Scientific Abstract Presentations: Practice Management Session 3 Friday, September 27 Fri, Sep 27 5:00-6:00 p.m. PDT

Purpose Residents of rural areas in the United States (US) experience health care disparities, including limited access to specialty care such as plastic and reconstructive surgery (PRS). These surgeons have broad skillsets and are capable of treating a diverse number of health conditions. Expanding rural communities' access to PRS could help reduce health care disparities and improve patient outcomes. This study aims to characterize the geographical distribution of active, board-certified plastic and reconstructive surgeons in the US and to identify factors associated with sustaining PRS providers in rural areas. Methods We queried the American Society of Plastic Surgeons (ASPS) membership directory for all board-certified plastic and reconstructive surgeons practicing in the US in December 2023. Zip codes were abstracted from each entry and converted to county Federal Information Processing Standards (FIPS) codes using the 2020 Zip Code Tabulation Area to County Relationship File. We queried the 2022 Area Health Resource File for county demographics and health care resources. We labeled counties as urban or rural based on the National Center for Health Statistics Urban-Rural Classification Scheme. T-test, Chi-squared test, and Wilcoxon rank-sum test were used to compare inter-county outcomes for those with and without PRS access; multivariate logistic regression was used to identify health resources associated with PRS access. Results We identified 3,913 active, board-certified plastic and reconstructive surgeons in the US; of these, 177 (5%) listed practice locations in more than one county. The South region represented the most surgeons (n=1,466, 37%), and the Midwest the fewest (n=677, 17%). There were 1,044 (27%) surgeons located in the West and 720 (18%) in the Northeast. Board-certified plastic surgeons served 626 counties throughout the US, accounting for 247,988,122 (75%) people. Counties without PRS (n=2,515) accounted for 81,486,655 (25%) people. Almost half (n=531, 46%) of all urban counties had a plastic and reconstructive surgeon while only 5% (n=95) of rural counties did (p<0.001). In counties with PRS, the median (interquartile range, IQR) PRS density per 100,000 population was 1.6 (0.88-2.8). Compared to counties with PRS, counties without PRS had a significantly smaller median (IQR) primary care density per 100,000 population (40 [23-58] vs. 75 [54-97], p<0.001) and general surgery density per 100,00 population (0 [0-7] vs. 10 [6-15], p<0.001). The mean (standard deviation, SD) hospital count in counties without PRS was also lower (1 [0.94] vs. 5.6 [7.8], p<0.001). Similarly, counties without PRS had a lower mean (SD) number of ambulatory surgery centers (0.31 [1.0] vs. 8.1 [16], p<0.001). After controlling for population age, income, education, and insurance status, the number of ambulatory surgery centers was significantly associated with access to PRS in rural areas (adjusted odds ratio: 1.50, 95% confidence interval: 1.18-1.91, p<0.001). Conclusions We found significant geographical variation in PRS access throughout the country, with many rural areas being without a plastic and reconstructive surgeon. Presence of an ambulatory surgery center increased the likelihood of access to PRS in rural counties. Additional studies are needed to identify necessary resources that may help recruit plastic and reconstructive surgeons to rural areas.

Purpose: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are becoming common pharmacotherapies for treating diabetes and weight management. Prescription rates have increased over 200% between 2016 and 2021 (1). These medications have multi-system impacts and no previous studies have examined their safety in surgical patients. This study examined the effect of GLP-1 receptor agonists on the rate of post-operative complications and rates of readmission in diabetic patients undergoing surgery.

Methods:  We identified all patients undergoing open and closed surgical procedures at a quaternary care hospital in New York City from February 1st, 2020 to July 1st, 2023. Eye and ear surgeries were excluded. Patients with Type 1 and Type 2 diabetes were divided into two groups: patients receiving GLP-1 RA drugs at the time of surgery as part of their diabetes management and patients receiving standard of care diabetes management without GLP-1 RA drugs. Primary outcomes were postoperative complications within six months of the surgery date and hospital readmissions within 30 days of discharge. Subgroup analyses were performed in open and closed procedures and common plastic surgery procedures.

