Publications by authors named "Christopher P Childers"

68 Publications

Replication Studies for Database Research.

JAMA Surg 2021 Sep 1. Epub 2021 Sep 1.

Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California.

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http://dx.doi.org/10.1001/jamasurg.2021.4132DOI Listing
September 2021

The USDA-ARS Ag100Pest Initiative: High-Quality Genome Assemblies for Agricultural Pest Arthropod Research.

Insects 2021 Jul 9;12(7). Epub 2021 Jul 9.

Genomics and Bioinformatics Research Unit, Jamie Whitten Delta States Research Center, Agricultural Research Service, USDA, 141 Experiment Station Road, Stoneville, MS 38776, USA.

The phylum Arthropoda includes species crucial for ecosystem stability, soil health, crop production, and others that present obstacles to crop and animal agriculture. The United States Department of Agriculture's Agricultural Research Service initiated the Ag100Pest Initiative to generate reference genome assemblies of arthropods that are (or may become) pests to agricultural production and global food security. We describe the project goals, process, status, and future. The first three years of the project were focused on species selection, specimen collection, and the construction of lab and bioinformatics pipelines for the efficient production of assemblies at scale. Contig-level assemblies of 47 species are presented, all of which were generated from single specimens. Lessons learned and optimizations leading to the current pipeline are discussed. The project name implies a target of 100 species, but the efficiencies gained during the project have supported an expansion of the original goal and a total of 158 species are currently in the pipeline. We anticipate that the processes described in the paper will help other arthropod research groups or other consortia considering genome assembly at scale.
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http://dx.doi.org/10.3390/insects12070626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8307976PMC
July 2021

Reflections on a virtual fellowship interview trail: Not as great as it may seem.

Surgery 2021 Oct 10;170(4):1290-1291. Epub 2021 Jul 10.

Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, CA. Electronic address:

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http://dx.doi.org/10.1016/j.surg.2021.06.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483887PMC
October 2021

Underrepresentation of pediatric operations in the relative value unit updating process.

J Pediatr Surg 2021 Jun 23;56(6):1101-1106. Epub 2021 Feb 23.

Division of Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.

Background: The Relative Value Unit (RVU) system was designed and implemented by Medicare to standardize physician payments for a given service. Because Medicare primarily cares for older adults, RVU assignments and updates may not consider pediatric-specific procedures, despite the fact that private insurers and Medicaid often base their payments on these RVU valuations.

Methods: The CPT codes of index pediatric operations were retrieved from the ACGME. We categorized these procedures into "Peds-specific" (eg, Ladd Procedure) versus those that could be performed in both children and adults, or "Non-specific" (eg, fundoplication). We merged these codes with RVU information from publicly available CMS files and the Resource-based Relative Value Scale Data Manager. Variables included were the date of last RVU update and the vignette used by survey respondents when asked to update the RVU valuation.

Results: Among 85 procedures, nearly three-quarters were Peds-specific (74%), with the remainder Non-specific. Approximately half of the 85 procedures (52%) had never been updated. Compared to Non-specific CPT codes, Peds-specific CPT codes were less likely to have been updated (38% vs. 91%, p < 0.001) and, among those that were updated, were updated more remotely (median year 2000 vs. 2005, p = 0.02). Among updated Non-specific CPT codes, the vignette written to justify the valuation was based on an adult patient in 85% of cases.

Conclusions: Peds-specific surgical CPT codes have either never been updated or have not been updated in decades. Procedures performed in both children and adults have been updated more often and more recently, but the vignette on which this valuation is based on is typically an adult patient. In order to remain relevant and reimburse pediatric surgeons accurately, the RVUs for pediatric procedures need to also be prioritized for revision and updating.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.026DOI Listing
June 2021

Association of Geriatric Events With Perioperative Outcomes After Elective Inpatient Surgery.

J Surg Res 2021 03 7;259:192-199. Epub 2020 Dec 7.

Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California.

Background: Older adults undergoing surgery are at risk for geriatric events (GEs: delirium, dehydration, falls or fractures, failure to thrive, and pressure ulcers). The prevalence and association of GEs with clinical outcomes after elective surgery is unclear.

