Edward F. X. Hughes

Open cholecystectomy. A contemporary analysis of 42,474 patients.

ObjectiveThis study evaluated, in a large, heterogeneous population, the outcome of open cholecystectomy as it is currently practiced. Summary Background and DataAlthough cholecystectomy has been the gold standard of treatment for cholelithiasis for more than 100 years, it has recently been challenged by the introduction of several new modalities including laparoscopic cholecystectomy. Efforts to define the role of these alternative treatments have been hampered by the lack of contemporary data regarding open cholecystectomy. MethodsA population-based study was performed examining all open cholecystectomies performed by surgeons in an eastern and western state during a recent 12-month period. Data compiled consisted of a computerized analysis of Uniformed Billing (UB-82) discharge analysis information from all non-Veterans Administration (VA), acute care hospitals in California (Office of Statewide Planning and Development [OSHPD]) and in Maryland (Health Services Cost Review Commission [HSCRC]) between January 1, 1989, and December 31, 1989. This data base was supplemented with a 5% random sample of Medicare UB-82 data from patients who were discharged between October 1,1988, and September 30, 1989. Patients undergoing cholecystectomy were identified based on diagnosis-related groups (DRG-197 and DRG-198), and then classified by Principal Diagnosis and divided into three clinically homogeneous subgroups: acute cholecystitis, chronic cholecystitis, and complicated cholecystitis. ResultsA total of 42,474 patients were analyzed, which represents approximately 8% of all patients undergoing cholecystectomy in the United States in any recent 12-month period. The overall mortality rate was 0.17% and the Incidence rate of bile duct injuries was approximately 0.2%. The mortality rate was 0.03% in patients younger than 65 years of age and 0.5% in those older than 65 years of age. Mortality rate, length of hospital stay, and charges were all significantly correlated (p < 0.001) with age, admission status (elective, urgent, or emergent), and disease status. ConclusionsThese data indicate that open cholecystectomy currently is a very safe, effective treatment for cholelithiasis and is being performed with near zero mortality. The ultimate role of laparoscopic

The effects of regulation, competition, and ownership on mortality rates among hospital inpatients

Abstract We examined the influence of the regulation of hospital rates, state certificate-of-need programs, competition, and hospital ownership on mortality rates among inpatients receiving care under Medicare for 16 selected clinical conditions that were studied as a group. Data were obtained from the records of 214,839 patients who received care in 981 hospitals in 45 states from July 1, 1983, through June 30, 1984. We found significant associations between higher mortality rates among inpatients and the stringency of state programs to review hospital rates (P≤0.05), the stringency of certificate-of-need legislation (P≤0.01), and the intensity of competition in the marketplace, as measured by enrollment in health maintenance organizations (P≤0.05). Hospitals in the states with the most stringent review procedures for hospital rates had ratios of actual to predicted death rates that were 6 to 10 percent higher than those of hospitals in states with less stringent rate-review programs (P≤0.001). Hospitals...

Assessing the impact of total quality management and organizational culture on multiple outcomes of care for coronary artery bypass graft surgery patients.

OBJECTIVES To assess the impact of total quality management (TQM) and organizational culture on a comprehensive set of endpoints of care for coronary artery bypass graft surgery (CABG) patients, including risk-adjusted adverse outcomes, clinical efficiency, patient satisfaction, functional health status, and cost of care. METHODS Prospective cohort study of 3,045 eligible CABG patients from 16 hospitals using risk-adjusted clinical outcomes, functional health status, patient satisfaction, and cost measures. Implementation of TQM was measured by a previously validated instrument based on the Baldridge national quality award criteria. Organizational culture was measured by a previously validated 20-item instrument. Generalized estimating equations were used to control for potential selection bias, repeated measures, and intraclass correlation. RESULTS A 2- to 4-fold difference in all major clinical CABG care endpoints was observed among the 16 hospitals, but little of this variation was associated with TQM or organizational culture. Patients receiving CABG from hospitals with high TQM scores were more satisfied with their nursing care (P = 0.005) but were more likely to have lengths of stay >10 days (P = 0.0003). A supportive group culture was associated with shorter postoperative intubation times (P = 0.01) but longer operating room times (P = 0.004). A supportive group culture was also associated with higher patient physical (P = 0.005) and mental (P = 0.01) functional health status scores 6 months after CABG. CONCLUSIONS There was little effect of TQM and organizational culture on multiple endpoints of care for CABG patients. There is a need to examine further the relationships among individual professional skills and motivations, group and microsystem team processes, specifically tailored interventions, and organization-wide culture, decision support processes, and incentives. Assessing the impact of such multifaceted approaches is an important area for further research.

