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PubMed2004

Robotic surgery and cancer: the present state, problems and future vision.

In the 1990s, laparoscopic surgery entirely changed the traditional style of surgical operations. Laparoscopic cholecystectomy has spread rapidly and is now established as the standard treatment. However, besides cholecystectomy, endoscopic procedures are still not applied so widely to a variety of surgical operations. This is because laparoscopic techniques, such as suturing or ligation, make it difficult for surgeons to perform other kinds of operations and thus greatly increase their mental and physical stress. It is necessary to introduce various advanced technologies such as: surgical robots, three dimensional (3D) images, computer graphics (CG), computer simulation technology and others. Surgical robots, including the AESOP, da Vinci and ZEUS systems, provide surgeons with technologically advanced vision and hand skills. As a result, such systems are expected to revolutionize the field of surgery. However, there have so far been few studies which discuss the indications of robotic surgery for tumors/cancer. Therefore, herein we review various studies published in English to focus on the application of robotic surgery to tumors/cancer. We point out that there are several problems to be solved for robot surgery: i) price of surgical robots, ii) training systems for surgeon, iii) coverage by medical insurance, iv) downsizing and v) navigation system. In conclusion, we believe that, in the near future as robotic technology continues to develop, almost all kinds of endoscopic surgery will be performed by this technology. It will replace traditional surgery not only in the treatment of benign diseases but also in malignant illnesses.

Cardiovascular Diseases↗
PubMed1984

Hospital costs of surgical complications.

Fifteen patients who had a general or gynecologic abdominal operation were operated on a second time for a complication of the first operation. There were three deaths. Extra costs attributable to the complications amounted to +211,503, of which one third was uncollectible. One half of the extra hospital days for surviving patients were spent in the intensive care unit.

Abdomen↗
PubMed1986

Coinsurance effects on dental prices.

For many Americans the cost of dental services represents a barrier to receiving regular dental care and maintaining proper oral health. The recent growth of the dental insurance industry, however, may partly offset this price barrier among insureds. Our purpose is to examine the relationship between coinsurance and dental prices for 16 dental services among a sample of Pennsylvania Blue Shield (PBS) adult insureds. The dependent price measure is the annual average gross price paid for 16 specific preventive, restorative, periodontic, endodontic, prosthodontic, and surgical dental services. Independent variables in the price model include the insured's age, education, coinsurance rates, time costs, market area, non-wage income, oral health status, area dentist-population ratio and usual source of care. Data sources are 1980 PBS claims and coinsurance rate data and a mail survey of sampled insureds. OLS regression analysis reveals that the model's independent variables explain little dental price variation. No variable is consistently significant across services, but market area, coinsurance rates, and time costs alternately dominate across equations. These results suggest that, among adult insureds, coinsurance and time costs influence dental fees in a minority of dental services. Insurance reduces the patient's sensitivity to money price, and non-price factors correspondingly seem to become more important in patient search.

Adolescent↗
PubMed2004

Multivariate analysis of the factors affecting duration of acute inpatient rehabilitation after hip and knee arthroplasty.

OBJECTIVE: To determine which factors predict length of stay at a rehabilitation hospital for total hip and knee arthroplasty patients. DESIGN: Length of stay at an acute rehabilitation hospital was analyzed with respect to demographic, surgical, and comorbidity factors using univariate and multivariate statistical techniques. Data were retrospectively collected of 808 hip and knee arthroplasty rehabilitation patients from years 2000 and 2001 at a large, urban, university-affiliated acute rehabilitation hospital. Demographic factors included age, insurance, marital status, sex, race, and body mass index. Surgical factors included knee/hip arthroplasty, unilateral/bilateral arthroplasty, and indication for surgery. Also, the 22 most prevalent comorbid illnesses for the patient group were analyzed for their association with length of stay. RESULTS: Significant factors for predicting length of stay were indication for surgery, number of comorbid illnesses, unmarried marital status, and black race. Also, advanced age and male sex approached significance. CONCLUSION: Length of stay in rehabilitation for total hip arthroplasty and total knee arthroplasty can be statistically modeled using various factors. These findings will help clinicians address prolonged length of stay and resource allocation issues.

Age Factors↗
PubMed2002

[Experiences with ambulatory arteriovenous shunt surgery. A cost-benefit analysis].