Materials And Methods: Using the 2013-2014 National Inpatient Sample, we analyzed hospital admissions for the five most common elective procedures (total knee arthroplasty, right hemicolectomy, carotid endarterectomy, aortic valve replacement, and radical prostatectomy) in older adults (age ≥ 65). Our primary variable of interest was presence of any GE. Logistic regression estimated the association of GEs with (1) age group and (2) perioperative outcomes (mortality, postoperative complications, prolonged length of stay, and discharge to skilled nursing facility).

Results: Of 1,255,120 admissions, 66.5% were aged ≥65. The overall rate of any GE was 2.4% and increased with age (55-64 y: 1.5%; 65-74: 2.2%; ≥75: 4.1%; P < 0.001). After adjustment, the probability of any GE increased with age (P < 0.001). Rates of GEs varied by procedure (P < 0.001). In comparison with admissions with no GEs, one or more GE was associated with higher probability of worse outcomes including mortality, postoperative complications, prolonged length of stay, and discharge to skilled nursing facility (all P < 0.001). In addition, there was a dose-dependent relationship between GEs and these poor perioperative outcomes.

Conclusions: GEs are strongly associated with poor perioperative outcomes. Efforts should focus on mutable factors responsible for GEs to optimize surgical care for older adults.
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http://dx.doi.org/10.1016/j.jss.2020.11.011DOI Listing
March 2021

Same Data, Opposite Results?: A Call to Improve Surgical Database Research.

JAMA Surg 2021 Mar;156(3):219-220

Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles.

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http://dx.doi.org/10.1001/jamasurg.2020.4991DOI Listing
March 2021

Refining Assumptions About Specialty Compensation Rates-Reply.

JAMA Surg 2020 11;155(11):1085-1086

Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.

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http://dx.doi.org/10.1001/jamasurg.2020.3028DOI Listing
November 2020

Management of penetrating aortic arch trauma.

J Trauma Acute Care Surg 2021 02;90(2):e50-e51

From the Division of Cardiac Surgery (J.H., R.M., P.B.), and Division of General Surgery (J.H., C.P.C., A.E.-S., P.S.), Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.

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http://dx.doi.org/10.1097/TA.0000000000003015DOI Listing
February 2021

The impact of removing global periods on pediatric surgeon reimbursement.

J Pediatr Surg 2021 Jan 6;56(1):71-79. Epub 2020 Oct 6.

Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California. Electronic address:

Purpose: CMS has proposed removing postoperative care from the global periods for surgical procedures and instead requiring surgeons to bill for postoperative visits using evaluation & management (E&M) codes. This policy may alter reimbursement to pediatric surgeons.

Methods: To assess the impact of this policy, NSQIP-pediatric data were used to calculate median LOS for high-volume procedures with 10 or 90 day global periods. We then merged these data with CMS physician work time and RVU files. A CMS LOS variable was created by counting the number of hospital-based E&M codes built into the global period based on the fact that if global periods are removed, surgeons may only bill one E&M code per postoperative day. We then compared the CMS and NSQIP LOS values.

Results: The dataset included 201 CPT codes with NSQIP LOS estimates derived from a median of 137 operations. Twenty-nine procedures (14.4%) had higher, 24 (16.9%) had the same, and 138 (68.7%) had lower NSQIP median LOS than current CMS values. On average, NSQIP values were 40.0% (95% confidence interval [95CI] -50.0, -29.9%) lower than CMS values. Based on a daily average work RVU per postoperative E&M code of 1.09 (95% CI 1.05, 1.12), and $35.78 per RVU (2017 rate), surgeons in this sample would experience a cumulative annual reduction in reimbursement of approximately $3.4 M following the policy change.

Conclusions: Most pediatric surgical procedures have RVU valuations that include more hospital-based E&M codes than the current median number of postoperative days. Holding all else equal, the removal of global periods would therefore reduce reimbursement for pediatric surgeons. The downstream effects of this policy change, such as the impact on the quality of clinical care, are uncertain and warrant further investigation.

Type Of Study: Clinical research paper.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.09.051DOI Listing
January 2021

Older veterans undergoing inpatient surgery: What is the compliance with best practice guidelines?

Surgery 2021 02 17;169(2):356-361. Epub 2020 Oct 17.

Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA. Electronic address:

Background: The United States population is aging, and the number of older adults requiring operative care is increasing at a rapid rate. In order to address this issue, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society created best practice guidelines surrounding optimal perioperative care for the older adult surgical patient. This study aimed to determine the documented compliance with these guidelines at a single institution.

