Pathologist workload, burnout, and wellness: connecting the dots.

No standard tool to measure pathologist workload currently exists. An accurate measure of workload is needed for determining the number of pathologists to be hired, distributing the workload fairly among pathologists, and assessing the overall cost of pathology consults. Initially, simple tools such as counting cases or slides were used to give an estimate of the workload. More recently, multiple workload models, including relative value units (RVUs), the Royal College of Pathologists (RCP) point system, Level 4 Equivalent (L4E), Work2Quality (W2Q), and the University of Washington, Seattle (UW) slide count method, have been developed. There is no "ideal" model that is universally accepted. The main differences among the models come from the weights assigned to different specimen types, differential calculations for organs, and the capture of additional tasks needed for safe and timely patient care. Academic centers tend to see more complex cases that require extensive sampling and additional testing, while community-based and private laboratories deal more with biopsies. Additionally, some systems do not account for teaching, participation in multidisciplinary rounds, quality assurance activities, and medical oversight. A successful workload model needs to be continually updated to reflect the current state of practice.Awareness about physician burnout has gained attention in recent years and has been added to the World Health Organization's International Classification of Diseases (World Health Organization, WHO) as an occupational phenomenon. However, the extent to which this affects pathologists is not well understood. According to the WHO, burnout syndrome is diagnosed by the presence of three components: emotional exhaustion, depersonalization from one's work (cynicism related to one's job), and a low sense of personal achievement or accomplishment. Three drivers of burnout are the demand for productivity, lack of recognition, and electronic health records. Prominent consequences of physician burnout are economic and personal costs to the public and to the providers.Wellness is physical and mental well-being that allows individuals to manage stress effectively and to thrive in both their professional and personal lives. To achieve wellness, it is necessary to understand the root causes of burnout, including over-work and working under stressful conditions. Wellness is more than the absence of stress or burnout, and the responsibility of wellness should be shared by pathologists themselves, their healthcare organization, and governing bodies. Each pathologist needs to take their own path to achieve wellness.

Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX).

BACKGROUND: Perceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement. METHODS: A prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units. RESULTS: Compared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts. CONCLUSIONS: Revision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

Objective assessment of physician work in infrainguinal arterial bypass surgery.

OBJECTIVE: The purpose of this study is obtain robust objective data from the Vascular Quality Initiative on physician work in infrainguinal artery bypass surgery. Operative time, patient comorbidities, anatomical complexity, consequences of adverse outcomes, and postoperative length of stay all factor into procedure relative value unit assignment and physician reimbursement. METHODS: Baseline demographics and comorbidities were identified among 74,920 infrainguinal bypass surgeries in Vascular Quality Initiative between 2003 and 2022. Investigation into areas of progressive complexity over time was conducted. Bypasses were divided into 10 cohorts based on inflow and target arteries and conduit type. Mean operative times, lengths of stay, major morbidity rates, and 90-day mortality rates were identified across the various bypasses. Comparison of relative value unit per minute service time during the acute inpatient hospital admission was performed between the most 4 common bypasses and 14 commonly performed highly invasive major surgeries across several subdisciplines. RESULTS: Patients undergoing infrainguinal arterial bypass have an advanced combination of medical complexities highlighted by diabetes mellitus in 40%, hypertension in 88%, body mass index >30 in 30%, coronary artery disease that has clinically manifested in 31%, renal insufficiency in 19%, chronic obstructive pulmonary disease in 27%, and prior lower extremity arterial intervention (endovascular and open combined) in >50%. The need for concomitant endarterectomy at the proximal anastomosis site of infrainguinal bypasses has increased over time (P < .001). The indication for bypass being limb-threatening ischemia as defined by ischemic rest pain, pedal tissue loss, or acute ischemia has also increased over time (P < .001), indicating more advanced extent of arterial occlusion in patients undergoing infrainguinal bypass. Finally, there has been a significant (P < .001) progression in the percentage of patients who have undergone a prior ipsilateral lower extremity endovascular intervention at the time of their bypass (increasing from 9.9% in 2003-2010 to 31.9% in the 2018-2022 eras). Among the 18 procedures investigated, the 4 most commonly performed infrainguinal bypasses were included in the analysis. These ranked 14th, 16th, 17th and 18th as the most poorly compensated per minute service time during the acute operative inpatient stay. CONCLUSIONS: Infrainguinal arterial bypass surgery has an objectively undervalued physician work relative value unit compared with other highly invasive major surgeries across several subdisciplines. There are elements of progressive complexity in infrainguinal bypass patients over the past 20 years among a patient cohort with a very high comorbidity rate, indicating escalating intensity for infrainguinal bypass.

