Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020.

BACKGROUND: With greater acceptance of postmastectomy breast reconstruction (PMBR) as a safe and reliable treatment option, the role of plastic surgeons in breast cancer management continues to rise. As Medicare reimbursements for surgical procedures decline, hospitals may increase charges. Excessive markups can negatively affect uninsured and underinsured patients. We aimed to analyze mastectomy and breast reconstruction procedures to gain insights into recent trends in utilization and billing. METHODS: We queried the 2013 to 2020 Medicare Provider Utilization and Payment Data with 14 Current Procedural Terminology (CPT) codes to collect service count numbers, hospital charges, and reimbursements. We calculated utilization (service counts per million female Medicare enrollees), weighted mean charges and reimbursements, and charge-to-reimbursement ratios (CRRs). We calculated total and annual percentage changes for the included CPT codes. RESULTS: Among the 14 CPT codes, 12 CPT codes (85.7%) with nonzero service counts were included. Utilization of mastectomy and breast reconstruction procedures decreased from 1,889 to 1,288 (-31.8%) procedures per million female Medicare beneficiaries from 2013 to 2020. While the utilization of immediate implant placements (CPT 19340) increased by 36.2%, the utilization of delayed implant placements (CPT 19342) decreased by 15.1%. Reimbursements for the included CPT codes changed minimally over time (-2.9%) but charges increased by 28.9%. These changes resulted in CRRs increasing from 3.3 to 4.4 (+33.3%) from 2013 to 2020. Free flap reconstructions (CPT 19364) had the highest CRRs throughout the study period, increasing from 7.0 in 2013 to 10.3 in 2020 (+47.1%). CONCLUSIONS: Our analysis of mastectomy and breast reconstruction procedures billed to Medicare Part B from 2013 to 2020 showed increasingly excessive procedural charges. Rises in hospital charges and CRRs may limit uninsured and underinsured patients from accessing necessary care for breast cancer management. Legislations that monitor hospital markups for PMBR procedures may be considered by policymakers.

Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020.

BACKGROUND: With greater acceptance of post-mastectomy breast reconstruction (PMBR) as a safe and reliable treatment option, the role of plastic surgeons in breast cancer management continues to rise. As Medicare reimbursements for surgical procedures decline, hospitals may increase charges. Excessive markups can negatively affect uninsured and underinsured patients. We aimed to analyze mastectomy and breast reconstruction procedures to gain insights into recent trends in utilization and billing. METHODS: We queried the 2013-2020 Medicare Provider Utilization and Payment Data with 14 Current Procedural Terminology (CPT) codes to collect service counts, hospital charges, and reimbursements. We calculated utilization (service counts per million female Medicare enrollees), weighted mean charges and reimbursements, and charge-to-reimbursement ratios (CRRs). We calculated total and annual % changes for the included CPT codes. RESULTS: Among the 14 CPT codes, 12 CPT codes (85.7%) with non-zero service counts were included. Utilization of mastectomy and breast reconstruction procedures decreased from 1,889 to 1,288 (-31.8%) procedures per million female Medicare beneficiaries from 2013 to 2020. While the utilization of immediate implant placements (CPT 19340) increased by 36.2%, the utilization of delayed implant placements (CPT 19342) decreased by 15.1%. Reimbursements for the included CPT codes changed minimally over time (-2.9%), but charges increased by 28.9%. These changes resulted in CRRs increasing from 3.3 to 4.4 (+33.3%) from 2013 to 2020. Free flap reconstructions (CPT 19364) had the highest CRRs throughout the study period, increasing from 7.0 in 2013 to 10.3 in 2020 (+47.1%). CONCLUSIONS: Our analysis of mastectomy and breast reconstruction procedures billed to Medicare Part B from 2013 to 2020 showed increasingly excessive procedural charges. Rises in hospital charges and CRRs may limit uninsured and underinsured patients from accessing necessary care for breast cancer management. Legislations that monitor hospital markups for post-mastectomy breast reconstruction procedures may be considered by policymakers.

Billing and Utilization Trends in Reconstructive Microsurgery Indicate Worsening Access to Care.

