Pediatric Echocardiography by Work Relative Value Units: Is Study Complexity Adequately Captured?

Consensus-Based Development of a Pediatric Echocardiography Complexity Score: Design, Rationale, and Results of a Quality Improvement Collaborative

BACKGROUND

The complexity of congenital heart disease has been primarily stratified on the basis of surgical technical difficulty, specific diagnoses, and associated outcomes. We report on the refinement and validation of a pediatric echocardiography complexity (PEC) score.

METHODS AND RESULTS

The American College of Cardiology Quality Network assembled a panel from 12 centers to refine a previously published PEC score developed in a single institution. The panel refined complexity categories and included study modifiers to account for complexity related to performance of the echocardiogram. Each center submitted data using the PEC scoring tool on 15 consecutive inpatient and outpatient echocardiograms. Univariate and multivariate analyses were performed to assess for independent predictors of longer study duration. Among the 174 echocardiograms analyzed, 68.9% had underlying congenital heart disease; 44.8% were outpatient; 34.5% were performed in an intensive care setting; 61.5% were follow-up; 46.6% were initial or preoperative; and 9.8% were sedated. All studies had an assigned PEC score. In univariate analysis, longer study duration was associated with several patient and study variables (age <2 years, PEC 4 or 5, initial study, preoperative study, junior or trainee scanner, and need for additional imaging). In multivariable analysis, a higher PEC score of 4 or 5 was independently associated with longer study duration after controlling for study variables and center variation.

CONCLUSIONS

The PEC scoring tool is feasible and applicable in a variety of clinical settings and can be used for correlation with diagnostic errors, allocation of resources, and assessment of physician and sonographer effort in performing, interpreting, and training in pediatric echocardiography.

Informatics tools to implement late cardiovascular risk prediction modeling for population management of high-risk childhood cancer survivors

BACKGROUND

Clinical informatics tools to integrate data from multiple sources have the potential to catalyze population health management of childhood cancer survivors at high risk for late heart failure through the implementation of previously validated risk calculators.

METHODS

The Oklahoma cohort (n = 365) harnessed data elements from Passport for Care (PFC), and the Duke cohort (n = 274) employed informatics methods to automatically extract chemotherapy exposures from electronic health record (EHR) data for survivors 18 years old and younger at diagnosis. The Childhood Cancer Survivor Study (CCSS) late cardiovascular risk calculator was implemented, and risk groups for heart failure were compared to the Children's Oncology Group (COG) and the International Guidelines Harmonization Group (IGHG) recommendations. Analysis within the Oklahoma cohort assessed disparities in guideline-adherent care.

RESULTS

The Oklahoma and Duke cohorts both observed good overall concordance between the CCSS and COG risk groups for late heart failure, with weighted kappa statistics of .70 and .75, respectively. Low-risk groups showed excellent concordance (kappa > .9). Moderate and high-risk groups showed moderate concordance (kappa .44-.60). In the Oklahoma cohort, adolescents at diagnosis were significantly less likely to receive guideline-adherent echocardiogram surveillance compared with survivors younger than 13 years old at diagnosis (odds ratio [OD] 0.22; 95% confidence interval [CI]: 0.10-0.49).

CONCLUSIONS

Clinical informatics tools represent a feasible approach to leverage discrete treatment-related data elements from PFC or the EHR to successfully implement previously validated late cardiovascular risk prediction models on a population health level. Concordance of CCSS, COG, and IGHG risk groups using real-world data informs current guidelines and identifies inequities in guideline-adherent care.

Relative Value Units Underestimate Reimbursement for Revision Shoulder Arthroplasty

INTRODUCTION

Relative value units (RVUs) have been fundamental to reimbursement calculations in payment models for arthroplasty surgeons. RVUs are based on various factors, including physician work, and have been higher for increased complexity, such as revision arthroplasty. The purpose of this study was to compare RVUs and estimated reimbursement differences between primary and revision shoulder arthroplasty.

METHODS

The National Surgical Quality Improvement Program database was used to collect primary and revision shoulder arthroplasty cases in 2017. Data variables collected included age at the time of surgery, surgical time, and RVU for each shoulder arthroplasty.