Methods: A retrospective chart review was performed on 86 older adults undergoing elective, inpatient coronary artery bypass graft, prostatectomy, or colectomy over a 2-year period (1/2016-12/2017) at a single Veterans Affairs institution. The primary outcome was compliance with the 38 measures from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society Best Practice Guidelines. The secondary outcome was postoperative (including geriatric-specific) complications.

Results: The mean reported compliance across all measures was 41% ± 4%. Of 38 analyzed measures, compliance for 10 measures was achieved for 0 patients, and only 1 patient for 7 measures. There was variance in compliance by phase of care (P < .05) with a high of 56% ± 8% (immediate preoperative phase of care) and a low of 35% ± 4% (intraoperative phase of care).

Conclusion: Overall reported compliance with the Best Practice Guidelines of the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society is low (41%) at this institution. This study identifies a need to improve the care provided to the vulnerable population of older adults undergoing an operation. Future work is needed to understand barriers for implementation and how compliance relates to outcomes.
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http://dx.doi.org/10.1016/j.surg.2020.08.033DOI Listing
February 2021

Perioperative and Long-Term Outcomes of Robot-Assisted Partial Nephrectomy: A Systematic Review.

Am Surg 2021 Jan 9;87(1):21-29. Epub 2020 Sep 9.

12222Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Background: Adoption of the robotic surgical platform for small renal cancers has rapidly expanded, but its utility compared to other approaches has not been established. The objective of this review is to assess perioperative and long-term oncologic and functional outcomes of robot-assisted partial nephrectomy (RAPN) compared to laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).

Methods: A search in PubMed, Embase, and Cochrane (2010-2019) was conducted. Of 3877 articles screened, 7 observational studies were included.

Results: RAPN was associated with 24-50 mL less intraoperative blood loss compared to LPN and 39-84 mL less than OPN. RAPN also demonstrated trends of other postoperative benefits, such as shorter length of stay and fewer major complications. Several studies reported better long-term functional kidney outcomes, but these findings were inconsistent. Recurrence and cancer-specific survival (CSS) were similar across groups. While RAPN had a 5-year CSS of 90.1%-97.9%, LPN and OPN had survival rates of 85.9%-86.9% and 88.5-96.3% respectively.

Conclusions: RAPN may be associated with a lower estimated blood loss and comparable long-term outcomes when compared to other surgical approaches. However, additional randomized or propensity matched studies are warranted to fully assess long-term functional kidney and oncologic outcomes.
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http://dx.doi.org/10.1177/0003134820948912DOI Listing
January 2021

Cost Saving of Short Hospitalization Nonoperative Management for Acute Uncomplicated Appendicitis.

J Surg Res 2020 11 15;255:77-85. Epub 2020 Jun 15.

Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California.

Background: Nonoperative management (NOM) of uncomplicated appendicitis has gained recognition as an alternative to surgery. In the largest published randomized trial (Appendicitis Acuta), patients received a 3-d hospital stay for intravenous antibiotics; however, cost implications for health care systems remain unknown. We hypothesized short stay protocols would be cost saving compared with a long stay protocol.

Materials And Methods: We constructed a Markov model comparing the cost of three protocols for NOM of acute uncomplicated appendicitis: (1) long stay (3-d hospitalization), (2) short stay (1-d hospitalization), and (3) emergency department (ED) discharge. The long stay protocol was modeled on data from the APPAC trial. Model variables were abstracted from national database and literature review. One-way and two-way sensitivity analyses were performed to determine the impact of uncertainty on the model.

Results: The long stay treatment protocol had a total 5-y projected cost of $10,735 per patient. The short stay treatment protocol costs $8026 per patient, and the ED discharge protocol costs $6,825, which was $2709 and $3910 less than the long stay protocol, respectively. One-way sensitivity analysis demonstrated that the relative risk of treatment failure with the short stay protocol needed to exceed 6.3 (absolute risk increase of 31%) and with the ED discharge protocol needed to exceed 8.75 (absolute risk increase of 45%) in order for the long stay protocol to become cost saving.