Application of a cost calculation approach in medical oncology: case of Hassan II university hospital in Morocco.

BACKGROUND: In Morocco, hospitals do not have cost accounting systems that allow them to produce reliable budget forecasts to know and justify the costs of their operations. Moroccan hospitals are thus among the public organizations that do not know the cost of their services. Faced with the lack of data on the cost of care for cancer patients, this research aims to implement an approach to calculate the cost of services provided at the level of the medical oncology department of the Hassan II University Hospital in Fez. The objective is to provide data that can be used in the pricing and financing process of the different services provided in medical oncology. METHODS: In this research work, we proposed a top-down costing approach. Two main qualitative data collection tools were used: observation and document analysis. We used mainly and Excel for data processing to determine costs and related statistics. RESULTS: The result of this study shows the possible application of a top-down approach to cost calculation which consists in determining the cost per department (oncology service) and per product (chemotherapy act, transfusion, ascites puncture, Inpatient day). Two main methods were mainly used, namely the volume-based allocation method and the method relative value units (RVU). The proposed top-down cost calculation approach has the advantage of being easy to implement, but on the other hand, it is not very accurate in producing results on the actual cost. The data from this study can be exploited to revise the prices of procedures provided in medical oncology.

Are Foot & Ankle Surgeons Being Adequately Compensated for Ankle Fractures? - An Analysis of Relative Value Units.

The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons - National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

Variation in state and federal reimbursement in the United States in the treatment of upper extremity fractures.

BACKGROUND: Medicare and Medicaid are 2 of the largest government-run health care programs in the United States. Although Medicare reimbursement is determined at the federal level by the Centers for Medicare & Medicaid Services, Medicaid reimbursement rates are set by each individual state. The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement rates for 12 orthopedic procedures performed to treat common fractures of the upper extremity. METHODS: Twelve orthopedic procedures were selected and their Medicare reimbursement rates were collected from the 2020 Medicare Physician Fee Schedule. Medicaid reimbursement rates were obtained from each state's physician fee schedule. Reimbursement rates were then compared by assessing the ratio of Medicaid to Medicare, the dollar difference in Medicaid to Medicare reimbursement, and the difference per relative value unit. The range of variation in Medicaid reimbursement and Medicare wage index-adjusted Medicaid reimbursement was calculated. Comparisons in reimbursement were calculated using coefficient of variation and Student t tests to evaluate the differences between the mean Medicaid and Medicare reimbursements. Two-sample coefficient of variation testing was used to determine whether dispersion in Medicare and Medicaid reimbursement rates differed significantly. RESULTS: There was significant difference in reimbursement rates between Medicare and Medicaid for all 12 procedures, with Medicare reimbursing on average 46.5% more than Medicaid. In 40 states, Medicaid reimbursed less than Medicare for all 12 procedures. Regarding the dollar difference per relative value unit, Medicaid reimbursed on average $18.03 less per relative value unit than Medicare. The coefficient of variation for Medicaid reimbursement rates ranged from 0.26-0.33. This is in stark contrast with the significantly lower variability observed in Medicare reimbursement, which ranged from 0.06-0.07. CONCLUSION: Our findings highlight the variation in reimbursement that exists among state Medicaid programs for 12 orthopedic procedures commonly used to treat fractures of the upper extremity. Furthermore, average Medicaid reimbursement rates were significantly lower than Medicare rates for all 12 procedures. Such discrepancies in reimbursement may act as a barrier, impeding many Medicaid patients from accessing timely orthopedic care.

