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PubMed2006

Volume and process of care in high-risk cancer surgery.

BACKGROUND: Although relations between procedure volume and operative mortality are well established for high-risk cancer operations, differences in clinical practice between high-volume and low-volume centers are not well understood. The current study was conducted to examine relations between hospital volume, process of care, and operative mortality in cancer surgery. METHODS: Using the Medicare claims database (2000-2002), we identified all patients undergoing major resections for lung, esophageal, gastric, liver, or pancreatic cancer (n=71,558). Preoperative, intraoperative, and postoperative processes of care potentially related to operative mortality were identified from inpatient, outpatient, and physician claims files using appropriate International Classification of Diseases--Clinical Modification (ICD-9) and Current Procedural Terminology (CPT) codes. We then assessed variation in the use of each process according to hospital volume, adjusting for patient characteristics and procedure type. Study Participants were US Medicare patients. The main outcome measure was specific processes of care. RESULTS: Relative to those at low-volume centers (lowest 20th by volume), patients at high-volume hospitals (highest 20th) were significantly more likely to undergo stress tests (odds ratio [OR]: 1.51, 95% confidence interval [CI]: 1.21-1.87), but not other preoperative imaging tests. They were more likely to see medical or radiation oncologists (OR: 1.37, 95% CI: 1.16-1.62), but not other specialists, preoperatively. Although blood transfusions and use of epidural pain management did not vary significantly by volume, patients at high-volume hospitals had significantly longer operations and were more likely to receive perioperative invasive monitoring (OR: 2.56, 95% CI: 1.82-3.60). Differences in measurable processes of care did not explain volume-related differences in operative mortality to any significant degree. CONCLUSIONS: Although high-volume and low-volume hospitals differ with regard to many aspects of perioperative care, mechanisms underlying volume-outcome relations in high-risk cancer surgery remain to be identified.

Aged↗
PubMed2004

Electrodiagnostic services in the United States.

To identify patterns of service provision in the United States, electrodiagnostic encounters were characterized by analyzing data from the 1998 MarketScan Commercial Claims & Encounters Database (The MEDSTAT Group). Electrodiagnostic-related claims were identified using CPT codes for nerve conduction studies, electromyography, and somatosensory evoked potentials. Over 130,000 electrodiagnostic claims representing 48,207 separate electrodiagnostic encounters were identified. Neurologists accounted for the highest percentage of physician providers (23.6%), followed closely by physiatrists (22%). Physiatrists performed the services at a higher rate than any other provider (886.3 studies per 100 practicing physiatrists). Electrodiagnostic encounters by nonphysician providers accounted for 16.9% of all studies. Physical therapists were the dominant nonphysician providers of electrodiagnostic services (9.3%), followed by podiatrists (5.5%). Physician providers had a median of three claims per encounter compared with one claim per encounter for nonphysician providers. The relatively large proportion of studies conducted by nonphysicians, as well as their limited extent of testing, raises concerns about the quality of care for these patients. These quality issues should be addressed in future studies.

Adolescent↗
PubMed2005

The economic impact of incorporating flexible endoscopy into a community general surgery practice.

BACKGROUND: Flexible endoscopy is a vital component of gastrointestinal surgery. It has and will replace many of the surgical procedures now commonly performed. Flexible endoscopy, unfortunately, is not an integral part of surgical residency training based on resident operative experience as reported by the Residency Review Committee. Moreover, general surgeons have deferred the practice of flexible endoscopy to the gastroenterologists because of concerns over turf battles and referral patterns. The purpose of this study was to assess the overall case load and the economic impact of flexible endoscopy on the practice of general surgery in a community hospital setting. METHODS: This retrospective review was performed over a 6-month period. The total cases and the total billings of inpatient and outpatient procedures for a group practice of five general surgeons in a community hospital were evaluated. The billings were the actual charges based on current procedural terminology (CPT) codes for these procedures using the Medicare fee schedule. RESULTS: Of the 2,159 procedures performed, 1,154 involved flexible endoscopy cases accounting for 54% of all cases (1,154 of 2,159) performed from February 1, 2003 to July 31, 2003. Flexible endocopy accounted for 43% of the total charges. A. total of 46 surgical procedures and 216 future endoscopies were generated from the flexible endoscopic procedures. Future endoscopic cases were for surveillance of colonic neoplasia and Barrett's esophagus. CONCLUSIONS: Flexible endoscopy contributed to a major portion of the caseload and revenue generated by the general surgery group studied. The overall impact of flexible endoscopy is even greater than reported because of the future endoscopic surveillance cases or surgical interventions generated on the basis of endoscopic findings.