RESULTS

A total of 4,948 shoulder arthroplasty patients (4,657 primary and 291 revision) were included in this study. The mean age was 69.1 years (9.6 SD) for primary shoulder arthroplasty and 67.8 years (10.4 SD) for revision shoulder arthroplasty, P = 0.02. RVU for primary shoulder arthroplasty was 22.1 (0 SD) compared with 26.4 (1.1 SD) for revision shoulder arthroplasty (P = 0.0001). Surgical time was significantly higher in revision versus primary cases, 131.5 minutes (89.0 SD) versus 109.3 minutes (42.5 SD) (P = 0.0001). RVUs per minute were near equivalent for primary and revision arthroplasty at 0.20 (0.1 SD) and 0.20 (01 SD), respectively. However, owing to the difference in surgical time and cases per day, this translates to an estimated reimbursement difference of $174,554.4 per year more for primary shoulder arthroplasty over revision cases.

CONCLUSION

The current RVU model does not adequately factor surgical time for revision shoulder arthroplasty and translates to a notable yearly reimbursement difference that favors primary shoulder arthroplasty.

Does Complexity Always Correlate With Compensation? An Analysis of Work Relative Value Units in 3 Common Nerve Decompression Syndromes

BACKGROUND

Work relative value units (wRVUs) are part of Resource Based Relative Value Scale system. It is expected that a more difficult and time-consuming procedure would yield higher wRVUs. Brachial plexus nerve decompression surgery is a more time-consuming procedure compared with carpal and cubital tunnel procedures. The aim of this study was to analyze physician reimbursement in upper limb decompression procedures by comparing mean operative times, wRVUs per minute, and dollars per minute.

METHODS

A retrospective cohort study was conducted from June 2016 to June 2019, including all patients who underwent carpal tunnel, cubital tunnel, and brachial plexus release procedures. Operating time was collected, and calculations of mean operative time, wRVUs per minute, and dollars per minute were performed and compared between groups.

RESULTS

A total of 209 cases were included. Carpal tunnel accounted for 75.1% of the cases, followed by cubital tunnel and brachial plexus releases. Brachial plexus release had the highest median operative time (147 minutes), followed by cubital tunnel (57 minutes) and carpal tunnel release (16 minutes, P < 0.0001). Carpal tunnel release procedures had a significantly higher wRVUs per minute (0.310) when compared with cubital tunnel and brachial pleaxus release procedures, 0.127 and 0.077, respectively (P < 0.0001). Same was true for dollars per minute; carpal tunnel procedures yielded significantly more compensation than cubital tunnel and thoracic outlet procedures (P < 0.0001).

CONCLUSIONS

More complex and time-consuming procedures yielded a lower reimbursement for physicians. The current work relative unit system does not account adequately for the time spent in each procedure.

Development of a local model for measuring the work of surgeons

Objective: The Relative Value Unit (RVU) is the main method of calculating surgeons’ reimbursements and a tool for measuring the work of surgeons. Existing evidence shows that the work Relative Value Unit (wRVU) does not accurately represent surgeon’s work. Therefore, the current study attempted to develop a local model to measure surgeons’ work.

Material and Methods: This study was conducted in two main phases of determining the metrics and model development using quantitative and qualitative approaches from December 2019 to April 2021. Literature review, focused group discussions, and interviews were used to collect data. Con- tent analysis and Exploratory Data Analysis techniques were applied to analyze data.

Results: The findings demonstrated that patient’s conditions (age, severity of disease at referring time, and comorbidities), disease specifications (time, complexity, physical effort, and risk), and provider characteristic (surgeon’s willingness, imposed stress, and surgeon’s skill) were important by 17, 51, and 32%, respectively, in determining surgeons’ work.

Conclusion: Determining a fixed value for each procedure does not accurately estimate the amount of required surgeon’s work for any procedure. Many factors, such as the patient’s condition, surgeon’s characteristics, and disease specification affect surgeons’ work in the operation room. Proper measurement of the surgeon’s work is an important step towards establishing equity in payment in the health system.

Leveraging Clinical Informatics Tools to Extract Cumulative Anthracycline Exposure, Measure Cardiovascular Outcomes, and Assess Guideline Adherence for Children With Cancer

PURPOSE

Cardiovascular disease is a significant cause of late morbidity and mortality in survivors of childhood cancer. Clinical informatics tools could enhance provider adherence to echocardiogram guidelines for early detection of late-onset cardiomyopathy.

