Irving Margolis

Surgonomics: The Identifier Concept

: Surgical care is entering a new payment era for inhospital care using the diagnostic related group (DRG) mechanism for Medicare. A study at The Long Island Jewish-Hillside Medical Center showed that a majority of its surgical DRGs would be unprofitable under the proposed reimbursement scheme. This study was undertaken to develop a method of allowing the hospital to group patients with each DRG that would show a difference in hospital charges and be clinically meaningful to surgeons. The study implementors tested the hypothesis that entities called identifiers, arbitrarily chosen as mode of admission [emergency (+ER vs. nonemergency (-ER)] and presence (+T) or absence (-T) of blood transfusion, would show a difference in charges (mean hospital charge exclusive of physician fees) within a DRG. Nine hundred five patients in nine DRGs encompassing general surgery, thoracic surgery, cardiac surgery, neurosurgery, orthopedics, urology, and head and neck surgery were studied. For ER identifier, eight of nine DRGs were found to be positive (greater than 20% difference in charges between positive and negative identifier); for T identifier, all DRGs (9) were positive. These findings demonstrate that these identifiers may enable teaching institutions to disaggregate each DRG and, in this way, propose more equitable reimbursement rates.

Financial risk, hospital cost, complications, and comorbidities in surgical noncomplication- and noncomorbidity-stratified diagnostic related groups.

The purpose of this study was to analyze resource consumption in the 147 non-complicating condition—stratified surgical diagnostic related groups (DRGs). Analysis of 2647 surgical patients in these non-CC-stratified surgical DRGs demonstrated that patients with more CCs per DRG generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under DRG payment, more outliers, and a higher mortality rates than patients in these same DRGs with fewer CCs. These findings suggest that the current DRG classification system may be inequitable to certain groups of patients or types of hospitals vis-a-vis the non-CC-stratified surgical DRGs. Financial disincentives to treat these patients may affect both their access and quality of care in the future.

Control of needle hole bleeding with ethylcyanoacrylate glue (Krazy Glue)

Needle hole bleeding from polytetrafluoroethylene (PTFE) grafts causes blood loss and prolongs vascular procedures. Past studies have shown the cyanoacrylate glues to polymerize rapidly and cause minimal tissue toxicity. This study was undertaken to evaluate the efficacy of ethyl-2-cyanoacrylate glue (Krazy Glue, KG) in obtaining prompt hemostasis in vascular anastomoses in a heparinized canine model. KG effected complete hemostasis in a significantly shorter time than oxidized cellulose and digital pressure in 18-gauge needle holes in PTFE grafts, graft to graft end-to-end anastomoses, and end of graft to side of artery anastomoses. The only limitation of KG was the development of a glue-adventitia plaque on the arterial side of some of the PTFE-artery anastomoses, causing the need for regluing. KG is an ideal agent for sealing defects in PTFE grafts.

DRGs, Orthopedic Surgery, and Age at an Academic Medical Center

The federal Medicare Diagnostic Related Group (DRG) hospital reimbursement system has been on line for 5 years. Hospitals contend that profit margins have dropped to dangerously low levels, due to the federal DRG Prospective Payment System. The authors analyzed all orthopedic surgical admissions to a large academic medical center under DRG reimbursement and characterized patients by age, resource utilization, and outcome. Total costs for the 1,040 orthopedic patients analyzed during a 15-month period added up to

Prevalence of Antibodies to HTLV-I, -II, and -III in Intravenous Drug Abusers From an AIDS Endemic Region

9,718,800. Mean hospital cost per patient, mean hospital length of stay, percent outliers, and mortality generally increased with age. All age categories of patients 65 years of age and above generated financial losses under DRGs. Older orthopedic patients consumed a disproportionately larger share of resources than younger patients, and were more frequent users of the SICU and blood. The current DRG reimbursement scheme may be inequitable in relation to the older orthopedic surgery patient. If these findings are demonstrated at other medical centers, older orthopedic surgical patients could be limited in both their access and quality of care in the future.