Association of intrapartum severe maternal morbidity with receipt of postpartum contraception among Medicaid recipients.

OBJECTIVES: We sought to determine the association between intrapartum severe maternal morbidity and receipt of postpartum contraception within 60 days among Medicaid recipients in Oregon and South Carolina. STUDY DESIGN: We conducted a historical cohort study of all Medicaid births in Oregon and South Carolina from 2011 to April 2018. Intrapartum severe maternal morbidity was measured using diagnosis and procedure codes according to the Center for Disease Control's classifications. Our primary outcome of interest was receipt of postpartum contraception within 60 days of birth. We captured permanent and reversible forms of contraception. We examined the association of intrapartum severe maternal morbidity with receipt of postpartum contraception, and whether this varied by type of Medicaid (Traditional vs Emergency). We used Poisson regression models with robust (sandwich) estimation of variance to calculate relative risk (RR) for each model. RESULTS: Our analytic cohort included 347,032 births. We identified 3079 births with evidence of intrapartum severe maternal morbidity (0.9% of all births). When adjusted for maternal age, rural vs urban status, and state of residence, Medicaid beneficiaries with births complicated by intrapartum severe maternal morbidity are 7% less likely to receive any contraception (RR 0.93, 95% CI (0.91, 0.95)) by 60 days postpartum. Among births complicated by severe maternal morbidity we found that Emergency Medicaid recipients were 92% less likely than Traditional Medicaid recipients to receive any method of contraception (RR 0.08, 95% CI (0.08, 0.08)). CONCLUSIONS: Medicaid recipients experiencing intrapartum severe maternal morbidity are less likely to receive contraception within 60 days than Medicaid beneficiaries with uncomplicated births. IMPLICATIONS: Medicaid recipients with intrapartum severe maternal morbidity are less likely to receive postpartum contraception, than Medicaid beneficiaries without severe maternal morbidity.

Postpartum Expansion of Emergency Medicaid is Associated with Increased Receipt of Recommended Glycemic Screening and Care.

Oregon expanded Emergency Medicaid coverage to 60 days of postpartum care in 2018, facilitating ongoing care for conditions such as gestational diabetes. We linked Medicaid claims and birth certificates from 2010 to 2019 in Oregon and South Carolina, which did not expand postpartum care. We used a difference-in-difference design to measure the effects of postpartum care coverage among Emergency Medicaid recipients with gestational diabetes. Primary outcomes were receipt of recommended glucose tolerance testing and new diagnosis of Type 2 diabetes. Our sample included 2,270 live births among a predominantly multiparous, Latina population. Postpartum coverage was associated with a significant increase in receipt of a recommended glucose tolerance test (23.1 percentage points, 95% CI 16.9-29.3) and in diagnosis of Type 2 diabetes (4.6 percentage points, 95% CI 3.3-65.9). Expansion of postpartum coverage increased recommended screenings and care among Emergency Medicaid enrollees with pregnancies complicated by gestational diabetes.

Relative value units do not adequately account for operative time in pediatric urology.

BACKGROUND: Relative value units (RVUs) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determines physician work RVU (wRVUs) based on operative time, technical skill and effort, mental effort and judgment, and stress. The primary aim of this study was to assess whether operative time is adequately accounted for in the wRVU system in pediatric urology. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Pediatric Participant User File (ACS-NSQIPP-PUF) was reviewed from 2012 to 2017. Most common single pediatric urology current procedural terminology (CPT) codes were included. The primary variable was wRVU per hour of operative time (wRVU/h). Linear regression analysis was used to assess the relative influence that operative time had on wRVU/h. RESULTS: 25,432 cases were included in the final study population from 45 unique CPT codes. The median operative time was 79 min, and the median RVU/h was 12.2. Procedures with operative time less than 79 min had higher wRVU/h compared with procedures longer than 79 min (14.5 vs 10.5, p < 0.001). Procedures with higher than average incidence of any complications had a lower wRVU/h (9.0 vs. 14.6 p < 0.001). Linear regression analysis revealed that each additional hour of operative time was expected to decrease wRVU/h by 4.2 (-0.70 per 10 min, 95% CI: -0.71 to -0.69, p < 0.001; R2 = 0.39). CONCLUSION: This analysis of contemporary large pediatric population national-level data suggests that the wRVU system significantly favors shorter and less complex procedures in Pediatric Urology. Pediatric urologists performing longer and more complex procedures are not adequately compensated for the increase in complexity. EVIDENCE LEVEL III: Retrospective comparative study.

RUC Operative Time Estimates are Inaccurate, Resulting in Decreased Work RVU Assignments for Longer Urologic Procedures.