Results: A total of 41,932 surgical procedures in 16,023 patients were included, with 9,118 (21.7%) procedures in patients with an active prescription for GLP-1 RA medications at or before the time of surgery. Patients on GLP-1 RAs were younger (65 vs. 68, p<0.001), had a higher BMI (29.23 kg/m2 vs. 28.19 kg/m2, p < 0.001), and had higher rates of T2DM (96.6% vs. 91.7%, p<0.001) compared to patients not taking GLP-1 RA medications. This group also had higher preoperative hemoglobin A1C and rates of comorbid arteriosclerosis, heart failure, cirrhosis, obesity, and hypercholesteremia/hyperlipidemia (p < 0.05). Postoperatively, the GLP-1 RA group had lower rates of hematoma (0.1% vs. 0.3%, p=0.002) and readmission within 30 days (5.4% vs. 7.6%, p<0.001). In sub-analyses, the readmission rate in the GLP-1 RA group was lower than the non-GLP-1 RA group in both open (6.6% vs. 8.3%, p<0.001) and closed (4.5% vs. 6.3%, p<0.001) procedures. Hematoma rates were decreased in the GLP-1 RA group only in open surgeries (0.2% vs. 0.4%, p=0.005). In plastic surgery procedures, active GLP-1 RA use was not associated with significant differences in complication or readmission rates (p>0.05), although this may reflect an insufficient number of patients/surgeries in this sub-analysis.

Conclusion: In this first study examining the effects of GLP-1 RA medications in surgical patients, we found these medications decreased postoperative hematoma and 30-day readmission rates, despite being taken by patients with higher Hgb A1C levels and rates of comorbidities. Further study is ongoing to elucidate the mechanism of the observed protective effect and to identify sub-groups of patients and procedures where taking GLP-1 RA medications is particularly beneficial. Plastic and reconstructive surgeons may be assured that active GLP-1 RA use is safe in diabetic patients undergoing surgery.

References: 1) Dzaye O, Berning P, Razavi AC, et al. Online searches for SGLT-2 inhibitors and GLP-1 receptor agonists correlate with prescription rates in the United States: An infodemiological study. Front Cardiovasc Med. 2022;9:936651. doi:10.3389/fcvm.2022.936651

Purpose: Accurate procedural coding reduces redundant costs and provides fair reimbursement in US healthcare. Coding standards in craniofacial surgery are unclear and poorly defined by governing organizations. We hypothesize variations in billing practices exist and aim to characterize such trends.

Methods and Materials: A 21-question survey was provided to 338 craniofacial surgeons and distributed to members of the American Society of Maxillofacial Surgeons and Craniofacial Surgery members. The anonymous survey collected demographics and current procedural terminology (CPT) code selections for six clinical vignettes: mandibular distraction (MDO), frontoorbital advancement (FOA), posterior vault distraction (PVD), posterior vault reconstruction (PVR), cranial springs, and le fort III distraction (LFD). Chi-squared analysis compared trends in responses.

Results: Of 187 recipients, 36 completed the survey (19.3%). For temporalis flaps performed in FOA, 23.5% added a muscle flap code (15733) in addition to cranioplasty codes, and this was more likely in integrated residency-trained respondents (p=.011). For MDO, 81.8% selected both codes for external fixation (20690/20692) and mandibular osteotomies (21193/21198). Craniectomy codes (61558/61559) were commonly selected in PVR (69.7%) and cranial springs (36.4%), and only 3% billed a co-surgeon modifier with neurosurgery. In bilateral cases, 54.6% billed per distractor in MDO and 46.9% in PVD. 23.5% billed bilateral temporalis flaps, and 22.7% billed for each cranial spring placed. Billing multiple or bilateral codes was more common in academia (temporalis: p=.04), fellowship-trained (MDO: p=.001), integrated residency-trained respondents (MDO: p=.034, temporalis: p=.036), and if craniofacial was >75% of their practice (temporalis: p=.04). Additional codes billed in LFD included placement of external fixation device in 44.8%, application of halo appliance in 27.6%, and lateral canthopexy in 17.2%.

Conclusion: CPT codes in craniofacial surgery are non-specific and adapted from other specialties, as evidenced by variations in code selection, bundling, and bilateral modifications. Current correct coding initiatives may not be relevant to craniofacial surgery, and thus training backgrounds inform billing practices. More work is needed to define precise, accurate coding in craniofacial surgery.

