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PubMed2002

An analysis of the respective risks of hematoma formation in 361 consecutive morphological and functional stereotactic procedures.

OBJECTIVE: The risk of hematoma formation in stereotactic procedures is generally considered to range between 1 and 4%, and it has been speculated that morphological procedures may have a higher risk of bleeding than functional procedures. METHODS: Between 1989 and 1999, all patients who underwent a stereotactic procedure performed by the same surgeon were enrolled sequentially onto the study. All patients had normal preoperative prothrombin time, partial thromboplastin time, and platelet count. High-resolution computed tomography or magnetic resonance imaging with a 1.5-T machine were used for the target definition. None of the patients had an angiogram before surgery. RESULTS: A total of 361 procedures was performed comprising 175 morphological procedures (139 biopsies, 18 lesion evacuations [cysts, abscesses, and hematomas], and 18 drain implantations) and 186 functional procedures (137 lesions [thalamotomy or pallidotomy], 47 deep brain electrode implantations, and two physiological explorations without lesions or implantations). There were no infections or seizures in either group. Three hematomas (1.7%) occurred in the morphological group, two of them in inflammatory lesions in immunocompromised patients (one death) and one in a pineal tumor. Three hematomas (1.6%) occurred in the functional group (no mortality). There was no statistically significant difference (P > 0.05; Fisher's exact test) in the risk of hematoma formation between morphological and functional stereotactic procedures. The morbidity and mortality related to bleeding also were not statistically different (P > 0.05; Fisher's exact test) between these two groups. CONCLUSION: In this series, the risk of bleeding was not higher for morphological procedures than for functional procedures. This suggests that the risk of bleeding for stereotactic procedures is related more to the patient than to the type of procedure performed. Our study confirms an overall risk of bleeding of 1.7% for any type of stereotactic procedure, resulting in a mortality of 0.3% and a morbidity of 1.4%.

Biopsy↗
PubMed2005

Underreporting of computed tomography and magnetic resonance imaging procedures in inpatient claims data.

BACKGROUND: ICD-9-CM procedure codes in inpatient claims data are used for a wide range of purposes, such as monitoring utilization, costs, and quality, and adjusting for patient risk. However, many procedures may be underreported because they are not required for reimbursement via Diagnosis-Related Group (DRG) assignment (non-DRG procedures). OBJECTIVES: This study examined the extent and variability of ICD-9-CM procedure code reporting for 2 commonly employed non-DRG imaging procedures, computerized tomography (CT) and magnetic resonance imaging (MRI). RESEARCH DESIGN: Using nonfederal hospital inpatient claims (n = 56,091) from Washington State Inpatient Data for 1997, ICD-9-CM procedure and Universal Billing revenue codes for CT and MRI were compared by payer and hospital characteristics. RESULTS: When compared with revenue codes, ICD-9-CM procedure coding was found to be considerably underreported and variable, with only 33% of CT and 43% of MRI procedures being recorded. Moreover, the frequency of underreporting of both procedures did not appear to be random, with 31 of 72 hospitals that reported revenue codes for the CT not recording any ICD-9-CM codes for the procedure. Of the 48 hospitals that reported revenue codes for the MRI, 15 failed to record any ICD-9-CM codes that indicated its use. Statistically significant differences in median coding frequencies by teaching and rural status were found for both procedures, while ownership was an important factor in CT reporting variability. CONCLUSIONS: This nonrandom variability in reporting can potentially bias utilization studies as well as risk-adjustment outcome estimates of techniques that rely on reporting of these procedures (eg, APR-DRG and AHRQ CCS). An effort to define a universally agreed upon list of non-DRG procedures to be coded in all US hospitals would greatly improve the capacity of health services researchers to conduct important utilization, outcome and policy studies.

Diagnosis-Related Groups↗
PubMed2003

Radiation doses in interventional radiology procedures: the RAD-IR study: part II: skin dose.

