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Cost Effectiveness and Resource... Sep 2023In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full...
BACKGROUND
In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full Cavity Shave (FCS) approach or adding the MarginProbe Radiofrequency Spectroscopy System.
OBJECTIVE
We sought to create a functioning Pro-Forma for use by facilities and payers to evaluate and compare the cost savings of implementing FCS or MarginProbe based on personalized variable inputs.
METHODS
A decision tree demonstrating three possible surgical pathways, BCS, BCS + FCS, and BCS + MarginProbe was developed with clinical inputs for re-excision rate, mastectomy as 2nd surgery, rate of reconstruction, and rate of 3rd surgery derived by a literature review. A surgical pathway cost formula was created using the decision tree and financial inputs derived by utilizing the nation's largest database of privately billed health insurance claims and Medicare claims data (fairhealth.org). Using the surgical pathway formula and financial inputs, a customizable Pro-Forma was created for immediate cost savings analysis of BCS + FCS and BCS + Marginprobe using variable inputs. Costs are from the perspective of third-party payers.
RESULTS
Utilizing MarginProbe to reduce re-excisions for positive margins can be associated with better cost-savings than FCS due to the increased pathology processing costs by using an FCS approach. The reduction in re-excision provided by both FCS and MarginProbe offset their increased expense to various degrees with cost savings of each method improving as baseline re-excisions rates increase, until ultimately each may become cost-neutral or cost-prohibitive when compared to BCS alone. Our data suggest that in the privately insured population, MarginProbe provides a cost-savings over BCS alone when baseline re-excision rates are over 20% and that FCS becomes cost-saving when baseline re-excision rates are over 29%. For Medicare patients, MarginProbe provides a cost-savings when baseline re-excision rates exceed 34%, and FCS becomes cost-saving for re-excision rates over 52%. Our Pro-Forma allows an individual provider or institution to evaluate the cost savings of the FCS approach and/or utilization of the MarginProbe device such that the additional cost or cost-savings of utilizing one or both of these methods can be quickly calculated based on their facility's volume and baseline re-excision rate.
CONCLUSIONS
Our data suggest that utilizing either an FCS approach or the MarginProbe radiofrequency spectroscopy system may be a cost-saving solution to reducing the rate of re-excisions depending on a facility or practice's surgical volume and baseline re-excision rate. The degree to which each of these interventions provides an added cost or cost-savings to healthcare payers can be evaluated by utilizing the Pro-Forma outlined herein with customizable variable inputs.
PubMed: 37716980
DOI: 10.1186/s12962-023-00477-1 -
Women's Health (London, England) Aug 2015Endometriosis is a common chronic disease mostly seen in young women. Endometriosis surgery may be considered as rather challenging in gynecology. In this article, we... (Review)
Review
Endometriosis is a common chronic disease mostly seen in young women. Endometriosis surgery may be considered as rather challenging in gynecology. In this article, we tried to emphasize on basic concepts of endometriosis surgery, the best surgical method that should be applied and the complications and the management of the complications.
Topics: Adult; Endometriosis; Female; Gynecologic Surgical Procedures; Humans; Infertility, Female; Laparoscopy; Postoperative Period; Risk Factors; Young Adult
PubMed: 26315050
DOI: 10.2217/whe.15.55 -
Translational Andrology and Urology Aug 2021It has been hypothesized that earlier onset of puberty, and thus a more prolonged exposure to high androgen levels, increases risk of prostate cancer development. Our...
BACKGROUND
It has been hypothesized that earlier onset of puberty, and thus a more prolonged exposure to high androgen levels, increases risk of prostate cancer development. Our objective was to determine whether earlier age of first shave and height, as surrogates of pubertal onset, were associated with risk of prostate cancer diagnosis.
METHODS
A prospectively collected outcomes registry of patients presenting for a prostate biopsy at the Charlie Norwood Veterans Affair Medical Center in Augusta, GA between July 1995 and June 2016 was utilized. The associations between age of first shave and height, each, and risks of a positive prostate biopsy, high grade cancer, and high volume disease were evaluated using univariable and multivariable logistic regression analysis, controlling for baseline patient demographic and oncologic characteristics.