Quantifying the Surgeon's Increased Burden of Postoperative Work for Modern Arthroplasty Surgery.

BACKGROUND: Arthroplasty payment traditionally includes 118 minutes for postoperative rounds and 69 minutes for postoperative office visits, amounting to 187 minutes and 7 work relative value units. Rapid recovery, ambulatory procedures, and bundled payments have altered the burden of care, with multiple studies showing an increase in physician work. Policy changes during the COVID-19 pandemic allow for precise documentation of patient touchpoints. We analyzed the duration of video, telephone, and text messaging to quantify modern arthroplasty work. METHODS: Consecutive primary hip, knee, and partial knee arthroplasties, performed 30 days before March 15, 2020 (date of practice closure), were included from a single institution, yielding 47 cases. We retrospectively quantified the duration of video telehealth documentation, telephone logs, and text messages over 90 days to calculate the postoperative work required in modern arthroplasty using descriptive statistics. RESULTS: An average of 9.4 touchpoints (2-14) by the surgeons occurred during the global period for this cohort, totaling 219 minutes (51-247 minutes). This included an average of 21 minutes of day-0 calls to family, 117 minutes for video visits, 52 minutes for phone calls, and 29 minutes for text messaging and wound photos. CONCLUSION: We found an undervaluation of 32 minutes of work. AAHKS leadership advocates for the fair payment of modern arthroplasty work. Cell phones have opened channels of contact that did not exist before, including phone accessibility, text messaging, and video calls. These data help defend against current payer efforts to cut work relative value units for arthroplasty. LEVEL OF EVIDENCE: II.

Comparison of 2015 Medicare relative value units for gender-specific procedures: Gynecologic and gynecologic-oncologic versus urologic CPT coding. Has time healed gender-worth?

BACKGROUND: In 1992, Congress implemented a relative value unit (RVU) payment system to set reimbursement for all procedures covered by Medicare. In 1997, data supported that a significant gender bias existed in reimbursement for gynecologic compared to urologic procedures. The present study was performed to compare work and total RVU's for gender specific procedures effective January 2015 and to evaluate if time has healed the gender-based RVU worth. METHODS: Using the 2015 CPT codes, we compared work and total RVU's for 50 pairs of gender specific procedures. We also evaluated 2015 procedure related provider compensation. The groups were matched so that the procedures were anatomically similar. We also compared 2015 to 1997 RVU and fee schedules. RESULTS: Evaluation of work RVU's for the paired procedures revealed that in 36 cases (72%), male vs female procedures had a higher wRVU and tRVU. For total fee/reimbursement, 42 (84%) male based procedures were compensated at a higher rate than the paired female procedures. On average, male specific surgeries were reimbursed at an amount that was 27.67% higher for male procedures than for female-specific surgeries. Female procedure based work RVU's have increased minimally from 1997 to 2015. CONCLUSION: Time and effort have trended towards resolution of some gender-related procedure worth discrepancies but there are still significant RVU and compensation differences that should be further reviewed and modified as surgical time and effort highly correlate.

Neurosurgeons' responses to changing Medicare reimbursement.

