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PubMed1980

In defense of the national health service.

Many influential British groups have taken the opportunity provided by the Royal Commission on the National Health Service to put forward proposals which would fundamentally damage that service. In this paper we discuss the implications of some of these proposals, and explain why we defend the NHS as the basis of an equitable method of providing health care. We consider the various methods which have been suggested to increase the revenue of the NHS. We compare the experiences of several Western countries, and show that the method of financing inevitably affects the pattern of medical care and the indices of health and illness. We examine the underlying motives of many critics of the NHS, and document the development of private medicine in the United Kingdom. We continue by discussing ways in which less money could be spent on health care without detriment to the patient. As an example, we look at several surgical procedures in detail and demonstrate the costs of uncertainty in surgical practice. Finally, we consider the continuing power of the medical profession, how it is maintained, and its implications. We conclude by summarizing why we support the NHS despite its imperfections, and why attempts to undermine it should be resisted.

Fees and Charges↗
PubMed1984

Health care experience among employees prior to and after enrollment in a prepaid health insurance plan (HMO).

Company medical and benefit records of employees who were enrolled in prepaid health insurance plans (HMOs) in Minneapolis, Washington, D.C., and Seattle were reviewed for hospital and surgical utilization prior to as well as after their enrollment. Comparisons were made for the same calendar periods with closely matched employees who were covered by Blue Cross/Blue Shield (BC/BS). The results indicate that after enrollment the HMO subjects at each location had lower rates for hospital and surgical utilization than the BC/BS controls. For the period prior to enrollment, during which time coverage was through BC/BS, the prospective HMO subjects at two locations had lower hospital and surgical utilization than the controls. Possible explanations of this potential self-selection bias are discussed.

Adult↗
PubMed1996

The shift toward a managed care environment in a multispecialty group practice model. Looking for reciprocal benefits.

Managed care is notably affecting the practice of surgery in the United States. Four principal elements are subject to change: (1) patient care patterns, (2) ethics, (3) education and research, and (4) surgeon compensation. The Virginia Mason Clinic, a multispecialty group practice, is adapting to the demands of managed and capitated care. With the patient as the primary focus of effort, the goal is to create optimum value in health care. The principles of Continuous Quality Improvement are used to increase value in health care by ensuring appropriate treatment with optimum outcome at reasonable cost. Practice patterns are shifting to provide value to patients and payers. Ethical conflicts threaten but have been avoided. Surgical education remains unaffected, but future funding is problematic. The emphasis in surgical research has shifted toward outcome-based studies. The conflict between work effort and resource conservation as determinants of physician compensation is less for surgical than for medical practitioners. Although the principal benefactors of the shift toward managed care have been the payers, patients have gained modestly through efficiencies in the health care process and more stable insurance premiums. The satisfaction level of the surgeons in our multispecialty group practice remains high. Surgical research is thriving, volumes and case mix remain excellent, and changes in practice pattern have enabled us to increase efficiency without compromising patient care.

Ethics, Medical↗
PubMed2004

Perceived outcomes and utilization of upper extremity surgical reconstruction in individuals with tetraplegia at model spinal cord injury systems.

STUDY DESIGN: Survey. OBJECTIVE: To measure the utilization of upper extremity reconstructive surgery and the clinicians' perceptions of the outcomes provided for persons with tetraplegia across the Model Spinal Cord (SCI) Injury Systems. SETTING: Model SCI Systems. METHODS PARTICIPANTS: A clinician from each of the Model Centers. MAIN OUTCOME MEASURE: A mailed survey eliciting responses with respect to: (1) utilization of upper extremity reconstructive procedures and (2) the clinicians' perceived outcomes of these procedures. RESULTS: In all, 76% responded positively about the availability and appropriateness of upper extremity surgical reconstruction at their center. Of the respondents, 75% felt that surgery recipients were generally satisfied with their surgeries, 80% felt that the surgery made a positive impact on recipients' lives, 81% felt that recipients showed increased independence, and 70% reported a positive impact on recipients' occupation. In all, 93% felt insurance companies should pay for the procedures. Compared to the satisfaction of surgery recipients using a similar instrument, clinicians anticipated slightly greater improvements in all areas except occupation. CONCLUSIONS: There is a positive perception of the benefits of reconstructive surgery for tetraplegia; however, procedures are not routinely offered at all centers. The primary reasons reported for this include the misconception that insurance does not remit payment, that a surgeon is not available, and that surgical candidates are referred to another center.