PURPOSE: To determine peak skin dose (PSD), a measure of the likelihood of radiation-induced skin effects, for a variety of common interventional radiology and interventional neuroradiology procedures, and to identify procedures associated with a PSD greater than 2 Gy. MATERIALS AND METHODS: An observational study was conducted at seven academic medical centers in the United States. Sites prospectively contributed demographic and radiation dose data for subjects undergoing 21 specific procedures in a fluoroscopic suite equipped with built-in dosimetry capability. Comprehensive physics evaluations and periodic consistency checks were performed on each unit to verify the stability and consistency of the dosimeter. Seven of 12 fluoroscopic suites in the study were equipped with skin dose mapping software. RESULTS: Over a 3-year period, skin dose data were recorded for 800 instances of 21 interventional radiology procedures. Wide variation in PSD was observed for different instances of the same procedure. Some instances of each procedure we studied resulted in a PSD greater than 2 Gy, except for nephrostomy, pulmonary angiography, and inferior vena cava filter placement. Some instances of transjugular intrahepatic portosystemic shunt (TIPS) creation, renal/visceral angioplasty, and angiographic diagnosis and therapy of gastrointestinal hemorrhage produced PSDs greater than 3 Gy. Some instances of hepatic chemoembolization, other tumor embolization, and neuroembolization procedures in the head and spine produced PSDs greater than 5 Gy. In a subset of 709 instances of higher-dose procedures, there was good overall correlation between PSD and cumulative dose (r = 0.86; P <.000001) and between PSD and dose-area-product (r = 0.85, P <.000001), but there was wide variation in these relationships for individual instances. CONCLUSIONS: There are substantial variations in PSD among instances of the same procedure and among different procedure types. Most of the procedures observed may produce a PSD sufficient to cause deterministic effects in skin. It is suggested that dose data be recorded routinely for TIPS creation, angioplasty in the abdomen or pelvis, all embolization procedures, and especially for head and spine embolization procedures. Measurement or estimation of PSD is the best method for determining the likelihood of radiation-induced skin effects. Skin dose mapping is preferable to a single-point measurement of PSD.

Fluoroscopy↗
PubMed2005

Treatments of osteoarthritis of the distal radioulnar joint: long-term results of three procedures.

Sixty-one wrists in 61 patients with osteoarthritis of the distal radioulnar joint treated by three consecutive procedures (20 Darrach, 25 Sauvé-Kapandji and 16 hemiresection-interposition arthroplastic procedures) were retrospectively evaluated. We preferred to perform Darrach's procedure in even the early stages of osteoarthritis of the distal radioulnar joint prior to introduction of Sauvé-Kapandji and hemirestion-interposition arthroplastic procedures. Subsequently the hemirestion-interposition arthroplasty was indicated when the triangular fibrocartilage cartilage was intact or could be reconstructed and the Sauvé-Kapandji when the triangular fibrocartilage complex could not be reconstructed or there was positive ulnar variance of more than 5 mm even though the triangular fibrocartilage complex was functional. Patient's age at operation averaged 59.8 years. There were 36 men and 25 women. There were 38 primary and 23 secondary osteoarthritis cases. Post-operative pain, range of motion, grip strength, return to work status; and radiographic results were evaluated. At the five- to 14-year (average, ten years) follow-up evaluation, relief of pain from Darrach procedure was inferior to the Sauvé-Kapandji procedure and hemiresection-interposition arthroplasty although this was not statistically significant. After both the Sauvé-Kapandji procedure and hemiresection-inteposition arthroplasty, post-operative improvements in flexion and extension of the wrist had statistical significance. Post-operative improvements in pronation and supination of the forearm showed statistical significances after all procedures. Improvements of post-operative grip strength and return to an original job in the Sauvé-Kapandji procedure and hemiresection-interposition arthroplasty were statistically superior to those with a Darrach's procedure. There were many post-operative complications following the Darrach's procedure. Darrach's procedure is better indicated for severe osteoarthritic changes of the distal radioulnar joint in elderly patients. We believe the operative indications between the Sauvé-Kapandji procedure and hemiresection-interposition arthroplasty are best determined prior to surgery by the existence and status of the triangular fibrocartilage complex and the amount of the positive ulnar variance.

Aged↗
PubMed1997

Electrophysiologic changes in arrhythmogenic substrate following the maze procedure in patients with lone and paroxysmal atrial fibrillation.