OBJECT: Medicare reimbursement for physician services has been declining even as the number of Medicare enrollees has been increasing. The number of Medicare participants will only continue to grow as the American population ages and the Patient Protection and Affordable Care Act goes into effect. Efforts to increase reimbursement for physician services through Medicare are often met with data showing that most neurosurgeons continue to participate in the program despite these cutbacks. To better understand this dichotomy, practicing neurosurgeons were surveyed to gauge their response to cutbacks in the Medicare program beyond just their participation status. METHODS: An Internet-based survey invitation was emailed to 3469 practicing neurosurgeons. Reminder emails were sent at intervals over several weeks to help increase the response rate. RESULTS: Among respondents, an overwhelming percentage (96.8%) participated in Medicare. The neurosurgeons indicated that about one-third of their patient population was covered by Medicare. They also reported limiting the number of Medicare patients they see through a variety of mechanisms: only seeing Medicare patients with a specific diagnosis or from certain referring physicians or limiting the number of appointment slots for Medicare patients. Many respondents stated that further declines in Medicare reimbursement would lead to a reduction in their participation. CONCLUSIONS: While most responding neurosurgeons do participate in the Medicare program, a substantial proportion modulates their participation through a variety of mechanisms. These barriers to care access for Medicare patients are only expected to become greater if further declines in reimbursement are implemented through the program.

Cost of an acting intern: clinical productivity in the academic emergency department.

BACKGROUND: A few studies suggest that an increasing clinical workload does not adversely affect quality of teaching in the Emergency Department (ED); however, the impact of clinical teaching on productivity is unknown. OBJECTIVES: The primary objective of this study was to determine whether there was a difference in relative value units (RVUs) billed by faculty members when an acting internship (AI) student is on shift. Secondary objectives include comparing RVUs billed by individual faculty members and in different locations. METHODS: A matched case-control study design was employed, comparing the RVUs generated during shifts with an Emergency Medicine (EM) AI (cases) to shifts without an AI (controls). Case shifts were matched with control shifts for individual faculty member, time (day, swing, night), location, and, whenever possible, day of the week. Outcome measures were gross, procedural, and critical care RVUs. RESULTS: There were 140 shifts worked by AI students during the study period; 18 were unmatchable, and 21 were night shifts that crossed two dates of service and were not included. There were 101 well-matched shift pairs retained for analysis. Gross, procedural, and critical care RVUs billed did not differ significantly in case vs. control shifts (53.60 vs. 53.47, p=0.95; 4.30 vs. 4.27, p=0.96; 3.36 vs. 3.41, respectively, p=0.94). This effect was consistent across sites and for all faculty members. CONCLUSIONS: An AI student had no adverse effect on overall, procedural, or critical care clinical billing in the academic ED. When matched with experienced educators, career-bound fourth-year students do not detract from clinical productivity.

Hospital payment systems and physician reimbursement: A primer for radiology residents.

Prior to practicing independently, radiology trainees spend considerable time and energy to learn and understand the practice of radiology. However, upon graduation trainees are often deficient in understanding the business of hospitals and the structure of reimbursement. Specifically, the workflow of relative value units (RVUs) and its impact on practice of radiology after completing training. In this manuscript, we provide a resource for trainees to understand the workflow of physician reimbursement. This article includes information on the mixed model healthcare structure of the United States and two government programs that influence reimbursement: Diagnosis-Related Groups (DRG) and Hospital Value-Based Purchasing (HVBP) programs. Furthermore, we explain the method by which the Center of Medicare and Medicate Service's (CMS) reimburses physicians via the Medicare Physician Fee Schedule (MPFS) using the Resource Based Relative Value Scale. Understanding the structure of these payments along with the challenges and current landscape of radiology reimbursement will help new radiologists prior to seeking employment where reimbursements are integral to contract expectations.

Inflation-adjusted medicare physician reimbursement for adult spinal deformity surgery substantially declined from 2002 to 2020.

