Finance modeling in the delivery of medical care in tertiary-care hospitals in the Department of Veterans Affairs.

BACKGROUND: In the mid-1990s, the Department of Veterans Affairs (DVA) implemented the Veterans Equitable Resource Allocation (VERA), a new financial model developed to attempt to better distribute the approximately $18 billion annual budget among roughly 170 Veterans Administration Medical Centers (VAMCs). VERA is based on a Health Maintenance Organization (HMO) model. VERA provides reimbursement to each of the 22 regional Veterans Integrated Service Networks (VISNs), and subsequent VISN distribution to individual VAMCs is based on an individual medical center's enrollment of unique social security numbers (uniques). In HMO vocabulary these are individual "covered lives." METHODS: Currently available demographic and staffing information regarding the DVA's 23 tertiary hospital systems (Category 7 hospitals) on the KLF database (DVA Austin Data Base) and published information on the DVA website were reviewed. The following was obtained: (1) staffing information-physician and nurse full-time employment equivalent (FTEE) staffing; (2) patient demographics and hospital workload-facility uniques (u), outpatient facility uniques, average daily census (ADC), discharges, and outpatient clinic visits. The following staffing ratios were calculated for both physician and nursing: FTEE/(u/1000), FTEE/(discharges/1000), FTEE/(clinic visits/1000), FTEE/ADC. For all categories the means +/- SD were calculated and correlation coefficients were calculated on pertinent pairings. RESULTS: Although categorized as similar tertiary care facilities, the 23 "Group 7" VA hospitals are anything but equivalent when reviewed using the VERA financing model with respect to physician staffing, nurse staffing, and facility uniques. Using VERA methodology, average physician FTEE and total nursing FTEE staffing/(u/1000) are 3.67 +/- 0.89 and 15.53 +/- 3.77, respectively. Correlation statistics of staffing versus unique SSNs demonstrated correlation coefficients of 0.46 and 0.59 with respect to physician and nurse staffing, respectively. On the other hand, when physician FTEE and nursing FTEE staffing were compared with VAMC workload parameters (total ADC, discharges, and outpatient visits), correlation coefficients were more consistent, ranging from 0.62 to 0.86. CONCLUSIONS: In the VERA model, the reward of a larger annual budget for an individual VAMC or the regional VISN is realized when staffing of VAMCs is minimized, overall provided medical services (especially costly tertiary services) are limited, and the number of covered lives is maximized. A VAMC staffing system that equates medical services delivered in a tertiary VAMC setting based on an HMO model like VERA (where the user population is skewed toward the sicker, older patient) shows decreased correlation when compared with VAMC workload model parameters.

Diagnosis and management of appendiceal mucoceles.

Preoperative diagnosis of appendiceal mucoceles is rare. If untreated, one type of mucoceles may rupture producing a potentially fatal entity known as pseudomyxoma peritonei. The importance of diagnosing appendiceal mucoceles is highlighted through a case presentation of a woman who had an incidental finding of mucinous cystadenoma of the appendix during colonoscopic evaluation for occult gastrointestinal bleeding. A detailed review of the medical literature regarding appendiceal mucoceles is presented, with emphasis on the pathologic, clinical, radiologic, and evolving endoscopic features. Surgical options and prognosis are discussed.

Evaluation of benzalkonium chloride chemoneurolytic proximal gastric vagotomy.

BACKGROUND: Transmucosal chemoneurolytic injection of benzalkonium chloride (BAC) has previously been shown to duplicate operative proximal gastric vagotomy (PGV) in controlling gastric acid secretion. In this study, BAC was evaluated as to efficacious dose, methods of delivery, and systemic toxicities. METHODS: Sham celiotomy, operative PGV controls, transmucosal injections through a gastrotomy, and transserosal injections of BAC (saline controls, 0. 625, 1.25, 2.5, 5.0, 10 mg BAC/kg body wt) were administered to Sprague-Dawley rats. After 3 months the rats underwent Congo red testing (CRT), horseradish peroxidase (HRP) neuronal staining, and necropsy. The color density change of the gastric mucosa from basic to acidic demonstrated by the CRT at the time of necropsy was used to calculate the residual anatomic acid-secreting area. Prior to necropsy, subserosal HRP injections into the anterior and posterior stomach walls assayed vagal neuronal viability via retrograde axonal flow. Results were compared by an ANOVA. RESULTS: The results demonstrated that 1.25-10 mg/kg transmucosal BAC replicated the results of operative PGV; 2.5 mg/kg was found to be the most effective dose. All injection groups including saline controls demonstrated similar diminished vagal retrograde axonal flow by HRP testing consistent with local BAC chemoneurolytic effects. No systemic toxic symptoms were observed after tail vein intravenous BAC 1.25, 2.5, and 5.0 mg/kg. CONCLUSIONS: These efficacy studies have demonstrated BAC's potential utility in the performance of endoscopic transmucosal chemoneurolytic PGV.

