Percutaneous image-guided cryoablation of spinal metastases: A systematic reviewAhmad Ozair
Percutaneous cryoablation (PCA) is a minimally invasive technique that has been recently used to treat spinal metastases with a paucity of data currently available in the literature. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Prospective or retrospective studies concerning metastatic spinal neoplasms treated with current generation PCA systems and with available data on safety and clinical outcomes were included. In the 8 included studies (7 retrospective, 1 prospective), a total of 148 patients (females = 63%) underwent spinal PCA. Tumors were located in the cervical (3/109 [2.8%], thoracic (74/109 [68.8%], lumbar (37/109 [33.9%], and sacrococcygeal (17/109 [15.6%] regions. Overall, 187 metastatic spinal lesions were treated. Thermo-protective measures (e.g., carbo-/hydro-dissection, thermocouples) were used in 115/187 [61.5%] procedures. For metastatic spinal tumors, the pooled mean difference (MD) in pain scores from baseline on the 0–10 numeric rating scale was 5.03 (95% confidence interval [CI]: 4.24 to 5.82) at a 1-month follow-up and 4.61 (95% CI: 3.27 to 5.95) at the last reported follow-up (range 24–40 weeks in 3/4 studies). Local tumor control rates ranged widely from 60% to 100% at varying follow-ups. Grade I-II complications were reported in 9/148 [6.1%] patients and grade III-V complications were reported in 3/148 [2.0%]) patients. PCA, as a stand-alone or adjunct modality, may be a viable therapy in appropriately selected patients with painful spinal metastases who were traditionally managed with open surgery and/or radiation therapy.
Percutaneous image-guided cryoablation of spinal metastases: A systematic reviewAhmad Ozair
Percutaneous cryoablation (PCA) is a minimally invasive technique that has been recently used to treat spinal metastases with a paucity of data currently available in the literature. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Prospective or retrospective studies concerning metastatic spinal neoplasms treated with current generation PCA systems and with available data on safety and clinical outcomes were included. In the 8 included studies (7 retrospective, 1 prospective), a total of 148 patients (females = 63%) underwent spinal PCA. Tumors were located in the cervical (3/109 [2.8%], thoracic (74/109 [68.8%], lumbar (37/109 [33.9%], and sacrococcygeal (17/109 [15.6%] regions. Overall, 187 metastatic spinal lesions were treated. Thermo-protective measures (e.g., carbo-/hydro-dissection, thermocouples) were used in 115/187 [61.5%] procedures. For metastatic spinal tumors, the pooled mean difference (MD) in pain scores from baseline on the 0–10 numeric rating scale was 5.03 (95% confidence interval [CI]: 4.24 to 5.82) at a 1-month follow-up and 4.61 (95% CI: 3.27 to 5.95) at the last reported follow-up (range 24–40 weeks in 3/4 studies). Local tumor control rates ranged widely from 60% to 100% at varying follow-ups. Grade I-II complications were reported in 9/148 [6.1%] patients and grade III-V complications were reported in 3/148 [2.0%]) patients. PCA, as a stand-alone or adjunct modality, may be a viable therapy in appropriately selected patients with painful spinal metastases who were traditionally managed with open surgery and/or radiation therapy.
The management of painful bone metastases requires multidisciplinary care, with external beam radiation therapy (EBRT) providing relief that is effective and time efficient.
In our study the efficacy of external beam irradiation in the palliation of bone metastasis-related symptoms is confirmed by this study, even with short treatments and single-dose administrations. This is important for both patient expectations and the necessity for improved resource allocation with reference to the territorial distribution and waiting lists of radiotherapy centers. The issue of their efficacy in combination with antiblastic drugs (Bisphosphonates drugs such as Zoledronic acid) and/or external beam irradiation(EBRT) remains open and will be clarified only with further randomized clinical trials.
The effect of clonidine on peri operative neuromuscular blockade and recoveryAhmad Ozair
Background: Alpha-2-agonists are as used adjunct for anaesthesia. We conducted this study with the aim to determine whether the addition of clonidine, an α-2-agonist, decreases the time to recovery from neuromuscular blockade caused by non-depolarising muscle relaxant. Secondary objectives were to know whether clonidine as an adjuvant improves hemodynamic stability, decreases stress hyperglycaemia, pain and time to discharge from Post-Anaesthesia Care Unit (PACU). Methods: This placebo-controlled clinical trial, enrolled 64 patients into clonidine (n = 32) or placebo (saline) group (n = 32). Study drug was given 1.5 mcg/kg IV bolus at the time of induction followed by infusion (1.5 mcg/kg/hour) intra-operatively. Extubation was started when train-of-four (TOF) count was ≥ 2. Primary outcome measure was time to achieve TOF ratio of ≥ 70% and ≥ 90%, assessed at 5, 15, 30- and 60-min intervals following extubation. Results: 2 patients in each group were excluded due to intra-operative requirement of additional supportive medications, hence in each group 30 were analysed. Significant difference was observed between clonidine and placebo groups in terms of time to achieve TOF ratio ≥ 70% and ≥ 90%, stress hyperglycemia, hemodynamic and pain profile, no statistical difference in the Ramsey sedation score and modified Aldrete score between groups. Patients given clonidine required repeat doses of non-depolarising muscle relaxant at longer intervals, with decrease in total amount administered. Clonidine group had a median time to achieve TOF ratio ≥ 70% at 15 min compared to 60 min in placebo group. Conclusion: Clonidine hastens the recovery from neuromuscular block with reduced stress hyperglycaemia and post-operative pain, along with unaffected Ramsey sedation score and modified Aldrete score.
Perceived benefits and barriers to exercise for recently treated patients wit...Enrique Moreno Gonzalez
Understanding the physical activity experiences of patients with multiple myeloma (MM) is essential to inform the development of evidence-based interventions and to quantify the benefits of physical activity. The aim of this study was to gain an in-depth understanding of the physical activity experiences and perceived benefits and barriers to physical activity for patients with MM.
