Treatment of liver injuries at level I and level II centers in a multi-institutional metropolitan trauma system. The Midwest Trauma Society Liver Trauma Study Group.

OBJECTIVE: The development of trauma systems and trauma centers has had a major impact on the fate of the critically injured patient. However, some have suggested that care may be compromised if too many trauma centers are designated for a given area. As of 1987, the state of Missouri had designated six adult trauma centers, two Level I and four Level II, for the metropolitan Kansas City, Mo, area, serving a population of approximately 1 million people. To determine whether care was comparable between the Level I and II centers, we conducted a concurrent evaluation of the fate of patients with a sentinel injury, hepatic trauma, over a 6-year period (1987-1992) who were treated at these six trauma centers. METHODS: All patients during the 6-year study period who suffered liver trauma and who survived long enough to be evaluated by computerized tomography or celiotomy were entered into the study. Patients with central nervous system trauma were excluded from analysis. Information concerning mechanism of injury, RTS, Injury Severity Score (ISS), presence of shock, liver injury scoring, mode of treatment, mortality, and length of stay were recorded on abstract forms for analysis. Care was evaluated by mortality, time to the operating room (OR), and intensive care unit (ICU) and hospital length of stay. RESULTS: Over the 6-year period 300 patients with non-central nervous system liver trauma were seen. Level I centers cared for 195 patients and Level II centers cared for 105. There was no difference in mean ISS or ISS > 25 between Level I and II centers. Fifty-five (28%) patients arrived in shock at Level I centers and 24 (23%) at Level II centers. Forty-eight patients (16%) died. Thirty-two (16%) died at Level I centers, and 16 (15%) died at Level II centers. Twenty of 55 patients (36%) in shock died at Level I centers, and 11 of 24 (46%) died at Level II centers (p = 0.428). Forty-three patients (22%) had liver scaling scores of IV-VI at Level I centers, and 10 (10%) had similar scores at Level II centers (p < 0.01). With liver scores IV-VI, 22 of 43 (51%) died at Level I centers and 10 of 14 (71%) died at Level II centers (p = 0.184). There was no difference in mean time or in delays beyond 1 hour to the OR for those patients in shock between Level I and II centers. There was a longer ICU stay at Level II centers (5.0 +/- 8.3 vs. 2.8 +/- 8.4 days, p = 0.04). This difference was confined to penetrating injuries. There was no difference in hospital length of stay. CONCLUSIONS: In a metropolitan trauma system, when Level I and II centers were compared for their ability to care for victims of hepatic trauma, there was no discernible difference in care rendered with respect to severity of injury, mortality, delays to the OR, or hospital length of stay. It was observed that more severe liver injuries were seen at Level I centers, but this did not seem to significantly affect care at Level II centers. There was a longer ICU stay observed at Level II centers owing to penetrating injuries, possibly because there were fewer penetrating injuries treated at these facilities. Although the bulk of patients were seen at Level I centers, care throughout the system was equivalent.

Managed care contracting/capitation.

Both the general approach for entering into a managed care contract and the subject of capitation are presented. The general approach section outlines the criteria that a physician group should apply in analyzing the feasibility of entering into a managed care contract with any insurer. The physician group's contracting process should be iterative and refined over time. The capitation section addresses issues revolving around the assessment of a capitated contract. The example assumes a typical health maintenance organization-primary care group contract. Not analyzed in this article are the exciting opportunities presented through specialty carveout capitation. Managing the transition to a more competitive environment will be the major challenge facing group practices. Survival in the tightening healthcare market will depend on sound strategic decisions regarding the physician group's mission as well as its relationship to its hospital partners and other delivery systems. To support these strategic decisions, a solid knowledge base and a thorough understanding of the terms and provisions regarding the formulation of these new relationships are necessary. The budget methodology is a relatively straightforward approach to establishing a capitation. Careful consideration will have to be given to the method of allocating the capitation among providers. A special concern is the risk-sharing arrangement with primary care physicians.

Surgical therapy of diabetic gastroparesis.

Diabetic gastroparesis is a complication of diabetes mellitus that usually responds to medical management. We report a patient in whom medical management failed, and a gastrostomy, pyloroplasty, and jejunostomy were done to insure nutrition and to decompress the stomach. We also review the surgical management of this condition.

Trouble in the medical staff: a practical guide to hospital initiated quality assurance.

This article offers a practical guide to hospital initiated quality assurance. After outlining the hospital's duty of care, the Article discusses both offensive and defensive strategies for dealing with the problem of an impaired or incompetent medical staff member. While the Article advocates informal resolution of the problem, it encourages the hospital and the medical staff to build a defense to liability based on strict adherence to hospital bylaws, rules and regulations governing medical staff organization, privileges and evaluation. The Article's ultimate concern is to avoid an escalated situation involving multiple lawsuits, patient harm, humiliation to the practitioner, and economic loss.