BACKGROUND: Within the last 20-years, Medicare reimbursements for microsurgery have been declining, while physician expenses continue to increase. As a result, hospitals may increase charges to offset revenue losses, which may impose a financial barrier to care. This study aimed to characterize the billing trends in microsurgery and their implications on patient care. METHODS: The 2013 to 2020 Provider Utilization and Payment Data Physician and Other Practitioners Dataset was queried for 16 CPT codes. Service counts, hospital charges, and reimbursements were collected. The utilization, weighted mean reimbursements and charges, and charge-to-reimbursement ratios (CRRs) were calculated. The total and annual percent changes were also determined. RESULTS: In total, 13 CPT codes (81.3%) were included. The overall number of procedures decreased by 15.0%. The average reimbursement of all microsurgical procedures increased from $618 to $722 (16.7%). The mean charge increased from $3,200 to $4,340 (35.6%). As charges had a greater increase than reimbursement rates, the CRR increased by 15.4%. At the categorical level, all groups had increases in CRRs, except for bone graft (-49.4%) and other procedures (-3.5%). The CRR for free flap breast procedures had the largest percent increase (47.1%). Additionally, lymphangiotomy (28.6%) had the second largest increases. CONCLUSION: Our analysis of microsurgical procedures billed to Medicare Part B from 2013 to 2020 showed that hospital charges are increasing at a faster rate than reimbursements. This may be in part due to increasing physician expenses, cost of advanced technology in microsurgical procedures, and inadequate reimbursement rates. Regardless, these increased markups may limit patients who are economically disadvantaged from accessing care. Policy makers should consider legislation aimed at updating Medicare reimbursement rates to reflect the increasing complexity and cost associated with microsurgical procedures, as well as regulating charge markups at the hospital level.

Plastic Surgery Residency Applicants' Perceptions of a Virtual Interview Cycle.

BACKGROUND: The 2020 to 2021 residency application cycle marked the first year of fully virtual integrated plastic surgery interviews. The virtual format was a double-edged sword for applicants with several advantages, such as reduced costs and time lost from travel, and disadvantages as the novel format introduced new stressors on top of an already demanding process. Concerns included unfair interview invitation distribution, interview "hoarding," and assessing "fit" virtually. In this study, the authors aimed to understand applicants' experiences of the 2020 to 2021 virtual plastic surgery interview cycle. METHODS: A survey was sent to 330 applicants in the 2020 to 2021 integrated plastic surgery application cycle. The survey included questions about participant demographics, preinterview preparation, virtual interview experiences, and postinterview process. Statistical comparisons were performed on responses using IBM SPSS Statistics version 25.0 (IBM, Armonk, N.Y.). RESULTS: Eighty-nine participants responded to the survey, representing a 27 percent response rate. Applicants received an average of 13.3 interview invitations (range, 0 to 45) and attended an average of 11.4 interviews (range, 0 to 30). Almost half (48.2 percent) did not feel interview invitations were distributed equitably, and more than half (68.2 percent) reported that there should be a limit on the number of interview invitations an applicant can accept. The majority of respondents (88.1 percent) reported spending $500 or less on virtual interviews. Half (50.6 percent) participated in virtual subinternships, of which 30.4 percent became significantly less interested in a program afterward. CONCLUSIONS: The inaugural virtual interview cycle had several advantages and disadvantages. Lessons learned from this year could be utilized toward building a more equitable, fair, and effective potential virtual cycle in years to come.

An Algorithmic Approach to the Surgical Management of Sternal Dehiscence: A Single-Center Experience.

BACKGROUND: Deep sternal wound complications following sternotomy represent a complex challenge. Management can involve debridement, flap reconstruction, and rigid sternal fixation (RSF). We present our 11-year experience in the surgical treatment of deep sternal wound dehiscence using a standardized treatment algorithm. METHODS: A retrospective review was conducted of all 134 cardiac patients who required operative debridement after median sternotomy at a single institution between October 2007 and March 2019. Demographics, perioperative covariates, and outcomes were recorded. Univariate and subgroup analyses were performed. RESULTS: One-hundred twelve patients (83.5%) with a deep sternal dehiscence underwent flap closure and 56 (50%) RSF. Of the patients who underwent flap closure, 87.5% received pectoralis advancement flaps. A 30-day mortality following reconstruction was 3.9%. Median length of stay after initial debridement was 8 days (interquartile range: 5-15). Of patients with flaps, 54 (48%) required multiple debridements prior to closure, and 30 (27%) underwent reoperation after flap closure. Patients who needed only a single debridement were significantly less likely to have a complication requiring reoperation (N = 10/58 vs. 20/54, 17 vs. 37%, p = 0.02), undergo a second flap (N = 6/58 vs. 17/54, 10 vs. 32%, p < 0.001), or, if plated, require removal of sternal plates (N = 6/34 vs. 11/22, 18 vs. 50%, p = 0.02). CONCLUSION: Although sternal dehiscence remains a complex challenge, an aggressive treatment algorithm, including debridement, flap closure, and consideration of RSF, can achieve good long-term outcomes. In low-risk patients, RSF does not appear to increase the likelihood of reoperation. We hypothesize that earlier surgical intervention, before the development of systemic symptoms, may be associated with improved outcomes.

Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard for autologous breast reconstruction at many institutions. Although the deep inferior epigastric artery displays significant anatomic variability in its intramuscular course, branching pattern and location of perforating vessels, the ability to preoperatively visualize and map relevant vascular anatomy has increased the efficiency, safety and reliability of the DIEP flap. While computed tomography angiography (CTA) is often cited as the preoperative imaging modality of choice for perforator flaps, more recent advances in ultrasound technology have made it an increasingly attractive alternative. METHODS: An extensive literature review was performed to identify the most common applications of ultrasound technology in the preoperative planning of DIEP flaps. RESULTS: This review demonstrated that multiple potential uses for ultrasound technology in DIEP flap reconstruction including preoperative perforator mapping, evaluation of the superficial inferior epigastric system and as a potential adjunct in flap delay procedures. Available studies suggest that ultrasound compares favorably to other widely-used imaging modalities for these indications. CONCLUSION: This article presents an in-depth review of the current applications of ultrasound in the preoperative planning of DIEP flaps and explores some potential areas for future investigation.

Applications of Ultrasound in the Postoperative Period: A Review.

BACKGROUND: Recent advances in ultrasound technology have further increased its potential for routine use by plastic and reconstructive surgeons. METHODS: An extensive literature review was performed to determine the most common applications of ultrasound in the postoperative care of plastic and reconstructive surgery patients. RESULTS: In contrast with other available imaging modalities, ultrasound is cost-effective, rapid to obtain, eliminates the need for ionizing radiation or intravenous contrast, and has virtually no contraindications. In addition to its diagnostic capabilities, ultrasound can also be used to facilitate treatment of common postoperative concerns conveniently at the bedside or in an office setting. CONCLUSION: This article presents a review of the current applications of ultrasound imaging in the postoperative care of plastic and reconstructive surgery patients, including free flap monitoring following microsurgery, diagnosis and treatment of hematoma and seroma, including those associated with BIA-ALCL, and breast implant surveillance.

Comparison of Various Modalities Utilized for Preoperative Planning in Microsurgical Reconstructive Surgery.

BACKGROUND: The benefits of preoperative perforator imaging for microsurgical reconstruction have been well established in the literature. METHODS: An extensive literature review was performed to determine the most commonly used modalities, and their applicability, advantages and disadvantages. RESULTS: The review demonstrated varioius findings including decreases in operative time and cost with the use of CT angiography to identification of perforators for inclusion in flap design with hand-held Doppler ultrasound. Modalities like MR angiography offer alternatives for patients with contrast allergies or renal dysfunction while maintaining a high level of clarity and fidelity. Although the use of conventional angiography has decreased due to the availability of less invasive alternatives, it continues to serve a role in the preoperative evaluation of patients for lower extremity reconstruction. Duplex ultrasonography has been of great interest recently as an inexpensive, risk free, and extraordinarily accurate diagnostic tool. Emerging technologies such as indocyanine green fluorescence angiography and dynamic infrared thermography provide real-time information about tissue vascularity and perfusion without requiring radiation exposure. CONCLUSION: This article presents an in-depth review of the various imaging modalities available to reconstructive surgeons and includes hand held Doppler ultrasound, CT angiography, MR angiography, conventional angiography, duplex ultrasonography, Indocyanine Green Fluorescence Angiography and Dynamic Infrared Thermography.

Virtual Interviews for the Integrated Plastic Surgery Residency Match: The Program Director Perspective.

