Biomedical subjects

John Windsor

Publications and source records attributed to John Windsor.

7 recordsLinked to original sources

PubMed2005

Dollars and sense. Is there a better way to determine private surgical fees in New Zealand?

In New Zealand, private insurers reimburse surgeons on a fee-for-service basis. Ideally, the level of reimbursements should reflect competitive market prices. Due to concerns such a market does not exist, other countries have adopted Relative Value Scales (RVS) to estimate a fair reimbursement level for different procedures. No such scale exists in New Zealand for surgeons, but it does for anaesthetists. This study compares reimbursements to surgeons and anaesthetists from private insurers using data from 3186 procedures performed between 1996 and 2002. We calculate an implicit hourly rate of reimbursement and compare the level of reimbursement between procedures and the variance of reimbursements within procedures for surgeons and anaesthetists. The results suggest that there are significantly greater deviations in average reimbursements between procedures for surgeons than for anaesthetists. Furthermore, the variability of reimbursements is greater for reimbursements to surgeons within specific procedures. While the results do not necessarily imply that surgical reimbursements are inconsistent with underlying market rates, the results are consistent with the hypothesis that anaesthetist's fees show greater stability because of the existence of a RVS. We conclude by discussing what would be required to implement a RVS for surgical fees in New Zealand.

Anesthesiology↗

PubMed2004

Trends in the management of severe acute pancreatitis: interventions and outcome.

BACKGROUND: Severe acute pancreatitis (SAP) in the intensive care unit (ICU) is a complex and challenging problem. The aim of the present study was to identify trends in management of SAP patients admitted to a tertiary level ICU, and to relate these to changes in interventions and outcome. METHODS: Patients admitted to the Department of Critical Care Medicine (DCCM), Auckland Public Hospital with SAP from 1988 to 2001 (inclusive) were identified from the DCCM prospective database, and data were extracted from several sources. RESULTS: One hundred and twelve patients (men 69, women 43, mean age (+/-SD) 57.3 years +/- 14.3) were admitted with SAP to DCCM in the 13-year period. Aetiology was gallstones (42%), alcohol (29%), or idiopathic (29%). At admission to DCCM the median duration of symptoms was 7 days (range 1-100) and the mean (+/-SD) Acute Physiology and Chronic Health Evaluation II score was 19.9 +/- 8.2. Ninety-nine patients (88%) had respiratory failure and 79 (71%) had circulatory failure. The number of necrosectomies peaked between 1991 and 1995 (17/35 patients (49%) compared to 4/22 (18%) prior 1991; chi(2) = 6.90, P = 0.032). Abdominal decompression, enteral nutrition, percutaneous tracheostomy, and the use of stents in endoscopic retrograde cholangiopancreatography were introduced over the study period. The length of stay in DCCM did not alter (median 4 days, range 1-60) but there was a reduction in the length of hospital stay (median 36 days to 15 days; anova= 6.16, P = 0.046). The overall mortality was 31% (35/112) and did not alter over the study period. CONCLUSIONS: SAP remains a formidable disease with a high mortality despite a number of changes in intensive care and surgical management.

APACHE↗

PubMed2004

Variation in specialist fees: evidence from New Zealand insurance claims.

OBJECTIVES: To examine the parity between specialties in reimbursements for surgical procedures in a private, fee-for-service setting and to ascertain whether differences exist after accounting for factors suggested by a Resource-Based Relative Value Scale (RBRVS). METHODS: A routinely updated database covering several private insurers (n = 8294 procedures from 1997 to 2002) was used to examine differences in overall and hourly reimbursement. Multiple regression analysis was used to control for factors that might be responsible for differences in payment (location, year, sex of patient and the associated anaesthetist fee). The resulting regression residuals were compared between specialties. RESULTS: Large differences between specialties in reimbursements were found in the overall amount paid. For most specialties, these differences were explained by factors such as time for procedure, location, complexity of procedure and sex of patients. However, hourly reimbursements for ophthalmologists were substantially higher (more than 50% above general surgery overall and 72% higher on an hourly basis). Some other smaller differences in overall and hourly reimbursement were also found. CONCLUSIONS: These results indicate that specialist fees vary significantly but many of the differences are explainable by factors incorporated into the RBRVS. However, significant variation remains for some specialties, most notably ophthalmology. Explanations for the results are discussed, including the possibility that political factors may influence the setting of specialist fees. This raises questions concerning the fairness of reimbursements and resulting solidarity within the medical profession.

Fee-for-Service Plans↗

PubMed2003

The Auckland experience with laparoscopic donor nephrectomy.

AIMS: To examine the initial experience of laparoscopic donor nephrectomy (LDN) in New Zealand and compare it with open donor nephrectomy (ODN). METHODS: All LDNs performed between June 2000 and June 2002 were reviewed. An equal number of ODNs were reviewed. Data were also collected on the recipients of the grafts. Key clinical data were prospectively collected; remaining data were collected by retrospectively reviewing patient charts. Auckland Hospital databases were accessed for costing analysis. RESULTS: Thirty five cases of each procedure had been performed. There has been 100% LDN graft survival. There was no significant difference in graft function (serum creatinine) at one and 12 months (p = 0.25 and 0.35) between the two groups. There was no significant difference in donor morbidity (26% vs 31%, p = 0.59). LDN resulted in a shorter hospital stay (3 vs 6.5 days, p <0.0001) and convalescence period (3 vs 6 weeks, p <0.0001). LDN was significantly more expensive (13 357 dollars vs 6713 dollars, p <0.0001). CONCLUSIONS: LDN in the New Zealand setting provides effective grafts for renal transplant recipients and is safe for the donor. Advantages for the donor are a shorter hospital stay and convalescence period. The major disadvantage of LDN is its higher cost compared with ODN.