Although the Maze procedure is highly successful in restoring sinus rhythm in patients with atrial fibrillation (AF), the electrophysiologic changes that occur after the Maze procedure and its mechanism of action are still unclear. The aims of the present study were to examine the electrophysiologic changes that occur in the arrhythmogenic substrate after the Maze procedure and to evaluate the mechanism by which it prevents lone and paroxysmal AF. The modified Maze procedure was performed in 6 patients (6 men, mean age 47 +/- 7 years) with lone and paroxysmal AF. Electrophysiologic studies were performed before and 35 +/- 8 days after the Maze procedure. Atrial mapping during sinus rhythm revealed that atrial activation propagated smoothly in a concentric circle from the sinus node to other regions in the right atrium and into the coronary sinus before the Maze procedure. Following the Maze procedure, atrial activation propagated selectively through routes produced by incisions or cryoablations in all 6 patients. In addition, double and triple potentials were recorded in regions where conduction blocks were created by the Maze procedure. Neither sinus node function nor AV conduction was changed following the Maze procedure. The Maze procedure did not affect the atrial effective refractory period or the zone of fragmented atrial activity, although the conduction delay zone was increased significantly (p < 0.05). AF was inducible in all 6 patients before the Maze procedure, whereas it was not inducible in any patients after the Maze procedure. The Maze procedure is effective in preventing AF without affecting sinus node function and AV conduction. Intra-atrial conduction block produced by incisions or cryoablations contributes to the prevention of AF.

Adult↗
PubMed2001

Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population.

BACKGROUND: The mortality and complication rates of many surgical procedures are inversely related to hospital procedure volume. The objective of this study was to determine whether the volumes of primary and revision total hip replacements performed at hospitals and by surgeons are associated with rates of mortality and complications. METHODS: We analyzed claims data of Medicare recipients who underwent elective primary total hip replacement (58,521 procedures) or revision total hip replacement (12,956 procedures) between July 1995 and June 1996. We assessed the relationship between surgeon and hospital procedure volume and mortality, dislocation, deep infection, and pulmonary embolus in the first ninety days postoperatively. Analyses were adjusted for age, gender, arthritis diagnosis, comorbid conditions, and income. Analyses of hospital volume were adjusted for surgeon volume, and analyses of surgeon volume were adjusted for hospital volume. RESULTS: Twelve percent of all primary total hip replacements and 49% of all revisions were performed in centers in which ten or fewer of these procedures were carried out in the Medicare population annually. In addition, 52% of the primary total hip replacements and 77% of the revisions were performed by surgeons who carried out ten or fewer of these procedures annually. Patients treated with primary total hip replacement in hospitals in which more than 100 of the procedures were performed per year had a lower risk of death than those treated with primary replacement in hospitals in which ten or fewer procedures were performed per year (mortality rate, 0.7% compared with 1.3%; adjusted odds ratio, 0.58; 95% confidence interval, 0.38, 0.89). Patients treated with primary total hip replacement by surgeons who performed more than fifty of those procedures in Medicare beneficiaries per year had a lower risk of dislocation than those who were treated by surgeons who performed five or fewer of the procedures per year (dislocation rate, 1.5% compared with 4.2%; adjusted odds ratio, 0.49; 95% confidence interval, 0.34, 0.69). Patients who had revision total hip replacement done by surgeons who performed more than ten such procedures per year had a lower rate of mortality than patients who were treated by surgeons who performed three or fewer of the procedures per year (mortality rate, 1.5% compared with 3.1%; adjusted odds ratio, 0.65; 95% confidence interval, 0.44, 0.96). CONCLUSIONS: Patients treated at hospitals and by surgeons with higher annual caseloads of primary and revision total hip replacement had lower rates of mortality and of selected complications. These analyses of Medicare claims are limited by a lack of key clinical information such as operative details and preoperative functional status.

Arthroplasty, Replacement, Hip↗
PubMed2006

Relationship between fluoroscopic time, dose-area product, body weight, and maximum radiation skin dose in cardiac interventional procedures.

