Modifier 22 Use in Fee-for-Service Medicare

Importance

Modifier 22 is a mechanism designed for surgeons to identify cases that are more complex than their Current Procedural Terminology code accounts for. However, empirical studies of the use and efficacy of modifier 22 are lacking.

Objective

To assess the use of modifier 22 in common surgical procedures and the association of use with compensation.

Design, Setting, and Participants

This was a cross-sectional analysis of the 2021 Physician/Supplier Procedure Summary Limited Data Set including all Part B carrier and durable medical equipment fee-for-service claims. Claims for 10 common surgical procedures were evaluated, including mastectomy, total hip arthroplasty, total knee arthroplasty, coronary artery bypass grafting, laparoscopic right colectomy, laparoscopic appendectomy, laparoscopic cholecystectomy, kidney transplant, laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy, and lumbar laminectomy. Data were analyzed from August to November 2023.

Main Outcomes and Measures

Rate of modifier 22 use, rate of claim denial, mean charges, mean payment for accepted claims, and mean payment for all claims.

Results

The sample included 625 316 surgical procedures performed in calendar year 2021. The proportion of modifier 22 coding for a procedure ranged from 5725 of 251 521 (2.3%) in total knee arthroplasty to 1566 of 18 459 (8.5%) in laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy. Submitted charges were 11.1% (95% CI, 9.1-13.2) to 22.8% (95% CI, 21.3-24.3) higher for claims with modifier 22, depending on the procedure. Among accepted claims, those with modifier 22 had increased payments ranging from 0.8% (95% CI, 0.7-1.0) to 4.8% (95% CI, 4.5-5.1). However, claims with modifier 22 were more likely to be denied (7.4% vs 4.0%; P < .001). As a result, overall mean payments were mixed, with 4 procedures having lower payments when modifier 22 was appended, 4 procedures having higher payments with modifier 22, and 2 procedures with no difference. The largest increase in mean payment for modifier 22 claims was for kidney transplant with an increased payment of $71.46 (95% CI, 55.32-87.60), which translates to a relative increase of 3.4% (95% CI, 2.9-4.6).

Conclusions and Relevance

The findings in this study suggest that modifier 22 had little to no financial benefit when appended to claims for a diverse panel of surgical procedures. In the current system, surgeons have little reason to request modifier 22, and no mechanisms currently exist for surgeons to recoup payment for difficult operations.

Postoperative Opioid Use Is Associated with Increased Rates of Grade B/C Pancreatic Fistula After Distal Pancreatectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a major source of morbidity after distal pancreatectomy. This study examined the association between postoperative opioid use and CR-POPF in the context of opioid-sparing postoperative care.

METHODS

A case-control study was performed on consecutive patients who underwent distal pancreatectomy between October 2016 and April 2022 at a single institution. Patients who developed CR-POPF were compared to controls. Multivariable regression modeling was used to identify factors associated with CR-POPF.

RESULTS

A total of 281 patients underwent 187 open, 20 laparoscopic, and 74 robotic-assisted operations. The rate of CR-POPF was 21% (n = 58). CR-POPF rate declined from 32 to 8% over the study period (p < 0.001). Median oral morphine equivalents (OME) administered on POD 0-1 and 0-3 were 94 and 129 mg, respectively, in patients who did not develop a fistula versus 130 and 180 mg in those who did (both p ≤ 0.001). POD 0-3 OME (OR 1.11, p = 0.044) was independently associated with increased odds of CR-POPF, with each additional 50 mg (equivalent to 10 tramadol pills) increasing the relative risk by 11% and absolute risk by 2%.

CONCLUSION

Early postoperative opioid use after distal pancreatectomy was associated with increased odds of CR-POPF. Decreasing perioperative opioid use through enhanced postoperative management is a low-cost and generalizable approach that may reduce rates of CR-POPF after distal pancreatectomy.

Insurance Disparities in Access to Robotic Surgery for Colorectal Cancer

BACKGROUND

The use of the robotic approach is increasing for colorectal cancer operations, but the added cost of the platform has the potential to introduce challenges in its dissemination. We hypothesized that adoption of the robot is introducing new disparities in access to minimally invasive surgery (MIS) for colorectal cancer, especially across patient insurance groups.

METHODS

This cross-sectional study analyzed surgical cases of stage I-III colorectal cancer from the National Cancer Database (NCDB) between 2010 and 2019. The primary outcome was surgical approach (robotic, laparoscopic, or the composite "MIS"). The predictor was a patient's primary payor. Potential confounders included sociodemographics, tumor characteristics, and the facility. Hierarchical multivariable models were generated, and sensitivity analyses were performed.

RESULTS

For colorectal cancer operations, the MIS approach increased from 39% in 2010 to 73% in 2019, driven predominantly by an increase in the robotic approach from 2 to 24%. For laparoscopy, the size of the disparity between patients with Private insurance and Medicaid shrank from 11% (2010) to 4% (2019), whereas this disparity increased for the robotic approach from 1% (2010) to 5% (2019). On adjusted analysis, patients with Medicaid (odds ratio [OR] 0.86 [CI 0.79-0.95]) and the Uninsured (OR 0.67 [CI 0.56-0.79]) had lower odds of receiving a robotic operation than those with Private insurance in 2019. This disparity remained consistent across five sensitivity analyses.

CONCLUSIONS

As the field of colorectal cancer surgery shifts away from laparoscopy and toward robotics, new inequities across patient insurance are emerging. Proactive efforts are needed to ensure all patients benefit from a minimally invasive approach.

