Feasibility of day case varicose vein surgery in a district general hospital.

BACKGROUND: Day case surgery may reduce inpatient bed requirements, and varicose surgery may be an ideal operation to test the functioning of a day surgery service. AIMS: To evaluate retrospectively the feasibility of day case varicose vein surgery in all-comers, and to identify the risk factors for admission. METHODS: Over a three-year period from July 1995 to July 1998, all patients requiring varicose vein surgery had their procedure performed as a day case. A standard technique of sapheno-femoral ligation with below-knee stripping of the long saphenous vein and multiple stab avulsions of varicosities was performed. All limbs were dressed with wool in crepe bandage and were reviewed post-operatively at six weeks. RESULTS: Five hundred and forty two patients underwent varicose vein surgery, of whom 26% had bilateral varicose veins, 88% had primary varicose veins and 22% had recurrent disease. The procedure was performed under general anaesthesia in 86% of cases and under spinal anaesthesia in the rest. There was no peri-operative mortality. Ten patients (1.9%) developed post-operative complications. Seventy two per cent of patients were discharged on the day of surgery, a further 25% required admission for one night due to minor anaesthetic complications and patient preference. Four per cent required admission for more than 24 hours. The need for overnight admission was associated with the age of the patients (p < 0.0001), bilateral varicose vein surgery (p < 0.005) and the use of spinal anaesthesia (p < 0.01). CONCLUSION: Although varicose vein surgery is safe, acceptable and cost-effective as a day case procedure, if attempted in all-comers, overnight admission will be required in a significant proportion. Pre-operative selection is advised.

Community mental health program efficiency.

Six urban community mental health centers participated in a capitated payment system designed for persons with severe mental illness who frequently used the state hospital. The centers and their funding agency agreed that a chief outcome measure would be the length of time clients were able to remain enrolled in the outpatient program. Clients of the six agencies were quite similar to one another. During the 18-month study length of enrollment in the outpatient program did not vary among the agencies whereas agency expenditures varied by more than three-fold. Although some of this expenditure variation was due to economies of scale at larger agencies, different practice styles also contributed to variable efficiency.

A capitated payment system for involuntary mental health clients.

This DataWatch examines an outpatient capitated payment system, in the state of Oregon, designed to enhance community services for persons with chronic mental illness who had repeatedly been hospitalized involuntarily. Special state funds and Medicaid dollars were used to pay providers prospectively on a risk-adjusted basis for the delivery of outpatient mental health services. During the three-year study period clients were able to be discharged from the state hospital. Although the data are not straightforward, capitated clients' use of the state mental hospital seems to have declined somewhat more than that of comparison subjects. Outpatient service use was modest and appeared to have little relationship to a client's level of illness severity. Indeed, it was not possible to predict prospectively these clients' outpatient mental health services expenditures.