Work intensity in sacroiliac joint fusion and lumbar microdiscectomy

Comparison of RVU Reimbursement in Anterior or Posterior Approach for Single- and Multilevel Cervical Spinal Fusion

STUDY DESIGN

Retrospective database study.

OBJECTIVE

This study aims to quantify and compare mean work RVUs (wRVUs), mean operative time (OpTime), and wRVUs/min in single- and multilevel anterior and posterior cervical spine fusions performed between 2011 and 2020.

SUMMARY OF BACKGROUND DATA

Prior research has demonstrated inconsistencies in technical skill, operative time, and surgical difficulty with reimbursement in various orthopedic subspecialties. Although trends investigating physician effort and reimbursement have been investigated in lumbar spine surgery, less research has examined these relationships with respect to cervical spine procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried for Current Procedural Terminology (CPT) codes reflecting anterior cervical discectomy and fusion (ACDF), posterior cervical decompression and fusion (PCDF), and the number of levels involved. The cohort was stratified into 10 groups: single-level, 2-level, 3-level, 4-level, 5+ level anterior or posterior cervical fusions. Mean operative times, mean wRVUs, and wRVU/min were calculated and compared by Student t test.

RESULTS

A total of 100,997 patients met inclusion criteria in this study, of which 79,141 (78.36%) underwent ACDF, whereas 21,836 (21.62%) underwent PCDF. One- and 2-level fusions were most common in both ACDF and PCDF. In 1-, 3-, 4-, and 5+ level fusion, the anterior approach demonstrated significantly lower mean wRVU ( P <0.001). In 1-, 2-, and 3-level fusions, the anterior approach had significantly lower operation times ( P <0.001). The anterior approach demonstrated significantly higher wRVU/min in 1- and 2- levels ( P <0.001) but lower wRVU/min in 3- and 4-level fusions ( P <0.001).

CONCLUSIONS

Clear discrepancies exist between surgical approach and levels of fusion in cervical spine procedures incongruous with markers of surgical difficulty, physician effort, or expertise required. These specific results suggest that the complexity of multi-level anterior cervical fusions are not effectively accounted for by existing RVU measures.

Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout?

INTRODUCTION

Assessing workload and mitigating burnout risk should be a constant goal within training programs. By using work relative value unit (wRVU) data in a non-elective orthopaedic trauma practice, we investigated seasonal variation in workload on an orthopaedic trauma service at a level I trauma centre. We also investigated whether there was a correlation in seasonal preventable adverse patient safety events (PSEs) and resident Epworth Sleepiness Scale (ESS) scores.

MATERIALS AND METHODS

Data on wRVUs were collected over an 8-year period for a single orthopaedic trauma surgeon with a non-elective practice. Monthly wRVU totals were tabulated over this 8-year period and compared with total hospital orthopaedic surgical trauma volume. The total number of wRVUs and surgical cases analysed were 80,955 and 9,928 respectively. A total of 1,560 PSEs and four years of resident ESS scores were analysed. Data on seasonal variations was evaluated for significance utilizing the Kruskal-Wallis test. WRVUs were then compared to total case volume, PSEs, and resident ESS scores using Spearman's correlation coefficients.

RESULTS

We found that wRVUs significantly differed by month (P-value < 0.001) and season (P-value < 0.001) with the highest volume occurring in the summer months. Seasonal variation in wRVUs demonstrated a positive linear correlation with total surgical volume (P-value <0.001) and resident reported ESS scores (P-value = 0.001). PSEs were highest in the summer (P = 0.026), but were not correlated with our findings of seasonal variations in orthopaedic volume (P-value = 0.741).

CONCLUSION

WRVUs of our single surgeon's orthopaedic trauma practice had a seasonal variation with significantly higher volume during the summer. These findings were representative of seasonal variations in total hospital orthopaedic trauma volume and also demonstrated correlation with objective resident sleepiness scores. PSEs were more frequent in the summer but not correlated with seasonal variation in volume. Burnout poses a risk to patient safety and has been shown to be correlated with increased work volume. These topics are important and applicable to various specialties involved in the care of patients with orthopaedic trauma injuries.

Reassessment of Relative Value in Shoulder and Elbow Surgery: Do Payment and Relative Value Units Reflect Reality?

BACKGROUD

Many U.S. health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. A major determinant of payment and wRVU assignments is operative time. We sought to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common shoulder/elbow procedures.

METHODS

We collected data on wRVUs, payments, and operative times from CMS for 29 types of isolated arthroscopic and open shoulder/elbow procedures. Using regression analysis, we compared relationships between these variables, in addition to median operative times reported by NSQIP (2013-2016). We then determined the relative valuation of each procedure based on operative time.