OBJECTIVE: Real-time maximum dose monitoring of the skin is unavailable on many of the X-ray machines that are used for cardiac intervention procedures. Therefore, some reports have recommended that physicians record the fluoroscopic time for patients undergoing fluoroscopically guided intervention procedures. However, the relationship between the fluoroscopic time and the maximum radiation skin dose is not clear. This article describes the correlation between the maximum radiation skin dose and fluoroscopic time for patients undergoing cardiac intervention procedures. In addition, we examined whether the correlations between maximum radiation skin dose and body weight, fluoroscopic time, and dose-area product (DAP) were useful for estimating the maximum skin dose during cardiac intervention procedures. MATERIALS AND METHODS: Two hundred consecutive cardiac intervention procedures were studied: 172 percutaneous coronary interventions and 28 cardiac radiofrequency catheter ablation (RFCA) procedures. The patient skin dose and DAP were measured using Caregraph with skin-dose-mapping software. RESULTS: For the RFCA procedures, we found a good correlation between the maximum radiation skin dose and fluoroscopic time (r = 0.801, p < 0.0001), whereas we found a poor correlation between the maximum radiation skin dose and fluoroscopic time for the percutaneous coronary intervention procedures (r = 0.628, p < 0.0001). There was a strong correlation between the maximum radiation skin dose and DAP in RFCA procedures (r = 0.942, p < 0.0001). There was also a significant correlation between the maximum radiation skin dose and DAP (r = 0.724, p < 0.0001) and weight-fluoroscopic time product (WFP) (r = 0.709, p < 0.0001) in percutaneous coronary intervention procedures. CONCLUSION: The correlation between the maximum radiation skin dose with DAP is more striking than that with fluoroscopic time in both RFCA and percutaneous coronary intervention procedures. We recommend that physicians record the DAP when it can be monitored and that physicians record the fluoroscopic time when DAP cannot be monitored for estimating the maximum patient skin dose in RFCA procedures. For estimating the maximum patient skin dose in percutaneous coronary intervention procedures, we also recommend that physicians record DAP when it can be monitored and that physicians record WFP when DAP cannot be monitored.

Body Weight↗
PubMed2004

[Evolution of radiation exposure to operator in diagnostic and interventional radiology procedures and reduction of radiation exposure to operator with protective device].

A study was performed to evaluate operator dose during diagnostic and interventional radiology procedures (IVR) and to establish methods of operator dose reduction with a radiation protective device. Operator dose was measured by glass dosimeters worn on the neck and on the abdomen outside the lead apron. In addition, the dose of the primary beam at the collimator surface was measured, which made it possible to define the correlation between the entrance air kerma, measured with Skin Dose Monitor, and operator dose exposed during the monitored procedure. IVR protectors were developed to decrease the amount of scatter radiation received by operators performing the procedures, and their effects were evaluated in abdominal and cardiac angiography procedures. The average effective dose and doses of the neck and abdomen outside the lead apron, estimated for individual procedures, were as follows: abdominal angiography procedures: effective dose, 0.07 mSv; neck area, 0.18 mSv; abdominal area, 0.51 mSv; cardiac angiography procedures: effective dose, 0.07 mSv; neck area, 0.13 mSv; abdominal area, 0.68 mSv. Operator doses were well correlated with exposure dose in abdominal angiography procedures (diagnostic procedure r=0.84, IVR r=0.77). It was found that 68.0% of the effective dose in abdominal angiography procedures and 43.0% of the effective dose in cardiac angiography procedures could be reduced by the use of IVR protectors. Operator and patient doses in interventional radiology were interdependent. The minimization of operator doses is particularly important during interventional radiology, and it is necessary to be aware of practical radiation protection procedures. Measures that reduce patient dose will also reduce occupational exposure. Moreover, operator dose could be substantially reduced by the use of IVR protectors in addition to wearing a protective lead apron during IVR. It was suggested that IVR protectors are effective radiation protective devices in interventional radiology procedures.

Angiography↗
PubMed2006

Pulse oximetry during gastrointestinal endoscopic procedures.

