Second opinion program reduces surgical procedures, produces no net savings.
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Blue Cross Blue Shield Insurance Plans↗
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The Blue Shield of New Jersey second surgical opinion program.
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Blue Cross Blue Shield Insurance Plans↗
Effects of payment incentives, hospital ownership and competition on hospitalization decisions for ambulatory surgical procedures.
OBJECTIVE: To test the hypotheses that (1) for-profit (FP) and not-for-profit (NFP) hospitals are less likely than public hospitals to admit cases reimbursed by prospective payment favoring ambulatory over inpatient care; (2) admission odds of public, FP and NFP hospitals will converge under increasing hospital competition. METHODS: Retrospective, population-based, cross-sectional study covering 29,699 cases of unilateral, femoral/inguinal hernia operation (major surgical procedure) and 60,626 cases of cataract surgery (local surgical procedure), from Taiwan's National Health Insurance database was used. Diagnosis-wise logistic regression analysis were done to examine associations between admission propensities of FP versus public and NFP hospitals (large teaching hospitals with > or = 250 beds versus district hospitals with < 250 beds) under high and low competition, adjusted for clinical complications, and patient as well as physician demographics. RESULTS: Large public teaching hospitals are significantly more likely than FP district hospitals to admit hernia patients (ORs = 1.9 and 2.6, respectively, under high and low competition), and cataract surgery patients (ORs = 5.0 and 5.4, respectively, under high and low competition). The corresponding odds ratios for public district hospitals (relative to FP district hospitals) are 1.2 and 3.9 for hernia and 4.9 and 2.7 for cataract surgery. Odds ratios show convergence of admission odds across hospital ownership under high competition relative to low competition for hernia (OR range for different hospital types under high competition, 1.0-1.9; and under low competition, 1.0-3.9). Cataract cases show high divergence of admission odds between public and FP/NFP hospitals regardless of competition level (OR range for different hospital types under high competition, 0.3-5.0; and under low competition, 0.3-5.4). CONCLUSION: Overall, our data support the study hypotheses. Differences in the relevance of inpatient care for hernia and cataract surgery may account for the lack of admission convergence of public hospitals and FPs under high competition among cataract surgery group.
Ambulatory Surgical Procedures↗
Insurance-mandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity.
BACKGROUND: Preoperative dietary counseling (PDC) before bariatric surgery is mandated by a growing number of insurance payers. Their claim is that PDC improves outcomes and postoperative compliance. We compared outcomes of GBP patients undergoing a mandatory 13 weeks of PDC (n = 72) to a contemporaneous group of patients with no such requirement (no-PDC; n = 252) who underwent operation between January 2000 and December 2002. METHODS: The PDC and no-PDC groups were characterized by similar male:female ratios (1:4 vs 1:4.6), mean age (42 years), mean body weight (324 lb vs 309 lb), and mean body mass index (BMI) (52 kg/m2 vs 50 kg/m2). The PDC group had a higher incidence of obstructive sleep apnea compared with the no-PDC group (41% vs 28%; P < .04) but otherwise the two groups had similar incidences of obesity-related comorbidities. The presurgery dropout rate was 50% higher in the PDC group than in the no-PDC group (28% vs 19%; P < .05). RESULTS: At 1 year follow-up, the no-PDC patients had a statistically greater percentage excess weight loss (67% vs 60%; P < .0001), lower BMI (32 vs 35; P < .015), and lower body weight (197 vs 218; P < .01). Resolution of major comorbidities, complication rates, 30-day postoperative mortality, and postoperative compliance with follow-up were similar in the two groups. CONCLUSIONS: The data demonstrate that insurance-mandated PDC is an obstacle to patient access for surgical treatment of severe obesity and has no impact on weight loss outcome or postsurgical compliance. PDC should be abandoned by the insurance industry.
Adult↗
[Standards, options and recommendations: practice guidelines for difficult diagnosis in surgical pathology or cytopathology in cancer patients].
CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993 is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for difficult diagnoses in surgical pathology or cytopathology in cancer patients. METHODS: Data were identified by searching Medline and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 71 independent reviewers. RESULTS: The main recommendations to prevent and reduce the number of difficult diagnoses in surgical pathology or cytopathology are: 1) The development of quality insurance programs with use of written procedures in each pathology laboratory (standard). 2) The knowledge of clinical data in order to explain surgical pathology or cytopathology results (standard). 3) The availability of complementary patient informations (radiologic data . . .) can be useful to explain surgical pathology or cytopathology results (option). The main recommendations to detect lesions associated with difficult diagnosis in surgical pathology or cytopathology are: 1) Tumor types known as potential difficult diagnosis in surgical pathology or cytopathology should be reviewed by a second pathologist. 2) The systematic second reviewing for every case is expensive but has to be done when the difficulty is know (sarcoma, lymphoma . . .) by experienced pathologists. The main recommendations to solve difficult diagnosis in surgical pathology or cytopathology are: 1) Block recuts, use of special techniques (immunocytohistochemistry and molecular biology), additional data from clinicians, second opinion by a local pathologist, or new specimen can be required for establishing the diagnosis (options). 2) Outside second opinion by expert pathologist has to be considered once the other steps did not allow to establish surgical or cytopathology diagnosis (recommendations, expert agreement).
Humans↗
Supporting future surgical innovation. Lung transplantation as a case study.
OBJECTIVE: Using lung transplantation as a case study, this article addressed the problem of supporting innovative clinical surgery in an era of increasing pressures for cost containment. SUMMARY BACKGROUND DATA: After sporadic attempts at lung transplantation during the 1960s and 1970s, its clinical development began in earnest during the early 1980s. As a result of a wide range of incremental advances, the results have improved significantly. The Health Care Financing Administration, however, has not yet issued a national policy covering lung transplants and has left the coverage decision to the discretion of its regional contractors. METHODS: The authors surveyed the major commercial insurers, the Blue Cross Blue Shield Association, and a sample of Medicare intermediaries to evaluate the coverage of lung transplantation. They also interviewed the National Heart, Lung, and Blood Institute and industrial firms about their support for clinical research. RESULTS: Government and industry funding were limited, and the development and assessment of lung transplants have been financed predominantly by academic institutions through cross-subsidization from patient care and teaching funds. The major private payers and Blue Cross Blue Shield decided to cover this procedure in the early 1990s. Coverage decisions by Medicare intermediaries, however, revealed considerable variability. Moreover, the absence of a specific diagnosis-related group for lung transplants had considerable consequences for institutions in all-payer states, in which payments appeared to be considerably lower than the mean costs of a transplant procedure (about $110,000). CONCLUSIONS: This analysis indicated that there was a growing disparity between the increasing demand for outcomes data about new procedures and the limited resources available for supporting the development and assessment of new operations. It this disparity is not addressed, the rate of surgical innovation may be jeopardized, and timely outcomes data may not be acquired. It was concluded that provisional coverage within a predetermined research protocol may be a promising mechanism to remedy this situation, providing timely assessment of new procedures before widespread application.
Centers for Medicare and Medicaid Services, U.S.↗
Perceived functional impact of abnormal facial appearance.
