Publications by authors named "Emily L Savoca"

6 Publications

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Characterizing the providers of and reimbursement for chronic migraine chemodenervation among the Medicare population.

Headache 2021 Feb 18;61(2):373-384. Epub 2020 Dec 18.

Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.

Objective: To characterize reimbursement trends and providers for chronic migraine (CM) chemodenervation treatment within the Medicare population since the introduction of the migraine-specific CPT code in 2013.

Methods: We describe trends in procedure volume and total allowed charge on cross-sectional data obtained from 2013 to 2018 Medicare Part B National Summary files. We also utilized the 2017 Medicare Provider Utilization and Payment Data to analyze higher volume providers (>10 procedures) of this treatment modality.

Results: The total number of CM chemodenervation treatments rose from 37,863 in 2013 to 135,023 in 2018 in a near-linear pattern (r = 0.999) and total allowed charges rose from ~$5,217,712 to $19,166,160 (r = 0.999). The majority of high-volume providers were neurologists (78.4%; 1060 of 1352), but a substantial proportion were advanced practice providers (APPs) (10.2%; 138 of 1352). Of the physicians, neurologists performed a higher mean number of procedures per physician compared to non-neurologists (59.6 [95% CI: 56.6-62.6] vs. 45.4 [95% CI: 41.0-50.0], p < 0.001). When comparing physicians and APPs, APPs were paid significantly less ($146.5 [95% CI: $145.6-$147.5] vs. $119.7 [95% CI: $117.6-$121.8], p < 0.001). As a percent of the number of total beneficiaries in each state, the percent of Medicare patients receiving ≥1 CM chemodenervation treatment from a high-volume provider in 2017 ranged from 0.024% (24 patients of 98,033 beneficiaries) in Wyoming to 0.135% (997 of 736,521) in Arizona, with six states falling outside of this range.

Conclusion: Chemodenervation is an increasingly popular treatment for CM among neurologists and other providers, but the reason for this increase is unclear. There is substantial geographic variation in its use.
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February 2021

High-Volume Billing and Reimbursement Trends for Endoscopic Swallowing Studies in the Medicare Population.

Dysphagia 2020 Nov 19. Epub 2020 Nov 19.

Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, 800 Howard Avenue, Fl 4., New Haven, CT, 06519, USA.

The aim of this study is to delineate the reimbursement trends in fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) and without sensory testing (FEES) in relation to that of speech-language pathology's (SLP) portion of modified barium swallow studies (MBS), as well as to document the types of providers billing for these procedures. We performed descriptive analyses of the volume of FEES/FEESST and MBS, and total reimbursements data obtained from 2013-2018 Medicare Part B National Summary files. We also utilized the 2017 Medicare Provider Utilization and Payment Data to analyze the higher volume providers (> 10 procedures annually) of either FEES and/or FEESST. From 2003 to 2018, there has been an average, annual increase of approximately 318 FEES/FEESST performed within the Medicare fee-for-service population (R = 0.9505 [95% CI 0.860-0.983]; p < 0.001) covered under Part B (which is largely outpatient coverage). Similarly, there was an increase in Medicare-specific FEES/FEESST reimbursement from $302,840 in 2003 to $1.2 million in 2018 (R = 0.9721 [95% CI 0.920-0.990; p < 0.001]). Prior to 2010, FEESST was performed more frequently than FEES (maximum annual difference of 1174), though from 2010 onward, relatively more annual FEES was performed. From 2003-2018, the reimbursement per procedure increased by $16.79 and $35.36 for FEESST and FEES, respectively, and by $32.84 for the SLP portion of the MBS. Among high-volume FEES/FEESST billers, 65.4% were otolaryngologists and 32.3% were independently billing SLPs. From 2003 to 2018, there has been a significant rise in the number of performed and reimbursed FEES/FEESST. From 2014 onward, compared to SLP-involved MBS, there has been a relative increase in performance of FEES/FEESST.
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November 2020

A Review of Telemedicine Applications in Otorhinolaryngology: Considerations During the Coronavirus Disease of 2019 Pandemic.

Laryngoscope 2021 04 1;131(4):744-759. Epub 2020 Oct 1.

Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A.

