Vertical integration of healthcare services has been viewed by hospitals as an effective strategy for maintaining institutional viability in the face of increased competitive pressures. This paper examines the effects of vertical integration on hospital utilization and market share, based on the experience of a selected set of hospitals that developed primary care group practices as part of a national demonstration program conducted over the period 1976 to 1982. Inpatient days and admissions for the average hospital increased 9.0 percent and 8.2 percent, respectively, over the initial four-year period of group operation, while average market share of inpatient days and admissions rose by 4.9 percent and 3.6 percent, respectively. The establishment of the group practices also helped most hospitals achieve a more favorable outpatient payor mix.

Financial Management↗

PubMedDate not supplied

Mycotic aneurysm of the suprarenal abdominal aorta.

We report on the successful treatment of a patient with a mycotic aneurysm of the suprarenal aorta. The aorta was resected and reconstructed using an in-situ polytetrafluoroethylene graft with a side arm branch to the left renal artery. The use of polytetrafluoroethylene graft for aortic reconstruction after suprarenal mycotic aneurysm resection has not been previously reported. The etiology, bacteriology, diagnosis, and principles of management of mycotic aneurysms of the suprarenal aorta are discussed.

Administration, Oral↗

PubMedDate not supplied

The Vena Tech filter: evaluation of a new inferior vena cava interruption device.

Expanded indications for caval interruption and earlier diagnosis of deep venous thrombosis have resulted in increased use of transvenous caval interruption devices and have intensified the search for the ideal caval filter. The Vena Tech vena cava filter is a percutaneous, transvenous caval interruption device which was recently introduced in the United States. We reviewed our experience with this filter. During the period of September 1989 to July 1990, 41 patients underwent placement of the Vena Tech filter. Indications for filter insertion included deep venous thrombosis with a contraindication to anticogulation (61%), pulmonary embolism while on anticoagulant therapy (29%), and prophylaxis (10%). Insertion was accomplished percutaneously in 40 patients (98%) and via cutdown in one patient. Thirty-nine (95%) were placed from the right internal jugular vein and two (5%) from the right femoral vein. There were no deaths related to filter placement. Incomplete opening of the filter occurred in 8 patients (19%); however, the incidence of deployment problems decreased as our experience increased. Pulmonary embolism after filter placement occurred in one patient (2%). Duplex scan was obtained postoperatively in 15 patients (mean follow-up 120 days). The inferior vena cava was patent in all patients, although nonoccluding thrombus was identified in the filter in one patient. We conclude the Vena Tech filter is an effective device for caval interruption, is easily inserted, and is associated with minimal morbidity.

Anticoagulants↗

PubMedDate not supplied

Retroperitoneal approach to aortic surgery.

The retroperitoneal approach has been recently advocated as an alternate approach to abdominal aortic surgery rather than the traditional transperitoneal approach. A comparative analysis of these two approaches was undertaken to clarify the differences. From June 1984 through June 1986, 172 patients underwent elective infrarenal abdominal aortic surgery on the Vascular Surgery Service at Eastern Virginia Medical School. One hundred nineteen were operated through a transperitoneal approach, and 53 through a retroperitoneal approach. The two groups were similar relative to age, sex, indications, risk factors and operations performed. The groups were then analyzed relative to operating time, blood transfusion, fluid replacement, ileus, morbidity, length of hospital stay, American Society of Anesthesiologists classification, and mortality. Significant differences were found: retroperitoneal patients had shorter operating time, shorter ileus, fewer cardiac complications, and shorter hospitalization than transperitoneal patients. This retrospective evaluation supports the conclusion that the retroperitoneal approach to abdominal aortic surgery is safe and beneficial in most patients. The retroperitoneal approach should therefore be given consideration in routine aortic surgery.

Adult↗

PubMedDate not supplied

Evaluation of the expanded polytetrafluoroethylene (EPTFE) suture in peripheral vascular surgery using EPTFE prosthetic vascular grafts.

A new suture material, EPTFE, is available for use in vascular anastomoses. This study evaluated the EPTFE suture in 115 procedures on 108 patients, resulting in 198 EPTFE anastomoses. Average length of follow-up was 12.8 months with a range of two to 26 months. No incidence of suture failure resulting in infection, false aneurysm, or anastomotic dehiscence was found. Handling characteristics were found to be favorable. Anastomotic bleeding was minimal in 79%, and excessive in 5%. Available data suggest that physical and biologic characteristics of EPTFE suture are favorable. Long-term clinical follow-up is needed.

Blood Vessel Prosthesis↗

PubMedDate not supplied

Failure of arteriovenous fistulas at distal tibial bypass anastomotic sites.

Arteriovenous fistula formation has been advocated to increase the outflow for tibial and peroneal distal bypass grafts. Between January, 1981 and September, 1981, twenty-seven patients underwent thirty femoral to distal tibial or peroneal artery bypass procedures with creation of an arteriovenous fistula at the site of the distal anastomosis. Limb salvage was the primary indication for surgery in 97% of this severely ischemic group, with a mean ankle pressure index of 0.32. Despite high flow rates averaging 260 cc/minute and an initial patency rate of 97%, there were only two fistulas patent in intact limbs at the conclusion of the initial eight month follow-up period with one additional occlusion at 16 months. Limb salvage to the present (July 1983) was achieved in only six cases. In the patients with limb salvage, three bypass grafts remain patent despite fistula occlusion, two patients have occlusion of both graft and fistula but no rest pain, and a single patient has maintained both graft and fistula patency for 23 months. Creation of an arteriovenous fistula at the distal anastomotic site of tibial bypass procedures augments graft flow in the immediate post-op period; but, has very low long term patency rates and is not beneficial to graft patency or effectiveness.

Amputation, Surgical↗