Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair.

BACKGROUND: Although geographic variations in the rates of orthopaedic procedures have been well documented, considerable controversy remains regarding the factors that drive these variations, particularly the role of the availability of orthopaedic surgeons. Moreover, little attention has been specifically focused on variations in the rates of commonly performed shoulder procedures. METHODS: The current study documents state-to-state variations in the rates of total shoulder replacement, humeral head replacement, and rotator cuff repair and examines factors that might account for these variations. The regional incidences of these three procedures were analyzed with use of the Health Care Financing Administration Medicare database (MEDPAR, 1992). The rates were age-adjusted, and variations were measured with use of high:low ratios, variation coefficients, and systematic components of variation. Potential causes of variation were analyzed with use of Spearman and partial correlations as well as with Poisson regression. RESULTS: Rates for the three procedures that were studied varied from one state to another by as much as tenfold. Humeral head replacement had the lowest rate of variation according to all three measures. All three procedures were performed less often in states that were more densely populated. With the numbers available for study, no consistent, significant relationship was found between the density of orthopaedists and shoulder surgeons and the rates of any procedure. CONCLUSIONS: The striking variations that were noted for these commonly performed procedures showed that there is a clear need for well designed clinical research to further define the factors that account for the variations and to examine the effectiveness and appropriate indications for the procedures.

Acute care hospital utilization by patients with visual impairment.

OBJECTIVE: To assess whether visual impairment contributes to average length of stay (ALOS) within inpatient care facilities. METHODS: We used the New York State Department of Health's Statewide Planning and Research Cooperative System (SPARCS) data for 1993, containing 1 principal diagnosis code and up to 8 secondary diagnosis codes for approximately 2.6 million hospital discharges. We evaluated ALOS differences in patients with and without visual impairment and in patients with eye pathologic conditions, including eye surgery. Visual impairment is not a primary admitting diagnosis, but may be coded as a secondary diagnosis. Eye pathology comprises a large variety of conditions, including corneal ulcers, abscesses, corneal deposits, edema, cataracts, vitreous hemorrhages, and many other eye disorders (ICD-9-CM codes 360-368.9 and 370-379). RESULTS: The ALOS was 13.4 days for patients with visual impairment (N = 5764), 11.9 days for patients with either eye pathology or visual impairment (N = 60,085), and 8.2 days for patients with no visual impairment (N = 2,546,586). Using a series of multivariate models that controlled for the variables of age, sex, and payer source, as well as disease, disorders, and ophthalmology procedures, we found that the existence of visual impairment added 2.4 days to the ALOS (P<.001), while eye pathology combined with a secondary diagnosis of visual impairment added 1.8 days to the ALOS (P<.001). CONCLUSIONS: Visual impairment contributes significantly to hospital length of stay. A better understanding of the functional care needs of patients with visual impairment in an acute care setting and at the time of discharge from the hospital may contribute to reducing excess ALOS and its related costs while improving the quality of patient care.

The validity of hospital administrative data in monitoring variations in breast cancer surgery.

To assess the validity of using hospital administrative data to measure variations in surgery for early-stage breast cancer, ICD-9-CM coded information was compared with corresponding tumor registry data for 1293 breast cancer patients undergoing lumpectomy or mastectomy at a tertiary referral center from January 1989 to October 1993. Relative to "gold standard" tumor registry data, the administrative data proved 83.4% sensitive and 80.4% specific in identifying women with localized disease who would be potential candidates for lumpectomy. The proportion of women with localized disease undergoing lumpectomy in groups defined by race and insurance status was nearly identical, whichever data were used. Administrative data, which is often readily and publicly available, may be useful in studying variations in breast cancer treatment in key demographic groups.

Sequential events contributing to variations in cardiac revascularization rates.

Numerous studies have demonstrated the importance of race, payor, and gender in determining the use of cardiac services, including revascularization procedures (bypass surgery and angioplasty). However, there has been less investigation into where and when in the process of care differences in utilization arise. In this report, the authors examined the sequence of events leading to the use of revascularization procedures, identifying four phases of care (prehospital, intrahospital, interhospital, and posthospital). Following a cohort of 5857 patients admitted to California hospitals with acute myocardial infarction in 1991, the authors found differences in treatment probabilities during nearly every phase for different racial and payor groups. For example, compared with patients who are uninsured, patients with private insurance were more likely to be admitted initially to a hospital offering revascularization (adjusted odds ratio [OR] = 1.40, 95% confidence interval [CI] 1.30 to 1.51). Moreover, once admitted to such a hospital, private patients were more likely to undergo revascularization (adjusted OR = 2.30; 95% CI 1.80 to 2.94). They were also more likely to undergo transfer to receive revascularization (adjusted OR = 1.22; 95% CI 1.03 to 1.45), and to be readmitted for revascularization (adjusted OR = 1.60; 95% CI 1.13 to 2.27). Previously reported discrepancies in service use represent the cumulative effects of multiple phases during which different racial and payor groups experience different processes of care.