Placement of arteriovenous (av) fistulas has been executed at the reporting surgical department for 3 years. Calculation of the reimbursement by the insurance companies is based on the so-called "Unique Evaluation Table" (Einheitlicher Bewertungsmassstab). The aim of the study was to evaluate the efficiency of the placement of av fistulas in an out-patient setting and the acceptance of this approach in the patients. The costs based on an average of the duration of the intervention and treatment at the out-patient clinic per time unit for surgeon, nurse and operating room, as well as costs for use of specific materials were listed, summarized, and compared with the amount of money which was reimbursed by the insurance companies according to the "Unique Evaluation Table". During the 3-year time period, 67 patients underwent 70 placements of av fistulas in an out-patient setting (in total, 532 interventions). Patients answered a questionnaire, and procedures were evaluated for average costs. Based on the table-dependent reimbursement of DM 274.00 (according to the "Unique Evaluation Table"), costs of DM 497.94 (DM 445.50 for 54 min of mean duration of surgical procedure plus DM 52.44 for materials) were determined, indicating that no full reimbursement was found despite the fact that there was only a minimal rate of early complications (thrombosis, n = 2 [3%]) (infection, n = 1 [1.5%]). The expenses were 81.7% on average above the level of the reimbursement. In conclusion, despite high acceptance of an out-patient setting for placement of av fistulas in patients (82%), it is not efficient from an economic point of view and can be only provided for specifically selected cases. Therefore, it is not advisable at present to place av fistulas at German out-patient clinics with no following admission of the patients, to avoid financial disadvantages for the surgical department. New negotiations between the medical profession and the insurance companies are urgently needed to ensure an improved financial outcome for the clinics.

Ambulatory Surgical Procedures↗
PubMedDate not supplied

Coding issues: global periods may look simple, but don't be fooled!

Coding for surgical procedures is often difficult. The problems are compounded when evaluation and management services are also included as part of the treatment. This article defines global periods and modifiers that may be used when subsequent procedures are required; in addition, evaluation and management services and illustrative scenarios are provided.

Fee Schedules↗
PubMed1989

[Urologic surgery and risks of complaints in medical responsibility].

The card-index study of specialized insurance companies allowed the analysis of 82 cases concerning urological surgical procedures. Forty-two cases went to the Civil Court, 10 to the Penal Court and 5 to the Administrative Tribunal, while 5 cases were simply declared to insurance companies without judiciary consequences. Sixty-two cases concerned private plaintiffs surgeons and 34 cases concerned non specialist urologic surgeons. Sixteen plaintiffs were compensated, 9 after a conciliatory agreement and 7 after trial. There were no penal condemnations (one case on the waiting list). Impotence was the most frequent cause for complaint which was compensated. Next, came incontinence generally secondary to endoscopic resection. Retrospectively, 19 cases seemed to be unwarranted due to the dishonesty of patients (3 patients were prosecuted for unwarranted procedures). On the other hand, 32 cases seemed to be due to a lack of information given to the patients themselves or to their families, either before of after the incriminated act. The risk of prosecution is relatively low in urology. It could be decreased by careful management of the medical chart, by rapid analysis of complications and by a constant effort to inform the patient and his family.

France↗
PubMedDate not supplied

Trends in temporomandibular joint surgery.

We examined a large population of patients undergoing temporomandibular joint (TMJ) surgery and provide a documentation of the average patient population, frequency of procedures, frequency of repeat procedures, and trends in open (arthrotomy) versus closed (arthroscopy) TMJ surgery. Data on 194 TMJ surgical procedures was extracted from line item claims information collected by Trigon Blue Cross/Blue Shield of Virginia. The frequency of arthroscopy increased during the study, while the incidence of arthrotomies remained relatively low. Approximately half of the hospitals statewide did not perform either procedure. There was a low frequency (3%) of repeat procedures. In the Commonwealth of Virginia, since the advent of TMJ arthroscopy, it has become the preferred surgical technique for treatment of internal derangement. There is a low incidence of repeat procedures for both types of treatment. Analysis of insurance carrier computer records is a valid technique for evaluating trends in surgical care.

Adolescent↗
PubMed2002

Office hysteroscopy: a valuable but under-utilized technique.

PURPOSE OF REVIEW: The purpose of this review is to remind gynecologists of the indications for office hysteroscopy as well as to provide an update on equipment, techniques, and reimbursements. RECENT FINDINGS: Office hysteroscopy is a technique that has been available for over three decades. Whereas nearly 100% of urologists utilize office cystoscopy to evaluate bladder pathology, it is estimated that less than 20% of gynecologists utilize office hysteroscopy to evaluate intrauterine pathology. Although no one knows for sure, I speculate that the reasons for its under-utilization include a perceived lack of patients who would benefit from the procedure, expensive capital equipment with poor reimbursement, and a lack of expertise in performing the procedure. SUMMARY: As a result of not routinely using office hysteroscopy, many women who could greatly benefit from the use of the office hysteroscope are being denied a technique that is likely to keep them from more invasive and less useful procedures, such as diagnostic hysteroscopy and dilatation and curettage performed in the operating room under general anesthesia. This paper addresses these misconceptions in an effort to encourage more gynecologists to employ this technology.

