Physician-directed therapeutic plan for large and small bowel procedures: a quality improvement project at St. Vincent's Medical Center

Project Overview: St. Vincent's Health System sought to increase the efficiency of and decrease costs for care of patients undergoing large or small bowel procedures (DRGs 148 and 149), while maintaining or improving patient outcomes. A multidisciplinary, physician-led task force developed a physician-directed therapeutic plan that was implemented in January 1992.

KEY FINDINGS

In 1992, the average cost per case for 188 patients in DRG 148 was $12,507, a 5.4 percent reduction from the 1991 cost (a 12.9 percent reduction when inflation is taken into account). Length of stay was reduced by nearly one day, from 15.48 days to 14.56 days.

Applying critical pathways to neurosurgery patients at the University of Michigan Medical Center

Project Overview: In April 1990, The University of Michigan Hospitals began a major, multidisciplinary project to standardize care processes in order to increase efficiency and reduce costs while maintaining the quality of clinical care. A team of nurses began the project by developing critical pathways for two neurosurgery procedures--lumbar laminectomy and transphenoidal pituitary tumor resection. The pathways were reviewed by physicians and other staff from other disciplines and were implemented in January of 1991.

KEY FINDINGS

Data from the first 14 months show a decrease in patients' average lengths of stay in both the intensive care unit (ICU) and routine care unit. Costs and variance data are being analyzed and further improvements to the pathways are being made. Eleven critical paths are now being used for neurosurgery patients. In retrospect, participants learned that physicians should be involved at the earliest stages of critical pathway development and in the process of implementation.

Improving patient outcomes following joint replacement surgery at Methodist Evangelical Hospital

Project Overview: In 1989, orthopedic surgeons at Methodist Evangelical Hospital began looking at the various components of arthroplasty, a surgical procedure in which an entire joint or part of a joint is replaced with metal or plastic components, in an effort to maximize the value of such procedures in terms of clinical outcome, quality of patient care, and cost.

KEY FINDINGS

The average length of stay has dropped from 11 days to 8.1 days, resulting in a savings of approximately $2,100 per patient. Preadmission autologous blood donations for total knee arthroplasty have been discontinued. By standardizing certain orthopedic implants, the hospital has been able to reduce its inventory and eliminate instrumentation and loaner fees--a savings of approximately $445,000 annually.

Comparing surgical efficiency in independent practice association HMOS and traditional insurance programs

This study examines the effect of Independent Practice Association (IPA) HMO membership on hospital total charges, ancillary charges and length of stay (LOS) for surgical patients. Intrahospital comparisons of IPA and traditional insurance patients are made after adjusting for surgical procedure, admission severity of illness, age, sex and year of admission. Our multiple regression model indicates that IPA patients undergoing 12 frequently occurring surgical procedures have lower resource use. Eight (80%) of the 10 study hospitals exhibit a negative IPA beta coefficient for total charges, ancillary charges and LOS. Five (50%) hospitals have statistically significant (p < 0.05) negative coefficients for total charges, while one (10%) hospital has a significant positive coefficient. IPA patients exhibit adjusted total charges that are 6% lower than traditional insurance, ancillary charges that are 4.3% lower, and LOS that is 10% shorter.

Blood use in spinal operations in children

This paper reports a retrospective analysis of blood use in 27 children undergoing major spinal surgery in Liverpool in 1990. Overall 133 units of blood were cross-matched, but only 60 units (45%) were used. The results of the analysis show a significant difference between the operative techniques used in elective spinal surgery. This hospital has now introduced new guidelines for the cross-matching of blood.

