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Lindquester WS, Chandra A, Dhangana R, Tublin ME. Percutaneous kidney biopsy trends in the Medicare population by specialty from 2011 to 2021: implications for nephrology training requirements and radiology referral patterns. Abdom Radiol (NY) 2023; 48:3506-3511. [PMID: 37668743 DOI: 10.1007/s00261-023-04030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE To study trends in volume and reimbursement for percutaneous kidney biopsy (PKB) by physicians and advanced practice providers (APPs) for Medicare enrollees from 2011-2021. METHODS Claims from the Medicare Part B Physician/Supplier Procedure Master File (a national Medicare database) for 2011-2021 were extracted using Current Procedural Terminology codes for PKB. Total volumes were compared by provider specialty. Non-facility reimbursement, work Relative Value Unit (RVU) non-facility practice expense RVU, and malpractice RVU were compared. RESULTS Between 2011 and 2021, total volume of PKB by physicians and APPs increased from 30,753 to 34,090 (10.9%), with a peak of 37,882 in 2019 prior to the COVID 19 pandemic. Radiology performed the majority of procedures during the study period. Relative share for radiology increased from 67.6% to 81.1% while the relative share for internal medicine/nephrology decreased from 24.3% to 14.3%, accelerating between 2019 and 2020. Volume and relative share for APPs marginally increased (from 0.9% to 1.2%). Non-facility reimbursement decreased from $578.96 in 2010 to $568.76 in 2021 (1.7%), work RVU decreased from 2.63 to 2.38 (9.5%), non-facility practice expense RVU decreased from 14.10 to 13.71 (2.8%), and malpractice RVU decreased from 0.31 to 0.21 (32.3%). CONCLUSION Volume and total share of PKB performed by radiology increased over the study period. Conversely, internal medicine/nephrology performed fewer kidney biopsies. Despite the expanding role for APPs in other image-guided procedures, very few PKBs were performed by APPs throughout the study period. Reimbursement and RVU for PKB declined over the study period.
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Affiliation(s)
- Will S Lindquester
- Division of Interventional Radiology and Image-guided Medicine, Emory University School of Medicine, 100 Lothrop Street, Atlanta, GA, 30322, USA
| | - Ashay Chandra
- Division of Interventional Radiology and Image-guided Medicine, Emory University School of Medicine, 100 Lothrop Street, Atlanta, GA, 30322, USA
| | - Rajoo Dhangana
- Department of Radiology, University of Pittsburgh Medical Center, Presbyterian University Hospital Suite E204, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
| | - Mitchell E Tublin
- University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15213, USA
- Department of Radiology, University of Pittsburgh Medical Center, Presbyterian University Hospital Suite E204, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
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Ray-Barruel G, Horowitz J, McLaughlin E, Flanders S, Chopra V. Barriers and facilitators for implementing peripherally inserted central catheter (PICC) appropriateness guidelines: A longitudinal survey study from 34 Michigan hospitals. PLoS One 2022; 17:e0277302. [PMID: 36331967 PMCID: PMC9635738 DOI: 10.1371/journal.pone.0277302] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022] Open
Abstract
Peripherally inserted central catheters (PICCs) are prevalent devices for medium-to-long-term intravenous therapy but are often associated with morbid and potentially lethal complications. This multi-center study sought to identify barriers and facilitators of implementing evidence-based appropriateness criteria to improve PICC safety and patient outcomes in a pay-for-performance model. Participating hospitals received an online toolkit with five recommendations: establishing a vascular access committee; implementing a clinical decision tool for PICC appropriateness; avoiding short-term PICC use (≤5 days); increasing use of single-lumen PICCs; and avoiding PICC placement in patients with chronic kidney disease. Longitudinal online surveys conducted biannually October 2014–November 2018 tracked implementation efforts. A total of 306 unique surveys from 34 hospitals were completed. The proportion of hospitals with a dedicated committee overseeing PICC appropriateness increased from 53% to 97%. Overall, 94% of hospitals implemented an initiative to reduce short-term and multi-lumen PICC use, and 91% integrated kidney function into PICC placement decisions. Barriers to implementation included: achieving agreement from diverse disciplines, competing hospital priorities, and delays in modifying electronic systems to enable appropriate PICC ordering. Provision of quarterly benchmarking reports, a decision algorithm, access to an online toolkit, and presence of local champion support were cited as crucial in improving practice. Structured quality improvement efforts including a multidisciplinary vascular access committee, clear targets, local champions, and support from an online education toolkit have led to sustained PICC appropriateness and improved patient safety.
