Roger Hand

The causes of cancelled elective surgery.

We reviewed causes of cancelled elective surgery in a community hospital. Over a 6-month period, during which 4100 operating room procedures were completed, cancellations occurred in 13% of cases scheduled for outpatient surgery, 9% of cases sched uled for admission the same day, and 17% of cases scheduled for inpatient surgery. Dental procedures had significantly higher rates of cancellation among outpatient procedures, and cardiovascular surgical procedures had significantly higher rates among in patient procedures. Chart review of cancelled inpa tient cases showed 43% due to administrative reasons with unsigned consent the most common cause. Med ical factors were responsible in the remaining cases, with reevaluation of the surgical condition and asso ciated medical illnesses equally common as reasons in this category. Appreciation of the usual reasons for cancellation can improve utilization by permitting administrators and providers to anticipate those cases in which problems might arise so that additional at tention can be paid to them.

Accuracy of precordial percussion in detecting cardiomegaly

STUDY OBJECTIVE To assess the value of precordial percussion in detecting cardiomegaly, and to compare it with palpation of the apical impulse. DESIGN Descriptive study. SETTING Hospitals and clinics of a university medical center. PATIENTS Light indirect percussion of the precordium was performed on 72 inpatients and 28 outpatients. All patients had a posteroanterior radiograph of the chest. Percussors were unaware of the clinical history and of chest roentgenogram results. MEASUREMENTS AND MAIN RESULTS Thirty-six patients (36%) had cardiomegaly, defined as a cardiothoracic ratio of greater than 0.5 on chest roentgenogram. The cardiothoracic ratio was significantly correlated with percussion distance from the midsternal line in the left fourth (r = 0.35, p less than 0.0006), fifth (r = 0.65, p less than 0.00001), and sixth (r = 0.40, p less than 0.0001) intercostal spaces. After adjustment for clinical symptoms and systolic and diastolic blood pressures, percussion distance in the left fifth intercostal space remained a significant independent predictor of the cardiothoracic ratio. Percussion distance in the left fifth interspace discriminated cardiomegaly with a receiver-operating characteristic (ROC) area of 0.95. Percussion dullness more than 10.5 cm from the midsternal line in the left fifth interspace had a sensitivity of 94.4% (95% confidence interval [CI], 79.9% to 99.0%) and a specificity of 67.2% (CI, 54.2% to 78.1%). Distance of the apical impulse from the midsternal line discriminated with an ROC area of 0.95, but an impulse was palpated in only 40% of cases. CONCLUSIONS Percussion in the left fifth intercostal space accurately discriminates patients with and without cardiomegaly, and adds information beyond that obtainable from the history and other parts of the physical examination.

Rural Hospital Mortality for Myocardial Infarction in Medicare Patients in Illinois

Objective: To compare rural and nonrural hospitals for mortality for Medicare patients with myocardial infarction. Design: A retrospective analysis of variance from Illi nois for the year 1989. Claims were aggregated by hospi tal and the hospitals grouped into geographic areas that were completely rural (N = 32), partially rural with small cities (N = 82), exurban (N = 21), suburban (N = 43), and urban (N = 44). Patients: 11,753 patients older than 65 years hospital ized for acute myocardial infarction. Results: In rural hospitals, the mean in-hospital mor tality rate was 24.3% compared to rates of 18.3-20.9% at hospitals in the other four regions (P = 0.10, power = 0.68). Rates for coronary angiography were 0% at rural hospitals compared to 8-20% at hospitals in the other four regions (P <0 0.0005, power = 0.99). Conclusion : There is a trend toward higher in-hospital mortality for myocardial infarction at rural hospitals. Whether this is caused by their inability to perform cor onary angiography during the index admission warrants further investigation.