Compliance of National Cancer Institute-Designated Cancer Centers With January 2021 Price Transparency Requirements

This cross-sectional study investigates the compliance rate of hospitals with National Cancer Institute–designated cancer center status with the Centers for Medicare &amp;amp; Medicaid Services January 2021 price transparency requirements.

Clinical outcomes and cost of robotic ventral hernia repair: systematic review

BACKGROUND

Robotic ventral hernia repair (VHR) has seen rapid adoption, but with limited data assessing clinical outcome or cost. This systematic review compared robotic VHR with laparoscopic and open approaches.

METHODS

This systematic review was undertaken in accordance with PRISMA guidelines. PubMed, MEDLINE, Embase, and Cochrane databases were searched for articles with terms relating to 'robot-assisted', 'cost effectiveness', and 'ventral hernia' or 'incisional hernia' from 1 January 2010 to 10 November 2020. Intraoperative and postoperative outcomes, pain, recurrence, and cost data were extracted for narrative analysis.

RESULTS

Of 25 studies that met the inclusion criteria, three were RCTs and 22 observational studies. Robotic VHR was associated with a longer duration of operation than open and laparoscopic repairs, but with fewer transfusions, shorter hospital stay, and lower complication rates than open repair. Robotic VHR was more expensive than laparoscopic repair, but not significantly different from open surgery in terms of cost. There were no significant differences in rates of intraoperative complication, conversion to open surgery, surgical-site infection, readmission, mortality, pain, or recurrence between the three approaches.

CONCLUSION

Robotic VHR was associated with a longer duration of operation, fewer transfusions, a shorter hospital stay, and fewer complications compared with open surgery. Robotic VHR had higher costs and a longer operating time than laparoscopic repair. Randomized or matched data with standardized reporting, long-term outcomes, and cost-effectiveness analyses are still required to weigh the clinical benefits against the cost of robotic VHR.

Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures

OBJECTIVE

The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures.

SUMMARY BACKGROUND DATA

Reducing surgical costs is paramount to the viability of hospitals.

METHODS

Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.

RESULTS

The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.

CONCLUSIONS

Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

Assessment of the Contribution of the Work Relative Value Unit Scale to Differences in Physician Compensation Across Medical and Surgical Specialties

Importance

The work relative value units (wRVUs) for a physician service can be conceptualized as the amount of time spent by the physician multiplied by a compensation rate (wRVUs/min). Disproportionately high compensation rates assigned to procedures have been blamed for pay differences across specialties, but to our knowledge, a comprehensive assessment is lacking.

Objective

To assess how compensation rates built into work RVUs contribute to differences in physician compensation across specialties.

Design, Setting, and Participants

This cross-sectional analysis examined 2017 Part B fee-for-service Medicare data. The data were analyzed from May 1 to May 30, 2019.

Main Outcomes and Measures

A specialty-wide compensation rate (wRVUs/min) was generated for 42 medical and surgical specialties defined as the sum of wRVUs for all billed current procedural terminology codes divided by the presumed time to perform those services. This measure accounted for the volume and diversity of services each specialty provides. Sensitivity analyses were performed to assess the association of errors in wRVU time estimates with average compensation rates.

Results

The final sample included 42 specialties and 6587 distinct Current Procedual Terminology (CPT) codes. The number of CPT codes attributed to a specialty ranged from 575 (medical oncology) to 4346 (general surgery). Compensation rates ranged from 0.029 wRVUs/min (pathology) to 0.057 wRVUs/min (emergency medicine). Most specialties (34/42 [81.0%]) had compensation rates between 0.035 and 0.045 wRVUs/min. The mean compensation rate for surgical specialties was 7.2% higher than for medical specialties, a difference that was not statistically significant. This narrow range reflects the fact that most specialties had more than 60% of time allocated to activities outside the intraservice period. Assuming that time values for surgical procedures are significantly overestimated increased the difference in average compensation between surgical and medical specialties to 23.4%.

Conclusions and Relevance

Compensation rates assumed in wRVU valuations are small contributors to differences in physician compensation. Factors outside of the wRVU system, such as payer mix and work hours, could be targeted if narrowing the difference in compensation across specialties is desired.

The impact of removing global periods on pediatric surgeon reimbursement

PURPOSE

CMS has proposed removing postoperative care from the global periods for surgical procedures and instead requiring surgeons to bill for postoperative visits using evaluation & management (E&M) codes. This policy may alter reimbursement to pediatric surgeons.

METHODS

To assess the impact of this policy, NSQIP-pediatric data were used to calculate median LOS for high-volume procedures with 10 or 90 day global periods. We then merged these data with CMS physician work time and RVU files. A CMS LOS variable was created by counting the number of hospital-based E&M codes built into the global period based on the fact that if global periods are removed, surgeons may only bill one E&M code per postoperative day. We then compared the CMS and NSQIP LOS values.

RESULTS

The dataset included 201 CPT codes with NSQIP LOS estimates derived from a median of 137 operations. Twenty-nine procedures (14.4%) had higher, 24 (16.9%) had the same, and 138 (68.7%) had lower NSQIP median LOS than current CMS values. On average, NSQIP values were 40.0% (95% confidence interval [95CI] -50.0, -29.9%) lower than CMS values. Based on a daily average work RVU per postoperative E&M code of 1.09 (95% CI 1.05, 1.12), and $35.78 per RVU (2017 rate), surgeons in this sample would experience a cumulative annual reduction in reimbursement of approximately $3.4 M following the policy change.

