Geographic access to health care services: the case of maintenance hemodialysis

A longitudinal study of the system for delivering maintenance hemodialysis services in St Louis, Missouri was conducted to determine the significance of geographic access in the selection and continued utilization of a treatment facility. Historically, center hemodialysis patients in this metropolitan area received care at four centrally located facilities. In 1981, two new, independent facilities were constructed; a satellite of an existing unit was opened in 1983. The data obtained in this study demonstrated that end-stage renal disease (ESRD) patients generally did not change their mode of maintenance therapy, their treatment facility, or the location of their personal residence. When such changes occurred, they were rarely precipitated by a desire to reduce travel time to treatment. Furthermore, the opportunity to improve geographic access by transferring to a closer unit was perceived by patients to be viable only if they could retain their physician. It was concluded, therefore, that travel time to treatment is a relatively unimportant aspect of the chronic care of center hemodialysis patients in a metropolitan area.     

Epidemiological trends in urolithiasis: impact on our health care systems

The progressive increase of the social cost for treating urolithiasis could be related to an increased incidence of the disease and/or to an increase of costs for diagnosing and treating renal stones. In the course of the last century, the incidence of renal stones has progressively increased in Europe, North America, and other industrialised countries. This has been explained in terms of changing social conditions and the consequent changes in eating habits. In contrast, renal stones were less frequent than in developing countries of the world but in the last 20 years investigators began to report high incidences of upper urinary stone disease also from some areas of the Third World concurring with the changing of economic and social conditions. Each stone episode involves the costs for emergency visits, diagnostic work up, and medical or surgical treatment. Furthermore, we have to consider the costs of follow-up visits and the costs of testing and drugs for stone prevention. In adjunct of direct costs for diagnosis and treatment, we should also take into account the indirect individual and social cost of workdays lost. Finally, we should estimate the costs of complications and outcomes of treatment with particular attention to the costs of chronic renal failure secondary to stone disease. The strategy of treatment of each stone centre involves different costs for the treatment of each single stone episode. On the other hand the choice of treatment can be driven by National Health Systems and insurance companies by their policy of reimbursement for different procedures. The trends of renal stone incidence will have different impact on health care systems in different countries. In Europe and North America, the peak of incidence has been probably reached but the increase of costs for diagnosing and treating each single stone episode will still increase the social cost for managing stone disease. For this reason the actual objective should be to optimise protocols avoiding redundant or expensive diagnostic procedures or inappropriate treatments. In developing countries, the incidence of stone disease is still increasing and it could reach peaks even higher as a consequence of hot climate in some geographical areas. In those countries the demand for treatment of symptomatic stones could dramatically increase involving a huge financial outlay.     

The impact of health literacy on urologic oncology care

Health literacy is the ability to access, comprehend, and act upon medical information to make health care decisions. In the United States, 12% of adults have proficient health literacy. Low health literacy has been associated with worse outcomes in several chronic medical conditions. In addition, low health literacy has been associated with longer hospital stays. In the urologic oncology literature low health literacy is associated with increased minor complications following radical cystectomy. There remains sparse data on health literacy and its impacts on prostate, kidney, testicular and penile cancer care. Going forward, in order to provide the best urologic oncology care to our patients it is critical to account for patients' health literacy status.     

The health care crisis: impact on surgery in the community hospital setting

Hospitals and health systems across the United States are in crisis. The causes of this crisis are multiple, and they reflect the interplay among reduced operating margins, workforce issues, the technology explosion, consumerism, and leadership. They affect hospitals of every type and location. In aggregate, they profoundly influence our trifold mission of patient care, education, and research. Departments of surgery have a disproportionate effect on hospital financial viability, and therefore, surgical leaders must work with other clinical and administrative leaders to manage these issues. This article is a personal view of how this crisis has affected our community-based academic medical center, William Beaumont Hospital, Royal Oak, Mich.     

The health care crisis: impact on surgery from a chief executive officer's perspective

Kaiser Permanente, in conjunction with the surrounding academic institutions, trains 64 surgical residents annually in Northern California. Although the current health care crisis has made resident education increasingly difficult, we are committed to maintaining and expanding our programs. The current health care crisis reflects the effect that for-profit health plans, hospitals, and pharmaceutical groups have had on medicine. Their negative impact has not been simply the extraction of resources from the delivery system to their equity shareholders, but the implementation of an authorization process designed to frustrate and deny. As executive director and chief executive officer of the Permanente Medical Group, I believe that resident training allows us to attract outstanding clinicians, train the physicians of the future, and improve the clinical care of our patients. The multispecialty nature of our medical group and our size allows us to work collaboratively, offer evidence-based approaches, preserve professional independence, and implement innovative programs to increase quality and service. Although it is uncertain how health care will evolve in the future, we at Kaiser Permanente are committed to maintaining and expanding our involvement in the education of the next generation of surgeons.     

Takotsubo cardiomyopathy: its possible impact during adult donor care

Takotsubo cardiomyopathy, the syndrome caused by an extreme release and circulation of catecholamines, shares several histopathological and clinical similarities with cardiac changes after brain death noted in animal investigations and human observation. Overwhelming stimulation of myocardial inotropic β receptors may alter their responsiveness and induce other biochemical processes, producing reduced cardiac contractility. Treatment methods in Takotsubo cardiomyopathy that use extracorporeal circulatory support and medications that do not rely on β-receptor stimulation and preemptive blockade of β receptors or calcium channels before brain death may be relevant to donor care.     

Financial impact of emergency hand trauma on the health care system

BACKGROUND: The US has a crisis of insufficient emergency coverage for hand trauma. One of the problems is the perceived financial loss associated with caring for this population. We evaluated the financial impact of treating emergency hand trauma patients on an academic medical practice and health care system. STUDY DESIGN: We examined billing records for 2,632 hand patients seen in the emergency department in 2005 at the University of Michigan. Financial data were separated into inpatient professional and facility revenues and costs. Professional net revenue was calculated by applying actual collection rates to procedural charges. Facility revenue was calculated by applying actual collection rates to the following downstream charge categories: inpatient/operating room (including nursing, anesthesia, and pharmacy), clinic facility, radiology, and occupational therapy. RESULTS: The payer mix for this analysis was 60.7% private insurance, 15.3% Medicare, 4.2% uninsured, 8.3% Medicaid, and 11.5% other. The net professional revenue and total costs for physician salary, malpractice, and benefits allocated to hand patients were $698,578 and $574,880, respectively, for a net profit margin of $123,698 (18%). Net health system facility revenue and total costs were $2,420,899 and $2,389,901, respectively, for a net profit margin of $30,998 (1%). CONCLUSIONS: Hand trauma at this academic medical center is fiscally advantageous for the surgical department and marginally advantageous for the health care system. Providing access to hand trauma patients may be fiscally advantageous in certain settings when the proportion of nonreimbursed care can be controlled.