Prospective evaluation of a new through-the-scope nasoduodenal enteral feeding tube.

BACKGROUND: With present techniques, transpyloric feeding tube placement is unreliable. This study evaluated a new nasoduodenal tube placed through a gastroscope. METHODS: A therapeutic gastroscope was advanced into the distal duodenum, and through the 3.7-mm channel this feeding tube was advanced under direct vision into the small bowel. The tube/guidewire combination was then advanced with the concomitant equidistant retraction of the scope until the wire could be grasped at the lips and exchanged to the nose using a nasal transfer tube. The guidewire was removed, and a "Y" connector was then attached to the end of the tube. RESULTS: Successful tube placement in all 21 patients (14M/7F) required an endoscopy time of 31 +/- 3.3 min and the tubes were utilized for 9.24 +/- 0.94 days. Tube tips were confirmed in the distal duodenum (10) or proximal jejunum (11) by radiographic contrast injection. CONCLUSION: This new through-the-scope tube can be placed in the distal duodenum quickly, safely, and consistently.

Spectrum of mucus-secreting pancreatic neoplasia.

Mucus-secreting pancreatic lesions, most commonly described by the Japanese, are often malignant (as in cystic or mucin-producing adenocarcinomas), but can be benign (hyperplastic or adenomatous cytology). We report a case of total pancreatic ductal enlargement without a localized lesion in which abdominal pain was relieved by endoscopic sphincterotomy and partial septotomy in which cytology remains benign. In the absence of pancreatic cyst, mass, or localized ductal abnormality, total pancreatectomy is the only treatment that can completely remove the risk of malignant degeneration of apparently benign, mucus-secreting pancreatic ductal enlargement. Disability after total pancreatectomy is severe, but the risk of metastasis from mucinous ductal ectasia is low without pancreatic cyst or mass. Therefore, regular observation of mucus-secreting ductal enlargement with computerized tomography and pancreatography are appropriate, especially in older patients. Endoscopic sphincterotomy may relieve symptoms and allow access for ampullary biopsy and brushings.

Laparoscopic fundoplication: a natural extension for the thoracic surgeon.

BACKGROUND: Thoracic surgeons have historically played a significant role in surgical treatment of benign esophageal disorders. With the advent of video-assisted thoracic surgical techniques, chest surgeons have also become adept at minimally invasive procedures. Thus, it seems appropriate that thoracic surgeons participate in minimally invasive antireflux operations, such as laparoscopic Nissen fundoplication. METHODS: From February 1993 to May 1995, 66 patients (32 male, 34 female) with a mean age of 45.5 years (range, 15 to 82 years) underwent a laparoscopic fundoplication. Gastroesophageal reflux disease was diagnosed on the basis of history and endoscopically documented esophagitis or abnormal esophageal pH testing or both. There were 45 type I, 3 type II, and 7 type III hiatal hernias. Eleven patients had gastroesophageal reflux disease with no hernia. RESULTS: Conversion to laparotomy occurred in 6 patients (9%) due to bleeding in 2 patients, inability to expose the gastroesophageal junction in 3, and gastric laceration in 1 patient. All but 1 patient underwent a Nissen fundoplication performed over a 50F to 60F dilator. The remaining patient (type II hernia without gastroesophageal reflux disease) underwent a reduction, closure, and anterior gastropexy. There was no operative mortality. Immediate postoperative morbidity included moderate dysphagia in 7 patients (11%), ileus in 2 patients (3%), and deep venous thrombosis and atrial arrhythmia in 1 each (1.5%). Excluding 1 patient hospitalized for 42 days due to severe psychosis, the mean postoperative stay was 4.0 +/- 2.5 days (median, 3 days). Three patients (5%) required dilation for dysphagia, and 1 (1.5%) has noted recurrent reflux during follow-up (mean, 14.4 months; range, 6 to 30 months). A single patient has undergone reoperation for persistent dysphagia (1.5%). CONCLUSIONS: A laparoscopic Nissen procedure is safe, effective treatment for refractory gastroesophageal reflux disease when performed by thoracic surgeons experienced in minimally invasive surgical procedures.

Prospective comparison of helium versus carbon dioxide pneumoperitoneum.