PURPOSE: Physician fees for orthopaedic surgeons by the Centers for Medicare and Medicaid Services (CMS) are increasingly scrutinized. The present retrospective review aims to assess whether adult spinal deformity (ASD) surgeries are properly valued for Medicare reimbursement. METHODS: Current Procedural Terminology (CPT) codes related to posterior fusion of spinal deformity of ≤ 6, 7-12, and ≥ 13 vertebral levels, as well as additional arthrodesis and osteotomy levels, were assessed for (1) Compound annual growth rate (CAGR) from 2002 to 2020, calculated using physician fee data from the CMS Physician Fee Schedule Look-Up Tool; and (2) work relative value units (RVUs) per operative minute, using data from the National Surgical Quality Improvement Program. RESULTS: From 2002 to 2020, all CPT codes for ASD surgery had negative inflation-adjusted CAGRs (range, - 18.49% to - 27.66%). Mean physician fees for spinal fusion declined by 26.02% (CAGR, - 1.66%) in ≤ 6-level fusion, 27.91% (CAGR, - 1.80%) in 7- to 12-level fusion, and 28.25% (CAGR, - 1.83%) ≥ 13-level fusion. Fees for both 7-12 (P < 0.00001) and ≥ 13 levels (P < 0.00001) declined more than those for fusion of ≤ 6 vertebral levels. RVU per minute was lower for 7- to 12-level and ≥ 13-level (P < 0.00001 for both) ASD surgeries than for ≤ 6-level. CONCLUSIONS: Reimbursement for ASD surgery declined overall. CAGR for fusions of ≥ 7 levels were lower than those for fusions of ≤ 6 levels. For 2012-2018, ≥ 7-level fusions had lower RVU per minute than ≤ 6-level fusions. Revaluation of Medicare reimbursement for longer-level ASD surgeries may be warranted. LEVEL OF EVIDENCE: III.

Paired Comparison Survey Analysis Utilizing Rasch Methodology of the Relative Difficulty and Estimated Work Relative Value Units of CPT Code 0202T.

BACKGROUND: In anticipation of Food and Drug Administration (FDA) approval of the Total Posterior Spine (TOPS) system, the International Society for the Advancement of Spine Surgery (ISASS) conducted a study to estimate the work relative value units (RVUs) for facet arthroplasty. The purpose of this study was to establish a valuation of work RVU for Current Procedural Terminology (CPT) Code 0202T in the interim until the Relative Value Scale Update Committee (RUC) can determine an appropriate value. The valuation established from this survey will assist surgeons to establish appropriate procedure reimbursement from third-party payers. METHODS: A survey was created and sent to 52 surgeons who had experience implanting the TOPS system during the investigational device exemption clinical trial. The survey included a patient vignette, a description of CPT Code 0202T along with a video of the TOPS system, and a confirmation question about the illustration's effectiveness. Respondents were asked to compare the work involved in CPT Code 0202T to 8 lumbar spine procedures. A Rasch analysis was performed to estimate the relative difficulty of CPT 0202T using the work RVUs of the comparable procedures. RESULTS: Forty-one surgeons responded to the survey. Of all the procedures, CPT Code 0202T received the most responses for equal work compared with posterior osteotomy (46%) followed by transforaminal lumbar interbody fusion (41%). The results of the regression analysis indicate a work RVU for CPT 0202T of 39.47. CONCLUSION: The study found an estimated work RVU of 39.47 for CPT Code 0202T using Rasch analysis. As an alternative to this Rasch methodology, one may consider a crosswalk methodology to the work RVUs for transforaminal lumbar interbody fusion procedurally, not as an alternative code. CLINICAL RELEVANCE: These recommendations are not a substitute for RUC methodology but serve as a reference for physicians and third-party payers to understand work RVU similarities for charge and payment purposes temporarily until RUC methodology provides accurate RVUs for the procedure.

A Novel Pediatric Surgery Division Incentive Program Engaging Faculty, Advanced Practice Providers and Staff Around a Single Financial Growth Target.

