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PubMed1976

Repair of the ligaments about the knee.

The evolution of techniques used to repair torn ligaments about the knee is described. A combination of repairs of the anterior cruciate ligament, medial collateral ligament, and posterior joint capsule along with transfer of the medial half of the semimembranosus tendon and transfer of the pes anserinus is described. The surgical procedures have been evolved over a three year period in an orthopedic practice in a skiing and resort community. These combinations of surgical techniques can insure stable knees for active persons without the need to resort to more formal and more extensive surgical procedures. It is also thought that repair of both fresh and old ligament tears in the manner described gives the athletic individual a better chance for continuing in recreational and competitive sports, as well as reducing the possibility of lateral degenerative joint changes.

Athletic Injuries↗
PubMed1981

Private health insurance plans in 1978 and 1979: a review of coverage, enrollment, and financial experience.

The private health insurance industry collected $55.9 billion in premiums in 1979 and returned $50.2 billion in benefits to its subscribers. Premiums rose 12.4 percent, slightly faster than in 1978 when premiums rose 11.4 percent, to $49.7 billion. Benefits rose 11.4 percent in 1979, down from the 12.6 rate in 1978. After operating expenses were deducted, the industry showed underwriting losses of $1.4 billion in 1979 and $1.5 billion in 1978. About 78 percent of the population was insured for hospital care, 76 percent for x-ray and laboratory examinations, and about 76 percent for surgical services in 1979. Smaller percentages had coverage for other types of care. An estimated 64 percent of the aged bought private hospital insurance, and about 43 percent bought surgical insurance, mostly to supplement Medicare benefits. An estimated 12 percent of persons under age 65 had no protection against the cost of hospital care either through private insurance or a public program such as Medicare or Medicaid.

Insurance↗
PubMed1989

Potential for inpatient-outpatient substitution with diagnosis-related groups.

Through analysis of data from the universal health insurance system in Manitoba, Canada, surgical diagnosis-related groups (DRG's) with the greatest potential for inpatient-outpatient substitution are identified. Candidates for both "inpatient shift" and "outpatient shift" are discussed. It is also suggested that determination of the procedure chiefly responsible for hospital admission complements approaches to improve the DRG classification system by measuring severity of illness. Thus, health care planners' efforts may be facilitated in establishing effective payment systems, though definitive guidelines are not provided.

Aged↗
PubMedDate not supplied

Relationship between type of health insurance and time to inpatient rehabilitation placement for surgical subspecialty patients.

A significant proportion of patients on a neurosurgical service require inpatient rehabilitation placement after discharge. The relationship between the type of health insurance of the patient at the time of admission and the time to placement of patients has not previously been addressed. We prospectively studied all patients on the adult neurosurgical service at our hospital to determine whether the type of health insurance carried by patients is related to the time necessary to arrange acceptance into inpatient rehabilitation facilities. Ninety-one patients (51 men, 40 women; mean age, 56 years) admitted to the neurosurgery service during a 6-month period required inpatient rehabilitation placement after discharge. The time in days between the request for placement into a rehabilitation facility and the acceptance of the patient was examined. The mean time for placement of patients with and without health insurance at the time of admission was 0.8 days and 2.1 days, respectively (overall mean, 1.1 days) (P < .002). No statistically significant associations were found between age, sex, or race of the patient and the time to placement. In addition, there was no difference in the time to placement between those patients admitted as a result of trauma and those patients admitted for reasons other than trauma. These results indicate that among patients on a neurosurgical service, patients with private health insurance are accepted into inpatient rehabilitation approximately 1 day sooner than patients without private health insurance. Patients without private health insurance are delayed in their transfer to inpatient rehabilitation facilities and more aggressive inpatient rehabilitation. How this finding translates into an increase in cost of care or a decrease in patient outcomes is unknown.

Adolescent↗
PubMed2004

Emergency room coverage: an evolving crisis.

