Surgical unit time utilization review: Resource utilization and management implications

As health care providers seek ways to reduce the cost of health care services, hospital operating rooms (ORs) have been identified as potential areas for cost reduction efforts. Cost containment efforts which have shifted significant portions of the inpatient population to ambulatory areas have resulted in an inpatient population which is sicker and more procedure-intensive. Efficient management of operating rooms has assumed even greater importance in this environment. Inefficient or inaccurate scheduling of OR time often results in delays of surgery or cancellations of procedures, which are costly to the patient and the hospital. Approaches to efficient use of ORs include computerized scheduling, utilization monitoring, and refinement of scheduling policies and procedures. In the absence of commercially avaiable software to meet operating room management information needs, Johns Hopkins developed its own system in 1983. This software provides detailed information for daily OR management and long-term planning. The computerized operating room scheduling and monitoring system is described in this article and an operational measure of scheduling accuracy is proposed. Suggestions are made for incorporating this measure into planning and allocation decisions.     

National health care surveys and health care management

The bulk of medical care in the United States is provided in hospitals, physicians' offices, and nursing homes. The National Center for Health Statistics conducts three health record surveys that collect information on patient and provider characteristics and the services provided in these three settings. This paper describes each of these three surveys in terms of background (scope and data set), design, collection, processing procedures, and data dissemination. In addition, specific examples of how the survey data have been or can be used for management purposes in terms of monitoring, evaluating, and planning the utilization of health care in the United States are given.     

Legal constraints and alternatives in the Veterans Administration

The Veterans Administration is a federal system that has functioned, so far, independently of state and local laws and rules. The system has proven flexible, however, as it has adjusted to meet needs perceived within its organization where legal justification has been found. The impact of the overall health care system in the United States is beginning to be felt within the Veterans Administration as the possibility of national health insurance implementation may greatly affect the number and kinds of patients seen in the hospitals. The response of the Veterans Administration system will have to be within its legal framework and an understanding of the relationship between the actual operation of the system and the law will be necessary. More and better understanding of the practical impact of external programs such as comprehensive health planning, manpower training and licensing laws will be necessary for the Veterans Administration to successfully adjust within the United States' health care framework.     

Radical cystectomy: defining the threshold for a surgeon to achieve optimum outcomes

Background

The reorganisation of cancer services in England will result in the creation of specialist high volume cancer surgery centres. Studies have suggested a relationship between increasing surgical volume and improved outcomes in urological pelvic cancer surgery, although to date, they have pre‐defined the definition of “high” and “low” volume surgeons.

Aim

To derive the minimum caseload a surgeon requires to achieve optimum outcomes and to examine the effect of the operating centre size upon individual surgeon''s outcomes.

Methods

All cystectomies performed for bladder cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. Statistical analysis was undertaken to describe the relationship between each surgeon''s annual case volume and two outcome measures: in‐hospital mortality rate, and hospital stay. The surgeon''s outcomes were then analysed with respect to the overall level of activity in their operating centre.

Results

A total of 6308 cystectomies were performed; the mean number of surgeons performing them annually was 327 with an overall mortality rate of 5.53%. A significant inverse correlation (−0.968, p<0.01) was found between case volume and mortality rate. Applying 95% confidence interval estimation, the minimum caseload required to achieve the lowest mortality rate was eight procedures per year. Increasing caseload beyond eight operations per year did not produce a significant reduction in mortality rate.