KinexCONNECT improves patient experience and therapy compliance during recovery from total knee replacement Focus groups conducted by Kinex Medical Company and HealthFactors. Authored by: Mike Buckholdt, BA, MPT, and Ram Rajagopalan, MS, MBA
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
Rapid review of current service provision following cancer treatmentNHS Improvement
NHS Improvement carried out a rapid review of current provision of services for breast, prostate and colorectal cancer patients following treatment during the summer of 2009 at the request of the National Cancer Survivorship Initiative (NCSI). This publication shares the findings from this review.
(Published September 2010)
Short-course radiotherapy followed by neo-adjuvant chemotherapy in locally ad...Enrique Moreno Gonzalez
Current standard for most of the locally advanced rectal cancers is preoperative chemoradiotherapy, and, variably per institution, postoperative adjuvant chemotherapy. Short-course preoperative radiation with delayed surgery has been shown to induce tumour down-staging in both randomized and observational studies. The concept of neo-adjuvant chemotherapy has been proven successful in gastric cancer, hepatic metastases from colorectal cancer and is currently tested in primary colon cancer.
Background: The transition from resident physician to independent practitioner is an important period for young physicians.Optimally, they would feel well prepared to independently care for all patients presenting to them for anesthesia, however, this is unlikely Methods: A survey was emailed to all accredited anesthesiology residency program coordinators in April 2018 for further distribution to their CA3 residents. The survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues as well as perform various procedures.
Study of the distribution and determinants of
health-related states or events in specified populations and the application of this study to control health problems.
John M. Last, Dictionary of Epidemiology
Please see the Creative Commons License on the second slide. This slide deck is for medical education uses only and does not constitute medical advice. Please consult with your own health care provider.
The management of painful bone metastases requires multidisciplinary care, with external beam radiation therapy (EBRT) providing relief that is effective and time efficient.
In our study the efficacy of external beam irradiation in the palliation of bone metastasis-related symptoms is confirmed by this study, even with short treatments and single-dose administrations. This is important for both patient expectations and the necessity for improved resource allocation with reference to the territorial distribution and waiting lists of radiotherapy centers. The issue of their efficacy in combination with antiblastic drugs (Bisphosphonates drugs such as Zoledronic acid) and/or external beam irradiation(EBRT) remains open and will be clarified only with further randomized clinical trials.
The effect of clonidine on peri operative neuromuscular blockade and recoveryAhmad Ozair
Background: Alpha-2-agonists are as used adjunct for anaesthesia. We conducted this study with the aim to determine whether the addition of clonidine, an α-2-agonist, decreases the time to recovery from neuromuscular blockade caused by non-depolarising muscle relaxant. Secondary objectives were to know whether clonidine as an adjuvant improves hemodynamic stability, decreases stress hyperglycaemia, pain and time to discharge from Post-Anaesthesia Care Unit (PACU). Methods: This placebo-controlled clinical trial, enrolled 64 patients into clonidine (n = 32) or placebo (saline) group (n = 32). Study drug was given 1.5 mcg/kg IV bolus at the time of induction followed by infusion (1.5 mcg/kg/hour) intra-operatively. Extubation was started when train-of-four (TOF) count was ≥ 2. Primary outcome measure was time to achieve TOF ratio of ≥ 70% and ≥ 90%, assessed at 5, 15, 30- and 60-min intervals following extubation. Results: 2 patients in each group were excluded due to intra-operative requirement of additional supportive medications, hence in each group 30 were analysed. Significant difference was observed between clonidine and placebo groups in terms of time to achieve TOF ratio ≥ 70% and ≥ 90%, stress hyperglycemia, hemodynamic and pain profile, no statistical difference in the Ramsey sedation score and modified Aldrete score between groups. Patients given clonidine required repeat doses of non-depolarising muscle relaxant at longer intervals, with decrease in total amount administered. Clonidine group had a median time to achieve TOF ratio ≥ 70% at 15 min compared to 60 min in placebo group. Conclusion: Clonidine hastens the recovery from neuromuscular block with reduced stress hyperglycaemia and post-operative pain, along with unaffected Ramsey sedation score and modified Aldrete score.
Perceived benefits and barriers to exercise for recently treated patients wit...Enrique Moreno Gonzalez
Understanding the physical activity experiences of patients with multiple myeloma (MM) is essential to inform the development of evidence-based interventions and to quantify the benefits of physical activity. The aim of this study was to gain an in-depth understanding of the physical activity experiences and perceived benefits and barriers to physical activity for patients with MM.
KinexCONNECT improves patient experience and therapy compliance during recovery from total knee replacement Focus groups conducted by Kinex Medical Company and HealthFactors. Authored by: Mike Buckholdt, BA, MPT, and Ram Rajagopalan, MS, MBA
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
Rapid review of current service provision following cancer treatmentNHS Improvement
NHS Improvement carried out a rapid review of current provision of services for breast, prostate and colorectal cancer patients following treatment during the summer of 2009 at the request of the National Cancer Survivorship Initiative (NCSI). This publication shares the findings from this review.
(Published September 2010)
Short-course radiotherapy followed by neo-adjuvant chemotherapy in locally ad...Enrique Moreno Gonzalez
Current standard for most of the locally advanced rectal cancers is preoperative chemoradiotherapy, and, variably per institution, postoperative adjuvant chemotherapy. Short-course preoperative radiation with delayed surgery has been shown to induce tumour down-staging in both randomized and observational studies. The concept of neo-adjuvant chemotherapy has been proven successful in gastric cancer, hepatic metastases from colorectal cancer and is currently tested in primary colon cancer.
Background: The transition from resident physician to independent practitioner is an important period for young physicians.Optimally, they would feel well prepared to independently care for all patients presenting to them for anesthesia, however, this is unlikely Methods: A survey was emailed to all accredited anesthesiology residency program coordinators in April 2018 for further distribution to their CA3 residents. The survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues as well as perform various procedures.
Study of the distribution and determinants of
health-related states or events in specified populations and the application of this study to control health problems.
John M. Last, Dictionary of Epidemiology
Please see the Creative Commons License on the second slide. This slide deck is for medical education uses only and does not constitute medical advice. Please consult with your own health care provider.