BACKGROUND: During prolonged laparoscopic operations with carbon dioxide (CO2) pneumoperitoneum (PP), hypercapnia with significant acidosis has been reported to occur in some patients with pulmonary dysfunction. An alternate inert insufflation gas like helium (He) could avoid this problem. METHODS: This prospective, IRB-approved study compared the cardiopulmonary response in 20 patients with both CO2 and He PP. With the minute ventilation held constant, baseline arterial blood gases and ventilatory and cardiac parameters were obtained after anesthetic induction but prior to CO2 PP. All values were repeated at 20 to 30 and 40 to 60-minute intervals after the insufflation of CO2 PP, then again during He PP. Values were compared by a paired t test analysis. RESULTS: Patients experienced significant hypercapnia during CO2 PP when compared with baseline arterial blood gases, but all values returned to baseline levels during He PP. CONCLUSIONS: He PP is an effective alternative to CO2 PP for a laparoscopic cholecystectomy avoiding CO2 retention and subsequent acidosis. Carbon dioxide retention may be dangerous in patients with pulmonary dysfunction who undergo laparoscopy.

Laparoscopic cholecystectomy can disseminate in situ carcinoma of the gallbladder.

BACKGROUND: Early case reports suggest more frequent and rapid recurrences of carcinoma of the gallbladder after laparoscopic cholecystectomy (LC) than after open cholecystectomy. This cancer has a poor prognosis and occurs in 1 percent of patients who undergo cholecystectomies. STUDY DESIGN: A recent community hospital series of gallbladder carcinoma (GBC) was reviewed and the total reported experience of GBC after LC was compiled. Diagnostic findings were compared for patients with GBC and a consecutive series of 24 patients who had LC for benign disease. RESULTS: Nine patients with GBC were found among 928 patients who had undergone cholecystectomy (0.97 percent incidence). Compared to patients without GBC, patients with carcinoma were older, had thicker gallbladder walls, and had more abnormalities detected intraoperatively (all p < or = 0.05). Recurrence of GBC occurred more rapidly after LC, and in diffuse peritoneal and port sites when compared with recurrence patterns after open cholecystectomy. CONCLUSIONS: In patients with GBC, LC may be sufficient when the disease is confined to the gallbladder mucosa and the gallbladder is excised intact without bile spillage. However, patients whose gallbladders are torn during dissection or patients who have invasive tumors should undergo laparotomy and local reexcision. In situ GBC can be implanted if the organ is torn during dissection. When gallbladders with suspicious wall thickening or adhesions are noted at LC, especially in older patients, the procedure should be converted to open cholecystectomy.

Video-assisted thoracic surgical repair of a foramen of Bochdalek hernia.

A case report of a congenital posterolateral diaphragmatic hernia in an adolescent is presented and a technique for thoracoscopic repair of Bochdalek hernia is described. Postoperative discomfort was minimal and the hospital stay was less than 24 hours. Video-assisted thoracic surgery may be the technique of choice for repair of certain congenital diaphragmatic hernias when identified after infancy.

Noncardiac operations in patients supported with mechanical circulatory support devices.

BACKGROUND: Recent advances in technology as well as refinements of patient selection criteria have improved results of ventricular assistance in patients with end-stage heart disease. With a "normal" cardiac output and the resultant improvement in end-organ perfusion, some patients revert to normal or near normal physiology. Seven patients supported with cardiac assist devices who have undergone general surgical, nonassist device related procedures with the assist device in place are presented. STUDY DESIGN: This is a historical review of seven cases. RESULTS: The surgical procedures included three cholecystectomies, one dialysis catheter placement, and one thoracoscopy. Six patients had Thoratec ventricular assist devices (Thoratec Laboratories Corp., Berkeley, CA) and one was supported with a Jarvik (Symbion, Inc., Tempe, AZ) total artificial heart. In one patient, postcholecystectomy bleeding was the only complication that may have been directly attributable to having an assist device in place. Four patients underwent successful transplantation and three patients died, two during support and one after transplantation. CONCLUSIONS: As heart transplant waiting lists become longer and when permanent ventricular assist devices become available, an increasing number of patients on ventricular assistance will have noncardiac related pathology requiring operative intervention. In our experience, patients supported on mechanical assist devices tolerated these procedures well.

Hyperbilirubinemia without common bile duct abnormalities and hyperamylasemia without pancreatitis in patients with gallbladder disease.

