Contemporary procedure characteristics and outcomes of accessory atrioventricular pathway ablations in an integrated community-based health care system using a tiered approach.

BACKGROUND: Since the early descriptions of large series of accessory atrioventricular pathway ablations in adults and adolescents over 20 years ago, there have been limited published reports based on more recent experiences of large referral centers. We aimed to characterize accessory pathway distribution and features in a large community-based population that influence ablation outcomes using a tiered approach to ablation. METHODS: Retrospective analysis of 289 patients (age 14-81) who underwent accessory ablation from 2015-2019 was performed. Pathways were categorized into anteroseptal, left freewall, posteroseptal, and right freewall locations. We analyzed patient and pathway features to identify factors associated with prolonged procedure time parameters. RESULTS: Initial ablation success rate was 94.7% with long-term success rate of 93.4% and median follow-up of 931 days. Accessory pathways were in left freewall (61.6%), posteroseptal (24.6%), right freewall (9.6%), and anteroseptal (4.3%) locations. Procedure outcome was dependent on pathway location. Acute success was highest for left freewall pathways (97.1%) with lowest case times (144 ± 68 min) and fluoroscopy times (15 ± 19 min). Longest procedure time parameters were seen with anteroseptal, left anterolateral, epicardial-coronary sinus, and right anterolateral pathway ablations. CONCLUSIONS: In this community-based adult and adolescent population, majority of the accessory pathways are in the left freewall and posteroseptal region and tend to be more easily ablated. A tiered approach with initial use of standard ablation equipment before the deployment of more advance tools, such as irrigated tips and 3D mapping, is cost effective without sacrificing overall efficacy.

Patient-reported outcome and cost implication of acute salvage of infected implant-based breast reconstruction with negative pressure wound therapy with Instillation (NPWTi) compared to standard care.

INTRODUCTION: Implant loss due to infection is the most devastating complication of implant-based breast reconstruction. The use of negative pressure wound therapy with instillation(NPWTi) for salvage of infected implant-based breast reconstructions has shown promising results allowing early reinsertion of a new implant as an alternative to the current management with delayed reinsertion. This study compares the patient-reported outcome and cost implication of NPWTi to the current management. METHODS: Twenty cases of infected breast implants treated with NPWTi(V.A.C. VERAFLO™ Therapy), followed by early reinsertion of new implants were compared to 20 cases that had delayed reinsertion(non-NPWTi). Patient satisfaction was evaluated using the BREAST-Q questionnaire. The average cost per patient was calculated using total operative expense, cost of inpatient stay, investigations, antibiotics, and outpatient visits. RESULTS: Treatment with NPWTi allowed earlier reinsertion of a new implant (NPWTi: 10.3 ± 2.77days vs. non-NPWTi: 247.45±111.28days, p<0.001). Patients in the NPWTi group reported higher satisfaction. The average cost per patient for NPWTi and non-NPWTi was £14,343.13±£2,786.70 and £8,920.31±£3,005.73, respectively(p<0.001). All patients treated with NPWTi had one admission and spent 11.9 ± 4.1days as inpatients, while non-NPWTi patients had 2.1 ± 0.3 admissions(p<0.001) and spent 7.1 ± 5.8days(p<0.004) as inpatients. Patients treated with NPWTi had more procedures (NPWTi:3.35±0.81 Vs. non-NPWTi:2.2 ± 0.41, p = 0.006); however, three non-NPWTi cases required flap reconstruction. CONCLUSION: Patients treated with NPWTi reported higher satisfaction, received a new and earlier implant, and had fewer admissions and outpatient visits; however, they incurred higher average costs, longer inpatient stays, and underwent more procedures. Early implant reinsertion preserves skin envelope; hence avoiding additional cost and stress related to further major autologous reconstruction.

Direct Inpatient Medical Costs of Operative Treatment of Periprosthetic Hip and Knee Infections Are Twofold Higher Than Those of Aseptic Revisions.