A descriptive study of emergencies admitted to a surgical department

A study was undertaken to evaluate the pattern of emergency admissions and their management by the surgical firm in a medium size (700 beds) general hospital. Over a three month period, 258 patients were admitted to one surgical team that was on take every third day. All patients were entered into a protocol that was updated daily by a registrar. In four (13.3%) of the 30 days on take, patients had to be referred to a nearby hospital due to shortage of emergency beds. The accuracy of diagnosis by the Accident and Emergency (A&E) resident, surgical resident and surgical team were 75.7, 77.2 and 88.4% respectively. The mean delay before attendance by an intern after admission was 47 (SD +/- 29) mins. Forty-four (17%) of these admissions were probably unnecessary. A further 22 (8.5%) patients had to be referred to other disciplines, indicating an initial wrong diagnosis. A substantial number of investigations were unnecessarily done on an emergency basis. Ninety-three (36.0%) patients required surgery. The median duration of hospital stay was three days. The overall morbidity was 4.2% and mortality 1.2%. The study was valuable in revealing the deficiencies in the existing emergency service; leading to new proposals to achieve our ultimate aim of providing high quality patient care.

[Quality assurance in a surgical department]

The quality of a given service in a surgical department depends on many factors. Most important are adequate resources, training of the surgeons and nurses and time for follow-up and clinical research. Quality standards should be defined in accordance with the international literature and results should be continuously surveyed to ensure that the agreed goals are met. This article describes various general rules and routines which have been established in our department, as well as the specific systems used to measure the quality of our surgical service in three special fields: Care of patients with tumour mammae, care of patients with gallstone disease, and prospective registration of complications for all gastroenterological patients in our surgical department.

Audit of general practitioner referrals to an acute surgical unit

One hundred and ninety referrals from general practitioners (GPs) to an acute surgical unit were audited prospectively over a 6-month period. A total of 78 admissions were considered inappropriate of whom 23 patients were thought to have needed neither surgical admission nor opinion. The estimated expenditure resulting from admissions deemed inappropriate was 25,000 pounds. The daytime commitments of more senior staff on routine emergency duty days meant they were not easily available to deal with calls concerning acute GP referrals. These admissions reduce the efficiency of the service; this may be improved by a senior member of the team accepting and screening GP calls.

[Combined operations as a method for increasing the capacity of a surgical clinic]

The work shows the economical effect of concurrent surgery on the abdominal organs and organs of the retroperitoneal space undertaken in 404 patients whose ages ranged from 16 to 81. The time taken by the concurrent operations and the duration of treatment at the hospital were studied. In 63.1% of patients the concurrent operations lasted up to 3 hours. The duration of treatment was least in concurrent appendectomy (14.2 +/- 0.5 days) and longest on oncological patients (40.9 +/- 2.2 days). It is noted that the sum terms of treatment reduce, while in separate performance of the operations they are prolonged. The highest economy of finances is noted in urolithiasis, nephroptosis, acute appendicitis, hernias, and cholelithiasis. The national economic effect in the treatment of 404 patients at the clinic came to 60,471 rubles and 18 kopecks.

Total joint replacement: implication of cancelled operations for hospital costs and waiting list management

OBJECTIVE

To identify aspects of provision of total joint replacements which could be improved.

DESIGN

10 month prospective study of hospital admissions and hospital costs for patients whose total joint replacement was cancelled.

SETTING

Information and Waiting List Unit, Musgrave Park Regional Orthopaedic Service, Belfast.

PATIENTS

284 consecutive patients called for admission for total joint replacement.

MAIN MEASURES

Costs of cancellation of operation after admission in terms of hotel and opportunity costs.

RESULTS

28(10%) planned operations were cancelled, 27 of which were avoidable cancellations. Five replacement patients were substituted on the theatre list, leaving 22(8%) of 232 operating theatre opportunities unused. Patients seen at assessment clinics within two months before admission had a significantly higher operation rate than those admitted from a routine waiting list (224/232(97%) v 32/52(62%), x2 = 58.6, df = 1; p < 0.005). Mean duration of hospital stay in 28 patients with cancelled operations was 1.92 days. Operating theatre opportunity costs were 73% of the total costs of cancelled total joint replacements.

CONCLUSION

Patients on long waiting lists for surgery should be reassessed before admission to avoid wasting theatre opportunities, whose cost is the largest component of the total costs of cancelled operations.