OBJECTIVE: To determine the changes in oxygen saturation, blood pressure and pulse rate during various endoscopic procedures and to find out the risk factors for these changes. DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan from June 2001 to December 2001 were included in the study. PATIENTS AND METHODS: Oxygen saturation, blood pressure and pulse were monitored during various endoscopic procedures using pulse oximeter. These changes were recorded from the start until 5 minutes after the procedure. The important variables which were evaluated in relation to these changes included age, gender, history of smoking, associated chronic obstructive airway disease (COAD), coronary artery disease (CAD), duration of procedure, elective versus emergency and diagnostic versus therapeutic procedures. RESULTS: Base line mean oxygen saturation was 98.1+/-0.98 %. The saturation decreased to 93.5+/-4.8 % (p=0.002) during the procedures and returned to base line after the procedures. Mild to moderate hypoxia was found in 59 (20.2%) patients. Severe hypoxia was found in 32 (11.5%) patients. Of these 21(65.6%) patients were having history of COAD. No patient developed serious complications. The changes in blood pressure and pulse were not significant. The variables which reached statistical significance for desaturation were age>50 years, history of smoking, emergency procedures, therapeutic procedures and associated COAD. Diabetes mellitus (DM) and hypertension (HTN) alone, CAD and duration of procedures did not affect oxygen saturation. CONCLUSION: Mild to moderate hypoxia is common during endoscopic procedures and of no serious consequence. Severe hypoxia is less common and is associated with underlying risk factors. Continuous monitoring is required in patients with age>50 years, history of smoking, emergency procedures, therapeutic procedures and history of COAD. Routine monitoring with pulse oximetry may not be required in patients with no risk factors.

Age Factors↗
PubMed2001

Patients' perceptions and responses to procedural pain: results from Thunder Project II.

BACKGROUND: Little is known about the painfulness of procedures commonly performed in acute and critical care settings. OBJECTIVE: To describe pain associated with turning, wound drain removal, tracheal suctioning, femoral catheter removal, placement of a central venous catheter, and nonburn wound dressing change and frequency of use of analgesics during procedures. METHODS: A comparative, descriptive design was used. Numeric rating scales were used to measure pain intensity and procedural distress; word lists, to measure pain quality. RESULTS: Data were obtained from 6201 patients: 176 younger than 18 years and 5957 adults. Mean pain intensity scores for turning and tracheal suctioning were 2.80 and 3.00, respectively (scale, 0-5), for 4- to 7-year-olds and 52.0 and 28.1 (scale, 0-100) for 8- to 12-year-olds. For adolescents, mean pain intensity scores for wound dressing change, turning, tracheal suctioning, and wound drain removal were 5 to 7 (scale, 0-10); mean procedural distress scores were 4.83 to 6.00 (scale, 0-10). In adults, mean pain intensity scores for all procedures were 2.65 to 4.93 (scale, 0-10); mean procedural distress scores were 1.89 to 3.47 (scale, 0-10). The most painful and distressing procedures were turning for adults and wound care for adolescents. Procedural pain was often described as sharp, stinging, stabbing, shooting, and awful. Less than 20% of patients received opiates before procedures. CONCLUSIONS: Procedural pain varies considerably and is procedure specific. Because procedures are performed so often, more individualized attention to preparation for and control of procedural pain is warranted.

Adolescent↗
PubMed2002

[Longitudinal study of procedural memory in patients with Alzheimer-type dementia].

We never forget how to ride a bicycle, and it is thought that procedural memories are retained for a long time. Recently, it was reported that patients with dementia of the Alzheimer type(DAT) could not only acquire, but also retain, long-lasting procedural memories. Previous group studies had shown procedural memory retention times of only 1 month in DAT patients, while amnesic patients and healthy people could retain such memories for 12 months. The relationship between the ability to retain procedural memory and the stage of the disease is not clear, as to date there has been no longitudinal study of procedural memory retention in DAT patients. Thus, we examined DAT patients' ability to retain long-term procedural memories (after 1, 5 and 20 months), and analyzed the relationship between procedural memory ability and the progress of disease. Motor-type procedural memory was examined using the mirror tracing task and the bi-manual coordinated tracing task. All three of the DAT patients showed improvement in their performance. The time required for the tracing was reduced between trials, and the improvement did not disappear between sessions, or rather, their times further decreased in subsequent sessions. Even the most severe DAT patient (Mini Mental State Examination(MMSE) score of 4) was able to acquire the procedural memory and retain it for at least 3 months. Furthermore, one of the subjects showed retention of the procedural memory at 20 months. Our results suggest that DAT patients can retain procedural memories for extended periods, with no relationship between retention ability and disease progression. It is possible for even severely demented patients to acquire and retain motor-type procedural memories. Cognitive rehabilitation in DAT appears to be effective, and it is possible for DAT patients to learn new things. It may be that DAT patients can ameliorate their quality of life by using retained procedural memory.