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Affiliation(s)
- Gillian Ray-Barruel
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia
- Herston Infectious Diseases Institute, The University of Queensland, Herston, Queensland, Australia
- Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia
- * E-mail:
| | - Jennifer Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, United States of America
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan, United States of America
| | - Elizabeth McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, United States of America
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan, United States of America
| | - Scott Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, United States of America
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan, United States of America
| | - Vineet Chopra
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan, United States of America
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
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Lindquester WS, Hawkins CM, Dhangana R. Reductions in Reimbursement and RVUs for Interventional Radiology Procedures: Trends from 2011 to 2021 Compared to Other Physician Specialties. J Vasc Interv Radiol 2022; 33:972-977. [PMID: 35487347 DOI: 10.1016/j.jvir.2022.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/28/2022] [Accepted: 04/18/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To compare recent trends in Medicare reimbursement and relative value units (RVUs) for interventional radiology (IR) procedures similar to those performed by non-IR specialties. MATERIALS AND METHODS Data from the CMS Physician Fee Schedule for facility reimbursement and RVU component values for 23 commonly performed single CPT IR procedures were compared to similar procedures or procedures for similar indications performed by non-IR specialties between 2011 and 2021. RESULTS The work RVU (wRVU) component decreased in 18 of 23 (78.3%) IR procedures compared to 6 of 23 (26.1%) similar procedures performed by non-IR specialties. The largest change in single RVU component was a 19.2% reduction in practice expense RVU for IR compared to a 16.5% reduction for similar procedures performed by non-IR specialties. CONCLUSION As a specialty, interventional radiology experienced a disproportionately greater reduction in reimbursement and RVU valuation for a range of comparable procedures performed by non-IR specialties.
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Affiliation(s)
- Will S Lindquester
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - C Matthew Hawkins
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Radiology and Imaging Sciences, Division of Pediatric Radiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Rajoo Dhangana
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Growth in Thoracentesis and Paracentesis Performed by Radiology and Advanced Practice Providers: Medicare Volume and Reimbursement Trends From 2012 to 2018. J Am Coll Radiol 2022; 19:597-603. [PMID: 35341699 DOI: 10.1016/j.jacr.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To study trends in volume and reimbursement for paracentesis and thoracentesis by physicians and advanced practice providers (APPs) after the introduction of discreet Current Procedural Terminology codes for image-guidance. METHODS Medicare claims for 2012 to 2018 (paracentesis) and 2013 to 2018 (thoracentesis) were extracted using Current Procedural Terminology codes for blind and image-guided paracentesis and thoracentesis. Total volumes were analyzed by provider specialty. Nonfacility reimbursement and relative value units were compared. RESULTS For blind paracentesis, volume decreased from 17,393 to 12,226 procedures from 2012 to 2018. Conversely, volume of image-guided paracentesis increased from 171,631 to 253,834 procedures. Radiology performed the majority of image-guide paracentesis (83.9% in 2012 and 77.1% in 2018). Volume and relative share for APPs dramatically increased (from 10.2% to 15.8%). For blind thoracentesis, volume decreased from 26,716 to 15,075 procedures from 2013 to 2018. Conversely, volume of image-guided thoracentesis increased from 187,168 to 222,673 procedures. Radiology performed the majority of image-guided thoracentesis (73.6% in 2013 and 66.2% in 2018). Volume and relative share for APPs dramatically increased (from 7.7% to 12.9%). Although reimbursement for both image-guided paracentesis and thoracentesis decreased, their reimbursement remained higher than that of blind paracentesis and thoracentesis throughout the study period. CONCLUSION A higher percentage of these procedures are being performed using image guidance; radiologists performed a growing number but declining percentage of image-guided paracentesis and thoracentesis. APPs are playing an increasing role, particularly using image-guidance. Given decreasing reimbursement for these procedures, APPs can provide a large cost advantage in procedural radiology practices.