Ambulatory Surgical Procedures↗
PubMed2005

CT directed diagnostic and therapeutic pericardiocentesis: 8-year experience at a single institution.

UNLABELLED: A retrospective review of the 8-year experience at a single institution performing more than 300 CT directed pericardiocenteses was performed. The technique, results, and complications were determined. Comparative data from the literature relating to cardiology and thoracic surgery are reviewed. A CPT code data base search was performed to identify all imaging directed pericardiocenteses at a 550 bed regional medical center between 1993 and 2001. Medical records, imaging studies, and reports as well as pertinent laboratory, chemistry and hematology values were reviewed. Demographics, results, fluid analyses, techniques, systems used and complications were recorded. RESULTS: Three hundred and nineteen pericardiocenteses using CT localization were attempted on 261 patients. One hundred and forty-two men were included and mean age was 61 years (range 6 months to 89 years). Mean volume aspirated was 418 cc (range 0-1,875 cc). The major complication rate was 0.3%; the minor complication rate was 6.9%. Technical success was achieved in 98.4% procedures. Emergent pericardiocentesis was performed on anticoagulated patients without significant bleeding. Seventy-nine percent of patients with echocardiographic evidence of tamponade had symptomatic improvement. Patients with marked shortness of breath without other evidence of tamponade benefited symptomatically in 78%. Pericardiocenteses with CT localization is relatively safe and many patients achieve symptomatic relief.

Adolescent↗
PubMed2005

Detection of vertebral fractures.

Despite the importance of vertebral compression fractures, there is much that remains uncertain. There is no "gold standard" for the definition which has led to epidemiologic and study differences. Height loss is a way to suspect vertebral fractures but it has its own issues. There are multiple radiographic systems for defining vertebral fractures, both prevalent and incident; risk factors for prevalent fractures have already been delineated. Recent studies have elucidated the risk factors for incident vertebral fractures including age, low weight, late menarche, lower bone mineral density, history of vertebral and nonvertebral fractures, smoking, and use of a walking aid. Fan beam densitometers have had improving ability to image the spine, a procedure now known as vertebral fracture assessment (VFA). Recently (in the United States) a CPT code and reimbursement was established. Yet, many vertebral fractures go undiagnosed, diagnosed but unreported, or reported but not utilized in patient care. Because of this, the International Osteoporosis Foundation developed a Vertebral Fracture Initiative for radiologists and the International Society for Clinical Densitometry began a VFA course. Both teaching programs use the semi-quantitative assessment of Genant to aid the radiologists and clinicians in detecting vertebral fractures.

Body Height↗
PubMed1992

Productivity of radiologists in the United States by imaging technique: a 16-year analysis based upon relative value units.

Professional Relative Value Units (RVUs) quantifying productivity of radiologists in the United States were used to study trends from 1973 to 1989 in the distribution of productivity among the various imaging techniques. Data from a 1989 survey were used to estimate the distribution of radiology examinations among techniques for 1989. A difficulty index (RVUs per examination) was calculated for each technique weighted by actual CPT-code occurrences reported in that survey. An RVU workload was estimated for each technique by multiplying the occurrences of the technique by its corresponding difficulty index. This analysis was applied first to the 1989 data, and second, retrospectively, to data from the literature that gave the distribution by technique of estimated national procedures for 1973 and 1980. The number of studies and RVUs in all techniques has increased from 1973 to 1989 with a relatively greater increase in the percentage of mammography and of sectional imaging examinations. Differences in difficulty index between the techniques leverage the changes in occurrence, causing a dramatic increase in the percentage of RVU workload represented by sectional imaging. The percentage of procedures and RVUs represented by vascular/interventional has remained relatively constant. The overall difficulty index has risen by 18% from 1973 to 1989. These trends should influence the allocation of space, equipment, and human resources in radiology department planning and management.