"Anche a cavallo tra Ottocento e Novecento il trasferimento delle tecnologie ha rappresentato un aspetto importante, ma a causa dell’asservimento coloniale è aumentato il differenziale di utilizzo produttivo nell’uso delle macchine, elemento che ha condizionato, e condiziona tuttora, il problema del sottosviluppo. Non dimentichiamo, infatti, che la globalizzazione internazionale, con i suoi flussi di merci e persone, deriva da un’esperienza coloniale, che non si traduce in maniera scontata in crescita economica auto sostenuta o in diffusione delle tecnologie industriali".
As the problem of sexual violence and assault escalates, new laws seek to protect and prevent. Building on the requirements of the Clery Act, the Campus Sexual Violence Act (Campus SaVE) was signed into law in March 2013 as a new amendment to the Violence Against Women Act of 1994.
The Campus SaVE Act expands on protected classes and prohibited behaviors and requires proactive training initiatives on the part of colleges and universities.
For quick access to the Workplace Answers website and the webinar, just click on the hyperlinks in the slideshow.
Analisi Statistico-Economica territoriale che riguarda il credito al consumo in Italia.Il software statistico utilizzato è Geoda.
Progetto presentato per l'esame in Statistica presso l'Università Parthenope
Contents lists available at ScienceDirectApplied Nursing RAlleneMcclendon878
Contents lists available at ScienceDirect
Applied Nursing Research
journal homepage: www.elsevier.com/locate/apnr
Original article
Optimize patient outcomes among females undergoing gynecological
surgery: A randomized controlled trial
Kari Johnson (PhD, RN, ACNS-BC, Hartford Scholar)⁎, Sherry Razo (M.A.-L., BSN, RN, NEA-BC),
Jeannie Smith (BSN, CMSRN), Alex Cain (RN), Kathi Soper (BSN, RN-BC)
Honor Health Thompson Peak Medical Center, 7400 E. Thompson Peak Parkway, Scottsdale, AZ 85255, United States
A R T I C L E I N F O
Keywords:
Gynecological surgery
Enhanced Recovery After Surgery (ERAS)
Hysterectomy
Bundle components
Institute of Healthcare Improvement
Length of stay
30 day readmission
Patient satisfaction
Randomized controlled trial
A B S T R A C T
Background: Optimizing early education in gynecological procedures utilizing an Enhanced Recovery after
Surgery (ERAS) program and a bundle concept may optimize patient outcomes after surgery.
Purpose: Evaluate whether an ERAS bundle compared to standard education can affect length of stay, 30 day
readmission, and patient satisfaction among patients undergoing gynecologic surgery.
Design: Prospective, comparative, randomized design
Setting: 28 bed Medical Surgical Unit
Sample/Intervention: 50 patients undergoing hysterectomy, 25 who received post-operative evidence based
bundle/standard education, and 25 who received standard education packet. Bundle components included 1)
early mobilization, 2) early transition to oral pain medication, 3) early feeding, and 4) chewing gum. A follow-up
phone call was made in two to three days following discharge for both groups utilizing teach-back.
Results: 84% (n = 21) patients in the bundle group were discharged in one day. There were no 30 day read-
missions for both groups. Twenty two (88%) participants met the bundle components 100% of the time. For the
indicator “walking helped with recovery” 100% (n = 25) responded “very good to excellent” for bundle group
and 96% (n = 24) responded “very good to excellent” for standard group. Twenty three (92%) of the bundle
group felt that that overall nursing care received was very good to excellent and 24 (96%) of the general group
felt that overall nursing care received was very good to excellent.
Conclusion: Optimizing peri-operative education using a bundle approach to provide evidence based interven-
tions can minimize risk and enhance early recovery for females undergoing gynecological surgery.
1. Introduction
A hysterectomy is a common gynecological surgical procedure with
minimally invasive methods including vaginal or laparoscopic proce-
dures. Studies have shown that preoperative patient education can
improve patient outcomes after surgery, including reduced length of
hospital stay, decreased post-operative complications, and increased
patient satisfaction with the surgical experience (Modesitt et al., 2016;
Steiner & Strand, 2017; Wijk, Franzen, Ljungqvist, & Nilsson, 2014).
Enhanced recovery p ...
Current Role of Surgery in Endometriosis; Indications and ProgressCrimsonpublisherssmoaj
Endometriosis is a chronic debilitating disease , which affects women of reproductive age group, although medical therapy may be helpful in managing pain associated with Endometriosis or infertility, surgery becomes an integral part of managing this disease .Although initially surgery was limited to l aporotomy associated with ovarian cystectomy and/or TAH with BSO. Laporoscopy gradually replaced that. Though diagnostic laparoscopy is used for confirmation of endometriosis by histological examination, it is not acceptable that Laporoscopy be done in multiple steps, initially to diagnose and later for treatment. Recently a lot of advancement has come in the imaging techniques by which one can combine planning of surgery based on the imaging classification. Deep endometriosis involving bowel, genitourinary tract can be dealt by careful dissection in controlled trained hands, in a well equipped set up to achieve the optimum results .Endometriosis associated infertility may or may not warrant surgery as with multiple studies operation on ovarian endometriomas might land up in reducing ovarian reserve - while doing straight IVF may result in better pregnancy rates ,getting good oocyte retrieval in contrast to poor ovarian reserve resulting from damage to ovarian morphology. Use of laser for ovarian cystectomy helps in getting better outcomes than simple drainage and coagulation procedures. Robotic surgery is the latest addition, which aids in better dissection and management but its problem is its cost, not accessible to many patients and not many trained personnel available.
By utilizing evidence based practice enhanced recovery after
surgery (ERAS) protocols implement several steps along the care pathway to help minimise the surgical stress response caused from surgical insult. Radical Cystectomy is associated with the highest morbidity of all urological procedures [1]; with extended length of hospital stay and high complication rates reported post operatively [1-
2]. In 2013, following a literature review the ERAS society published guidelines detailing 22 ERAS items for patients undergoing radical cystectomy.
