Real-World Evidence on the Use of Ecmo in Hospitalized COVID-19 Patients: Results from a Linked Closed and Open Claims Database in the US

Objectives: To describe the use of extracorporeal membrane oxygenation (ECMO) among hospitalized coronavirus disease 2019 (H-COVID-19) patients in a linked closed claims (CC) and open claims (OC) database. Method(s): This analysis identified H-COVID-19 patients between April 2020 (Q2 2020) and June 2022 (Q2 2022) in CHRONOS, a linked CC and OC database. The index event was the date of hospitalization, defined as an inpatient claim within 21 days of a COVID-19 diagnosis in the CC. The occurrence of ECMO 30 days after index was identified using CC data alone and then CC and OP data in combination to assess missing data. Study exclusions included patients under the age of 18, a first COVID-19 diagnosis that did not result in hospitalization, and less than 12-months of continuous enrollment in the CC before index. Study criteria were defined by the presence of an ICD-10-CM, ICD-10-PCS, or CPT code on a claim. Results are reported as percentages and 95% confidence intervals. Result(s): Of 321,687 patients with H-COVID-19, the mean age was 50.1 (SD:12.8) with the highest proportion of hospitalizations occurring in Q3 2021 (19.4%). Overall, 0.50% (0.48%-0.52%) of patients in the CC data received ECMO, increasing to 0.61% (0.58%-0.64%) with the inclusion of OC data. The use of ECMO to treat H-COVID-19 patients decreased between Q2 2021 and Q2 2022, with the highest rates occurring in Q2 of 2020 (0.78%) and Q2 2021 (0.80%). The addition of OC data increased rates to 1.12% and 0.89% in Q2 of 2020 and Q2 2021. Conclusion(s): Although use of ECMO decreased in the later months of the pandemic, it represents a substantial burden. The current analysis demonstrates that CC data, often sourced from payers, may underestimate the use of ECMO in real-world settings. Opportunities exist to mitigate issues of missing data by linking CC, OC, and other real-world data sources.Copyright © 2023

The impact of COVID-19 on colorectal screening in Puerto Rico

INTRODUCTION: Puerto Rico has endured three major environmental and public health crises (Hurricane Irma, Hurricane Maria, the unprecedented seismic activity of January 2020) and the coronavirus disease 2019 (COVID-19) pandemic during the past 5 years. All these events might lead to an unquestionable deleterious impact in the prevention of cancer and across the cancer continuum, exacerbating cancer health disparities in the future. Cancer screening plays a critical role in early cancer detection. COVID-19 has significantly hampered screening programs in many countries' cancer screening infrastructure and services, affecting adherence. Cancer is the leading cause of morbidity and mortality in Puerto Rico. Limited information is available about the impact the current pandemic on colorectal cancer screening. In this study, we aim to describe the impact of the COVID-19 pandemic on colorectal cancer screening in 2020 and assess if this impact varied by health regions. METHOD(S): This study analyzed administrative data claims from the Public Health System of Puerto Rico which is managed by the Government of Puerto Rico through the Health Insurance Administration. The Current Procedural Terminology (CPT) codes included for this study were (81528, 82270, G0104, G0105, G0121, G0328, G0464). To assess changes in the numbers of colorectal cancer screening claims between the incurred year (2016 and 2020), Poisson regression was used. Initially, we fitted this model with only the incurred year as the predictor and offsetting the model with the annual average of total insured (univariate model). Based on this model, we estimate the magnitude of association between the number of claims and incurred year using the Prevalence Ratio (PR) of claims. Lastly, Poisson univariate regression model were used for each of the seven health regions (Ponce, Bayamon, Caguas, Mayaguez, Metro, Arecibo and Fajardo) to assess potential geographic disparities. RESULT(S): The numbers of colorectal cancer screening claims significantly decreased by 40% (PRcrude: 0.60, 95%CI: 0.59, 0.62) in 2020 when compared to 2016. However, when adjusting for claim incurred month, sex, health region and offsetting the model with the annual average of total insured, the numbers of colorectal cancer screening claims significantly decreased by 34%, (PRadj: 0.66, 95%CI: 0.64, 0.67). The numbers of colorectal cancer screening claims significantly decreased in all health regions in 2020 when compared to 2016 (p<0.05). However, the most impacted region was the Eastern region, Fajardo, with a 64% (PRFajardocrude: 0.36, 95%CI: 0.30, 0.42) significant decrease in numbers of colorectal cancer screening claims. CONCLUSION(S): COVID-19 had a profound negative effect on colorectal screening in Puerto Rico. Moreover, despite the beneficiaries of this governmental health plan sharing similar sociodemographic and socioeconomic background, regional differences were observed.