Measuring efficiency in acute care hospitals: an application of data envelopment analysis

In this article, the authors attempted to demonstrate how DEA can be useful to hospital administrators and health care planners. They used actual data collected by the American Hospital Association through its Monitrend Data Service. Since these were national data, they are presented here for illustrative purposes only. The efficiency with which a hospital operates may well depend upon the local or regional labor market, the competition among health care providers in that market, and the demographics of the service area. The choice of variables was dictated by reasonableness and availability of data. Given the routine collection of case mix data by DRG since 1984, the use of a different set of output variables for any future studies would be quite appropriate. Additionally, if DEA were to be used, a consensus concerning relevant controllable and non-controllable input variables would need to be achieved. There are more technical caveats of which the reader should be aware. 1) The efficiency scores are all relative and are based on the performance of the other hospitals being compared; nothing can be said about the absolute efficiency of a given hospital. However, the relative ratings are conservative in that the approach "bends over backwards" to give the individual hospital the benefit of the doubt in terms of the relative importance of the various outputs and inputs utilized. The approach maintains equity in that any weights chosen for a given hospital must be feasible for all of the other hospitals. 2. The ratings assume a causal impact of the inputs on the outputs. In addition, it is possible that inclusion of additional inputs and outputs could modify the relative scores and/or help explain the differences. However, based on the factors available, any unit rated inefficient is inferior in a very real and demonstrable sense. 3. DEA is based on the generalized notion of convexity which assumes that the performance arrived at by taking any linear weighted combination of other hospitals' inputs and outputs represents a feasible and achievable technology. The general frontier surface is approximated by piecewise-linear segments with the result that observed differences in efficiency cannot be explained away as differences in economies of scale. 4. The inefficiency score and the resource conservation potentials are based on a unit's so-called contraction path, i.e., all of the controllable inputs are required to be reduced by the same factor.(ABSTRACT TRUNCATED AT 400 WORDS)

Evaluation of post-operative stay after inpatient major surgery--a prospective study

The present study was carried out at a single surgical unit of AIIMS, to evaluate the risk and benefit of short post-operative stay in adult population after inpatient surgery under general anaesthesia for various intra-abdominal, Genitourinary, breast and thyroid disorders including emergency procedures. The age of the patients ranged from 17-71 years. Patients with minor surgical procedures were excluded from the study. A total number of 138 patients were included in the study comprising of Test group. The patients were discharged within 5 days of the operative procedure. There was no major morbidity or mortality related to early discharge. The mean duration of postoperative length of hospital stay was 5.25 days in test group of patients as compared to 10.20 in control group of patients. In conclusion therefore, short hospitals stay following major procedures is safe and effective in reducing the cost of hospital care to the patient and hospital both.

Cost effectiveness of minor surgery in general practice: a prospective comparison with hospital practice

The cost effectiveness of general practitioners undertaking minor surgery in their practices was determined in a prospective comparison of patients having minor surgery undertaken in five general practices over a 12 week period in 1989, and in the departments of dermatology and general surgery in Rotherham District General Hospital over a contemporaneous eight week period. There were no differences between the settings in the reported rates of wound infection or other complications and only one general practice patient was subsequently referred to hospital for specialist treatment. General practitioners sent a smaller proportion of specimens to a histopathology laboratory than hospital doctors (61% versus 90%, P less than 0.001); incorrectly diagnosed a larger proportion of malignant conditions as benign (10% versus 1%, P less than 0.05) and inadequately excised 5% of lesions where this never happened in hospital (difference not significant). General practice patients had shorter waiting times between referral and treatment, spent less time and money attending for treatment and more of them were satisfied with their treatment. The cost of a procedure undertaken in general practice was less than in hospital--pounds 33.53 versus pounds 45.54 for the excision of a lesion and pounds 3.00 versus pounds 3.22 for cryotherapy of a wart (1989-90 prices). Performing minor surgery in general practice would seem cost effective compared with a hospital setting. However, the risk of general practitioners inadequately excising a malignancy and not sending it to a histopathology laboratory must be addressed and the conclusion regarding cost effectiveness only applies where general practice is a substitute for the hospital setting and not an additional activity.

