ABSTRACT
INTRODUCTION: We determined the incidence of NSQIP (National Surgical Quality Improvement Project) indexed complications by tumor size and investigated the related financial implications based on contemporary reimbursement schedules. METHODS: Transurethral bladder tumor resection procedures performed from 2010 to 2012 were identified and stratified by size specific CPT coding. Preoperative characteristics, surgical parameters and 30-day perioperative outcomes were compared using chi-square analysis and Student's t-test. Financial data for all inpatient transurethral bladder tumor resections performed during the most recent fiscal year at our institution were collected and analyzed, and a comparison was made using up-to-date Medicare reimbursement schedules. RESULTS: We identified 8,116 cases, including 3,533 coded as small (43.3%), 2,734 medium (33.5%) and 1,849 large (22.6%). Large resections required longer operative time (small-25.8 minutes, medium-33.0 minutes, large-49.0 minutes, p <0.01) and length of stay (small-0.67 days, medium-1.1 days, large-1.9 days, p <0.006), and had higher rates of transfusion (small-0.74%, medium-1.5%, large-3.7%, p <0.001), sepsis (small-0.23%, medium-0.44%, large-0.92%, p <0.05), renal insufficiency (small-0.17%, medium-0.15%, large-0.60%, p <0.01) and 30-day mortality (small-0.2%, medium-1%, large-1.8%, p <0.05) independent of preoperative parameters. Large resections were also associated with higher rates of 30-day readmission (small-4.3%, medium-6.3%, large-9.4%, p <0.001) and reoperation (small-2.1%, medium-2.7%, large-4.5%, p <0.001). Institutional data demonstrate that the most common Diagnosis Related Group classification results in an operating loss when treating Medicare beneficiaries. CONCLUSIONS: Urologist selected coding directly correlates with NSQIP indexed postoperative complications. Many cases of transurethral bladder tumor resection with associated complications may result in financial loss for the performing institutions. Efforts to improve quality of care and reimbursement seem warranted.
ABSTRACT
Antibodies evoke cellular responses through the binding of their Fc region to Fc receptors, most of which contain immunoreceptor tyrosine-based activation motif domains and are thus considered "activating." However, there is a growing appreciation of these receptors for their ability to deliver an inhibitory signal as well. We previously described one such phenomenon whereby interferon (IFN)γ signaling is inhibited by immune complex signaling through FcγRI. To understand the implications of this in the context of therapeutic antibodies, we assessed individual IgG subclasses to determine their ability to deliver this anti-inflammatory signal in monocyte-derived macrophages. Like IgG1, we found that IgG4 is fully capable of inhibiting IFNγ-mediated events. In addition, F(ab')2 fragments that interfere with FcγRI signaling reversed this effect. For mAbs developed with either an IgG1 or an IgG4 constant region for indications where inflammation is undesirable, further examination of a potential Fc-dependent contribution to their mechanism of action is warranted.