Temporal Analysis of Medicare Physician Reimbursement for Common Gastroenterology Procedures From 2007 to 2022

Introduction: As the U.S. population ages, gastroenterologists will provide care for an increasing number of older patients - many of whom use Medicare. In recent years there have been significant policy changes surrounding Medicare reimbursement for physicians. Understanding reimbursement trends can help reveal the financial impact of these policies on gastroenterologists. Our study aims to analyze the trends in Medicare reimbursement of common gastrointestinal (GI) services from 2007 to 2022. Method(s): The top 10 GI procedures and their respective CPT codes were identified through a joint list published by the American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, and American Gastroenterological Association. The top 5 5 CPT codes relating to office/inpatient visits provided by gastroenterologists to Medicare Part B beneficiaries was identified using data from CMS. The Physician Fee Schedule Look-Up Tool from CMS was queried for the selected CPT codes from 2007 to 2022, to determine the facility reimbursement rate by Medicare for each service. The reimbursement data were adjusted to January 2022 U.S. dollars using the U.S. Department of Labor's Bureau of Labor Statistics' consumer price index inflation calculator. Result(s): The unadjusted physician reimbursement for GI procedures exhibited an average decrease of 7.0% (95% CI, 29.9% to 24.1%) from 2007 to 2022. After adjusting for inflation, the mean decrease in physician reimbursement for procedures was 33.0% (95% CI, 235.1% to 230.9%). The mean annual growth rate in reimbursement was 22.6% (95% CI, 22.8% to 22.4%). The unadjusted physician reimbursement for inpatient and outpatient visits exhibited an average increase of 32.1% (95% CI, 4.8% to 59.3%). After adjusting for inflation, physician reimbursement for patient visits exhibited a mean decrease of 4.92% (Figure 1). Conclusion(s): The analysis revealed a steady decline in adjusted and non-adjusted reimbursement between 2007 and 2022. Decreasing Medicare reimbursement may impact health outcomes, healthcare access, and patient satisfaction. Reimbursement policies must be scrutinized particularly in the light of high inflation and increased costs due to additional costs associated with care during the COVID-19 pandemic, staffing shortages, and increased staffing salaries. (Figure Presented).

Post-Operative Outcomes in 'Monti' Construction for Neurogenic Bladders in an Adult Population

INTRODUCTION AND OBJECTIVE: Various diversion techniques exist for the management of neurogenic bladders. In pediatrics, the appendicovesicostomy is a successful approach but may not be applicable for all patients. An alternative is the Yang-Monti ("Monti") catheterizable conduit, created using a section of small bowel. Although commonly used in pediatrics, there are very few series evaluating adults. This study aims to evaluate "Monti" outcomes in an adult population. METHOD(S): Between 1999 and 2022, "Monti" procedures at a single institution were identified using CPT codes, and the list was reviewed to select for adult patients with neurogenic bladder dysfunction. Preoperative data included indications for surgery and patient demographics. Perioperative (day 0 to end of hospital stay) data included time to return of bowel function, length of stay, and perioperative complications. Long-term complications included infections, hospital admissions, and reoperations. Data are presented as means or percentages. RESULT(S): 21 adult patients (male n=8;female n=13) with neurogenic bladder dysfunction were identified. 14 patients developed neurogenic bladder secondary to trauma, while other indications for surgery included idiopathic urinary retention (n=1), tumors (n=2), congenital abnormalities (n=2), multiple sclerosis (n=1), and autoimmune neuropathy (n=1). The mean follow-up time was 3.13 years and mean age at surgery was 35.5 years. The mean time to return of bowel function was 2.7 days (n=14) and postoperative hospital stay was 4.3 days (n=16). Perioperative complications occurred in 10 patients (47.6%) in the first 30 days including UTIs (n=3), surgical site infection (n=3), ileus (n=1), small bowel obstruction (n=1), and suprapubic tube related complications (n=3). Five emergency room admissions for urologic concerns occurred within this period with a total of 28 visits overall. At six month follow-up, a total of six (28.6%) patients had longer-term complications. These included a takedown, a scheduled revision, a hospitalization for complicated UTI, and three patients who were unable to catheterize. Overall, nine patients (42.9%) required reoperation, including three revisions and one cystectomy with conversion to ileal conduit. Two patients expired during the course of this study due to COVID pneumonia and suspected sepsis. CONCLUSION(S): "Monti" procedures are useful for adult patients with neurogenic bladder dysfunction. However, these procedures are associated with significant complications. This information should be used to aid in presurgical counseling.

The 2023 CPT Coding and Medicare Payment Update

There are a host of changes that will affect family physicians, including new vaccine codes and bundled Medicare payments for chronic pain management.

Undercounting of COVID-19 Vaccinations in Fee-for-Service Medicare Claims

Background: Older individuals and those with certain underlying conditions were among the earliest groups offered COVID-19 vaccinations. While patients with ESKD did not initially receive priority, a federal program permitted vaccinations to be administered in dialysis clinics starting in March 2021. We studied early uptake of COVID-19 vaccinations in Medicare fee-for-service beneficiaries with ESKD. Method(s): We included beneficiaries aged >=18 years with ESKD on December 1, 2020 from the US Renal Data System. Vaccinations covered by Medicare were identified using CPT codes. The cumulative monthly incidence of first vaccination dose through June 2021 was compared by modality (HD, PD, transplant) and stratified by age and race/ ethnicity. Death was treated as a competing risk. Result(s): By June 30, 2021, the cumulative incidence of receiving a Medicare-covered first vaccination dose was <40% in patients receiving HD (Figure A), well under the estimate reported by dialysis facilities to the CDC by this date (72%). Although caution is required, some interpretation of the Medicare vaccination data may still be permitted. After the allocation of vaccines to dialysis clinics, Medicare-covered vaccinations surged in patients receiving HD relative to the other modalities. In patients receiving HD, uptake of Medicare-covered vaccinations was initially highest among those aged >=65 years and then surged in younger patients following the federal vaccine allocation (Figure B). Conclusion(s): COVID-19 vaccination rates are severely underestimated using Medicare administrative data. It is unclear whether missingness of vaccination data is differential by demographic groups, such as race/ethnicity. Inferences based on these data should be made with caution.

