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PubMed2005

Ethical issues in surgical research.

Higher standards of evidence for surgical procedures are likely to be demanded in the future by health insurance providers. Consequently, more formal and rigorous surgical research, including RCTs, will become more prevalent. Facing the ethical challenges of surgical research requires understanding of the ethically significant differences between surgical practice and research and the ways in which the ethical standards appropriate for the design and conduct of clinical research differ from the ethics of clinical care.

Ethics, Clinical↗
PubMed1986

Chemonucleolysis versus surgical discectomy. Comparison of costs and results in workers' compensation claimants.

A retrospective review of insurance claim files was conducted to compare the costs of chemonucleolysis with surgical discectomy. Twenty-nine surgeons performed 61 chemonucleolysis procedures and 44 surgical discectomies on SAIF (State Accident Insurance Fund, Inc.--a major Oregon workers' compensation insurance company) claimants between December 1982 and April 1984. Clinical data and treatment costs were tabulated during February 1985. In this population of 105 workers' compensation claimants, the average cost/claim of the workers treated by chemonucleolysis was higher than the average cost/claim of workers treated initially by surgical discectomy. The average cost/claim was somewhat lower in successful chemonucleolysis cass than in successful surgical discectomy cases, but the average cost/claim of unsuccessful chemonucleolysis cases was much higher than unsuccessful surgical discectomy cases. In order for chemonucleolysis to be a cost effective method compared to initial surgical discectomy, it would be necessary to attain a much higher chemonucleolysis success rate than observed in this group of patients.

Adult↗
PubMed1996

[Second opinion--from the medical insurance viewpoint].

The history of the initial second opinion programmes is summarized. The original expectations in these programmes and their goals are stated. Some studies on second opinion programmes showed cost-savings in health care expenditure. However, there are no valid studies proving that the health care budget had been decreased. Improvements in the patient doctor relationship were demonstrated although improvements in the quality of patient care through second opinion programmes could not be ascertained. This lack of consistency reflects the limited reliability of clinical judgements. J. R. Clarke demonstrated that analysing the decision path leading to a surgical procedure was superior to second opinion programmes in achieving a correct surgical therapy. The Swiss Accident Insurance Company (SUVA) is organized in regionally assigned physicians and a dense network of administrative offices providing proficient advisory (support?) services to physicians in practice. Additional programmes are therefore not advocated and a mandatory confirmation of the need for certain surgical indications through second opinion programmes is not required. Instead, we advise to employ decision analysis in order to strengthen the foundation of clinical judgments and to improve the selection of therapies. It is proposed that elaborating medical-surgical decision paths should include psychological, socio-economical and cultural issues affecting the patient's welfare, in addition to anatomical and technical aspects determining the therapeutic feasibility.

Cost-Benefit Analysis↗
PubMed2004

Morbidity and mortality of colorectal carcinoma surgery differs by insurance status.

BACKGROUND: Uninsured and underinsured patients are reported to be at an increased risk for impaired access to healthcare, delayed medical treatment, and the receipt of substandard care. These differences in care may result in disparities in surgical outcomes among patients with different types of insurance. In the current study, the authors examined associations between the insurance provider and short-term surgical outcomes after surgery for colorectal carcinoma and evaluated the extent to which two risk factors (comorbid disease and admission type) might explain any observed association. METHODS: The authors conducted a nationally representative retrospective cohort study of 13,415 adults ages 40-64 years who were admitted for surgery for colorectal carcinoma to hospitals that participated in the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project National Inpatient Sample, releases 6 and 7, in 1997 and 1998. Multivariate logistic regression models were developed to describe the correlations between insurance status and the risks of a postoperative complication or postoperative death after adjustment for socioeconomic factors, comorbid conditions, and admission type. RESULTS: Uninsured and Medicaid patients were found to have more emergent admissions and more comorbid disease compared with patients with private health insurance. Patients without private health insurance had higher rates of postoperative complications and in-hospital death compared with those patients with private insurance. After adjusting for patient and hospital characteristics, patients with Medicaid were found to be 22% more likely to develop a complication during their hospital admission (odds ratio [OR] of 1.22; 95% confidence interval [95%CI], 1.06-1.40) and 57% more likely to die postoperatively (OR of 1.57; 95% CI, 1.01-2.42) compared with patients with private insurance. CONCLUSIONS: The current study findings suggest that the uninsured and Medicaid populations are at greater risk of developing postoperative complications and dying than the privately insured population due only in part to preexisting medical comorbidities and emergent admission type.

Adult↗
PubMed2004

Outcome of patients after surgical closure of ventricular septal defect at young age: longitudinal follow-up of 22-34 years.

