Economic Impact of Facial Plastic and Reconstructive Surgery: The Case Mix Index

Background: The case mix index (CMI) represents the average medicare severity-diagnosis related group relative weight over a period of time. The higher the CMI, the more the hospital gets reimbursed, on average. Little has been published in regards to CMI within Otolaryngology particularly in Facial Plastic and Reconstructive Surgery. Aim: This study was performed to determine the economic impact of Facial Plastic and Reconstructive Surgery has on hospital medicare reimbursements. Methods: In a retrospective review we analyzed the admissions of facial plastic and reconstructive surgeons as well as general otolaryngologists at a tertiary medical center from October 2015 through May 2018. General otolaryngology excluded pediatrics, otology, and admissions under fellows. The admissions analyzed were limited to patients that required observation or intervention from a plastics perspective. Of the FPRS admissions, there were no patients included that were admitted for oncologic resection or surgeries that would have fallen within other specialties of otolaryngology. The case mix index was then calculated for each admission. Results: There were two facial plastic and reconstructive surgeons and thirteen general otolaryngology surgeons who admitted patients from October 2015 through May 2018. A total of 103 admissions were found to have plastics-only observation or intervention. The average CMI for these patients was 2.92. Of the 1,918 general otolaryngology admissions, the average CMI was 2.62. There were 14 FPRS admissions that had a CMI of less than 1.00, and five of those did not have a procedure completed during the admission. Conclusion: At the studied tertiary care center, case mix index values greater than a value of 2.2 indicated that the average medicare reimbursements per admission surpassed the costs of the admission. The result is a profit for the hospital. As demonstrated in our study, FPRS admissions consistently produced a profit for this tertiary medical center. Furthermore, FPRS admissions resulted in a greater average CMI as compared to admissions under general otolaryngologists

Otolaryngology Subspecialty Surgical Rescheduling Rates During the COVID-19 Pandemic

Objective: In the beginning of the COVID-19 pandemic in spring 2020, elective and oncologic surgical cases were cancelled. After adequate safety protocols were established, each subspecialty within otolaryngology faced unique challenges in reengaging patients for surgical scheduling. Study design: Retrospective review from March to May 2020. Setting: Single academic institution. Methods: Patients whose otolaryngology surgery was cancelled due to COVID-19 hospital precautions were identified. Rescheduling rates were analyzed by subspecialty. Case completion was determined as the percentage of initially cancelled cases that were completed within 6 months of their original planned dates. Results: Of 833 otolaryngology cases scheduled between March 16 and May 29, 2020, a total of 555 (66.63%) were cancelled due to COVID-19 precautions, and 71.17% were rescheduled within 6 months. Cancellation and rescheduling rates per subspeciality were as follows, respectively: head and neck surgery, 42.79% and 88.76%; sleep surgery, 83.92% and 64.07%; rhinology and skull base, 72.67% and 64.80%; facial plastic and reconstructive surgery, 80.00% and 74.17%; otology and neurotology, 71.05% and 66.67%; and laryngology, 68.57% and 79.17%. The case completion rates were as follows: head and neck surgery, 95.2%; laryngology, 85.7%; facial plastic and reconstructive surgery, 79.3%; otology and neurotology, 76.3%; rhinology and skull base, 74.4%; and sleep surgery, 69.9%. Conclusion: Differences for surgical rescheduling rates during the COVID-19 pandemic shutdown exist among otolaryngology subspecialties. Our experience suggests that subspecialties that functioned on an elective nature were more likely to face lower rates of case completion

Association of operative approach with postoperative outcomes in neonates undergoing surgical repair of esophageal atresia and tracheoesophageal fistula