Comprehensive Surgical Thyroid Management in a Rural Health System During the Global Pandemic

Introduction: Access to high-quality, comprehensive, subspecialty care is challenging in rural health care settings under ideal circumstances. In the clinically restricted environment created by the SARS-CoV-2 pandemic, this has been even more problematic. The regional distribution of a broad patient demographic across multiple tertiary care centers within a large rural health care system presents unique challenges. Here we describe our system platform for the management of a large population of thyroid patients across an expansive rural health system during the pandemic. Method(s): This retrospective review was approved by our institutional review board. Patients undergoing surgical management of thyroid and parathyroid disease were identified using a system electronic medical record via Current Procedural Terminology codes. Applications essential for management of these patients included implementation of an endocrine database, utilization of a multidisciplinary thyroid cancer tumor board, and coordination of regional patient access through the Geisinger System Program for Thyroid and Parathyroid Disorders. Result(s): We identified 930 endocrine surgical cases at our institution managed over the past 3 years. A total of 281 patients have been reviewed thus far. A total of 185 thyroid surgeries were performed on 173 patients. Final pathology was benign in 99 (53.5%) patients;77 (41.6%) were welldifferentiated thyroid carcinomas. The average elapsed days from fine needle aspiration biopsy to surgery was 54.8 (with those >100 days excluded). Average elapsed days from biopsy to surgery in patients with molecular testing was 61.5 days compared with 49.9 days for those without molecular testing. These 2 averages were significantly different from each other (P=.02) but not from the overall average. Conclusion(s): In this presentation, the effective management of a large population of thyroid patients is demonstrated through the utilization of several critical clinical applications. We propose a care delivery scheme for the evaluation and management of thyroid patients utilizing multiple clinical access points together with a multidisciplinary program for endocrine disease management.

Robotic Telepresence Consults in Underserved Community-Based Vision Threatening Disease Screenings During COVID-19

Purpose : Vision Threatening Diseases (VTDs) (age-related macular degeneration, cataracts, diabetic retinopathy, glaucoma) affect 36 million individuals in the United States. 50% are unaware they have a VTD, disproportionally affecting minorities and lowincome groups with less access to eye care. While screening programs in underserved communities result in early detection, less than half of subjects with findings follow up with a specialist. This number is four times lower during COVID-19. Methods : Robotic Telepresence (RT) was implemented in this pilot study during COVID19 to increase real-time access to specialist care. 58 subjects (age 56, 45% male) underwent a non-mydriatic screening protocol over five screenings. They were divided into three groups for consult: In Person (IP) followed by RT (N = 21), RT followed by IP (N = 19), and IP only (N = 18). IP consult was done by an on-site certified reader. RT consult was done by an off-site glaucoma or retina specialist with access to blood pressure, visual acuity, intraocular pressure, 45° retinal images, and ocular coherence tomography Bscans via cloud-based software. Video connection for RT was established via HIPAAcompliant mobile hotspot. Subject demographics and preferences were collected afterwards via survey. Results : Of 40 RT consults, 26 were second opinion for VTD suspect and 14 were wellness encounters. 24 reported their last eye care visit >3 years ago or never. Following RT consult, 18 subjects received one or multiple VTD diagnosis and 3 with glaucoma were referred for pressure-lowering eye drops. In the group with IP consult first, preferences were 5% RT, 52% IP, and 43% none. In the group with RT consult first, preferences were 5% RT, 58% IP, and 37% none. There was no significant difference in number of questions asked, wait time, or encounter length between IP and RT consults. Conclusions : RT consults proved valuable in community-based VTD screenings, particularly during COVID-19 when access to eye care is further limited. Most subjects preferred IP. However subjects with VTD that face socioeconomic barriers benefit from immediate RT consult and management directives from remote subspecialists. Further studies should incorporate consults from additional specialties (endocrinologists, general practitioners, social workers) and include telehealth CPT code for reimbursement.