CONCLUSIONS

Most pediatric surgical procedures have RVU valuations that include more hospital-based E&M codes than the current median number of postoperative days. Holding all else equal, the removal of global periods would therefore reduce reimbursement for pediatric surgeons. The downstream effects of this policy change, such as the impact on the quality of clinical care, are uncertain and warrant further investigation.

TYPE OF STUDY

Clinical research paper.

LEVEL OF EVIDENCE

Level II.

Association of Geriatric Events With Perioperative Outcomes After Elective Inpatient Surgery

BACKGROUND

Older adults undergoing surgery are at risk for geriatric events (GEs: delirium, dehydration, falls or fractures, failure to thrive, and pressure ulcers). The prevalence and association of GEs with clinical outcomes after elective surgery is unclear.

MATERIALS AND METHODS

Using the 2013-2014 National Inpatient Sample, we analyzed hospital admissions for the five most common elective procedures (total knee arthroplasty, right hemicolectomy, carotid endarterectomy, aortic valve replacement, and radical prostatectomy) in older adults (age ≥ 65). Our primary variable of interest was presence of any GE. Logistic regression estimated the association of GEs with (1) age group and (2) perioperative outcomes (mortality, postoperative complications, prolonged length of stay, and discharge to skilled nursing facility).

RESULTS

Of 1,255,120 admissions, 66.5% were aged ≥65. The overall rate of any GE was 2.4% and increased with age (55-64 y: 1.5%; 65-74: 2.2%; ≥75: 4.1%; P < 0.001). After adjustment, the probability of any GE increased with age (P < 0.001). Rates of GEs varied by procedure (P < 0.001). In comparison with admissions with no GEs, one or more GE was associated with higher probability of worse outcomes including mortality, postoperative complications, prolonged length of stay, and discharge to skilled nursing facility (all P < 0.001). In addition, there was a dose-dependent relationship between GEs and these poor perioperative outcomes.

CONCLUSIONS

GEs are strongly associated with poor perioperative outcomes. Efforts should focus on mutable factors responsible for GEs to optimize surgical care for older adults.

Older veterans undergoing inpatient surgery: What is the compliance with best practice guidelines?

BACKGROUND

The United States population is aging, and the number of older adults requiring operative care is increasing at a rapid rate. In order to address this issue, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society created best practice guidelines surrounding optimal perioperative care for the older adult surgical patient. This study aimed to determine the documented compliance with these guidelines at a single institution.

METHODS

A retrospective chart review was performed on 86 older adults undergoing elective, inpatient coronary artery bypass graft, prostatectomy, or colectomy over a 2-year period (1/2016-12/2017) at a single Veterans Affairs institution. The primary outcome was compliance with the 38 measures from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society Best Practice Guidelines. The secondary outcome was postoperative (including geriatric-specific) complications.

RESULTS

The mean reported compliance across all measures was 41% ± 4%. Of 38 analyzed measures, compliance for 10 measures was achieved for 0 patients, and only 1 patient for 7 measures. There was variance in compliance by phase of care (P < .05) with a high of 56% ± 8% (immediate preoperative phase of care) and a low of 35% ± 4% (intraoperative phase of care).

CONCLUSION

Overall reported compliance with the Best Practice Guidelines of the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society is low (41%) at this institution. This study identifies a need to improve the care provided to the vulnerable population of older adults undergoing an operation. Future work is needed to understand barriers for implementation and how compliance relates to outcomes.

Perioperative and Long-Term Outcomes of Robot-Assisted Partial Nephrectomy: A Systematic Review

Background

Adoption of the robotic surgical platform for small renal cancers has rapidly expanded, but its utility compared to other approaches has not been established. The objective of this review is to assess perioperative and long-term oncologic and functional outcomes of robot-assisted partial nephrectomy (RAPN) compared to laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).

Methods

A search in PubMed, Embase, and Cochrane (2010-2019) was conducted. Of 3877 articles screened, 7 observational studies were included.

Results

RAPN was associated with 24-50 mL less intraoperative blood loss compared to LPN and 39-84 mL less than OPN. RAPN also demonstrated trends of other postoperative benefits, such as shorter length of stay and fewer major complications. Several studies reported better long-term functional kidney outcomes, but these findings were inconsistent. Recurrence and cancer-specific survival (CSS) were similar across groups. While RAPN had a 5-year CSS of 90.1%-97.9%, LPN and OPN had survival rates of 85.9%-86.9% and 88.5-96.3% respectively.

Conclusions

RAPN may be associated with a lower estimated blood loss and comparable long-term outcomes when compared to other surgical approaches. However, additional randomized or propensity matched studies are warranted to fully assess long-term functional kidney and oncologic outcomes.

Association of Work Measures and Specialty With Assigned Work Relative Value Units Among Surgeons

Importance

The primary data sources used to generate and update work relative value units (RVUs) are surveys of small groups of specialists who are asked to estimate the time and intensity needed to perform surgical procedures. Because these surveys are conducted by specialty societies and rely on subjective data, these sources have been challenged as potentially biased.

Objective

To assess whether objective work measures are associated with a surgical procedure's assigned work RVUs and whether differences exist by surgical specialty.

Design, Setting, and Participants

This cross-sectional study obtained data from the 2016 and 2017 participant use files of the American College of Surgeons National Surgical Quality Improvement Program. The 2017 physician fee schedule of the Centers for Medicare & Medicaid Services was a secondary data source. Procedures were included if they had at least 100 patient-level observations over the 2-year period. Data were analyzed from August 29, 2018, to April 2, 2019.