Conclusion

Analysis of HES data confirms an inverse relationship between surgeon''s caseload and mortality for radical cystectomy. A caseload of eight operations per year is associated with the lowest mortality rate.The theory that increased surgical caseload leads to improved outcomes has been advocated in a number of recent studies.¹ Healthcare providers in both the USA and the UK have taken this into account, through the creation of guidelines favouring high volume centres. In the USA the Leapfrog Group, a coalition of purchasers, has set minimal volume criteria for certain procedures,² and in England and Wales a central theme of the National Institute for Health and Clinical Excellence (NICE) urological cancer guidelines³ is centralisation of surgical cancer care services. These guidelines advised that, in the short term, surgeons performing fewer than five cystectomies a year should refer patients to more specialised teams. Creation of centralised specialist teams performing a combined total of at least 50 radical cystectomies and radical prostatectomies a year is then planned. The guidelines do not suggest a threshold case load for surgeons working within these centres.The evidence for a volume–outcome relationship in radical cystectomy is limited to studies from the USA. The only study to date, by Birkmeyer et al,² examining the effect of individual surgeon volume on outcome revealed a significant inverse association between surgeon''s case volume and mortality. The paper pre‐defined the case load that constituted a low (<2 cystectomies/year), medium (2–3.5) and high (>3.5) volume surgeon. Most urologists believe in the principle of setting a threshold level for surgeons performing radical cystectomy.⁴ However, the caseload that constitutes this threshold is contentious.To date, there has been no research evaluating the existence of a surgeon volume to outcome relationship for urological cancer in the UK. No study has attempted to determine whether a threshold case volume exists above which point a surgeon is likely to have optimal outcomes.We have attempted to determine whether a relationship exists between individual surgeon''s case volume and outcomes by analysing the Department of Health Hospital Episode Statistics (HES) data over a 5 year period (1998–2003) for all cystectomies performed in England for urological cancer. We have then evaluated these data to establish if a case volume threshold exists where a surgeon should achieve optimum outcomes.     

Handheld Technology to Improve Patient Care: Evaluating a Support System for Preference-based Care Planning at the Bedside

Objective: Despite an increasing movement toward shared decision making and the incorporation of patients'' preferences into health care decision making, little research has been done on the development and evaluation of support systems that help clinicians elicit and integrate patients'' preferences into patient care. This study evaluates nurses'' use of choice, a handheld-computer–based support system for preference-based care planning, which assists nurses in eliciting patients'' preferences for functional performance at the bedside. Specifically, it evaluates the effects of system use on nurses'' care priorities, preference achievement, and patients'' satisfaction.Design: Three-group sequential design with one intervention and two control groups (N=155). In the intervention group, nurses elicited patients'' preferences for functional performance with the handheld-computer–based choice application as part of their regular admission interview; preference information was added to patients'' charts and used in subsequent care planning.Results: Nurses'' use of choice made nursing care more consistent with patient preferences (F=11.4; P<0.001) and improved patients'' preference achievement (F=4.9; P<0.05). Furthermore, higher consistency between patients'' preferences and nurses'' care priorities was associated with higher preference achievement (r=0.49; P<0.001).Conclusion: In this study, the use of a handheld-computer–based support system for preference-based care planning improved patient-centered care and patient outcomes. The technique has potential to be included in clinical practice as part of nurses'' routine care planning.With the recent movement toward shared decision making in health care, a number of models, methods, and evaluative strategies to foster shared decision making have been developed. In the clinical, health services, and methodological literature, shared decision making refers to the concept of involving patients and their health care providers in making treatment decisions that are informed by the best available evidence about treatment options and that consider patients'' preferences.Devices to assist patients in shared decision making have been called “decision aids,”¹ and cumulative evidence supports their effectiveness. Studies evaluating decision aids for patients have reported higher scores on cognitive functioning and social support,² more active and satisfying participation in decision making,³ better scores on general health perceptions and physical functioning,⁴ improved knowledge,⁵ and reduced decisional conflict.¹ However, decision aids have so far been confined to the relatively narrow segment of decisions about single episodes of screening or treatment choices. Little attention has been given to the development of systems that help clinicians elicit and integrate patients'' preferences into the ongoing processes of care over time and as part of clinical practice.Although decision aids have been shown to be helpful to patients, it has been argued that decision support systems for eliciting patients'' preferences could also support clinicians in making care decisions consistent with patients'' preferences, and that successful efforts in this direction would lead to better patient outcomes.^6,7 However, the development of decision support systems designed to support clinicians in eliciting and integrating patients'' preferences into their clinical practice has received little attention. Developments of decision support systems for clinicians have mainly been devoted to knowledge-based systems designed to produce patient-specific options and recommendations, such as computer-based clinical guidelines. Other examples of clinical decision support systems include systems that apply rules to detect undesirable trends and events during treatment, offer reminders and messages about diagnostic and therapeutic possibilities, and alert clinicians to potential serious situations.⁸Evidence shows that clinical decision support systems can enhance clinicians'' compliance with system recommendations and to some degree improve clinical patient outcomes.^9,10 Yet such systems rarely offer systematic methods for eliciting patients'' preferences or incorporate algorithms for the integration of patients'' preferences into care planning. Furthermore, there has been only limited research addressing 1) whether the use of computer-based decision support systems to assist in the elicitation of patients'' preferences would in fact prompt clinicians to make care decisions consistent with patients'' preferences, and 2) whether decisions based on the use of such tools would improve patient outcomes. Developing and testing the effects of clinical support systems for preference elicitation and care planning on clinical decisions and patient outcomes can, therefore, make an important contribution to research in this area and, ultimately, to patient-centered care.This paper reports the results of nurses'' use of Choice (Creating better Health Outcomes by Improving Communication about Patients'' Expectations), a handheld-computer–based support system for preference-based care planning, which helps nurses elicit patients'' preferences for functional performance at the bedside—specifically, the effects of its use on nurses'' care priorities and patient outcomes of preference achievement and satisfaction.     

