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This article describes the history of ambulatory surgery and anesthesia in the United States. The innovations in surgical instrumentation and techniques, newer anesthesia drugs and techniques, as well as insurance provider changes that have led to an increase in the numbers and types of surgeries performed in outpatient settings in the United States, are detailed.
The study aimed at examining the effects of type of hospital and health insurance status on hospital length of stay for three identified medical and surgical conditions. Medical records of 520 patients for the year 1991 were reviewed in one public and one private hospital. Comparison of hospital length of stay for the private (n = 185) versus public sector patients (n = 335) was carried out. The effect of presence of health insurance (n = 189) and the lack of it (n = 325) was also studied. It was found that the average length of stay in the public hospital was significantly longer than the private one (3.3 versus 2.7 days). In addition, insured patients had significantly longer hospital length of stay (3.3 versus 3.0 days). The results of the multi-variate analysis showed that after socioeconomic factors and clinical conditions of patients were adjusted for, the influence of hospital type and health insurance on hospital length of stay was about one day. The paper also discusses the need to base hospital cost-containment strategies on studies of hospital behaviour and performance.
The authors have documented 50 cases of U.R., out 2,151 normal deliveries. During the same period, 614 surgeries for caesarean sections were performed. The U.R. frequency has been estimated at 1.80%. 98% of the U.R. were referred to us from outside in the vicinity maternities of Niamey. The maximum number of frequencies occurs between the ages of 15-42 years, and in decreasing order, among multiparas (with a parity of 5 and above). Uterine scars are among the principal causing factors. Sub total hysterectomy was the most widely used surgical method (60%). Among the 50 cases, 8 maternal deaths (16%) and 48 fatal deaths were reported (96%). The average length of stay in hospital was between 4 and 7 days. The shortest was 5 day and the longest 17 days. In order to alleviate this dramatic situation, the authors suggest the following measures: the implementation of a family planning programme (to discourage multiparity) a wide information campaign of the population, the insurance of a better treatment of uterus scars, the building of surgical units closer to rural areas, the provision of a better equipment to medical centres, the retraining of medical personnel.
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BACKGROUND: Orthopaedic surgeons routinely obtain informed consent prior to surgery. Legally adequate informed consent requires a thorough discussion of treatment options and risks and proper documentation; however, there is little data to guide orthopaedic surgeons regarding effective methods of obtaining informed consent. METHODS: We performed a closed claims analysis on malpractice claims involving an allegation of inadequate informed consent brought during a twenty-four-year period with two malpractice insurers. Relevant malpractice claims were reviewed, and data were abstracted. We then performed statistical analyses to identify factors that positively correlated with a successful defense. RESULTS: We identified twenty-eight lawsuits that included a claim of inadequate informed consent. All of the cases involved elective orthopaedic surgical procedures; there were no emergent cases. Three cases involved a disputed surgical site; all three cases involved foot and ankle surgery and resulted in an indemnity payment. Documentation of appropriate informed consent in the office notes of the surgeon was associated with a decreased indemnity risk (p < 0.005). Obtaining the informed consent on the hospital ward or in the preoperative holding area was associated with an increased indemnity risk (p < 0.004). When informed consent was obtained in the office by the operating surgeon, the risk of malpractice payment was significantly decreased (p < 0.004). CONCLUSIONS: Surgeons may be able to decrease the risk of a malpractice claim by obtaining informed consent in their offices, rather than in the preoperative holding area, and by documenting the informed consent discussion within their dictated office or operative notes.