Main Outcomes and Measures

The dependent variable was a procedure's assigned work RVU. Independent variables of work RVUs were 4 procedure-level work measures (median operative time, median postoperative length of stay, all-cause 30-day readmission rate, and all-cause 30-day reoperation rate) and surgeon specialty (10-level category using general surgery as the reference).

Results

The data set included 628 unique Current Procedural Terminology (CPT) codes and 726 CPT-specialty combinations from 1 239 991 patient observations. Statistically significant associations were found between each work measure and assigned work RVU, as follows: median operative time (R2 = 0.74; 95% CI, 0.71-0.78), postoperative length of stay (R2 = 0.42; 95% CI, 0.36-0.48), rate of readmission (R2 = 0.18; 95% CI, 0.13-0.23), and rate of reoperation (R2 = 0.15; 95% CI, 0.10-0.20). Including all 4 measures explained 80.2% (95% CI, 77.3%-83.1%) of the variation. Adding the surgical specialty improved the overall fit of the model (likelihood ratio test χ2 = 231.27; P < .001). Cardiac (7.78; 95% CI, 4.25-11.31; P < .001) and neurosurgery (2.46; 95% CI, 1.08-3.83; P < .001) had higher work RVUs compared with general surgery, whereas orthopedics (-1.53; 95% CI, -2.48 to -0.59; P = .002), urology (-1.58; 95% CI, -2.88 to -0.29; P = .02), plastics (-2.70; 95% CI, -4.39 to -1.01; P = .002), and otolaryngology (-3.05; 95% CI, -4.69 to -1.42; P < .001) had lower work RVUs compared with general surgery.

Conclusions and Relevance

Objective work measures appeared to be associated with assigned work RVUs, predominantly with operative time; registry data can be used to augment and inform the generation and updating processes of the work RVUs.

Geriatric Events among Older Adults Undergoing Nonelective Surgery are Associated with Poor Outcomes

Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55–64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure ( P < 0.001). After adjustment, the probability of any GE increased with age category ( P < 0.001); having any GE was associated with higher probability of all outcomes ( P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose–response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.

Cost Saving of Short Hospitalization Nonoperative Management for Acute Uncomplicated Appendicitis

BACKGROUND

Nonoperative management (NOM) of uncomplicated appendicitis has gained recognition as an alternative to surgery. In the largest published randomized trial (Appendicitis Acuta), patients received a 3-d hospital stay for intravenous antibiotics; however, cost implications for health care systems remain unknown. We hypothesized short stay protocols would be cost saving compared with a long stay protocol.

MATERIALS AND METHODS

We constructed a Markov model comparing the cost of three protocols for NOM of acute uncomplicated appendicitis: (1) long stay (3-d hospitalization), (2) short stay (1-d hospitalization), and (3) emergency department (ED) discharge. The long stay protocol was modeled on data from the APPAC trial. Model variables were abstracted from national database and literature review. One-way and two-way sensitivity analyses were performed to determine the impact of uncertainty on the model.

RESULTS

The long stay treatment protocol had a total 5-y projected cost of $10,735 per patient. The short stay treatment protocol costs $8026 per patient, and the ED discharge protocol costs $6,825, which was $2709 and $3910 less than the long stay protocol, respectively. One-way sensitivity analysis demonstrated that the relative risk of treatment failure with the short stay protocol needed to exceed 6.3 (absolute risk increase of 31%) and with the ED discharge protocol needed to exceed 8.75 (absolute risk increase of 45%) in order for the long stay protocol to become cost saving.

CONCLUSIONS

Short duration hospitalization protocols to treat appendicitis nonoperatively with antibiotics are cost saving under almost all model scenarios. Future consideration of patient preferences and health-related quality of life will need to be made to determine if short stay treatment protocols are cost-effective.

Clinical Effectiveness and Resource Utilization of Surgery versus Endovascular Therapy for Chronic Limb-Threatening Ischemia

BACKGROUND

The clinical effectiveness of surgical versus endovascular therapy for chronic limb-threatening ischemia (CLTI) continues to be debated, and the resources required for each therapy are unclear.

METHODS

Systematic review of randomized controlled trials (RCTs) and observational studies comparing surgery with endovascular therapy for CLTI, which reported clinical effectiveness and resource utilization. Short-term and long-term clinical outcomes were examined.

RESULTS

The search yielded 4,231 titles, of which 17 publications met our inclusion criteria. Five publications were all from 1 RCT, and 12 publications were observational studies. In the RCT, the surgical approach had greater resource use in the first year (total hospital days across all admissions for surgery versus angioplasty: 46.14 ± 53.87 vs. 36.35 ± 51.39; P < 0.001; also true for days in high-dependency and intensive therapy units), but differences were not statistically significant in subsequent years. All-cause mortality presented a nonsignificant difference favoring angioplasty in the first 2 years (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [95% CI], 0.75-2.15), but after 2 years, it favored surgical treatment (aHR, 0.34; 95% CI, 0.17-0.71). The observational studies reported short-term effectiveness and resource utilization favoring endovascular therapy, but most differences were not statistically significant. Long-term outcomes were more mixed; in particular, mortality outcomes generally favored surgery, although concluding that cause and effect is not possible as endovascularly treated patients tended to be older and may have had a shorter life expectancy regardless of therapy.

CONCLUSIONS

The clinical effectiveness and resource utilization of surgery compared with endovascular therapy for CLTI is not known with certainty and will not be known until ongoing trials report results. It is likely that findings will vary by the time horizon, where initial outcomes and utilization tend to favor endovascular interventions, but long-term outcomes favor surgical revascularization.