Aged↗
PubMed2002

The cost of angiography procedures: OHIP gets a bargain.

OBJECTIVE: To determine the costs for 1000 randomized interventional angiographic procedures. METHODS: An 9-page paper form was used to manually record the consumables, technologist time, room occupancy time and recovery room time for 80 different procedures collected over a 2-year period. The average cost for expendables per procedure was calculated for procedures that occurred 5 or more times. RESULTS: Of the 1000 procedures surveyed, there were 20 that had 10 or more occurrences, 9 that occurred 5-9 times and 51 that occurred less than 5 times, of which 32 had only a single occurrence. The total expendables used were $514,008. The total examination time was 1158 hours. The total technologist time was 2493 hours, and the total recovery room time was 1806 hours. Examples of the average cost per procedure are: cerebral angiogram (n = 249), avg. cost $441.24, and transvenous liver biopsy (n = 30), avg. cost $642.89. The coefficient of variation for procedure costs ranged from 15% to 139%. There were no correlations of technician time or procedure technical cost with the date of scan, indicating that there was no systematic increase or decrease in costs over the survey period. There were moderate correlations of the technical cost of a procedure with technologist time (Pearson r = 0.69) and the duration of a procedure (Pearson r = 0.73). The technical costs of interventional procedures were significantly underfunded; the reimbursement from the Ontario Hospital Insurance Plan was $278,446, or 54% of the actual costs. Fourteen procedures were reimbursed at below 50% of their costs. CONCLUSION: This shortfall in funding has serious consequences for the types and numbers of procedures that are possible in radiology departments. Funds must be diverted from other places to prevent serious rationing of these services.

Angiography↗
PubMed1988

The role of lateral extra-articular procedures for anterolateral rotatory instability.

The goal of any surgical procedure to correct the instability caused by loss of the ACL is to control the abnormal anterior excursion of the tibia on the femur. Because the main problem is loss of the ACL, it would seem most reasonable to approach this problem by performing an intra-articular reconstruction of the ACL, thus approximating as closely as possible the normal anatomy of the ACL. The classic open intra-articular ACL reconstructions are technically demanding surgical procedures that usually require a significant "learning curve" to achieve a level of technical expertise and confidence. In addition, postoperative complications such as adhesions, loss of motion, prolonged muscle atrophy, and a long rehabilitation period are well known. Thus, it would appear that the extra-articular reconstructive procedures for the anterior cruciate-deficient knee would offer some advantage over these more formidable surgical procedures. Whereas the main problem is certainly the loss of the ACL, the extra-articular procedures are directed more toward the most symptomatic anterior excursion of the tibia on the femur, the pivot shift phenomenon, where the anterolateral portion of the tibia moves anterior in relation to the femur. Thus, the goal of the extra-articular reconstructive procedures for anterolateral rotatory instability is to eliminate functional instability. These goals are most readily achieved by positioning some portion of the iliotibial tract posterior to the transverse center of rotation of the knee to provide a reinforcement for the lateral tibial plateau as the knee approaches terminal extension. All of the extra-articular procedures discussed in this article have been used successfully as reported by the various authors. There are many technical details inherent in each of these surgical procedures, and the reader is referred to the original articles for a more explicit description of these surgical procedures. For the individual surgeon to participate in and view the actual surgical procedure that he or she intends to perform would be the ideal situation. Various workshops where surgical procedures of the knee are actually performed and studied are currently available and are of great value to the surgeon. Of equal importance to the technical demands of the various surgical procedures is selection of the appropriate procedure for each patient. The selection must be based on many factors. The most important factor is the identification of the patient with a high level of athletic activity who is unwilling to modify his or her activity level to compensate for a deficient ACL.(ABSTRACT TRUNCATED AT 400 WORDS)

Arthroplasty↗
PubMed2003

Analysis of efficiency of common otolaryngology operations: comparison of operating room vs short procedure room in a pediatric tertiary hospital.

