2018. Patient demographics, comorbidities, burn etiologies, operative data, and postoperative care were reviewed. The primary outcome is complications involving major graft loss requiring reoperation. One hundred and sixty-five patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. Annual outpatient procedure volume increased 48% from 23 to 34 cases over the 9-year period. The median (interquartile range) grafted percentage total body surface area was 1.0 (1.0)%. Rate of major graft loss requiring reoperation was 5.2% (9/172) and the most common site was the lower extremity (8/9, 88.9%). Age, sex, comorbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rates. The outpatient burn surgery model was estimated to save CA$8170 per patient from inpatient costs. Demonstration of the safety and cost savings associated with outpatient acute burn surgery is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

Outpatient ureteric stent removal following kidney transplantation.

During a kidney transplant, a plastic tube (stent) is placed in the ureter, connecting the new kidney to the bladder, in order to keep the new join open during the initial phase of transplantation. The stent is then removed after a few weeks via a camera procedure (cystoscopy), as it is no longer needed. The present study compared performing this in the operating theatre or in clinic for transplanted patients using a new single-use type of camera with an integrated grasper system. The results have shown that it is safe and cost-effective to do this in clinic, despite patients being susceptible to infection after transplantation.

Treatment Patterns, Outcomes, and Costs Associated With Localized Upper Tract Urothelial Carcinoma.

Background: Upper tract urothelial carcinoma (UTUC) is a heterogeneous disease that presents a clinical management challenge for the urologic surgeon. We assessed treatment patterns, costs, and survival outcomes among patients with nonmetastatic UTUC. Methods: We identified 4114 patients diagnosed with nonmetastatic UTUC from 2004 to 2013 in the Survival Epidemiology, and End Results-Medicare population-based database. Patients were stratified into low- or high-risk disease groups. Median total costs from 30 days prior to diagnosis through 365 days after diagnosis were compared between groups. Overall and cancer-specific survival were evaluated using Cox proportional hazards regression. All statistical tests were 2-sided. Results: After risk stratification, 1027 (24.9%) and 3087 (75.0%) patients were classified into low- vs high-risk UTUC groups. Most patients underwent at least 1 surgical intervention (95.1%); 68.4% underwent at least 1 endoscopic intervention. Patients diagnosed with high- vs low-risk UTUC were more likely to undergo nephroureterectomy (83.6% vs 72.0%; P < .001); few patients with low-risk disease were exclusively managed endoscopically (16.9%). At 365 days after diagnosis, costs of care for high- vs low-risk UTUC were statistically significantly higher ($108 520 vs $91 233; median difference $16 704, 95% confidence interval [CI] = $11 619 to $21 778; P < .001). Those with high-risk UTUC had worse cancer-specific and overall survival compared with patients with low-risk UTUC (cancer-specific survival hazard ratio [HR] = 4.14, 95% CI = 3.19 to 5.37; overall survival HR = 1.78, 95% CI = 1.62 to 1.96). Conclusions: UTUC continues to be managed primarily with nephroureterectomy, regardless of risk stratification, and patients with high-risk UTUC have worse overall and cancer-specific survival. Substantial costs are associated with management of low- and high-risk UTUC, with the latter being more costly up to 1 year from diagnosis.

Mobile Hysteroscopy With the Use of a Smartphone as a Cost-Effective, Diagnostic Technique.

BACKGROUND: Smartphone technology can be adapted to promote cable-free, wireless, and cost-effective diagnostic mobile office hysteroscopy. INSTRUMENT: We developed a new cable-free setup by coupling a rigid 30°, 2-mm-diameter hysteroscope to a smartphone using a commercially available adapter and using a portable and rechargeable light-emitting diode cold light source. The new setup cost is considerably lower compared with that of a typical endoscopic tower. EXPERIENCE: We performed both standard hysteroscopy and hysteroscopy using the new portable setup in 40 patients for a variety of benign gynecologic indications. The operating time was compared between the two methods, as was the pain perceived by the patients. Videos from the two setups were blindly reviewed and scored by experts regarding image resolution, brightness, color, and overall image quality. The new technique was acceptable for diagnosis in 97.5% of the videos. CONCLUSION: We report a promising initial experience using a smartphone to provide a convenient, cable-free, low-cost, office hysteroscopy system.