Interviews for the integrated plastic surgery residency match took place in a virtual format for the 2020-2021 application cycle. Current literature lacks the perspectives of program directors (PDs) on virtual interviews compared with traditional in-person interviews. METHODS: Following institutional review board approval, an anonymous 17-question survey was distributed by email to 82 program directors of integrated plastic surgery residency programs in the United States. Participants were asked baseline program information, the number of positions and interview invites offered, and their perspectives on various aspects of the virtual interview process. RESULTS: Sixty-two (75.6%) PDs completed the survey. Thirty-seven percent reported increasing the number of interview offers per available residency spot. On a five-point Likert scale (1, not well at all; 5, extremely well), PDs showed no significant differences in their ability judge an applicant's professionalism (3.1 ± 1.1), interpersonal and communication skills (3.2 ± 1.1), and "fit" with their program (2.9 ± 0.9) during virtual interviews (P = 0.360). Sixty-eight percent reported being satisfied (15.3% extremely satisfied, 52.5% somewhat satisfied) with the virtual interview process, though 76.3% preferred in-person interviews. CONCLUSIONS: This study is the first to provide insight into PDs' impressions of virtual residency interviews. Although most reported being satisfied with the virtual interview process, the majority still preferred in-person interviews. Further long-term studies evaluating the pros and cons of each interview modality may provide more information on whether virtual interviews could become a sustainable alternative to the traditional in-person residency interview.

Evaluation of online Spanish and English health materials for preventive mastectomy. are we providing adequate information?

PURPOSE: Breast cancer remains the leading cause of cancer-related death in US Hispanic women. When present, lower health literacy levels potentially within this patient population require tailored materials to address health disparities. We aim to evaluate and compare Spanish and English online health care informative resources on preventive mastectomy. METHODS: A Google web search using "preventive mastectomy" and "mastectomía preventiva" was conducted. The first ten institutional/organizational websites in each language were selected. Assessment of mean reading grade level, cultural sensitivity, understandability, and actionability was carried out utilizing validated tools. RESULTS: The mean reading grade level for English materials was 14.69 compared with 11.3 for Spanish, both exceeding the recommended grade level established by the AMA and NIH. The mean cultural sensitivity score for English information was 2.20 compared with 1.88 for Spanish information, both below the acceptability benchmark of 2.5. English webpages scored 65% and 35% for understandability and actionability, respectively, while Spanish webpages scored 47% and 18%. CONCLUSIONS: Online English and Spanish preventive mastectomy materials were written at an elevated reading level and lacked cultural sensitivity. Spanish language information demonstrated inferior understandability, actionability, and cultural sensitivity. Addressing these issues provides an opportunity to help resolve health literature disparities regarding preventive mastectomy for US Hispanic women.

Refining the Latissimus Dorsi Flap: A Useful Tool to Salvage Complex Breast Defects.

The latissimus dorsi flap has been used to reconstruct mastectomy defects for more than 100 years. It has remained relevant in breast reconstruction because of its consistent anatomy, robust vascular supply, congruent vector, and ability to cover large surface areas. With the evolution of oncologic and reconstructive techniques as well as improvements in prosthetic devices, however, this myocutaneous flap has largely fallen out of favor in primary breast reconstruction. Our experience demonstrates that the latissimus dorsi flap remains a versatile flap that may be tailored to reconstruct various oncologic breast defects and deformities in an expeditious fashion.

A Deceptive Diagnosis: Pyoderma Gangrenosum After Breast Surgery-A Case Series and Literature Review.

Postsurgical pyoderma gangrenosum is a rare neutrophilic dermatosis that presents with characteristic ulcerative lesions and systemic signs and symptoms of inflammation. It has been well documented after both cosmetic and reconstructive breast surgeries. Given its similarity to postoperative infectious processes, a high index of suspicion is necessary to initiate treatment with immunosuppression and avoid unnecessary and potentially disfiguring debridements. We present our experience with 4 cases of pyoderma gangrenosum after breast reconstruction and review the existing literature regarding pyoderma gangrenosum after breast surgery.

Demographics and socioeconomic status as predictors of weight loss after laparoscopic sleeve gastrectomy: A prospective cohort study.