Ambulatory Surgical Procedures↗
PubMed2000

[A trial of prospective payment system (DRGs/PPS) in Sendai National Hospital].

This study was undertaken to compare the difference between the total payment that was actually paid in accordance with the rules of DRGs/PPS, and the medical fee calculated by the present Japanese medical insurance system. From Nov. 1st '98 to Oct. 31st '99, the DRGs/PPS was applied to the 1,723(21.4%) out of 8,042 acute inpatients who were discharged after short-term stay. The total payment by the DRGs/PPS(yen 1,450,725,370) was smaller than the medical fee by the present Japanese insurance system(yen 1,504,686,240). In MDC (Major Diagnostic Category) 1(nervous system), 2(eye), 3(ear, nose, throat) and 4(circulatory system) the payment by the DRGs/PPS was greater than the fee calculated by the present medical insurance system. On the other hand, patients who belonged to the other 9 MDC groups paid smaller amounts by the DRGs/PPS. The major factors accounting for the difference(yen 53,960,870) between total payment DRGs/PPS and the fee by the present insurance system were period of hospital stay, treatment in the intensive care unit, complication, cancer chemotherapy, expensive surgical materials etc.

Diagnosis-Related Groups↗
PubMed2002

Quantitative evaluation of prostatectomy for benign prostatic hypertrophy under a national health insurance law: a multi-centre study.

Assessing regional variation between various medical centres in diagnostic and surgical processes is an approach aimed at evaluating the quality of care. This study analyses the differences between eight medical centres in Israel, where all citizens are covered by medical insurance, through the National Health Insurance Law (NHIL). The analysis refers to the diagnostic process, type of surgery and immediate post-surgical complications associated with prostatectomy for benign prostatic hypertrophy (BPH), which is the most frequent surgical procedure performed on men aged 50+. The study sample was comprised of 261 consecutive prostatectomy patients operated on in eight Israeli medical centres (MC), located in various parts of the country, between November 1996 and April 1997. Co-operation with participating directors of surgical wards was obtained after confidentiality of information had been assured. Surgeons in selected departments abstracted data routinely recorded in the patient's file and filled-out a standard one-page questionnaire. The following items were included: age, the presence of accompanying chronic diseases, preoperative tests, type of operation, and post-surgical complications. In the various MCs 32.6% of the patients underwent more than five preoperative tests ranging from 8.9% to 88.9% (<0.01). Assessment of kidney and bladder normality ranged from 75% to 100% (P < 0.01). The rate of patients whose prostatic symptoms (I-PSS) were assessed ranged from 0% to 79% (P < 0.01). There were also differences in severity of prostatism between the MCs, with severe symptoms ranging from 54.0% to 89.3% (P < 0.05), for type of operation performed (for 'open' prostatectomies, 35.4% to 68.0%, P < 0.01) and post-operative complications (19.0% to 41.6%, P = 0.07). After controlling for case-mix, type of operation was the most important predictor for post-surgical complications. MCs with low volume of surgeries had a higher rate of postoperative complications. We conclude that diagnostic and type of operation and post-surgical complications differed between various MCs. Participating surgeons were willing to fill out a one-page standard questionnaire from data routinely recorded in patients' files.

Aged↗
PubMed1979

Paying the physician's fee: Blue Shield and the reasonable charge.

At a time of debate over physicians' fees and income, we describe the evolution of Blue Shield plans and programs to pay physicians' fees. We review how Medicare's "reasonable-charge" formulas fostered Blue Shield "usual, customary, and reasonable" (UCR) contracts. In a three-year period in the Washington, DC, area, Blue Shield UCR protocols permitted "customary" allowances for selected surgical procedures to rise 29 to 75 per cent; charges by two physicians increased allowances for coronary-artery bypass from $2000 to $3500. We find little justification for secrecy in fee-payment protocols. Physicians dominate the District of Columbia Blue Shield Board and its committees, and they control fee-payment formulas. Nationally, 61 per cent of Blue Shield boards have majorities of health-care providers; approximately two thirds of fee-related committees have physician majorities. We urge increased public debate, public representation, and accountability in monitoring and reforming the programs that we describe.

Blue Cross Blue Shield Insurance Plans↗