Functional facial deformities are usually described as those that impair respiration, eating, hearing, or speech. Yet facial scars and cutaneous deformities have a significant negative effect on social functionality that has been poorly documented in the scientific literature. Insurance companies are declining payments for reconstructive surgical procedures for facial deformities caused by congenital disabilities and after cancer or trauma operations that do not affect mechanical facial activity. The purpose of this study was to establish a large, sample-based evaluation of the perceived social functioning, interpersonal characteristics, and employability indices for a range of facial appearances (normal and abnormal). Adult volunteer evaluators (n = 210) provided their subjective perceptions based on facial physical appearance, and an analysis of the consequences of facial deformity on parameters of preferential treatment was performed. A two-group comparative research design rated the differences among 10 examples of digitally altered facial photographs of actual patients among various age and ethnic groups with "normal" and "abnormal" congenital deformities or posttrauma scars. Photographs of adult patients with observable congenital and posttraumatic deformities (abnormal) were digitally retouched to eliminate the stigmatic defects (normal). The normal and abnormal photographs of identical patients were evaluated by the large sample study group on nine parameters of social functioning, such as honesty, employability, attractiveness, and effectiveness, using a visual analogue rating scale. Patients with abnormal facial characteristics were rated as significantly less honest (p = 0.007), less employable (p = 0.001), less trustworthy (p = 0.01), less optimistic (p = 0.001), less effective (p = 0.02), less capable (p = 0.002), less intelligent (p = 0.03), less popular (p = 0.001), and less attractive (p = 0.001) than were the same patients with normal facial appearances. Facial deformity caused by trauma, congenital disabilities, and postsurgical sequelae present with significant adverse functional consequences. Facial deformities have a significant negative effect on perceptions of social functionality, including employability, honesty, and trustworthiness. Adverse perceptions of patients with facial deformities occur regardless of sex, educational level, and age of evaluator.
Adolescent↗
Business knowledge in surgeons.
BACKGROUND: Surgeons and residents in training receive little, if any, formal education in the economic side of clinical practice during medical school or residency. As medical professionals face shrinking reimbursement, loss of control over health care decisions, and limited resources, surgical specialties must reevaluate the need to teach their members business survival skills. Before designing business related-teaching modules, educators must know the exact gaps in knowledge that exist among surgeons. METHODS: This article reports a survey of 133 surgeons in the Midwest who were asked to rate their knowledge base in 11 business topics relevant to the practice of medicine. RESULTS: The survey showed that the average surgeon perceives himself or herself to be poorly equipped to understand basic financial accounting principles, financial markets, economics of health care, tools for evaluating purchases, marketing, budgets, antitrust and fraud and abuse regulations, and risk and return on investments. CONCLUSIONS: Armed with this data, teaching faculty, health care systems, and medical specialty societies should design business education seminars to better position surgical specialists and trainees to communicate with insurers, hospital administrators, health care organizations, and their own personal financial advisors.
Accounting↗
[Psychosomatic aspects of obesity].
Overweight and obesity are widespread in industrial countries and are considered to be serious health problems in these countries. Population-based studies in Germany have shown that between 12 and 18 % of the adult population is obese. Overweight and obesity are accompanied by a large spectrum of health disorders and extreme psychosocial burdens. Besides the hereditary disposition, the life style including both intra- and inter-individual aspects determines the complex etiology of obesity. Within the collective sample of the obese, one sub-sample is the "psychogenic obese" i. e. in which psychiatric disorders lead to a change in both eating and exercise behavior, the result then being a continuous positive energy reserve in the form of overweight and obesity. The paper describes the psychosocial problems of obese persons; especially the controverse question with regard to psychiatric morbidity in general and eating disorders in particular are emphasized. The results of past, mainly behavioral oriented treatment concepts are presented and various concepts beyond single school orientation are discussed. Finally, the problems with psychiatric psychological diagnostics in those obese patients with the request for surgical weight reduction within the context of insurance coverage and the surgeons are presented.
Animals↗
The oral examination: awesome or awful?
Medical and surgical specialty boards are constantly striving to insure that those seeking certification in their specialty are adequately trained and sufficiently evaluated to guarantee the highest quality of patient care. One traditional component of the evaluation process, the oral examination, has been discontinued by some specialty boards but is still retained by most. A review of the history of the oral examination, combined with personal experiences of the author, suggests that this particular rite of passage may have outlived its usefulness in all but a few areas of medical specialization. Addressing the most pressing problems of patient mismanagement in the most visible area of practice, the hospital environment, requires that major emphasis be on the improvement of hospital practices rather than on doctors' qualifications. Only in this way can we ensure patient safety and restore patients' confidence in the care they receive and in the doctors responsible for administering it.
