Capture of complexity of specialty care in pediatric cardiology by work RVU measures

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.

A system for equitable workload distribution in clinical medical physics

Background

Clinical medical physics duties include routine tasks, special procedures, and development projects. It can be challenging to distribute the effort equitably across all team members, especially in large clinics or systems where physicists cover multiple sites. The purpose of this work is to study an equitable workload distribution system in radiotherapy physics that addresses the complex and dynamic nature of effort assignment.

Methods

We formed a working group that defined all relevant clinical tasks and estimated the total time spent per task. Estimates used data from the oncology information system, a survey of physicists, and group consensus. We introduced a quantitative workload unit, “equivalent workday” (eWD), as a common unit for effort. The sum of all eWD values adjusted for each physicist's clinical full‐time equivalent yields a “normalized total effort” (nTE) metric for each physicist, that is, the fraction of the total effort assigned to that physicist. We implemented this system in clinical operation. During a trial period of 9 months, we made adjustments to include tasks previously unaccounted for and refined the system. The workload distribution of eight physicists over 12 months was compared before and after implementation of the nTE system.

Results

Prior to implementation, differences in workload of up to 50% existed between individual physicists (nTE range of 10.0%–15.0%). During the trial period, additional categories were added to account for leave and clinical projects that had previously been assigned informally. In the 1‐year period after implementation, the individual workload differences were within 5% (nTE range of 12.3%–12.8%).

Conclusion

We developed a system to equitably distribute workload and demonstrated improvements in the equity of workload. A quantitative approach to workload distribution improves both transparency and accountability. While the system was motivated by the complexities within an academic medical center, it may be generally applicable for other clinics.

A comparison of the workload between pediatric and adult ophthalmology encounters

PURPOSE

To explore the differences in workload between pediatric and adult ophthalmology encounters in the private clinics of an academic medical center.

METHODS

Complete encounters from four different subspecialties were analysed: pediatric ophthalmology, pediatric ophthalmology/neuroophthalmology, anterior segment, and retina. Five parameters were studied: time waiting for assistant, time with assistant, time waiting for physician, time with physician, and total visit time. Imaging or procedures performed during the clinic visit were recorded. A regression analysis by age was also performed.

RESULTS

Of 8,545 clinic visits reviewed, 5,611 were complete and included. Pediatric patients spent more time than adults with assistants (10.6 ± 11.5 vs 7.3 ± 6.8 min; P < 0.001) and more time with physicians (25.9 ± 21.6 vs 17.0 ± 13.8 min; P < 0.001) but less time waiting for the physician. Total visit time and time waiting for an assistant did not differ significantly between groups. Adults who underwent a procedure or imaging during their visit had significantly longer times in most components of the encounter. Age was positively correlated with time waiting for physician, time with physician, and total visit time in the adult group. In the pediatric group, age was positively correlated with time with assistant and negatively correlated with time with physician.

CONCLUSIONS

Our study showed that pediatric patients waited a shorter duration for their physicians than adults; however, they required more time with both the physician and the assistant. Total visit time was similar between groups.

The Composite Severity Score for Lumbar Spine MRI: a Metric of Cumulative Degenerative Disease Predicts Time Spent on Interpretation and Reporting

Conventional measures of radiologist efficiency, such as the relative value unit, fail to account for variations in the complexity and difficulty of a given study. For lumbar spine MRI (LMRI), an ideal performance metric should account for the global severity of lumbar degenerative disease (LSDD) which may influence reporting time (RT), thereby affecting clinical productivity. This study aims to derive a global LSDD metric and estimate its effect on RT. A 10-year archive of LMRI reports comprising 13,388 exams was reviewed. Objective reporting timestamps were used to calculate RT. A natural language processing (NLP) tool was used to extract radiologist-assigned stenosis severity using a 6-point scale (0 = “normal” to 5 = “severe”) at each lumbar level. The composite severity score (CSS) was calculated as the sum of each of 18 stenosis grades. The predictive values of CSS, sex, age, radiologist identity, and referring service on RT were examined with multiple regression models. The NLP tool accurately classified LSDD in 94.8% of cases in a validation set. The CSS increased with patient age and differed between men and women. In a univariable model, CSS was a significant predictor of mean RT (R² = 0.38, p < 0.001) and independent predictor of mean RT (p < 0.001) controlling for patient sex, patient age, service location, and interpreting radiologist. The predictive strength of CSS was stronger for the low CSS range (CSS = 0–25, R² = 0.83, p < 0.001) compared to higher CSS values (CSS > 25, R² = 0.15, p = 0.05). Individual radiologist study volume was negatively correlated with mean RT (Pearson’s R =  − 0.35, p < 0.001). The composite severity score predicts radiologist reporting efficiency in LMRI, providing a quantitative measure of case complexity which may be useful for workflow planning and performance evaluation.