Enhanced Recovery (ERAS) in Colorectal Surgery is a relatively novel concept in patient care. It involves a multidisciplinary team approach (surgeons, anesthetists, ERAS nurse, nutritionist, physiotherapist, pain team, hospital administration and patient motivation) comprising of certain key aspects in the pre, intra and post-operative settings.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
The impact of minimally invasive surgery on complex drg assignments
1. MARCH 2014 / MANAGED CARE 47
The Impact of Minimally Invasive Surgery
On Complex DRG Assignments
Santosh J. Agarwal, BPharm, MS, Covidien, Mansfield, MA; Gary V. Delhougne, JD, MHA, Covidien, Boulder, CO;
Levi Citrin, JD, Numerof & Associates Inc., St. Louis, MO; Jill E. Sackman, DVM, PhD, Numerof & Associates Inc.;
and Anthony J. Senagore, MD, MS, MBA, Department of Surgery, Keck School of Medicine of University of Southern
California, Los Angeles, CA.
ABSTRACT
Purpose: Minimally invasive
surgery is associated with improved
clinical outcomes and reduced costs.
We hypothesize that in patients with
similar preoperative characteris-
tics, hysterectomy, colectomy, and
thoracic resection performed via
minimally invasive surgery (MIS)
approach would be associated with
fewer complex Diagnosis Related
Group (cDRG) assignments and sub-
sequently result in reimbursement
savings.
Methodology: Premier hospital
database was used to examine in-
patient discharges of open and MIS
colectomy, hysterectomy and thoracic
resection. Open and MIS groups were
matched based on propensity score.
Descriptive statistics and regression
analysis were used to assess the im-
pact of MIS on cDRG assignment.
Potential reimbursement savings to
the U.S. health care system, assum-
ing a 10% increase in MIS utilization,
was estimated using Medicare’s Fis-
cal Year (FY) 2013 national average
reimbursement data and Premier’s
procedure volume projections.
Results: Compared with open
surgery, the MIS group had a statis-
tically significantly lower percent-
age of cDRG assignment (colectomy,
57% vs. 71%; hysterectomy, 15% vs.
19%; thoracic resection, 62% vs. 70%;
P<.001 for each). Open surgery, when
compared to MIS, increased the odds
of cDRG assignment by 67% (odds
ratio [OR], 1.67; 95% confidence in-
terval [CI], 1.62–1.71). We estimated
that a 10% increase in MIS utiliza-
tion would lead to annual payer re-
imbursement savings of about $24.4
million (colectomy, $17 million;
hysterectomy, $5 million; thoracic
resection, $2.4 million).
Conclusion: Health care reform
laws and economic pressures are
causing a shift in focus from vol-
ume-based to value-based care. MIS
approaches reduce payer expense
based on fewer expensive cDRG as-
signments. Further adoption of MIS
may lead to improved outcomes and
additional savings.
INTRODUCTION
Adoption of minimally invasive
surgery (MIS) has advanced rapidly
in the past 2 decades. Minimally
invasive procedures offer patients
reduced pain and scarring, shorter
hospitalization, and a quicker return
to activities of daily living. Studies
demonstrate that MIS is frequently
associated with reduced rates of com-
plications, mortality, and morbidity
(Tiwari 2011, Bilimoria 2008, Del-
aney 2008, Kiran 2010, Varela 2008,
Chalermchockchareonkit 2012,
Cheng 2007, Cho 2011, Howington
2012, Murthy 2012, Sawada 2008,
Villamizar 2009, Epstein 2013). The
data also suggest that MIS is asso-
ciated with cost benefits, likely due
to reduced length of stay (LOS) and
fewer complications (Varela 2008,
Cho 2011, Swanson 2011, Casali 2009,
Alkhamesi 2011, Eisenberg 2010,
Jensen 2012, Senagore 2002, Noblett
2007, Vaid 2012, Bosio 2007, Barnett
2010, Bijen 2009, Lenihan 2004). The
potential net result of replacing open
procedures with MIS is that both the
payer and the provider could see im-
proved outcomes and a more favor-
able cost structure.
The comparison of several types
of hysterectomy demonstrates the
improved outcomes offered by
laparoscopy (ACOG 2009, Sarmini
2005). Laparoscopic hysterectomy
is associated with less postoperative
pain, lower stress levels, and better
cosmetic results than abdominal
hysterectomy (Olsson 1996). In their
2005 meta-analysis of 27 random-
ized controlled trials comparing
laparoscopic-assisted vaginal hyster-
ectomy (LAVH), total laparoscopic
hysterectomy (TLH), and abdomi-
nal hysterectomy for benign uterine
disease, the Cochrane Collaboration
found a significant advantage of
laparoscopy over open procedures
Corresponding author
Santosh J. Agarwal, BPharm, MS
Phone: (508) 452-1610
E-mail:
Santosh.Agarwal@covidien.com
Funding source: This research
project was sponsored by
Covidien, a global company that
manufactures, distributes, and
provides services for a diverse range
of medical devices and supplies.
Disclosure statement: Santosh
Agarwal and Gary Delhougne are
employees of, and hold stock in,
Covidien, a medical device and
supplies manufacturer. Jill Sackman
and Levi Citrin report being paid
by Covidien to provide editorial
services. Anthony Senagore reports
no disclosures.
2. 48 MANAGED CARE / MARCH 2014
(Nieboer 2009). Laparoscopic hys-
terectomy led to fewer wounds or
abdominal wall infections, less pain,
less pyrexia, a smaller drop in hemo-
globin, shorter hospitalization, and a
faster return to work; though opera-
tive times were longer and urinary
tract injuries were more common
(Lenihan 2004, Nieboer 2009, Shen
2003, Hidlebaugh 1994, Epstein 2013).
Like laparoscopic procedures,
video-assisted thoracoscopic proce-
dures (VATS) have also developed
rapidly in the past 2 decades. In fact,
VATS has been widely adopted for use
in simple thoracic operations, such as
the treatment of pneumothorax and
pleural effusion (Howington 2012).
VATS wedge resection has also been
established as a diagnostic tool for
lung cancer staging (Sihoe 2004).
VATS lobectomy for lung cancer has
numerous reported benefits, includ-
ing earlier chest tube removal, less
postoperative pain, shorter hospital-
ization, less inflammation, and better
long-term functional level (Murthy
2012, Sawada 2008, Kaseda 2002,
Swanson 2002).