Objective/hypothesis: Review the published literature of telemedicine's use within otorhinolaryngology (ORL), highlight its successful implementation, and document areas with need of future research.

Study Design: State of the Art Review.

Methods: Three independent, comprehensive searches for articles published on the subject of telemedicine in ORL were conducted of literature available from January 2000 to April 2020. Search terms were designed to identify studies which examined telemedicine use within ORL. Consensus among authors was used to include all relevant articles.

Results: While several, small reports document clinical outcomes, patient satisfaction, and the cost of telemedicine, much of the literature on telemedicine in ORL is comprised of preliminary, proof-of-concept reports. Further research will be necessary to establish its strengths and limitations.

Conclusions: Particularly during the coronavirus disease of 2019 pandemic, telemedicine can, and should, be used within ORL practice. This review can assist in guiding providers in implementing telemedicine that has been demonstrated to be successful, and direct future research. Laryngoscope, 131:744-759, 2021.
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April 2021

Outpatient Otolaryngology in the Era of COVID-19: A Data-Driven Analysis of Practice Patterns.

Otolaryngol Head Neck Surg 2020 07 12;163(1):138-144. Epub 2020 May 12.

Division of Otolaryngology, School of Medicine, Yale University, New Haven, Connecticut, USA.

Introduction: Coronavirus disease 2019 (COVID-19) has induced a prioritization of acute care and telehealth, affecting the quantity of patients seen and the modality of their care.

Study Design: Retrospective review.

Setting: Single-institution study conducted within the Division of Otolaryngology at the Yale School of Medicine.

Subjects And Methods: Data on all outpatient appointments within the Division of Otolaryngology were obtained from administrative records of billing and scheduling from March 16 to April 10, 2020. For comparison, a corresponding period from 2019 was also utilized.

Results: Of 5913 scheduled visits, 3665 (62.0%) were seen between March 18 and April 12, 2019, in comparison with 649 of 5044 (12.9%) during the corresponding COVID-19-affected period. The majority of completed visits performed in weeks 1 and 2 were in person, while the majority in weeks 3 and 4 were via telehealth. Among subspecialties, a larger proportion of completed visits in 2020 were performed by pediatric and head and neck oncology otolaryngologists as compared with general/specialty otolaryngologists ( < .001). Older adults (≥65 years) were less likely to have telehealth visits than younger adults (18-64 years; 45.6% vs 59.6%, = .003).

Conclusions: A major decrease in the completion rates of scheduled visits was seen in the COVID-19-affected period, though this was not proportional among subspecialties. An associated increase in telehealth visits was observed. After COVID-19-related hospital policy changes, approximately 2 weeks passed before telehealth visits surpassed in-person visits, though this was not true among older adults.
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July 2020

Prognostic Case Volume Thresholds in Patients With Head and Neck Squamous Cell Carcinoma.

JAMA Otolaryngol Head Neck Surg 2019 Aug;145(8):708-715

Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.

Importance: Though described as an important prognostic indicator, facility case volume thresholds for patients with head and neck squamous cell carcinoma (HNSCC) have not been previously developed to date.

Objective: To identify prognostic case volume thresholds of facilities that manage HNSCC.

Design, Setting, And Participants: Retrospective analysis of 351 052 HNSCC cases reported from January 1, 2004, through December 31, 2014, by Commission of Cancer-accredited cancer centers from the US National Cancer Database. Data were analyzed from August 1, 2018, to April 5, 2019.

Exposures: Treatment of HNSCC at facilities with varying case volumes.

Main Outcomes And Measures: Using all-cause mortality outcomes among adult patients with HNSCC, 10 groups with increasing facility case volume were created and thresholds were identified where group survival differed compared with each of the 2 preceding groups (univariate log-rank analysis). Groups were collapsed at these thresholds and the prognostic value was confirmed using multivariable Cox regression. Prognostic meaning of these thresholds was assessed in subgroups by category (localized [I/II] and advanced [III/IV]), without metastasis (M0), with metastasis (M1), and anatomic subsites (nonoropharyngeal HNSCC and oropharyngeal HNSCC with known human papillomavirus status).

