Compliance With Federal Price Transparency Rules and Cost Estimation at United States Hospitals With Neurosurgical Training Programs.

BACKGROUND AND OBJECTIVES: The Centers for Medicare & Medicaid Services implemented federal requirements on January 1, 2021, under the Public Health Service Act that require hospitals to provide a list of payer-negotiated prices or "standard charges" in a machine-readable file and in a patient-friendly online estimator for standard services. We sought to assess compliance by United States hospitals associated with neurosurgical training programs with these federal requirements for 11 common neurosurgical procedures. METHODS: We performed a cross-sectional analysis in March 2023 of 116 United States hospitals associated with a neurosurgical training program to assess compliance with the new federal requirements to have a machine-readable, downloadable file with standard charges and a patient-friendly online estimator for two spinal procedures. RESULTS: A total of 110/114 (96.5%) hospitals were compliant with the requirement for a machine-readable file with payer-negotiated prices. A total of 47/110 hospitals (42.7%) were compliant with downloadable machine-readable files and reported at least one payer-negotiated price for 1 of the 11 common neurosurgical procedures. A total of 45/110 (40.9%) used bundled Diagnosis-Related Group codes, and 18/110 (16.4%) did not contain any price information for neurosurgical procedures. For neurosurgical procedures, the percent difference between the average negotiated private insurance and Medicare price per procedure ranged from 17.5% to 77.6%. Medicare and private insurance data for each procedure were available on average for 10.3 states (SD = 3.8) and 15.6 states (SD = 4.8), respectively. CONCLUSION: While hospital compliance with federal requirements for machine-readable files with payer-negotiated prices was high, availability of payer-negotiated prices for 4 major insurance types across 11 common neurosurgical procedures based on Current Procedural Terminology codes was sparce. Consequently, meaningful conclusions on procedure-related charges for elective procedures are difficult for patients to make because of the unintelligible format of data and a lack of reporting of charges per Current Procedural Terminology code in a comprehensive manner.

Asleep deep brain stimulation with intraoperative magnetic resonance guidance: a single-institution experience.

OBJECTIVE: Deep brain stimulation (DBS) is traditionally performed on an awake patient with intraoperative recordings and test stimulation. DBS performed under general anesthesia with intraoperative MRI (iMRI) has demonstrated high target accuracy, reduced operative time, direct confirmation of target placement, and the ability to place electrodes without cessation of medications. The authors describe their initial experience with using iMRI to perform asleep DBS and discuss the procedural and radiological outcomes of this procedure. METHODS: All DBS electrodes were implanted under general anesthesia by a single surgeon by using a neuronavigation system with 3-T iMRI guidance. Clinical outcomes, operative duration, complications, and accuracy were retrospectively analyzed. RESULTS: In total, 103 patients treated from 2015 to 2019 were included, and all but 1 patient underwent bilateral implantation. Indications included Parkinson's disease (PD) (65% of patients), essential tremor (ET) (29%), dystonia (5%), and refractory epilepsy (1%). Targets included the globus pallidus pars internus (12.62% of patients), subthalamic nucleus (56.31%), ventral intermedius nucleus of the thalamus (30%), and anterior nucleus of the thalamus (1%). Technically accurate lead placement (radial error ≤ 1 mm) was obtained for 98% of leads, with a mean (95% CI) radial error of 0.50 (0.46-0.54) mm; all leads were placed with a single pass. Predicted radial error was an excellent predictor of real radial error, underestimating real error by only a mean (95% CI) of 0.16 (0.12-0.20) mm. Accuracy remained high irrespective of surgeon experience, but procedure time decreased significantly with increasing institutional and surgeon experience (p = 0.007), with a mean procedure duration of 3.65 hours. Complications included 1 case of intracranial hemorrhage (asymptomatic) and 1 case of venous infarction (symptomatic), and 2 patients had infection at the internal pulse generator site. The mean ± SD voltage was 2.92 ± 0.83 V bilaterally at 1-year follow-up. Analysis of long-term clinical efficacy demonstrated consistent postoperative improvement in clinical symptoms, as well as decreased drug doses across all indications and follow-up time points, including mean decrease in levodopa-equivalent daily dose by 53.57% (p < 0.0001) in PD patients and mean decrease in primidone dose by 61.33% (p < 0.032) in ET patients at 1-year follow-up. CONCLUSIONS: A total of 205 leads were placed in 103 patients by a single surgeon under iMRI guidance with few operative complications. Operative time trended downward with increasing institutional experience, and technical accuracy of radiographic lead placement was consistently high. Asleep DBS implantation with iMRI appears to be a safe and effective alternative to standard awake procedures.

Neurosurgeons in 2020: the impact of gender on neurosurgical training, family planning, and workplace culture.

