Time, Resident Involvement, and Supply Drive Cost Variability in Septoplasty with Turbinate Reduction

Time is money: An analysis of cost drivers in ambulatory sinus surgery

BACKGROUND

Functional endoscopic sinus surgery (FESS) is one of the most commonly performed otolaryngologic procedures and is associated with significant cost variability.

METHODS

We performed a retrospective analysis of all inflammatory sinus surgeries at a single tertiary care medical center from July 2021 to July 2023. The electronic medical record was reviewed for patient factors and cost variables for each procedure, and multivariable analysis was performed.

RESULTS

A total of 221 patients were included in analysis with a mean age of 48.2 years. There was a 44.8% incidence (n = 99) of nasal polyps and 31.2% (n = 69) of cases were revision surgeries. The average total cost for the surgical encounter was $8960.31 (standard deviation $1967.97). Operating room time represented $4912.46 (54.8% of all costs), while average operating room supply costs were $1296.06 (14.5%) and recovery room costs were $919.48 (10.3%). Total costs were significantly associated with length of surgery ($7.83/min, p = 0.04), in addition to presence of nasal polyps ($531.96, p = 0.04). There was no significant association between total costs and the remaining clinical and demographic factors.

CONCLUSIONS

Costs associated with ambulatory FESS for inflammatory sinus disease vary across patients and this cost variability is predominantly driven by time efficiency within the operating room, as well as supply utilization and nasal polyposis to a lesser degree. As a result, operating room efficiency represents a primary target for cost-related interventions. Additionally, our data provide a framework for surgeons and hospitals to make evidence-based decisions on intraoperative equipment in a tradeoff between efficiency and supply costs. Our findings indicate that an approach focused on streamlining efficiency across the entire ambulatory surgery encounter will have the greatest impact on reducing healthcare expenses for both the patient and the health system.

Impact of Prolonged Operative Time on Complications Following Endoscopic Sinonasal Surgery

OBJECTIVE

To determine how prolonged operative time (POT) impacts 30-day outcomes in patients undergoing endoscopic sinonasal surgery (ESNS).

STUDY DESIGN

Retrospective study.

METHODS

Data from patients who underwent ESNS (nonsinus, sinus, and extended sinus) between 2005 to 2018 were collected from the American College of Surgeons National Surgical Quality Improvement database. Univariate and multivariate analyses were performed to evaluate the effect of POT on postoperative outcomes.

RESULTS

Among 1,994 ESNS cases, 495 nonsinus procedures, 1,191 sinus procedures, and 308 extended sinus procedures were identified. Median OT was 90 minutes (interquartile range [IQR], 51-165 minutes) for nonsinus procedures, 113 minutes (IQR, 66-189 minutes) for sinus procedures, and 187 minutes (IQR, 137-251 minutes) for extended sinus procedures. Other than older age (P = .008), POT was not significantly associated with baseline demographics and comorbidities for patients undergoing non-sinus procedures. Older age (P < .001), White and Black race (P < .001), ASA physical classifications III or IV (P < .001), and several preoperative comorbidities, including obesity (P = .045), and hypertension (P < .001) were associated with POT for sinus procedures. Older age (P = .030), male sex (P = .010), and lower body mass index (P = .004) were associated with POT for extended sinus procedures. After risk-adjustment, POT was independently associated with prolonged hospital stay (LOS) for all procedure categories, and associated with overall surgical complications and postoperative bleeding for sinus and extended sinus procedures specifically.

CONCLUSION

POT is independently associated with several adverse outcomes following ESNS, including prolonged LOS, overall surgical complications, and bleeding. Preoperative planning should include optimizing modifiable patient risk factors for POT and identifying surgeon-specific factors to enhance surgical efficiency.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:51-58, 2023.

Sociodemographic Disparities in Access to Cleft Rhinoplasty

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Septoplasty Training During the COVID-19 Era: Development and Validation of a Novel Low-Cost Simulation Model

OBJECTIVE

In a context of increasingly limited surgical exposition, enhanced by the coronavirus disease 2019 (COVID-19) pandemic context, the objective of this article is to explain the development of a novel low-cost and simple replication animal-based septoplasty training model for otolaryngology residents, to assess its face and construct validity, and to validate a specific rating scale for each task.