BACKGROUND: Periprosthetic joint infections (PJIs) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are associated with substantial morbidity. A better understanding of the costs of PJI treatment can inform prevention, treatment, and reimbursement strategies. The purpose of the present study was to describe direct inpatient medical costs associated with the treatment of hip and knee PJI. METHODS: At a single tertiary care institution, 176 hips and 266 knees that underwent 2-stage revisions for the treatment of PJI from 2009 to 2015 were compared with 1,611 hips and 1,276 knees that underwent revisions for aseptic indications. In addition, 84 hips and 137 knees that underwent irrigation and debridement (I&D) with partial component exchange were compared with 39 hips and 138 knees that underwent partial component exchange for aseptic indications. Line-item details of services billed during hospitalization were retrieved, and standardized direct medical costs were calculated in 2018 inflation-adjusted dollars. RESULTS: The mean direct medical cost of 2-stage revision THA performed for the treatment of PJI was significantly higher than that of aseptic revision THA ($58,369 compared with $22,846, p < 0.001). Similarly, the cost of 2-stage revision TKA performed for the treatment of PJI was significantly higher than that of aseptic revision TKA ($56,900 compared with $24,630, p < 0.001). Even when the total costs of aseptic revisions were doubled for a representative comparison with 2-stage procedures, the costs of PJI procedures were 15% to 28% higher than those of the doubled costs of aseptic revisions (p < 0.001). The mean direct medical cost of I&D procedures for PJI was about twofold higher than of partial component exchange for aseptic indications. CONCLUSIONS: The direct medical costs of operative treatment of PJI following THA and TKA are twofold higher than the costs of similar aseptic revisions. The high economic burden of PJI warrants efforts to reduce the incidence of PJI. Reimbursement schemes should account for the high costs of treating PJI in order to ensure sustainable patient care. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Cost Effectiveness of Dilute Betadine Lavage for Infection Prophylaxis in Total Joint Arthroplasty.

BACKGROUND: This article presents a break-even analysis for intraoperative Betadine lavage for the prevention of infection in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Protocol costs, baseline infection rates after arthroplasty, and average revision costs were obtained from institutional records and the literature. The break-even analysis determined the absolute risk reduction (ARR) in infection rate required for cost effectiveness. RESULTS: At our institutional price of $2.54, dilute (0.35%) Betadine lavage would be cost effective if initial infection rates of both TKA (1.10%) and THA (1.63%) have an ARR of 0.01%. At a hypothetical lowest cost of $0.50, the ARR is so low as to be immediately cost effective. At a hypothetical high price of $40.00, Betadine is cost effective with ARRs of 0.16% (TKA) and 0.13% (THA). CONCLUSION: Intraoperative Betadine lavage, at typical institutional prices, can be highly cost effective in reducing infection after joint arthroplasty.

A nationwide analysis of failed irrigation and debridement for pediatric septic arthritis of the hip.

Irrigation and debridement (I&D) is the gold standard for treatment of pediatric septic arthritis of the hip. If the index surgery fails, subsequent surgery may be required to eradicate the infection, resulting in substantial increases in morbidity, healthcare costs, and psychosocial burden. The purpose of this study was to identify the incidence of failed I&D for pediatric septic arthritis of the hip, defined by the need for at least one subsequent surgical intervention, and potential risk factors for failed initial I&D. The Kids' Inpatient Database was used to extract data for pediatric patients diagnosed with septic arthritis of the hip from 1997 to 2012. Factors such as patient demographics, preoperative comorbidities, inpatient variables, and hospitals variables were assessed for associations with successful versus failed I&Ds. During the period examined, 3341 (94.3%) children were successfully treated with a single I&D, whereas 203 (5.7%) children required at least one additional surgery during the same hospitalization. Univariate analysis found anemia, coagulopathy, and electrolyte disorders to be associated with repeat surgery. Patients who required multiple surgeries had significantly longer lengths of stay (11.3 vs. 6.9 days), higher likelihood of being discharged with home health (39 vs. 25%), and higher total overall inpatient costs ($58 400 vs. $31 900). On the basis of the results of this study, the nationwide incidence of patients requiring multiple I&Ds was 5.7%. Patient preoperative comorbidities such as coagulopathy, and hospital characteristics such as government ownership and teaching status were significantly associated with failed initial I&D for septic arthritis of the hip. We believe this data can be useful in guiding future research efforts and providing clearer anticipatory guidance to patients and guardians. Level of evidence: Level III: Retrospective comparative study.