Adult↗

PubMed2003

Patients' perception of the adequacy of informed consent: a pilot study of elective general surgical patients in Auckland.

AIM: This study was designed to determine the adequacy of the informed consent process from the patient's perspective and in the light of published standards. METHODS: A pre-operative survey questionnaire was filled in during an interview with 77 patients before an elective general surgery operation. Forty two (58%) of the patients also completed a post-operative postal questionnaire. RESULTS: The results show that there is a need for more specific information (including the nature of the planned operation, the alternatives and complications) to be given by the senior doctor undertaking the procedure and before the patient is admitted to hospital. This study has highlighted the importance of confirming that the patient considers that they understand and are fully satisfied with the information provided, and that they have been able to ask questions without any sense of pressure. CONCLUSIONS: In giving voice to our patients' views on the adequacy of the informed consent process, this study has identified where improvements could be made in this important aspect of patient care.

Attitude to Health↗

PubMed2003

Factors determining the return to normal activity after appendicectomy.

BACKGROUND: The ability of a patient to return to their normal activities is an important outcome of an operation. The present study was designed to identify and rank factors that are important in determining this return to normal activity (RTNA) after appendicectomy. METHODS: Consecutive patients were identified prospectively following appendicectomy at North Shore Hospital between February and April 2000. Data regarding 25 different factors were obtained by a structured patient interview before and after discharge from hospital and by review of the medical records. Statistical analysis involved analysis of variance and logistic regression analysis. RESULTS: There were 98 patients (median age 28, range 15-69 years, male : female ratio 48:50) who had an appendicectomy. An open appendicectomy was performed in 74 patients, a laparoscopic appendicectomy in 22 patients and a laparotomy in two patients. This includes the 16 patients who were converted from laparoscopic to open appendicectomy (conversion rate 42% 16/38). Acute appendicitis was confirmed by histology in 67 (68%) patients. The significant independent variables identified by anova were ranked by logistic regression analysis. The most important determinant for the time to RTNA was what the doctor advised (chi-squared 43.7, P < 0.0001). The other determinants were the physical activity of their primary occupation (chi-squared 21.5, P < 0.017), the need for strong postdischarge analgesia (chi-squared 21.1, P < 0.13), the American Society of Anesthesiologists (ASA) category (chi-squared 13.6, P < 0.018) and the total sick leave obtained (chi-squared 9.6, P < 0.08). CONCLUSION: It has been shown that the most significant factor in determining the RTNA after appendicectomy was the advice given by the doctor, and that this was more important than the surgical approach, pathology, complications, age or occupation of the patient.

Adolescent↗

PubMed2002

Gall bladder cancer, extrahepatic bile duct cancer and ampullary carcinoma in New Zealand: Demographics, pathology and survival.

INTRODUCTION: The aim of present paper was to document the incidence of gall bladder cancer, cancer of the extrahepatic bile ducts and ampullary carcinoma in New Zealand. METHODS: Data were collected from the New Zealand Cancer Registry from 1980 to 1997 and combined with national census statistics to give crude and age standardized incidence rates. RESULTS: Over the 18-year study period, 226 carcinomas of the ampulla of Vater, 608 gall bladder cancers, and 486 extrahepatic cholangiocarcinomas were registered. The age standardized incidence rates for gall bladder carcinoma in all New Zealanders were 0.41/100 000 in men and 0.74/100 000 in women. The age standardized incidence rates for gall bladder cancer in Maori were 1.49/100 000 in Maori men and 1.59/100 000 in Maori women. The corresponding age standardized incidence rates for extrahepatic bile duct cancers were 0.67/100 000 in men and 0.45/100 000 in women. There were insufficient cases to calculate an age standardized incidence in Maori or Pacific Islanders. For carcinoma of the ampulla, the age standardized rates were 0.34/100 000 in men and 0.25/100 000 in women. There were insufficient cases to calculate an age standardized incidence rate for Maori or Pacific Islanders. When histology was defined adenocarcinoma was the most common form of cancer occurring in 66% of gall bladder cancers, 91% of extrahepatic bile duct cancers and 70% of ampullary cancers. Most tumours were advanced at presentation with regional or distant metastases present in 72% of gall bladder cancers, 63% of extrahepatic bile duct cancers and 69% of ampullary tumours at diagnosis. Survival was poor with median survivals of 86 days, 151 days and 440 days recorded for gall bladder cancer, extrahepatic bile duct cancer and ampullary cancer, respectively. CONCLUSIONS: The demographic profile, pathology and survival of patients with gall bladder cancer, extrahepatic bile duct cancer and ampullary carcinoma are similar in New Zealand to that of other Western countries. However New Zealand Maori have a relatively high incidence of gall bladder cancer, and the incidence is equal in both Maori men and women, while cancers of the extra-hepatic bile duct and ampulla of Vater are rare in Maori. In comparison, cancers of the gall bladder, extrahepatic bile ducts and ampulla are rare in Pacific Islanders.

Adenocarcinoma↗