Diagnostic Imaging↗
PubMed1992

Reimbursement of biotherapy: present status, future directions--perspectives of the office-based oncology nurse.

Economic forces are stimulating cost sensitivity and the need for clinical efficiency in medicine. The federal government has led the way with Medicare reform, and cost-containment efforts are evident in all health care payer programs. More and more, the office-based oncology nurse is involved in reimbursement issues as both a colleague and a patient advocate. Creative solutions to the challenges of reimbursement require knowledge of the issues, familiarity with patient-specific therapies, and recognition of unique cost and billing issues. Biologic agents frequently used in office-based oncology practice are easy targets for reimbursement denials because of regulations against their investigational status, "off-label" use, method of administration, and relatively high cost. Such agents include interferon, erythropoietin (EPO), granulocyte and granulocyte-macrophage colony-stimulating factors (G-CSF and GM-CSF, respectively), and interleukin-2 (IL-2). Reimbursement decisions are often characterized by inconsistency and uncertainty, and rulings are based not only on law, but also on interpretation. The need for clarification often opens a window for negotiation for the complex reimbursement issues associated with biotherapy. In addition to thoroughly determining cost and accurately assigning appropriate Current Procedural Terminology (CPT) codes, office-based oncology nurses can pursue various strategies to help their patients and practices obtain reimbursement of biotherapy. Chief among these is educating third-party payers on the appropriateness and necessity of newer treatment modalities. In individual cases, documentation of the scientific data, clinical outcomes, and cost benefits supporting a treatment decision almost always gains reimbursement.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost Allocation↗
PubMed2005

Current trends in the reimbursement of professional neuropsychological services.

Professional members of the National Academy of Neuropsychology (NAN) completed a survey focusing on clinicians' time requirements for activities, number of yearly claims to funding sources, average reimbursement rates, reimbursement rates associated with specific current procedural terminology (CPT) codes, managed care tolerance, hourly reimbursement rates, and other relevant practice issues such as incident-to. Clinicians continue to offer neuropsychological services through traditional assessment and evaluation activities, receive referrals from other healthcare professionals (i.e., neurologists, other medical specialists), and answer traditional referral questions related to patient diagnoses and determination of neuropsychological deficits. Two-thirds of respondents disapprove of managed care, and clinicians engage in activities which appear to minimize the ongoing changes in, and detrimental effects of, managed-care-based funding, in the form of dropping managed care panels, opting for fee-for-service, requiring self-pay patients, or spending more time in clinical activities for which there is a higher percentage of time approved such as forensic evaluations and evaluations for private practice. Clinicians continue to rely on managed care for their referrals even though they are only being reimbursed at about 50%. Overall, across service providers, clinicians are only receiving 60% of their hourly rate, and only 22% report receiving full compensation for their hourly rate. These results suggest that the effects of managed care have, for better or worse, altered the practice of clinical neuropsychology.

Attitude of Health Personnel↗
PubMed2006

Gender disparities in colorectal cancer screening: true or false?

To date, nearly all studies examining gender disparities in colorectal cancer screening report a lower endoscopic screening rate in women. Using a statewide claims database, gender differences in screening rates were analyzed in an attempt to validate gender disparities reported in prior survey-based studies. Procedural-level dataset containing all patient encounters for 2003 in which a colonoscopy or flexible sigmoidoscopy were performed was created. Procedures were selected using CPT codes and univariate analysis was performed using SAS v 8.0. Statewide for average-risk individuals 50 years or older, 65,232 endoscopic procedures were performed in 2003. The majority (83%) of endoscopic screening procedures were colonoscopies. Overall, the rate of screening in average-risk women 50 years or older (38 procedures/1000 people) was slightly lower than in men (42/1000) but not statistically significant. The rates of screening were higher in women before the age of 60 years and lower after the age of 60 years. No clinically significant difference was found in the type of screening procedure performed. Gender disparities in rates and types of colorectal cancer screening reported in prior survey studies are not validated in this patient encounter data study.