STUDY DESIGN

Experimental study.

SETTING

Surgical simulation laboratory.

METHODS

Septoplasty experts divided the procedure into key tasks. A simulator model to perform tasks was developed using pig ears to imitate human nasal septum cartilage, and a Specific Rating Scale was constructed. Trainees and faculty performed all tasks in the model. The participants were videotaped, and operative time, hand movements, and path length were recorded using a motion sensor device. Two blinded experts evaluated the videos with Global and Specific Rating Scales. All participants answered a satisfaction survey.

RESULTS

Fifteen subjects were recruited (7 trainees and 8 faculty). Significantly higher Global Rating Scale score, shorter operative time and path length, and fewer hand movements were observed in the faculty group. The satisfaction survey showed high applicability to a real scenario (mean score of 4.6 out of 5). Specific Rating Scale showed construct and concurrent validity and high reliability.

CONCLUSION

This simulation model and its specific rating scale can be accurately used as a validated surgical assessment tool for endonasal septoplasty skills. Its low cost and simple replicability make it a potentially useful tool in any otolaryngology surgical training program.

Variability drivers of treatment costs in hospitals: A systematic review

OBJECTIVES

Studies on variability drivers of treatment costs in hospitals can provide the necessary information for policymakers and healthcare providers seeking to redesign reimbursement schemes and improve the outcomes-over-cost ratio, respectively. This systematic literature review, focusing on the hospital perspective, provides an overview of studies focusing on variability in treatment cost, an outline of their study characteristics and cost drivers, and suggestions on future research methodology.

METHODS

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Handbook for Systematic Reviews of Interventions. We searched PubMED/MEDLINE, Web of Science, EMBASE, Scopus, CINAHL, Science direct, OvidSP and Cochrane library. Two investigators extracted and appraised data for citation until October 2020.

RESULTS

90 eligible articles were included. Patient, treatment and disease characteristics and, to a lesser extent, outcome and institutional characteristics were identified as significant variables explaining cost variability. In one-third of the studies, the costing method was classified as unclear due to the limited explanation provided by the authors.

CONCLUSION

Various patient, treatment and disease characteristics were identified to explain hospital cost variability. The limited transparency on how hospital costs are defined is a remarkable observation for studies wherein cost variability is the main focus. Recommendations relating to variables, costs, and statistical methods to consider when designing and conducting cost variability studies were provided.

Otolaryngology resident clinic participation and attending electronic health record efficiency-A user activity logs study

OBJECTIVES

In an era of increasing electronic health record (EHR) use monitoring and optimization, this study aims to quantify resident contributions and measure the effect of otolaryngology resident coverage in clinic on attending otolaryngologist EHR usage.

METHODS

In one academic otolaryngology department, monthly attending provider efficiency profile metrics, data collected by the EHR vendor (Epic Systems Corporation) between January and June 2019 were accessed. Using weekly resident schedules, resident coverage of attending outpatient clinics was categorized by junior (post-graduate year [PGY] 1-3) and senior levels (PGY-4 through fellows) and correlated with attending EHR metrics using linear mixed effect models.Results: Thirteen attending otolaryngologists on average spent 58.8 minutes per day interacting with the EHR. In modeling, one day of trainee clinic coverage was associated with a 22 minutes reduction (95% CI [-37, -6]) in total daily attending EHR time and a 12 minutes reduction (95% CI [-21, -3]) in per day note time (P < .05). When stratifying by trainee level, senior coverage was associated with significantly reduced total daily time in EHR, per day time in clinical review, notes, and orders, as well as per appointment time in notes and clinical review (P < .05). Junior coverage was only associated with reduced per day note time (P < .05).

CONCLUSIONS

Increasing resident clinic coverage was inversely related to attending time spent in the EHR and writing notes. Resident contributions to EHR workflows and hospital system productivity should continue to be studied and considered in EHR use measurement studies.

