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PubMed2003

Is discharge policy a balanced decision between clinical considerations and hospital ownership policy? The CABG example.

OBJECTIVES: To explore to what extent patient discharge from the hospital is a balanced decision between clinical considerations and management policy; specifically: (1) to assess the role of patient risk as a determinant of discharge in comparison with administrative factors such as hospital ownership; (2) to evaluate whether variations in discharge policy were translated into differences in clinical outcomes. METHODS: A national study of coronary artery bypass surgery was used as an example. The population included 4778 patients undergoing coronary artery bypass surgery in 14 institutions. The mode of discharge day, rather than the mean, was used as the best indicator of discharge policy. Parametric survival model was used to assess factors associated with the day of discharge. RESULTS: The mode of discharge day varied widely among institutions. This variation between 4 and 7 days after surgery corresponded to hospital ownership. The mode of discharge day was almost invariant to the patients' risk, but serious postoperative complications resulted in prolonged stay for a minority of the patients. The influence of hospital ownership prevailed over patient insurance carriers. Differences in discharge policies were not associated with increased risk of late mortality or rehospitalization. CONCLUSIONS: Discharge policy beyond the rare occurrence of dramatic patient postoperative complications was mainly dependent on hospital owner's cost-effectiveness considerations. However, despite the weight given to administrative factors in the decision-making process, it did not affect the outcome of care.

Coronary Artery Bypass↗
PubMed2002

The risk takers.

Explore the source record for details and available documents.

Humans↗
PubMed1990

The advent of clinical standards for professional liability.

The development of clinically based written standards to reduce the frequency and severity of medical malpractice loss appears to be gaining in popularity among provider specialty groups and professional liability underwriters. To date, such standards have addressed problems in specialties such as obstetrics and anesthesia where dollar losses associated with malpractice claims have been high. Guidelines can be developed and used by providers on a purely voluntary basis or mandated on an involuntary basis by third parties such as malpractice insurance companies or legislators. Because the advent of risk-control standards is a relatively new phenomenon, formal scientific studies on the long-term benefits of such guidelines have not yet been published. However, it appears that sharp reductions of malpractice losses in specialties such as anesthesia have coincided with the implementation of formal written standards specifically designed for liability control. This has led some liability insurance carriers to decrease premiums associated with specialists following such standards. Many providers are understandably concerned about the potential use of written standards by plaintiff attorneys in medical malpractice suits. Although it is possible that such policies and guidelines could be admitted into evidence to show that a provider breached the legal duty or standard of care owed to a patient, it is uncertain whether these risk-control standards could ultimately pass the evidentiary rules of relevancy or materiality in a given lawsuit. It is clear, however, that the consensus-based process of creating clinical standards and guidelines specifically for controlling professional liability losses is itself a powerful and emerging standard for health care risk management programs.

Clinical Competence↗
PubMed2002

Health insurer monopsony power: the all-or-none model.

The textbook model of monopsony that is typically employed in analyzing health insurer monopsony power does not adequately describe the supply decision of physicians confronting a dominant health insurer. Rather than restricting purchases in order to extract a lower price for provider services, monopsonistic insurers are able to obtain discounts from providers without experiencing a decrease in quantity when physicians are forced to operate along their "all-or-none" supply curve. The welfare effects of the all-or-none model of monopsony are compared to those implied by the traditional model.

Antitrust Laws↗
PubMed1990

Preventability of malpractice claims in emergency medicine: a closed claims study.

We conducted a retrospective study of 262 malpractice claims against emergency physicians insured in Massachusetts by the state-mandated insurance carrier; these 262 claims were closed in the years 1980 through 1987. A total of $11,800,156 in indemnity and expenses was spent for these 262 claims. In 211 cases, the allegation was failure to diagnose a medical or surgical problem. One hundred eighty-four of these cases were included in the following eight diagnostic categories: chest pain, abdominal pain, wounds, fractures, pediatric fever/meningitis, aortic aneurysm, central nervous system bleeding, and epiglottitis. These eight categories accounted for 66.44% of the total dollars spent for the 262 claims. Because of the high incidence and dollar losses attached to these eight diagnostic categories, the Massachusetts Chapter of the American College of Emergency Physicians (MACEP) has developed clinical guidelines for the evaluation of these high-risk areas. Of the 184 high-risk claims, 99 claim files were reviewed; 45 of these reviewed claims were judged by physician reviewers as preventable by the application of the MACEP high risk clinical guidelines. From 22.26% to 46.4% of the $11,800,156 spent on the 262 claims could have been saved by the application of the MACEP clinical guidelines.

Chest Pain↗
PubMed1987

Emergency department complaints: a one-year analysis.