The Impact of Medical Scribes on Relative Value Units in a Pediatric Primary Care Practice

OBJECTIVE

Our study assessed the impact of adding medical scribes to an academic pediatric primary practice by measuring the relationship between work relative value units (wRVUs) and use of the medical scribe.

METHODS

This is a retrospective comparative study on the effect of medical scribes on average wRVUs per patient encounter. wRVUs were abstracted from procedure codes in the billing system.

RESULTS

Six clinicians performed 2277 patient visits included in the study over 2 different time periods during 2017 and 2018. The first period was without the use of medical scribes and the second period included scribes. Average clinician wRVU production per visit increased by 7.68% (P < .001) with medical scribes over the previous period without them.

CONCLUSIONS

This study shows that scribes contribute to improving the wRVU per visit in a primary pediatric practice. This finding is consistent with other research showing that scribes help increase volume and improve wRVUs for specialists who perform complex procedures.

Leveraging the electronic health record to evaluate the validity of the current RVU system for radiologists

BACKGROUND

Relative value units (RVUs) are utilized to evaluate physician productivity in many fields, including radiology. The goal of this paper is to use the electronic medical record (EMR) to evaluate whether the current RVU system allows for fair comparison between radiologists' time effort.

MATERIALS AND METHODS

The study was approved by the local Institutional Review Board (IRB). Over 600,000 radiology studies with unique current procedural terminology (CPT) codes were evaluated, and after exclusion of studies interpreted in conjunction with trainees or interpreted using other software systems, a total of 241,627 studies remained. The median 25%ile, 50%ile, 65%ile, 75%ile and modal study ascribable times (SATs) for each CPT code was calculated across all radiologists. To evaluate the potential bias incurred using the current RVU system, the number of days required to achieve the Association of Administrators in Academic Radiology AAARAD 65%ile were calculated.

RESULTS

RVU values were positively correlated with SATs (r = 0.69-0.71, p < 0.001). The variability in the radiologists' time to achieve the AAARAD 65%ile benchmark was highest for musculoskeletal imaging, and lowest for thoracic imaging. The discrepancy in the number of days of work required to achieve the AAARAD 65%ile benchmark was 141.1% (197.7 days) for musculoskeletal imaging, 107.5% (161.9 days) for neuroimaging, 89.6% (185.9 days) for body imaging, and 72.2% (84.0 days) for thoracic imaging.

CONCLUSION

The current RVU system is not strongly correlated with radiologist effort measured by radiologists' time. A time-based metric is more representative of radiologist work. However, there is no perfect method to measure radiologists' work.

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.

Measuring the differences in work ratios between pediatric and adult ophthalmologic examinations

PURPOSE

To assess the differences in work needed for pediatric and adult ophthalmologic examinations.

METHODS

Seven ophthalmology residents conducted slit-lamp and refraction examinations on children 3-7 years of age and adults 20-69 years of age. The examiners reported the magnitude estimate (ME) of their work in relation to two references (cross-reference ME): average adult examination and average pediatric examination. The examination time was also measured.

RESULTS

For the slit-lamp examination, 50 children and 58 adults were recruited. The ME was 1.45 (95% CI, 1.30-1.62) times higher for the pediatric examinations than for the adult examinations when the reference was an average adult case. With respect to time, the pediatric examinations took 1.22 (95% CI, 1.06-1.41) times longer than the adult examinations. For the refraction examinations, 58 children and 96 adults were recruited. The ME was 1.35 (95% CI, 1.21-1.52) times higher for the pediatric examinations. The pediatric examination took 1.32 (95% CI, 1.16-1.50) times longer than the adult examination. The cross-reference ME ratios measuring the pediatric over adult examinations against both the pediatric and adult reference cases were equivalent in both the slit-lamp and the refraction examinations; however, the ME and time ratios of the pediatric over the adult examinations were not equivalent for the slit-lamp or for the refraction examinations.

CONCLUSIONS

The cross-reference ME showed that pediatric ophthalmologic examinations require more work than the adult examination with validity and reliability. The time estimate was insufficient as a single indicator for work estimation.

Outcomes of Surgeries Performed in Physician Offices Compared With Ambulatory Surgery Centers and Hospital Outpatient Departments in Florida

BACKGROUND

The proportion of outpatient surgeries performed in physician offices has been increasing over time, raising concern about the impact on outcomes.

OBJECTIVE

To use a private insurance claims database to compare 7-day and 30-day hospitalization rates following relatively complex outpatient surgical procedures across physician offices, freestanding ambulatory surgery centers (ASCs), and hospital outpatient departments (HOPDs).