LEVEL OF EVIDENCE

Level 4.

Is septal deviation associated with headache?: A nationwide 10-year follow-up cohort study

To investigate the potential relationship between septal deviation (SD) and headache using nationwide representative cohort sample data.This study used a nationwide cohort sample from the Korean National Health Insurance Service database. The cohort sample was composed of 1 million patients, which is obtained by propensity score matching from 2002 to 2013. There were 9171 individuals in the SD group and 28243 in the control or no SD group. The Kaplan-Meier survival analysis, the log-rank test, and Cox proportional hazard regression analysis were used to calculate the incidence, survival curve, and hazard ratio of headache for each group.There were no statistically significant differences in sex (P = .7708), age (P = .991), residential area (P = .9626), or socioeconomic status (P = .9982) between the 2 groups. The survival curve between SD and control or no SD showed a statistically significant difference. The adjusted hazard ratio for headache incidence during the 10-year follow-up period of the SD group was 1.37 (95% CI: 1.31-1.43).This cohort study suggests that SD is associated with headache. Therefore, these findings suggest that septoplasty can be considered as 1 of the treatment option in SD patients with headache.

Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopaedic Sports Medicine: A Matched-Pair Analysis

PURPOSE

To quantify the cost of resident involvement in academic sports medicine by examining differences in operative time, relative value units (RVUs) per case, and RVUs per hour between attending-only cases and cases with resident involvement.

METHODS

A retrospective analysis of common sports medicine procedures identified by Current Procedural Terminology code was performed using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2015. Matched cohorts were generated based on demographic variables, comorbidities, preoperative laboratory values, and surgical procedures. Bivariate analysis examined mean differences in operative time, RVUs per case, and RVUs per hour between attending-only cases and cases with resident involvement. A cost analysis was performed to quantify differences in RVUs generated per hour in terms of dollars per case.

RESULTS

A total of 14,840 attending-only cases and 2,230 resident-involved cases were used to generate 2 matched cohorts (N = 4,460). Resident cases had greater mean operative times than attending-only cases, with operative time increasing as residents became more senior (P < .01). Residents participated in cases with larger mean RVUs per case (P < .01). Cases with lone attendings showed greater RVUs per hour (P < .01). The cost of resident involvement increased nearly 8-fold from postgraduate year 1 to postgraduate year 6 residents ($25.70 vs $200.07).

CONCLUSIONS

In academic sports medicine, the involvement of resident physicians increases operative time. The associated decrease in attending physician efficiency in RVUs per hour equates to an average cost per case of $159.18, with costs increasing as residents become more senior.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Does Surgical Volume and Complexity Affect Cost and Mortality in Otolaryngology–Head and Neck Surgery?

Objectives

(1) To evaluate whether admission volume and case complexity are associated with mortality rates and (2) evaluate whether admission volume and case complexity are associated with cost per admission.

Study Design

Retrospective case series.

Setting

Tertiary academic hospital.

Subjects and Methods

The Vizient database was queried for inpatient admissions between July 2015 and March 2017 to an otolaryngology–head and neck surgery service. Data collected included admission volume, length of stay, intensive care unit (ICU) status, complication rates, case mix index (CMI), and cost data. Regression analysis was performed to evaluate the relationship between cost, CMI, admission volume, and mortality rate.

Results

In total, 338 hospitals provided data for analysis. Mean hospital admission volume was 182 (range, 1-1284), and mean CMI was 1.69 (range, 0.66-6.0). A 1-point increase in hospital average CMI was associated with a 40% increase in odds for high mortality. Admission volume was associated with lower mortality, with 1% lower odds for each additional case. A 1-point increase in CMI produces a $4624 higher total cost per case (95% confidence interval, $4550-$4700), and for each additional case, total cost per case increased by $6.

Conclusion

For otolaryngology inpatient services at US academic medical centers, increasing admission volume is associated with decreased mortality rates, even after controlling for CMI and complication rates. Increasing CMI levels have an anticipated correlation with higher total costs per case, but admission volume is unexpectedly associated with a significant increase in average cost per case.