Influence of esophageal motility on the outcome of laparoscopic total fundoplication.

The aim of this study is to evaluate if esophageal dysmotility can influence the outcome of laparoscopic total fundoplication for gatro-esophageal reflux disease (GERD). The advent of laparoscopic fundoplication has greatly reduced the morbidity of antireflux surgery and by now, it should be considered the surgical treatment of choice for GERD. Some authors assert that total versus partial fundoplication should improve the rate of postoperative dysphagia or gas bloat syndrome, particularly in patients with esophageal dysmotility. From September 1992 to December 2005, 420 consecutive patients 171 male and 249 female, mean age 42.8 years (range 12-80) underwent laparoscopic Nissen-Rossetti fundoplication. At manometric evaluation, we divided patients into two groups: group A (163/420; 38.8%) with impaired esophageal peristalsis (peristaltic waves with a pressure < 30 mmHg), and group B (257/420; 61.2%) without impaired peristalsis. We followed up clinically 406 out of 420 (96.7%) patients, 156/163 patients (95.7%) in group A and 250/257 patients (97.3%) in group B. An excellent outcome was observed in 143/156 (91.7%) group A patients and in 234/250 (93.6%) group B patients (P = NS). Both groups showed significant improvement in clinical symptom score with no statistically significant difference between patients with normal and impaired peristalsis. Thus, preoperative defective esophageal peristalsis is not a contraindication to total laparoscopic fundoplication.

MR imaging: quality assessment method and ratings at 33 centers.

PURPOSE: To outline a quality assessment method with peer review for magnetic resonance (MR) imaging. MATERIALS AND METHODS: Thirty-three providers in the Philadelphia area were rated on a random sample of 132 brain, 124 cervical spine, and 113 lower extremity MR imaging examinations performed during 1990. Blinded peer review was performed by panels of three subspecialty-trained academic radiologists. Technical performance, completeness, and report appropriateness of each MR imaging examination were evaluated. Aggregated scores were calculated to rate provider performance for each of the three parameters of quality. RESULTS: Two or three panelists assessed technical performance as inadequate in 15 cases, completeness as incomplete in 58 cases, and the interpretative report as inappropriate and affecting treatment in 72 cases. Eleven providers received an unsatisfactory rating on one or more parameters of quality. The association between unsatisfactory ratings and the use of low-field-strength (< or = 0.6-T) imagers was statistically significant (P < .008). CONCLUSION: Substantial deficiencies were identified in the performance of examinations and interpretation of MR images in the Philadelphia area in 1990. These findings indicate the need for a program to monitor quality of MR imaging.

Self-referral in private offices for imaging studies performed in Pennsylvania Blue Shield subscribers during 1991.

PURPOSE: To define the frequency of physician self-referral for diagnostic imaging studies. MATERIALS AND METHODS: High-volume radiographic (n = 65) and ultrasound (US) (n = 29) procedural codes in claims filed by Pennsylvania Blue Shield subscribers were analyzed to determine private-office (nonhospital) utilization of these examinations by radiologists and nonradiologists during 1991. A total of 787,703 radiographic and 159,281 US claims were filed. RESULTS: Nonradiologists self-referred 550,878 radiographic examinations (69.9%) and 99,931 US examinations (62.7%). Patterns of utilization varied considerably by anatomic category: The imaging studies with the highest rates of utilization by nonradiologists were skeletal radiography, vascular US, and obstetric and pelvic US. Aggregate reimbursement allowance by Pennsylvania Blue Shield for all examinations in these 94 codes was approximately $68 million, of which $44 million (65%) went to non-radiologists.

An analysis of cesarean deliveries among Pennsylvania Blue Shield subscribers.

In recent years, increased attention has focused on the relatively high rate of Cesarean deliveries in the U.S. Though the medical necessity and indications for Cesarean deliveries have been heavily debated, there still remains considerable disagreement among professionals about which Cesarean deliveries are inappropriate. To contribute to an understanding of these issues, Pennsylvania Blue Shield prepared a profile of Cesarean deliveries in Pennsylvania relative to Blue Shield's claim experience. The results of the study are presented in this article.

Disparities in reimbursement to radiologists and nonradiologists for 65 common outpatient imaging studies.

The authors examined global charges (incorporating both technical and professional components) and global reimbursement allowances for all radiographic and ultrasound (US) examinations performed on Pennsylvania Blue Shield subscribers in the Lehigh Valley area of Pennsylvania during 1990. Data for radiologists and nonradiologists were compared with respect to all procedure codes for which at least 25 claims were submitted, yielding a sample of 40,619 radiographic examinations (54 procedure codes) and 9,761 US examinations (11 procedure codes). Radiologists' mean charges were higher than those of nonradiologists for 38 of the 54 radiographic codes. However, nonradiologists received higher mean reimbursement allowances for 39 of the 54 codes. Among the 11 US codes, nonradiologists' mean charges were higher for 10 and they received higher mean reimbursement allowances for seven. The averages of the mean reimbursement allowances for individual codes were higher for nonradiologists in both the radiographic and US categories. Pennsylvania Blue Shield has begun steps to eliminate disparities in reimbursements to providers who submit claims for imaging examinations.

Diagnostic radiology peer review: a method inclusive of all interpreters of radiographic examinations regardless of specialty.

A proposed method of assessing the quality of diagnostic radiographic examinations includes peer review designed to evaluate physicians, including nonradiologists, involved in the performance and interpretation of such examinations. A pilot project evaluated this system with randomly selected Pennsylvania Blue Shield data files of 10 providers billing for chest radiography interpretations during the second quarter of 1989. Of the 98 chest radiographs reviewed blindly, all inadequately marked radiographs and incomplete written reports were produced by nonradiologists. Technical quality of images obtained by radiologists did not significantly differ from that of images obtained by nonradiologists (P = .189). All five interpretive errors that could have seriously affected the patient's health care were produced by nonradiologists (P = .019). Four of these serious errors were made by providers billing for fewer than 25 radiographs. While administrative and time cost limitations are obvious, this method of peer review encompasses all physicians billing for a particular radiographic service, irrespective of specialty.