Conclusions: Short duration hospitalization protocols to treat appendicitis nonoperatively with antibiotics are cost saving under almost all model scenarios. Future consideration of patient preferences and health-related quality of life will need to be made to determine if short stay treatment protocols are cost-effective.
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http://dx.doi.org/10.1016/j.jss.2020.05.028DOI Listing
November 2020

Clinical Effectiveness and Resource Utilization of Surgery versus Endovascular Therapy for Chronic Limb-Threatening Ischemia.

Ann Vasc Surg 2020 Oct 19;68:510-521. Epub 2020 May 19.

Department of Surgery, Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA.

Background: The clinical effectiveness of surgical versus endovascular therapy for chronic limb-threatening ischemia (CLTI) continues to be debated, and the resources required for each therapy are unclear.

Methods: Systematic review of randomized controlled trials (RCTs) and observational studies comparing surgery with endovascular therapy for CLTI, which reported clinical effectiveness and resource utilization. Short-term and long-term clinical outcomes were examined.

Results: The search yielded 4,231 titles, of which 17 publications met our inclusion criteria. Five publications were all from 1 RCT, and 12 publications were observational studies. In the RCT, the surgical approach had greater resource use in the first year (total hospital days across all admissions for surgery versus angioplasty: 46.14 ± 53.87 vs. 36.35 ± 51.39; P < 0.001; also true for days in high-dependency and intensive therapy units), but differences were not statistically significant in subsequent years. All-cause mortality presented a nonsignificant difference favoring angioplasty in the first 2 years (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [95% CI], 0.75-2.15), but after 2 years, it favored surgical treatment (aHR, 0.34; 95% CI, 0.17-0.71). The observational studies reported short-term effectiveness and resource utilization favoring endovascular therapy, but most differences were not statistically significant. Long-term outcomes were more mixed; in particular, mortality outcomes generally favored surgery, although concluding that cause and effect is not possible as endovascularly treated patients tended to be older and may have had a shorter life expectancy regardless of therapy.

Conclusions: The clinical effectiveness and resource utilization of surgery compared with endovascular therapy for CLTI is not known with certainty and will not be known until ongoing trials report results. It is likely that findings will vary by the time horizon, where initial outcomes and utilization tend to favor endovascular interventions, but long-term outcomes favor surgical revascularization.
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http://dx.doi.org/10.1016/j.avsg.2020.04.043DOI Listing
October 2020

Inaccuracies in Postoperative Inpatient Stays Assumed in the Valuation of Surgical RVUs.

Ann Surg 2021 01;273(1):13-18

Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Objective: The aim of this study was to assess the accuracy of inpatient postoperative visits assumed in the valuation of surgical relative value units (RVUs).

Summary Background Data: Medicare reimburses physicians based on the number of RVUs assigned to a service. For surgical procedures with a 10- or 90-day global period, the RVU valuation is based, in part, on a presumed number of inpatient postoperative visits whether or not those visits occur. The Centers for Medicare and Medicaid Services (CMS) have recently proposed changing all surgical procedures to a 0-day global period.

Methods: We combined 2017 National Surgical Quality Improvement (NSQIP) data with physician time and RVU files from CMS. We then compared the number of inpatient postoperative visits assumed in the valuation to actual length of stay (LOS) information from the surgical registry.

Results: The analysis included 10 specialties and 601 distinct current procedural terminology codes. The number of patient observations underlying NSQIP LOS estimates ranged from 50 to 57,904. Eighty-three percent of procedures had median NSQIP LOS values that were shorter than the values assumed in the global period. These differences varied by specialty, with the largest discrepancy in neurosurgery. Procedures in this sample were last reviewed, on average, in 2000, with procedures reviewed more recently having more accurate valuations with respect to LOS.

Conclusions: The number of postoperative visits assumed in the valuation of surgical RVUs is grossly inaccurate. Holding all else equal, removing global periods from surgical RVUs would dramatically reduce surgeon compensation.
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http://dx.doi.org/10.1097/SLA.0000000000003918DOI Listing
January 2021

Assessment of the Contribution of the Work Relative Value Unit Scale to Differences in Physician Compensation Across Medical and Surgical Specialties.

JAMA Surg 2020 06;155(6):493-501

David Geffen School of Medicine, Department of Surgery, University of California, Los Angeles, Los Angeles.

