Chow, Nathan

Disseminated cutaneous coccidioidomycosis (DCC) is an uncommon manifestation of Coccidioides infection resulting from hematogenous spread to the skin. While recurrence after treatment discontinuation has been reported in 17 to 50 percent of cases, associated frequency, timing, and risk factors are not well defined. We conducted a retrospective review of biopsy-proven or probable DCC cases between January 2008 and March 2024, and investigated for evidence of recurrence. Demographic, clinical, and treatment data were abstracted, including antifungal regimen, adherence, immune status, and coccidioidal titers. A total of 45 subjects met the inclusion criteria, including 27 immunocompetent and 18 immunosuppressed patients. Eleven (24.4%) experienced one or more recurrences, totaling 22 recurrences; 19 of these (86.4%) occurred at previously affected sites. Ten immunocompetent patients (37.0%) had 21 total recurrences, while one immunosuppressed patient (5.6%) experienced a single recurrence. Median antifungal-free interval before recurrence was 14 months (range, 1–96), and 10 recurrences (90.9%) occurred while off antifungal therapy. Ten patients underwent initial surgical excision, with four (40.0%) experiencing a total of 11 recurrences afterwards. DCC recurrence was common, mostly among immunocompetent individuals not on suppressive antifungal therapy, and frequently presented with multiple recurrences. Recurrences were almost always at prior lesion sites, often years after treatment discontinuation.

Abstract Background Coccidioidomycosis (cocci) is a fungal infection caused by Coccidioides and a common cause of community acquired pneumonia in endemic regions. Disseminated cocci occurs in ≤ 1% of persons with cocci, and among these, disseminated cutaneous coccidioidomycosis (DCC) is estimated to occur in 15 to 67% of cases, however little data exists to describe its frequency and timing of recurrence. Limited small studies show recurrence rates from 17 to 50% and often do not distinguish skin dissemination from other soft tissues. Our aim was to determine the frequency, timeframe and risk factors for relapsed DCC. Methods Potential cases of disseminated cocci were identified by ICD-10 codes 38.3, 38.7, 38.9 (& ICD-9 equivalents) and keyword-based search of pathology reports from 1/1/2008 - 3/31/2024. We included patients with proven or probable DCC. We excluded patients with primary cutaneous cocci or reactive rash. We performed a retrospective review to identify episodes of recurrence, comorbidities, and antifungal regimen. Results We identified 44 proven and 3 probable cases of DCC (33 males, 14 females), median age 48 years, 66.0% white, 21.3% black, 5.4% Hispanic. 18 (38.3%) were immunosuppressed and 6 (13.6%) had diabetes mellitus. Median follow-up duration was 68 months; 12 (25.5%) patients had ≥1 recurrence, 7 (14.9%) of whom relapsed ≥2 times. Median interval off of antifungals until recurrence was 14 months (range: 1 - 96). 3 (6.4%) patients had recurrence within three months of diagnosis, and 6 (13.0%) and 11 (23.9%) had a recurrence by the 1st and 5th follow-up year, respectively. 21 (87.5%) recurrences were at the same site as a prior occurrence, 4 (18.2%) occurred on antifungal therapy. There were no significant differences in recurrence rates by race or diabetes. Of the 18 immunosuppressed cases, there was 1 (5.6%) recurrence, though 14 (77.8%) continued antifungal therapy throughout follow-up. Conclusion Once antifungal treatment was discontinued, recurrence of disseminated cutaneous cocci was common, and among those whose DCC relapsed, multiple relapses were noted. Longer follow up is needed to better characterize the risk of long-term recurrence. Disclosures All Authors: No reported disclosures

