Do administrative databases accurately measure waiting times for medical care? Evidence from general surgery.

We abstracted the records of patients from general surgeons' offices in Winnipeg to compare waiting times from charts (i.e., the gold standard) with waiting times using administrative data. The administrative data method relies on physicians' billing data to identify a visit to the surgeon preoperatively to mark the start of the waiting time. There was no difference between waiting times using patient records versus administrative data. The study supported the use of administrative data to monitor waiting times.

Epidemiology, clinical presentation, and pathophysiology of atypical and recurrent hemolytic uremic syndrome.

Hemolytic uremic syndrome (HUS) includes a heterogeneous group of hemolytic disorders. Among the identified causes of HUS are infections, particularly infections with Shiga toxin-producing ESCHERICHIA COLI (STEC), complement disorders, and disorders interfering with the degradation of von Willebrand factor (VWF). Other causes for atypical HUS include the cobalamin metabolism; pregnancy/hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP); drugs; and other disorders (e.g., systemic diseases appearing as HUS, such as systemic lupus erythematosus and rejection after transplantation). The group not related to STEC is often also called atypical HUS. Most of the occurrences of infectious HUS have only one episode. Recurrent episodes (recurrent HUS) have strong relationships to diseases of the complement system. In these two subgroups the prognosis is poor, with severe renal insufficiency, together with the need for renal replacement therapy. Severe arterial hypertension is common. Treatment options are limited. To better define this group of patients, the European Society for Pediatric Nephrology supported an initiative to develop a European HUS registry. In this registry, 167 patients were acquired; 73 were female (43.8%). The year of onset of the disease ranged from 1974 to 2005. The prevalence of atypical HUS/recurrent HUS can be calculated as 3.3 per million child population (< 18 years). Underlying disorders included factor H, factor I, MCP-1, pneumococci, and von Willebrand factor disturbances. In 33 patients at least one renal transplantation was performed (total, 55 kidneys); 18% were successful and 73% demonstrated recurrence or thrombosis. Treatment options were plasma substitution or plasmapheresis. Despite continued efforts, transplantation is not recommended at present for these patients. Living-related transplantation should be abandoned. New therapeutic strategies are urgently needed.

Developing priority criteria for general surgery: results from the Western Canada Waiting List Project.

OBJECTIVE: The Western Canada Waiting List Project (WCWL) is a federally funded partnership of 19 organizations, including medical associations, health authorities, ministries of health and research organizations that was created to develop tools for improving the management of waiting lists. The WCWL general surgery panel was 1 of 5 panels constituted under this project. METHOD: The panel developed and tested a set of standardized clinical criteria for setting priorities among patients awaiting elective general surgery of all kinds. The criteria were applied to 561 patients in 3 western provinces. Regression analysis was used to determine the set of criteria weights that collectively best predicted clinicians' overall urgency ratings. RESULTS: The priority criteria accounted for almost two-thirds of the observed variance in clinicians' urgency ratings (adjusted R2 = 64.1%) for a mixed group of patients. The panel modified the criteria and weights based on empiric findings and clinical judgment. Interrater and test-retest reliability of criteria items appeared to be good, based on clinicians' ratings of 6 videotaped, standardized patient interviews. CONCLUSIONS: The panel considered the criteria easy to use and reasonably reflective of expert surgical judgement regarding clinical urgency. Further development and testing of the tool appears warranted.

Factors associated with the high cost of liver transplantation in adults.

OBJECTIVES: To determine the overall direct cost of liver transplantation in Canadian adults and to identify the factors that are associated with high cost. METHODS: The direct cost of liver transplantation from the perspective of third-party payers was determined in a retrospective analysis of data from hospital charts and databases. A consecutive series of 119 adults who underwent liver transplantation between 1991 and 1992 was followed from the date of listing for transplantation to the second anniversary of the transplant. Patient-specific services during the pre-transplantation, transplantation and post-transplantation phases were compiled and costed. The primary consideration was the impact of complications on the cost of transplantation. Secondary considerations were the impact of age, sex of the patient, diagnosis and severity of liver disease on the total cost. RESULTS: The overall mean measured cost of liver transplantation was Can$89,066 (range from Can$30,505-Can$690,431). The multivariate logistic regression model for overall costs revealed that severe liver disease (OR = 11.97), cytomegalovirus infection (OR = 6.12), additional operative procedure (OR = 4.22) and biliary complications (OR = 5.00) were associated with an increased likelihood of high cost. The addition of services that were not measured in the present analysis increased the total overall cost to a mean of $121,732 (1998 Canadian dollars, follow-up costs discounted and inflation adjusted). INTERPRETATION: The factors that were associated with high cost of liver transplantation in Canadian adults were advanced liver disease, postoperative cytomegalovirus infection, the requirement for additional operative procedures and biliary complications.