Ileostomy versus fecal diversion device to protect anastomosis after rectal surgery: a randomized clinical trial.

PURPOSE: Patients with rectal anastomosis commonly experience various ileostomy-related complications. This study aimed to elucidate the usefulness of a fecal diversion device (FDD) as an alternative to ileostomy for protecting rectal anastomosis. METHODS: Patients with rectal anastomosis were randomly assigned to the ileostomy and FDD groups except in cases of emergency surgery. The primary endpoint was the clinical safety and effectiveness of FDD. The mean operation time, delay of diet advancement, length of hospital stay, FDD and stoma durations, and anastomotic leakage (AL) management methods were compared. RESULTS: A total of 54 patients were enrolled in this study. No cases of mortality occurred. Overall morbidity was similar between groups (P = 0.551). Six patients (22.2%) in the FDD group and nine (29.0%) in the stoma group (P = 0.555) had AL. The mean total hospital stay was 16.4 ± 6.7 and 23.4 ± 8.7 days in the FDD and stoma groups, respectively (P = 0.002). The mean total hospital cost was 12,726.8 ± 3422.8 USD and 17,954.9 ± 9040.3 USD in the FDD and stoma groups, respectively (P = 0.008). The mean FDD and stoma durations were 21.6 ± 6.1 days and 114.9 ± 41.3 days, respectively (P < 0.0001). CONCLUSIONS: This study demonstrated FDD safety and effectiveness. We identified the possibility of FDD as an alternative technique to conventional stoma procedures.

An empiric analysis of 5 counter measures against surgical site infections following spine surgery-a pragmatic approach and review of the literature.

BACKGROUND CONTEXT: Surgical site infections (SSI) following spine surgery are debilitating complications to patients and costly to the healthcare system. PURPOSE: Review the impact and cost effectiveness of 5 SSI prevention interventions on SSI rates in an orthopedic spine surgery practice at a major quaternary healthcare system over a 10-year period. STUDY DESIGN: Retrospective observational study. PATIENT SAMPLE: All of the surgical patients of the 5 spine surgeons in our department over a 10-year period were included in this study. OUTCOME MEASURES: SSI rates per year, standardized infection ratios (SIR) for laminectomies and fusions during the most recent 3-year period, year of implementation, and frequency of use of the different interventions, cost of the techniques. METHODS: The SSI prevention techniques described in this paper include application of intrawound vancomycin powder, wound irrigation with dilute betadine solution, preoperative chlorhexidine gluconate scrubs, preoperative screening with nasal swabbing, and decolonization of S. aureus, and perioperative antibiotic administration. Our institution's infection prevention and control data were analyzed for the yearly SSI rates for the orthopedic spine surgery department from 2006 to 2016. In addition, our orthopedic spine surgeons were polled to determine with what frequency and duration they have been using the different SSI prevention interventions. RESULTS: SSI rates decreased from almost 6% per year the first year of observation to less than 2% per year in the final 6 years of this study. A SIR of less than 1.0 for each year was observed for laminectomies and fusions for the period from 2013 to 2016. All surgeons polled at our institution uniformly used perioperative antibiotics, Hibiclens scrub, and the nasal swab protocol since the implementation of these techniques. Some variability existed in the frequency and duration of betadine irrigation and application of vancomycin powder. A cost analysis demonstrated these methods to be nominal compared with the cost of treating a single SSI. CONCLUSIONS: It is possible to reduce SSI rates in spine surgery with easy, safe, and cost-effective protocols, when implemented in a standardized manner.