METHODS

Cancer registry data were linked to electronic health record data. Structured query language facilitated the construction of anthracycline-exposed cohorts at a single institution. Primary outcomes included the data quality from automatic anthracycline extraction, sensitivity of International Classification of Disease coding for heart failure, and adherence to echocardiogram guideline recommendations.

RESULTS

The final analytic cohort included 385 pediatric oncology patients diagnosed between July 1, 2013, and December 31, 2018, among whom 194 were classified as no anthracycline exposure, 143 had low anthracycline exposure (< 250 mg/m²), and 48 had high anthracycline exposure (≥ 250 mg/m²). Manual review of anthracycline exposure was highly concordant (95%) with the automatic extraction. Among the unexposed group, 15% had an anthracycline administered at an outside institution not captured by standard query language coding. Manual review of echocardiogram parameters and clinic notes yielded a sensitivity of 75%, specificity of 98%, and positive predictive value of 68% for International Classification of Disease coding of heart failure. For patients with anthracycline exposure, 78.5% (n = 62) were adherent to guideline recommendations for echocardiogram surveillance. There were significant association with provider adherence and race and ethnicity (P = .047), and 50% of patients with Spanish as their primary language were adherent compared with 90% of patients with English as their primary language (P = .003).

CONCLUSION

Extraction of treatment exposures from the electronic health record through clinical informatics and integration with cancer registry data represents a feasible approach to assess cardiovascular disease outcomes and adherence to guideline recommendations for survivors.

Time is Money: Relative Value Units and Operative Time in Otolaryngology

OBJECTIVES

Physician compensation for procedures is typically rooted in the work relative value unit (wRVU) system. Operative time is one of the factors that goes into the determination of wRVU assignment. There should be consistency between the wRVU/hr rate, irrespective of average operative time required to perform certain procedures. We investigate if wRVU assignment for otolaryngology procedures adequately accounts for increased operative time.

STUDY DESIGN

Retrospective analysis of a surgical database.

METHODS

NSQIP was queried from 2015-2018 for the top 50 most frequently performed otolaryngology Current Procedural Terminology (CPT) codes completed as standalone procedures. Median operative time was determined for each CPT code, and wRVU/hr was calculated. Correlations between operative time, wRVU, and wRVU/hr were investigated using linear regression analysis. A secondary analysis using complication rate as an indicator for procedure complexity was performed to examine the relation between wRVUs and complication rates.

RESULTS

Fifty CPT codes containing 64,084 patients where only one code was reported were included in this analysis. The median operative time was 84 minutes, median wRVU was 11.23, and median wRVU/hour was 7.96. Linear regression analysis demonstrated a strong positive correlation between operative time and wRVU assignment (R² = 0.805, P < .001). Further analysis found no correlation between operative time and wRVU/hr (R² = 0.008, P = .525). Linear regression of wRVU/hr and complication rate showed a statistically significant positive correlation (R² = 0.113, P = .017).

CONCLUSION

This analysis suggests that compensation for otolaryngology procedures is positively correlated with operative time. Surgeries where more than one code is reported could not be evaluated, thus excluding some common combination of procedures performed by otolaryngologists.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E395-E400, 2021.

Not all primary total hip arthroplasties are equal-so is there a difference in reimbursement?

Background

Relative value units (RVUs) are a physician reimbursement model based on the effort required, or value, in providing a procedure or service for a patient. Procedures such as conversion total hip arthroplasties (THAs) can be compared to primary THAs, but many studies have revealed increased difficulties in conversion cases. Despite the increased time and effort for conversion THA, it is unknown if this is reflected in the RVU compensation model. Therefore, the purpose of this study was to compare the: (I) mean operative times; (II) mean RVUs; (III) RVU/minute for primary and conversion THAs; and (IV) perform an individualized idealized surgeon annual cost difference analysis.

Methods

A total of 103,702 primary THA patients were identified using CPT code 27130 and 2,986 conversion THA patients were identified using CPT code 27132 using the National Surgical Quality Improvement Program (NSQIP) database. The mean RVUs, operative times (minutes), and RVU/minute were calculated and compared. An annualize cost analysis of dollar amounts per case, day, and the year was also performed.