Design of a management support system for hospital strategic planning

Recent changes in the health care industry that foster competition are drastically affecting hospital planning and marketing activities. Increased price competition, the development of less costly alternative health care delivery systems and providers, and the shift to prospective average-cost reimbursement for Medicare beneficiaries are major factors promoting a new emphasis on strategic hospital planning. Hospital information systems do not currently support the sophisticated data-collection and analysis requirements that will be needed to implement strategic planning activities. New data must be collected and old data must be analyzed and stored in new ways. New hospital information systems designs are needed to cope with the change in the economic structure of the health care industry and its effects on hospital information needs. This paper proposes a system design for a management support system that will assist hospital administrators and planners in analyzing internal organizational data and external industry data to develop strategic planning objectives, strategies, and business plans. Analysis of the structure and process of hospital strategic planning was performed to identify the information needs of hospital planners. A prototype system is currently being implemented at the University of Arizona. The system provides an integrating framework for data base management systems, executive information systems, model management systems, and dialogue management systems. Objective analytical models and subjective strategic planning models are available to assist with idea structuring and decision processing.     

User comments

An automated medical record system (AMRS) at the Harvard Community Health Plan supports medical records membership and the management needs of the 146,000-member health maintenance organization. The ARMS is fully integrated into the operation of HCHP's health centers and into the clinical practice of the medical staff. User interviews conducted as part of a systems planning effort revealed a high level of satisfaction with the system. The acceptance of and enthusiasm for the AMRS was coupled with a variety of ideas for improvement and enhancements to the system. Most of these suggestions were not uniquely related to the automated technology supporting the system but rather addressed medical records issues familiar to conventional paper systems. While this distinction is subtle, it further confirms the viability of an automated system and suggests directions for future growth.     

Medical applications in the TANDEM-16 multiple computer system environment

This paper addresses the question of reliability and the TANDEM-16 approach to facilitate reliable computers. Specifically, the use of the TANDEM-16 within the medical environment is described. Three current applications within the Medical Computing Resources Center at The University of Texas Health Science Center at Dallas are developed, each characterized by different reliability considerations.     

The organization of health services research in the Veterans Administration

The VA health services research, development, and education efforts are organized in four main programs: (1) the Intramural Research Program, (2) the VA-University Health Services Research Affiliation Program, (3) the Health Services Research Training Program, and (4) the Contract Research Program. This report first describes the administrative location and structure of the Health Services Research and Development Service within the VA Department of Medicine and Surgery. Then the goals, organizational structure, and major activities of each program are presented.     

Designing an outcome-oriented computer decision-support system for cardiovascular ICU—A preliminary report

This paper describes the conceptual framework and preliminary results of an outcome-oriented decision-support system prototype for the cardiovascular intensive care unit (CVICU). The major characteristics of this design include: (1) its problem-based approach to solving clinical problems; (2) an integrated structure with the hospital information system in terms of its data, model and knowledge bases; (3) proposed alternative modes of interaction that include monitoring and critiquing; (4) and research modules that design, manage, and analyze outcome-based clinical studies. At present, an initial prototype has been implemented on a PC as a set of modules accessible from a main menu. The structural framework of the overall system is fairly well defined but only limited quantitative, statistical and expert knowledge has been captured. The second phase of the project involves porting the prototype to a Unix workstation environment, refining and adding models to the model base, expanding its knowledge bases, reasoning capability, and testing the prototype with actual clinical cases in a real-time fashion.     