Which way is best for stone fragments and dust extraction during percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) is a commonly used type of minimally invasive treatment in kidney stone surgeries. Surgical success is assessed according to residual stone amount after surgery. The purpose of this study is to compare the two methods' success and practicality that are applied after the fracture of the stone in the patients who applied PCNL and which enable the removal of the residual stones. Among 102 patients who underwent a single-session of PCNL at our department between June 2015 and November 2016 were evaluated. Previously identified irrigation method and our aspiration method which described used in post-operative patients divided into two groups of residual fragments was assessed by computed tomography. The results were evaluated in statistical analyses. Significant p was accepted as p < 0.05. The age and gender distribution of patients in the irrigation and aspiration groups did not differ significantly (p > 0.05). In irrigation and aspiration groups, stone size did not differ significantly (p > 0.05). The amount of residue stones and dust remaining in the irrigation group was significantly higher (p < 0.05) than the aspiration group. Although many methods have been tried before, we think that the aspiration method we have described is a cheaper, more effective and feasible option.

Repositioning of central venous access devices using a high-flow flush technique - a clinical practice and cost review.

BACKGROUND: Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions.The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning. METHODS: This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia.7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions. RESULTS: There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition. CONCLUSIONS: Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.

Comparison of costs associated with substituting culture medium with saline solution for follicular flushing during oocyte retrieval.

OBJECTIVES: To compare culture medium and saline solution for follicular flushing during oocyte retrieval with assisted reproductive technologies. METHODS: The present retrospective study analyzed data collected at Galway Fertility Clinic, Galway, Ireland, between January 1, 2015 and August 31, 2016; all patients attending the clinic for in vitro fertilization/intracytoplasmic sperm injection during this period were included. Data were stratified by whether follicular flushing was performed with culture medium or saline, and the oocyte yield rate, fertilization rate, embryo utilization rate, and biochemical and clinical pregnancy rates were compared between the groups. RESULTS: In total, 422 oocyte retrieval procedures with culture medium and 277 with normal saline were analyzed. The fertilization (P=0.676) and clinical pregnancy rates (P=0.593) did not differ between the groups. Using normal saline resulted in an approximately 41-fold per-patient cost saving compared with culture medium. CONCLUSION: Switching from culture medium to normal saline for follicular flushing significantly reduced oocyte-retrieval costs without adversely affecting reproductive outcomes.

Extended applications of the reamer-irrigator-aspirator (RIA) system.

While the RIA system was initially designed for reaming and clearing the femoral canal contents in preparation for femoral nailing, it has since been used in various other applications in the field of orthopaedic surgery. The RIA is an ideal device for accessing large quantities of autogenous bone graft, to be used in the treatment of nonunions, segmental bone loss, or arthrodesis. The RIA has also been used for treatment of intramedullary infections and osteomyelitis, as well as intramedullary nailing of long bones with metastatic lesions, as it allows for clearing the canal of infectious/tumour burden, and lowers the risk of dissemination into the soft tissues and systemic circulation. There is also some limited evidence that the RIA may be used for clearing the femoral/tibial canal of cement debris. Despite multiple applications, the use of RIA has a risk of eccentric reaming and iatrogenic fractures. RIA is also a costly procedure, and its routine use may not be advantageous in the setting of limited health care resources.

Controlled Suction with Venous Catheter Irrigation in Neurosurgery: A Cost Effective Technique.

BACKGROUND: Keeping the operating field clean and visible is an important technique in neurosurgery. Continuous irrigation-suction (IS) of the surgical field is currently often done using devices available that are expensive and demand technical proficiency. We report a simple method of continuous IS using a widely available central venous catheter and a controlled suction cannula. METHODS: We used a controlled suction cannula attached to a central suction system. A single lumen central venous catheter is passed through the keyhole of a controlled suction cannula, which is connected to a continuous irrigation system. RESULTS: The operative field was clean throughout the procedure, obviating the need for an assisting surgeon to irrigate into the deep operating field and, hence, reducing the duration of surgery. CONCLUSIONS: The proposed IS system could be surgeon friendly, easily manageable, yet cost-effective and efficient.

Long-Term Cost-Effectiveness of Transanal Irrigation in Patients with Neurogenic Bowel Dysfunction.