Results

The mean operative times for the primary and conversion THA cohorts were 94 vs. 146 minutes (P<0.001) and mean RVUs were 21.24 vs. 25.68 (P<0.001). Interestingly, the mean RVU per minute was higher for the primary THA compared to the conversion THA groups (0.26 vs. 0.21, P<0.001). Annualized cost analysis revealed a potential $173,529 difference from performing primary vs. conversion THAs.

Conclusions

Even though conversion THA can be considered to a more complex and demanding procedure, based on RVUs per minute of surgery, orthopaedic surgeons are reimbursed better for primary THA cases. This data could be used by orthopaedic surgeons to administer their practices better to yield the highest return on time.

A comparison of relative value units in revision hip versus revision knee arthroplasty

The purpose of this study was to compare the: 1) RVUs; 2) lengths-of-surgery; 3) RVU per minute between revision hip (THA) and knee (TKA) arthroplasties; and 4) perform an annualized surgeon cost analysis. Using the ACS-NSQIP from 2008 to 2015, 8081 revision TKAs, 7233 THAs were compared. Revision THA had greater mean RVUs (30.27 vs. 27.10 RVUs, p < 0.001), operative times (152 vs. 149 min, p < 0.001), and RVU/minute (0.3 vs. 0.2 RVUs per minute, p < 0.001). Cost analysis yielded and annual $89,922.73 difference. Revision THA, therefore, is reimbursed at a significantly higher "hourly rate," when compared to revision TKA.

What provides a better value for your time? The use of relative value units to compare posterior segmental instrumentation of vertebral segments

BACKGROUND CONTEXT

Relative value units (RVUs) are a compensation model based on the effort required to provide a procedure or service to a patient. Thus, procedures that are more complex and require greater technical skill and aftercare, such as multilevel spine surgery, should provide greater physician compensation. However, there are limited data comparing RVUs with operative time. Therefore, this study aims to compare mean (1) operative times; (2) RVUs; and (3) RVU/min between posterior segmental instrumentation of 3-6, 7-12, and ≥13 vertebral segments, and to perform annual cost difference analysis.

METHODS

A total of 437 patients who underwent instrumentation of 3-6 segments (Cohort 1, current procedural terminology [CPT] code: 22842), 67 patients who had instrumentation of 7-12 segments (Cohort 2, CPT code: 22843), and 16 patients who had instrumentation of ≥13 segments (Cohort 3, CPT code: 22844) were identified from the National Surgical Quality Improvement Program (NSQIP) database. Mean operative times, RVUs, and RVU/min, as well as an annualized cost difference analysis, were calculated and compared using Student t test. This study received no funding from any party or entity.

RESULTS

Cohort 1 had shorter mean operative times than Cohorts 2 and 3 (217 minutes vs. 325 minutes vs. 426 minutes, p<.05). Cohort 1 had a lower mean RVU than Cohorts 2 and 3 (12.6 vs. 13.4 vs. 16.4). Cohort 1 had a greater RVU/min than Cohorts 2 and 3 (0.08 vs. 0.05, p<.05; vs. 0.08 vs. 0.05, p>.05). A $112,432.12 annualized cost difference between Cohorts 1 and 2, a $176,744.76 difference between Cohorts 1 and 3, and a $64,312.55 difference between Cohorts 2 and 3 were calculated.

CONCLUSION

The RVU/min takes into account not just the value provided but also the operative times required for highly complex cases. The RVU/min for fewer vertebral level instrumentation being greater (0.08 vs. 0.05), as well as the $177,000 annualized cost difference, indicates that compensation is not proportional to the added time, effort, and skill for more complex cases.

A Comparison of Relative Value Units in Primary Versus Revision Total Knee Arthroplasty

BACKGROUND

In total knee arthroplasty (TKA), revision cases are often technically more challenging, and require more operative time and aftercare than primary cases. These time and effort differences should therefore be appropriately compensated for when using the relative value unit (RVU) system. Therefore, the purpose of this study is to compare the mean (1) RVUs; (2) operative times; and (3) RVU/min; and (4) perform an individualized idealized surgeon annual cost difference analysis for primary vs revision TKA.

METHODS

Current Procedural Terminology code 27447 identified 165,439 primary TKA patients, while Current Procedural Terminology code 27487 identified 8081 revision TKA patients from the National Surgical Quality Improvement Program database. The mean RVUs, operative times, and RVU/min were calculated. Dollar amount per minute, per case, per day, and year were also calculated. Student's t-test, with a cut-off P-value of <.05, was used in order to identify any statistical differences in mean RVUs, operative times, and RVU/min.

