Jonathan Showstack

Hospital resource utilization for primary and revision total hip arthroplasty

BACKGROUND Previous reports have suggested that hospital resource utilization for revision total hip arthroplasty is substantially higher than that for primary total hip arthroplasty. However, current United States Medicare hospital-reimbursement policy does not distinguish between the two procedures. The purpose of this study was to compare primary and revision total hip arthroplasties with regard to actual hospital resource utilization and to identify clinical and demographic factors that are predictive of higher resource utilization associated with these procedures. METHODS We evaluated the clinical, demographic, and economic data associated with 491 consecutive unilateral primary or revision total hip arthroplasties performed by two surgeons at a single institution between January 2000 and December 2002. The distributions of various demographic, clinical, and utilization characteristics were compared between the two types of arthroplasty procedures, and multivariable linear regression techniques were used to determine independent patient characteristics that were predictive of higher costs for both the primary and the revision procedures. RESULTS The mean total hospital cost was

Implementation of a Voluntary Hospitalist Service at a Community Teaching Hospital: Improved Clinical Efficiency and Patient Outcomes

31,341 for the revision procedures compared with

Factors associated with birthweight: an exploration of the roles of prenatal care and length of gestation.

24,170 for the primary procedures (p < 0.0001). The mean operative time was 41% longer for the revisions than for the primary procedures (4.5 hours compared with 3.2 hours, p < 0.0001), the mean estimated blood loss was 160% higher (1348 mL compared with 518 mL, p < 0.0001), the mean complication rate was 32% higher (29% compared with 22%, p = 0.072), and the mean length of the hospital stay was 16% longer (6.5 days compared with 5.6 days, p = 0.0005). A higher severity-of-illness score (a measure of preoperative medical health) was predictive of higher resource utilization for both primary and revision arthroplasty even after adjustment for other factors. Preoperative femoral and ace-tabular bone loss and a diagnosis of periprosthetic fracture were predictive of higher resource utilization associated with revision procedures. CONCLUSIONS At one institution, hospital resource utilization for revision total hip arthroplasty was found to be significantly higher than that for primary arthroplasty. This information is not reflected by current United States Medicare hospital reimbursement, which is the same for all lower-extremity arthroplasty procedures, regardless of the diagnosis, the complexity of the procedure, or the patients baseline medical health. If these findings are generalizable to other institutions, appropriate reimbursement formulas should be developed to accurately reflect the true costs of caring for patients with a failed total hip arthroplasty.