Certification↗
[Telepathology at presence and in the future].
Telepathology is the performance of pathology at distance using available telecommunication links such as optic fiber, communication satellite, and integrated services digitized network (ISDN). The main applications of telepathology are to provide frozen section service, consultation between pathologists at a distance, and conducting conferences using displays. These activities are required due to the shortage and disproportional distribution of pathologists. Telepathology for frozen section service is fairly effective in providing indications for surgical procedures by discriminating malignant tumor from benign tumor, confirming metastasis to distant organs or lymph nodes, and decisions regarding the surgical margin. However, there are several public insurance problems in the spread and practice of telepathology. To solve these problems, not only from a medical approach but also from the development of mechanical engineering, economic and legal issues must be considered.
Diagnosis, Differential↗
[Economic aspects of bone infection].
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Amputation, Surgical↗
[Villous adenoma of the rectum. Review of the literature and personal experience].
Potential malignancy of rectal villous adenomas is referred as varying from 20 to 30%; an appropriate surgical excision is required in order to insure an effective cancer prophylaxis and to improve the accuracy of the pathologic assessment. The Authors review their series concerning 15 patients with one or more polyps of villous type, located at the lower third of the rectum and with precise indications for transanal excision. In 13 cases histology demonstrated the presence of an adenoma with different grade of dysplasia, which simply entered a follow-up together with a case of an adenoma with carcinoma in situ. The latter, because of the presence of invasive carcinoma, underwent radical surgery. No postoperative morbidity was observed. Recurrence rate was 8%. After an accurate review of the Literature, a radical management of the rectal villous tumour performed on routine basis seems unjustified. The Authors suggest the indication for a modern proceeding.
Adenoma↗
Neonatal circumcision: associated factors and length of hospital stay.
BACKGROUND: Controversy exists regarding the efficacy of routine neonatal circumcision of male infants. Little is known about parental or provider characteristics or the use of medical resources associated with this procedure. METHODS: Records of 3703 male infants born during 1990 and 1991 at four US sites were analyzed to discern associations between circumcision and the above factors. Analyses were limited to healthy infants. RESULTS: Eighty-five percent of the infants in the study population were circumcised. White and African-American male infants were much more likely to be circumcised than those of other races (odds ratios [ORs], 7.3 and 7.1, respectively, P < .001). Compared with self-pay patients, those covered by private insurance were 2.5 times more likely to be circumcised (P < .001). Logistic regression showed that rates for obstetricians and family physicians were not significantly different. Increased odds of circumcision were found if the mother received an episiotomy (OR = 1.9, P < .001) or cesarean section (OR = 2.1, P < .001). Circumcised infants stayed in the hospital an average of one fourth of a day longer than did those who were not circumcised (mean difference, 0.26 days; 95% confidence interval, 0.16 to 0.36). CONCLUSIONS: Mother's insurance status and race as well as surgical interventions during delivery are related to circumcision. Associations with episiotomy and cesarean section suggest physician and/or parental preference for interventional approaches to health care. Generalizing the difference in hospital length of stay to the United States suggests an annual cost between $234 million and $527 million beyond charges for the procedure itself.
Circumcision, Male↗
In their own words: a model of a successful surgical practice.
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Group Practice↗
Acoustic neuroma surgical cost and outcome by hospital volume in California.