RESULTS
Our cohort included 2,456 patients. Biopsies were positive in 1,257 (51.2%) patients, of whom 293 (23.3%) and 407 (32.4%) had high grade and volume disease, respectively. Median age of first shave was 17.0 years (interquartile range 16.0-19.0) and height was 177.7 cm (172.8-182.9). On multivariable analysis, later of age of first shave was significantly associated with increased odds of a positive prostate biopsy (odds ratio for >18 versus <16 years: 5.34, P=0.02) and taller patients had significantly increased odds of high grade cancer (odds ratio for 175-180 versus <175 cm: 7.46, P=0.037).
CONCLUSIONS
Amongst patients presenting for a prostate biopsy, those with a later age of first shave and taller height have an increased risk of a positive prostate biopsy and high grade prostate cancer, respectively.
PubMed: 34532261
DOI: 10.21037/tau-21-433 -
Plastic and Reconstructive Surgery.... Dec 2020Proper management of Spitz nevi continues to be debated, with treatment ranging from observation to surgery. To better characterize the outcome of surgical procedures...
UNLABELLED
Proper management of Spitz nevi continues to be debated, with treatment ranging from observation to surgery. To better characterize the outcome of surgical procedures performed for incomplete initial excision or biopsy, we sought to ascertain the histopathological presence of residual Spitz nevi in a set of surgical specimens.
METHODS
We retrospectively reviewed 123 records with histologically-confirmed Spitz nevus. Data concerning treatment, clinical features, histopathological margin involvement, and presence of residual lesion on subsequent procedural specimens were collected.
RESULTS
Fifty-three percent of lesions (n = 65) were initially sampled by shave or punch biopsy, and the remainder (n = 58) were formally excised without initial biopsy. The rates of re-excision for involved margins were: shave biopsy (92.2%), punch biopsy (78.6%), and formal excision (13.8%). In total, 61.0% of patients who underwent an initial procedure of any kind had involved margins, but only half of those re-excised for involved margins (57.6%) had histologically residual lesion on repeated excision. A significantly higher proportion of initial punch biopsies (90.9%) resulted in residual lesion (in secondary excision specimens) when compared with shave biopsy (48.9%) and formal excision (62.5%; < 0.05).
CONCLUSIONS
Findings suggest that clinicians may consider shave biopsy over punch biopsy for diagnosing suspected lesions, when indicated and appropriate. Given the rarity of malignant transformation and the frequency of residual nevus, observation may be reasonable for managing pediatric patients with histologically-confirmed Spitz nevi, who are post initial biopsy or excision despite known histopathological margin involvement.
PubMed: 33425580
DOI: 10.1097/GOX.0000000000003244 -
BioMed Research International 2016Endometriosis is defined as the presence of endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Deep infiltrating... (Review)
Review
Endometriosis is defined as the presence of endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Deep infiltrating endometriosis (DIE) is considered the most aggressive presentation of the disease, penetrating more than 5 mm in affected tissues, and it is reported in approximately 20% of all women with endometriosis. DIE can cause a complete distortion of the pelvic anatomy and it mainly involves uterosacral ligaments, bladder, rectovaginal septum, rectum, and rectosigmoid colon. This review describes the state of the art in laparoscopic approach for DIE with a special interest in intestinal involvement, according to recent literature findings. Our attention has been focused particularly on full-thickness excision versus shaving technique in deep endometriosis intestinal involvement. Particularly, the aim of this paper is clarifying from the clinical and methodological points of view the best surgical treatment of deep intestinal endometriosis, since there is no standard of care in the literature and in different surgical settings. Indeed, this review tries to suggest when it is advisable to manage the full-thickness excision or the shaving technique, also analyzing perioperative management, main complications, and surgical outcomes.
Topics: Adult; Endometriosis; Female; Humans; Laparoscopy
PubMed: 27579309
DOI: 10.1155/2016/3617179 -
JAMA Dermatology Nov 2021Medicare enrollment, dermatologist utilization of Medicare, and dermatologic procedural volume have all increased over time. Despite this, there are limited studies...
IMPORTANCE
Medicare enrollment, dermatologist utilization of Medicare, and dermatologic procedural volume have all increased over time. Despite this, there are limited studies evaluating changes in Medicare reimbursement within dermatology.
OBJECTIVE
To identify trends in Medicare reimbursement for 46 common dermatologic procedures from 2007 to 2021.