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Liu B, Wu Z, Lin C, Li L, Kuang X. Applicability of TIVAP versus PICC in non-hematological malignancies patients: A meta-analysis and systematic review. PLoS One 2021; 16:e0255473. [PMID: 34343193 PMCID: PMC8330915 DOI: 10.1371/journal.pone.0255473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 07/17/2021] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Applicability of totally implantable venous access port (TIVAP) and peripherally inserted central venous catheter (PICC) in non-hematological malignancies patients remains controversial. METHODS A systematic studies search in the public databases PubMed, EMBASE, Wan Fang, CNKI (China National Knowledge Infrastructure), the Cochrane Library and Google Scholar (updated to May 1, 2020) was performed to identify eligible researches. All statistical tests in this meta-analysis were performed using Stata 12.0 software (Stata Corp, College Station, TX). A P value less than 0.05 was considered statistically significant. RESULTS Thirteen studies were included in this final meta-analysis. The pooled data showed that compared with PICC, TIVAP was associated with a higher first-puncture success rate (OR:2.028, 95%CI:1.25-3.289, P<0.05), a lower accidental removal rate (OR:0.447, 95%CI:0.225-0.889, P<0.05) and lower complication rates, including infection (OR:0.570, 95%CI: 0.383-0.850, P<0.05), occlusion (OR:0.172, 95%CI:0.092-0.324, P<0.05), malposition (OR:0.279, 95%CI:0.128-0.608, P<0.05), thrombosis (OR:0.191, 95%CI, 0.111-0.329, P<0.05), phlebitis (OR:0.102, 95%CI, 0.038-0.273, P<0.05), allergy (OR:0.155, 95%CI:0.035-0.696, P<0.05). However, no difference was found in catheter life span (P>0.05) and extravasation (P>0.05). Moreover, TIVAP is more expensive compared with PICC in six-month use (weighted mean difference:3.132, 95%CI:2.434-3.83, P<0.05), but is much similar in 12 months use (P>0.05). CONCLUSION For the patients with non-hematological malignancies, TIVAP was superior to PICC in the data related to placement and the incidence of complications. Meanwhile, TIVAP is more expensive compared with PICC in six-month use, but it is much similar in twelve-month use.
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Affiliation(s)
- Baiying Liu
- Department of Gastrointestinal Surgery, The Third XiangYa Hospital of Central South University, Changsha, China
| | - Zhiwei Wu
- Department of Gastrointestinal Surgery, The Third XiangYa Hospital of Central South University, Changsha, China
| | - Changwei Lin
- Department of Gastrointestinal Surgery, The Third XiangYa Hospital of Central South University, Changsha, China
| | - Liang Li
- Department of Gastrointestinal Surgery, The Third XiangYa Hospital of Central South University, Changsha, China
| | - Xuechun Kuang
- Department of Geratic Surgery, Xiangya Hospital of Central South University, Changsha, Hunan, China
- * E-mail:
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Krein SL, Harrod M, Weston LE, Garlick BR, Quinn M, Fletcher KE, Chopra V. Comparing peripherally inserted central catheter-related practices across hospitals with different insertion models: a multisite qualitative study. BMJ Qual Saf 2021; 30:628-638. [PMID: 33361343 PMCID: PMC8222389 DOI: 10.1136/bmjqs-2020-011987] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/03/2020] [Accepted: 12/09/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Peripherally inserted central catheters (PICCs) provide reliable intravenous access for delivery of parenteral therapy. Yet, little is known about PICC care practices or how they vary across hospitals. We compared PICC-related processes across hospitals with different insertion delivery models. METHODS We used a descriptive qualitative methodology and a naturalist philosophy, with site visits to conduct semistructured interviews completed between August 2018 and January 2019. Study sites included five Veterans Affairs Medical Centres, two with vascular access teams (VATs), two with PICC insertion primarily by interventional radiology (IR) and one without on-site PICC insertion capability. Interview participants were healthcare personnel (n=56), including physicians, bedside and vascular access nurses, and IR clinicians. Data collection focused on four PICC domains: use and decision-making process, insertion, in-hospital management and patient discharge education. We used rapid analysis and a summary matrix to compare practices across sites within each domain. RESULTS Our findings highlight the benefits of dedicated VATs across all PICC-related process domains, including implementation of criteria to guide PICC placement decisions, timely PICC insertion, more robust management practices and well-defined patient discharge education. We also found areas with potential for improvement, such as clinician awareness of PICC appropriateness criteria and alternative devices, deployment of VATs and patient discharge education. CONCLUSION Vascular access nurses play critical roles in all aspects of PICC-related care. There is variation in PICC decision-making, care and maintenance, and patient education across hospitals. Quality and safety improvement opportunities to reduce this variation are highlighted.