RESULTS

Seventy-nine percent of CMS operative time were longer than NSQIP time (R2 = 0.58), including, but not limited to, shoulder arthroplasty and arthroscopic shoulder surgery. The correlation between payments and operative times was stronger between CMS data (R2 = 0.61) than NSQIP data (R2 = 0.43). Similarly, the correlation between wRVUs and operative times was stronger when using CMS data (R2 = 0.87) than NSQIP data (R2 = 0.69). Nearly all arthroscopic shoulder procedures (aside from synovectomy, debridement, and decompression) were highly valued according to both datasets. Per NSQIP, compensation for revision total shoulder arthroplasty ($10.14/min; 0.26 wRVU/min) was higher than that for primary cases ($9.85, 0.23 wRVU/min) and nearly twice the CMS rate for revision cases ($5.84/min; 0.13 wRVU/min).

CONCLUSIONS

CMS may overestimate operative times compared to actual operative times as recorded by NSQIP. Shorter operative times may render certain procedures more highly valued than others. Case examples show that this can potentially affect patient care and incentivize higher compensating procedures per operative time when less-involved, shorter operations have similar patient-reported outcomes.

International Society for the Advancement of Spine Surgery Policy 2020 Update-Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity

The index 2014 International Society for the Advancement of Spine Surgery Policy Statement-Minimally Invasive Surgical Sacroiliac Joint Fusion-was generated out of necessity to provide an International Classification of Diseases, Ninth Revision (ICD-9)-based background and emphasize tools to ensure correct diagnosis. A timely ICD-10-based 2016 update provided a granular threshold selection with improved level of evidence and a more robust and relevant database (Appendix Table A1). As procedures and treatment options have evolved, this 2020 update reviews and analyzes the expanding evidence base and provides guidance relating to differences between the lateral and dorsal surgical procedures for minimally invasive surgical sacroiliac joint fusion.

Misvaluation of Hospital-Based Upper Extremity Surgery Across Payment, Relative Value Units, and Operative Time

BACKGROUND

Many US health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. Among other factors, a major determinant of payment and wRVU assignments is operative time. Our objective was to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common hospital-based hand and upper extremity procedures.

METHODS

Data on wRVUs, surgeon payment, and estimated operative times were collected from CMS for 53 procedures. We used regression models to compare relationships between these variables, in addition to actual median operative times as reported in the NSQIP database, from 2011 to 2016. We then determined the relative valuation of each procedure based on operative time.

RESULTS

There was a wide discrepancy between CMS and NSQIP operative times (R²=0.49), with 60% of CMS times being longer than NSQIP times. Payment correlated more strongly with CMS operative times (R²=0.55) than with NSQIP operative times (R²=0.24). Similarly, wRVUs more strongly correlated with CMS operative times (R²=0.84) than with NSQIP operative times (R2=0.51). In general, for trauma-related procedures, any distal radius open reduction internal fixation (ORIF) had the highest valuation while any ORIF proximal to the distal radius had lower valuation in analysis of both databases. While 61% of trauma procedures were highly valued, 70% of elective procedures had a low valuation, including nearly all elective tendon procedures. Notable compensation differences were found between trapeziectomy versus ligament reconstruction and tendon interposition, epicondyle debridement with tendon repair versus denervation, proximal row carpectomy versus four corner fusion, and distal radius open versus percutaneous fixation.

CONCLUSIONS

CMS may misvalue payment and wRVU rates of hospital-based hand procedures due to inaccurate operative time estimates. By identifying which procedures are misvalued in terms of payment and wRVU per operative time, providers and payors may be able to address these imbalances and maximize appropriate care delivery incentives.Level of Evidence: III.

Menstrual disorders and occupational exposures among female nurses: A nationwide cross-sectional study

BACKGROUND

The regularity of menstrual cycles is one of the important indicators of female reproductive health. However, the current evidence on the association of occupational exposures and menstrual disorders is scarce.

OBJECTIVES

This study aims to elucidate the relationship between occupational hazards and menstrual characteristics in female nurses and non-nurse health care workers in China.

DESIGN

We conducted a national cross-sectional study on the reproductive health of female nurses in China.

SETTINGS

A total of 1, 300 medical institutions in 15 provincial administrative regions in China participated in the study.

PARTICIPANTS

There were 8, 904 nurses and 3, 977 non-nurse health care workers who were selected using simple random sampling method.

METHODS

All participants were administered a face-to-face standardized questionnaire, including personal socio-demographic information, occupational activities, and self-reported menstrual characteristics. Univariate and multivariate logistic regressions were used for statistical analyses.

RESULTS

The results demonstrated that 41% of nurses experienced menstrual disorders. We found handling disinfectants was the most significant risk factor for menstrual disorders (OR = 1.53, 95% CI: 1.39-1.68), followed by abnormal workload (OR = 1.28, 95% CI: 1.19-1.39), and occupation as a nurse (OR = 1.28, 95% CI: 1.18-1.40). Noise, prolonged standing or frequent heavy lifting, night work, anti-cancer drug exposure, and overtime work were moderately associated with the occurrence of menstrual disorder (OR > 1).

CONCLUSIONS

This national-wide cross-sectional study has revealed the significant association between menstrual disorders and occupational hazards among female nurses in China.