Background: A systematic review conducted in 2017 found that Musculoskeletal (MSK) injuries were prevalent amongst surgeons.1 Few studies have assessed the role that poor surgical ergonomic practices have had in the development of MSK injuries in plastic and reconstructive surgery (PRS), and fewer specifically in craniofacial surgeons.2,3,4 The impact that MSK injuries have on the emotional well-being of craniofacial surgeons is also not well understood.

Methods: A branched logic survey with a maximum of 35 questions pertaining to surgical practices, MSK injuries, and emotional well-being was distributed to all members of the American Society of Maxillofacial Surgeons (ASMS). The responses were divided into two groups, surgeons who reported developing MSK injuries or physical discomfort, and those who denied developing MSK injuries or physical discomfort. Data analysis was performed to determine which factors contributed to the incidence of MSK injury and the emotional impact that these injuries had on surgeons.

Results: Eighty-two surgeons completed responses to the survey for an overall response rate of 16.6%. Of which, 65.9% (n=54) suffered MSK injuries or physical discomfort, with 53.7% (29/54) reporting that they had trouble falling or staying asleep because of these symptoms within the last year. Both male and female respondents reported experiencing some level of anxiety or depression because of their MSK injuries.

Conclusion: The impact of developing a MSK injury may impact physical and emotional wellness. This study found that a high percentage of craniofacial surgeons have developed MSK-injuries while some have reported a negative impact on their sleep and emotional well-being.

1. Catanzarite T, Tan-Kim J, Whitcomb EL, Menefee S. Ergonomics in Surgery: A Review. Female Pelvic Med Reconstr Surg. 2018;24(1):1-12. doi:10.1097/SPV.0000000000000456
2. Kokosis G, Dellon LA, Lidsky ME, Hollenbeck ST, Lee BT, Coon D. Prevalence of Musculoskeletal Symptoms and Ergonomics Among Plastic Surgery Residents: Results of a National Survey and Analysis of Contributing Factors. Ann Plast Surg. 2020;85(3):310-315. doi:10.1097/SAP.0000000000002147
3. Fisher SM, Teven CM, Song DH. Ergonomics in the Operating Room: The Cervicospinal Health of Today's Surgeons. Plast Reconstr Surg. 2018;142(5):1380-1387. doi:10.1097/PRS.0000000000004923
4. Khansa I, Khansa L, Westvik TS, Ahmad J, Lista F, Janis JE. Work-Related Musculoskeletal Injuries in Plastic Surgeons in the United States, Canada, and Norway. Plast Reconstr Surg. 2018;141(1):165e-175e. doi:10.1097/PRS.0000000000003961

Introduction: Pressure ulcers represent a significant challenge medically, and when we consider the financial burdens they impose on healthcare systems in resource-poor settings, it becomes evermore evident. It is critical to recognize that pressure ulcers are preventable. Understanding the complex interplay between patient-related variables and pressure ulcer characteristics is paramount for effective management and prevention, especially in resource-deprived settings.

Methods: Data was obtained from a tertiary hospital located in Abuja, Nigeria. Predetermined variables were obtained, encompassing patient age, gender, living conditions, ambulatory status, mobility, pressure ulcer stage, ulcer sites, infection status, necrotic tissue presence, and treatment interventions between January and June 2023. Chi-squared tests, logistic regression models, and Fisher tests were employed to uncover relationships and associations within the dataset.

Results: Of the 747 patients admitted to the hospital, pressure ulcers were prevalent in 4.68% (n=35) of cases. The most prevalent age group was 57 years, constituting 11.43% of the patient cohort. In terms of gender distribution, 71.43% were male, while 28.57% were female. Interestingly, the pressure ulcer stage did not exhibit significant associations with ulcer sites (p = 0.08), suggesting a susceptibility to advanced pressure ulcer stages across all anatomical locations. However, a significant association was observed between being bed-bound and the site of the ulcer, which was statistically significant (p=0.0085). The sacral region emerged as the most common ulcer site, affecting 45.71% of patients, followed by multiple sites, affecting 17.14% of cases. The majority of patients (74.29%) exhibited necrotic tissue when present, while 25.71% did not. Additionally, 60% of patients received wound dressing as a treatment intervention, while 40% received surgical debridement. Notably, logistic regression analysis revealed that mobility significantly predicted treatment interventions (p = 0.0175), underscoring its role in guiding treatment decisions. Specifically, lower ambulation status was associated with an increased likelihood of higher-stage pressure ulcers (p<0.001). As ambulation status worsened, the odds of higher-stage pressure ulcers increased by a factor of approximately 0.291.