DESIGN, SETTING, AND PARTICIPANTS
In this cross-sectional study, reimbursement data were obtained from the Centers for Medicare & Medicaid Services Physician Fee Schedule for commonly used dermatologic Current Procedural Terminology (CPT) codes from 2007 to 2021. The CPT codes in several major dermatologic categories were analyzed, including skin biopsy, shave removal, benign/premalignant/malignant destruction, benign/malignant excision, Mohs micrographic surgery, simple/intermediate/complex repair, flap, graft, and laser/phototherapy. All procedure prices were adjusted for inflation to January 2021 dollar value.
MAIN OUTCOMES AND MEASURES
The primary outcomes were percentage changes and cumulative annual growth rates of pricing for each dermatologic procedure.
RESULTS
From 2007 to 2021, there was a mean decrease in dermatologic procedure reimbursement of -4.8% after adjusting for inflation. Mean inflation-adjusted changes in reimbursements during this time period significantly varied by procedure type, including skin biopsy (+30.3%), shave removal (+24.5%), benign/premalignant/malignant destruction (-7.5%), Mohs micrographic surgery (-14.4%), benign/malignant excision (-3.9%), simple/intermediate/complex repair (-9.9%), flap repair (-14.1%), graft repair (-12.0%), and laser/phototherapy (-6.6%; P < .001). Changes in reimbursement did not vary by anatomical risk categories.
CONCLUSIONS AND RELEVANCE
The findings of this cross-sectional analysis suggest that changes in Medicare reimbursement can have several downstream effects, including concomitant private insurance changes and decreased patient access. Future adjustments in reimbursement should balance high-value care with sustainable pricing to optimize patient access.
Topics: Aged; Cross-Sectional Studies; Current Procedural Terminology; Humans; Insurance, Health, Reimbursement; Medicare; Physicians; United States
PubMed: 34524396
DOI: 10.1001/jamadermatol.2021.3453 -
Plastic Surgery (Oakville, Ont.) 2015Vapocoolant sprays are commonly used to minimize pain following minor interventions such as venipuncture, shave biopsy or needle insertion. Although these sprays have...
BACKGROUND
Vapocoolant sprays are commonly used to minimize pain following minor interventions such as venipuncture, shave biopsy or needle insertion. Although these sprays have been widely used in clinical practice, little is known about their effect on microcirculation or cutaneous blood flow.
OBJECTIVE
To evaluate the real-time effect of a topical vapocoolant using a well-established, rat cremaster muscle microcirculatory model, allowing direct measurement of changes in vessel diameter, capillary density and leukocyte behaviour.
METHODS
Fifty rats were divided into a control and four experimental groups: group 1: 4 s spray with vapocoolant at 18 cm distance; group 2: 10 s spray at 18 cm distance; group 3: 4 s spray at 8 cm distance; and group 4: 10 s spray at 8 cm distance. Vessel diameters, capillary density and leukocyte behaviour were monitored for 1 h thereafter. Muscle was harvested for immunohistochemistry analysis of proangiogenic markers (vascular endothelial growth factor and von Willebrand factor), leukocyte behaviour markers (E-selectin, vascular cell adhesion molecule, intercellular adhesion molecule), pimonidazole-hypoxia staining and ApopTag (Millipore, USA) staining for apoptosis. Gene expression for inflammatory markers (interleukin [IL]-1β, IL-2, IL-4, IL-6, IL-10, tumour necrosis factor-alpha and interferon-gamma) was evaluated using polymerase chain reaction and myeloperoxidase assay for inflammation was performed.
RESULTS
The use of refrigerant spray decreased vessel diameter and capillary density initially, although none of these decreases were statistically significant. Polymerase chain reaction showed no significant changes. The myeloperoxidase assay showed statistically significant increase in myeloperoxidase activity in groups 2, 3 and 4. Immunohistochemistry was negative for angiogenic and proinflammatory markers.
CONCLUSIONS
The lack of statistically significant changes in vessel diameter and inflammatory markers corroborated the safety on microcirculation.
PubMed: 26090345
DOI: 10.4172/plastic-surgery.1000917 -
Dermatologic Surgery : Official... Nov 2015The shave biopsy using a razor with an open blade is the current standard of care for sampling superficial skin lesions.
BACKGROUND
The shave biopsy using a razor with an open blade is the current standard of care for sampling superficial skin lesions.