Tripal EUtils: a Tripal module to increase exchange and reuse of genome assembly metadata

Data and metadata interoperability between data storage systems is a critical component of the FAIR data principles. Programmatic and consistent means of reconciling metadata models between databases promote data exchange and thus increases its access to the scientific community. This process requires (i) metadata mapping between the models and (ii) software to perform the mapping. Here, we describe our efforts to map metadata associated with genome assemblies between the National Center for Biotechnology Information (NCBI) data resources and the Chado biological database schema. We present mappings for multiple NCBI data structures and introduce a Tripal software module, Tripal EUtils, to pull metadata from NCBI into a Tripal/Chado database. We discuss potential mapping challenges and solutions and provide suggestions for future development to further increase interoperability between these platforms. Database URL: https://github.com/NAL-i5K/tripal_eutils.

Evaluating Surgeons on Intraoperative Disposable Supply Costs: Details Matter

BACKGROUND

Cost report cards have demonstrated variation in intraoperative supply costs and may allow comparisons between surgeons. However, cost data are complex and, if not properly vetted, may be inaccurate.

METHODS

A retrospective assessment of intraoperative supply costs for consecutive laparoscopic cholecystectomies (2013-2017) at a 4-facility academic center was performed. Using unadjusted data (akin to an auto-generated report card), surgeons were ranked and highest to lowest-cost ratios were calculated. Then, four stepwise adjustments were performed: (1) excluded non-comparable operations and low volume (< 10 cases) surgeons, (2) eliminated outlier cases based on instrument profiles, (3) stratified by facility, and (4) adjusted prices (assigned one price; corrected aberrant/missing prices). Surgeon rank and highest to lowest-cost ratios were then re-calculated.

RESULTS

The unadjusted data identified 1392 cases for 33 surgeons (range, 1-317 cases). The ratio between the highest cost and lowest cost surgeon was 4.13. Steps 1 and 2 excluded 272 cases and 15 surgeons. Facility sample sizes ranged from 144 to 621 (step 3). Adjusting prices (step 4) required manual review of 472 unique items: 45% had > 1 price and 16 had missing prices. After all adjustments, surgeons had different rankings and highest to lowest-cost ratios within sites were smaller (ratio range, 1.17-2.10).

CONCLUSIONS

Evaluating surgeons based on intraoperative supply costs is sensitive to analytic methods. Surgeons who were initially considered cost outliers became the least expensive within a given site. Auto-generated cost report cards may require additional analyses to produce accurate comparative assessments.

A Comparison of Costs: How California Teaching Hospitals Achieved Slower Growth Than Nonteaching Hospitals in Operating Room Costs From 2005 to 2014

PURPOSE

Historically, teaching hospitals have had higher costs than nonteaching hospitals, introducing potential financial risk in value-based payment models. This study compared risk-adjusted operating room (OR) costs between California teaching and nonteaching hospitals.

METHOD

Using 2,992 financial statements from fiscal years (FYs) 2005-2014, the authors extracted data for OR total costs, components of direct costs, and indirect costs. Cross-sectional and longitudinal models estimated OR costs per minute of surgery by teaching status, ownership, case mix index, and geographic area.

RESULTS

Risk-adjusted cost was $9.44 per minute less in teaching than nonteaching hospitals in FY 2014 (95% CI, 3.03-15.85, P = .004). Between FY 2005 and FY 2014, OR costs grew more slowly at teaching hospitals because of slower wage growth and indirect costs per minute (-$0.13 and -$0.77 per minute per year, respectively, P = .005 and P < .001). Hourly pay rose more at teaching hospitals ($0.26 per hour per year, P = .008) but was offset by slower full-time equivalents growth (-0.002 per 10,000 OR minutes per year, P = .001). Between FY 2005 and FY 2014, operative volume increased at teaching hospitals and decreased at nonteaching hospitals.

CONCLUSIONS

By 2014, California teaching hospitals had lower OR costs per minute than nonteaching hospitals because of relative labor productivity gains and slower indirect cost growth. The latter likely resulted from a volume shift from nonteaching to teaching facilities. These trends will help teaching hospitals compete under value-based models. Implications for patients and nonteaching hospitals warrant evaluation.

Geriatric Events Among Older Adults Undergoing Nonelective Surgery Are Associated with Poor Outcomes

Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55-64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure (P < 0.001). After adjustment, the probability of any GE increased with age category (P < 0.001); having any GE was associated with higher probability of all outcomes (P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose-response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.

Hospital experience predicts outcomes after high-risk geriatric surgery

BACKGROUND

Geriatric patients require specialized perioperative care, yet the impact of geriatric surgery proportion (a measure of experience) and geriatric surgery volume, on clinical outcomes is unknown. This study analyzes the association between proportion and volume and clinical outcomes after high-risk geriatric surgery.

METHODS

Using the 2014 National Inpatient Sample, hospital encounters for older adults (≥65 years) undergoing high-risk geriatric surgery were identified. Geriatric surgery volume was defined as a hospital's annual volume of geriatric patients undergoing high-risk geriatric surgery. Geriatric surgery proportion was calculated as volume divided by the sum of high-risk surgeries in all ages. Hierarchical multivariable regression models identified predictors of inpatient mortality, postoperative length of stay, and discharge to nursing facility.