Conclusion: While the prevalence of pressure ulcers in this study was lower than the global prevalence of pressure ulcers identified in the literature, the significant association between lower ambulation status and higher-stage pressure ulcers emphasizes the need for tailored interventions to improve mobility and prevent advanced ulcer stages in these settings.

Purpose:

Operating rooms are significant contributors to environmental waste, pollution, and healthcare expenses. As the world grapples with the climate crisis, it is imperative that surgeons adopt innovative strategies to minimize the ecological footprint of surgical procedures and advance sustainability in healthcare. Despite compelling arguments questioning the necessity of full gowning and draping during procedures limited to the skin, many surgeons continue to adhere to traditional practices, resulting in excessive waste generation. Disposable gowns and drapes, commonly fabricated from Spunbond-Meltblown-Spunbond (SMS) polypropylene plastic, are particularly problematic due to their carbon-intensive production and non-biodegradability. Implementing measures to curtail resource consumption within healthcare is essential for the preservation of our planet. Our study aimed to measure the effect of a minimal draping technique within a pediatric craniofacial surgery setting.

Methods:

The amount of waste produced by three different craniofacial surgeons was measured during cases at a children's hospital over a two-week period. One surgeon adhered to a minimal draping protocol. Waste was sorted and measured post operatively by research personnel. Clinical outcomes were collected by chart review.

Results:

Data was collected from 12 cases. The results demonstrated a waste reduction of 2.1 kg (p = 0.006) when using minimal draping, primarily driven by decreased drape and gown usage. Standard draping created an average of 5.6 kg of waste per case compared to 3.5 kg with the minimal draping protocol. Standard draping produced an average of 1.07 kg of draping waste per case, with minimal draping the waste was decreased to 0.43 kg (p= .04). Additionally, without minimal draping gowns accounted for .6 kg per case, while this was reduced to 0 kg with minimal draping. There was no significant difference in the types of cases performed or the duration of cases between the two groups (50 min vs 60 min, p= 0.37). There were no post operative infections at either group within 30 days of surgery.

Conclusion:

This study compared waste generation during skin-only surgical procedures performed by craniofacial surgeons using a minimal draping technique with those employing standard draping practices. Our results demonstrated a significant reduction in waste when minimal draping was applied. While this study represents an initial observational endeavor, it offers crucial insights for further advancements in the field. The acceptance of minimal draping and semi-sterile techniques in hand surgery warrants exploration across other surgical domains. The limitations of the study include its small sample size and the absence of clinical outcome measures, which will be integrated into forthcoming research efforts. These findings underscore the urgency of reevaluating surgical practices to align with sustainable healthcare principles and combat the environmental challenges posed by healthcare-related waste.

Purpose: Medical micro-tourism is the practice of patient-directed transition of care amongst patients seeking medical care from a surgeon within 250 miles of their index operation, not as a direct referral (1). This can be due to patient preference, follow up at an outside emergency room, surgeon retirement or relocation, complications out of scope of primary surgeon, or other factors. This practice is not well-documented but can be frequently encountered. There is no regulation or standardization of the management of these patients, and typical medical tourism guidelines may not apply. This study aims to further evaluate and characterize medical micro-tourism experiences and practices among surgeons.

Methods: A twenty-question survey was designed to evaluate surgeons' experience with medical micro-tourism patients and practice patterns utilized in their management. Institutional review board approval was attained for a survey study of practicing surgeons. The survey was distributed in December 2023 to surgical Program Chairs at a single institution for disbursement to attending surgeons, as well as online in several national surgical community spaces. Medical micro-tourism was defined as travel less than 250 miles from the patient's current residence for medical care.