Historically, a newly graduated plastic surgeon in the United States could build a practice from his or her emergency room coverage. The historical cliche was for the surgeon to be affable, able, and available, and from that basis one's practice would grow. Emergency room exposure was an avenue for starting a practice, developing recognition, and, after that, building a referral pattern. Recently, the cross-shifting influence of management care, rising malpractice insurance costs, and risk ratio are changing this cliche to a crisis. An evaluation of a 2 1/2-year exposure to emergency room coverage has revealed a completely different profile. A total of 300 patient visits resulting in 69 surgical operations were evaluated for insurance and remuneration history. The findings indicated a significant remuneration dilemma for emergency room coverage. Interestingly, a remuneration problem exists in a market different from what one would expect. In this study, a sample from a suburban hospital, rather than an inner-city university hospital, is the greater problem.

Cost Control↗
PubMed1982

[Ambulatory surgery].

Explore the source record for details and available documents.

Ambulatory Surgical Procedures↗
PubMed2000

The relationship between managed care insurance and use of lower-mortality hospitals for CABG surgery.

CONTEXT: Explicit information about the quality of coronary artery bypass graft (CABG) surgery has been available for nearly a decade in New York State; however, the extent to which managed care insurance plans direct enrollees to the lowest-mortality CABG surgery hospitals remains unknown. OBJECTIVE: To compare the proportion of patients with managed care insurance and fee-for-service (FFS) insurance who undergo CABG surgery at lower-mortality hospitals. DESIGN: A retrospective cohort study of CABG surgery discharges from 1993 to 1996, using New York Department of Health databases and multivariate analysis to estimate the use of lower-mortality hospitals by patients with different types of health insurance. SETTING: Cardiac surgical centers in New York, of which 14 were classified as lower-mortality hospitals (mean rate, 2.1%) and 17 were classified as higher-mortality hospitals (mean rate, 3.2%). PATIENTS: A total of 58,902 adults older than 17 years who were hospitalized for CABG surgery. Patients were excluded if their CABG surgery was combined with any valve procedure or left ventricular aneurysm resection or if they were younger than 65 years and enrolled in Medicare FFS or Medicare managed care. MAIN OUTCOME MEASURE: Probability of a patient receiving CABG surgery at a lower-mortality hospital. RESULTS: Compared with patients with private FFS insurance (n = 18,905), patients with private managed care insurance (n=7169) and Medicare managed care insurance (n=880) were less likely to receive CABG surgery at a lower-mortality hospital (relative risk [RR] of surgery at a lower-mortality hospital compared with patients with private FFS insurance, 0.77; 95% confidence interval [CI], 0.74-0.81; P<.001; and RR, 0.61; 95% CI, 0.54-0.70; P<.001, respectively, after controlling for multiple potential confounding factors). Patients with Medicare FFS insurance used lower-mortality hospitals at rates more similar to those with private FFS insurance (n = 31,948; RR, 0.95; 95% CI, 0.91-0.98; P=.004). CONCLUSIONS: Patients in New York State with private managed care and Medicare managed care insurance were significantly less likely to use lower-mortality hospitals for CABG surgery compared with patients with private FFS insurance.

Aged↗
PubMed1984

Nephrosonography and renal scintigraphy in evaluation of newborn with renomegaly.

Prompt diagnosis of renomegaly in the newborn is necessary for appropriate medical or surgical management to insure maximal recovery of renal function. To investigate both renal structure and function without iodinated contrast infusion, combined ultrasonography and nuclear scintigraphy were evaluated in 17 newborns with renomegaly and 6 infants with cystic renal abnormalities detected in utero. In 18 patients, intravenous pyelography (IVP) and/or voiding cystourethrography (VCUG) were performed subsequently. While ultrasonography or scintigraphy alone provided the major diagnosis in 48 per cent and 30 per cent of cases, respectively, the combination of both studies yielded the major diagnosis in 87 per cent. Subsequent IVP was less informative than combined sonography and scintigraphy in 5 of 15 patients, and VCUG confirmed the final diagnosis in 4 of 13 patients. We conclude that initial evaluation of the newborn with renomegaly should comprise ultrasonography followed by nuclear scintigraphy. This combination of studies provides adequate information to determine subsequent management in nearly 90 per cent of cases without subjecting infants to the risks of contrast infusion or higher doses of diagnostic levels of radiation.