BACKGROUND: Productivity-based financial incentive programs for faculty are common. We implemented a novel Division wide clinical productivity incentive sharing professional fee collections across faculty, nurses, and staff with half of bonuses reserved to be given out proportionally to achievement of the annual growth target. METHODS: A novel bonus plan was formulated to incentivize collection of professional fees to achieve a 15% annual growth target. The 15% was divided equally between the clinical provider, the responsible provider's center(s) of excellence, and all Division members. 50% of the bonus pool was paid out monthly and the remaining 50% was held for an end of the year payout proportional to achievement of the Divisional professional fee collection annual growth target. PRINCIPAL FINDINGS: During the initial year of the program, overall Division collections and charges grew 30% and 17%, respectively. Average monthly bonuses paid through the new incentive program for faculty, advanced practice providers, and staff were $1,700, $700, and $200, respectively. The program cost $525,000 in additional bonuses over the previous year while the Division saw an increase of 2 million dollars in collections over the previous year. CONCLUSION: A clinical productivity incentive program based upon professional fee collections distributed across faculty, nurses, and staff was feasible and successful in its first year. Collections increased by a significantly higher percentage than charges, we believe collections incentive including support staff will be most useful in practices with lower rates of charge collection. Further study is needed to measure the effects of different components of the program. LEVEL OF EVIDENCE: Level IV. STUDY TYPE: Cost Effectiveness Study.

Diagnostic Imaging Utilization in the Emergency Department: Recent Trends in Volume and Radiology Work Relative Value Units.

PURPOSE: The aim of this study was to quantify and characterize the recent trend in emergency department (ED) imaging volumes and radiology work relative value units (wRVUs) at level I and level III trauma centers. METHODS: Total annual diagnostic radiology imaging volumes and wRVUs were obtained from level I and level III trauma centers from January 2014 to December 2021. Imaging volumes were analyzed by modality type, examination code, and location. Total annual patient ED encounters (EDEs), annual weighted Emergency Severity Index, and patient admissions from the ED were obtained. Data were analyzed using annual imaging volume or wRVUs per EDE, and percentage change was calculated. RESULTS: At the level I trauma center, imaging volumes per EDE increased for chest radiography (5.5%), CT (35.5%), and MRI (56.3%) and decreased for ultrasound (-5.9%) from 2014 to 2021. Imaging volumes per EDE increased for ultrasound (10.4%), CT (74.6%), and MRI (2.0%) and decreased for chest radiography (-4.4%) at the level III trauma center over the same 8-year period. Total wRVUs per EDE increased at both the level I (34.9%) and level III (76.6%) trauma centers over the study period. CONCLUSIONS: ED imaging utilization increased over the 8-year study period at both level I and level III trauma centers, with an increase in total wRVUs per EDE. There was a disproportionate increased utilization of advanced imaging, such as CT, over time. ED utilization trends suggest that there will be a continued increase in demand for advanced imaging interpretation, including at lower acuity hospitals, so radiology departments should prepare for this increased work demand.

Segmental Duodenal Resections: Toward Defining Indications, Complexity, and Coding.

BACKGROUND: Segmental resections of the duodenum are uncommonly performed and are technically challenging due to intimate relationships with the biliary tree, pancreas, and superior mesenteric vessels. The objective of this study was to assess indications, operative strategy, and outcomes of duodenal resections and to advocate that this form of resection deserves its own unique Current Procedural Terminology (CPT) and Relative Value Unit (RVU) structure. METHODS: Patients undergoing isolated and partial duodenal resection from 2008-2023 at University of Tennessee Health Science Center affiliated hospitals were retrospectively reviewed. Factors examined included clinical presentation, diagnostic evaluation, operative time, and technique, 90-day morbidity and mortality, and pathologic and survival outcomes. RESULTS: Thirty-one patients were identified with majority female and a median age of 61. Diagnostic studies included computed tomography and upper (including push) endoscopy. Reconstruction most often involved side-to-side duodenojejunostomy following distal duodenal resection. Intraoperative evaluation (IOE) of the biliary tree was utilized to assess and protect pancreaticobiliary structures in eleven patients. Median operative time was 206 min, increasing to 236 min when IOE was necessary. Procedure-related morbidity was 23% with one 90-day mortality. Median postoperative length of stay was 9 days. Pathology included benign adenoma, adenocarcinoma, GIST, neuroendocrine neoplasms, and erosive metastatic deposit. CONCLUSION: Duodenal resections can be effectively employed to safely address diverse pathologies. These procedures are characterized by long operative times, extended hospital stays, and an incidence of postoperative complications that mimics that of pancreatic resection. This work highlights the need for modification to the CPT system to accurately define these distinct procedures for future research endeavors and development of a more accurate valuation unit.