[A utilization review program of cefoxitin]

A drug utilization review program of cefoxitin was conducted in a 714-bed teaching hospital. Health records of all 43 in-patients who received cefoxitin during the month of November 1987 were reviewed retrospectively. The use of cefoxitin (47 courses) was evaluated on the basis of "appropriate use" criteria developed from the literature and the physician's clinical experience. Of the 47 courses evaluated, cefoxitin was prescribed for prophylaxis in 47%, and its use was considered inappropriate in 86% of these. Overall, 66% of total cefoxitin usage was deemed inappropriate in this hospital. The cost associated with inappropriate use was estimated at $2672 for the period of the study. Corrective measures were then implemented to rectify the identified problems. A second study was conducted 2 years later to assess the impact of the corrective measures. This utilization review program of cefoxitin showed that optimal use of a drug requires not only close collaboration between pharmacists and physicians but a continuous and not a sporadic process of surveillance of the prescription for the drug being studied.

Measurement issues in evaluating physicians' practice patterns using hospital billing and surgeon's self-report data

The availability of computerized case mix data, which merge medical records information and patient billing data, provide opportunity for measuring physician-specific practice patterns. However, the validity of physician comparisons is a concern when total patient charges are measured at two points in time. In this physician-initiated multicenter study, comparisons using samples of uncomplicated, baseline cases, as determined from medical records chart reviews of five surgical procedures at three institutions, demonstrated a statistically significant reduction in average length of stay (ALOS) from 0.8 to 2.8 in seven of the 15 studies while total patient charges increased in 11 of the studies from one to 29 per cent. Billing data were useful in measuring ALOS and the frequency of specific laboratory tests ordered and then comparing these to physicians' self-report practice.

[Quality assurance in Norwegian somatic hospitals]

In 1990, 70 Norwegian hospitals were mailed a questionnaire asking about quality assurance (QA) activities in the departments of internal medicine, surgery, gynaecology/obstetrics and pediatrics. Responses from 173 departments at 58 hospitals showed a marked interest in improving quality and quality assurance. However, few departments had implemented QA to any noticeable extent in their clinical practices. There were few differences between surgical and non-surgical departments. Only 30% of the respondents had established routines aimed at ensuring complete medical records. 47% had not established committees to record and evaluate accidents, or report hazards to patients, in spite of the fact that only 5% assumed QA was of little usefulness. In 1990, little time was spent on specific QA activities; the most common estimate was one hour per week. In our estimate, full QA in clinical department would require 2-5% of the total contribution of work.

Impact of the use of absorbable fracture fixation implants on consumption of hospital resources and economic costs

Within a 6-year period (1984-1989) absorbable pins, rods, and screws made of polyglycolide, polylactide, or lactide-glycolide copolymer were used in the internal fixation of 881 fractures, 73.1% of which were displaced malleolar fractures of the ankle. During the last 3 years the patients treated using absorbable fracture fixation constituted 19.6% of all fracture patients managed by internal fixation at the department. The number of hardware removal procedures avoided during the 6-year period as a result of the use of the absorbable implants was estimated at approximately 700. By determining all direct and indirect costs associated with internal fracture fixation and the influence of the percentage of hardware removal, a cost coefficient was calculated for certain fracture types when treated using absorbable versus metallic internal fixation. In bimalleolar fractures, an optimal indication for absorbable fixation, the coefficient was 1.04 (cost of absorbable fixation 4% higher than that of metallic fixation) if the removal percentage with metallic fixation was zero and 0.91 (cost of absorbable fixation 9% lower than that of metallic fixation) if the removal percentage was 100%. The breakeven point was a removal rate of 31%.

