Second surgical opinion programs: dead or alive?

BACKGROUND: In the 1970s, second surgical opinion programs were established in an effort to improve medical care and to control health care costs. The cost-effectiveness of these programs has been questioned recently. STUDY DESIGN: A retrospective review was conducted of elective second-opinion surgical consultations for members of Local 32B-J of the International Service Employees Union for the years 1993-1994. Nonconfirmed consultations were reviewed against claims history data for the subsequent 2 years. Data were analyzed for rates of nonconfirmation by diagnosis and surgical specialty and for cost-effectiveness benefit. RESULTS: Of the 5,601 second surgical consultations performed, 490 procedures were not confirmed as medically necessary (9%). Claims history survey for these 490 patients for the 2 years following the consultation revealed that no operation was performed in 62%. The highest nonconfirmation rate (41%) was in plastic and reconstructive surgery, followed by gynecology (22%). The cost-benefit ratio for the program was calculated to be 1.34. CONCLUSIONS: A second surgical opinion program confers both cognitive and psychologic beneficial effects on Joint Trust Fund members and their dependents who are advised to undergo elective operations. Our current second surgical opinion nonconfirmation rate is 9%, with hysterectomy, prostatectomy, and bunionectomy among the procedures most frequently nonconfirmed. The cost-benefit ratio was estimated at 1.34.

An analysis of substance abuse patterns, medical expenses and effectiveness of treatment in the workplace: long-term followup.

This study of workplace substance abuse programs indicates that they are effective for many participants and also shows that these programs can significantly lower medical expenses for those who successfully complete them.

Second opinion programs: continued savings from nonconfirmed surgeries.

A second opinion program for elective surgery was one of the first tools utilized by employers to "manage" health care costs. These authors argue that second opinion programs continue to demonstrate their usefulness as part of overall health care cost-management effort.

An analysis of substance abuse patterns, medical expenses and effectiveness of treatment in the workplace.

This article examines the effectiveness of substance abuse treatment offered by the Members Assistance Program of a self-insured union welfare fund. The authors find that medical costs decreased dramatically for participants who were under treatment for at least one year.

The use and value of third surgical opinions.

The results of new research into the contributions of third surgical opinions to health care quality and cost-effectiveness are reported by the Director and top Marketing and Research officers of the Health Benefits Research Center. As executives of the oldest second surgical opinion network in the U.S., the authors were able to test widespread beliefs about second and third opinion programs. Some, they found, did not hold up.

Second opinion for urologic surgery.

Second opinion elective surgery programs provide a mechanism to obtain consultation from a board-certified specialist by patients to whom an elective operation has been recommended. We focus on a second opinion program for urologic cases. Of 931 individuals who received a second opinion for urologic surgery the need was confirmed in 692 (74.3 per cent) and was not confirmed in 239 (25.7 per cent). The most common procedure not confirmed was transurethral resection of the prostate. Common reasons for nonconfirmation were the need for further testing, medication preferable to an operation and symptoms not severe enough to warrant an operation. Of patients confirmed for the need for surgery 28.2 per cent did not undergo an operation, while 33.0 per cent of those not confirmed did.

Podiatric Surgery: the need for a second opinion.

A second-opinion podiatry program, designed to contain costs and enhance the quality of care, was established in the greater New York City area by the Building Service Employees' Health Fund. All nonemergency foot surgery recommended by a podiatrist that cost over $100 was included in this program. Of the 363 individuals who had a second opinion, 82 per cent were confirmed for surgery; however, the confirmation rate among those seeing a podiatrist serving as consultant was 94.3 per cent, while the confirmation rate of those seeing an orthopedists serving as consultant was 49.5 per cent. For every condition, the podiatrists overwhelmingly confirmed the need for surgery. Conversely, the orthopedists were more conservative in their recommendations regarding surgery. The program's cost was $311,813. If a second opinion consultation wasn't required for removal of corns or ingrown toenails, the total would be much less. It seems sensible (economically and medically) to encourage or require a consultation with an orthopedist for conditions such as bunions, hammertoes and heel spurs, and not to require a second opinion consultation for superficial podiatric conditions such as corns and ingrown toenails, which are treated predominantly by the podiatrist.

The current status of surgical second opinion programs.

Second opinion programs proliferated in the 1970s, and most of these were voluntary programs. Until more complete evaluations of voluntary and mandatory programs are done, it seems likely that second opinion programs will continue to be on a voluntary basis. Second opinion programs have been shown to identify potential surplus surgery and are designed to contain costs.

The efficacy of second-opinion consultation programs: a cost-benefit perspective.