Similarly, meta-analyses and large
randomized trials have demonstrated
the safety and efficacy of laparoscopic
colectomy as an alternative to open
surgery in patients with conditions
ranging from Crohn’s disease, diver-
ticulitis, and ulcerative colitis (UC)
to colon cancer (Nash 2010, Ful-
lum 2010, Bonjer 2007). The Clini-
cal Outcomes of Surgical Therapy
study (COST Study Group 2004)
involved 48 centers and 872 patients
who underwent either open or lapa-
roscopic-assisted colectomy. There
was no difference in overall survival
(86% for laparoscopic-assisted and
85% for open) at 3 years. The lapa-
roscopic group demonstrated faster
recovery with a shorter median hos-
pital stay (5 vs 6 days) and lower use
of postoperative narcotics.
Throughout the literature, MIS
tends to be associated with lower
hospital costs, shorter hospitaliza-
tion, a quicker return to activities of
daily living, and a faster return to
work compared to open procedures
(Varela 2008, Swanson 2011, Casali
2009, Alkhamesi 2011, Eisenberg
2010, Jensen 2012, Senagore 2002,
Noblett 2007, Vaid 2012, Bosio 2007,
Barnett 2010, Bijen 2009, Hidlebaugh
1994, Epstein 2013, Fullum 2010).
Most of the literature concern-
ing MIS-associated cost benefits has
focused on provider cost reduction.
Few studies consider implications for
payers utilizing a prospective pay-
ment program (Senagore 2005).
In the United States, inpatient
procedures are reimbursed based
on the Medicare Severity Diagnosis
Related Groups (MS-DRG) system,
which provides one single reimburse-
ment for the entire inpatient hospi-
talization, accounting for diagnosis
and procedures performed during
the hospital stay. MS-DRGs provide
higher reimbursement for procedures
with complications and/or comor-
bidities (CC) and major complica-
tions and/or comorbidities (MCC).
Patients with significant comorbidi-
ties prior to the surgery or who expe-
rience complications during or after
the surgery (prior to discharge) are
assigned a complex DRG (cDRG).
Reduction in certain postoperative
complications, such as surgical site
infections, translates into a higher
rate of assignment of DRGs without
complications and/or comorbidities,
provided patients have similar pre-
existing comorbidities.
Payers generally reimburse the
provider a set amount according
to a predetermined fee schedule.
Procedures assigned to a cDRG are
reimbursed at a higher rate on aver-
age than those assigned to the corre-
sponding noncomplex, or base, DRG.
The implications of DRG assignment
for the payer are important because
cDRGs typically result in a substan-
tially increased expense.
We hypothesize that when all pre-
operative patient and provider char-
acteristics are similar and the only
difference is the surgical approach,
MIS is associated with a lower rate
of postoperative complications com-
pared to open procedures. Postopera-
tive complications are an important
predictor of cDRG assignment and,
thus, cost for payers.
Senagore (2005) evaluated this re-
lationship for colectomy using data
from a single institution. We con-
ducted a retrospective cohort study
using a large hospital database to
demonstrate that among patients
with similar preoperative characteris-
tics but different surgical approaches
(open vs a nonrobotic laparoscopic or
MIS), MIS was associated with fewer
cDRG assignments. Procedures such
as colectomy, hysterectomy, and tho-
racic resection were selected because
these are high-volume surgeries with
a high percentage of open procedures
and significant payment differentials
between cDRGs and non-cDRGs.
METHODS
Data Source
This study utilized the Premier
hospital database, one of the largest
administrative and resource utiliza-
tion databases in the United States,
covering approximately 20% of hospi-
tal discharges. The database contains
more than 42 million discharges from
morethan600hospitals.Contributing
hospitals send data on patient demo-
graphics; hospital, surgeon, and payer
characteristics; and resource utiliza-
tion, including diagnosis and proce-
dures. Diagnoses and procedures are
coded using the International Clas-
sification of Diseases, Ninth Revision
Clinical Modification (ICD-9-CM)
codes. All data undergo a quality-
review process for validation.
Patients and Procedures
All surgical discharges for adult
patients (age ≥18 years) between the
3. MARCH 2014 / MANAGED CARE 49
years 2009 and 2011 with a primary
surgical procedure of either open or
laparoscopic colectomy, hysterec-
tomy, or thoracic resection were in-
cluded in this analysis. Relevant dis-
charges were identified and selected
using a combination of ICD-9-CM
(Appendix Table 1), Current Proce-
dural Terminology (CPT), and billing
codes. The analysis excluded cases
with missing data on cost or severity,
with patients who were deceased at
discharge, and where robotic surgical
procedures were used.
The primary outcome of interest
was complex MS-DRG (cDRG) code
assignment (see Appendix Table 1).
MS-DRG codes that ended with MCC
or CC were classified as cDRG. MS-
DRG was coded as a variable in the
Premier hospital database.
The main independent (predictor)
variable was open or laparoscopic
surgery. Confounders were identified
from variables available in the data-
base and were similar to variables
included in previous database stud-
ies (Delaney 2008, Swanson 2011).
These included patient characteris-
tics (age, gender, race, comorbidities),
hospital characteristics (geographic
location, teaching, urban, number
of beds), payer, procedure charac-
teristics (elective admission, proce-
dure including subtype, procedural
approach, principal diagnosis), and
surgeon specialty.
Comorbidities selected were from
the Charlson Comorbidity Index
(CCI), which includes 17 conditions.
Hypertension and obesity, two condi-
tions not included in the CCI, were
considered as relevant comorbidities
and were included.
Statistics
Descriptive analyses using a chi-
square test were performed to analyze
differences between open/laparos-
copy and cDRG assignment rates for
the three procedures.
To evaluate the impact of surgi-
cal approach on cDRG assignment,
propensity score matching was con-
ducted. Propensity score matching
attempts to predict assignment to a
particular group by accounting for a
set of variables. We used propensity
score matching to build a model of
open/MIS group assignment control-
ling for patient, provider, and payer
characteristics. The open and MIS
groups were then matched 1:1 based
on propensity score. The procedure
type (hysterectomy, colectomy, tho-
racic resection) was chosen for exact
matching, enabling a 50:50 split of
open and laparoscopic procedures.