Physicians' opinions of a health information exchange

Background

Arizona Medicaid developed a Health Information Exchange (HIE) system called the Arizona Medical Information Exchange (AMIE).

Objective

To evaluate physicians'' perceptions regarding AMIE''s impact on health outcomes and healthcare costs.

Measurements

A focus-group guide was developed and included five domains: perceived impact of AMIE on (1) quality of care; (2) workflow and efficiency; (3) healthcare costs; (4) system usability; and (5) AMIE data content. Qualitative data were analyzed using analytical coding.

Results

A total of 29 clinicians participated in the study. The attendance rate was 66% (N=19) for the first and last month of focus-group meetings and 52% (N=15) for the focus group meetings conducted during the second month. The benefits most frequently mentioned during the focus groups included: (1) identification of “doctor shopping”; (2) averting duplicative testing; and (3) increased efficiency of clinical information gathering. The most frequent disadvantage mentioned was the limited availability of data in the AMIE system.

Conclusion

Respondents reported that AMIE had the potential to improve care, but they felt that AMIE impact was limited due to the data available.     

MDA-Image: An environment of networked desktop computers for teleradiology/pathology

MDA-Image, a project of The University of Texas M. D. Anderson Cancer Center, is an environment of networked desktop computers for teleradiology/pathology. Radiographic film is digitized with a film scanner and histopathologic slides are digitized using a red, green, and blue (RGB) video camera connected to a microscope. Digitized images are stored on a data server connected to the institution's computer communication network (Ethernet) and can be displayed from authorized desktop computers connected to Ethernet. Images are digitized for cases presented at the Bone Tumor Management Conference, a multidisciplinary conference in which treatment options are discussed among clinicians, surgeons, radiologists, pathologists, radio-therapists, and medical oncologists. These radiographic and histologic images are shown on a large screen computer monitor during the conference. They are available for later review for follow-up or representation.     

An ultrasonic head position interface for wheelchair control

To give quadriplegics independent mobility, a “smart” microprocessor-based electric wheelchair has been developed by the Palo Alto Veterans Administration Medical Center and Stanford University. Ultrasound distance-ranging technology is employed to track the user's head position in two-dimensional space. These data are then used to determine the chair's direction and speed. A working prototype vehicle using this type of motion control has been successfully demonstrated. Obstacle detection, wall-following, and cruise control modes are other implemented features of the current design.     

Automation: The competitive edge for HMOs and other Alternative Delivery Systems

Until recently, many, if not most, Health Maintenance Organizations (HMO) were not automated. Moreover, HMOs that were automated tended to be automated only on a limited basis. Recently, however, the highly competitive marketplace within which HMOs and other Alternative Delivery Systems (ADS) exist has required that they operate at a maximum effectiveness and efficiency. Given the complex nature of ADSs, the volume of transactions in ADSs, the large number of members served by ADSs, and the numerous providers who are paid at different rates and on different bases by ADSs, it is impossible for an ADS to operate effectively or efficiently, let alone show optimal performance, without a sophisticated, comprehensive automated system. Reliable automated systems designed specifically to address ADS functions such as enrollment and premium billing, finance and accounting, medical information and patient management, and marketing have recently become available at a reasonable cost.     

Health services research in alcoholism

Alcoholism has become an important health care problem for the United States and the VA medical care system. The percentage of inpatients in Veterans Administration hospitals with a diagnosis of alcoholism rose from 13.0% in 1970 to a high of 15.6% in 1977. Health services research work in alcoholism has generally fallen into four major areas: community diagnosis; utilization of services by alcoholics; the effectiveness, efficiency, and quality of services; and the organization of information systems and their applicability to alcoholism. Obstacles to research include a poor understanding of the prevalence of the disease among the veteran's population, but the system offers many more opportunities than obstacles. A new information system. SATAR (Substance Abuse Treatment Automated Records), offers a chance for large-scale investigation of the problem of alcoholism among VA patients when combined with other information systems and allows for special comparisons through its large, integrated network of hospitals and clinics.     