Importance: The work relative value units (wRVUs) for a physician service can be conceptualized as the amount of time spent by the physician multiplied by a compensation rate (wRVUs/min). Disproportionately high compensation rates assigned to procedures have been blamed for pay differences across specialties, but to our knowledge, a comprehensive assessment is lacking.

Objective: To assess how compensation rates built into work RVUs contribute to differences in physician compensation across specialties.

Design, Setting, And Participants: This cross-sectional analysis examined 2017 Part B fee-for-service Medicare data. The data were analyzed from May 1 to May 30, 2019.

Main Outcomes And Measures: A specialty-wide compensation rate (wRVUs/min) was generated for 42 medical and surgical specialties defined as the sum of wRVUs for all billed current procedural terminology codes divided by the presumed time to perform those services. This measure accounted for the volume and diversity of services each specialty provides. Sensitivity analyses were performed to assess the association of errors in wRVU time estimates with average compensation rates.

Results: The final sample included 42 specialties and 6587 distinct Current Procedual Terminology (CPT) codes. The number of CPT codes attributed to a specialty ranged from 575 (medical oncology) to 4346 (general surgery). Compensation rates ranged from 0.029 wRVUs/min (pathology) to 0.057 wRVUs/min (emergency medicine). Most specialties (34/42 [81.0%]) had compensation rates between 0.035 and 0.045 wRVUs/min. The mean compensation rate for surgical specialties was 7.2% higher than for medical specialties, a difference that was not statistically significant. This narrow range reflects the fact that most specialties had more than 60% of time allocated to activities outside the intraservice period. Assuming that time values for surgical procedures are significantly overestimated increased the difference in average compensation between surgical and medical specialties to 23.4%.

Conclusions And Relevance: Compensation rates assumed in wRVU valuations are small contributors to differences in physician compensation. Factors outside of the wRVU system, such as payer mix and work hours, could be targeted if narrowing the difference in compensation across specialties is desired.
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http://dx.doi.org/10.1001/jamasurg.2020.0422DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160740PMC
June 2020

All-payer Spending on Common Hospital-based Services in California.

Med Care 2020 06;58(6):534-540

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Background: Hospital-based care accounts for one third of US health spending or over $1 trillion annually, yet a detailed all-payer assessment of what services contribute to this spending is not available.

Study Design: Cross-sectional and longitudinal evaluation of hospital financial statements from acute-care general hospitals in California between fiscal years 2007 and 2016. The amounts spent on 41 different revenue centers were included. The primary outcome was state-level and hospital-level spending for each revenue center including decomposing growth trends into changes in volume and prices.

Results: The analysis included 2941 annual financial statements from 331 hospitals. Between 2007 and 2016, total spending across all centers increased 66.6% from $43.7B to $72.9B. Five centers-surgery and recovery, drugs sold to patients, acute medical/surgical floor, the clinical laboratory, and emergency services-accounted for over 50% of total spending in 2016. Overall spending growths ranged from 1.1%/y (acute pediatrics) to 17.9%/y (observation). Other revenue centers with large increases in spending included emergency services (164.7%), clinics (on-site 114.5%, satellite 129.7%), anesthesia (119.6%), echocardiography (114.4%), and computed tomography (100.8%). Most services had volume growths within ±2%/y, although there were exceptions (eg, observation hours increased 10.0%/y). Prices grew fastest for echocardiograms (10.5%/y), cardiac catheterization (9.7%/y), therapeutic radiology (8.0%/y), and emergency visits (7.5%/y). In general, median prices for services in 2016 were larger than Medicare allowed amounts.

Conclusions: Overall hospital-based spending increased 66.6% between 2007 and 2016 in California, but there was wide variation in spending growth across revenue centers. Understanding this variation-including the relative contributions of volumes and prices-can guide efforts to curb excessive health care spending and optimize resource dedication to current and future patient care needs.
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http://dx.doi.org/10.1097/MLR.0000000000001303DOI Listing
June 2020

Surgeon work captured by the National Surgical Quality Improvement Program across specialties.

Surgery 2020 03 19;167(3):550-555. Epub 2019 Dec 19.

Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: The National Surgical Quality Improvement Program (NSQIP) database is increasingly used for surgical research. However, it is unclear how well this database represents the breadth of work performed by different specialties.

