Ambulatory visit groups: an outpatient classification system.
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Ambulatory Care↗
Biomedical subjects
J L Freeman
Publications and source records attributed to J L Freeman.
Are hospital services rationed in New Haven or over-utilised in Boston?
The populations of New Haven and Boston are demographically similar and receive most of their hospital care in university hospitals, but in 1982 their expenditures per head for inpatient care were $451 and $889, respectively. The 685,400 residents of Boston incurred about $300 million more in hospital expenditures and used 739 more beds than they would have if the use rates for New Haven residents had applied. Most of the extra beds were invested in higher admission rates for medical conditions in which the decision to admit can be discretionary. The overall rates for major surgery were equal, but rates for some individual operations varied widely. These findings indicate that academic standards of care are compatible with widely varying patterns of practice and that medical care costs are not necessarily high in communities served largely by university hospitals. They also emphasise the need for increased attention to the outcome and cost implications of differences in practice styles.
Adolescent↗
Metastatic neck disease. A clinical/radiographic/pathologic correlative study.
The concept of treating prophylactically the neck of the patient with head and neck cancer is based on the presence of neck metastases in a large number of cases, even if not always detected by physical examination. A modality that could reveal abnormal nodes accurately would change this management attitude so that a number of necks could be left untreated. A retrospective comparative study was undertaken to determine whether high-resolution computed tomographic (CT) scanning might play this role, and whether it has any advantage over physical examination. The radiographic findings of 79 patients with head and neck cancer who had undergone a total of 100 neck dissections were compared with the findings of physical and histopathologic examinations. This study shows similar sensitivity rates for both physical examination and CT scanning (61.55% and 59.6%, respectively) and slight superiority of the positive predictive values of physical examination (91.4%) over those of CT scanning (81.6%). The study suggests that CT offers no advantage over physical examination and should therefore not be used for neck management decisions. Measuring the size of involved lymph nodes showed that occult nodes fall within the same range as normal nodes and thus cannot be differentiated from normal nodes by size alone.
Head and Neck Neoplasms↗
A review of conventional and CT imaging in the evaluation of thyroid malignancies.
Conventional imaging modalities available for investigating suspected or confirmed malignancies of the thyroid are reviewed. CT scan, a relatively new tool in this area, is discussed in some detail, and its advantages outlined and illustrated with clinical examples.
Adult↗
Thyroid cartilage imaging with diagnostic ultrasound. Correlative studies.
In 1976, Noyek observed that the thyroid cartilage framework of the larynx could be imaged by diagnostic ultrasound; the image appeared uniquely independent of the presence or absence of calcification. It was suggested that ultrasound, with its simple, nonroentgenographic, noninvasive features, might permit screening detection of thyroid cartilage destruction. It might, therefore, give direction to better computed tomographic (CT) imaging, and, specifically, more effectively identify T4 laryngeal cancer. Since that time, with improving generations of ultrasound transducers, more than 130 clinically correlated laryngeal ultrasound examinations have been recorded. Thirty CT, ultrasound, and pathologically correlated advanced cases of laryngeal carcinoma were critically evaluated by the Departments of Otolaryngology and Radiology at Mount Sinai Hospital, Toronto. Our diagnostic imaging approach has resulted in remarkably improved thyroid cartilage imaging by CT when "directed" by preliminary ultrasound.
Carcinoma↗
Diagnosis related groups: product line management within hospitals.
The hospital is viewed as a human service enterprise whose primary function is the provision of diagnostic and therapeutic medical services. Its products are the specific sets of services provided to individual patients. A system for defining hospital products based on the characteristics of patients receiving similar sets of services has been developed and is referred to as Diagnosis Related Groups (DRGs). The system is described, and its implications for improved hospital management are discussed.
Accounting↗
Pectoralis major myocutaneous flap in oropharyngeal reconstruction.
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Female↗
DRGs: how they evolved and are changing the way hospitals are managed.
Medicare uses Diagnosis-related Groups for prospective hospital payments nationwide, but the groups were not originally intended as such. The authors trace the development of this landmark program and explore the concept of product line management. Dr. Fetter, a leading authority in health care resource allocation, developed the entire framework for DRGs as a method to predict hospital resource requirements. He is currently extending the DRG concepts to outpatient and long-term care facilities. This article is adapted from Dr. Fetter's presentation at the Bridgeport Symposium entitled "Performance Requirements for Clinical Laboratories Under Prospective Reimbursement and DRGs." The Nov. 15-16, 1984 symposium was sponsored by Bridgeport Hospital, Bridgeport, Conn., and supported by contributions from 20 companies (listed on page 29). Portions of this article are also based on a presentation by Drs. Freeman and Mullin at the Tri-Service Performance Measurement Conference, June 11-15, 1984, sponsored by the Army Medical Department.
Costs and Cost Analysis↗
The double paddle pectoralis major myocutaneous flap.
Many extended defects involving cover and lining about the head and neck can be rehabilitated by the double paddle pectoralis major myocutaneous flap. In this report, the flap, its technique of development, uses, and advantages are highlighted in 10 cases.
Adult↗
Management of the parathyroids in surgery for advanced malignancy of the larynx and hypopharynx.