Activities of Daily Living↗
PubMed1996

[Amputation of the lower extremities for non-traumatic causes in Slovakia in 1995].

The authors submit a questionnaire-based epidemiological study from 61 surgical departments in Slovakia, focused on the problem of amputation of the lower extremities. The objective of the study was to evaluate indirectly the standard of care of diabetic feet in Slovakia. In the study 61 surgical departments participated with a catchment area comprising 4,814,000 insured persons, i.e. 85% of the Slovak population. In these patients a total of 2116 amputations on account of non-traumatic causes were performed (44/100000 population). This number included 1578 diabetic patients (74.6%). Minor amputations were performed 1044 times, incl. 92.2% in diabetic subjects. Major amputations were made 1072 times, incl. 57.3% in diabetics. The prevalence of major amputations in 1995 was 21.8/100000 population. The authors recorded a 2.65 fold increase of the total number of amputations since 1985. They recorded dissatisfaction with the small number of revascularization operations-total 294 (13.9%) which is only one quarter of the desirable number. The authors submit their study as the basis for a systemic solution of care of the diabetic foot in Slovakia and as a challenge for its improvement.

Amputation, Surgical↗
PubMed2001

[Possibilities and limits of ambulatory surgery: demands and reality in plastic surgery].

With the development of office-based operating rooms and improved office anesthesia, the ability to perform more extensive surgery outside the hospital is now given. Experience with the tumescent technique for liposuction and abdominoplasty has demonstrated that extensive plastic surgery can performed with minimal postoperative discomfort. An emergency phone after surgery is necessary, and a call on the operating day evening and the initial postoperative day is a safe strategy with high patient acceptance for most types of plastic surgery. Additionally, the cost savings of office-based plastic surgery makes this surgery much cheaper for the patients and the health insurance organizations.

Ambulatory Surgical Procedures↗
PubMed1996

Appendicitis in children in the managed care era.

Acute appendicitis is the most common condition requiring emergency operation in children. Late appendicitis is still a major source of morbidity and potential mortality. It has been suggested that managed care programs are responsible for a delay in surgical referral and consequently an increased risk of morbidity and mortality. In light of the increasing use of managed care, the authors reviewed their experience with pediatric acute appendicitis in managed care and indemnity insurance patients. The charts of all pediatric appendectomy patients treated between January 1990 and March 1995 were reviewed. Payor status, surgical and pathological findings, hospital course, and follow-up findings were documented. If the operative note or the pathology report described the appendix as gangrenous or perforated, the case was considered to be late appendicitis. Group I patients had traditional indemnity insurance; group II patients were in our institution's managed care plan. One hundred two patients were identified (28 in group 1, 74 in group II). Late appendicits was found less often in the managed care group (21.6% v 42.9%; P < .01). This resulted in a lower rate of major complications (1.4% v 3.6%) and a lower overall complication rate (2.7% v 7.1%). Group II also had a shorter hospital stay (2.6 days v 4.5 days; (P < .01) and lower average hospital charges ($6,507 v $8,754 (P < .01). These results do not demonstrate any adverse affect on outcome for children with acute appendicitis who have a managed care plan. In fact, the incidence of late appendicitis among these patients was half of that of the indemnity-insured patients. The lower risk of late appendicitis resulted in a shorter length of stay and lower hospital charges. These results suggest that managed care programs can provide quality care along with a significant reduction in costs; no delay in appropriate surgical referral was demonstrated.

Acute Disease↗
PubMed1997

Staging endometrioid adenocarcinoma. Clinical and financial comparison of laparoscopic and traditional approaches.

OBJECTIVE: To compare laparoscopically assisted surgical staging (LASS) of endometrioid adenocarcinoma with traditional surgical staging by laparotomy. STUDY DESIGN: A retrospective review of all cases of uterine cancer (n = 108) insured by one health maintenance organization during 1990-1995. During this period, 29 patients underwent successful LASS and were compared to 64 who underwent laparotomy for treatment of surgical stage I endometrioid adenocarcinoma. RESULTS: LASS was performed successfully in 29 of 32 attempted cases. All patients on whom LASS was attempted were found to have surgical stage I. Laparoscopic pelvic lymphadenectomy was highly successful, with no failures and a mean number of 14 nodes obtained. The overall complication rate was significantly higher for laparotomy than for LASS (28% vs. 7%, P < .001). The average length of stay for laparotomy was significantly higher than for LASS (5.1 vs. 2.3 days, P < .001). CONCLUSION: LASS for stage I endometrioid adenocarcinoma is an attractive alternative to traditional surgical staging. It causes fewer complications and shortens the hospital stay.