METHODS

A multivariable logistic regression model was used to compare the risk-adjusted probability of hospitalization among patients after any of the 88 study outpatient procedures at physician offices, ASCs, and HOPDs over 2008-2012 in Florida.

RESULTS

Risk-adjusted hospitalization rates were higher following procedures performed in physician offices compared with ASCs for all procedures grouped together, for most procedures grouped by type, and for many individual procedures.

CONCLUSIONS

Hospitalizations following surgery were more likely for procedures performed in physician offices compared with ASCs, which highlights the need for ongoing research on the safety and efficacy of office-based surgery.

Perioperative outcomes for pediatric neurosurgical procedures: analysis of the National Surgical Quality Improvement Program-Pediatrics

OBJECTIVE Existing studies have shown a high overall rate of adverse events (AEs) following pediatric neurosurgical procedures. However, little is known regarding the morbidity of specific procedures or the association with risk factors to help guide quality improvement (QI) initiatives. The goal of this study was to describe the 30-day mortality and AE rates for pediatric neurosurgical procedures by using the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatrics (NSQIP-Peds) database platform. METHODS Data on 9996 pediatric neurosurgical patients were acquired from the 2012-2014 NSQIP-Peds participant user file. Neurosurgical cases were analyzed by the NSQIP-Peds targeted procedure categories, including craniotomy/craniectomy, defect repair, laminectomy, shunts, and implants. The primary outcome measure was 30-day mortality, with secondary outcomes including individual AEs, composite morbidity (all AEs excluding mortality and unplanned reoperation), surgical-site infection, and unplanned reoperation. Univariate analysis was performed between individual AEs and patient characteristics using Fischer's exact test. Associations between individual AEs and continuous variables (duration from admission to operation, work relative value unit, and operation time) were examined using the Student t-test. Patient characteristics and continuous variables associated with any AE by univariate analysis were used to develop category-specific multivariable models through backward stepwise logistic regression. RESULTS The authors analyzed 3383 craniotomy/craniectomy, 242 defect repair, 1811 laminectomy, and 4560 shunt and implant cases and found a composite overall morbidity of 30.2%, 38.8%, 10.2%, and 10.7%, respectively. Unplanned reoperation rates were highest for defect repair (29.8%). The mortality rate ranged from 0.1% to 1.2%. Preoperative ventilator dependence was a significant predictor of any AE for all procedure groups, whereas admission from outside hospital transfer was a significant predictor of any AE for all procedure groups except craniotomy/craniectomy. CONCLUSIONS This analysis of NSQIP-Peds, a large risk-adjusted national data set, confirms low perioperative mortality but high morbidity for pediatric neurosurgical procedures. These data provide a baseline understanding of current expected clinical outcomes for pediatric neurosurgical procedures, identify the need for collecting neurosurgery-specific risk factors and complications, and should support targeted QI programs and clinical management interventions to improve care of children.

Determinants of Resource Utilization in a Tertiary Pediatric and Congenital Echocardiographic Laboratory

We sought to determine the relation between technical charges for transthoracic echocardiograms (TTE) and total time for study completion (TT), identify factors associated with high TT, and create a scoring system to predict high TT studies. We analyzed a quality improvement database that prospectively tracked patient flow through TTEs in our laboratory for 3 consecutive months. The performing sonographer or fellow recorded TT and its components for every study. Patient and scan characteristics were abstracted from the clinical database and technical charges from the financial database. Factors independently associated with high TT (top quartile ≥85 minutes) were identified in 1,686 studies and validated in the remaining 847 studies. Median age was 7.8 years (0 to 77.9) and median TT was 65 minutes (14 to 370 minutes). Charges correlated poorly with TT (r = 0.2). Multivariate analysis identified several independent factors associated with high TT. The final model had an area under the curve of 0.78 in the development sample and 0.75 in the validation sample. On the basis of the final model, we developed a risk score for TT ≥85 minutes. The prevalence of high TT was 15% in low-score studies, 51% in medium-score studies, and 81% in high-score studies. In conclusion, this is the first study to demonstrate poor correlation between technical charges for pediatric/congenital echocardiography and TT, identify risk factors for high TT, and develop a high TT risk scoring system. These data may assist in resource allocation for pediatric/congenital echocardiograms and inform reimbursement systems.

A method to account for variation in congenital heart surgery charges

BACKGROUND

In response to societal pressure to reduce expenditures and increase quality, we sought to develop a methodology to predict hospital charges related to congenital heart surgery.