An improved model for predicting postoperative nausea and vomiting in ambulatory surgery patients using physician-modifiable risk factors

Objective

Postoperative nausea and vomiting (PONV) is a frequent complication in patients undergoing ambulatory surgery, with an incidence of 20%–65%. A predictive model can be utilized for decision support and feedback for practitioner practice improvement. The goal of this study was to develop a better model to predict the patient''s risk for PONV by incorporating both non-modifiable patient characteristics and modifiable practitioner-specific anesthetic practices.

Materials and methods

Data on 2505 ambulatory surgery cases were prospectively collected at an academic center. Sixteen patient-related, surgical, and anesthetic predictors were used to develop a logistic regression model. The experimental model (EM) was compared against the original Apfel model (OAM), refitted Apfel model (RAM), simplified Apfel risk score (SARS), and refitted Sinclair model (RSM) by examining the discriminating power calculated using area under the curve (AUC) and by examining calibration curves.

Results

The EM contained 11 input variables. The AUC was 0.738 for the EM, 0.620 for the OAM, 0.629 for the RAM, 0.626 for the SARS, and 0.711 for the RSM. Pair-wise discrimination comparison of models showed statistically significant differences (p<0.05) in AUC between the EM and all other models, OAM and RSM, RAM and RSM, and SARS and RSM.

Discussion

All models except the OAM appeared to have good calibration for our institution''s ambulatory surgery data. Ours is the first model to break down risk by anesthetic technique and incorporate risk reduction due to PONV prophylaxis.

Conclusion

The EM showed statistically significant improved discrimination over existing models and good calibration. However, the EM should be validated at another institution.     

Is Z-Plasty closure reasonable in pilonidal disease?

A PROSPECTIVE, randomised, controlled trial of radical excision of pilonidal disease with primary closure versus Z-plasty closure was carried out. The operator was a general surgeon, and no case was excluded because of infection. Twenty patients were operated upon of which twelve had abscesses. The results of surgery were compared and finally reviewed by an independent plastic surgeon after six months. No patient who was operated on during an infective episode developed a wound infection. Eleven patients had a Z-plasty closure and one recurred. Nine patients had a simple closure and two recurred.     

Risk in a “Fee for Service” Health Care System

This paper describes an approach for assessing the financial risk inherent in a bid for the development and operation of a Management Information System (MIS) that includes processing of claims associated with a “Fee for Service” Health Care System. The discussion establishes the motivation for a risk assessment, defines the context of the problem, and proposes a risk-analysis procedure. Results attainable with the proposed approach are compared with those of a conventional analysis. The advantages of the proposed approach are addressed in terms of the added effort required.     

The Health Maintenance Facility

The Health Maintenance Facility (HMF) is the code name for a space-based medical clinic. The HMF is an integral part of the U.S. sponsored space station program due to be launched in the late 1990s. Contained in this module will be equipment, facilities, and supplies that can be used to support space station crew health. The range of medical care will depend upon the skill of the crew, the tools available, and the support systems that can be used from earth. The design of this system and its heavy dependence upon computer resources provide an excellent model for looking forward into the earth based medical clinics of the future.     

A personal computer database system for head and neck cancer records

The computerized database system described was initially developed in 1986 to facilitate analysis of retrospective head and neck cancer data from the Royal Adelaide Hospital Department of Otolaryngology. This has now been expanded to become an on-going patient information management system. It is based on the dBase-III-Plus database package and is implemented on an IBM XT compatible computer. The system was designed to be used by staff without specialist computer skills and is therefore largely “menu-driven.” The main functions include patient record creation, update, and retrieval, and the production of reports including graphical presentations. There is also a powerful but easy to use query facility. The system has already provided much useful epidemiological material but is now beginning to fulfill an even more important role in patient follow-up and in assisting evaluation of alternative treatment protocols.