BACKGROUND: People suffering from neurogenic bowel dysfunction (NBD) and an ineffective bowel regimen often suffer from fecal incontinence (FI) and related symptoms, which have a huge impact on their quality of life. In these situations, transanal irrigation (TAI) has been shown to reduce these symptoms and improve quality of life. AIM: To investigate the long-term cost-effectiveness of initiating TAI in patients with NBD who have failed standard bowel care (SBC). METHODS: A deterministic Markov decision model was developed to project the lifetime health economic outcomes, including quality-adjusted life years (QALYs), episodes of FI, urinary tract infections (UTIs), and stoma surgery when initiating TAI relative to continuing SBC. A data set consisting of 227 patients with NBD due to spinal cord injury (SCI), multiple sclerosis, spina bifida and cauda equina syndrome was used in the analysis. In the model a 30-year old individual with SCI was used as a base-case. A probabilistic sensitivity analysis was applied to evaluate the robustness of the model. RESULTS: The model predicts that a 30-year old SCI patient with a life expectancy of 37 years initiating TAI will experience a 36% reduction in FI episodes, a 29% reduction in UTIs, a 35% reduction in likelihood of stoma surgery and a 0.4 improvement in QALYs, compared with patients continuing SBC. A lifetime cost-saving of £21,768 per patient was estimated for TAI versus continuing SBC alone. CONCLUSION: TAI is a cost-saving treatment strategy reducing risk of stoma surgery, UTIs, episodes of FI and improving QALYs for NBD patients who have failed SBC.

Health economic analysis of laparoscopic lavage versus Hartmann's procedure for diverticulitis in the randomized DILALA trial.

BACKGROUND: Open surgery with resection and colostomy (Hartmann's procedure) has been the standard treatment for perforated diverticulitis with purulent peritonitis. In recent years laparoscopic lavage has emerged as an alternative, with potential benefits for patients with purulent peritonitis, Hinchey grade III. The aim of this study was to compare laparoscopic lavage and Hartmann's procedure with health economic evaluation within the framework of the DILALA (DIverticulitis - LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) trial. METHODS: Clinical effectiveness and resource use were derived from the DILALA trial and unit costs from Swedish sources. Costs were analysed from the perspective of the healthcare sector. The study period was divided into short-term analysis (base-case A), within 12 months, and long-term analysis (base-case B), from inclusion in the trial throughout the patient's expected life. RESULTS: The study included 43 patients who underwent laparoscopic lavage and 40 who had Hartmann's procedure in Denmark and Sweden during 2010-2014. In base-case A, the difference in mean cost per patient between laparoscopic lavage and Hartmann's procedure was €-8983 (95 per cent c.i. -16 232 to -1735). The mean(s.d.) costs per patient in base-case B were €25 703(27 544) and €45 498(38 928) for laparoscopic lavage and Hartmann's procedure respectively, resulting in a difference of €-19 794 (95 per cent c.i. -34 657 to -4931). The results were robust as demonstrated in sensitivity analyses. CONCLUSION: The significant cost reduction in this study, together with results of safety and efficacy from RCTs, support the routine use of laparoscopic lavage as treatment for complicated diverticulitis with purulent peritonitis.

Irrigation with Liquid Sevoflurane and Healing of a Postoperative, Recurrent Epidural Infection: A Potential Cost-Saving Alternative.

BACKGROUND: The general inhalation anesthetic sevoflurane can be used for the topical treatment of complicated wounds. It is applied in liquid form and may be used to irrigate the inside of cavities. Sevoflurane also exhibits in vitro antimicrobial activity. Therefore, sevoflurane may be used as an alternative to typical antibiotic or surgical treatment of complicated, localized infections. CASE DESCRIPTION: The case of a 61-year-old male patient who suffered a cranioencephalic trauma 18 years previously is presented. The patient underwent surgeries related to the trauma on numerous occasions. To date, he has suffered various recurrent epidural abscesses, which have been treated with surgical cleaning and antibiotic treatment. In the most recent episode, he presented a frontal epidural abscess 25 mm in diameter with fistulization of the skin. The patient gave written informed consent to be treated with sevoflurane irrigation, and the Pharmacy Service authorized the off-label use. Sevoflurane was applied via a catheter placed inside the cavity during weekly outpatient procedures. The procedures began 8 weeks after the clinically and radiologically verified recovery of the abscess. By avoiding surgery and the associated hospital admission, this novel alternative may prevent patient morbidity and, furthermore, may produce important economic savings. CONCLUSIONS: The treatment of complicated wounds with liquid sevoflurane may be an effective and economically efficient clinical alternative for some patients.