Female↗
PubMed2002

Striving towards efficiency in the Greek hospitals by reviewing case mix classifications.

In order to verify the efficiency level of Greek public hospitals, this paper evaluates the most recent indicators. Relevant data were collected from the two following databases: (a) hospitals' utilisation data generally and per clinical speciality [Ministry of Health, Athens, (Data based) 1995]; (b) Patients' and hospitals' characteristics per diagnosis [National Statistical Office, Athens, (Data based) 1993]. As explanatory variables, the study examines supply and demand factors following case mix classifications. Firstly, average length of stay (ALOS) and secondly, cost per case were regressed as dependent variables. The study highlights the extent of variability across hospitals for different groups of patients with the same condition. The results specify the most important factors that affect ALOS and cost pertaining to efficiency. Per speciality analysis shows occupancy, size-type of the hospital, beds and doctors per speciality, access and use of outpatient services, and surgical operations, etc. as the most significant factors. Per disease-diagnosis analysis shows age of over 65 years, gender, residence, marital status, surgical operation and insurance as the most important factors. General cost analysis in all National Health Systems (NHS) hospitals shows that economies of scale appear in: (a) district and/or specialised hospitals of 250-400 beds; (b) regional and/or teaching hospitals of over but near to 400 beds. Consequently, the author determines the 'Greek' Diagnostic Related Groups (DRGs), based on the cost per clinical speciality in the nine basic specialities and on the cost per diagnosis of the top 15 diagnoses. Further to the scientific results, such studies will enhance much necessary discussions on the organisation of service delivery and financing, by following case mix classification.

Adolescent↗
PubMed1998

Occupationally related tumors in tar refinery workers.

BACKGROUND: The study comprised 606 workers with tar-induced dermatosis employed in a German tar refinery. During the period from 1946 to 1996 they were recognized as having an occupational disease. OBJECTIVE: The aim of this study was to characterize the histologic findings and the localization of the occupational dermatosis and to determine the latency period of the carcinomas from the beginning of exposure in the tar refinery to the first occurrence of malignant skin tumors. Furthermore, the study aimed to check whether other skin changes were frequently diagnosed in addition to known tar-induced tumors. METHODS: The data were collected retrospectively from the documents of the Employer's Liability Insurance Association. RESULTS: Surgical removal of 4754 skin tumors was documented up to the end of 1996 in the study. In 90% of cases the histologic diagnosis was confirmed. Among other conditions, this yielded 2490 precancerous stages, 380 squamous cell carcinomas, 218 basal cell carcinomas, and 182 keratoacanthomas. The skin tumors were found mainly in the facial area, as well as on the forearms and hands. Latency from the first exposure in the tar refinery until manifestation of tar-induced dermatosis covered a period of 57 years. CONCLUSION: In comparison to the general population, the ratio of squamous cell to basal cell carcinomas was shifted toward the squamous cell carcinomas (1.7:1). Sunlight is known to be a cofactor in the pathogenesis of keratosis, squamous cell carcinomas, and basal cell carcinomas. However, the difference in location of these tumors shows that the role sunlight plays in the pathogenesis of precancerous lesions and squamous cell carcinomas may be overvalued. The latency period from the beginning of exposure to the manifestation of squamous cell carcinomas could not be evaluated because of an intervention bias as a result of preventive excisions of precancerous lesions. The frequent occurrence of keratoacanthomas (in 18.7% of the workers) and the early age at which this disease became manifest relative to the general population (median, 55 years) indicate that employment in a tar refinery can primarily or secondarily cause keratoacanthomas.

Adolescent↗
PubMed1980

The value of choledochoscopy in exploration of the common bile duct.