This study evaluates a mandatory second-opinion consultation program administered on behalf of a large Taft-Hartley welfare fund providing medical care coverage for 120,000 beneficiaries and covered dependents. During a two-year intake period (1977-1978), 2,284 individuals received second-opinion consultations for an elective surgical procedure recommended by a first-contact physician or surgeon. Of this group, 366 received a nonconfirmation of their need for surgery. Medical claims data were available for 342 individuals in this group, and they constitute the base for the current analysis. A comparable number of individuals who received a positive confirmation were randomly selected and served as a control for estimating program savings. Both groups were followed for a one-year period from the date of their consultations. Total program savings were estimated at $534,791. Of this amount, medical care utilization savings were $361,756 and productivity savings were $173,035. The cost of the program was $203,300, yielding a benefit-cost ratio of 2.63. These findings indicate that mandatory second-opinion consultation programs, which are consumer oriented and intervene before care is rendered, are clearly cost-effective.

Second consultant opinion for elective orthopedic surgery.

We abstracted records of 369 patients whose recommendations for elective orthopedic surgery were not confirmed by a second opinion consultant. Six months or more after the initial recommendation for surgery, 82 per cent had not had the operation performed, irrespective of the diagnosis and the characteristics of the physician recommending surgery. Reasons for consultant non-confirmation included: use of a cast, brace, or corrective footwear preferable (26.3 per cent), symptoms not severe enough (18.4 per cent), and physical therapy/exercises preferable (17.8 per cent).

Second opinions on elective surgery. The Cornell/New York Hospital study.

Programmes for securing second opinions on elective surgery are designed to help patients make a more informed decision once elective surgery has been recommended. The patient is assessed before surgery is performed, which allows alternatives to be considered. The Cornell/New York Hospital second opinion programme is the only one to have accumulated statistics on voluntary and mandatory programmes. Data from the mandatory programme showed that 18.7% of the 6799 patients screened were no confirmed for surgery. Follow-up data at one year showed that 67.5% of the unconfirmed patients had not in fact had surgery. A cost-benefit analysis showed that for every $1.00 spent there was a benefit of $2.63.

Effect of low-dose irradiation on pregnant mouse haemopoiesis.

The effects of low-dose gamma radiation to haemopoietic progenitor cell compartments of the marrow and spleen of virgin female mice and pregnant mice were studied. Microplasma clot cultures were used to asses burst-forming unit-erythroid (BFU-E) and colony-forming unit-erythroid (CFU-E) activity, and double-layer agar cultures were established to evaluate granulocyte-macrophage colony-forming cell (GM-CFC) and macrophage colony-forming cell (M-CFC). The apparent shift in maternal erythropoiesis from the bone marrow to the enlarged spleen was reflected by an increase in the numbers of CFU-E and BFU-E per spleen and a concomitant decrease in CFU-E and BFU-E per femur. Whereas maternal GM-CFC values per femur increased 36%, maternal GM-CFC per spleen increased by 172% compared to virgin values. There was a greater decrease in M-CFC per spleen than per femur in the pregnant animal when values were compared to the virgin animal. Total-body irradiation to the day-10.5 pregnant mouse caused a further suppression of day-14.5 medullary erythropoiesis (i.e. decreased CFU-E values) compared to the response of the virgin female mouse. An ability of the maternal spleen to support further compensatory erythropoiesis following increasing doses of radiation was demonstrated. 4 d after 1.0 Gy exposure, maternal values for GM-CFC per femur or spleen decreased to nonirradiated virgin mice values. M-CFC per maternal femur decreased following 1.5 Gy, but M-CFC per spleen appeared to be unaffected with doses from 0.5 to 2.0 Gy.

Second consultant opinion for elective gynecologic surgery.

Medical records of 516 patients not confirmed for previously recommended elective gynecologic surgery were abstracted. All had participated in the Cornell second opinion elective surgery program between 1972 and 1979. Gynecology was selected because previous analyses consistently have shown that this subspecialty has one of the highest nonconfirmation rates. Moreover, the majority of program participants follow the advice of the second opinion consultant; hence, it was deemed important to look at reasons for nonconfirmation. Findings showed that in 51% of the cases, the consultants believed either that the patient's clinical symptoms were not severe enough to warrant surgery or that further evaluation was needed. In 14.3% of the cases, no pathologic justification for surgery was evident.

Surgical utilization in the U.S.A.

Data complied by The National Center for Health Statistics show that surgical utilization has increased dramatically, particularly during 1971-1977 (+34 per cent). Increases were greater among females than males, primarily because of an increase in gynecologic surgery. The 15-year-and-younger cohort was the only age group that did not show an increase, while surgical patients per 1,000 increased consistently with advancing age. Many factors probably have contributed to the increase in surgical utilization, yet the one factor which as been suggested more frequently than any other is surgical manpower (there may be too many doctors performing surgery for the needs of the population and this situation may lead to excessive surgery). This issue of how many physicians there should be in surgical training is widely disputed and politically volatile, however. The problems inherent in estimating future manpower requirements are many, making it hard to derive "optimal" distribution patterns.