Joint-Venture Ambulatory Surgery Centers: The Perfect Partnership.

BACKGROUND: Ambulatory surgery growth has increased in the last few decades as ambulatory surgery centers have been shown to succeed in cost efficiencies through their smaller size and breadth, specialization of care, and ability to quickly participate in perioperative process improvement and education. METHODS: A 5-year retrospective fiscal review was performed for all Northwell Health-physician ambulatory surgery center joint ventures. The outcome measures studied included model of ownership, specialty types, and gross revenue. Additional facility characteristics were studied, including growth trajectory, facility size, and cost to build a de novo facility. RESULTS: Eleven free-standing ambulatory surgery centers were identified at Northwell Health during the 5-year study period. The total gross revenue for all Northwell clinical joint ventures for 2019 alone was $102,854,000. Northwell Health is a majority stakeholder in eight of their joint venture ambulatory surgery centers, with an average Northwell ownership of 53 percent and an average number of physician owners per facility of 11. The number of hospital-physician joint-venture ambulatory surgery centers grew from two to 11 facilities during the study period (450 percent). Surgical volume followed a similar trajectory, increasing 295 percent over the same time period. CONCLUSIONS: The ambulatory surgery center setting provides a vast number of possibilities for key stakeholders, including patients themselves, to benefit from financial and clinical efficiencies. Ambulatory surgery centers have been popular, as they meet patient expectations for convenience of elective surgery, reduce payer and clinical pressures to minimize length of stay in hospitals, and achieve similar or higher quality care with less intense resources.

Endoscopic Third Ventriculostomy and Endoscopic Intracranial Cyst Fenestration in an Outpatient Ambulatory Surgery Center Yields Reduced Cost But Equal Efficacy and Safety Compared with Surgery in the Hospital.

BACKGROUND: A transition is underway in neurosurgery to perform relatively safe surgeries outpatient, often at ambulatory surgery centers (ASC). We sought to evaluate whether simple intracranial endoscopic procedures such as third ventriculostomy and cyst fenestration can be safely and effectively performed at an ASC, while comparing costs with the hospital. METHODS: A retrospective chart review was performed for patients who underwent elective intracranial neuroendoscopic (NE) intervention at either a quaternary hospital or an affiliated ASC between August 2014 and September 2017. Groups were compared on length of stay, perioperative and 30-day morbidity, as well as clinical outcome at last follow-up. The total cost for these procedures were compared in relative units between all ASC cases and a small subset of hospital cases. RESULTS: In total, 16 NE operations performed at the ASC (mean patient age 29.8 years) and 37 at the hospital (mean age 15.4 years) with average length of stay of 3.5 hours and 23.1 hours respectively (P < 0.05). There were no acute complications in either cohort or morbid events requiring hospitalization within 30 days. Surgical success was noted for 75% of the ASC patients and 73% of the hospital cohort. The mean cost of 5 randomly selected hospital operations with same-day discharge and 5 with overnight stay was 3.4 and 4.1 times that of the ASC cohort, respectively (P < 0.05). CONCLUSIONS: Elective endoscopic third ventriculostomy and other simple NE procedures can be safely and effectively performed at an ASC for appropriate patients with significantly reduced cost compared with the hospital.

Unplanned hospital visits after ambulatory surgical care.

OBJECTIVES: We sought to assess the rate of unplanned hospital visits among patients undergoing ambulatory surgery. SUMMARY BACKGROUND DATA: The majority of surgeries performed in the United States now take place in outpatient settings. Post-discharge hospital visit rates have been shown to vary widely, suggesting variation in surgical or discharge care quality. Complicating efforts to address quality, most facilities and surgeons are unaware of their patients' hospital visits after surgery since patients may present to a different hospital. METHODS: We used state-level, administrative data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project from California to assess unplanned hospital visits after ambulatory surgery. To compare rates across centers, we determined the age, sex, and procedure-adjusted rates of hospital visits for each facility using 2-level, hierarchical, generalized linear models using methods similar to existing Centers for Medicare and Medicaid Services measures. RESULTS: Among a total of 1,260,619 ambulatory same-day surgeries from 440 surgical facilities, the risk adjusted 30-day rate of unplanned hospital visits was 4.8%, with emergency department visits of 3.1% and hospital admissions of 1.7%. Several patient characteristics were associated with increased risk of unplanned hospitals visits, including increased age, increased number of comorbidities (using the Elixhauser score), and type of procedure (p<0.001). CONCLUSIONS: The overall rate unplanned hospital visits within 30 days after same-day surgery is low but variable, suggesting a difference in the quality of care provided. Further, these rates are higher among specific patient populations and procedure types, suggesting areas for targeted improvement.