Expansion of a teleophthalmology program for diabetic retinopathy screening during the COVID19 pandemic

Purpose : The COVID-19 pandemic prompted efforts to encourage social distancing and minimize non-urgent in-person eye care. Here, we report the outcomes of a teleophthalmology program for diabetic retinopathy screening at an integrated health system in California that was expanded during the pandemic. Methods : We performed a retrospective review of patients who underwent remote retinal imaging as part of a teleophthalmology program for diabetic retinopathy (DR) screening using Current Procedural Terminology (CPT) codes 92227 and 92228 at the University of California, Davis Health system between May 31st , 2019 and June 8th , 2021. Retinal images were captured at primary care locations using a Topcon NW400, Nikon RetinaStation, or Optos Primary fundus cameras, and image grading were performed by trained ophthalmologists or optometrists using a store-and-forward method. Patient records were reviewed to collect demographic, follow-up, and clinical outcomes information. Results : During COVID19 pandemic, the teleophthalmology program screened 570 individuals (mean age 63.2 ± 13.7). There was a significant increase in the number of patients screened per month prior to and following the COVID-19 lock-down in March 2020 (5.0 ± 3.1 patients screened per month prior to and 39.1 ± 34.8 patients per month following, P = 0.0004). Among these, 204 patients received a recommendation for in-person eye care referral, of which 127 received a referral to the UC Davis Eye Center, 85 appointments were scheduled, and 82 patients were followed in person, with a median time of 108 days between screening and in-person follow-up. Follow-up rates were generally lower during the initial months after the pandemic and increased over time. Among the patients who followed in person (mean age 63.9 ± 13.8), 10% of eyes had mild non-proliferative DR (NPDR), 5% had moderate NPDR, 3% had severe NPDR, 2% had PDR, and 4% had diabetic macular edema (DME), with similar proportions before and after the COVID-19 lockdown. Conclusions : Expansion of a teleophthalmology program during the COVID19 pandemic demonstrated improved DR screening rates, increased referrals, and improved follow-up for diabetic eye care at an integrated health system in Northern California.

Trends in California ophthalmology surgical volume during the COVID pandemic

Purpose : Pandemic era restrictions on non-essential travel, redistribution of healthcare resources, and nursing shortages have impacted the ability of ophthalmologists to deliver care. California had among the strictest 2020 restrictions during the pandemic with reallocation of non-essential surgical resources. This study assesses changes in surgical volume of common ophthalmic procedures in California since the COVID-pandemic. Methods : The California Health and Human Services Agency (Office of Statewide Health Planning & Development) maintains ambulatory and emergency room procedural databases. Common ophthalmic procedures and surgical volumes were extracted for 29 CPT codes from 2014-2020. Procedures with fewer than 100 cases were excluded. Results : Overall, ophthalmology surgical volume decreased by 19% from 2019 to 2020. Greatest declines were for anterior lamellar corneal transplant (39%) and pterygium with graft (38%). Simple cataract surgeries declined by 29% in 2020, compared to an average annual decline of 3% from 2014-2019. Volume increased only for two surgeries: aqueous shunt with graft (2%) and complex retinal detachment (0.2%). Temporal artery biopsies, historically stable with 0.2% average change from 2014-2019, declined by 28% in 2020. Retinal detachment repairs declined by 20% and 17% (with and without vitrectomy, respectively). In comparison, laparoscopic appendectomy only declined by 2% in 2020. Limitations of this study include role of population changes and changes in annual coding practices. Conclusions : COVID era declines were noted across almost all ophthalmic surgeries with steep drops in perceived non-urgent procedures such as pterygium and cataract. However, delays in cataracts and other conditions can result in increased disease burden and morbidity for patients. Uniquely, tube shunt procedures increased, perhaps due to progression of glaucoma from delayed routine care. For vision-preserving surgeries such as retinal detachment repair, lack of accessible care during the pandemic is especially concerning.

Utilization and insurance coverage of tele-retinal imaging during the COVID-19 pandemic

Purpose : Greater utilization and insurance coverage for tele-retinal screening during the COVID-19 pandemic in 2020 may enhance awareness and expand remote retinal imaging services. In this study, we performed a retrospective, cross-sectional analysis of utilization and insurance payments of tele-retinal imaging services in the United States in 2020. Methods : We examined remote retinal imaging utilization and insurance payments from January 1, 2020, to December 31, 2020, using the OptumLabs® Data Warehouse (OLDW), a comprehensive database of de-identified administrative claims for commercial and Medicare Advantage enrollees in the U.S. We evaluated frequency of claims and insurance payment for services using Current Procedural Terminology codes 92227 and 92228 for remote eye imaging by any provider, and 92250 for fundus photography by non-eye care providers. Results : Use of remote retinal imaging declined rapidly from 3627 claims in February 2020 to 1414 claims in April 2020, but returned to 3133 claims by December 2020, similar to pre-pandemic levels in 2019 (2841 ± 174.8 claims). Proportion of insurance payments for remote imaging increased temporarily from 47.4% in February to 56.7% in April, then returned to 45.9% in December. Conclusions : Utilization of tele-retinal imaging declined steeply while insurance coverage increased during the initial COVID-19 lockdown in 2020, but returned to pre-pandemic levels by end-of-year. Changes in utilization and relaxed restrictions on insurance reimbursements for remote retinal imaging during the COVID-19 pandemic were not sustained.