Descriptive characteristics (mean
age, CCI, propensity score) were
evaluated to assess the impact of
matching. Thus, the propensity score
matching process helped reduce the
inherent systematic differences be-
tween the 2 groups.
Multivariate logistic regression
was performed on the matched popu
lation to assess the impact of MIS
on cDRG assignment. All the con-
founding factors used to create the
propensity score were included in the
multivariate regression to account for
differences that may have remained
postmatching. All statistical analyses
were conducted using SAS 9.2.
Finally, we built a model to esti-
mate the reimbursement impact on
the U.S. health care system resulting
from increased MIS utilization. We
used projection weights provided by
Premier to obtain national estimates
of inpatient discharges. We projected
the cost savings using Fiscal Year
(FY) 2013 Medicare national aver-
age reimbursement rates (Appendix
Table 2). A 10% increase in MIS uti-
lization was considered an achievable
yet conservative shift, considering
regional variations and MIS adop-
tion in general surgical procedures.
Reimbursement rates for cDRG were
based on the reimbursement rates
for the corresponding MS-DRG with
Complications and/or Comorbidities
(CC). For hysterectomy, we averaged
the base reimbursement for the non-
cDRGs (735, 738, 741, and 743) and
the cDRGs (734, 737, 740, and 742).
Reimbursement was calculated by
factoring in the annual number of
projected inpatient procedures in the
United States, prevailing and pro-
jected share of MIS, split of cDRG for
open and MIS cases, and Medicare’s
average national reimbursement rates
for FY 2013.
RESULTS
During the study period, there
were 292,443 hospital discharges
with colectomy, hysterectomy, or tho-
racic resection surgery as the primary
inpatient procedure. We excluded
certain discharges (n=25,435) for
the following reasons: involvement
of patients under age 18 (n=1,324),
patients being deceased in the hospi-
tal (n=3,103), lack of information on
costs or severity (n=3), and the use
of robot-assisted surgery (n=22,005).
The three procedures accounted for
266,008 discharges (Table 1); among
them, 37% of the colectomies, 23% of
the hysterectomies, and 58% of the
thoracic resections were performed
using MIS. Raw cDRG assignment
rates are presented in Table 1. For all
three procedures, the MIS cohort had
a lower percentage of discharges as-
signed to a cDRG.
Logistic regression on the overall
cohort before propensity matching
highlighted that, after accounting
for confounders, open surgery in-
creased the odds of cDRG assignment
by 74% (odds ratio [OR], 1.74; 95%
confidence interval [CI], 1.70–1.78)
compared with MIS. The factors used
for matching and their odds ratios
predicting the use of MIS surgery
are presented in Appendix Table 3.
Pre- and post-matching descriptive
characteristics are given in Table 2.
After adjusting for all confound-
ers, the MIS cohort had a statisti-
cally significantly lower percentage
4. 50 MANAGED CARE / MARCH 2014
of cDRG assignment. Across the
three procedures, 48% of the open
procedures were assigned to cDRG,
compared with 39% of laparoscopic
procedures (P<.001). Further, as pre-
sented in Table 3, colectomy MIS dis-
charges were assigned to a cDRG less
often than open (57% vs. 71%, respec-
tively; relative reduction [RR], 20%),
hysterectomy MIS discharges were
assigned to a cDRG less often than
open (15% vs. 19%; RR, 23%), and
thoracic resection MIS discharges
were assigned to a cDRG less often
(62% vs. 70%; RR, 11%) than open.
In the post-matching logistic re-
gression model, again accounting
for confounders, open surgery was
associated with a 67% (OR, 1.67; 95%
CI, 1.62–1.71) increased cDRG as-
signment rate compared to MIS.
The model we employed to esti-
mate the reduction in payer reim-
bursement across the United States,
assuming a 10% increase in MIS, is
presented in Table 4. It should be
acknowledged that not all patients
are ideal candidates for under
going MIS. Patient factors such as
comorbidities, physician skills, and
hospital infrastructure could influ-
ence the access to MIS. The model
was limited to hospital reimburse-
ment for inpatient care, and does not
include reimbursement associated
with follow-up visits. In total, based
on the Premier-provided projection
weights, there were an estimated
224,592 colectomy, 279,748 hyster-
ectomy, and 63,768 thoracic resection
discharges, across the U.S. annually.
Our model presents a conservative
estimate of projected savings as the
cDRG reimbursement was based on
reimbursement for CC DRGs and a
TABLE 1
Description of discharges with open and MIS procedures (before matching)
Procedure Discharges (n) MIS (%)
Open cases
with cDRG (%)
MIS cases
with cDRG (%)
Colectomy 94,383 37 80 54
Hysterectomy 142,220 23 24 15
Thoracic resection 29,405 58 73 56
TABLE 2
Pre- and post-matching descriptive characteristics
Pre-matching Post-matching
Open MIS P value Open MIS P value
n 181,901 84,107 67,532 67,532
Age, mean 54.6 55.4 <.001 55.1 55.1 .5368
Charlson Comorbidity Index, mean 1.49 1.48 .2952 1.50 1.48 .1447
Propensity score, mean 0.2408 0.4791 <.001 0.4146 0.4225 <.001
TABLE 3
Post-matching cDRG assignment rates by procedure
Procedure Discharges (n)
Open cases
with cDRG (%)
MIS cases
with cDRG (%) P value
Colectomy 57,032 71 57 <.001
Hysterectomy 59,782 19 15 <.001
Thoracic 18,250 70 62 <.001
TABLE 4
Estimated reduction in reimbursement from a 10% increase in MIS utilization
Estimated 2011 discharges 10% increase in MIS discharges
Projected savingsMIS (%) Total reimbursement MIS (%) Total reimbursement
Colectomy 37 $2,921,587,369 47 $2,904,575,293 $17,012,076
Hysterectomy 23 $2,070,305,973 33 $2,065,321,210 $4,984,762
Thoracic 58 $858,915,011 68 $856,479,211 $2,435,800
Total $5,850,808,353 $5,826,375,714 $24,432,638
5. MARCH 2014 / MANAGED CARE 51
10% increase in MIS share, which
can be easily achieved given the
regional variation and adoption of
MIS in similar general surgeries. Our
model projects $24.4 million in an-
nual savings from reduction in payer
reimbursement for colectomy ($17
million), hysterectomy ($5 million),
and thoracic resection ($2.4 million).