Methods: Using the 2017 NSQIP participant use file and the 2017 Medicare Physician/Supplier Procedure Summary file, we evaluated (1) what proportion of surgical work is captured by NSQIP, (2) what procedures and disciplines are undersampled, and (3) the overall concordance between the NSQIP sample and a national sample.

Results: The NSQIP database reported at least one case for 4,463 out of the 5,272 Current Procedures Terminology codes in the Medicare file, potentially capturing 97.8% of surgical work across all 10 specialties. However, this proportion decreased to 72.1% when only procedures with at least 100 cases in NSQIP were considered. Limiting our analysis to only those procedures with 100 cases had markedly different effects by specialty. In part, this was owing to undersampling of minor procedures, which are more common in disciplines such as otolaryngology and urology. The overall association between the size of the NSQIP sample and the Medicare sample was 0.08.

Conclusion: Although NSQIP has the potential to capture a diverse surgical caseload, some specialties and procedures are undersampled, limiting the ability for NSQIP to generate valid benchmarks. There was little correlation between the sample sizes in NSQIP and a national sample. Increasing sampling of underrepresented procedures and developing weights to scale NSQIP to a national sample would strengthen the program's ability to inform health outcomes research and provide valid comparisons across procedures and specialties.
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http://dx.doi.org/10.1016/j.surg.2019.11.013DOI Listing
March 2020

Varying Estimations of Surgical Work Value Units.

JAMA Surg 2020 02;155(2):178

Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles.

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http://dx.doi.org/10.1001/jamasurg.2019.4644DOI Listing
February 2020

Geriatric Events Among Older Adults Undergoing Nonelective Surgery Are Associated with Poor Outcomes.

Am Surg 2019 Oct;85(10):1089-1093

Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55-64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure ( < 0.001). After adjustment, the probability of any GE increased with age category ( < 0.001); having any GE was associated with higher probability of all outcomes ( < 0.001): mortality (4.5% 0.8%), postoperative complications (61.7% 24.9%), prolonged length of stay (24.3% 7.9%), and skilled nursing facility discharge (46.6% 10.3%). In addition, there was a dose-response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019520PMC
October 2019

Association of implicit intensity values incorporated into work RVUs with objective measures.

Am J Surg 2020 06 24;219(6):976-982. Epub 2019 Sep 24.

Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.

Background: The "intensity" of a surgical procedure is supposed to be incorporated into work RVUs to allow higher compensation rates for more complex procedures. However, updates to work RVUs are subjective and it is unclear if these intensity values correlate to objective measures of a procedure's complexity.

Methods: Centers for Medicare and Medicaid Services (CMS) data were used to calculate intraservice intensity values for CPT codes in 2017 ("CMS intensity values"). Twenty-six objective measures- spanning patient, case, and risk characteristics - were generated using the 2017 participant use file from NSQIP. CMS intensity values were compared to objective measures using scatterplots and correlations.

Results: Among 473 CPT codes, CMS intensity values ranged from 0.0031 to 0.142 work RVUs/minute. CMS intensity values were positively associated with 3 objective measures, negatively associated with 5 measures, and not associated with the remaining 18 measures.

Conclusions: Despite intensity values - and therefore compensation rates - varying over 40-fold in the wRVU scale, there was generally no association between their magnitude and objective measures of surgical intensity.
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http://dx.doi.org/10.1016/j.amjsurg.2019.09.022DOI Listing
June 2020

Hospital experience predicts outcomes after high-risk geriatric surgery.

Surgery 2020 02 10;167(2):468-474. Epub 2019 Sep 10.

Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA.

Background: Geriatric patients require specialized perioperative care, yet the impact of geriatric surgery proportion (a measure of experience) and geriatric surgery volume, on clinical outcomes is unknown. This study analyzes the association between proportion and volume and clinical outcomes after high-risk geriatric surgery.

Methods: Using the 2014 National Inpatient Sample, hospital encounters for older adults (≥65 years) undergoing high-risk geriatric surgery were identified. Geriatric surgery volume was defined as a hospital's annual volume of geriatric patients undergoing high-risk geriatric surgery. Geriatric surgery proportion was calculated as volume divided by the sum of high-risk surgeries in all ages. Hierarchical multivariable regression models identified predictors of inpatient mortality, postoperative length of stay, and discharge to nursing facility.