Introduction: Minimally invasive surgery (MIS) is gaining traction as a first-line approach to repair congenital anomalies. This study aims to evaluate outcomes for neonates undergoing open versus MIS repairs for esophageal atresia/tracheoesophageal fistula (EA/TEF). Methods: Neonates undergoing EA/TEF repair from 2013-2020 were identified using the National Surgical Quality Improvement Program-Pediatric database. Proportions of operative approach (open vs. MIS) over time were analyzed. A propensity score-matched analysis using preoperative characteristics was performed and outcomes were compared including composite morbidity and reintervention rates (overall, major [thoracoscopy, thoracotomy], and minor [chest/feeding tube placement, endoscopy]) between operative approaches. Pearson’s chi-square or Fisher’s exact test were used as appropriate. Results: We identified 1738 neonates who underwent EA/TEF repair. MIS utilization increased over time (p=0.019). Pre-match, neonates undergoing open repair were more likely premature, lower weight, and higher ASA class. Post-match, the groups were similar and included 183 neonates per group. MIS repair was associated with longer median operative time (206 vs. 180 minutes, p\u3c0.001), increased overall reintervention rates (MIS 9.8% vs. open 3.3%, p=0.011), and increased minor reintervention rates (MIS 7.7% vs. open 2.2%, p=0.016). There were no differences in composite morbidity (MIS 20.2% vs. open 26.8%, p=0.14) or major reinterventions (MIS 2.2% vs. open 1.1%, p=0.41). Discussion: MIS is gaining traction as a first-line approach for neonates with EA/TEF but appears to be associated with a higher rate of reinterventions. Further studies evaluating MIS approaches for the repair of EA/TEF are needed to better define short and long-term outcomes to optimize patient selection

Minimally Invasive Surgery in Neonates with Congenital Anomalies: Experience from the NSQIP-P

Background: Congenital diaphragmatic hernias (CDH) and tracheoesophageal fistulas (TEF) are managed with minimally invasive surgery (MIS) or open surgery. Little is known about the patient populations and outcomes for those treated by each approach. Hypothesis/Specific Aims: We expect that there will be fewer complications, better outcomes, and longer operative times for the MIS group versus the open group. Methods: National Surgical Quality Improvement Program-Pediatric Participant Use Files (NSQIP-P PUFs) from 2012-2015 were used to identify neonates (up to 30 days old) who underwent CDH and TEF repair. The patient characteristics, post-operative complications, and 30-day mortality were analyzed using multivariable logistic regression to determine morbidity associated with each. Data/Results: We identified 1,142 neonates who underwent CDH (n=577) and TEF (n=565) repair. Neonates who underwent open repair were sicker than those who underwent MIS and had slightly worse select outcomes. Median operative time was longer for both CDH and TEF with the MIS approach. However, multivariable logistic regression analysis adjusting for patient comorbidities showed that open versus MIS surgical approach was not associated with increased morbidity. Discussion: Neonates who underwent MIS repair had fewer co-morbidities and better outcomes. This surgical approach was not associated with any adverse 30-day outcomes in the multivariable models. This suggests that MIS repair of CDH and TEF can be safely performed in a subset of patients, but further research is needed to understand whether surgical approach affects the incidence of longer-term complications such as CDH recurrence or esophageal stricture

Evaluating Barriers to Clinical Trial Enrollment in Head and Neck Surgical Oncology

Introduction and Objectives: Clinical trials are an important focus in academic otolaryngology practices, but busy practices may pose difficulty for identification and enrollment of patients eligible for trials. We will identify barriers to enrollment from the perspective of both head and neck surgical oncologists and their patients. Methods: Patients who were eligible for any of the eight clinical trials offered at Jefferson between August and November 2020 were identified. We utilized an Epic EMR phrase to capture if a trial was offered or not and why, whether a patient refused enrollment and why, and patient wait time. Results: During the 4 month period, the clinic saw 45 new patients with a cancer diagnosis and the EMR SmartPhrase was used 32 times. For those offered a trial, 18.8% agreed to enroll and 6.3% deferred to make a final decision at a later appointment. Of patients that were eligible for a trial but declined, 60% were due to concerns about clinical trial enrollment and 40% because of general disinterest. Reasons for ineligibility were more difficult to track in the group where SmartPhrase was not used because the providers’ thought processes were not declared. We will present average wait time data. Discussion: Use of the Epic SmartPhrase for evaluation of common barriers to clinical trial enrollment has allowed further documentation for explanations of ineligibility or refusal to enroll. In conjunction, we expect lowering wait times will help optimize trial enrollment