Direct visualization of the biliary tree using choledochoscopy has been recommended as a technique to improve the accuracy of common duct exploration. In several series the incidence of retained biliary calculi has been dramatically reduced using choledochoscopy, and some authors have reported the findings of other unsuspected benign and malignant lesions as well. During an eight-year period 288 patients underwent exploration of the common bile duct specifically for calculous disease. Operative rigid choledochoscopy was performed in 140 patients in this group, with 79 found to have choledocholithiasis; seven retained stones occurred in this group for an incidence of 8.9%. Routine common duct exploration in the other 148 patients revealed 67 to have choledocholithiasis; six retained stones occurred in this group for an incidence of 9.0%. Though there was no difference in the incidence of retained stones with or without choledochoscopy, 20 patients were found to have stones missed during routine exploration once the rigid choledochoscope was inserted. In addition to the obvious value of the choledochoscope in identifying and removing common duct stones, it was also found to be an aid in removing stones in the intra-hepatic ducts and in clarifying atypical anatomy. Other causes of biliary obstruction such as a liver fluke, benign polyp, benign strictures, and ductal carcinomas were identified by use of biopsy forceps inserted through the choledochoscope. It is recommended that routine choledochoscopy be performed during common duct explorations and that surgical training programs insure that residents learn the technique of operative choledochoscopy.

Cholestasis, Extrahepatic↗
PubMed1978

Hospital admission before and after Medicare in Quebec.

A 1 in 60 random sample of Quebec hospital admission records ("separations") for the years 1966 through 1974 was studied for evidence of change associated with the introduction in 1970 of universal health insurance. Non-surgical separation rates continued to decline in Montreal and remained steady in the rest of the province. In contrast, separations following surgical operation did not decline in Montreal and have increased substantially since 1970 in the rest of the province. Ten operative procedures accounting for 41 per cent of all surgical admissions were selected for separate study: of these, cholecystectomy, hysterectomy and hernia repairs conformed most closely to the new pattern. Directly or indirectly, Medicare may have contributed to these changes but more study is required to confirm or explain this.

Bed Occupancy↗
PubMed1989

Spinal epidural abscess. An infectious emergency. Case report and review.

Spinal epidural abscess is an unusual disease in the pediatric age group, requires early diagnosis and prompt surgical drainage to insure a good clinical outcome. Back pain and fever are usually the only presenting symptoms occurring before precipitous neurologic deterioration. The causative organism is most often Staphylococcus aureus, which presumably is spread to the epidural space hematogenously. Diagnosis is facilitated by computed tomography (CT) scan, but the entire spine must be imaged by either myelography or magnetic resonance imaging (MRI) to assess for skip lesions.

Abscess↗
PubMedDate not supplied

Evidence of inappropriate application of autologous cartilage transplantation therapy in an uncontrolled environment.

Autologous chondrocyte transplantation is a new procedure developed for the treatment of focal articular cartilage defects of the knee. The exact indications and limitations of this procedure have not yet been completely defined through prospective, randomized studies. The purpose of this study was to examine the indications and contraindications for surgery in consecutive cases initially rejected for reimbursement of surgical expenses by insurance companies, but now on appeal, to assess whether patients referred by the physicians met the procedure criteria. Twenty-four consecutive candidates were referred for adjudication when the recommending orthopaedic surgeon appealed a rejection by a medical reviewer. The factors examined included the number and size of the cartilage lesions, the presence of tricompartmental arthritis, transplantation proposed for patellar lesions, patient age, and sagittal plane deformity. In 23 of 24 cases (96%) the indications for the procedure were not met or specific contraindications were present. In 15 of 24 cases (63%) there were multiple contraindications. The results of this study underscore the importance of controlled, application-limited experience before the release of new procedures for widespread clinical applications. The uncontrolled use of this procedure may negatively skew the overall results for this technique, prejudicing a procedure that may be successful for the correct indications.

Adolescent↗