OBJECTIVE: To determine the incidence of jaundice and hyperamylasemia in the absence of common bile duct abnormalities or clinical pancreatitis in patients undergoing cholecystectomy. DESIGN: A continuous, prospective analysis of a consecutive case series was performed on all patients undergoing cholecystectomy. SETTING: An urban, tertiary care university hospital. PATIENTS: Adult patients with gallbladder disease. INTERVENTION: All patients underwent cholecystectomy. MAIN OUTCOME MEASURES: The presence or absence of common bile duct abnormalities was evaluated by cholangiography, and pancreatitis was identified by clinical signs, imaging studies, and direct visual inspection during cholecystectomy. RESULTS: All patients (N = 1746) undergoing cholecystectomy were prospectively categorized as having chronic calculous (n = 1410), acute calculous (n = 217), chronic acalculous (n = 70), or acute acalculous (n = 49) gallbladder disease. It was uncommon for patients with chronic calculous cholecystitis to have an elevated bilirubin level with no choledocholithiasis and a normal common bile duct or to have hyperamylasemia without pancreatitis. Twenty-five percent of the patients with acute calculous cholecystitis had a serum bilirubin level between 34 and 86 mumol/L (2.0 and 5.0 mg/dL) with no common bile duct abnormality and 4% had hyperamylasemia without pancreatitis. Over one third of the patients with acute acalculous cholecystitis had an elevated bilirubin level with a normal common bile duct or an elevated amylase level without pancreatitis. CONCLUSION: Jaundice and hyperamylasemia can be produced by gallbladder disease alone.

Laparoscopic cancer surgery. Lessons from gallbladder cancer.

Laparoscopic cholecystectomy (LC) may inhibit the discovery of unsuspected gallbladder cancer, and the effect of LC on the prognosis of gallbladder cancer is unknown. We present two cases of unsuspected gallbladder cancer removed laparoscopically and report the discovery of peritoneal tumor implantation at the umbilical port site 21 days after LC. Although gallbladder carcinoma flow cytometry has been reported to be of prognostic value by Japanese investigators, this technique did not distinguish herein between an invasive adenocarcinoma and carcinoma in situ. A cellular doubling time of 56 h was calculated from one tumor. When unsuspected invasive gallbladder cancer is found after LC, laparoscopic port sites should be inspected at reoperation and, at a minimum, the port site through which the gallbladder was removed should be widely excised. This demonstration of cancer recurrence in laparoscopic port sites may limit the application of laparoscopy to elective cancer resection.

Evaluation of alternative proximal gastric vagotomy techniques after a 9-month interval in a rat model.

Proximal gastric vagotomy (PGV) is an accepted operation for patients with ulcers that are refractory to medical management. Results comparable to those of standard, operative PGV have previously been demonstrated using endoscopic chemoneurolytic injection or laparoscopic laser seromyotomy in a porcine model. In this study, we evaluated several PGV techniques in regard to long-term effects on acid secretion, ulcer prophylaxis, and permanent vagal denervation in a rat model. Trans-mucosal injection of chemoneurolytic agents (cobaltous chloride, benzalkonium chloride, and phenol) and seromyotomy by CO2 laser were performed. After 9 months, all rats received sub-serosal gastric injections of horseradish peroxidase (HRP) during laparotomy. Twenty-four hours later, an ulcerogenic dose of pentagastrin was administered sub-cutaneously. Three days after administration of HRP (to allow time for retrograde axonal transport and labeling of cells of the dorsal vagal nucleus with HRP), necropsy was performed. The pre-pyloric gastric mucosa was inspected for ulcerogenic changes, and a Congo red solution was applied to the gastric mucosa to map the acid-secreting areas. All PGV methods significantly diminished pentagastrin-induced ulceration when compared to sham controls. Benzalkonium chloride chemoneurolytic and laser methods were most effective for decreasing the size of acid-secreting areas. A reduced number of HRP-stained cells in the dorsal vagal nucleus indicated permanent denervation of vagal-gastric connections by operative and laser techniques.

Cardiorespiratory effects of laparotomy in patients with spinal cord injury.

Patients with spinal cord injuries who require laparotomy are often difficult to diagnose and have an acute illness superimposed on a background of respiratory and cardiovascular abnormalities. Although pulmonary capacity is markedly reduced by paralysis, these patients tolerate elective laparotomy well. Emergency surgery for abdominal infection led to cardiac instability in two patients and prolonged respirator support in a third. This series of 12 patients supports elective colostomy for colon and perineal problems in these patients, even those with poor ventilatory volumes. Emergency surgery was marked by dramatic cardiovascular problems, which were corrected with pulmonary artery pressure monitoring of fluid resuscitation.

Cholecystectomy. Which procedure is best for the high-risk patient?