OBJECTIVE
To enhance safety, the authors developed a novel biopsy device with a closed blade design for removing the epidermal layer of skin and evaluated against the open razor blade for tolerability, scarring, and accuracy in histological diagnosis.
MATERIALS AND METHODS
Shave biopsies were performed using the novel device or razor blade on benign epidermal skin lesions in 10 patients on comparable body parts. Digital photography, colorimetry, scar scale evaluations, and questionnaires were used to evaluate the efficacy and tolerability of the devices.
RESULTS
For all patients, accurate histological diagnoses were made regardless of device type. No statistically significant differences were detected between the novel device and razor blade in terms of scar scale assessments, colorimetry, and questionnaire responses. Both patients and the participating dermatologist reported satisfaction with the safety and performance of the novel device. No injuries to the provider occurred with either instrument.
CONCLUSION
The rotating sphere biopsy device is a potential alternative to the razor blade with comparable tolerability, scarring, and accuracy in histological diagnoses, offering improved safety for patients and health care providers.
Topics: Aged; Aged, 80 and over; Attitude of Health Personnel; Biopsy; Cicatrix; Colorimetry; Female; Follow-Up Studies; Hemangioma; Humans; Keratosis, Seborrheic; Male; Middle Aged; Nevus; Patient Satisfaction; Photography; Skin; Skin Neoplasms; Surveys and Questionnaires
PubMed: 26506067
DOI: 10.1097/DSS.0000000000000530 -
American Family Physician Jul 2012Family physicians are regularly faced with identifying, treating, and counseling patients with skin cancers. Nonmelanoma skin cancer, which encompasses basal cell and... (Review)
Review
Family physicians are regularly faced with identifying, treating, and counseling patients with skin cancers. Nonmelanoma skin cancer, which encompasses basal cell and squamous cell carcinoma, is the most common cancer in the United States. Ultraviolet B exposure is a significant factor in the development of basal cell and squamous cell carcinoma. The use of tanning beds is associated with a 1.5-fold increase in the risk of basal cell carcinoma and a 2.5-fold increase in the risk of squamous cell carcinoma. Routine screening for skin cancer is controversial. The U.S. Preventive Services Task Force cites insufficient evidence to recommend for or against routine whole-body skin examination to screen for skin cancer. Basal cell carcinoma most commonly appears as a pearly white, dome-shaped papule with prominent telangiectatic surface vessels. Squamous cell carcinoma most commonly appears as a firm, smooth, or hyperkeratotic papule or plaque, often with central ulceration. Initial tissue sampling for diagnosis involves a shave technique if the lesion is raised, or a 2- to 4-mm punch biopsy of the most abnormal-appearing area of skin. Mohs micrographic surgery has the lowest recurrence rate among treatments, but is best considered for large, high-risk tumors. Smaller, lower-risk tumors may be treated with surgical excision, electrodesiccation and curettage, or cryotherapy. Topical imiquimod and fluorouracil are also potential, but less supported, treatments. Although there are no clear guidelines for follow-up after an index nonmelanoma skin cancer, monitoring for recurrence is prudent because the risk of subsequent skin cancer is 35 percent at three years and 50 percent at five years.
Topics: Aminoquinolines; Antineoplastic Agents; Biopsy; Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Cryotherapy; Curettage; Dermatologic Surgical Procedures; Desiccation; Fluorouracil; Humans; Imiquimod; Mohs Surgery; Risk Factors; Skin; Skin Neoplasms
PubMed: 22962928
DOI: No ID Found -
Proceedings (Baylor University. Medical... Jul 2020A 66-year-old man with a recent history of herpes zoster in the second division of the trigeminal nerve presented with hyperkeratotic plaques along his left cheek and...
A 66-year-old man with a recent history of herpes zoster in the second division of the trigeminal nerve presented with hyperkeratotic plaques along his left cheek and temple. A shave biopsy was found to be consistent with postherpetic hyperkeratosis. This case represents a unique presentation of Wolf's postherpetic isotopic response: a new skin disorder emerging at the site of a previously healed herpetic, predominantly zoster, infection. We aim to increase awareness of an unusual complication of herpes zoster and the importance of appropriate vaccination to help protect patients from these potential postinfection effects.
PubMed: 33100534
DOI: 10.1080/08998280.2020.1775481