BACKGROUND: Prior studies have established that race and socioeconomic factors may influence weight loss after bariatric surgery. Few studies have focused on laparoscopic sleeve gastrectomy (LSG). The objective of this study is to determine if demographic factors may predict postoperative weight loss following LSG. METHODS: Prospectively collected data on 713 consecutive primary LSG operations performed with the same technique between February 2010 and May 2016 by a single surgeon (PG) were analyzed. Multiple regression analysis was done to determine if gender, race, or socioeconomic factors such as insurance and employment status correlated with postoperative weight loss. The presence of chronic comorbidities affecting quality of life such as Type II Diabetes and Obstructive Sleep Apnea (OSA) were also recorded and analyzed. RESULTS: All studied groups had similar preoperative body mass index (BMI) (mean 46 kg/m2). Race was not significantly associated with weight loss at any postoperative interval. Male gender was associated with increased weight loss through the first three months (48.2 ±â€¯12.5 lbs vs. 40.5 ±â€¯11 lbs; p = 0.0001). Patients with diabetes had significantly less weight loss at the 6 through 18 month intervals (50.4 ±â€¯17.9 lbs vs. 59.6 ±â€¯15.6 lbs at six months; p = 0.00032; 53.3 ±â€¯25.4lbs vs. 80.5 ±â€¯31.3lbs at 18 months; p = 0.008). Patients with obstructive sleep apnea had significantly less weight loss at the two-year interval (57.5 ±â€¯29.2 lbs) vs. those without obstructive sleep apnea (69.6 ±â€¯23.5 lbs; p = 0.047). Those with Medicare compared to Medicaid or commercial insurance had decreased weight loss through the first year (52.8 ±â€¯20.8 lbs vs. 71.4 ±â€¯26.4 lbs vs. 68.6 ±â€¯24.7 lbs; p = 0.0496). Notably, a higher percentage of patients in the Medicare insurance group were also diabetic and had OSA (65% vs. 34% vs. 36%; p = 0.002; 80% vs. 55% vs. 57%; p = 0.01). Finally, those patients who were students had the greatest weight loss at two years postoperatively with the least weight loss seen in retired patients followed by those on disability (108.0 ±â€¯21.5 lbs vs. 26.0 lbs vs. 46.0 ±â€¯19.7 lbs; p = 0.04). CONCLUSIONS: Several demographic factors including comorbidities, insurance status, and employment may significantly affect weight loss patterns following LSG. Further studies are needed to evaluate whether demographic differences impact long term weight loss. Differences in outcomes based on patient demographics may be beneficial in the planning of the allocation of healthcare resources.

Glomangiosarcoma Arising from a Prior Biopsy Site.

Glomangiosarcoma represents a rare malignant variant of the benign glomus tumor that typically presents as a tender, slowly growing nodule with a predilection for the lower extremities. Unlike their benign counterparts, glomangiosarcomas may display aggressive characteristics such as large size, local invasion, and a tendency to recur after excision. Although wide local excision remains the treatment of choice, rare cases of systemic metastasis have been previously reported. We present a case of glomangiosarcoma arising at a prior biopsy site after excision of an unknown soft tissue lesion.

Readmission Following Laparoscopic Sleeve Gastrectomy.

BACKGROUND AND OBJECTIVES: Prior studies have established a 1.7-4.33% readmission rate for laparoscopic sleeve gastrectomy (LSG), a rate that falls within the reported range for other bariatric procedures. The current report describes the incidence of 30-day readmission after primary LSG procedures performed at a single bariatric center of excellence (COE) and examines factors that may be associated with readmission. METHODS: Data on 343 consecutive LSG operations performed from February 2010 to May 2014 by a single surgeon (PG) were analyzed. Patients readmitted within 30 d were compared to the remaining patients by using Student's t test for continuous variables and the χ2 test for categorical variables. RESULTS: All LSGs were completed laparoscopically with no conversions to open procedures. There were no reoperations, leaks, perioperative hemorrhages, or mortalities. Twelve patients (3.5%) were readmitted; 1 was readmitted twice. There were no identified risk factors for readmission, including patient demographics, comorbidities, and perioperative factors. Notably, 7 (7%) readmissions occurred in the initial 100 patients and 5 (2%) in the remaining 243 patients (P = .04). Clinical pathways were modified after the initial 100 patients; routine contrast esophagograms were no longer performed, and a 1-day routine postoperative stay was adopted. Operative time also decreased from 94.2 ± 23.8 to 78.2 ± 20.0 min (P < .001). CONCLUSIONS: Readmission rates after LSG remain in a range similar to those described for other laparoscopic bariatric procedures. Larger prospective studies are needed to identify patterns of complications and readmissions in patients undergoing LSG that may differ from other bariatric procedures.