A thyroidectomy is required in the surgical management of advanced malignancy of the larynx and hypopharynx when there is direct or potential extension to the thyroid of disease from the primary site or adjacent, involved lymph nodes. The parathyroids are at risk of injury either by inadvertent sacrifice with the en bloc resection, or as a result of surgical devascularization. At times the glands must be resected with the specimen. The incidence of postoperative parathyroid insufficiency may be decreased by re-implantation of the glands into the antecubital fossa. A series of parathyroid re-implantations in patients with advanced malignancy of the larynx and hypopharynx is reviewed.
Aged↗
The clinical significance of radionuclide bone and gallium scanning in osteomyelitis of the head and neck.
Osteomyelitis of the head and neck remains a difficult clinical problem both in diagnosis and treatment evaluation. The purpose of this manuscript is to review our clinical experience with 25 cases of osteomyelitis distributed evenly among the temporal bone and skull base, the paranasal sinuses, and the mandible. Radionuclide bone and gallium scan images accurately depicted the biologic activity of the disease process and permitted accurate treatment evaluation and patient monitoring. This work demonstrates the potentials and limitations of radionuclide imaging with bone and gallium scan agents and attempts to define a role for their contemporary use in the management of osteomyelitis of the head and neck.
Adult↗
Ambulatory visit groups: a framework for measuring productivity in ambulatory care.
This article describes Ambulatory Visit Groups (AVGs) and the process by which they were defined. An approach to the analysis of physician productivity in the ambulatory setting is then demonstrated, with data derived from the National Ambulatory Medical Care Survey [1]. Finally, recommendations for future work are presented to make this approach more effective in designing and managing ambulatory care delivery organizations.
Ambulatory Care↗
Late post radiation necrosis and fibrosis of the larynx.
Radiation has been used to treat carcinoma of the larynx for some 60 years. We have seen some very late complications of radiation to this region. In this paper we present three patients who had radiation-induced necrosis and fibrosis 13, 19, and 22 years after initial treatment. The problem exists of diagnosing and differentiating perichondritis/fibrosis from recurrent carcinoma. However, many times it is impossible to make this distinction clinically, endoscopically, radiologically, or even pathologically. The pathogenesis, clinical features, and treatment of this rare late complication of radionecrosis and/or fibrosis are presented.
Adult↗
Hair-bearing flaps in head and neck reconstructive surgery.
Pedicled flaps of scalp are invaluable for reconstructing other hair-bearing regions about the head and neck. The flap is based on the posterior branch of the superficial temporal artery whose course is mapped out pre-operatively with Doppler. The flap is carefully measured and transferred, delayed after two weeks, and set in at three weeks. Complications were minimal in the authors' series of 22 cases.
Face↗
Thyroid tumor imaging.
Clinical assessment of a patient with a focal or diffuse thyroid tumor is but the first step in diagnostic evaluation. The diagnostic imaging process augments information obtained by the inspecting eye and the palpating hand; it allows the qualification (for example, cystic v solid) and the quantification (for example, size, extension, and assessment of physiologic function) of the thyroid tumor mass. This diagnostic input allows the establishment of a more realistic provisional diagnosis and directs a rational treatment approach to the patient. This presentation reviews the major imaging modalities available for thyroid tumor evaluation: diagnostic ultrasound, radionuclide scans, and conventional radiology and computed tomography. The applications of these various modalities and their critical potentials and limitations are placed in a contemporary clinical setting. It is hoped that an increasing familiarity with these imaging modalities will give better direction to the specialist in otolaryngology--head and neck surgery and greater surgical benefit to his or her patients.
Adenocarcinoma↗
Analysis of data from successive complex sample surveys, with an example of hypertension prevalence from the United States Health Examination Survey.
There are a number of ongoing large complex sample surveys focused on health data being undertaken at present. Because of time and cost constraints, these surveys are usually highly stratified multistage cluster samples. The complexity of this design has made the usual simple random sampling assumptions untenable and therefore analyses are rarely more than descriptive in nature with some pairwise comparison using t-tests. Generalized regression procedures using weighted least squares are now available for solving this difficulty by incorporating the sample design into the data analysis through the variances and covariances of the sample estimates. These procedures are extended to the analysis of data from complex surveys conducted at two or more different points in time (successive surveys). The method is illustrated with an example taken from published data of hypertension prevalence estimates from the Health Examination Survey-Cycle I (1960-1962) and the Health and Nutrition Examination Survey (1971-1975).
Adult↗
The thick-walled usually opacified maxillary sinus-conventional CT radionuclide ultrasound correlative studies.
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Adult↗
Greater omentum used for carotid cover after pharyngolaryngoesophagectomy and gastric 'pull-up' or colonic 'swing'.
An excellent method of rehabilitation for swallowing after total pharyngolaryngoesophagectomy is the reconstruction of the pharyngoesophagus with an autogenous visceral transplant. The most popular and reliable methods are the gastric "pull-up" and colonic "swing." A complication of this procedure--which can result in morbidity as well as mortality--is carotid artery rupture, especially when a neck dissection is performed. This is usually the result of wound breakdown secondary to adjunctive use of radiotherapy. When we have performed a radical neck dissection in conjunction with a visceral transplantation, we have used pedicled omentum as a live, durable cover for the carotid artery. ?
Carotid Artery Diseases↗