OBJECTIVE: To compare the operative times of routine otolaryngologic procedures performed with 2 different operating room staffing models: the traditional model with 2 staff, a scrub nurse and a circulator, and the short procedure room (SPR) setting, with a circulator only. DESIGN: Retrospective comparison of operative procedure times. Data were extracted from a prospectively maintained database of electronic medical records. SETTING: All data were from procedures performed at a tertiary care children's hospital operating room suite. PATIENTS OR OTHER PARTICIPANTS: Data for the year 2000 were extracted for all outpatient otolaryngology cases of bilateral myringotomy and tube placement (BMT), tonsillectomy and adenoidectomy (TA), and adenoidectomy alone. MAIN OUTCOME MEASURES: The mean +/- SD operative time intervals (operative procedure times and total operative procedure time), anesthesia start times, surgical preparation times, and anesthesia end times of the 2 sites were compared. These time intervals were also compared for the 3 surgeons performing TAs in both settings. RESULTS: Total operative procedure times were significantly shorter in the SPR setting for TA and BMT, but not for adenoidectomy. For TA procedures, operative procedure times and anesthesia end times were significantly shorter in the SPR setting (P<.05). For BMT procedures, all operative times were significantly shorter in the SPR setting. All 3 surgeons who performed TAs in both settings had significantly shorter total operative procedure times in the SPR setting than in the traditional setting. CONCLUSIONS: Despite fewer assisting staff, the SPR setting showed a statistically significant reduction in total operative procedure times for TA and BMT, and results were similar for adenoidectomy. Reducing operating room personnel costs is possible in addition to achieving modest gains in efficiency.

Age Factors↗
PubMed2004

A prospective, single-center clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation.

OBJECTIVE: The Cox maze III procedure has excellent long-term efficacy in curing atrial fibrillation. It has not been widely practiced because it is technically challenging and requires prolonged cardiopulmonary bypass. The aim of this study was to examine a simplified Cox maze III procedure that uses bipolar radiofrequency energy as an ablative source. METHODS: Beginning January 2002, a total of 40 consecutive patients underwent a modified Cox maze III procedure with bipolar radiofrequency energy. Nineteen had a lone maze procedure and 21 had a maze procedure plus a concomitant operation. One month after the operation, the first 8 patients were investigated with high-resolution magnetic resonance imaging. Patients were followed up monthly with clinical examination and electrocardiography. RESULTS: There was no operative deaths. The crossclamp times were 47 +/- 26 minutes for the modified lone Cox maze III procedure and 92 +/- 37 minutes for the Cox maze III procedure plus concomitant procedures. These were significantly shorter than our previous times for the traditional Cox maze III procedure (93 +/- 34 minutes and 122 +/- 37 minutes, respectively, P <.05). Follow-up magnetic resonance imaging showed no evidence of pulmonary vein stenosis, and atrial contractility was preserved in all patients. There were no late strokes. At 6-month follow-up, 91% of patients (21/23) were in sinus rhythm. CONCLUSIONS: Bipolar radiofrequency ablation can be used to replace the surgical incisions of the Cox maze procedure. This energy source did not result in pulmonary vein stenosis. The modification of the Cox maze III procedure to use bipolar radiofrequency ablation simplified and shortened this procedure without sacrificing short-term efficacy.

Atrial Fibrillation↗
PubMed2005

Racial trends in the use of major procedures among the elderly.