RESULTS

The mean RVUs for primary TKA was 22, while for revision TKA was 27 (P < .001). The mean operative time for primary TKA was 94 minutes, while for revision TKA was 149 minutes (P < .001). The mean RVU/min for primary TKA was 0.26, while for revision TKA was 0.22 (P < .001). The dollar amounts calculated for primary vs revision TKA were per minute ($9.33 vs $7.90), per case ($877.12 vs $1176.43), per day ($4385.60 vs $3529), and projected a $137,008.70 annual cost difference.

CONCLUSION

Orthopedic surgeons are reimbursed at a higher rate per minute for primary cases compared to revision TKA (0.26 vs 0.22, P < .001). The annual difference can amount to nearly $140,000. Orthopedic surgeons can use this information to better understand the dynamics of their time, compensation, and ultimately, their practice. Furthermore, it can be argued that there needs to be a shift to increase the RVU per unit time for revision TKAs.

Are We Appropriately Compensated by Relative Value Units for Primary vs Revision Total Hip Arthroplasty?

BACKGROUND

Relative value units (RVUs) are used to evaluate the effort required for providing a service to patients in order to determine compensation. Thus, more complicated cases, like revision arthroplasty cases, should yield a greater compensation. However, there are limited data comparing RVUs to the time required to complete the service. Therefore, the purpose of this study is to compare the (1) mean RVUs, (2) mean operative times, and (3) mean RVU/minute between primary and revision total hip arthroplasty (THA) and (4) perform an individualized idealized surgeon annual cost difference analysis.

METHODS

A total of 103,702 patients who underwent primary (current procedural terminology code 27130) and 7273 patients who underwent revision THA (current procedural terminology code 27134) were identified using the National Surgical Quality Improvement Program database. Mean RVUs, operative times (minutes), and RVU/minute were calculated and compared using Student t-test. Dollar amount per minute, per case, per day, and year was calculated to find an individualized idealized surgeon annual cost difference.

RESULTS

The mean RVU was 21.24 ± 0.53 (range, 20.72-21.79) for primary and 30.27 ± 0.03 (range, 30.13-30.28) for revision THA (P < .001). The mean operative time for primary THA was 94 ± 38 minutes (range, 30-480 minutes) and 152 ± 75 minutes (range, 30-475 minutes) for revision THA (P < .001). The mean RVU/minute was 0.260 ± 0.10 (range, 0.04-0.73) for primary and 0.249 ± 0.12 (range, 0.06-1.0) for revision cases (P < .001). The dollar amounts calculated for primary vs revision THA were as follows: per minute ($9.33 vs $8.93), per case ($877.12 vs $1358.32), per day ($6139.84 vs $5433.26), and a projected $113,052.28 annual cost difference for an individual surgeon.

CONCLUSION

Maximizing the RVU/minute provides the greatest "hourly rate." The RVU/minute for primary (0.260) being significantly greater than revision THA (0.249) and an annualized $113,052.28 cost difference reveal that although revision THAs are more complex cases requiring longer operative time, greater technical skill, and aftercare, compensation per time is not greater.

A Resource-Based Relative Value for Clinical Research Nurses' Workload

BACKGROUND

This study was conducted to measure the relative value (RV) of clinical research nurses' (CRNs') workload based on the resource-based relative value scale.

METHODS

A quantitative, descriptive research design was used. Data were collected from 70 CRNs in 7 clinical trial institutions using a structured questionnaire including time, technical effort, mental effort, and stress for each service. The RV of work (RVW) of each service was calculated by multiplying time and relative value of intensity based on "explaining the informed consent" as the reference service.

RESULTS

The CRNs' RVW was the highest in "preparing auditing" and the lowest in "paying compensation" among 55 services. Ten services showed higher RV intensity than the reference service, 26 services were lower, and 18 services were equal to the reference service. While the service that showed the highest and lowest RVW was the same in 3 specialties (oncology, cardiology, and endocrinology), the rank of the other services was not consistent by specialty.

CONCLUSION

The RVW derived from this study makes it easy to calculate each CRN's total workload, so we recommend that the managers use RVW to assign the new services or studies to a certain CRN. And, we also recommend future studies using an objective method such as observations to calculate the time of each service.