Adult↗
PubMed2003

Optimization of operating room allocation using linear programming techniques.

BACKGROUND: New and innovative approaches must be used to rationally allocate scarce resources such as operating room time while simultaneously optimizing the associated financial return. In this article we use the technique of linear programming to optimize allocation of OR time among a group of surgeons based on professional fee generation. STUDY DESIGN: For the period of December 1, 2000, to July 31, 2002, the following individualized data were obtained for the Division of General Surgery at Duke University Medical Center: allocated OR time (hours), case mix as determined by CPT codes, total OR time used, and normalized professional charges and receipts. Inpatient, outpatient, and emergency cases were included. The Solver linear programming routine in Microsoft Excel (Microsoft Corp.) was used to determine the optimal mix of surgical OR time allocation to maximize professional receipts. RESULTS: Our model of optimized OR allocation would maximize weekly professional revenues at 237,523 US dollars, a potential increase of 15% over the historical value of 207,700 US dollars or an annualized increase of approximately 1.5 million US dollars. CONCLUSIONS: Our results suggest that mathematical modeling techniques used in operations research, management science, or decision science may rationally optimize OR allocation to maximize revenue or to minimize costs. These techniques may optimize allocation of scarce resources in the context of the goals specific to individual academic departments of surgery.

Fees, Medical↗
PubMed2005

Economic evaluation of minimally invasive colectomy.

BACKGROUND: We performed a cost-benefit analysis of minimally invasive colectomy (MIC) with the appreciation that this approach extends the duration of the operation and requires additional instruments and equipment when compared with the open procedure. These negatives may be offset by decreased pain, earlier initiation of oral feeding, and a shorter hospitalization. STUDY DESIGN: We reviewed operating room records of all open colectomies (OCs) and MICs performed at Strong Memorial Hospital between January 1, 2000, and March 31, 2004, as defined by CPT codes. Operating room times, total operating room costs, lengths of hospital stay, and total hospital costs were calculated for each procedure. RESULTS: Sixty-eight right hemicolectomies (54 OCs and 14 MICs) were performed. Operating room time was significantly longer for MIC compared with OC (214 +/- 41 minutes versus 170 +/- 56 minutes, p = 0.01). Length of hospital stay was shorter for MIC compared with OC (4.5 +/- 1.3 days versus 7.4 +/- 2.5 days, p = 0.004). There were 131 left hemicolectomies (104 OCs and 27 MICs) performed. Operating room time was significantly longer for left MIC compared with left OC (256 +/- 46 minutes versus 213 +/- 60 minutes, p = 0.005). Length of hospital stay was shorter for left MIC than for left OC (4.4 +/- 1.3 days versus 7.9 +/- 3.0 days, p = 0.001). Total hospital costs were significantly lower for MIC compared with OC (8,580 US dollars +/- 1,358 US dollars versus 10,303 US dollars +/- 3,299 US dollars, p = 0.046). CONCLUSIONS: MIC is associated with a significantly longer operating room time and a shorter hospital stay than OC. Operating room cost is significantly higher for MIC, but total hospital cost is lower. MIC is cost effective and results in significant savings to the health-care system.

Aged↗
PubMed2006

Automated identification of adverse events related to central venous catheters.

Methods for surveillance of adverse events (AEs) in clinical settings are limited by cost, technology, and appropriate data availability. In this study, two methods for semi-automated review of text records within the Veterans Administration database are utilized to identify AEs related to the placement of central venous catheters (CVCs): a Natural Language Processing program and a phrase-matching algorithm. A sample of manually reviewed records were then compared to the results of both methods to assess sensitivity and specificity. The phrase-matching algorithm was found to be a sensitive but relatively non-specific method, whereas a natural language processing system was significantly more specific but less sensitive. Positive predictive values for each method estimated the CVC-associated AE rate at this institution to be 6.4 and 6.2%, respectively. Using both methods together results in acceptable sensitivity and specificity (72.0 and 80.1%, respectively). All methods including manual chart review are limited by incomplete or inaccurate clinician documentation. A secondary finding was related to the completeness of administrative data (ICD-9 and CPT codes) used to identify intensive care unit patients in whom a CVC was placed. Administrative data identified less than 11% of patients who had a CVC placed. This suggests that other methods, including automated methods such as phrase matching, may be more sensitive than administrative data in identifying patients with devices. Considerable potential exists for the use of such methods for the identification of patients at risk, AE surveillance, and prevention of AEs through decision support technologies.