Anterior Supine Intermuscular Total Hip Arthroplasty at an Ambulatory Surgery Center Versus Hospitalization: Cost and Adverse Events.

This study compares anterior supine intermuscular total hip arthroplasty performed at an ambulatory surgery center with the same procedure performed in a hospital setting in regard to complications and costs. The ambulatory surgery center had significantly shorter postoperative stays and superior visual analog pain scores at 3 months. No differences were noted in operative time, blood loss, or complications. Costs were significantly different between groups, with significant cost savings noted in the ambulatory surgery center group.

Does perioperative respiratory event increase length of hospital stay and hospital cost in pediatric ambulatory surgery?

OBJECTIVE: We examined the consequences of perioperative respiratory event (PRE) in terms of hospitalization and hospital cost in children who underwent ambulatory surgery. METHODS: This subgroup analysis of a prospective cohort study (ClinicalTrials.gov: NCT02036021) was conducted in children aged between 1 month and 14 years who underwent ambulatory surgery between November 2012 and December 2013. Exposure was the presence of PRE either intraoperatively or in the postanesthetic care unit or both. The primary outcome was length of stay after surgery. The secondary outcome was excess hospital cost excluding surgical cost. Financial information was also compared between PRE and non-PRE. Directed acyclic graphs were used to select the covariates to be included in the multivariate regression models. The predictors of length of stay and excess hospital cost between PRE and non-PRE children are presented as adjusted odds ratio (OR) and cost ratio (CR), respectively with 95% confidence interval (CI). RESULTS: Sixty-three PRE and 249 non-PRE patients were recruited. In the univariate analysis, PRE was associated with length of stay (p = 0.004), postoperative oxygen requirement (p <0.001), and increased hospital charge (p = 0.006). After adjustments for age, history of snoring, American Society of Anesthesiologists physical status, type of surgery and type of payment, preoperative planned admission had an effect modification with PRE (p <0.001). The occurrence of PRE in the preoperative unplanned admission was associated with 24-fold increased odds of prolonged hospital stay (p <0.001). PRE was associated with higher excess hospital cost (CR = 1.35, p = 0.001). The mean differences in contribution margin for total procedure (per patient) (PRE vs non-PRE) differed significantly (mean = 1,523; 95% CI: 387, 2,658 baht). CONCLUSION: PRE with unplanned admission was significantly associated with prolonged length of stay whereas PRE regardless of unplanned admission increased hospital cost by 35% in pediatric ambulatory surgery. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT02036021.

A policy of day-case sinonasal surgery is safe, well tolerated and cost-effective.

OBJECTIVE: Practices vary regarding the timing of discharge after sinonasal surgery. This study aimed to examine the cost-effectiveness of same-day discharge compared to next-day discharge after sinonasal surgery. METHODS: A retrospective single-surgeon audit of sinonasal surgery over a 12-month period was performed. Demographic and clinical details, including distance travelled home, timing of discharge, hospital re-presentation, and complications, were collected and compared between the same-day discharge and next-day discharge groups. A cost-effectiveness analysis was performed. RESULTS: A total of 181 patients were identified; 117 underwent day-case surgery, of which 6 re-presented to the emergency department. Sixty-four patients stayed overnight after surgery, and six of those patients re-presented to the emergency department. The per patient cost was $3262 for day-case sinonasal surgery and $5050 for those admitted overnight after surgery (p < 0.001). CONCLUSION: Routine same-day discharge after sinonasal surgery is achievable, safe and cost-effective.