OBJECTIVE: To assess whether inaccurate operative time estimates utilized by the Relative Value Update Committee (RUC) contribute to the undervaluation of longer urologic procedures. METHODS: The National Surgical Quality Improvement Program (NSQIP) and Centers for Medicare and Medicaid Services (CMS) data sets were reviewed from 2015 to 2017. NSQIP operative time is directly measured, contrasting with CMS times which are determined by the RUC via survey-generated estimates. The 50 most frequently coded urology current procedural terminologies were included. Operative time difference was compared between the 2 data sets, and Spearman's correlation coefficient was utilized to assess differences in wRVU/h. RESULTS: A total of 105,931 cases were included. Overall, RUC operative time estimates were longer than NSQIP (124.4 vs 103.5 minutes, P < .001). RUC data overestimated operative time by 42.9% for procedures ≤90 minutes and 16.4% for longer procedures (P < .001). Using NSQIP, procedures ≤90 minutes had higher wRVU/h than longer procedures (12.2 vs 8.7, P < .001), but this was not statistically different using RUC estimates (8.4 vs 7.7, P = .13). Spearman's correlation coefficient confirmed a statistically significant negative relationship between wRVU/h and operative time using NSQIP data (r = -0.57, 95% confidence interval: -7.4 to -0.36), and no statistically significant relationship using RUC data (r = -0.24, 95% confidence interval: -0.49 to 0.04). CONCLUSION: The RUC-intended wRVU/h is more equitable than the NSQIP real-world wRVU/h with regard to operative time. Inaccurate RUC operative time estimates contribute to the undervaluation of longer urologic procedures.

Work relative value units do not account for complexity and operative time in hypospadias surgery.

INTRODUCTION: Relative value units (RVU) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determine physician work RVU (wRVU) based on operative time, technical skill and effort, mental effort and judgement, and stress. In theory, wRVU should account for the complexity and operative time involved in a procedure. OBJECTIVE: The primary aim of this study is to assess if operative time and complexity of hypospadias surgery is adequately accounted for by the current wRVU assignments. STUDY DESIGN: The American College of Surgeons National Surgical Quality Improvement Program Participant User File (ACS-NSQIP PUF) database was utilized from 2012 to 2017. Single stage hypospadias current procedural terminology (CPT) codes (including acceptable secondary CPT codes) were extracted. Using total wRVU and total operative time, the primary variable of wRVU per hour was calculated (wRVU/hr). Multivariable linear regression analysis was used to assess the relative influence that wRVU and operative time had on the wRVU/hr variable. RESULTS: 9810 cases were included in the final study population divided into four categories: simple distal (eg. MAGPI, V-Flap), single stage distal, single stage mid, single stage proximal. On analysis of variance, there was statistically significant different wRVU/hr for the four different types of hypospadias repairs with simple distal having the highest mean wRVU/hr of 19.5 and the lowest being proximal hypospadias repairs at 13.2. Simple distal, distal and midshaft hypospadias had statistically significantly higher wRVU/hr compared to proximal hypospadias (16.2, 95% CI: 15.8-16.5 vs. 13.2, 95% CI 10.9-15.5; p<0.001). Multivariable linear regression revealed that each additional hour of operative time was expected to decrease wRVU/hr by 10.5 (-10.5, 95% CI: -11.0 to -10.1, p < 0.001); total work wRVU had a statistically significant independent association with wRVU/hr (0.6, 95%CI: 0.5-0.7, p <0.001). DISCUSSION: This the first objective assessment of the current wRVU assignments with regards to one stage hypospadias repairs. More complex and longer hypospadias procedures are not adequately compensated by wRVU. Most notably, simple distal procedures are reimbursed at a mean of 19.5 wRVU/hr compared to 13.2 wRVU/hr for one stage proximal repairs. CONCLUSION: This analysis of national-level data suggests that the current wRVU assignments significantly favor shorter and simpler procedures in hypospadias surgery.

Perioperative complications within 30 days of hypospadias surgery: Results from NSQIP-Pediatrics.

INTRODUCTION: There are no large multi-institutional studies reporting on perioperative complications of hypospadias repairs. We sought to determine perioperative complications of hypospadias repairs from the National Surgical Quality Improvement Program Pediatrics (NSQIP-P) to aid in patient counseling. STUDY DESIGN: This cohort study from 2012 to 2017 was conducted using NSQIP-P database. Pediatric patients undergoing hypospadias surgery were identified and compared based on 4 major categories: distal/midshaft repair, one-stage repair proximal, stage one repair, and stage two repair. Baseline demographics between the four groups and perioperative parameters were compared. Multivariable logistic regression analysis models including type of repair was used to determine associations with overall complications, infectious complications, and dehiscence. DISCUSSION: There were 11,292 patients identified in the study population. Overall, 78% underwent distal/midshaft hypospadias repair, 12% underwent one-stage proximal repair, 1.4% underwent proximal first stage repair and 9% underwent proximal second stage repair. Multivariable logistic regression analysis revealed that proximal first stage procedures had similar overall complications to distal/mid repairs but proximal one-stage and proximal second stage procedures were associated with significantly more overall complications, local infectious complications, and dehiscence. Age, race, operative time, prematurity were also independently associated with increased overall complications. As expected, complication rates are higher in those with proximal hypospadias. In staged hypospadias, first stage has a lower complication rate compared to second stage. All complications, especially of infectious and dehiscence are the highest in the one-stage proximal and proximal second stage repairs. CONCLUSION: We report large multi-institutional analysis of 30-day peri-operative hypospadias repair complications; this information is useful for patient counseling and education.