RESULTS

There were an estimated 514,950 hospital encounters for older adults undergoing high-risk geriatric surgery from 3,115 hospitals. Mean proportion was 0.53 ± 0.19; median volume was 60 cases per year, ranging from 5 to 3,235. After adjustment, comparing the 90th to 10th percentiles, higher proportion was associated with decreased mortality (odds ratio [95% confidence interval] 0.81 [0.73-0.88]; P < .001) and shorter postoperative length of stay (-4.44% (-5.49 to -3.39%); P < .0001). Higher volume was not associated with mortality but was associated with longer length of stay (7.76% [6.75-8.77%]; P < .0001) and decreased discharge to nursing facility (0.87 [0.79-0.95]; P= .003).

CONCLUSION

Treatment of geriatric patients at hospitals with the highest proportion of high-risk geriatric surgery, or the most experience, is associated with improved outcomes. High-proportion hospitals should be examined to understand the mechanisms by which better quality geriatric surgical care is achieved, while lower-proportion hospitals may be targets for quality improvement efforts.

Differences in Outcomes Based on Sex for Pediatric Patients Undergoing Pyloromyotomy

BACKGROUND

Males and females are known to have varied responses to medical interventions. Our study aimed to determine the effect of sex on surgical outcomes after pyloromyotomy.

MATERIALS AND METHODS

Using the Kids' Inpatient Database for the years 2003-2012, we performed a serial, cross-sectional analysis of a nationally representative sample of all patients aged <1 y who underwent pyloromyotomy for hypertrophic pyloric stenosis. The primary predictor of interest was sex. Outcomes included mortality, in-hospital complications, cost, and length of stay. Regression models were adjusted by race, age group, comorbidity, complications, and whether operation was performed on the day of admission with region and year fixed effects.

RESULTS

Of 48,834 weighted operations, 81.8% were in males and 18.2% were in females. The most common reported race was white (47.3%) and most of the patients were ≥29 days old (72.5%). There was no difference in the odds of postoperative complications, but females had a significantly longer length of stay (incidence rate ratio, 1.28; 95% confidence interval [95% CI], 1.18-1.39; P ≤ 0.01), higher cost (5%, 95% CI, 1.02-1.08; P ≤ 0.01), and higher odds of mortality (odds ratio, 3.26; 95% CI, 1.52-6.98; P ≤ 0.01).

CONCLUSIONS

Our study demonstrated that females had worse outcomes after pyloromyotomy compared with males. These findings are striking and are important to consider when treating either sex to help set physician and family expectations perioperatively. Further studies are needed to determine why such differences exist and to develop targeted treatment strategies for both females and males with pyloric stenosis.

A Comparison of Payments to a For-profit Dialysis Firm From Government and Commercial Insurers

This study assesses differences in payments from government and commercial insurers to dialysis clinics using data from a single for-profit organization.

Molecular evolutionary trends and feeding ecology diversification in the Hemiptera, anchored by the milkweed bug genome

BACKGROUND

The Hemiptera (aphids, cicadas, and true bugs) are a key insect order, with high diversity for feeding ecology and excellent experimental tractability for molecular genetics. Building upon recent sequencing of hemipteran pests such as phloem-feeding aphids and blood-feeding bed bugs, we present the genome sequence and comparative analyses centered on the milkweed bug Oncopeltus fasciatus, a seed feeder of the family Lygaeidae.

RESULTS

The 926-Mb Oncopeltus genome is well represented by the current assembly and official gene set. We use our genomic and RNA-seq data not only to characterize the protein-coding gene repertoire and perform isoform-specific RNAi, but also to elucidate patterns of molecular evolution and physiology. We find ongoing, lineage-specific expansion and diversification of repressive C2H2 zinc finger proteins. The discovery of intron gain and turnover specific to the Hemiptera also prompted the evaluation of lineage and genome size as predictors of gene structure evolution. Furthermore, we identify enzymatic gains and losses that correlate with feeding biology, particularly for reductions associated with derived, fluid nutrition feeding.

CONCLUSIONS

With the milkweed bug, we now have a critical mass of sequenced species for a hemimetabolous insect order and close outgroup to the Holometabola, substantially improving the diversity of insect genomics. We thereby define commonalities among the Hemiptera and delve into how hemipteran genomes reflect distinct feeding ecologies. Given Oncopeltus's strength as an experimental model, these new sequence resources bolster the foundation for molecular research and highlight technical considerations for the analysis of medium-sized invertebrate genomes.

Molecular evolutionary trends and feeding ecology diversification in the Hemiptera, anchored by the milkweed bug genome

BACKGROUND

The Hemiptera (aphids, cicadas, and true bugs) are a key insect order, with high diversity for feeding ecology and excellent experimental tractability for molecular genetics. Building upon recent sequencing of hemipteran pests such as phloem-feeding aphids and blood-feeding bed bugs, we present the genome sequence and comparative analyses centered on the milkweed bug Oncopeltus fasciatus, a seed feeder of the family Lygaeidae.

RESULTS

The 926-Mb Oncopeltus genome is well represented by the current assembly and official gene set. We use our genomic and RNA-seq data not only to characterize the protein-coding gene repertoire and perform isoform-specific RNAi, but also to elucidate patterns of molecular evolution and physiology. We find ongoing, lineage-specific expansion and diversification of repressive C2H2 zinc finger proteins. The discovery of intron gain and turnover specific to the Hemiptera also prompted the evaluation of lineage and genome size as predictors of gene structure evolution. Furthermore, we identify enzymatic gains and losses that correlate with feeding biology, particularly for reductions associated with derived, fluid nutrition feeding.