DISCUSSION
Our results considerably extend
previous single-procedure, single-
institution research (Senagore 2005)
showing the association between
MIS and lower cDRG assignment
by analyzing data from a large na-
tional claims database and multiple
procedures. To our knowledge, this
is the first such national study per-
formed. We risk-adjusted the data by
propensity-matching the open and
MIS cases based on patient charac-
teristics including comorbidities,
hospital characteristics, procedural
characteristics, payer, and surgeon
specialty. After accounting for a ma-
jority of confounders, we found an
association between MIS and a lower
rate of cDRG assignment for all three
procedures analyzed. Although there
might be other clinical reasons for
why the MIS cohort was associated
with fewer cDRG assignments, hav-
ing accounted for the most common
preoperative patient related clinical
factors, we believe the difference in
the rate of postoperative complica-
tions as a result of the surgical ap-
proach remains the principal reason
for cDRG assignment.
The Center for Medicare and
Medicaid Services’ (CMS) acute In-
patient Prospective Payment System
(IPPS) is used to pay for inpatient
stays under Medicare Part A. Each
discharge is assigned a DRG, which
has an associated payment weight
based on average resources used. The
more complex and resource-intensive
the DRG, the higher the weight as-
signed. To determine reimbursement
for a given discharge, Medicare uses a
formula that multiplies the DRG’s rel-
ative weight by the base payment rate
(in 2013, this was $5,774.25). Medi-
care further adjusts the reimburse-
ment amount based on a number of
largely nonclinical factors, including
hospital location, teaching status, and
percentage of low-income patients.
Appendix Table 2 presents the
2013 Medicare base reimbursement
for the DRGs in this study. There is a
significant difference in reimburse-
ment between non-cDRG and cDRG
discharges. In 2013, the base Medi-
care reimbursement for non-cDRG
colectomy discharges was $9,447.25,
while cDRG reimbursement was
$14,857.72 to $30,371.98. Hysterec-
tomy and thoracic resection show
similar differences. With hundreds of
thousands of procedures performed
each year, reducing the number of
cDRG assignments based on post-
operative complications can result in
significant cost savings from a payer
perspective.
Our results suggest that MIS can
help reduce overall U.S. health care
system reimbursement costs. Our
model conservatively estimates
nearly $24.4 million in annual sav-
ings for a 10% increase in MIS uti-
lization. MIS is also associated with
fewer readmissions and faster recov-
ery time, which could further add to
the savings.
Administrative claims databases,
such as Premier, allow for the study
of large populations, but there are
limitations. Patients were not ran-
domized, so there is potential for
selection bias.
Although we attempted to control
for clinical severity, surgeons may
have used additional clinical data
available to select their approach.
Also, based on data available, we
could not identify and eliminate the
MIS procedures that were converted
to open procedures. There might be
coding errors, documentation errors,
and incomplete records. However,
these errors should be distributed
equally between the MIS and open
groups. Factors such as surgeon
training or other surgeon preferences
could not be accounted for and might
affect results.
Despite these limitations, this
study presents the first national-
level payer view of the potential as-
sociation between MIS utilization
and cDRG assignment. Collectively,
this study, along with others dem-
onstrating MIS’s superior outcomes,
supports greater adoption of MIS for
colectomy, hysterectomy, and tho-
racic procedures.
Further research, including a pro-
spective cohort study, are required
to definitively determine if MIS is
the reason for the lower rate of cDRG
assignment.
CONCLUSION
The U.S. health care industry is in
the midst of a fundamental trans-
formation, stemming largely from
rising costs and inconsistent qual-
ity of care. Health care reform laws
and economic pressures are causing
a shift in focus from volume-based
to value-based care.
Payers and providers continue to
explore innovations that improve
clinical outcomes and reduce costs,
and MIS is one such innovation.
MIS approaches in colectomy,
hysterectomy, and thoracic resec-
tion have demonstrated significant
clinical benefits, including a reduc-
tion in both hospital cost per case
and payer reimbursement expense
based on fewer cDRG assignments.
Further adoption of MIS may lead to
improved outcomes and additional
savings.