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Affiliation(s)
- Sarah L Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Molly Harrod
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Lauren E Weston
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Brittani R Garlick
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Martha Quinn
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathlyn E Fletcher
- Internal Medicine, Clement J. Zablocki VAMC, Milwaukee, Wisconsin, USA
- Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Vineet Chopra
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Moss JG, Wu O, Bodenham AR, Agarwal R, Menne TF, Jones BL, Heggie R, Hill S, Dixon-Hughes J, Soulis E, Germeni E, Dillon S, McCartney E. Central venous access devices for the delivery of systemic anticancer therapy (CAVA): a randomised controlled trial. Lancet 2021; 398:403-415. [PMID: 34297997 DOI: 10.1016/s0140-6736(21)00766-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/19/2021] [Accepted: 03/26/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hickman-type tunnelled catheters (Hickman), peripherally inserted central catheters (PICCs), and totally implanted ports (PORTs) are used to deliver systemic anticancer treatment (SACT) via a central vein. We aimed to compare complication rates and costs of the three devices to establish acceptability, clinical effectiveness, and cost-effectiveness of the devices for patients receiving SACT. METHODS We did an open-label, multicentre, randomised controlled trial (Cancer and Venous Access [CAVA]) of three central venous access devices: PICCs versus Hickman (non-inferiority; 10% margin); PORTs versus Hickman (superiority; 15% margin); and PORTs versus PICCs (superiority; 15% margin). Adults (aged ≥18 years) receiving SACT (≥12 weeks) for solid or haematological malignancy from 18 oncology units in the UK were included. Four randomisation options were available: Hickman versus PICCs versus PORTs (2:2:1), PICCs versus Hickman (1:1), PORTs versus Hickman (1:1), and PORTs versus PICCs (1:1). Randomisation was done using a minimisation algorithm stratifying by centre, body-mass index, type of cancer, device history, and treatment mode. The primary outcome was complication rate (composite of infection, venous thrombosis, pulmonary embolus, inability to aspirate blood, mechanical failure, and other) assessed until device removal, withdrawal from study, or 1-year follow-up. This study is registered with ISRCTN, ISRCTN44504648. FINDINGS Between Nov 8, 2013, and Feb 28, 2018, of 2714 individuals screened for eligibility, 1061 were enrolled and randomly assigned, contributing to the relevant comparison or comparisons (PICC vs Hickman n=424, 212 [50%] on PICC and 212 [50%] on Hickman; PORT vs Hickman n=556, 253 [46%] on PORT and 303 [54%] on Hickman; and PORT vs PICC n=346, 147 [42%] on PORT and 199 [58%] on PICC). Similar complication rates were observed for PICCs (110 [52%] of 212) and Hickman (103 [49%] of 212). Although the observed difference was less than 10%, non-inferiority of PICCs was not confirmed (odds ratio [OR] 1·15 [95% CI 0·78-1·71]) potentially due to inadequate power. PORTs were superior to Hickman with a complication rate of 29% (73 of 253) versus 43% (131 of 303; OR 0·54 [95% CI 0·37-0·77]). PORTs were superior to PICCs with a complication rate of 32% (47 of 147) versus 47% (93 of 199; OR 0·52 [0·33-0·83]). INTERPRETATION For most patients receiving SACT, PORTs are more effective and safer than both Hickman and PICCs. Our findings suggest that most patients receiving SACT for solid tumours should receive a PORT within the UK National Health Service. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Jonathan G Moss
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
| | - Olivia Wu
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - Roshan Agarwal
- Department of Oncology, Northampton General Hospital, Northampton, UK
| | - Tobias F Menne
- Department of Haematology, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Brian L Jones
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Robert Heggie
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Steve Hill
- Procedure Unit, The Christie NHS Foundation Trust, Withington, UK
| | - Judith Dixon-Hughes
- Cancer Research UK Glasgow Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Eileen Soulis
- Cancer Research UK Glasgow Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Evi Germeni
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Susan Dillon
- Cancer Research UK Glasgow Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Elaine McCartney
- Cancer Research UK Glasgow Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
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