British Columbia sends patients to Seattle for coronary artery surgery. Bypassing the queue in Canada

Concern about waiting lists for elective procedures has become a highly visible challenge to the universal health insurance program in Canada. In response to lengthening queues for patients waiting for cardiac surgery, British Columbia made contracts with four Seattle hospitals to send a total of 200 patients for coronary artery bypass surgery. This article examines the cause of the queue for cardiac surgery in British Columbia and the events that led to outside contracting. Global hospital budgets and restrictions on capital expansion have limited hospital capacity for cardiac surgery. This constrained supply, combined with periodic shortages in critical care nurses and cardiac perfusion technologists, has resulted in a rapid increase in the waiting list. Reducing wide variations in the lengths of queues for individual surgeons may afford an opportunity to reduce long waits. While the patient queue for cardiac surgery has sparked a public debate about budget limits and health care needs, its clinical impact remains uncertain.

Management importance of common treatments: contribution of top 20 procedures to surgical workload and cost

OBJECTIVE

To assess the contribution of the most frequently performed procedures to surgical workload and to evaluate the financial implications.

DESIGN

Analysis of data held on the department's computerised clinical information system.

SETTING

Department of surgery in a district general hospital.

PATIENTS

4845 patients were treated by surgeons in three consultant firms over an 18 month period and 5346 patients by surgeons in a single firm over a five year period.

MAIN OUTCOME MEASURES

Percentage and cumulative percentage contribution to workload in order of frequency by procedure. Costs of the commonest and costliest treatments.

RESULTS

Half of the workload of the department was encompassed by eight procedures. Twenty procedures accounted for 70% of the work. For a single firm 20 procedures represented over 80% of all the surgical work. Transurethral prostatectomy was the treatment that consumed most resources (pounds 240,900 for 198 patients in 18 months). The costliest patients were those who had undergone complicated large bowel surgery, vascular reconstructions, or amputation.

CONCLUSIONS

Clinicians and managers need to appreciate the importance of the most common surgical procedures. It is vital that performance and costing of these procedures are optimum as they contribute disproportionately to overall results and finance.

Cutting the cost of cataract surgery--a financial audit

We have analysed the cost of disposable equipment used during cataract surgery by eight different surgeons over a six-month period in the same hospital. By comparing the costs of single-use items used by each surgeon we highlight how significant savings can be made by change of technique (without an adverse effect on surgical outcome).

Hospital financial performance under the prospective payment system by type of admission: psychiatric versus medical/surgical

We performed detailed simulations of DRG-based payments to general hospitals for treatment of nonexempt psychiatric and medical/surgical patients under Medicare's prospective payment system (PPS). We then compared these results to calculated costs for the same patients. Hospitals without specialized psychiatric units tend to fare better financially on their psychiatric than on their medical/surgical caseloads, although the levels of gain for these two types of patients are correlated. Hospitals with nonexempt psychiatric units generally have similar rates of gain on psychiatric and medical/surgical patients. Comparing psychiatric treatment in "scatter-bed" sites with that provided in nonexempt units, the higher rate of gain under PPS for treatment in scatter beds results largely from shorter lengths of stay. We discuss hospital behavior and the relationships between treatment of psychiatric illness under DRG-based payment and its treatment in exempt psychiatric units, which are excluded from DRG-based payment.

Steps towards cost-benefit analysis of regional neurosurgical care

OBJECTIVE

To determine the cost of averting death or severe disability by neurosurgical intervention.

DESIGN

Retrospective analysis of one year's admissions for neurosurgery; comparison of outcome with expected outcome in the absence of neurosurgical intervention and with the cost of neurosurgery.

SETTING

Wessex Neurological Centre.

PATIENTS

1026 Patients were admitted to the neurosurgical service in 1984. Of 1185 admissions, 978 case records were available and outcome was known in 919.