A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes

Context Many studies suggest that hospitalists reduce average length of stay and costs but have little or no effect on patient survival. Contribution This 2-year cohort study from a community-based urban teaching hospital found that patients cared for by faculty hospitalists rather than community physicians had shorter lengths of stay, lower costs, and better in-hospital and 1- and 2-month survival rates. Implications Length of stay and cost benefits were apparent only in year 2 of the study, which suggests that experience is an important aspect of successful care by hospitalists. Cautions The study was retrospective, was done in a single site, and involved only five hospitalists. The Editors The organization of inpatient services has been transformed with the development of the hospitalist (1). Traditionally, primary care physicians have cared for their own inpatients. In the hospitalist model, a hospitalist becomes the patients attending physician during hospitalization and the outpatient physician resumes supervision of the patient after discharge (2). Several studies have demonstrated improved clinical efficiency in the hospitalist model, but these studies have focused largely on academic centers or health maintenance organizations, or have not used concurrent controls or reported longer periods of follow-up (3-7). One published study examining a hospitalist system at a community-based teaching hospital suggested improvement in clinical efficiency and a reduction in readmissions (8). However, analytic limitations open these findings to many interpretations. To examine the effects of implementation of a hospitalist service on resource utilization and patient outcomes over time, we studied 5308 consecutive patients admitted to an urban community teaching hospital in San Francisco, California. Methods Study Site Mount Zion Hospital (San Francisco, California) was a 280-bed community-based teaching hospital affiliated with University of California, San Francisco. Mount Zions inpatient facilities were closed in November 1999 because of financial pressures. During the year before closure, all physicians were aware of the hospitals financial difficulties, but no individual or group was made a focus of efforts to improve clinical efficiency. Discussions about possible closure began 1 month after this study ended, and the hospital closed 5 months later. Medical patients at Mount Zion Hospital were admitted to one of four medical teams composed of a resident, one to two interns, and zero to three medical students. Mount Zion medical teams cared for common inpatient diagnoses, as well as specialty-associated diagnoses such as cancer, acute myocardial infarction, and cerebrovascular accidents. Housestaff wrote all orders and provided 24-hour coverage to inpatients. Each team had a ward attending physician who before 1 July 1997 was a full-time faculty member serving in this role for 1 month each year. Community-based physicians remained the physician of record for most patients and worked with house officers in the care of their hospitalized patients. On 1 July 1997, Mount Zion implemented a voluntary hospitalist service. Hospitalists, who were University of California, San Francisco, faculty based at Mount Zion, served as ward attendings 6 to 8 months per year and spent their remaining time in ambulatory practice or teaching. Hospitalists cared for patients without primary physicians, patients with faculty or house officer primary care physicians, and patients whose community-based physician chose to use the hospitalist service. Rotating nonhospitalist faculty continued to provide some inpatient care after implementation of the hospitalist service. Patients were admitted to rotating faculty according to the same criteria used for hospitalist services. There were no differences in other inpatient care systems available to community, rotating, or hospitalist physicians (for example, level of housestaff coverage, computer systems, case managers, social workers, or nursing staff). Patients Between 1 July 1997 and 30 June 1999, 5907 patients 18 years of age or older were admitted to the medical service at Mount Zion Hospital. We excluded patients who were admitted for chemotherapy or as part of a research protocol (n = 167) and those for whom some data on primary diagnosis were missing (n = 30). The resulting cohort was composed of 5710 patients, of whom 3693 (65%) were cared for by community-based physicians, 1615 (28%) were cared for by hospitalists, and 402 (7%) were cared for by rotating faculty. Data Management At Mount Zion Hospital, data were drawn from TSI (Transition Systems, Inc., Boston, Massachusetts) administrative databases, a cost-accounting system that collects data abstracted from patient charts at discharge. These databases contain information on sociodemographic characteristics, principal diagnosis (in the form of International Classification of Diseases, 9th revision, codes), diagnosis-related group, length of stay, costs, number of consultations, and whether the patient was in an intensive care unit during hospitalization. Data were manually screened for validity of physician designation as hospitalist or community physician by using previously published definitions of hospitalist physician characteristics (1, 2). Discharge summaries of patients who died during hospitalization were examined to validate deaths. An additional 200 discharge summaries of randomly selected patients discharged alive were also reviewed, revealing no errors. Information regarding physician characteristics and board certification was obtained from hospital credentialing databases. Patient survival to points in time after hospitalization was determined by using data from the California State Death Index (for patients admitted before 1 January 1999) and Social Security death indexes (for patients admitted on or after 1 January 1999 and for those who did not reside in California). Statistical Analysis To satisfy normality requirements and stabilize variance of residuals, we explored two methods of transforming skewed data on cost and length of stay: logarithmic conversion and truncation at the mean + 3 SDs. Since both techniques yielded similar results, we chose to present results by using truncation, as has been done in previous studies of inpatient costs and utilization (4, 9-11). All costs were adjusted to 1999 U.S. dollars by using an annual inflation rate of 3% (4). Primary analyses compared 5308 patients cared for by community or hospital-based physicians; we excluded the few patients cared for by rotating physicians from core analyses. This method was chosen to maximize our ability to discern differences in rare outcomes (such as death or readmission), to determine trends in frequent outcomes (such as length of stay), and to maintain focus on our primary question: hospitalist-directed versus community physiciandirected inpatient care. For bivariable comparisons, we used the Fisher exact test or the Wilcoxon rank-sum test. Unadjusted survival rates were estimated by using KaplanMeier product-limit methods. We then used multivariable models to determine the independent effect of hospitalist care on patient outcomes. Using automated forward and stepwise selection techniques along with manually entered variables, we fit multivariable linear regression models to determine the independent association of hospitalist care with length of stay and costs. Items were selected on the basis of the statistical significance of their association with the outcome or on observed confounding with other independent variables, or to maintain face validity of the model. Similar methods were used in fitting logistic models of readmission; use of consultations; and Cox proportional-hazards models of survival to discharge, 30 days, and 60 days. All analyses were performed by using SAS software, version 8.0 for Windows (SAS Institute, Inc., Cary, North Carolina). Multivariable models contained adjustment for patient age, sex, ethnicity, insurance type, source of admission (for example, emergency department), site of discharge, whether a cardiovascular procedure was performed during hospitalization, whether the patient received care in an intensive care unit during hospitalization, and case-mix measures. For case-mix measures, specific diagnoses were defined by using International Classification of Diseases, 9th revision, codes for pneumonia, asthma, congestive heart failure, acute myocardial infarction, angina, unstable angina, chest pain, cancer, gastrointestinal hemorrhage, HIV infection, and cerebrovascular accident. Models also contained a variable indexed to admission date to adjust for secular trends. Trends in adjusted outcomes were tested by using variables dummy-coded to indicate service and year of admission. Because patients were not randomly assigned to hospitalists or community physicians, we performed secondary analyses using a propensity score (12, 13). In our analyses, the propensity score represents the likelihood that any given patient would be admitted to a hospitalist attending physician. The propensity score was calculated in a logistic regression model with attending designation [that is, hospitalist vs. community physician] as the dependent variable. The model contained all covariates in core models, as well as variables found to contribute to nonrandom allocation of patients to specialty care at a P value less than or equal to 0.20. The propensity score was then used in analyses of cost, length of stay, and mortality in two ways: 1) multivariable analyses stratified within tertiles of propensity score and 2) multivariable analyses using the score as a continuous adjustment variable. Results Physician Characteristics One hundred thirteen community physicians, 20 rotating physicians, and 5 hospitalist physicians admitted patients to Mount Zion Hospital during the 2 years of this study. The mean age was 34 years for hospital