Results: Preliminary data from forty respondents represent a variety of surgical specialties. Surgeons encountered medical micro-tourism patients frequently in both pre- and post-operative settings, most commonly for reasons including cost, access to specialized procedures, and insurance barriers. Most surgeons do not have standardized practices for management of post-operative medical micro-tourism patients. 80% of surgeons will typically stabilize any life-threatening problems and then recommend returning to the primary surgeon for further management.

Conclusions: Medical micro-tourism is a poorly defined area of medical care that is anecdotally prevalent in the surgical field, typically as a 'second opinion'. Nearly all surgeons have encountered these patients, not uncommonly in the post-operative setting. Additional work in this area should focus on further understanding the surgeon and patient experience in this setting and creating a standardized framework for management of micro-tourism patients.

References:

1. Iorio ML, Verma K, Ashktorab S, Davison SP. Medical tourism in plastic surgery: ethical guidelines and practice standards for perioperative care. Aesthetic Plast Surg. 2014 Jun;38(3):602-7. doi: 10.1007/s00266-014-0322-6. Epub 2014 May 6. PMID: 24797678.

Background: Depression and anxiety have been shown to affect surgical outcomes following surgery. Our study aims to describe the prevalence of depression and anxiety in the pediatric surgical population to increase awareness and advocate for addressing mental health issues in this population to optimize surgical outcomes. Methods: This study was a retrospective review examining all patients with a concurrent diagnosis of depression or anxiety seen by a surgical care team at Lurie Children's from January 2012 to December 2022. Patients were included if they presented to their surgical subspecialty visit with an ICD-10 code for depression and/or anxiety. Statistical analyses compared the prevalence of depression or anxiety within surgical subspecialties and identified plastic surgery procedures most associated with mental health comorbidities. Results: The study evaluated 494,034 patients from 7 surgical subspecialties: neurosurgery (5.3%), ophthalmology (10.6%), orthopedic surgery (29.1%), otolaryngology (22.4%), pediatric surgery (13.1%), plastic surgery (4.7%), and urology (14.8%). Among plastic surgery patients with depression or anxiety, 47.7% were diagnosed with gender dysphoria, 17.4% were diagnosed with soft tissue repair, and 11.6% were diagnosed with macromastia. Pediatric plastic surgery patients were more likely to have a concurrent diagnosis of depression compared to orthopedic surgery, otolaryngology, pediatric surgery, and urology (OR 2.80, 9.48, 3.46, 6.26, respectively, p-value <0.001), and were more likely to have a concurrent diagnosis of anxiety compared to ophthalmology, orthopedic surgery, otolaryngology, pediatric surgery, and urology (OR 4.19, 4.62, 3.37, 2.11, 3.60, respectively, p-value <0.001). When gender dysphoria patients were excluded, pediatric plastic surgery patients were still more likely to have anxiety compared to orthopedic surgery, otolaryngology, and urology (OR 2.65, 1.93, 2.06, respectively, p-value <0.001, 0.003, 0.002, respectively). Conclusions: Our single-institution study demonstrates that rates of depression and anxiety are higher in pediatric plastic surgery patients compared to other surgical subspecialties. We found that diagnoses of gender dysphoria, soft tissue repair, and macromastia were most associated with mental health comorbidities. This information is important so that plastic surgeons may play a role in caring for their patients holistically and provide appropriate supplementary care to promote improved surgical outcomes.

Objectives: Hyperbaric Oxygen Therapy (HBOT) is a safe and effective treatment modality in which oxygen is administered under pressures exceeding 1 atmosphere absolute (ATA) to enhance delivery to tissues.1 Increased oxygen content is thought to aid in wound healing and fighting infections.2 While HBOT is generally considered safe, it is linked to some adverse events, most notably myopia and cataract formation.3 Prior studies on HBOT vary in their reported incidence of ophthalmologic complications; thus the incidence and progression of these adverse events is difficult to quantify. We conducted a comprehensive systemic review and meta-analysis of the ophthalmologic complications associated with HBOT to further investigate these events.