US National Trends in Ophthalmic Procedures During the COVID-19 Pandemic

Purpose : To evaluate the relationship between COVID-19 case volume and ophthalmic procedural volume during the pandemic. Methods : A retrospective cohort study using TriNetX (Cambridge, MA, USA), a federated electronic health records research network comprising multiple large health organizations in the United States. Monthly Current Procedural Terminology (CPT)- specific volumes per HCO were clustered chronologically to calculate average volumes into three-month seasons to calculate average volumes. Seasonal averages from a combination of 2018 and 2019 data were used to provide a baseline comparison to pre-pandemic procedural volume. An aggregate of the total pandemic period (March 2020-August 2021) was compared to the corresponding figures in pre-pandemic timeframes. Results : 670,541 unique ophthalmic procedures from among 573 HCOs between March 2018 and August 2021 were included. Intravitreal injections was the most prevalent procedure with 320,106 occurrences. Phacoemulsification cataract surgery was the second most prevalent (N = 176,095) procedure with 144,816 uncomplicated (82.2%) and 31,279 complicated (17.8%). Intravitreal injections had the highest mean seasonal volume per HCO for each of the five COVID-19 pandemic seasons. From March 2020-August 2021, a mean pandemic volume of 266.7 (SD = 15) was observed, a 5% decrease (p<0.05) in procedures compared to pre-pandemic mean of 280.8 (SD = 26.1). During the five COVID-19 pandemic seasons, the seasonal mean volume almost always differed from pre-pandemic comparisons. Spring 2020 exhibited the sharpest seasonal decrease in procedural volume (88%). Spring 2021 had the largest count of significant increase in procedure volume (18%). Aggregate mean volume per HCO showed significant decreases for 11 out of 17 procedures in the 12-month March 2020-February 2021 timeframe and significant decreases for 10/17 procedures over the 18-month March 2020-August 2021 timeframe. A relative inverse relationship between COVID-19 case volume and ophthalmic procedure volume was observed. Conclusions : This study highlights the relative inverse relationship between COVID-19 cases and ophthalmic procedure volume in the US. Reduction in procedural volume may result in delayed care with potential for vision loss. Awareness and understanding of these trends could help ophthalmologists prepare should a similar cycle occur in the setting of the omicron and future variants.

The Impact of COVID-19 on Periocular NonMelanoma Skin Cancer in the Veteran Population

Purpose : Despite an increasing incidence of skin cancer over the last decade, studies have reported a decline in the diagnosis and treatment of skin cancer during the COVID19 pandemic. We performed a retrospective cohort study using a large population-based cohort from the Veterans Health Administration (VHA) to determine how the pandemic has affected tumor size and morbidity in veterans with periocular non-melanoma skin cancer. Methods : Electronic health records from all VHA sites were accessed through the VA Informatics and Computing Infrastructure (VINCI). Data were stored in the Observational Medical Outcomes Partnership (OMOP) model and queried via SQL Server. ICD-10 and current procedural terminology codes were used to identify patients who received Mohs surgery for periocular basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) between 08/01/2018 and 09/10/2021. A combination of structured algorithms and manual review were used to extract patient demographics, lesion characteristics, and surgical outcome at three time points, ie. pre-COVID, early, and late COVID. Unpaired t-tests were used to assess statistical significance. Results : Patient characteristics were similar between pre- and post-COVID cohorts in terms of gender, age, race, and tumor type. The average number of Mohs periocular surgeries performed per week were 23.1% (7.31 vs 5.62) and 13.1% (7.49 vs 6.51) lower in the early and later pandemic, respectively, compared to similar pre-COVID timeframes by month (Figure 1). Mean lesion size (maximum diameter) was 1.35 cm larger post-COVID compared to pre-COVID (95% CI 0.19 2.51, P=0.022);however, the defect size remained similar (Figure 2). Stratifying by tumor type, the same trends were noted in BCC, particularly early in the pandemic. However, mean SCC lesion and defect sizes did not vary over time. Conclusions : Periocular Mohs surgery rates declined in the COVID pandemic across VHA. Lesions were larger particularly in the earlier phase of the pandemic for BCC. Future analyses using this cohort will attempt to determine if telehealth and travel time were associated with distinct outcomes.

UTILITY OF TELEMEDICINE IN PATIENTS UNDERGOING TREATMENT FOR OVERACTIVE BLADDER

Introduction: Throughout the COVID-19 pandemic, medical office culture has changed to incorporate telemedicine. Now that regular office visits are occurring once again, many health care settings are left with a hybrid model. Throughout the pandemic, patients with incontinence were treated with telemedicine through many successful avenues. Behavioral, medical, and conservative management are valuable first-line interventions for overactive bladder and are possible in the telemedicine setting. It is important to examine the usefulness of telemedicine to discern if this is an appropriate alternative throughout the future of medicine. Objective: To assess the utility of telemedicine for patients undergoing management of overactive bladder. Methods: This is a retrospective chart review spanning March of 2019 through November 2021 at a urogynecologic practice. Patients were included based on CPT codes (N39.41, N32.81, N39.46). These codes are specifically for overactive bladder, urge, or mixed incontinence, respectively. Telemedicine visits started after April of 2020. Visit types including cancellations, re-scheduled visits, and no shows were compiled to look at compliance of in-person versus telemedicine visits. Analytical methods were performed using Python software. Descriptive analysis for all primary and secondary objective variables are reported independently and presented as percent and count within category. Results: There were 2176 patients who met inclusion criteria during the 32 month time frame. Patient compliance was the measure used to determine the utility of telemedicine visits. It was measured by collecting patient cancellations and rescheduled visits. In the time before April 2020 16.1% of visits resulted in patients not attending their originally scheduled appointment in comparison to 17.8% after. When broken down into the type of visit, 10% of telemedicine visits were not attended versus 18.2% of in-person visits. Of the visits that were not attended, if a visit was originally for in-person it was rare (4%) that they would switch their next visit to be telemedicine. And the same was true for telemedicine visits. However, when compiling no-show visits, 2.5% of in-person visits resulted in no-show in comparison to 4.4% of telemedicine visits. Conclusions: There were fewer canceled or rescheduled telemedicine visits overall in our sample of visits for urge incontinence. This could be due to greater flexibility of appointment type and decreased barriers such as transportation or timing of the appointment. Increased compliance with the originally scheduled appointment time strengthens the argument that telemedicine is a useful alternative to in-person appointments. This seems especially useful in the management of chronic medical conditions, such as urge incontinence, which do not require an in-person exam. Interestingly, the no-show rate was greater among telemedicine visits. Patients who do not show up for their appointment without notifying the office prior seem to be a different group from those who cancel. This could highlight a difference in the way patients view this type of medical care. Further research is needed to determine behavioral aspects of telemedicine care.