Residency Training in Internal Medicine: Time for a Change?

To assess the association with birthweight of prenatal medical care, length of gestation, and other prenatal factors, birth certificate data were studied for babies born in 1978 to mothers who were residents of Alameda or Contra Costa counties, California. Using multiple regression data analytic techniques, adequate prenatal care (defined by the number of prenatal care visits compared to length of gestation and month of start of care) was found to be associated with an increase of 197 grams in average birthweight. This effect was even greater for Black infants and infants of short length of gestation. Adding length of gestation to the equation increased significantly the proportion of the variance in birthweight accounted for. For babies of short gestation (less than or equal to 280 days), the addition of length of gestation was associated with a halving of the association of prenatal care with birthweight. The results suggest that researchers need to take into account the nonlinear relationship between length of gestation and birthweight when assessing factors that affect birthweight.

Sexual functioning after total compared with supracervical hysterectomy: a randomized trial.

Abstract Objective To compare surgical complications and clinical outcomes after total versus supracervical abdominal hysterectomy for control of abnormal uterine bleeding, symptomatic uterine leiomyomata, or both. Methods We conducted a randomized intervention trial in four US clinical centers among 135 patients who had abdominal hysterectomy for symptomatic uterine leiomyomata, abnormal uterine bleeding refractory to hormonal treatment, or both. Patients were randomly assigned to receive a total or supracervical hysterectomy performed using the surgeons customary technique. Using an intention-to-treat approach, we compared surgical complications and clinical outcomes for 2 years after randomization. Results Sixty-eight participants were assigned to supracervical hysterectomy (SCH) and 67 to total abdominal hysterectomy (TAH). Hysterectomy by either technique led to statistically significant reductions in most symptoms, including pelvic pain or pressure, back pain, urinary incontinence, and voiding dysfunction. Patients randomly assigned to (SCH) tended to have more hospital readmissions than those randomized to TAH, but this difference was not statistically significant. There were no statistically significant differences in the rate of complications, degree of symptom improvement, or activity limitation. Participants weighing more than 100 kg at study entry were twice as likely to be readmitted to the hospital during the 2-year follow-up period (relative risk [RR] 2.18, 95% confidence interval [CI] 1.06, 4.48, P = .034). Conclusion We found no statistically significant differences between (SCH) and TAH in surgical complications and clinical outcomes during 2 years of follow-up.

Epidemiology and Prevention of Periodontal Disease in Individuals With Diabetes

Internal medicine residencies risk becoming obsolete if they are not adjusted to changing patterns of medical practice. Declining length of hospital stay, increased intensity of hospital care, movement of critical management decisions to outpatient settings, increased proportions of admissions for specific diagnostic procedures, and increased needs for perioperative consultations all erode the foundation of traditional internal medicine training. Furthermore, demographic shifts, the move to prepaid care, and a projected oversupply of subspecialists warrant more exposure to generalism and geriatrics. To prepare internists for clinical practice, some training should shift from medical wards and intensive care units to outpatient settings and surgical consultation, additional process skills must be taught, and the epidemiologically important non-internal-medicine disciplines should be included in the curriculum. These shifts will require changes in methods to pay for residency training, accreditation procedures for residency programs, and the residency certifying process. Most importantly, the model and organization of internal medicine training need to be reconsidered.

Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States

OBJECTIVE: To compare sexual functioning and health-related quality-of-life outcomes of total abdominal hysterectomy (TAH) and supracervical hysterectomy (SCH) among women with symptomatic uterine leiomyomata or abnormal uterine bleeding refractory to hormonal management. METHODS: We randomly assigned 135 women scheduled to undergo abdominal hysterectomy in 4 U.S. clinical centers to either a total or supracervical procedure. The primary outcome was sexual functioning at 2 years, as assessed by the Medical Outcomes Study Sexual Problems Scale. Secondary outcomes included specific aspects of sexual functioning and health-related quality-of-life at 6 months and 2 years. RESULTS: Sexual problems improved dramatically in both randomized groups during the first 6 months and plateaued by 1 year. Health-related quality-of-life scores also improved in both groups. At 2 years, both groups reported few problems with sexual functioning (mean score on the Sexual Problems Scale for SCH group 82, TAH group 80, on a 0-to-100 scale with 100 indicating an absence of problems; difference = +2, 95% confidence interval –8 to + 11), and there were no significant differences between groups. CONCLUSION: Supracervical and total abdominal hysterectomy result in similar sexual functioning and health-related quality of life during 2 years of follow-up. This information can help guide physicians as they discuss surgical options with their patients. LEVEL OF EVIDENCE: I

Financial incentives to perform medical procedures and laboratory tests: illustrative models of office practice.

Objective This article reviews the epidemiological evidence of the relationship between diabetes and periodontal disease, possible physiological mechanisms for the association, and effects of interventions on the occurrence and severity of periodontal disease among individuals with diabetes. Research Design And Methods A comprehensive qualitative review of published literature in the area was performed. Results Much of the research in this area was found to contain methodological problems, such as failing to specify the type of diabetes, small sample sizes, and inadequate control of covariates such as age or duration of diabetes. Conclusions Trends indicate that periodontal disease is more prevalent and more severe among individuals with diabetes. This trend may be modified by factors such as oral hygiene, duration of diabetes, age, and degree of metabolic control of diabetes. Generally, poor oral hygiene, a long history of diabetes, greater age, and poor metabolic control are associated with more severe periodontal disease. The association of diabetes and periodontal disease may be due to numerous physiological phenomena found in diabetes, such as impaired resistance, vascular changes, altered oral microflora, and abnormal collagen metabolism. With some modifications, the same prevention and treatment procedures for periodontal disease recommended for the general population are appropriate for those with diabetes. People with diabetes who appear to be particularly susceptible to periodontal disease include those who do not maintain good oral hygiene or good metabolic control of their diabetes, those with diabetes of long duration or with other complications of diabetes, and teenagers and pregnant women.

Costs of infertility treatment: results from an 18-month prospective cohort study

STUDY OBJECTIVE The rise in emergency department (ED) use in the United States is frequently attributed to increased visits by the uninsured. We determine whether insurance status is associated with the increase in ED visits. METHODS Using the national Community Tracking Study Household Surveys from 1996 to 1997, 1998 to 1999, 2000 to 2001, and 2003 to 2004, we determined for each period the proportion of reported adult ED visits according to insurance status, family income, usual source of care, health status, and outpatient (non-ED) visits. Trends over time were tested for statistical significance. RESULTS The proportion of adult ED visits by persons without insurance was stable across the decade. Uninsured individuals accounted for 15.5% of ED visits in 1996 to 1997, 16.1% in 1998 to 1999, 15.2% in 2000 to 2001, and 14.5% of visits in 2003 to 2004 (P for trend=.43). The proportion of visits by persons whose family income was greater than 400% of the federal poverty level increased from 21.9% to 29.0% (P=.002). The proportion of visits by those whose usual source of care was a physicians office increased from 52.4% in 1996 to 1997 to 59.0% in 2003 to 2004 (P=.002), whereas the proportion of visits by those without a usual source of care was essentially unchanged (9.7% of visits in 1996 to 1997 and 9.6% in 2003 to 2004; P=.74). CONCLUSION The rise in ED visits between 1996 and 2003 cannot be primarily attributed to the uninsured. Major contributors to increasing ED utilization appear to be disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physicians office.