Results: There were an estimated 514,950 hospital encounters for older adults undergoing high-risk geriatric surgery from 3,115 hospitals. Mean proportion was 0.53 ± 0.19; median volume was 60 cases per year, ranging from 5 to 3,235. After adjustment, comparing the 90th to 10th percentiles, higher proportion was associated with decreased mortality (odds ratio [95% confidence interval] 0.81 [0.73-0.88]; P < .001) and shorter postoperative length of stay (-4.44% (-5.49 to -3.39%); P < .0001). Higher volume was not associated with mortality but was associated with longer length of stay (7.76% [6.75-8.77%]; P < .0001) and decreased discharge to nursing facility (0.87 [0.79-0.95]; P= .003).

Conclusion: Treatment of geriatric patients at hospitals with the highest proportion of high-risk geriatric surgery, or the most experience, is associated with improved outcomes. High-proportion hospitals should be examined to understand the mechanisms by which better quality geriatric surgical care is achieved, while lower-proportion hospitals may be targets for quality improvement efforts.
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http://dx.doi.org/10.1016/j.surg.2019.07.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019519PMC
February 2020

Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures.

Ann Surg 2021 07;274(1):107-113

Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA.

Objective: The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures.

Summary Background Data: Reducing surgical costs is paramount to the viability of hospitals.

Methods: Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.

Results: The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.

Conclusions: Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.
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http://dx.doi.org/10.1097/SLA.0000000000003571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035992PMC
July 2021

Differences in Outcomes Based on Sex for Pediatric Patients Undergoing Pyloromyotomy.

J Surg Res 2020 01 14;245:207-211. Epub 2019 Aug 14.

Department of General Surgery, University Of California - Los Angeles, Los Angeles, California; Department of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, California. Electronic address:

Background: Males and females are known to have varied responses to medical interventions. Our study aimed to determine the effect of sex on surgical outcomes after pyloromyotomy.

Materials And Methods: Using the Kids' Inpatient Database for the years 2003-2012, we performed a serial, cross-sectional analysis of a nationally representative sample of all patients aged <1 y who underwent pyloromyotomy for hypertrophic pyloric stenosis. The primary predictor of interest was sex. Outcomes included mortality, in-hospital complications, cost, and length of stay. Regression models were adjusted by race, age group, comorbidity, complications, and whether operation was performed on the day of admission with region and year fixed effects.

Results: Of 48,834 weighted operations, 81.8% were in males and 18.2% were in females. The most common reported race was white (47.3%) and most of the patients were ≥29 days old (72.5%). There was no difference in the odds of postoperative complications, but females had a significantly longer length of stay (incidence rate ratio, 1.28; 95% confidence interval [95% CI], 1.18-1.39; P ≤ 0.01), higher cost (5%, 95% CI, 1.02-1.08; P ≤ 0.01), and higher odds of mortality (odds ratio, 3.26; 95% CI, 1.52-6.98; P ≤ 0.01).

Conclusions: Our study demonstrated that females had worse outcomes after pyloromyotomy compared with males. These findings are striking and are important to consider when treating either sex to help set physician and family expectations perioperatively. Further studies are needed to determine why such differences exist and to develop targeted treatment strategies for both females and males with pyloric stenosis.
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http://dx.doi.org/10.1016/j.jss.2019.07.042DOI Listing
January 2020

Valuations of Surgical Procedures in the Medicare Fee Schedule.

N Engl J Med 2019 07;381(4):390-391

David Geffen School of Medicine at UCLA, Los Angeles, CA

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http://dx.doi.org/10.1056/NEJMc1906724DOI Listing
July 2019

Association of Work Measures and Specialty With Assigned Work Relative Value Units Among Surgeons.

JAMA Surg 2019 10;154(10):915-921

Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles.

Importance: The primary data sources used to generate and update work relative value units (RVUs) are surveys of small groups of specialists who are asked to estimate the time and intensity needed to perform surgical procedures. Because these surveys are conducted by specialty societies and rely on subjective data, these sources have been challenged as potentially biased.

Objective: To assess whether objective work measures are associated with a surgical procedure's assigned work RVUs and whether differences exist by surgical specialty.

Design, Setting, And Participants: This cross-sectional study obtained data from the 2016 and 2017 participant use files of the American College of Surgeons National Surgical Quality Improvement Program. The 2017 physician fee schedule of the Centers for Medicare & Medicaid Services was a secondary data source. Procedures were included if they had at least 100 patient-level observations over the 2-year period. Data were analyzed from August 29, 2018, to April 2, 2019.