BACKGROUND: Long-term survival and clinical outcome after surgical closure of a VSD is poorly documented. Such data are important for the future perspectives, medical care, employability, and insurability of these patients. METHODS: 176 consecutive patients underwent surgical closure of an isolated VSD between 1968 and 1980 in our hospital. A systematic follow-up study was performed in 1990 and again in 2001. FINDINGS: Late survival was poorer than in the general population. Pulmonary hypertension and right ventricular hypertrophy were present in the 4 patients who died suddenly, late after operation. During follow-up no new pulmonary hypertension became manifest. Re-operations were necessary in 6%. Some patients (4%) developed sinus node disease late after repair, requiring pacemaker implantation. At last follow-up (91 survivors) 92% of the patients were in NYHA class I. Pulmonary hypertension was found in 4%, and aorta insufficiency in 16%. Patients experienced difficulties when applying for insurance. CONCLUSION: Among patients with surgically repaired VSDs, late results were good, although some late sudden deaths occurred in the patients with pulmonary hypertension. Furthermore, some patients developed sinus node disease late after repair, requiring pacemaker implantation. Employability is good, but pregnancy and insurance matters need further attention.

Adolescent↗
PubMed2000

Coronary heart disease and life insurance.

Coronary heart disease morbidity and mortality are dynamic issues. Outcomes from medical and surgical treatments are having dramatic effects. For the life insurer it is vital to follow closely the changing history of the disease.

Actuarial Analysis↗
PubMed1986

Residential facility is "hospital" in group medical policy dispute.

A residential facility that treated preadolescent children suffering from functional nervous disorders was considered to be a "hospital" for purposes of coverage under a group medical insurance policy, despite the fact that it lacked an on-premises surgical facility and did not provide 24-hour nursing services by registered nurses. The insurance company had waived the surgical facility requirement. Additionally, since the policy in question did not contain a definition of "nursing services," there was no requirement that these services be provided 24 hours a day by registered nurses. Thus the insureds were entitled to coverage of the treatment for their son in the residential facility. But a bad faith claim was denied because the insurer's interpretation of its policy was not found to be unreasonable.

Insurance Benefits↗
PubMed1978

Comparative absence experience among employees covered by a prepaid or a Blue Cross/Blue Shield health insurance program.

Health maintenance organizations report lower hospitalization and surgical experience than fee-for-service practice. If this is true, then sickness absence should be less. This pilot study compared morbidity experience of 247 pairs of Mountain Bell Telephone Company employees--HMO-enrolled employees matched with employees covered only by Blue Cross/Blue Shield. The study period extended before and after enrollment of the HMO subjects. Rates for the HMO group for hospitalization and surgery decreased after enrollment, whereas rates for the Blue Cross/Blue Shield group increased. The absence disability rate for the HMO group remained constant but increased for the BC/BS group. Differences in absenteeism may exist due to the type of medical insurance. The potential impact of such a difference upon absence costs is considerable.

Absenteeism↗
PubMed1989

[Organ transplantation: development, possibilities, socioeconomic aspects].

The dramatic development in clinical organ transplantation has been continued and expanded. Due to the discovery and clinical application of Cyclosporin A--the most potent immunosuppressive drug so far known--the results (1-year-graft survival rate) in the field of kidney, pancreas, liver and heart transplantation have drastically improved. This has led to a remarkable widening of indications for the different types of organ transplantation. The surgical technique of organ transplantation has been solved in kidney, liver, and heart transplantation, but remains to be solved in pancreatic transplantation. The evaluation from the medical-insurance--print of view of this surgical treatment should be restricted to successfully kidney transplanted patients at the time being. It has to be stressed that a success can be assessed only from the 2nd year post-transplant on words. According to considerations on the basis of medical insurance high risk factors have to be distinguished in regard to the transplant (e.g. poor HLA-matching) as well as to the patients (age, secondary diseases, etc.).

Cost-Benefit Analysis↗
PubMed1996

Cost-effectiveness of lumbar discectomy for the treatment of herniated intervertebral disc.

STUDY DESIGN: A cost-effectiveness analysis of lumbar discectomy based on existing efficacy data and newly gathered cost data. OBJECTIVES: For patients with herniated lumbar discs unresponsive to conservative management, surgery relieves pain more rapidly but at higher costs than continued medical therapy. We evaluated the cost-effectiveness of lumbar discectomy for these patients. SUMMARY OF BACKGROUND DATA: Effectiveness estimates were based on the results of a published trial of 126 herniated disc patients randomized to surgical or nonsurgical treatment. Quality of life values were based on a study of 83 subjects with low back pain. Treatment costs for herniated discs were estimated from insurance data for 372 patients treated surgically and 1,803 treated medically. METHODS: Efficacy results were weighted by quality of life values to estimate the quality-adjusted benefit of surgery. Cost-effectiveness was calculated in dollars per quality-adjusted year of life gained. Supplemental data sources for cost and effectiveness provided ranges for sensitivity analyses. RESULTS: Surgery increased average quality-adjusted life expectancy by 0.43 years during the decade following treatment, a benefit similar to extending a healthy life by 5 months. Reimbursements for surgical patients were $12,550 more than for medical patients. Nondiscounted and 5% discounted cost-effectiveness were $29,200 and $33,900 per quality-adjusted year of life gained. Supplemental analyses confirmed the basecase effectiveness estimates but suggested that the cost of discectomy was overestimated. Replacing the main cost estimate with one based on HMO patients lowered discectomy's cost to $12,000 per quality-adjusted life-year gained. CONCLUSION: For carefully selected patients with herniated discs, surgical discectomy is a cost-effective treatment. Discectomy's favorable cost-effectiveness results from its substantial effect on quality of life and moderate costs.

Cost-Benefit Analysis↗