PATIENT SATISFACTION WITH SAME-DAY DISCHARGE AFTER UROGYNECOLOGIC SURGERY FOR APICAL VAGINAL PROLAPSE DURING THE COVID-19 PANDEMIC

Introduction: To alleviate strain on hospital resources during the COVID-19 pandemic, urogynecologists at our institution transitioned to same-day discharge for patients undergoing minimally invasive urogynecologic surgery for apical vaginal prolapse. Such practice has previously been shown to be safe and effective. Objective: This study aims to investigate patient satisfaction with same-day discharge after minimally invasive urogynecologic surgery for apical vaginal prolapse during the COVID-19 pandemic. Additionally, we aim to identify demographic and surgical characteristics that may influence patient satisfaction. Methods: All patients undergoing apical prolapse surgery at a single academic institution during the COVID-19 pandemic (n = 137) from March 2020 to December 2021 were queried using applicable CPT codes. In this retrospective, observational cohort study, each participant was surveyed by phone. The survey included questions on patient demographics, the Surgical Satisfaction Questionnaire (SSQ-8) to assess general satisfaction with the surgical experience, and questions on the impact of the COVID-19 pandemic on satisfaction with the surgical experience. The SSQ-8 is an eight-question validated survey with scores ranging from 8-40, higher scores indicating greater satisfaction. Participants responding “satisfied” or “very satisfied” with an average overall score ≥ 32 were classified as “Satisfied.” Participants with scores <32 were considered “Unsatisfied.” Those with missing values were excluded from analysis. Surgical satisfaction relating to the COVID-19 pandemic was assessed with Likert scale and open-ended questions. Crosstab tables were generated with chi-squared testing to compare patients that were defined as “satisfied” and “unsatisfied.” Results: We identified 137 patients who met inclusion criteria and obtained responses from 60 patients with a response rate of 43.8%. Among surveyed patients, mean age was 64 and 47 (78.3%) self-identified as white (Table 1). SSQ-8 scores revealed high overall satisfaction with the surgical experience (34.7 ± 5.7 out of 40). Itemized SSQ-8 results are included in Table 2. When considering the COVID-19 pandemic, 54 (90%) patients reported feeling “very” or “somewhat” safe going home the day of surgery and only 14 (23.3%) patients would have preferred to stay overnight (Table 2). The majority of patients, 43 (71.7%), found that the ongoing COVID-19 pandemic had “no impact” on their surgical satisfaction. When examining global satisfaction, pain control, and return to baseline as measured by the SSQ-8, there were no statistical differences in demographic or surgical factors between satisfied and unsatisfied patients (p > 0.05, Table 3). Patients with “poor or fair” general health selfassessments were more likely to be unsatisfied (P = 0.02). Additionally, having surgery during the early COVID-19 pandemic prior to widespread vaccine availability in April 2021, compared to having surgery after widespread vaccine availability had no impact on patient satisfaction (P = 1.00). Conclusions: Same-day discharge after surgery for apical vaginal prolapse is regarded as highly satisfactory and safe by the majority of patients. Of specific patient characteristics, poor or fair general health self-assessment had a negative impact on patient satisfaction. Overall, the COVID-19 pandemic had no impact on patient satisfaction with same-day discharge after urogynecologic surgery at our institution (Table Presented).

Real-world treatment patterns in patients with Sézary syndrome in the United States and the impact of Covid-19