MAIN OUTCOME MEASURES

Outcome was assessed with the Glasgow outcome scale, modified as necessary, from the case notes, or by letter follow up to the general practitioner. Expected outcomes for each of the 54 diagnoses were derived from both published reports where available and an expert panel of 18 consultant neurosurgeons. The cost of the neurosurgical service for 1983-4 was known from a separate study and the cost per patient was calculated using the length of stay.

RESULTS

The cost of neurosurgery in 1983-4 was 1.8 million pounds. In all, 243 deaths or severe disabilities were estimated to have been averted at an average cost of 7325 pounds (range 5000 pounds to 70,000 pounds). The overall cost per quality adjusted life year (QALY) was 350 pounds (range 34 pounds to greater than 400,000 pounds). The cost of long term care for severely disabled survivors is at least 18-fold greater than the cost of neurosurgical intervention to avert such disability.

CONCLUSIONS

In Britain neurosurgery is not expensive in comparison with the costs and benefits of other areas of medicine, and the cost per QALY is unexpectedly low except for severe diffuse head injury, malignant brain tumors, and cerebral metastases. The neurosurgical budget should be assessed in the context of managing a patient in hospital and subsequently in the community.

Academic consequences of a trauma system failure

Houston is served by only two trauma centers: Hermann Hospital (University of Texas Medical School at Houston [UTMSH]), and Ben Taub General Hospital (Baylor College of Medicine). In mid-1988, Hermann Hospital, prompted by a shortage of ICU nurses and +8.0 million/yr of uncollectible trauma charges, began to divert critically ill and injured patients to the already overburdened Ben Taub General Hospital. The academic consequences to UTMSH included a severe loss of clinical experience by the surgical residents and medical students and a severe reduction in faculty-generated billing. The lost billing from the trauma service and the other clinical services approximated +8.0 million/yr. This equated to an +13.5 million decrease in the anticipated billings for the year. Alternative revenue sources were not apparent. Other centers with a heavy trauma system commitment are at risk to suffer similar unsettling academic sequelae as our trauma systems fail.

[Intensification of surgical activities in the department of general surgery]

The authors intensified and improved considerably the qualitative indices of surgical activity in a department of general surgery by means of simple and practicable organizational measures and by changing the tactics of surgical management of some diseases. This allowed the conclusion that the number of beds in the department must be reduced by 15 without reduction of the staff, which will not affect the activity of the department unfavourably. The organization of a resuscitation department without additional expenses is planned at the cost of the measures mentioned above.

[Economic substantiation of intensifying the activities of pediatric surgical departments]

The article calculates the economical efficacy and averted economical loss in intensive work of a pediatric surgical department. The introduction of a complex of therapeutic and preventive measures producing a purposeful effect on the wound process made it possible to reduce postoperative complications to 0.3% and the general hospital stay to 3.0 days in a group of patients with "minor" surgical diseases and to hospitalize additionally at least 900 patients annually. More than 203,000 roubles are saved annually due to a shorter stay in the hospital and increased bed turnover.

[A questionnaire study of day care. Big differences and unused possibilities among Norwegian hospitals]

We have studied the use of day care surgery in surgical, gynecological and ENT-departments in Norwegian hospitals. A questionnaire was sent to 129 departments at 79 hospitals. The response rates were 95.3% and 98.7%. We asked about 28 diagnoses and procedures and whether day care surgery was used systematically. We also asked how day care surgery was organized, how the operations were registered, how the patients were informed about the different procedures and if they had to pay part of the fee themselves. Many departments always hospitalize patients for minor and intermediate surgery, and there are big differences between the hospitals in regard to the extent of day care surgery. Many hospitals do not make full use of available resources because day care surgery is not organized as an alternative to hospitalization.

[Is short-stay treatment profitable?]