Results: Of 250 229 eligible patients treated at 1229 facilities in the United States, there were 185 316 (74.1%) men and 64 913 (25.9%) women and the mean (SD) age was 62.8 (12.1) years. Three case volume thresholds were identified (low: ≤54 cases per year; moderate: >54 to ≤165 cases per year; and high: >165 cases per year). Compared with the moderate-volume group, multivariate analysis found that treatment at low-volume facilities (LVFs) was associated with a higher risk of mortality (hazard ratio [HR], 1.09; 99% CI, 1.07-1.11), whereas treatment at high-volume facilities (HVFs) was associated with a lower risk of mortality (HR, 0.92; 99% CI, 0.89-0.94). Subgroup analysis with Bonferroni correction revealed that only the moderate- vs low- threshold had meaningful differences in outcomes in localized stage (I/II) cancers, (LVFs vs moderate-volume facilities [MVFs]: HR, 1.09 [99% CI, 1.05-1.13]; HVF vs MVF: HR, 0.95 [99% CI, 0.90-1.00]), whereas both thresholds were meaningful in advanced stage (III/IV) cancers (LVF vs MVF: HR, 1.09 [99% CI, 1.06-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.88-0.94]). Survival differed by prognostic thresholds for both M0 (LVF vs MVF: HR, 1.09 [99% CI, 1.07-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.89-0.94]) and nonoropharyngeal HNSCC (LVF vs MVF: HR, 1.10 [99% CI, 1.07-1.13]; HVF vs MVF: HR, 0.93 [99% CI, 0.90-0.97]) site cases, but not for M1 (LVF vs MVF: HR, 1.00 [99% CI, 0.92-1.09]; HVF vs MVF: HR, 0.94 [99% CI, 0.83-1.07]) or oropharyngeal HNSCC cases (when controlling for human papillomavirus status) (LVF vs MVF: HR, 1.10 [99% CI, 0.99-1.23]; HVF vs MVF: HR, 1.07 [99% CI, 0.94-1.22]).

Conclusions And Relevance: Higher volume facility threshold results appear to be associated with increases in survival rates for patients treated for HNSCC at MVFs or HVFs compared with LVFs, which suggests that these thresholds may be used as quality markers.
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August 2019

Nonsquamous cell laryngeal cancers: Incidence, demographics, care patterns, and effect of surgery.

Laryngoscope 2019 11 10;129(11):2496-2505. Epub 2019 Jan 10.

Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, U.S.A.

Objectives: To analyze the incidence and clinical profile of nonsquamous cell (non-SCC) laryngeal carcinomas and to analyze the effect of surgery on survival.

Study Design: A retrospective analysis of the National Cancer Database (2004-2014).

Methods: Adult patients with non-SCC laryngeal cancers were divided into six major histological subtypes. A descriptive clinical profile was obtained for non-SCC patients, and multivariate regressions were performed to analyze the effect of surgery on survival within the non-SCC cohort.

Results: We identified 878 cases of non-SCC laryngeal cancers, representing 1.02% of all malignant laryngeal cancers. Neuroendocrine tumors and bone/cartilage sarcomas made up the largest groups (37.02% and 32.35%, respectively). Metastasis (M) was higher in neuroendocrine tumors, representing 19.1% of those with known clinical M stages. Of those treated, the majority of patients with bone/cartilage sarcomas (80.9%) and minor salivary gland tumors (82.6%) received surgery as part of their treatment. Survival varied significantly based upon histology, with bone/cartilage sarcomas having the highest 5-year survival at 90.4%, and neuroendocrine tumors exhibiting the poorest 5-year survival at 25.7%. Multivariate analyses found surgery to be significantly associated with improved survival (hazard ratio: 0.679; 95% confidence interval: 0.472-0.976; P = 0.036). The specific surgical method (i.e., local excision vs. partial vs. total laryngectomy) did not have any effect on survival.

Conclusion: Approximately 1% of all malignant laryngeal cancers are non-SCC in origin. At presentation, neuroendocrine tumors have the highest rate of distant metastasis and have the worst prognosis of the non-SCC cancers. Most non-SCC patients received surgery as part of their treatment regimen.

Level Of Evidence: NA. Laryngoscope, 129:2496-2505, 2019.
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November 2019