Use of Statistical Control Charts to Assess Outcomes of Medical Care: Pneumonia in Medicare Patients

Detection of nonrandom variation in outcomes with statistical control charts is at the heart of quality improvement techniques. The authors examined the charts ability to detect variations in outcome of pneumonia. They surveyed Medicare claims data for DRG 89, pneumonia with complications or co-morbidities, from November 1988 through October 1991 at 20 Illinois hospitals with the most Medicare discharges for DRG 89. Control charts were constructed on five outcomes—mean length of stay, range of length of stay, mortality, readmissions, and complications. Standard techniques from industrial statistics were used to construct the historical means and control limits derived from 2 years of data, to plot the monthly samples from the 3rd year of data and to score the control charts for nonrandom variation at less than 1% probability. The observed number of control charts with nonrandom variation was 33 of 100; the expected number was 9.18 (p < 0.0001). Nineteen hospitals had 1 to 3 control charts with nonrandom variation on the five outcomes, whereas only one hospital had none. The number of control charts with nonrandom variation per hospital did not correlate with hospital size, occupancy, teaching status, location, or payer-mix. Statistical control charts provide simple tools for identification of nonrandom variation in outcomes. To the extent that these variations can be related to quality issues, the charts will be useful for quality management.

Postoperative Hospital Retention Following Ambulatory Surgery in a Hospital-Based Program

In an effort to learn more about resource utilization on ambulatory surgery in hospital departments of surgery and its impact on quality of care, we re viewed the causes of postoperative hospital retention following ambulatory surgery in a hospital-based program. Of 1971 patients operated on in a 6-month period, 188 were retained for a rate of 9.5%. Of these, 71 (3.6%) were retained for observation and 42 (2.1%) for surgery more extensive than planned. The remaining 75 (3.8%) patients represent complications of surgery or anesthesia. The age distribution of pa tients with complications was the same as the group overall with a single mode at about 30 years, while the distribution of patients retained for observation or who were admitted the day of surgery was bimodal with a second peak at about 70 years. All surgical specialties had comparable rates of postoperative re tention, except gynecology which was significantly lower. Many of the patients had multiple procedures or surgery more extensive than planned.

Secondary Diagnoses as Predictive Factors for Survival or Mortality in Medicare Patients with Acute Pneumonia

We wished to determine if a claims-based method for severity adjustment would predict mortality or survival in pneumonia based on age, gender, and secondary diag noses. We used a discriminant analysis model of severity of illness developed from Medicare Part A claims data. Our data base was taken from a hospitalized population age 65 years or older coded as DRG 89 (pneumonia with complications/comorbidities). There were 35,677 cases with a mortality = 11.2% in the derivation cohort from 1989 to 1990, and 19,915 cases with a mortality = 9.8% in the validation cohort from 1991. In the derivation cohort, 98% of patients predicted to live, lived, whereas 18% of patients predicted to die, died. Of the three vari ables, secondary diagnoses had greatest explanatory power. Receiver operating characteristic curves showed that the model performed best at 40% survival. Results were confirmed with the 1991 validation cohort. The model could be applied to hospitals with as few as 172 discharges. This simple, claims-based method can pre dict survival in pneumonia. It may be useful in selecting medical records for intensified review of medical quality.

Persistent viral hepatitis

Abstract The discovery of the HB antigen has resulted in a relatively simple way to detect the HB virus. This has allowed not only the separate nature of the two main forms of acute viral hepatitis to be confirmed, but has also allowed an assessment of the role of the HB virus in chronic liver disease. Investigations on the latter have indicated that the HB virus may be responsible for a very significant proportion of cases of serious chronic liver disease. As yet it is not known how the HB virus causes acute or chronic liver damage, although immunologic mechanisms are suggested. The HB virus can spread by other than parenteral routes, and investigations for the HB antigen indicate that spread by at least the saliva and across the placenta may be among these. Insect vectors may be important in certain areas.

Medical readiness education and training exercises by United States army medical personnel in Kenya

Medical Readiness Education and Training Exercises (MEDRETEs) enable United States military medical personnel to sharpen their skills in diagnosis and treatment of common illnesses in rural third world populations. We report our experiences on MEDRETEs conducted during recent exercises in the Republic of Kenya involving United States and Kenyan forces. Respiratory, musculoskeletal, and eyes, ears, nose, and throat conditions comprised 55% of cases. In 73% of cases, the final diagnosis and the chief complaint were in the same diagnostic category. In asymptomatic patients, 17% had physical findings suggestive of significant disease. Anecdotal experiences demonstrated the importance of the local environment and social customs in the genesis of certain illnesses and symptoms.