It is often said that the reimbursement from public insurance is too small to make it profitable for hospitals to perform day surgery and outpatient surgery. It is essential to make it clear whether one is referring to transferring a patient from inpatient stay to an outpatient situation of treatment or a patient who would alternatively not have been treated in hospital. In the first case outpatient treatment will be profitable for the hospital even if there is no specific reimbursement. If suitable patients are not transferred to the outpatient department, this must be because the hospital does not find the reimbursement profitable enough to compensate for problems connected with the organizational change. The second case represents an increase in the hospital's capacity and, strictly speaking, is quite different from a comparison of inpatient stays and outpatient treatment. To illustrate the method used to calculate the costs and benefits to the society from day surgery or outpatient treatment, we present key results from an examination of a short-stay unit at the county hospital of Ostfold, in Fredrikstad. Although this was not a pure day surgical unit (60 per cent of the patients remained until the next day), the results shed light on the economic aspects of pure day surgery as well. The most important effect of this unit was an increase in treatment capacity and a reduction in the time the patients spent waiting for treatment. We show that the unit was certainly profitable if patients were on sick leave for at least one percent of the months spent waiting.

Resource-based relative values for invasive procedures performed by eight surgical specialties

We surveyed approximately 850 physicians in eight surgical specialties to investigate physicians' work in performing invasive services. Building on our analysis of physician work, we developed a relative value scale of physicians' services based on resource costs. First, we found that physician charges are not set in proportion to the resources required to perform a given procedure: there is a threefold variation, across hospital-based invasive procedures, in the ratio of charges to resource-based relative values. Second, for most procedures, the preoperative and postoperative periods represent 60% to 75% of a physician's total service time, but only 35% to 50% of the total service work. Lastly, intraoperative work per unit of time varies greatly. Work per minute for invasive procedures is two to three times that of medical office visits and is strikingly greater for some specialties. The Resource-Based Relative Value Scale, at a minimum, represents a useful tool for payers to identify procedures with potentially aberrant charges and also offers unique insights into the nature of physicians' work.

A study of change in clinical service for general surgical patients

The department of surgery at Long Island Jewish Medical Center in New York City conducted a study examining resource consumption and quality of care for patients referred to surgery from other hospital services, or "referred patients." Referred patients were compared with "nonreferred" surgery patients using several indicators of resource consumption. A quality assessment was also performed on a random sample from both groups using peer review organization guidelines. The study found that referred patients consumed more resources and may have received poorer quality care than nonreferred patients. Previous studies suggest that some resource utilization by referred patients may be avoidable. Thus, referral to the department of surgery may serve as an indicator for identifying patients in need of ongoing quality and/or utilization monitoring.

Strategic automation for surgery

Recent advances in automated systems for surgical department management include enhancements in management methodology and improved economics of the surgical suites. Requirements of accountability legislation have stimulated development of a new generation of highly efficient software applicable to the surgical suite. These include surgical scheduling, preference lists in picking order, materials management, surgically related data and statistics, deployment of personnel and assignment of facilities. With recent advances in computer hardware and the availability of applicable software, the return on investment of these systems makes them affordable. Strategic surgical software can improve productivity, accuracy, efficiency of service and quality control while enhancing revenues to a surgical department.

Day-care versus inpatient pediatric surgery: a comparison of costs incurred by parents

The cost-effectiveness for parents of day-care pediatric surgery was assessed by comparing time and financial costs associated with two surgical procedures, one (squint repair) performed exclusively as a day-care procedure, the other (adenoidectomy) performed exclusively as an inpatient procedure. All but 1 of 165 eligible families participated. The children underwent surgery between February and July 1981. The day-care surgery group (59 families) incurred average total time costs of 16.1 hours, compared with 37.1 hours for the inpatient surgery group (105 families), as parents in the latter group remained with their child during the longer hospital stay. Parents from out of town incurred the greater time and financial costs. In both groups parents of younger children tended to spend more time at the hospital than parents of older children. Type of surgical management was not a significant factor in out-of-pocket expenses. Loss of income was associated with employment of the mother as a professional or a manager and may reflect inequalities in access to compassionate leave between men and women in equivalent positions. Opening day-care surgery facilities on weekends might reduce the financial burden on working mothers. Overall, day-care surgery was found to be cost-effective for families.