CONCLUSIONS

With the milkweed bug, we now have a critical mass of sequenced species for a hemimetabolous insect order and close outgroup to the Holometabola, substantially improving the diversity of insect genomics. We thereby define commonalities among the Hemiptera and delve into how hemipteran genomes reflect distinct feeding ecologies. Given Oncopeltus's strength as an experimental model, these new sequence resources bolster the foundation for molecular research and highlight technical considerations for the analysis of medium-sized invertebrate genomes.

Painting a portrait: Analysis of national health survey data for cancer genetic counseling

BACKGROUND

Despite a growing body of literature describing the geographic and sociodemographic distribution of cancer genetic testing, work focused on these domains in cancer genetic counseling is limited. Research describing the epidemiology of cancer genetic counseling has mainly focused on isolated populations, a single gender (women) and a single condition (hereditary breast and ovarian cancer). Study findings to date are contradictory, making it unclear what, if any, disparities in receipt of cancer genetic counseling exist.

METHODS

Utilizing the 2015 National Health Interview Survey (NHIS)-a cross-sectional, in person interview survey collecting self-reported health data for the US population-geographic and sociodemographic factors were compared between those receiving genetic counseling and the national sample. Bivariate analysis and subsequent multivariable logistic regression were performed with stratification by cancer status (affected/unaffected). Reason for (eg, doctor recommended) and focus of (eg, breast/ovarian) genetic counseling were also assessed. To generate nationally representative estimates, all analyses were adjusted for survey weights.

RESULTS

An estimated 4.8 million individuals in the United States had cancer genetic counseling. On bivariate analysis, there were significant differences in proportions undergoing genetic counseling by sex, race/ethnicity, insurance, citizenship, education, age, and cancer status (P < 0.01). After adjustment, however, only female sex (Odds Ratio [OR]: 1.78 [95% CI: 1.18-2.67]) remained a significant predictor of genetic counseling among the affected. Among the unaffected, female sex (OR: 1.70 [1.30-2.21]), non-Hispanic black race (OR: 1.44 [1.02-2.05], reference: non-Hispanic white), graduate education (OR: 1.76 [1.03-2.98], reference: less than high school), and age (OR: 1.06 [1.01-1.11]) predicted higher rates of genetic counseling. An estimated 2.1 million individuals have undergone genetic counseling focused on breast/ovarian cancer, 1.3 million on colorectal cancer, and 1.4 million on "other" cancers. Of those receiving genetic counseling focused on breast/ovarian cancer, 3% were male and 97% female (breast cancer alone-4% male, 96% female); for colorectal cancer, 49% male and 51% female, and for "other" cancers, 60% male and 40% female. The majority of individuals receiving genetic counseling reported they did so because their doctor recommended it (66%), with smaller proportions describing self (12%), family (10%), or media (5%) influences as the primary reason.

CONCLUSION

This is the first study to depict the sociodemographic and geographic distribution of cancer genetic counseling at the national level. Despite perceived disparities in access, cancer genetic counseling in the United States appears to be accessed by individuals of diverse racial/ethnic backgrounds, with various insurance coverage and educational levels, and across a broad range of ages and geographic regions. The only sociodemographic factor that independently predicted receipt of genetic counseling across both the affected and unaffected population was sex. With physician recommendation as the predominant driver for counseling, targeting physician education, and awareness is crucial to utilization.

The GFF3toolkit: QC and Merge Pipeline for Genome Annotation

The GFF3toolkit ( https://github.com/NAL-i5K/GFF3toolkit ) supported by the i5k Workspace@NAL provides a suite of tools to handle gene annotations in GFF3 format from arthropod genome projects and their research communities. To improve GFF3 formatting of gene annotations, a quality control and merge procedure is proposed along with the GFF3toolkit. In particular, the toolkit provides functions to sort a GFF3 file, detect GFF3 format errors, merge two GFF3 files, and generate biological sequences from a GFF3 file. This chapter explains when and how to use the provided tools to obtain nonredundant arthropod gene sets in high quality.

The genome of the water strider Gerris buenoi reveals expansions of gene repertoires associated with adaptations to life on the water

BACKGROUND

Having conquered water surfaces worldwide, the semi-aquatic bugs occupy ponds, streams, lakes, mangroves, and even open oceans. The diversity of this group has inspired a range of scientific studies from ecology and evolution to developmental genetics and hydrodynamics of fluid locomotion. However, the lack of a representative water strider genome hinders our ability to more thoroughly investigate the molecular mechanisms underlying the processes of adaptation and diversification within this group.

RESULTS

Here we report the sequencing and manual annotation of the Gerris buenoi (G. buenoi) genome; the first water strider genome to be sequenced thus far. The size of the G. buenoi genome is approximately 1,000 Mb, and this sequencing effort has recovered 20,949 predicted protein-coding genes. Manual annotation uncovered a number of local (tandem and proximal) gene duplications and expansions of gene families known for their importance in a variety of processes associated with morphological and physiological adaptations to a water surface lifestyle. These expansions may affect key processes associated with growth, vision, desiccation resistance, detoxification, olfaction and epigenetic regulation. Strikingly, the G. buenoi genome contains three insulin receptors, suggesting key changes in the rewiring and function of the insulin pathway. Other genomic changes affecting with opsin genes may be associated with wavelength sensitivity shifts in opsins, which is likely to be key in facilitating specific adaptations in vision for diverse water habitats.

CONCLUSIONS

Our findings suggest that local gene duplications might have played an important role during the evolution of water striders. Along with these findings, the sequencing of the G. buenoi genome now provides us the opportunity to pursue exciting research opportunities to further understand the genomic underpinnings of traits associated with the extreme body plan and life history of water striders.