METHODS

Patients undergoing congenital heart surgery at Boston Children's Hospital in fiscal years 2007 to 2009 comprised the derivation cohort. Clinical data, including Current Procedural Terminology coding of the primary surgical intervention, were collected prospectively and linked to total hospital charges for an episode of care. Surgical charge categories were developed to group surgical procedure types using empiric data and expert consensus. A multivariable model was built using surgical charge categories and additional patient and procedural characteristics to predict the outcome, total hospital charges. A contemporary cohort for fiscal years 2010 to 2012 was used to validate surgical charge categories and the multivariable model.

RESULTS

In the derivation cohort, 2,105 cases met inclusion criteria. One hundred three surgical procedure types were categorized into seven surgical charge categories, yielding a grouper variable with an R(2) explanatory value of 47.3%. Explanatory value increased with consideration of patient age, admission status, and preoperative ventilator dependence (R(2) = 59.4%), as well as weight category, noncardiac abnormality, and genetic syndrome other than trisomy 21 (R(2) = 61.5%). Additional variability in charge was explained when extracorporeal membrane oxygenation utilization and greater than one operating room visit during the episode of care were added (R(2) = 74.3%). The contemporary cohort yielded an R(2) explanatory value of 67.7%.

CONCLUSIONS

The combination of clinical data with resource utilization information resulted in a statistically valid predictive model for total hospital charges in congenital heart surgery.

Substantial radiation reduction in pediatric and adult congenital heart disease interventions with a novel X-ray imaging technology

Background

Pediatric catheterization exposes patients to varying radiation doses. Concerns over the effects of X-ray radiation dose on the patient population have increased in recent years. This study aims at quantifying the patient radiation dose reduction after the introduction of an X-ray imaging technology using advanced real time image noise reduction algorithms and optimized acquisition chain for fluoroscopy and exposure in a pediatric and adult population with congenital heart disease.

Methods

Patient and radiation dose data was retrospectively collected (July 2012–February 2013) for 338 consecutive patients treated with a system using state of the art image processing and reference acquisition chain (referred as “reference system”). The same data was collected (March–October 2013) for 329 consecutive patients treated with the new imaging technology (Philips AlluraClarity, referred as “new system”). Patients were divided into three weight groups: A) below 10 kg, B) 10–40 kg, and C) over 40 kg. Radiation dose was quantified using dose area product (DAP), while procedure complexity using fluoroscopy time, procedure duration and volume of contrast medium.

Results

The new system provides significant patient dose reduction compared to the reference system. Median DAP values were reduced in group A) from 140.6 cGy·cm² to 60.7 cGy·cm², in group B) from 700.0 cGy·cm² to 202.2 cGy·cm² and in group C) from 4490.4 cGy·cm² to 1979.8 cGy·cm² with reduction of 57%, 71% and 56% respectively (p < 0.0001 for all groups).

Conclusions

Despite no other changes in procedural approach, the novel X-ray imaging technology provided substantial radiation dose reduction of 56% or higher.

•

x-ray radiation dose in pediatric patients is of specific concern as congenital heart disease is more often treated by interventional measures.

•

the effect of advanced real time image noise reduction algorithms and optimized acquisition chain for fluoroscopy and exposure was studied.

•

A state of the art image processing and reference acquisition chain was compared to the new imaging technology in 338 vs 329 consecutive patients.

•

Patients were divided into three weight groups: A) below 10 kg, B) 10-40 kg, and C) over 40 kg according to clinical practice and procedure complexity.

•

the novel X-ray imaging technology provided substantial radiation dose reduction of 56% or higher.

Development of a charge adjustment model for cardiac catheterization

A methodology that would allow for comparison of charges across institutions has not been developed for catheterization in congenital heart disease. A single institution catheterization database with prospectively collected case characteristics was linked to hospital charges related and limited to an episode of care in the catheterization laboratory for fiscal years 2008-2010. Catheterization charge categories (CCC) were developed to group types of catheterization procedures using a combination of empiric data and expert consensus. A multivariable model with outcome charges was created using CCC and additional patient and procedural characteristics. In 3 fiscal years, 3,839 cases were available for analysis. Forty catheterization procedure types were categorized into 7 CCC yielding a grouper variable with an R (2) explanatory value of 72.6%. In the final CCC, the largest proportion of cases was in CCC 2 (34%), which included diagnostic cases without intervention. Biopsy cases were isolated in CCC 1 (12%), and percutaneous pulmonary valve placement alone made up CCC 7 (2%). The final model included CCC, number of interventions, and cardiac diagnosis (R (2) = 74.2%). Additionally, current financial metrics such as APR-DRG severity of illness and case mix index demonstrated a lack of correlation with CCC. We have developed a catheterization procedure type financial grouper that accounts for the diverse case population encountered in catheterization for congenital heart disease. CCC and our multivariable model could be used to understand financial characteristics of a population at a single point in time, longitudinally, and to compare populations.