We conducted an analysis of all complaints received in a busy suburban emergency department during 1985. All complaints were handled in a standardized fashion, and were categorized as billing, physician, nursing, or miscellaneous. Data were expressed as a "complaint frequency" (complaints per 1,000 patient visits). Complaints were analyzed for the following characteristics: reason, gender of the patient, gender of the complaining party, relationship of the complaining party to the patient, health care provider, patient age, and patient disposition. The chi-square method was used to identify characteristics associated with a high risk for complaints. There were a total of 244 complaints, arising from 64,910 patient visits, yielding an overall complaint frequency of 3.8. The largest number of complaints (135), involved billing (frequency, 2.0). The most common (60) was insurance carrier rejection of the bill as a nonemergency. The next most common billing complaint (25) was a charge mistakenly billed too high by the ED. There were 70 complaints regarding emergency physicians, for a complaint frequency of 1.1. Of these, 17 were due to a perceived lack of communication with the patient, the patient's family, or the patient's private physician. Eighteen complaints were regarding a perceived misdiagnosis. One physician had a significantly higher complaint frequency than the group as a whole (P less than .005). There were 17 complaints regarding the nursing staff, for a complaint frequency of 0.2. Twenty-two complaints were classified as miscellaneous. Expressing data as complaint frequencies allows comparison of trends in a department, staff members, and different EDs with varied patient populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2000

Assessing costs and cost effectiveness of pneumococcal disease and vaccination within Kaiser Permanente.

OBJECTIVE: To review studies of the costs of pneumococcal disease and the cost effectiveness of pneumococcal conjugate vaccination conducted in association with the Kaiser Permanente Pneumococcal conjugate Efficacy Trial. RESULTS: for each birth cohort of 3.8 million infants, routine pneumococcal conjugate vaccination program for healthy infants would prevent more than 12000 (78% of potential) meningitis and bacteremia cases, 53000 (69% of potential) pneumonia cases, and 1 million (8% of potential) otitis media episodes. Before accounting for vaccine costs, the vaccination program would reduce the costs of pneumococcal disease by $342 million in medical and $415 million in work-loss and other costs. Vaccination of healthy infants would result in net savings for society if the vaccine cost less than $46 per dose, and net savings for the health care payer if the vaccine cost less than $18 per dose.

Absenteeism↗
PubMed1993

Insurability for asymptomatic hematuria or proteinuria during childhood.

The objective of this survey was to describe life insurance underwriting practices concerning children with asymptomatic hematuria and proteinuria. A questionnaire was sent to 200 companies licensed to issue life insurance policies in the state of New York. The medical director of each company was asked to respond to the insurability of children with asymptomatic hematuria and proteinuria. Two case summaries were provided with the questionnaire. Of 97 companies, 66 would offer insurance to the patient with hematuria, although 38 (58%) would charge additional premiums. In response to the problem of proteinuria, 61 companies would offer life insurance, although 50 (82%) would require higher premium charges (P < 0.002 compared with hematuria). We conclude that children with asymptomatic hematuria and proteinuria can usually obtain life insurance, although often at higher cost. Invasive diagnostic tests are not necessary for insurers to offer insurance.

Child↗
PubMed1993

Management of midface fractures: fifty years later.

Much has changed in the 50 years since Dr Parker described the development of rapid means of transportation as a portent of an increase in maxillofacial trauma. Contemporary surgeons must concern themselves with a host of nonsurgical care issues that are an integral part of oral and maxillofacial surgery practice. Expectations related to the patient, government, insurance carrier, and hospital staff have created a new practice environment. Standards of care are high and surgeon and patient needs are more complex. Dramatically improved diagnostic capabilities, use of open surgical techniques, improved rigid fixation devices, advances in techniques of resuscitation, and more focused surgical training have markedly improved the care of the facial trauma patient. The midface remains the central focus of our gaze when we engage in interpersonal relationships. Developmental and acquired aberrations of this region are likely to be more obvious than lower face abnormalities and, therefore, perceived as more disfiguring. Complex midface trauma repair requires precise surgical technique, with little margin for error. When ideal results are not achieved, the common contributing factors are intercurrent serious injury, anatomic and wound repair considerations, and failure to execute fracture repair principles. Hard and soft tissue volume changes may further compromise midface fracture repair, irrespective of the quality of the surgical outcome. Despite the advances made in the last 50 years, there is still room for future progress. An interdisciplinary committee of surgeons treating facial trauma should convene to establish a classification system for midface fractures that would satisfy medical record keeping and coding requirements, and facilitate fair and consistent reimbursement.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗
PubMed1996

Seven-Year Experience with Office Microlaparoscopy and Hysteroscopy

Since 1989 more than 1200 office-based endoscopies have been performed at our facility. Visualization was initially achieved with 1.6-mm optical catheters, but recently, we have used larger-diameter fiber and glass rod endoscopes. Ancillary instruments progressed from 5- to 2-mm diameters, although occasionally we used up to 20-mm cannula punctures. Anesthesia remained consistent, with local infiltration followed by conscious sedation given by an on-site anesthesiologist. Lately, alternative methods of anesthesia including hypnosis and acupuncture have had some initial success. To date, we have performed 156 tubal ligations, 293 diagnostic laparoscopies, 151 treatments of endometriosis, 43 ovarian cyst aspirations, 29 adhesiolyses, 263 second-look procedures, 21 ectopic pregnancy removals, 198 diagnostic hysteroscopies, 64 endometrial biopsies, 20 fibroid resections, and 39 endometrial ablations. Patient response has been rewarding, thanks to decreased time off work, decreased cost of procedures to health insurance carriers, and immediate satisfaction from the diagnosis and treatment of their conditions.

Journal Article↗