Artificial Intelligence↗
PubMed2004

Understanding work-related injuries in children: a perspective in West Virginia using the state-managed workers' compensation system.

BACKGROUND/PURPOSE: Little data exist that defines the consequences of occupational injuries in children. Traditional assessment of work-related injury is coupled with disability payments based on salary, which give little insight into etiology and severity. The authors hypothesize that the risk and pattern of occupational injuries in young workers are different then adults. METHODS: Claims from 1996 through 2000 were analyzed from the West Virginia Bureau of Workers Compensation. To define the significance of an injury, child and adult groups were subdivided into injuries that required surgery (ie, serious injuries). Current Procedural Terminology (CPT) codes for anesthesia and surgical procedures were cross referenced with the claims to ensure group designation. Relative risks (RR) were used to compare groups. RESULTS: Between 1996 and 2000, 364,063 claims were submitted, 14,093 in workers < or =19 years of age. Two hundred seventy claims in children required surgery. Serious injuries in children occur more often in boys 2.2x mainly in the (16 to 24 hours) evening (48% v 23.13%; P <.05) and in July/August (26.5 v 18.4; P <.001). Falls were the main mechanism of injury. Proportionately fingers (1.70x) and hands (1.64x, 1.6 to 1.7) were injured in children. Lacerations (3.4x), fractures (1.4x), and amputations (3.75x) frequently resulted in general anesthetic procedures, and the RR of these injuries were increased versus adults. Service, manufacturing, construction, and agriculture were the main injury-related occupations in children. CONCLUSIONS: For any job category, injuries in children have unique features, tend to be more serious, and require a surgical intervention proportionately more frequently than adults.

Accidental Falls↗
PubMed2006

Assessing urinary diversion experience in urologic residency programs-are we adequately training the next generation?

PURPOSE: Operative experience is important in developing surgical skills and technical competency. There is also emerging evidence directly linking increased surgical volume to patient outcomes. Accordingly, resident training should provide the framework for mastery of complex operations. We evaluated the current urological residency experience in performing adult urinary diversion. MATERIALS AND METHODS: The Accreditation Council for Graduate Medical Education-Residency Review for Urology Operative Log Reports were reviewed from 2000 to 2004 with an emphasis on urinary diversion experience. Resident logs were analyzed specifically for all procedures that included CPT codes for continent and incontinent diversions. The logs were compared by year of training and type of urinary diversion. RESULTS: Overall, the total number of urinary diversions performed by graduating residents from 4-year programs has increased from 2,259 (2000 to 2001) to 4,017 (2003 to 2004). In addition, the mean and median number of urinary diversion cases among residents completing training have remained relatively constant. For graduating urology residents in 2003 to 2004, the mean (median) number of continent urinary diversion and incontinent urinary diversion cases were only 6.7 (3.0) and 9.5 (4), respectively. CONCLUSIONS: Current Accreditation Council for Graduate Medical Education data suggest the average urology resident has limited exposure to urinary diversion in general, and even less experience with more complex continent urinary diversion. These results suggest that many urology residency programs may not have sufficient volume to provide residents with a broad experience in urinary diversion, and alternative strategies to ensure proper training should be explored.

Internship and Residency↗
PubMed2005

Long limb Roux en Y gastric bypass revisited.

Roux-en-Y gastric bypass (RYGB) that is performed with at least a 150-cm Roux limb results in significantly greater weight loss than shorter (<100-cm) Roux limb procedures in superobese patients(BMI >50 kg/m2). Conversely, longer Roux limb procedures do not provide greater weight loss in less obese (BMI <50 kg/m2)patients. Modest elongation of the Roux limb-in the range of 150 cm to 200 cm-does not result in more frequent nutritional sequelae compared with shorter Roux limb procedures. This article discusses the current status of long limb Roux-en-Y gastric bypass in the context of weight loss, metabolic sequelae and CPT coding.

