Value of anaerobic blood cultures in pediatrics

The aim of the study presented here was to evaluate the utility of anaerobically incubated blood cultures for detecting infections in pediatric patients. During a 2-year period 9,165 pediatric blood samples were processed, and significant microorganisms were recovered from 497 (5.4%) of them. Only two of the microorganisms isolated were strictly anaerobic. Of the total isolates, 13% were detected in anaerobic bottles solely. Considering that the quantity of blood available from pediatric patients for blood cultures is usually small, it may be reasonable to limit the use of anaerobic blood cultures to patients with the highest risk.

Health insurers’ medical necessity determinations for bariatric surgery

PURPOSE

This study explored how state managed-care patient protection laws affect health insurers' criteria for medical necessity, using bariatric surgery for weight reduction as a case in point.

METHODS

Six states and three national insurers were selected for in-depth case studies to represent a range of market, demographic, and legal conditions. In each state, 10-12 qualitative interviews were conducted in 2002 with insurers, regulators, providers, and healthcare attorneys, for a total of 71 interview subjects.

RESULTS

Denials of coverage for bariatric surgery are a frequent source of appeals to external review, and external reviewers frequently overturn these denials. However, few insurers feel pressured to approve most or all requests for coverage because external review decisions do not set binding precedents. Instead, insurers continue to assert their own criteria for medical necessity, relying on the insurance contract's general definition of medical necessity. Some insurers, however, specifically exclude all weight reduction surgery because of the difficulty of defending case-by-case denials on appeal.

CONCLUSIONS

Unlike most areas of medicine, in which health insurers have greatly scaled back their past efforts to scrutinize medical necessity, for bariatric surgery, many insurers continue to apply a more stringent standard for medical necessity than the one that independent practicing physicians use.

Picking up the tab. Healthcare chains put the past behind them, resolving past unpleasantries in order to make a clean start in the new year

It's something of a holiday tradition: legal settlements at major investor-owned healthcare companies. But will Tenet's and HealthSouth's multimillion-dollar mea culpas over allegations of providing unnecessary care have the same healing effect that HCA's pair of year-end settlements yielded? Tenet's E. Peter Urbanowicz, left, said his company's moves show "the real progress we are making to put our legal challenges ... behind us".

A nutrition support team led by general surgeons decreases inappropriate use of total parenteral nutrition on a surgical service

The purpose of this study was to decrease the number of inappropriate orders for total parenteral nutrition (TPN) in surgical patients. From February 1999 through November 2000 and between July 2001 and June 2002, the surgeon-guided adult nutrition support team (NST) at a university hospital monitored new TPN orders for appropriateness and specific indication. In April 1999, the NST was given authority to discontinue inappropriate TPN orders. Indications, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) standards, included short gut, severe pancreatitis, severe malnutrition/catabolism with inability to enterally feed > or =5 days, inability to enterally feed >50 per cent of nutritional needs > or =9 days, enterocutaneous fistula, intra-abdominal leak, bowel obstruction, chylothorax, ischemic bowel, hemodynamic instability, massive gastrointestinal bleed, and lack of abdominal wall integrity. The number of inappropriate TPN orders declined from 62/194 (32.0%) in the first 11 months of the study to 22/168 (13.1%) in the second 11 months (P < 0.0001). This number further declined to 17/215 (7.9%) in the final 12 months of data collection, but compared to the second 11 months, this decrease was not statistically significant (P = 0.1347). The involvement of a surgical NST was associated with a reduction in inappropriate TPN orders without a change in overall use.

A tale of medical shopping or the hazards of repetitious cytological screening of the cervix

A 65-year-old woman had on her own initiative three cervical smears taken at very short intervals. The second smear was taken only 1 day after the first one. It contained necrotic cellular material with atypia due to the scraping on the day before; it was at first mistakenly interpreted as showing malignant features. This led to the performance of various diagnostic procedures, and a considerably greater cost for the medical insurance system.

[Waste of medical tests in preoperative evaluation for cataract surgery]

The objective of this clinical trial was to determine the frequency of medical tests considered unnecessary in routine preoperative evaluation for cataract surgery. Unnecessary costs with these tests were also evaluated. For patients assigned to the selective testing group, it was requested that no preoperative testing be performed unless the patient presented a new or worsening medical problem warranting medical evaluation with testing. For patients assigned to the routine testing group, three tests were requested: a 12-lead electrocardiogram, complete blood count, and serum glucose level. The costs of tests considered unnecessary were calculated. The sample of 1,025 patients consisted of 512 assigned to the routine testing group and 513 to the selective testing group. Cumulative rate of medical events was similar in the two groups (p=0.923). The selective group underwent 60.7% fewer tests. The results suggest that selective preoperative testing in cataract surgery does not harm patients in terms of peri-operative clinical complications and also represents a significant cost reduction compared to routine testing.

Technology Assessment for Radiologists

Health technology assessment is the systematic and quantitative evaluation of the safety, efficacy, and cost of health care interventions. This article outlines aspects of technology assessment of diagnostic imaging. First, it presents a conceptual framework of a hierarchy of levels of efficacy that should guide thinking about imaging test evaluation. In particular, the framework shows how the question answered by most evaluations of imaging tests, "How well does this test distinguish disease from the nondiseased state?" relates to the fundamental questions for all health technology assessment, "How much does this intervention improve the health of people?" and "What is the cost of that improvement?" Second, it describes decision analysis and cost-effectiveness analysis, which are quantitative modeling techniques usually used to answer the two core questions for imaging. Third, it outlines design and operational considerations that are vital if researchers who are conducting an experimental study are to make a quality contribution to technology assessment, either directly through their findings or as an input into decision analyses. Finally, it includes a separate discussion of screening--that is, the application of diagnostic tests to nonsymptomatic populations--because the requirements for good screening tests are different from those for diagnostic tests of symptomatic patients and because the appropriate evaluation methods also differ.