Adenocarcinoma↗
PubMed2001

Deriving the indications for laparoscopic appendectomy from a comparison of the outcomes of laparoscopic and open appendectomy.

BACKGROUND: Indications for laparoscopic appendectomy (LA) remain controversial and poorly defined. We sought to identify indications for LA through a comparison of LA and open appendectomies (OA). METHODS: We reviewed demographics, coexisting medical conditions, radiology and pathology data, hospital course, and complications from charts on all LA patients and a comparison group of OA done from 1991 to 1998. RESULTS: The following were significantly associated with LA: female sex, higher mean body mass index (BMI), coexisting medical problems, private insurance, and daytime surgery. The OA group was significantly more likely to have: a radiology report suggesting the diagnosis of acute appendicitis, perforation of the appendix, intensive care unit admission, and complications in their hospital course. Forty-one percent of the LA patients did not have appendicitis, compared with 20% of the OA patients. CONCLUSIONS: Daytime surgery, women, private insurance, coexisting medical problems, prior abdominal surgery, higher BMI, and less severe disease appear to be used by surgeons as indicators for LA. The threshold for surgical exploration appears to be lower for LA.

Adult↗
PubMedDate not supplied

Partial mastectomy and limited axillary dissection performed as a same day surgical procedure in the treatment of breast cancer.

A series of 133 patients treated for breast cancer with partial mastectomy and limited axillary dissection performed as a same day procedure is presented. For comparison purposes an additional 45 patients are presented who had the same operative procedure but stayed for 1 or more nights as an in-patient. Of those having the procedure on a same day basis complications included hematoma (0.8%), seroma (2.3%), infection (1.5%) and miscellaneous (0.8%). These results are similar to those for patients staying overnight. It is concluded that partial mastectomy and limited axillary dissection can be safely performed as a same day procedure with advantages to the patient of avoiding hospitalization, to the surgeon in avoiding excessive paperwork and in-hospital responsibilities, and to the third party insurers in reducing costs.

Ambulatory Surgical Procedures↗
PubMed1975

Postoperative bronchopleural fistula: clinical and experimental study.

It is a well-known fact that in pulmonary tuberculosis patients treated by resection, the quality of the suture material used for closing the bronchial stump plays an important role in the pathogenesis of postoperative bronchopleural fistula. Of 426 cases treated surgically and in whom silk suture thread was used, 23 developed bronchopleural fistula, whereas none of the 220 cases sutured with nylon monofilament developed abnormality. Statistical analysis of 100 surgical cases with silk thread suture and of 100 cases with nylon monofilament suture showed that the two groups had no marked differences as to background factors. Howevers, as compared with the silk-thread suture group, the nylon-monofilament suture group revealed more consistently favorable postoperative bronchoscopic findings. Experimental studies with dogs showed a similar lack of complications when the monofilament suture material was used, as contrasted were conducted in hospital by the same surgical personnel using the same procedures, it can be said that, to insure prevention of complications, the suture material for bronchial stump closure should be of non-irritating nature and preferably of monofilament strength and quality, such as nylon monofilament.

Animals↗
PubMed1982

Organizational and financial influences on patterns of surgical care.

Rates of surgery for similar patient groups are lower in well-established prepaid group plan forms of HMO than in either independent practice association forms of HMO or in traditional fee-for-service care arrangements. The biologic outcomes of care are at least as good in prepaid group plan settings as in other settings. The implications of these conclusions for the future are discussed.

Consumer Behavior↗
PubMed1995

[Quality assurance from the viewpoint of medical management by health insurance].

Legal requirements of SGB V make provisions for quality assurance (QA) activities in relation to inpatient and outpatient care. Available contracts between health providers and institutions covering costs presently regulate QA in three distinct areas in surgery: inpatient and outpatient care, Fallpauschale (fee for case) and Sonderentgelte (fee for service), and out-patient surgical treatment. MDK as a medical counselling and review agency working on behalf of health insurance companies has a more or less well defined role in the organization (board membership) and actual work (evaluation and probing) of external QA. Its participation and competence derive from legal authorization (SGB V) and hence from its given assignments: review of indication, economical aspects and quality of services provided--each on a single case basis and on a more general basis, nursing care, hospital budgets and finally planning capacity for hospital care.

Cost Control↗