Survival outcomes and practice trends for off-label use of adjuvant targeted therapy in high-risk locoregional renal cell carcinoma.

IMPORTANCE: The appropriate use of adjuvant targeted therapy (TT) for high-risk locoregional renal cell carcinoma (RCC) after nephrectomy is currently unclear due to mixed results from the relevant randomized controlled trials. National-level survival outcomes and practice trends for the use of adjuvant TT in the United States have not been reported. OBJECTIVE: To compare overall survival for patients who did and did not receive adjuvant TT after nephrectomy for high-risk locoregional RCC. DESIGN, SETTING, AND PARTICIPANTS: This cohort study reviewed the National Cancer Database from 2006 to 2015. Patients with nonmetastatic clear cell RCC who underwent nephrectomy with either stage pT3a or greater or pN+ were included. MAIN OUTCOMES AND MEASURES: Adjuvant TT was defined as receipt of TT within 3 months of nephrectomy. The primary end point was overall survival from initial diagnosis to date of death or censored at last follow-up. Baseline characteristics were described, and a multivariable analysis identified associations for receipt of adjuvant TT. Nearest-neighbor propensity matching was performed to create similar groups for comparison. A survival analysis was performed using Kaplan-Meier analysis and log-rank test. RESULTS: The final study population included 41,127 patients. Two thousand seventy-one patients (5.04%) received off-label adjuvant TT. Younger age, white race, private insurance, positive margins, pT4, and pN+ were associated with receipt of adjuvant TT. After nearest-neighbor propensity matching for clinically and statistically relevant covariates, 1,604 patients remained in the matched cohort, with statistically nonsignificant differences between the groups for all baseline characteristics. Median overall survival was 52 months for patients in the Adjuvant TT group versus 79 months for those who did not receive adjuvant TT (P < 0.001). Decreased overall survival for patients receiving adjuvant therapy was also seen in pathologic subgroups with and without lymph node involvement. CONCLUSIONS: The propensity matched survival analysis revealed significantly decreased overall survival in patients who received off-label adjuvant TT for high-risk locoregional RCC.

Relative Value Units do Not Adequately Account for Operative Time of Urological Surgery.

PURPOSE: Physician work relative value units are determined based on operative time, technical skill, mental effort and stress. In theory, work relative value units should account for the operative time involved in a procedure, resulting in similar work relative value units per unit time for short and long procedures. We assessed whether operative time is adequately accounted for by the current work relative value units assignments. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2015 to 2017. The 50 most frequently coded urology CPT codes were included in the study. The primary variable was work relative value units per hour of operative time (work relative value units per hour). Linear regression analysis was used to assess the associations between work relative value units, operative time and the work relative value units per hour variable. RESULTS: A total of 105,931 cases were included in the study. Among the included urology CPTs the median work relative value units was 15.26, median operative time was 48 minutes and median work relative value units per hour was 11.2. CPTs with operative time less than 90 minutes had higher work relative value units per hour compared with longer procedures (12.2 vs 8.7, p <0.001). Univariable analysis revealed that each additional hour of operative time was associated with a decrease in work relative value units per hour by 1.32 (-0.022 per minute, 95% CI -0.037 - -0.001, p <0.001) and that work relative value units were not statistically associated with work relative value units per hour (-0.093, 95% CI -0.193 - 0.007, p=0.07). CONCLUSIONS: This analysis of large population, national level data suggests that the current work relative value units assignments do not proportionally compensate for longer operative times.

The estimated prevalence of missed positive lymph nodes based on extent of lymphadenectomy at radical prostatectomy.

PURPOSE: To determine practice patterns for the extent of lymphadenectomy at radical prostatectomy and associations with detection of pN1 prostate cancer, as well as the impact of lymphadenectomy extent on underdetection of pN1 disease and overall survival. MATERIALS AND METHODS: Prostatectomy cases in the NCDB from 2004 to 2013 were included. Lymphadenectomy extent was defined by the number of nodes examined. Logistic regression was used to identify risk factors for the top quartile of lymph node count and pN1 disease. This model was created to estimate the expected prevalence of pN1, and generated observed over expected ratios. A Cox regression model was used to evaluate the effect of lymph node count on overall survival. RESULTS: Lymphadenectomy was performed in 209,789 (60%) of 358,522 surgeries, with pN1 in 6,428 (3.08%). Increasing quartiles for lymph node count was associated with pN1 (3-5 nodes OR 2.11; 6-8 nodes OR 3.12; ≥9 nodes OR 5.91, all P< 0.001). The logistic regression model suggested that 59% of pN1 cases are missed due to low lymph node count. Increased lymph node count was associated with increasing pN1 detection (O/E: 1-2 nodes = 0.18; 3-5 nodes = 0.37; 6-8 nodes = 0.56; ≥9 nodes = 1.01). Cox proportional hazards modeling demonstrated that the top quartile for lymph node count had improved overall survival (HR 0.93, CI 0.87-0.99, P= 0.03). CONCLUSIONS: Increasing lymphadenectomy extent was associated with pN1 disease on multivariate analysis, and logistic regression modeling suggested a substantial proportion of pN1 were missed due to low lymphadenectomy extent across all risk groups.