Outcomes after cardiac surgery are a concern for patients, health care providers, and insurers. Because of the current economic climate, there is a demand for positive outcomes and an evaluation of negative results. The results of this study showed significant differences in nursing resource utilization, postoperative length of stay, and hospital costs by risk classification group. Risk classification models could serve as a template for staffing patterns and reimbursement based on patients' clinical profiles.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Each year fatalities in the United States increase as a result of gunshot wounds to the head. This increase, coupled with the progressive limitation of medical and economic resources available at major trauma centers, has brought into question the concept that everything possible should be done to save the lives of victims, who have only a minimal and nonpredictable chance of having a good outcome. Thus, consideration must be given to the economics of treating cranial gunshot wounds and the relationship of this treatment to outcome. When a good outcome can be predicted, treatment should be aggressive. However, when a good outcome cannot be predicted, surgical intervention will have no effect and the potential costs of aggressive treatment must also be considered. Clearly, there are ethical dilemmas involved in withholding operative treatment from any individual, even if there is only a minimal chance of a reasonable neurologic recovery. A negotiation-based approach should be used in determining the medical and ethical benefits of aggressive management strategies. Unfortunately, the care of critically ill patients is inconsistent with this approach. In order to insure that the best decision is made, guidelines dictating when to surgically intervene must be made an essential part of the patient/health care provider negotiation--even in worst case scenarios. The combination of an extremely poor prognosis for these injuries, and economic constraints faced by government-run facilities today could suggest that some patients should be allowed to die. Thus, the physician must be a source of information for the families, providing support and becoming a decision-making partner regarding potential intervention. In each situation, a strict set of guidelines must be formulated to establish a moral foundation for the ultimate mutual decision.
The Society of Surgical Oncology has developed a position statement54 that lists conditions warranting consideration of prophylactic mastectomy (Table 4). It must be stressed that there are no absolute indications for prophylactic mastectomy. The data are limited about the efficacy of prophylactic mastectomy in humans, but recent studies suggest that it results in up to 90% reduction in the risk for breast cancer. Total mastectomy is technically a more definitive procedure, although reported series have had a predominance of patients undergoing subcutaneous, nipple-sparing procedures. Prophylactic mastectomy may improve longevity in BRCA mutation carriers, but this must be balanced against the impact on quality of life. The benefits of prophylactic mastectomy relative to chemoprevention are unclear because there are no prospective randomized studies comparing these two strategies. Contralateral prophylactic mastectomy in patients with a unilateral cancer is unlikely to improve survival, but this approach may be considered for high-risk or difficult-to-observe patients, to facilitate breast reconstruction, and for the psychologic benefits. Patients considering prophylactic mastectomy should be well informed of risk-reduction alternatives and the limitations in the efficacy and cosmetic results of the procedure.
BACKGROUND/PURPOSE: Billing and reimbursement for pediatric surgical services is a complicated process that has not been rigorously evaluated. This study evaluates pediatric surgery billing and reimbursement and compares the process between third party payors. METHODS: The authors tracked all noncapitated bills from submission to final payment for all cases performed during 1 month. Data included operation, insurance type, amount billed, and amount collected. If payments were denied, the reasons were ascertained and the appropriateness verified. Chi-square and Student's t tests were used for comparisons. RESULTS: The billing process for all noncapitated pediatric surgical cases during May 2000, was reviewed (n = 136). The majority of bills (79%) were paid outright. Of the rejected bills, 76% were denied inappropriately. Inappropriate denial of payment was most frequent among patients insured by Medicaid. Mean time to complete payment was longest among patients insured by managed care groups. Percent of total charges reimbursed for surgical services was significantly lower for patients insured by Medicaid and Health Maintenance Organizations (HMO). CONCLUSIONS: A significant number of bills for pediatric surgical services are rejected inappropriately. Careful analysis of one's rejected bills can recoup up to 20% of revenue. HMO's and Medicaid are more likely to deny payment inappropriately, take longer to make payments, and reimburse less for pediatric surgical services.
AUDIENCE: This article is designed both for graduate medical educators and financial officers of teaching hospitals. GOAL: To present the financial and clinical implications of a resident-run, attending-supervised office-based surgery center. OBJECTIVES: 1. Describe the recent changes in volume of patients available for resident education in obstetrics and gynecology. 2. Describe the accounting method of calculating the cost of office versus hospital outpatient procedures. 3. Describe the financial and educational benefits of an office-based surgery program run by residents with the supervision of attending physicians.
The current criminal law regarding medical malpractice is based on the over 100 years old principle of personal injury, as defined in Section 223 of the criminal code. Attempts to revise this legislation have failed repeatedly in the past. The surgeon's duty of disclosure has gained pivotal importance, often being a handicap for differential surgical treatment. The lack of a specific criminal law regarding medical malpractice in combination with the theoretical construct of a surgical intervention as an authorized personal injury is disadvantageous for both patient and surgeon, since the surgeon is led to deny malpractice and therefore compensation by the liability insurance is not guaranteed. The threat with criminal penal for the surgeon which acted wrong but not gross negligent should be diminished by a definition of a specific criminal law on medical and surgical malpractice.