OBJECTIVE: In 2008, a Women in Neurosurgery Committee white paper called for increased women applicants and decreased women's attrition in neurosurgery. However, contributing factors (work-life balance, lack of female leadership, workplace gender inequality) have not been well characterized; therefore, specific actions cannot be implemented to improve these professional hurdles. This study provides an update on the experiences of neurosurgeons in 2020 with these historical challenges. METHODS: An anonymous online survey was sent to all Accreditation Council for Graduate Medical Education (ACGME)-accredited US neurosurgical programs, examining demographics and experiences with mentorship, family life, fertility, and workplace conduct. RESULTS: A total of 115 respondents (64 men, 51 women; age range 25-67 years) had trained at 49 different US residencies. Mentorship rates were very high among men and women in medical school and residency. However, women were significantly more likely than men to have a female mentor in residency. During residency, 33% of women versus 44% of men had children, and significantly fewer women interested in having a child were able to do so in residency, compared to men. Significantly more women than men had a child only during a nonclinical year (56.3% vs 19.0%, respectively). Thirty-nine percent of women and 25% of men reported difficulty conceiving. The major difficulty for men was stress, whereas women reported the physical challenges of pregnancy itself (workplace teratogens, morning sickness, etc.). Failed birth rates peaked during residency (0.33) versus those before (0.00) and after residency (0.25).Women (80%) experience microaggressions in the workplace significantly more than men (36%; p < 0.001). Ninety-five percent of macro-/microaggressions toward female neurosurgeons were about their gender, compared to 9% of those toward men (p < 0.001). The most common overall perpetrators were senior male residents and attendings, followed by male patients (against women) and female nurses or midlevel providers (against men). CONCLUSIONS: Accurate depictions of neurosurgery experiences and open discussions of the potential impacts of gender may allow for 1) decreased attrition due to more accurate expectations and 2) improved characterization of gender differences in neurosurgery so the profession can work to address gender inequality.

The Effect of Obesity on Operating Room Utilization in Breast Surgery.

BACKGROUND: The current obesity epidemic is associated with increased health care costs associated with comorbidities such as diabetes and heart disease as well as postoperative complications. However, the effect of obesity on operating room (OR) utilization, especially in common breast procedures, has not been completely evaluated. Our study is the first to examine the effect of patient obesity on operative time (OPT) for common breast procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Project databases for 2010-2018 were searched for this retrospective review. Patients undergoing common breast operations (lumpectomy, lumpectomy with sentinel lymph node biopsy (SLNB) (+/- injection), lumpectomy and axillary lymph node dissection (ALND), simple mastectomy, mastectomy with SLNB (+/- injection), and mastectomy with ALND) were filtered out by Current Procedural Terminology code and divided into three groups based on their body mass index (BMI) and weight. Using the two-sample t-test, OPT for the procedures was compared among the lowest and highest BMI and weight categories. We also used a linear regression t-test to demonstrate that for every unit increase in BMI, there was a corresponding increase in OPT for each procedure. RESULTS: When the lowest and highest BMI and weight groups were compared, significant differences in OPT (P < 0.0001) were seen for each of the procedures. Numerous factors that could affect the complexity of surgery and thus OR time were identified. The correlation between BMI and weight and OPT remained significant after controlling for these variables. The differences between the highest and lowest BMI groups were most pronounced for higher complexity procedures, such as lumpectomy with ALND and mastectomy with ALND, with average operating times increasing by 18.2 min and 18.6 min, respectively, for patients with a higher BMI. CONCLUSIONS: Patient BMI and weight significantly affect OPT for common breast procedures. Therefore, patient BMI should be taken into account to improve OR scheduling.

Mus81-mediated DNA cleavage resolves replication forks stalled by topoisomerase I-DNA complexes.

Deoxyribonucleic acid (DNA) topoisomerases are essential for removing the supercoiling that normally builds up ahead of replication forks. The camptothecin (CPT) Top1 (topoisomerase I) inhibitors exert their anticancer activity by reversibly trapping Top1-DNA cleavage complexes (Top1cc's) and inducing replication-associated DNA double-strand breaks (DSBs). In this paper, we propose a new mechanism by which cells avoid Top1-induced replication-dependent DNA damage. We show that the structure-specific endonuclease Mus81-Eme1 is responsible for generating DSBs in response to Top1 inhibition and for allowing cell survival. We provide evidence that Mus81 cleaves replication forks rather than excises Top1cc's. DNA combing demonstrated that Mus81 also allows efficient replication fork progression after CPT treatment. We propose that Mus81 cleaves stalled replication forks, which allows dissipation of the excessive supercoiling resulting from Top1 inhibition, spontaneous reversal of Top1cc, and replication fork progression.