High-Risk Colorectal Surgery: What Are the Outcomes for Geriatric Patients?

The population is aging and more geriatric patients are undergoing surgery. The national burden and age-specific outcomes of previously defined high-risk colorectal procedures (HRCP) remain unknown. Using the 2014 National Inpatient Sample, patients were stratified into nongeriatric (NG, <65 years), younger geriatric (YG, 65–79 years), and older geriatric (OG, ≥80 years) cohorts. Cases were grouped into nonelective admissions (NA) and elective admissions (EA). Nationally representative outcomes were compared across age group and admission type. Of 215,425 patients undergoing HRCP, 47.3 per cent were ≥65 years. During NA and EA, inpatient mortality, discharge to nursing facility, and median postoperative length of stay increased with each increasing age category ( P < 0.001). Outcomes during NA were worse than EA in all age groups ( P < 0.001). For example, rates of discharge to nursing facility were 13.4 per cent NG, 39.4 per cent YG, and 64.7 per cent OG during; NA and 3.1 per cent NG, 13.3 per cent YG, and 34 per cent OG during EA. During NA and EA, cost was equal in YG and OG but greater than in NG. Outcomes after HRCP are worse for older patients and for nonelective cases. This information can inform preoperative counseling and targeted quality improvement projects. Further work is needed to understand geriatric-specific risk factors and outcomes to provide high-quality patient-centered care.

High-Risk Colorectal Surgery: What Are the Outcomes for Geriatric Patients?

The population is aging and more geriatric patients are undergoing surgery. The national burden and age-specific outcomes of previously defined high-risk colorectal procedures (HRCP) remain unknown. Using the 2014 National Inpatient Sample, patients were stratified into nongeriatric (NG, <65 years), younger geriatric (YG, 65-79 years), and older geriatric (OG, ≥80 years) cohorts. Cases were grouped into nonelective admissions (NA) and elective admissions (EA). Nationally representative outcomes were compared across age group and admission type. Of 215,425 patients undergoing HRCP, 47.3 per cent were ≥65 years. During NA and EA, inpatient mortality, discharge to nursing facility, and median postoperative length of stay increased with each increasing age category (P < 0.001). Outcomes during NA were worse than EA in all age groups (P < 0.001). For example, rates of discharge to nursing facility were 13.4 per cent NG, 39.4 per cent YG, and 64.7 per cent OG during; NA and 3.1 per cent NG, 13.3 per cent YG, and 34 per cent OG during EA. During NA and EA, cost was equal in YG and OG but greater than in NG. Outcomes after HRCP are worse for older patients and for nonelective cases. This information can inform preoperative counseling and targeted quality improvement projects. Further work is needed to understand geriatric-specific risk factors and outcomes to provide high-quality patient-centered care.

Estimation of the Acquisition and Operating Costs for Robotic Surgery

This study used 1999-2017 financial statements from INTUITIVE, the company that supplies most robotic technology, to establish a hospital cost benchmark to inform future cost-effectiveness evaluations.

Surgical Technical Evidence Review of Hip Fracture Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Background:

Enhanced recovery pathways (ERPs) have been shown to improve patient outcomes in a variety of contexts. This review summarizes the evidence and defines a protocol for perioperative care of patients with hip fracture and was conducted for the Agency for Healthcare Research and Quality safety program for improving surgical care and recovery.

Study Design:

Perioperative care was divided into components or “bins.” For each bin, a semisystematic review of the literature was conducted using MEDLINE with priority given to systematic reviews, meta-analyses, and randomized controlled trials. Observational studies were included when higher levels of evidence were not available. Existing guidelines for perioperative care were also incorporated. For convenience, the components of care that are under the auspices of anesthesia providers will be reported separately. Recommendations for an evidence-based protocol were synthesized based on review of this evidence.

Results:

Eleven bins were identified. Preoperative risk factor bins included nutrition, diabetes mellitus, tobacco use, and anemia. Perioperative management bins included thromboprophylaxis, timing of surgery, fluid management, drain placement, early mobilization, early alimentation, and discharge criteria/planning.

Conclusions:

This review provides the evidence basis for an ERP for perioperative care of patients with hip fracture.

The Toxicogenome of Hyalella azteca: A Model for Sediment Ecotoxicology and Evolutionary Toxicology

Hyalella azteca is a cryptic species complex of epibenthic amphipods of interest to ecotoxicology and evolutionary biology. It is the primary crustacean used in North America for sediment toxicity testing and an emerging model for molecular ecotoxicology. To provide molecular resources for sediment quality assessments and evolutionary studies, we sequenced, assembled, and annotated the genome of the H. azteca U.S. Lab Strain. The genome quality and completeness is comparable with other ecotoxicological model species. Through targeted investigation and use of gene expression data sets of H. azteca exposed to pesticides, metals, and other emerging contaminants, we annotated and characterized the major gene families involved in sequestration, detoxification, oxidative stress, and toxicant response. Our results revealed gene loss related to light sensing, but a large expansion in chemoreceptors, likely underlying sensory shifts necessary in their low light habitats. Gene family expansions were also noted for cytochrome P450 genes, cuticle proteins, ion transporters, and include recent gene duplications in the metal sequestration protein, metallothionein. Mapping of differentially expressed transcripts to the genome significantly increased the ability to functionally annotate toxicant responsive genes. The H. azteca genome will greatly facilitate development of genomic tools for environmental assessments and promote an understanding of how evolution shapes toxicological pathways with implications for environmental and human health.