BACKGROUND: Differences in the use of major procedures according to patients' race are well known. Whether national and local initiatives to reduce these differences have been successful is unknown. METHODS: We examined data for men and women enrolled in Medicare from 1992 through 2001 on annual age-standardized rates of receipt of nine surgical procedures previously shown to have disparities in the rates at which they were performed in black patients and in white patients. We also examined data according to hospital-referral region for three of the nine procedures: coronary-artery bypass grafting (CABG), carotid endarterectomy, and total hip replacement. RESULTS: Nationally, in 1992, the rates of receipt for all the procedures examined were higher among white patients than among black patients. The difference between the rates among whites and blacks increased significantly between 1992 and 2001 for five of the nine procedures, remained unchanged for three procedures, and narrowed significantly for one procedure. We examined rates of CABG, carotid endarterectomy, and total hip replacement in 158 hospital-referral regions (79 hospital-referral regions for black men and white men and 79 for black women and white women) with an adequate number of persons for each procedure. We found that in the early 1990s, whites had higher rates for these procedures than blacks in every hospital-referral region. By 2001, the difference between whites and blacks (both men and women) in the rates of these procedures narrowed significantly in 22 hospital-referral regions, widened significantly in 42, and were not significantly changed in the remaining hospital-referral regions. At the end of the study period, we found no hospital-referral region in which the difference in rates between whites and blacks was eliminated for men or women with regard to any of these three procedures. CONCLUSIONS: For the decade of the 1990s, we found no evidence, either nationally or locally, that efforts to eliminate racial disparities in the use of high-cost surgical procedures were successful.

Aged↗
PubMed2000

Surgeon and type of anesthesia predict variability in surgical procedure times.

BACKGROUND: Variability in surgical procedure times increases the cost of healthcare delivery by increasing both the underutilization and overutilization of expensive surgical resources. To reduce variability in surgical procedure times, we must identify and study its sources. METHODS: Our data set consisted of all surgeries performed over a 7-yr period at a large teaching hospital, resulting in 46,322 surgical cases. To study factors associated with variability in surgical procedure times, data mining techniques were used to segment and focus the data so that the analyses would be both technically and intellectually feasible. The data were subdivided into 40 representative segments of manageable size and variability based on headers adopted from the common procedural terminology classification. Each data segment was then analyzed using a main-effects linear model to identify and quantify specific sources of variability in surgical procedure times. RESULTS: The single most important source of variability in surgical procedure times was surgeon effect. Type of anesthesia, age, gender, and American Society of Anesthesiologists risk class were additional sources of variability. Intrinsic case-specific variability, unexplained by any of the preceding factors, was found to be highest for shorter surgeries relative to longer procedures. Variability in procedure times among surgeons was a multiplicative function (proportionate to time) of surgical time and total procedure time, such that as procedure times increased, variability in surgeons' surgical time increased proportionately. CONCLUSIONS: Surgeon-specific variability should be considered when building scheduling heuristics for longer surgeries. Results concerning variability in surgical procedure times due to factors such as type of anesthesia, age, gender, and American Society of Anesthesiologists risk class may be extrapolated to scheduling in other institutions, although specifics on individual surgeons may not. This research identifies factors associated with variability in surgical procedure times, knowledge of which may ultimately be used to improve surgical scheduling and operating room utilization.

Adolescent↗
PubMed2002

What sample sizes are required for pooling surgical case durations among facilities to decrease the incidence of procedures with little historical data?

BACKGROUND: Better predictions of each case's duration would reduce operating room labor costs and patient waiting times. A barrier to using historical case duration data to predict the duration of future cases is the absence for some cases of previous data for the same scheduled procedure from the same facility. The authors examined sample size requirements for pooling case duration data from several facilities to create a 90% chance of having case duration data for almost all procedures. METHODS: Four academic medical centers provided data, totaling 200,401 cases classified by the scheduled Current Procedural Terminology codes. RESULTS: The 12% of cases in which procedures occurred once or twice accounted for 79% of procedures or combinations of procedures. When a procedure was being performed for the first time at a facility, that same procedure had been performed previously at least once at one or more of the other three facilities only 13-25% of the time. More than 1 million cases would be needed to have a 90% chance of having at least 3 cases for each procedure observed in the original 200,401 cases. However, with N = 200,401 cases in our initial data set, we observed less than one third of the estimated total number of possible procedures. CONCLUSIONS: The lack of historical case duration data for scheduled procedures is an important cause of inaccuracy in predicting case durations. However, millions of cases probably would be required to provide historical case duration data for almost all procedures.

Academic Medical Centers↗