Keys for successful implementation of total quality management in hospitals.

Editors Note: This article reports the findings of an analysis of the implementation of continuous quality improvement (CQI) or total quality management (TQM) programs in 10 hospitals. This analysis is the result of a 2-year study designed to identify and assess the ingredients that lead to the successful implementation of CQI programs in acute care hospitals. This article first appeared in Health Care Management Review 21(1), 48-60. Copyright

An integrative model for organization-wide quality improvement: lessons from the field.

This article describes a model of CQI that is designed to characterize the elements necessary for successfully improving quality at an organization-wide level; describe and understand the organizational dynamics in implementing an organization-wide effort; and aid in diagnosing and solving common implementation challenges. Three cases illustrate the model and how it can be used.

Training house officers to be cost conscious: Effects of an educational intervention on charges and length of stay

Two annual cost-containment educational programs, featuring involvement of respected senior physicians, lectures, comparative feedback, chart reviews, and small group discussions, were designed to reduce interns’ generated costs in a private and a VA university hospital affiliated with Northwestern University Medical School. To evaluate the impact of this randomized educational intervention, hospital data on inpatient charges and length of stay (LOS) were collected for 12 common medical diagnoses and adjusted by the Severity of Illness Index. Interns who were randomized to the program were found to have significantly lower per patient costs and LOS than control group interns at both hospitals. These reductions in resource use and LOS were not associated with differences in patients’ residual impairment on discharge, the incidence of inpatient complications, or the percentage of deaths and readmissions within 30 days. Our results suggest that the current hospital cost-containment environment may be far more conducive to physician cost-containment education than indicated by the earlier literature.

Utilization of Surgical Manpower in A Prepaid Group Practice

The median operative workload of seven general surgeons comprising the general surgical staff of a prepaid group practice of 158,000 enrollees was 9.9 hernia equivalents (HE) a week. The value was over three times that of a previously studied population of 19 general surgeons in fee-for-service community practice, and approximated a consensus standard of a full surgical workload. The median complexity of operations was 1.00 HE, similar to the community practice, and evidence suggested the most complex operation were handled by6 the surgeons with the most training. 23.6% of operations were performed on an ambulatory basis. The results suggest that the prepaid group practice under study possesses administrative mechanisms to efficiently utilize both general surgeons and the resources devoted to general surgery.

Operative Work Loads in One Hospital's General Surgical Residency Program

Abstract Residents training in medical specialties represent an expanding, expensive and largely unstudied pool of medical manpower. This study applies quantification technics to the operative work...

Time utilization of a population of general surgeons in a prepaid group practice.

Seven general surgeons in a prepaid group practice previously shown to have a mean operative work load of 9.2 hernia equivalents (HE) per week were found to have a standardized mean daytime working week of 56.2 hours, exclusive of evening activities of which 50.7 hours were devoted to professional activities. The surgeons also devoted a mean of 6.7 evening hours per week to professional activities for a mean net professional week of 57.4 hours. Comparisons with a population of previously studied community surgeons revealed that the prepaid group surgeons were able to produce a surgical output more than double that of the community surgeons while devoting only one and a half as much time to professional activities. Economies in the utilization of surgical manpower in the prepaid group appear to stem from: 1) restriction of practice setting to a single geographic location, 2) restriction of patients to surgical patients, 3) reduced surgeon waiting time in the office, and 4) the utilization of paraprofessional personnel for selected operative assisting. These economies were achieved while the prepaid group surgeons were observed to average more time per patient visit both on rounds and in the office than the community surgeons.

Medicare beneficiary decision making about health insurance: Implications for a voucher system

A two-phase study involving focus group interviews and a survey of 2,016 Medicare beneficiaries was conducted to examine beneficiary decision making about health insurance under a hypothetical Medicare voucher program. Some of the major findings were that: (1) beneficiaries lack important information about Medicare and health insurance in general; (2) plans with physician restrictions, no restrictions on hospitals, and benefits for custodial long-term care at home or in nursing homes are most preferred when prices are roughly equal to actuarial costs; (3) plan features often interact rather than combine additively to affect choices; (4) price sensitivity is small in comparison with sensitivity to other plan features; (5) price sensitivity is particularly small for plans with custodial long-term care benefits; (6) Medicare would not experience substantial selection bias in a voluntary system containing a wide range of plans preferred by beneficiaries; (7) physician-restricted plans would experience favorable selection; (8) plans with long-term custodial care benefits would experience some adverse selection which might be handled by modest price adjustments in view of the relatively low price elasticity of preferences.