CONTEXT: Successful outcome of complex surgical techniques depend on the surgical team's level of experience. However, unless benefit is demonstrated in the presence of cost savings, insurance companies are reluctant to approve care from highly experienced hospitals and surgical teams. OBJECTIVE: To determine the relationship between the number of acoustic neuroma surgeries performed at California hospitals with surgical outcome and hospital stay cost. DESIGN: Acoustic neuroma surgery information was extracted from the California hospital discharge database and was grouped according to the number of surgeries performed at each hospital. SETTING: A database review of California hospitals. PATIENTS: Persons (n=1,213) undergoing acoustic neuroma surgery at a California hospital between 1996 and 1998. Main outcome measures Outcome measures included discharge status (routine vs. not routine), medical procedures indicating surgical complications, total cost of hospitalization, and average cost per hospitalization day. Odds ratios were used to compare the hospital volume groups on likelihood of a routine surgical outcome. RESULTS: The frequency of routine surgical outcome increased as hospital acoustic neuroma surgical volume increased, ranging from 68% among patients in the lowest volume group to 97% in the highest hospital volume group. Patients in the highest hospital volume group were 15 times more likely to have a routine surgical outcome than patients in the lowest hospital volume group. Patients in the second highest volume group were 5 times more likely to have a routine surgical outcome than in the lowest volume group. The two highest volume hospital groups had lower total charges and average charges per day than the two lower volume hospital groups. CONCLUSIONS: Acoustic neuroma surgeries at higher volume hospitals had higher frequency of routine discharge, lower frequency of apparent complications, and lower average cost of hospitalization.
California↗
Factors associated with waiting time for surgery.
OBJECTIVE: To explore the factors associated with waiting times for surgery in public hospitals. SETTING: Three major acute care public hospitals in one Area Health Service. PARTICIPANTS: 691 adult patients entered onto the computerised booking list between 16 and 22 November 1994, and then between 16 January and 12 February 1995, were interviewed prospectively and followed up over a minimum of 18 months. Data were obtained from the Area Health Service's computerised booking system and patient self-report. RESULTS: Relevant surgical specialty, urgency rating, employment status and health insurance status were significantly associated with waiting time. Age, hospital, sex, country of birth, education, marital status and holding a Health Care Card were not significantly associated with waiting time. Self-reported health status (as measured by the SF-36) was not associated with waiting time for surgery. CONCLUSIONS: Waiting time for surgery was not simply determined by how urgently patients need surgery, but also by the type of surgery needed and patient's employment and health insurance status. The extent of disability experienced by patients, as measured by the SF-36, was not reflected in waiting times for surgery.
Adult↗
Postoperative course after inguinal herniorrhaphy. A case-controlled comparison of patients receiving workers' compensation vs patients with commercial insurance.
OBJECTIVE: To confirm our observation that patients with work-related hernias, when compared with self-employed patients, had longer recovery times and prolonged pain after hernia repairs, we reviewed our recent experience in a series of patients undergoing inguinal hernia repairs. DESIGN: The study design was matched retrospective case-control. Each patient receiving workers' compensation was age and sex matched with a control patient with commercial insurance whose repair was done during the same year. SETTING: All inguinal herniorrhaphies were performed at a single clinic by one of seven surgeons. PATIENTS: Twenty-two consecutive patients receiving workers' compensation and 22 patients with commercial insurance were studied. MAIN OUTCOME MEASURES: The postoperative courses in 22 consecutive patients with workers' compensation were compared with those in 22 control patients with commercial insurance. The principal factors compared were indications for surgery, type of hernia, surgical repair performed, the duration of postoperative pain, and the number of days off daily work. RESULTS: The average age in both groups was 46 years. Hernias in the workers' compensation group were more frequently symptomatic. The duration of postoperative pain (mean +/- SE) was 111.0 +/- 42.2 days for patients with workers' compensation and 17.8 +/- 7.9 days for patients with commercial insurance (P < .05). The number of days off work (mean +/- SE) was 33.5 +/- 4.6 days for patients receiving workers' compensation and 12.6 +/- 2.3 days for patients with commercial insurance (P < .001). CONCLUSIONS: We believe our results confirm the observation that type of insurance coverage influences post-operative recovery time after inguinal herniorrhaphy. Other studies measuring a patient's outcome after surgical procedures such as herniorrhaphy should include type of insurance coverage as a factor that might affect early return to work. Using multivariate analysis, the only variable independently affecting the duration of pain after hernia repair was the type of insurance coverage (P < .005).
Case-Control Studies↗