Anastomosis, Roux-en-Y↗
PubMed1997

A community collaborative practice experience between Med/Peds and family practice.

PURPOSE: The medical literature has followed educational outcomes of Medicine-Pediatric (Med/Peds) physicians, but limited studies exist as to clinical outcomes for these combined specialty physicians. Although a variety of practice environments are available for a growing number of Med/Peds physicians, a collaborative practice setting with family physicians may optimize the Med/Peds practice potential. This study investigates clinical practice outcomes and utilization efficiencies of collaborative Med/Peds family practice physicians within a community, which should provide an effective model in a growing managed care environment. PATIENTS AND METHODS: Two collaborative practice settings in a moderate size Midwest community were analyzed with respect to patient demographics and utilization scores provided by a practice management group and a nationally based health care network. Current Procedural Terminology (CPT) coding was used to follow demographic trends for over 45,000 patient visits for 1 year. Efficiency ratings (Z-scores) were used over the same year for over 6,000 health care network patient visits to 10 collaborative practice-based physicians, which were then compared to 141,101 community family practice patient encounters, 26,617 general internist patient encounters, and 29,995 patient encounters to pediatricians for utilization trends. RESULTS: Med/Peds and Family Practice patient care data reflected nearly identical patient demographics between specialties with only a few exceptions. Med/Peds physicians cared for three times the total number of children less than 2 years old. Med/Peds physicians experienced a higher complexity of illness, in part due to a 40% increase in internal referrals from family practice colleagues in the ambulatory care setting, while maintaining a third of the proportion of outpatient referrals. Cost-effective interoffice utilization was still maintained, supported by a more optimal efficiency rating for Med/Peds physicians compared to collaborative family practice colleagues. Inpatient efficiency was demonstrated for Med/Peds specialists even though a threefold increase in hospitalizations was observed, in part resulting from physicians within these collaborative practices arranging all newborn nursery and pediatric admissions be covered by Med/Peds physicians. Both collaborative primary care specialists demonstrated more cost-effective overall practice utilization scores when compared to community-based primary care specialists. CONCLUSIONS: Med/Peds physicians in this study have been trained to provide cost-effective patient care in both outpatient and inpatient settings. Decreased outside referrals by collaborative family practice physicians through utilization of Med/Peds colleagues serves to optimize practice economy by eliminating the threat of competition that exists among community-based generalists. Such a model helps to control an overused referral system to subspecialists.

Community Health Services↗
PubMed1998

Treatment outcomes with mandibular removable partial dentures: a population-based study of patient satisfaction.

STATEMENT OF PROBLEM: Little is known about the outcomes of treatment with mandibular removable partial dentures provided by dentists in private dental practice. PURPOSE: This study examined 15 aspects of patient satisfaction and explored the factors found to be associated with dissatisfaction. MATERIAL AND METHODS: A questionnaire was mailed to people whose dental insurance claims included CPT Code 5214 within the last 5 years. A composite measure of treatment outcome was created by combining the responses to the 15 satisfaction items, and 10 factors were then tested statistically to determine their relationship to dissatisfaction. RESULTS: A majority of the respondents were satisfied with the prosthesis, but a substantial amount of dissatisfaction existed. Dissatisfaction was greater when there was no previous wearing experience or when there was an opposing maxillary removable partial denture. Respondents under the age of 60 expressed more dissatisfaction than did those over the age of 60, and subjects with lower levels of general health also reported less satisfaction. One third of the respondents believed their prosthesis required adjustment or replacement, and one fourth said the removable partial denture had caused a problem with the natural teeth. CONCLUSION: A majority of survey respondents treated with a mandibular removable partial denture in private dental practice were satisfied with the prosthesis, but a substantial amount of dissatisfaction existed. Dissatisfaction was related to age, health, prior experience with a prosthesis, and the type of opposing dentition.

Denture, Partial, Removable↗