Laparoscopic cholecystectomy (LC), which results in less postoperative pain, disability, and scarring, has become an attractive alternative method of surgical management of the ambulatory patient with gallbladder disease. The best procedure for severely ill patients who are poor operative risks but require cholecystectomy, however, is unknown since the operative morbidity and mortality of LC in this group of patients had not been studied. All patients (177) undergoing cholecystectomy at one institution were evaluated. Based on their preoperative state of health as defined by a modified acute physiologic score (APS), patients were divided into two groups; one group was defined by an APS of less than 10, indicating they were in good health, and the other had an APS greater than or equal to 10, indicating that the group had multiple risk factors, predicting an increased postoperative morbidity and mortality. Selection for either procedure, LC or open cholecystectomy (OC), was made independently of the patient's preoperative status. Patients' past medical histories; demographic, physiologic, and laboratory data; and postoperative complications were evaluated. When all cholecystectomy patients were arranged into the respective risk groups, the age and severity of illness scores (APS) between LC and OC were not statistically different. Intraoperative and postoperative complications were not significantly different when patients undergoing LC were compared to patients undergoing OC. Laparoscopic cholecystectomy was associated with decreased hospitalization when compared to patients undergoing OC. The overall mortality of the patients undergoing OC was significantly greater than those undergoing LC. LC is an acceptable surgical alternative for high-risk patients requiring cholecystectomy.

Preoperative pulmonary function evaluation for laparoscopic cholecystectomy.

OBJECTIVE: Hypercarbia with respiratory acidosis is a recognized complication of laparoscopic cholecystectomy. This study was performed to identify preoperatively those patients who may develop hypercarbia and acidosis during the procedure. DESIGN: Retrospective analysis of preoperative variables. PATIENTS: Thirty-one consecutive patients underwent laparoscopic cholecystectomy at one institution who were receiving both preoperative pulmonary function tests and arterial blood gas analysis. RESULTS: More than 80 demographic, laboratory, and perioperative variables were entered into a univariate analysis to identify predictors of intraoperative acidosis (pH, < 7.35). Patient age, duration of the procedure, and preoperative blood gas values were not predictors of intraoperative acidosis. Several univariant predictors for patients experiencing carbon dioxide pneumoperitoneum-induced hypercarbia were identified; these included an elevated American Society of Anesthesiologists classification and significant decreases in forced expiratory flow at 25% of maximum, maximal forced expiratory flow, maximal voluntary ventilation, vital capacity, inspiratory capacity, and diffusing capacity of the lung for carbon monoxide. CONCLUSIONS: This study suggests that neither age nor preoperative arterial blood gas values are predictive of intraoperative hypercarbia and acidosis during periods of carbon dioxide pneumoperitoneum. However, preoperative pulmonary function measures of decreased flow, limited capacity, and compromised diffusion do correspond to the development of intraoperative acidosis. Preoperative evaluation with pulmonary function tests demonstrating forced expiratory volumes less than 70% of predicted values and diffusion defects less than 80% of predicted values can identify those patients who are at risk of developing hypercarbia and acidosis.

Proximal gastric vagotomy by minimally invasive methods in an acute rat model.

In this prospective study, minimally invasive methods of proximal gastric vagotomy (PGV) were investigated in male Sprague-Dawley rats. Completeness of vagotomy by traditional operative therapy, by laser denervation of the gastric serosa, and by subserosal or transmucosal injections of chemoneurolytic agents was evaluated with postoperative Congo red testing, ulcerogenic stimulation of the gastric mucosa, and histochemical labeling of whatever vagal fibers remained in the gastric wall. Short-term results demonstrate that successful PGV can be performed with minimally invasive methods.

Evaluations of surgery resident performance correlate with success in board examinations.

BACKGROUND: American Board of Surgery (ABS) In-Training Examination (ABSITE) scores correlate with future examination scores, but faculty evaluations of resident skill have not been shown to predict future performance. METHODS: Objective and subjective evaluations during the past 15 years in our columnar university surgical residency were reviewed to assess their ability to predict success on the qualifying (written) and oral (certifying) examinations offered by the ABS. RESULTS: The ABSITE scores correlated with success on the qualifying examination (multiple R2 = 0.473). Subjective assessments of resident knowledge at any level did not correlate with ABSITE or qualifying scores, but above average scores did predict success on the certifying examination (chi 2, p < 0.005). Chief-year ABSITE total percentile score and score of first qualifying examination also predicted success on the certifying examination. The attrition rate in our nonpyramidal program was 23%, of which more than one half were voluntary. One of 11 residents leaving the program has subsequently attained ABS certification. CONCLUSIONS: This study shows that faculty's subjective evaluations predicted resident success on the ABS certifying examination and also endorses the ABS oral examination as an effective measure of the candidate's ability to communicate surgical knowledge.