Purpose Development of appropriate reimbursement models for breast reconstruction in the United States requires an understanding of relevant economic trends. The purpose of this study is to evaluate longitudinal patterns in Medicare reimbursement for frequently performed breast reconstruction procedures between 2000 and 2019. Methods Reimbursement data for 15 commonly performed breast reconstruction procedures were analyzed using the Centers for Medicare & Medicaid Services Physician Fee Schedule Look-Up Tool for each Current Procedural Terminology code. By utilizing changes to the US consumer price index, monetary data were adjusted for inflation to 2019 US dollars. Inflation-adjusted trends were used to calculate average annual and total percentage changes in reimbursement over time. Results From 2000 to 2019, average adjusted reimbursement for all procedures fell by 13.32%. All procedures demonstrated a negative adjusted reimbursement rate other than immediate insertion of breast prosthesis, which increased by 55.37%. The largest mean decrease was observed in breast reconstruction with other technique (−28.63%), followed by single pedicle transverse rectus abdominis myocutaneous flap (−26.02%), single pedicle transverse rectus abdominis myocutaneous flap with microvascular anastomosis (−23.33%), latissimus dorsi flap (−19.65%), and free flap reconstruction (−19.36%). Conclusions There has been a steady yet substantial decline in Medicare reimbursement for the majority of breast reconstruction procedures over the last 20 years. Given increasing medical costs and the financial uncertainty of the US health care system, an understanding of Medicare reimbursement trends is vital for policymakers, administrators, and physicians to develop agreeable reimbursement models that facilitate growth and economic vitality of breast reconstruction in the United States.

Abstract Background Microsurgery is being increasingly utilized across surgical specialties, including plastic surgery. Microsurgical techniques require greater time and financial investment compared with traditional methods. This study aimed to evaluate 20-year trends in Medicare reimbursement and utilization for commonly billed reconstructive microsurgery procedures from 2000 to 2019. Methods Microsurgical procedures commonly billed by plastic surgeons were identified. Reimbursement data were extracted from The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services for each current procedural terminology (CPT) code. All monetary data were adjusted for inflation to 2019 U.S. dollars. The average annual and total percentage changes in reimbursement were calculated based on these adjusted trends. To assess utilization trends, CMS physician/supplier procedure summary files were queried for the number of procedures billed by plastic surgeons from 2010 to 2018. Results After adjusting for inflation, the average reimbursement for all procedures decreased by 26.92% from 2000 to 2019. The greatest mean decrease was observed in CPT 20969 free osteocutaneous flaps with microvascular anastomosis (−36.93%). The smallest mean decrease was observed in repair of blood vessels with vein graft (−9.28%). None of the included procedures saw an increase in reimbursement rate over the study period. From 2000 to 2019, the adjusted reimbursement rate for all procedures decreased by an average of 1.35% annually. Meanwhile, the number of services billed to Medicare by plastic surgeons across the included CPT codes increased by 42.17% from 2010 to 2018. Conclusion This is the first study evaluating 20-year trends in inflation-adjusted Medicare reimbursement and utilization in reconstructive microsurgery. Reimbursement for all included procedures decreased over 20% during the study period, while number of services increased. Increased consideration of these trends will be important for U.S. policymakers, hospitals, and surgeons to assure continued access and reconstructive options for patients.

Background: Medicare reimbursement trends across multiple surgical subspecialties have been analyzed; however, little has been reported regarding the long-term trends in reimbursement of hand surgery procedures. The aim of this study is to analyze trends in Medicare reimbursement for commonly performed hand surgeries. Methods: Using the Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File, we determined the 20 hand surgery procedure codes most commonly billed to Medicare in 2016. Reimbursement rates were collected and analyzed for each code from The Physician Fee Schedule Look-Up Tool for years 2000 to 2019. We compared the change in reimbursement rate for each procedure to the rate of inflation in US dollars, using the Consumer Price Index (CPI) over the same time period. Results: The reimbursement rate for each procedure increased on average by 13.9% during the study period while the United States CPI increased significantly more by 46.7% ( P < .0001). When all reimbursement data were adjusted for inflation to 2019 dollars, the average reimbursement for all included procedures in this study decreased by 22.6% from 2000 to 2019. The average adjusted reimbursement rate for all procedures decreased by 21.92% from 2000 to 2009 and decreased by 0.86% on average from 2009 to 2019 ( P < .0001). Conclusion: When adjusted for inflation, Medicare reimbursement for hand surgery has steadily decreased over the past 20 years. It will be important to consider the implications of these trends when evaluating healthcare policies and the impact this has on access to hand surgery.