Are Orthopedic Hand Surgeons Undercompensated for Time Spent in the Operating Room? A Study of Relative Value Units.

BACKGROUND: This study aims to investigate whether compensation is equitable among the most commonly performed orthopedic hand surgeries and when compared with general orthopedic procedures. METHODS: The National Surgical Quality Improvement Program database was queried for all orthopedic procedures, from 2016 to 2018, performed more than 150 times using Current Procedural Terminology (CPT) codes. Physician work relative value unit (wRVU) data were obtained from the 2020 US Centers for Medicare and Medicaid Services fee schedule. Linear regressions were used to determine whether there was an association among wRVU, operative time, and wRVU per hour (wRVU/h). Reimbursement for hand surgery CPT codes was compared with that of nonhand orthopedic CPT codes. The CPT codes were stratified into quartile cohorts based on mean operative time, major complication rate, mortality rate, American Society of Anesthesiologists class, reoperation rate, and readmission rate. Student t tests were used to compare wRVU/h between cohorts. RESULTS: Forty-two hand CPT codes were identified from 214 orthopedic CPT codes, accounting for 32 333 hand procedures. The median wRVU/h was significantly lower for procedures in the longest operative time quartile compared with the shortest operative time quartile (P < .001). Compared with hand procedures, nonhand procedures were found to have significantly higher mean operative time (P < .001), mean complication rate (P < .001), mean wRVU (P = .001), and mean wRVU/h (P = .007). CONCLUSIONS: The 2020 Physician wRVU scale does not allocate proportional wRVUs to orthopedic hand procedures with longer mean operative times. There is a decrease in mean reimbursement rate for hand procedures with longer mean operative time. When compared with general orthopedic procedures, hand procedures have a lower mean wRVU/h and complication rate.

Alignment of RVU Targets With Operating Room Block Time.

Background: Surgeon productivity is measured in relative value units (RVUs). The feasibility of attaining RVU productivity targets requires surgeons to have enough allocated block time to generate RVUs. However, it is unknown how much block time is required for surgeons to attain specific RVU targets. We aimed to estimate the effect of surgeon and practice environment characteristics (SPECs) on block time needed to attain fixed RVU targets. Methods: We computationally simulated individual surgeons' annual caseloads under a variety of SPECs in the following way. First, empirical case data were sampled from ACS NSQIP in accordance with surgeon specialty, case-mix complexity, and RVU target. Surgeons' operating schedules were then constructed according to the block length, turnover time, and scheduling flexibility of the practice environment. These 6 SPECs were concurrently varied over their ranges for a 6-way sensitivity analysis. Results: Annual operating schedules for 60,000,000 surgeons were simulated. The number of blocks required to attain RVU targets varied significantly with surgeon specialty and increased with increased case-mix complexity, increased turnover time, and decreased scheduling flexibility. Intraspecialty variation in block requirement with variation in environmental characteristics exceeded interspecialty variation with fixed environmental characteristics. Multivariate linear models predicted block utilization across surgical specialties with consideration for the stated factors. An online tool is shared with which to apply these results to one's particular practice. Conclusions: Block time required to attain RVU targets varies widely with SPECs; intraspecialty variation exceeds interspecialty variation. The feasibility of attaining RVU targets requires alignment between targets and allocated operating time with consideration for surgical specialty and other practice conditions.