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7. MARCH 2014 / MANAGED CARE 53
Appendix Table 1
ICD procedure and MS-DRG codes used to select discharges
Procedure
MIS Open MS-DRG
ICD
code
ICD
code Code Description
cDRG
assignment
Colectomy 17.31 45.71 329 Major Small and Large Bowel Procedures w MCC Yes
17.32 45.72 330 Major Small and Large Bowel Procedures w CC Yes
17.33 45.73 331 Major Small and Large Bowel Procedures w/o CC/MCC No
17.34 45.74
17.35 45.75
17.36 45.76
17.39 45.79
45.81 45.82
Hysterectomy 68.31 68.39 734 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy
w CC/MCC
Yes
68.41 68.49 735 Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy
w/o CC/MCC
No
68.51 68.59 736 Uterine and Adnexa Procedures for Ovarian or Adnexal Malig-
nancy w MCC
Yes
68.61 68.69 737 Uterine and Adnexa Procedures for Ovarian or Adnexal Malig-
nancy w CC
Yes
738 Uterine and Adnexa Procedures for Ovarian or Adnexal Malig-
nancy w/o CC/MCC
No
739 Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy
w MCC
Yes
740 Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy
w CC
Yes
741 Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy
w/o CC/MCC
No
742 Uterine and Adnexa Procedures for Nonmalignancy w CC/MCC Yes
743 Uterine and Adnexa Procedures for Nonmalignancy w/o CC/MCC No
Thoracic 32.20 32.29 163 Major Chest Procedures w MCC Yes
32.30 32.39 164 Major Chest Procedures w CC Yes
32.41 32.49 165 Major Chest Procedures w/o CC/MCC No
CC=complications and comorbidities, cDRG=complex Diagnosis Related Groups, ICD=International Classification of Diseases,
MCC=major complications and comorbidities, MIS=minimally invasive surgery, MS-DRG=Medicare Severity Diagnosis Related Groups
APPENDIX
8. 54 MANAGED CARE / MARCH 2014
Appendix Table 3
Predictors of minimally invasive surgery
Effect
Odds
Ratio
95% CI
Lower Upper
36–45 vs ≤35 years 0.88 0.85 0.92
46–55 vs ≤35 0.87 0.84 0.91
56–65 vs ≤35 0.80 0.76 0.83
66–75 vs ≤35 0.76 0.72 0.80
76–85 vs ≤35 0.71 0.67 0.76
85+ vs ≤35 0.67 0.62 0.73
Male vs female 0.96 0.94 0.98
Black vs white 0.80 0.77 0.82
Others vs white 0.86 0.84 0.88
Northeast vs South 1.13 1.10 1.16
Midwest vs South 0.83 0.80 0.85
West vs South 0.94 0.91 0.96
Urban vs rural 1.35 1.30 1.39
Teaching vs nonteaching 0.93 0.91 0.95
100–249 beds vs <100 beds 1.29 1.22 1.36
250–499 beds vs <100 beds 1.16 1.10 1.22
>500 beds vs <100 beds 1.32 1.25 1.40
Medicaid vs Medicare 0.86 0.82 0.90
Managed care vs Medicare 1.17 1.13 1.21
Uninsured vs Medicare 0.72 0.67 0.76
Others vs Medicare 0.97 0.91 1.04
Nonelective vs elective admission 0.43 0.41 0.44
Myocardial infarction 0.94 0.88 0.99
Congestive heart failure 0.83 0.78 0.88
Peripheral vascular disease 0.87 0.82 0.93
Appendix Table 2
Medicare national average reimbursement rates for FY 2013 by MS-DRG
MS-DRG Average payment
329: Major Small and Large Bowel Procedures w MCC $30,371.98
330: Major Small and Large Bowel Procedures w CC $14,857.72
331: Major Small and Large Bowel Procedures w/o CC/MCC $9,447.25
734: Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy w CC/MCC $15,389.53
735: Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy w/o CC/MCC $6,745.48
736: Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy w MCC $25,487.54
737: Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy w CC $11,576.79
738: Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy w/o CC/MCC $7,421.64
739: Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy w MCC $19,181.48
740: Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy w CC $9,058.64
741: Uterine, Adnexa Procedures for Nonovarian/Adnexal Malignancy w/o CC/MCC $6,639.81
742: Uterine and Adnexa Procedures for Nonmalignancy w CC/MCC $8,174.61
743: Uterine and Adnexa Procedures for Nonmalignancy w/o CC/MCC $5,573.88
163: Major Chest Procedures w MCC $29,560.12
164: Major Chest Procedures w CC $15,123.34
165: Major Chest Procedures w/o CC/MCC $10,348.61
9. MARCH 2014 / MANAGED CARE 55
Appendix Table 3
Predictors of minimally invasive surgery
Effect
Odds
Ratio
95% CI
Lower Upper
Cerebrovascular disease 0.94 0.86 1.03
Dementia 0.73 0.55 0.96
COPD 0.88 0.85 0.90
Rheumatic disease 0.97 0.90 1.04
Ulcers 0.92 0.82 1.05
Liver disease, mild 1.01 0.87 1.17
Liver disease, moderate/severe 0.85 0.66 1.09
Diabetes 0.94 0.91 0.97
Diabetes + sequelae 1.03 0.94 1.13
Chronic renal failure 0.84 0.79 0.89
Malignancy 0.82 0.76 0.88
Metastatic solid tumor 0.56 0.54 0.59
Paralysis 0.67 0.52 0.87
AIDS 0.70 0.47 1.04
Obesity 0.86 0.84 0.89
Hypertension 0.94 0.92 0.97
Others vs general surgeons 0.85 0.81 0.89
Colorectal surgeons vs general surgeons 1.73 1.67 1.81
Obstetrics and gynecology vs general surgeons 0.62 0.57 0.67
Thoracic surgeon vs general surgeons 1.09 1.03 1.16
Colectomy vs hysterectomy 2.36 2.08 2.68
Thoracic vs hysterectomy 3.68 3.34 4.06
Multiple segmental large bowel resection vs abdominal hysterectomy 1.16 0.93 1.46
Cecectomy vs abdominal hysterectomy 2.04 1.83 2.29
Right hemicolectomy vs abdominal hysterectomy 2.06 1.87 2.26
Transverse colon resection vs abdominal hysterectomy 1.19 1.05 1.34
Left hemicolectomy vs abdominal hysterectomy 1.23 1.12 1.36
Sigmoidectomy vs abdominal hysterectomy 1.71 1.56 1.87
Unspecified partial large intestine resection vs abdominal hysterectomy 0.80 0.72 0.90
Total intra-abdominal colectomy vs abdominal hysterectomy 0.00 0.00 0.00
Supracervical/subtotal hysterectomy vs abdominal hysterectomy 8.10 7.76 8.45
Vaginal hysterectomy vs abdominal hysterectomy 13.10 12.64 13.58
Radical hysterectomy vs abdominal hysterectomy 2.97 2.67 3.31
Wedge resection vs abdominal hysterectomy 6.46 6.09 6.86
Segmental resection vs abdominal hysterectomy 1.89 1.71 2.08
Lung lobectomy vs abdominal hysterectomy 0.00 0.00 0.00
Other diagnosis vs malignancy 0.55 0.51 0.60
Benign neoplasm of colon vs malignancy 1.93 1.78 2.10
IBD / diverticulitis vs malignancy 0.94 0.87 1.02
Benign fibroids vs malignancy 0.44 0.40 0.47
Endometriosis vs malignancy 0.68 0.62 0.74
Menstrual disorders vs malignancy 0.60 0.55 0.65
Genital prolapse vs malignancy 0.09 0.08 0.10
Secondary neoplasm of respiratory system vs malignancy 0.87 0.79 0.97
Pulmonary fibrosis vs malignancy 1.25 1.09 1.43
Pneumothorax vs malignancy 2.41 2.08 2.77
, continued