Background: Sézary syndrome (SS) is an aggressive type of cutaneous T-cell lymphomas (CTCL). Due to its low prevalence, there are limited data on real-world treatment patterns of currently available SS therapies. Furthermore, recent approvals of new agents for patients with CTCL as well as COVID-19 likely impacted real-world treatment patterns. Objective: To examine real-world treatment patterns and the impact of COVID-19 among SS patients treated in 2018-2020 in the US. Methods: Patients with public or private insurance in the 2018-2020 Symphony Health Solutions database were classified into 3 groups: ≥1 diagnosis of SS (ICD-10-CM code: C84.1x) in 2018, 2019, and 2020, respectively. Patient characteristics and treatment patterns for all therapies recommended by the National Comprehensive Cancer Network guidelines version 2.2021 were examined: systemic therapy (e.g., extracorporeal photopheresis (ECP), parenteral, or oral agents), skin-directed therapy (SDT, e.g., topical, local radiation, total skin electron beam therapy, or phototherapy) and bone marrow transplant. The impact of COVID-19 was assessed via quarterly analysis. National drug codes, current procedural terminology and healthcare common procedure coding system codes were used to identify all treatments. Results: The analyses included 869, 882, and 853 SS patients in 2018, 2019, and 2020, respectively (mean age: 66.3, 66.9 and 67.3 years;male: 54.4%, 54.8%, and 55.6%). Overall, systemic therapy increased from 2018 to 2020 (41.8% to 46.5%), with increased parenteral (20.7% to 28.7%) but decreased ECP (17.0% to 13.5%) usage. SDT increased from 2018 to 2020 (48.9% to 52.9%), with increased topical (42.3% to 48.3%) but decreased phototherapy (6.3% to 4.1%) usage. ECP, mogamulizumab, and bexarotene were the most prescribed systemic therapies in 2019-2020, with mogamulizumab being the only one with increased usage over time. Quarterly analysis showed a decreasing ECP from Q1 to Q4 within each year, with a notable drop in Q2 2020. For parental systemics, there was an increasing trend in 2019 and 2020, but utilization in Q4 2020 was lower than that of Q3 2020. For oral systemic, there was a notable drop in Q2 2020 but an increased trend in Q3-Q4 2020. Conclusions: This claims analysis indicated increased use in systemic and SDT among SS patients in 2018-2020. The quarterly analysis indicated that the drop in ECP and oral systemic usage in Q2 2020 coincided with the onset of the pandemic, but there was a stable use of parenteral systemic during 2020.

A preliminary review of adoption of new HCPCS codes for NGS in CMS claims

Background: Adequate reimbursement is considered a prerequisite for adoption of new diagnostic technologies that facilitate patient access to better treatments. Detailed longitudinal investigation of the adoption of new HCPCS codes and the factors influencing it are scarce, although the availability of large-scale claims databases should facilitate such studies. We examined claims for three CPT codes used for next generation sequencing (NGS): 81445, 81450 and 81455 in a large database of claims data from CMS and attempted to correlate presumptive drivers of test adoption such as coverage decisions and payments with test volume. Methods: CMS claims data were accessed using CMS' Virtual Research Data Center (VRDC) under data use agreement 50486. Any claim with a CPT code of 81445, 81450 or 81455 was extracted from the data and analysed using SAS Enterprise Guide with results summarised in Microsoft Excel. Data relating to national/local coverage determinations were located by internet searches. Results: Test volumes for all 3 codes showed significant variability, including a large decrease around Q1-2 of 2020, likely due to the COVID-19 pandemic. Utilization of the 3 CPT codes varied by patient diagnosis. Details of the top 5 diagnoses for each CPT are given in the Table. The top 30 diagnoses for each CPT code accounted for 80.33%-88.45% of patients. Conclusions: Utilisation of NGS testing from 2016-2021 was highly variable, confounding attempts to match potential drivers to changes in monthly test volumes. A relatively small number of conditions accounted for >80% test use. Increased use of 81445 and 81450 from 2019 onwards may be related to CMS LCD issued in March 2018, suggesting that it can take 8-9 months or more for a LCD to filter through to testing practice. Decreases in test volume around March 2020 coincide with decreased patient presentation and testing for cancer because of the COVID-19 pandemic indicating that factors beyond reimbursement can significantly affect test use. Changes in reimbursement or adoption of proprietary lab analysis (PLA) codes covering specific NGS tests may have caused the drop in test volumes in the latter half of 2021. This study demonstrates that determination of factors affecting adoption of a test technology can be problematic due to wide variation in claims over a relatively short space of time. However, determination of these factors is important as they ultimately affect patient access to testing and potentially to therapy. (Table Presented).

The impact of COVID on bariatric surgery in Texas 2019-2020

Benjamin Clapp El Paso TX1, Jisoo Kim 1, Brittany Harper El Paso TX1, John Marr El Paso TX1, Hani Annabi El Paso TX1, Luis Alvarado 1, Brian Davis El Paso TX1 Texas Tech HSC Paul Foster School of Med1 Introduction: All fields of medicine were affected by the COVID pandemic including metabolic and bariatric surgery (MBS). Across the nation there was a moratorium on elective surgical cases that started in the second quarter of 2020 and continued on and off for the rest of the year. The negatively affected the health of bariatric patients who had their surgeries delayed. Our aim was to determine the decrease in the volume of MBS cases from 2019 to 2020. Methods: The Texas Inpatient and Outpatient Public Use Data File for the years 2019 and 2020 were evaluated. We searched for the Current Procedural Terminology (CPT) codes and International Classification of Diseases version 10 (ICD10) procedure codes for common bariatric operations in both databases. Descriptive statistics were applied and the data was separated by quarter. Results: There were 21,043 MBS cases performed in Texas in 2020. There was an 11% decrease in MBS in Texas from the year 2019 to 2020. The decrease was most noticeable in the 1st and 2nd quarter of 2020 with a subsequent rebound. There were 2,511 less cases in 2020. Sleeve gastrectomies remained the dominant procedure and the percentage of outpatient sleeves increased from 30% to 37% Conclusion: The COVID pandemic caused a 11% decrease in MBS in the year 2020 from the previous year. There was a shift toward performing more outpatient cases. There was a rebound in the second half of the year, with more cases being performed than in the previous 3rd and 4th quarter.