Negative short-term impact of intraoperative biliary lavage in patients with hepatolithiasis.

AIM: To evaluate short-term outcomes following intraoperative biliary lavage for hepatolithiasis. METHODS: A total of 932 patients who were admitted to the West China Medical Center of Sichuan University between January 2010 and January 2014 and underwent bile duct exploration and lithotomy were retrospectively included in our study. The patients were divided into the lavage group and the control group. Related pre-, intra-, and postoperative factors were recorded, analyzed, and compared between the two groups in order to verify the effects of biliary lavage on the short-term outcome of patients with hepatolithiasis. RESULTS: Amongst the patients who were included, 678 patients with hepatolithiasis were included in the lavage group, and the other 254 patients were enrolled in the control group. Data analyses revealed that preoperative baseline and related intraoperative variables were not significantly different. However, patients who underwent intraoperative biliary lavage had prolonged postoperative hospital stays (6.67 d vs 7.82 d, P = 0.024), higher hospitalization fees (RMB 28437.1 vs RMB 32264.2, P = 0.043), higher positive rates of bacterial cultures from blood (13.3% vs 25.8%, P = 0.001) and bile (23.6% vs 40.7%, P = 0.001) samples, and increased usage of advanced antibiotics (26.3% vs 38.2%, P = 0.001). In addition, in the lavage group, more patients had fever (> 37.5 °C, 81.4% vs 91.1%, P = 0.001) and hyperthermia (> 38.5°C, 39.7% vs 54.9%, P = 0.001), and higher white blood cell counts within 7 d after the operation compared to the control group. CONCLUSION: Intraoperative biliary lavage might increase the risk of postoperative infection, while not significantly increasing gallstone removal rate.

Economic and Demographic Characteristics of Cerumen Extraction Claims to Medicare.

IMPORTANCE: Cerumen extractions are performed in a large portion of otolaryngology and head and neck surgery practices. The burden on the health care system of cerumen extractions is unknown and demographics have not been characterized at a population level. OBJECTIVE: To quantify the cost burden and health care burden of cerumen extraction among Medicare recipients in the United States. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cross-sectional study was conducted of all cerumen disimpactions documented in the Centers for Medicare & Medicaid Services Provider Utilization and Payment database from January 1 to December 31, 2012. Data analysis was conducted from August 4, 2014, to July 24, 2015. EXPOSURE: Cerumen disimpaction. MAIN OUTCOMES AND MEASURES: Cerumen extractions were analyzed by state, medical or surgical specialty, reimbursement, and type of health care professional performing the extraction. RESULTS: The Centers for Medicare & Medicaid Services reimbursed $46.8 million for 1.3 million cerumen disimpactions in 2012 (mean, $35.38 per procedure). The mean reimbursement rate per cerumen disimpaction varied by state from $25.41 in Puerto Rico to to $40.24 in New Jersey. The percentage of Medicare beneficiaries receiving cerumen extractions per state ranged from 0.55% in Puerto Rico to 4.92% in New Jersey. California had the overall highest total number of cerumen disimpactions (n = 132 823). The majority of cerumen extractions were performed by otolaryngology-head and neck practitioners (67.60%), although internal medicine (32.66%) and family practice (33.87%) had a higher amount of practitioners performing the procedure. The majority of cerumen extractions are performed by physicians (90.53%). CONCLUSIONS AND RELEVANCE: Cerumen extraction is one of the most common procedures performed by otolaryngology health care professionals. Practice patterns and reimbursement rates vary greatly across the country.