Main Outcomes And Measures: The dependent variable was a procedure's assigned work RVU. Independent variables of work RVUs were 4 procedure-level work measures (median operative time, median postoperative length of stay, all-cause 30-day readmission rate, and all-cause 30-day reoperation rate) and surgeon specialty (10-level category using general surgery as the reference).

Results: The data set included 628 unique Current Procedural Terminology (CPT) codes and 726 CPT-specialty combinations from 1 239 991 patient observations. Statistically significant associations were found between each work measure and assigned work RVU, as follows: median operative time (R2 = 0.74; 95% CI, 0.71-0.78), postoperative length of stay (R2 = 0.42; 95% CI, 0.36-0.48), rate of readmission (R2 = 0.18; 95% CI, 0.13-0.23), and rate of reoperation (R2 = 0.15; 95% CI, 0.10-0.20). Including all 4 measures explained 80.2% (95% CI, 77.3%-83.1%) of the variation. Adding the surgical specialty improved the overall fit of the model (likelihood ratio test χ2 = 231.27; P < .001). Cardiac (7.78; 95% CI, 4.25-11.31; P < .001) and neurosurgery (2.46; 95% CI, 1.08-3.83; P < .001) had higher work RVUs compared with general surgery, whereas orthopedics (-1.53; 95% CI, -2.48 to -0.59; P = .002), urology (-1.58; 95% CI, -2.88 to -0.29; P = .02), plastics (-2.70; 95% CI, -4.39 to -1.01; P = .002), and otolaryngology (-3.05; 95% CI, -4.69 to -1.42; P < .001) had lower work RVUs compared with general surgery.

Conclusions And Relevance: Objective work measures appeared to be associated with assigned work RVUs, predominantly with operative time; registry data can be used to augment and inform the generation and updating processes of the work RVUs.
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http://dx.doi.org/10.1001/jamasurg.2019.2295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647362PMC
October 2019

A Comparison of Costs: How California Teaching Hospitals Achieved Slower Growth Than Nonteaching Hospitals in Operating Room Costs From 2005 to 2014.

Acad Med 2019 10;94(10):1539-1545

C.P. Childers is resident physician, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA), and postdoctoral fellow, Department of Health Policy and Management, Fielding School of Public Health at UCLA, Los Angeles, California; ORCID: https://orcid.org/0000-0002-6489-8222. M. Maggard-Gibbons is professor, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California. T. Nuckols is associate professor and director, Division of General Internal Medicine, Cedars-Sinai Medical Center, and vice chair for clinical research, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California.

Purpose: Historically, teaching hospitals have had higher costs than nonteaching hospitals, introducing potential financial risk in value-based payment models. This study compared risk-adjusted operating room (OR) costs between California teaching and nonteaching hospitals.

Method: Using 2,992 financial statements from fiscal years (FYs) 2005-2014, the authors extracted data for OR total costs, components of direct costs, and indirect costs. Cross-sectional and longitudinal models estimated OR costs per minute of surgery by teaching status, ownership, case mix index, and geographic area.

Results: Risk-adjusted cost was $9.44 per minute less in teaching than nonteaching hospitals in FY 2014 (95% CI, 3.03-15.85, P = .004). Between FY 2005 and FY 2014, OR costs grew more slowly at teaching hospitals because of slower wage growth and indirect costs per minute (-$0.13 and -$0.77 per minute per year, respectively, P = .005 and P < .001). Hourly pay rose more at teaching hospitals ($0.26 per hour per year, P = .008) but was offset by slower full-time equivalents growth (-0.002 per 10,000 OR minutes per year, P = .001). Between FY 2005 and FY 2014, operative volume increased at teaching hospitals and decreased at nonteaching hospitals.

Conclusions: By 2014, California teaching hospitals had lower OR costs per minute than nonteaching hospitals because of relative labor productivity gains and slower indirect cost growth. The latter likely resulted from a volume shift from nonteaching to teaching facilities. These trends will help teaching hospitals compete under value-based models. Implications for patients and nonteaching hospitals warrant evaluation.
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http://dx.doi.org/10.1097/ACM.0000000000002844DOI Listing
October 2019
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