Integrating Oral Health into Pediatric Telemedicine Visits

Background: Connecting the mouth to the rest of the body is critical for providing whole-person, patient-centered, comprehensive healthcare. The COVID-19 crisis has provided an opportunity for elevation and expansion of oral health prevention education into telemedicine, particularly using video connections. Access to dental care substantially decreased during this time. Public acceptance and demand have increased simultaneously. Most oral health conditions are preventable (-30-85%) with improvement of personal habits and quality dental care. Integration of prevention-centric approaches to oral health care into telemedicine can overcome barriers and have a favorable impact on oral and overall health of all populations. Using a DEI lens, we propose to create a compendium of effective best practices/innovations for oral health integration in telemedicine (OHFT) that can be adopted widely at minimal cost to support the value of oral health to overall health throughout pediatric healthcare. Methods: To create comprehensive guidance around best practices/innovations incorporating oral health into telemedicine visits, we will conduct expansive focus groups (30+) to research and pilot an assortment of modalities and messages for OHFT in the next 12 months. HTHC at PAAAP will continue working towards collective impact with Primary Care Collaborative, the Oral Health Section of the American Academy of Pediatrics (AAP) and OPEN in subsequent years to 1) monitor pilots/innovations, 2) initiate establishing a CPT procedure code with RVUs, 3) seek USPSTF recommendation of “A” or “B”, and 4) work with AAP Bright Futures Guideline for inclusion of the procedure. We will seek and spread via publication and conference presentations best practices/innovations providing an assortment of modalities and messages for inclusion across the spectrum of telemedicine visits, beginning with pediatric telemedicine visits. Results: Implementation of OHFT will insure reaching all in need. Sustainability would be provided by assuring reimbursement for clinician time spent on implementing OHFT. We postulate a dramatic increase in population oral health and OH literacy from implementation of OHFT. Conclusion: In summary: • OHFT serves families without transportation, CSHCN who are difficult to transport, etc. Many occupy homes impacted by discriminatory practices and poverty. • Smartphone pictures of teeth, mouth, toothbrush, and toothpaste, emailed in advance of the visit ,can be used to aid in addressing the specific needs of the child via video telemedicine - all in about 2 minutes. • Best patient/family centered OHFT practices will be updated frequently for needs of specific communities - CSHCN, limited resources, persons of color, etc. • A CPT Code with RVUs for payment for the services as a procedure, will build profit center capacity increasing oral health literacy of the community along with adoption of good prevention practices. • Medical telehealth visits are demanded by the public. Best practices/innovations must be evaluated through lenses of quality as well as DEI.

Cholecystitis treatment and reimbursement trends

Purpose: Cholecystitis accounts for more than 200,000 hospital admissions per year in the United States with increasing rates and hospital charges over the past two decades (Wadhwa et al. 2017). Recent evidence-based guidelines have advocated for early surgical cholecystectomy (SC), reserving percutaneous cholecystostomy (PC) for the critically ill or patients with prohibitive co-morbidities. Purpose: To identify management trends of cholecystitis to validate current practice patterns and reimbursement rates Materials and Methods: All patients undergoing PC placement in a tertiary care hospital from 2010 to 2020 were reviewed. Inclusion criteria consisted of age >18, indication of cholecystitis, and no past PC. Additionally, all patients undergoing SC (laparoscopic or open approach) were reviewed, with surgical data becoming available in 2014. Inclusion criteria included age >18 and indication of cholecystitis. Medicare reimbursement was determined by Current Procedural Terminology (CPT) code. Years with multiple reimbursement rates were averaged. Linear regression analysis was performed. Results: A total of 2522 patients presenting for procedural treatment of cholecystitis were included. 391 underwent PC with interventional radiology with an average age (± stdev) of 64 ± 14.9 years (range: 20-96). 2131 patients underwent SC, average age 55.1 ± 17.6 years (range: 20-100). Over the follow up period, there was a significant increasing trend in PC placement (R2=0.58, P=0.006). Trend of surgical data is notable for a non-linear, though upward trend, increasing from a rate of 181 cases/year in 2014 and 2015, peaking at 481 in 2018, then followed by sharp decline over the subsequent two years, with 260 cases in 2020. From 2010-2020, Medicare reimbursement stayed relatively stable with overall small decreases in payment. There were notable declines for PC reimbursement from 2010 to 2011, decreasing from $551.2 to $392.77 and laparoscopic cholecystectomy reimbursement from $817.28 to $728.69 between 2012 and 2013. Conclusion: The increasing rate of cholecystitis over the past decades is associated with increases in both PC and SC and declines in the rates of reimbursement. After trending upward, surgical intervention was shown to decline after 2018, possibly secondary to availability of PC, or macroeconomic factors such as changes in management guidelines, reimbursement rates, or the COVID-19 pandemic.