Recent Trends in Medicare Utilization and Reimbursement for Orthopaedic Procedures Performed at Ambulatory Surgery Centers.

BACKGROUND: As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017. METHODS: This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization. RESULTS: A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South. CONCLUSIONS: This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.

Exploring the rapid expansion of office-based laboratories and peripheral vascular interventions across the United States.

OBJECTIVE: To characterize the relationship between office-based laboratory (OBL) use and Medicare payments for peripheral vascular interventions (PVI). METHODS: Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty, stent placement, and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level. RESULTS: Between 2014 and 2017, 2641 providers performed 308,247 procedures. The mean payment for OBL stent placement in 2017 was $4383.39, and mean payment for OBL atherectomy was $13,079.63. The change in the mean payment amount varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. The change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R2 = 0.40; P < .001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R2 = 0.85; P < .001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (P < .001). CONCLUSIONS: A rapid shift into the office setting for PVIs occurred within some HRRs, which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL use and, in particular atherectomy, to better align the policy with its intended goals.

Analysis of patient characteristics, health care costs by surgical venue, and opioid utilization for common orthopedic procedures in the United States.

BACKGROUND: Orthopedic surgery can be performed in hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs), as well as in traditional inpatient venues. Patients who undergo orthopedic surgery may be prescribed opioids for the management of postsurgical pain. However, the association between surgery venue, postsurgical opioid use, and health care costs remains unclear. OBJECTIVE: To compare postsurgical opioid use and health care costs associated with 6 different orthopedic surgical procedures performed at inpatient, ASC, and HOPD venues. METHODS: Using the Optum Research Database, this retrospective study analyzed commercial health care claims from adult patients in the United States undergoing specific orthopedic procedures (total knee arthroplasty, partial knee arthroplasty, total hip arthroplasty, total shoulder arthroplasty, rotator cuff repair, and lumbar spinal fusion) between April 1, 2012, and December 31, 2017. The date of the first procedure in that period was the index date; continuous insurance coverage for 12 months before the index date (baseline period) to 6 months following the index date (postsurgical period, which includes the index date) was required. Opioid use and all-cause costs were measured in the postsurgical period. Baseline patient characteristics included demographics, Quan-Charlson Comorbidity Index, and opioid use. Multivariable analysis identified factors influencing postsurgical costs and persistent opioid use (defined as ≥ 1 opioid fill within 3 days after surgery [or discharge for inpatient stay] and ≥1 additional opioid fill during the postsurgical period at least 90 days after the index date). RESULTS: The sample included 126,172 patients (mean age, 58 years; 49% female). Overall, most procedures were performed at inpatient venues (68%), followed by HOPDs (18%) and ASCs (14%); the percentage of procedures performed at ASCs increased from 12% to 17% from 2012 to 2017. Patients whose procedures were performed at ASCs reported the lowest adjusted percentage of persistent opioid use following the procedure (18%) compared with those with procedures performed at HOPDs (24%) or inpatient venues (26%). Adjusted 30-day costs were 14% and 27% lower for patients with procedures in HOPDs and ASCs, respectively, compared with inpatient venues (P < 0.001 for both), and adjusted costs over the first 90 days were similar. CONCLUSIONS: All-cause costs on the day of surgery through 30 days after surgery for these 6 orthopedic procedures were significantly lower in HOPDs and ASCs compared with inpatient venues, even after adjustment for cohort, surgery year, demographic characteristics, baseline Quan-Charlson Comorbidity Index, and any opioid use within 90 days before the procedure. Additionally, patients undergoing orthopedic surgery at ASCs had the lowest adjusted percentage of persistent opioid use compared with those undergoing surgery at HOPDs or inpatient venues. Migration of certain orthopedic procedures from inpatient venues to HOPDs or ASCs may reduce health care costs and decrease the potential for persistent opioid use. DISCLOSURES: This study and editorial support for the preparation of this manuscript was funded by Pacira BioSciences, which contracted with Optum to conduct the study. Cisternas, Korrer, and Wilson are employees of Optum. Waterman was employed with Pacira BioSciences at the time of the study. Portions of this work were presented at AMCP Nexus 2019; October 29-November 1, 2019; National Harbor, MD.