Methods: A systematic review of PubMed, Embase, Cochrane Library, and Scopus from inception to June 15, 2023 was performed to identify studies reporting adverse effects on ophthalmologic health following HBOT. According to PRISMA 2020 guidelines, an initial screening of titles and abstracts was performed, followed by a full-text analysis and data extraction. Studies reporting ophthalmologic complications due to HBOT were included. Meta-analysis was then performed on relevant studies.

Results: A search for articles on HBOT ophthalmologic complications yielded 3,395 articles, of which 183 were relevant by abstract review. 30 studies ultimately met inclusion criteria. 836 (15.77%) of 5,301 patients treated with HBOT experienced adverse events. Myopia comprised 97.0% of events, cataract formation accounted for 1.25%, and 2.28% included other complications such as changes in intraocular pressure, lens swelling, macular edema, retinopathy, and presbyopia. Resolution of myopia varied in timing, with 13.6% of studies indicating resolution immediately following cessation of HBOT and 54.5% resolving within 1-3 months. All cases of myopia were self-resolving, while cataract formation required surgical removal. Meta-analysis further stratified studies by location and design. While location was not a statistically significant factor in complication rates, prospective and randomized study designs had a significantly higher complication rate than retrospective reviews, suggesting that complications may be observed more frequently when patients are assessed throughout their treatment course.

Conclusions: To date, this is the largest systematic review and meta-analysis assessing ophthalmologic complications associated with HBOT. Our findings provide insights derived from 30 studies encompassing 5,301 patients and have important clinical implications for the use of HBOT. Given the high incidence of myopia and the severity of cataract formation, clinicians should be vigilant in monitoring patients receiving HBOT and must consider the potential for exacerbating symptoms in patients with pre-existing ophthalmologic disorders. Close monitoring and counseling can benefit these patients and increase their likelihood of completing HBO treatment successfully.

References:

1. Tibbles PM, Edelsberg JS. Hyperbaric-oxygen therapy. N Engl J Med. Jun 20 1996;334(25):1642-8. doi:10.1056/NEJM199606203342506
2. Sahni T, Singh P, John MJ. Hyperbaric oxygen therapy: current trends and applications. J Assoc Physicians India. Mar 2003;51:280-4.
3. Gengel KC, Hendriksen S, Cooper JS. Hyperbaric Related Myopia and Cataract Formation. StatPearls. 2024.

INTRODUCTION: Google's Bard and OpenAI's ChatGPT are two advanced language models that hold immense potential in the medical field. Burn care is a field where additional support in management would be useful. Optimal burn care is vital for minimizing complications and enhancing the well-being of affected individuals. The purpose of this comparative study is to evaluate the accuracy of ChatGPT and Bard in answering burn-related questions. In doing so, this study aims to provide insights into the strengths and limitations of each model, contributing to the ongoing dialogue on the applicability of these language models in the healthcare domain.

METHODS: Both ChatGPT-4 and Bard were queried with 34 questions encompassing topics such as chemical burns (n=6), burn severity classification (n=6), calculation of total body surface area (TBSA) of burn involvement (n=4), calculation of caloric needs using the Curreri formula (n=10), and calculation of fluid resuscitation requirements using the Parkland formula (n=8). A new tab was used for each question.

RESULTS: Overall, ChatGPT answered burn-related questions with 85.3% accuracy, which was significantly higher than Bard's 44.1% (p-value <0.001). ChatGPT-4 correctly answered 81.8% of calculated-based questions compared to Bard at 22.7%. For calculation-based questions, ChatGPT's incorrect answers were off by a median of 6.6% [IQR 3.9-14.3%] compared to Bard's incorrect calculations, which were off by a median of 130.4% [IQR 50.6-308.6%] (p-value 0.015). ChatGPT's poorest performance was in applying the Curreri formula, with a 60% accuracy rate in calculating caloric need calculations. With only 10% accuracy, Bard's poorest performance was determining fluid resuscitation requirements using the Parkland formula.

CONCLUSION: Compared to Bard, ChatGPT demonstrated superior accuracy in answering burn-related questions and performing resuscitation calculations. Even when incorrect, ChatGPT's calculations were relatively close. These findings underscore the promising role of ChatGPT in offering support and information in burn care management.