Computer-generated informational messages directed to physicians: effect on length of hospital stay.

OBJECTIVE: With the advent of hospital payment by diagnosis-related group (DRG), length of stay (LOS) has become a major issue in hospital efforts to control costs. Because the Columbia-Presbyterian Medical Center (CPMC) has had above-average LOSs for many DRGs, the authors tested the hypothesis that a computer-generated informational message directed to physicians would shorten LOS. DESIGN: Randomized clinical trial with the patient as the unit of randomization. SETTING AND STUDY POPULATION: From June 1991 to April 1993, at CPMC in New York, 7,109 patient admissions were randomly assigned to an intervention (informational message) group and 6,990 to a control (no message) group. INTERVENTION: A message giving the average LOS for the patient's admission or provisional DRG, as assigned by hospital utilization review, and the current LOS, in days, was included in the main menu for review of test results in the hospital's clinical information system, available at all nursing stations in the hospital. MAIN OUTCOME MEASURE: Hospital LOS. RESULTS: The median LOS for study patients was 7 days. After adjustment for covariates including age, sex, payor, patient care unit, and time trends, the mean LOS in the intervention group was 3.2% shorter than that in the control group (p = 0.022). CONCLUSION: Computer-generated patient-specific LOS information directed to physicians was associated with a reduction in hospital LOS.

A length of stay study of the dually entitled Medicare and Medicaid population: challenges for managed competition.

Length of stay (LOS) differences were not observed between the dually entitled and other Medicare stroke patients when complexity of disease was considered. LOS for dually entitled heart failure patients was 33.2 percent longer than other Medicare heart failures and were equally likely to be in the extreme DRG subclass. Patients with extreme heart failure stayed 15.5 days longer than those with mild heart failure. LOS differences (+4.5 days) were observed between the dually entitled and other Medicare heart failures when complexity of disease was considered. Within these two DRGs, incremental health care needs for dually entitled equalled 10 percent of the hospital's total Medicare days associated with stroke and heart failure.

Supporting future surgical innovation. Lung transplantation as a case study.

OBJECTIVE: Using lung transplantation as a case study, this article addressed the problem of supporting innovative clinical surgery in an era of increasing pressures for cost containment. SUMMARY BACKGROUND DATA: After sporadic attempts at lung transplantation during the 1960s and 1970s, its clinical development began in earnest during the early 1980s. As a result of a wide range of incremental advances, the results have improved significantly. The Health Care Financing Administration, however, has not yet issued a national policy covering lung transplants and has left the coverage decision to the discretion of its regional contractors. METHODS: The authors surveyed the major commercial insurers, the Blue Cross Blue Shield Association, and a sample of Medicare intermediaries to evaluate the coverage of lung transplantation. They also interviewed the National Heart, Lung, and Blood Institute and industrial firms about their support for clinical research. RESULTS: Government and industry funding were limited, and the development and assessment of lung transplants have been financed predominantly by academic institutions through cross-subsidization from patient care and teaching funds. The major private payers and Blue Cross Blue Shield decided to cover this procedure in the early 1990s. Coverage decisions by Medicare intermediaries, however, revealed considerable variability. Moreover, the absence of a specific diagnosis-related group for lung transplants had considerable consequences for institutions in all-payer states, in which payments appeared to be considerably lower than the mean costs of a transplant procedure (about $110,000). CONCLUSIONS: This analysis indicated that there was a growing disparity between the increasing demand for outcomes data about new procedures and the limited resources available for supporting the development and assessment of new operations. It this disparity is not addressed, the rate of surgical innovation may be jeopardized, and timely outcomes data may not be acquired. It was concluded that provisional coverage within a predetermined research protocol may be a promising mechanism to remedy this situation, providing timely assessment of new procedures before widespread application.

A case-mix in-service education program.

The new case-mix in-service education program at the Presbyterian Hospital in the City of New York is a fine example of physicians and administration working together to achieve success under the new prospective pricing system. The hospital's office of Case-Mix Studies has developed an accurate computer-based information system with historical, clinical, and demographic data for patients discharged from the hospital over the past five years. Reports regarding the cases, diagnoses, finances, and characteristics are shared in meetings with the hospital administration and directors of sixteen clinical departments, their staff, attending physicians, and house officers in training. The informative case-mix reports provide revealing sociodemographic summaries and have proven to be an invaluable tool for planning, marketing, and program evaluation.