Payment by results: are we missing something?

PURPOSE: Payment by results (PbR) was introduced to reward hospitals for productivity. In orthopaedic clinics there is a separate tariff for two procedures: removal of sutures (ROS) and attention to dressing (AD). The Trust claims a fee each time these have been performed. The purpose of this paper is to look at how many of these procedures were performed in an outpatient setting but were not claimed for because of poor documentation. DESIGN/METHODOLOGY/APPROACH: A retrospective study was performed analysing all orthopaedics clinics occurring in one month. After each consultation the clinician completes a coding pro forma and dictates a clinic letter. The pro forma contains a list of the orthopaedic procedures attracting a tariff and used for coding. A comparison was made between what was documented on the pro forma and the clinic letter to see how many times ROS and AD were done. FINDINGS: A total of 72 letters were extracted which contained ROS and AD. Only one of the ROS was documented on the pro forma and subsequently captured by the coders. In one month the Trust failed to claim 9,838 pounds. Annually this equates to a revenue loss totaling 118,056 pounds. Practical implications - Current coding practice is substandard. To maintain financial security Trusts must improve their coding policies as a matter of urgency. ORIGINALITY/VALUE: The paper demonstrates clearly that hospital trusts are losing out financially from this suboptimal practice.

Acute lower back pain mapped by dermatomal scarification in urban Malawi.

Lower back pain is a problem that affects many and generates an economic burden on the National Health Service. In modern days, although it is tempting to rely on specialist imaging for the initial investigation of back pain, it is often unnecessary. Comprehensive clinical examination is immediately available and should detect neurological impairments where they exist. A 32-year-old man from Malawi presented to clinic with lower back pain radiating to the right leg. Inspection revealed traditional scarification marks along the classical path of lumbar nerve root, which coincided with his L5 dermatomal pain. The distribution of his 'Mphini' along the typical path of lumbar nerve was identical to his myelography. This report strongly illustrates that in the Western medical setting, accurate history and examination would have allowed correct interpretation of these symptoms and correctly indicated the need for myelography.

Long-term follow-up of a hydroxyapatite ceramic-coated threaded cup: an analysis of survival and fixation at up to 15 years.

We evaluated the survival of 112 consecutive JRI hydroxyapatite ceramic-coated threaded acetabular components (JRI Ltd, London, UK). Follow-up was for a minimum of 13 years (range, 13-15 years). Patients were assessed clinically and radiographically using the Merle d'Aubigné and Postel scoring systems and the De Lee and Charnley zones. Cup angle, migration, and signs of radiolucency were used to assess loosening. The criteria for failure were revision or impending revision due to pain and septic or aseptic loosening. The mean results of the Merle d'Aubigné and Postel score for pain, motion, and ability to walk were 2.2/2.7/2.2 preoperatively and 5.6/4.3/5.1 postoperatively. There was 100% endosteal bone formation in De Lee and Charnley zones 1 and 3 and 87% in zone 2. No reactive lines were seen in any zone in any cup. There were no cases of migration, change in cup angle, or revision for loosening. Our survival was 99% at 13 years (95% confidence interval, 96-100).

Surgery in Malawi - a national survey of activity in rural and urban hospitals.

INTRODUCTION: Malawi is a poor country with few doctors. It has 21 district hospitals all of which have operating theatres but none of which has a permanent surgeon. It also has 4 central hospitals, each with one or more surgeons. Most district hospitals are manned by a single doctor and two or more paramedical clinical officers. PATIENTS AND METHODS: All district and central hospitals were visited, and theatre logbooks analysed. All cases performed in 2003 were recorded. RESULTS: In 2003, a total of 48,696 surgical operations were recorded, of which 25,053 were performed in 21 district hospitals and 23,643 in 4 central hospitals. Caesarean section is the commonest major surgical procedure in district hospitals and is performed in approximately 2.8% of all births, compared to 22% in the UK. Very few major general surgical or orthopaedic procedures are carried out in district hospitals. CONCLUSION: This study underlines Malawi's need for more surgeons to be trained and retained.

A national survey of surgical activity in hospitals in Malawi.

Malawi is a poor country with few doctors. It has 21 district hospitals, all of which have operating theatres but none of which has a surgeon. Most district hospitals are manned by a single doctor and two or more paramedic clinical officers. In 2003, a total of 28,594 operations were performed in district hospitals. In all, 12,506 (44%) of these were obstetric or gynaecological procedures, but only 821 (3%) were general surgical cases. It appears that district clinicians are happy to attempt emergency obstetric and gynaecological cases but tend to refer emergency general surgical cases.

Results of manipulation of idiopathic clubfoot deformity in Malawi by orthopaedic clinical officers using the Ponseti method: a realistic alternative for the developing world?

This study looks at whether orthopaedic clinical officers, a cadre of clinicians who are not doctors, can effectively manipulate idiopathic clubfeet using the Ponseti technique. One hundred consecutive cases of uncomplicated idiopathic clubfeet in newborn babies were manipulated by orthopaedic clinical officers. Fifty-seven of these were fully corrected to a plantigrade position by Ponseti manipulation alone, and a further 41 were corrected by manipulation followed by a simple percutaneous tenotomy. Orthopaedic clinical officers therefore corrected 98 out of 100 feet; the remaining 2 feet were referred for surgical correction. This shows that the Ponseti method is suitable for use by nonmedical personnel in the developing world to achieve a plantigrade foot.

Bulk femoral-head autografting in uncemented total hip arthroplasty for acetabular dysplasia: results at 8 to 11 years follow-up.

Acetabular dysplasia causes difficulty in achieving adequate coverage of the acetabular component during total hip arthroplasty (THA). Bulk femoral-head autografting is one technique that has been used to achieve better coverage of the acetabular component. Long-term follow-up studies have shown a significant failure rate when this technique has been used in conjunction with a cemented acetabular component; however, with uncemented components, early results have been encouraging. In our study, 15 patients with acetabular dysplasia underwent uncemented THA, during which bulk femoral-head autografts were used. At an average follow-up of 10 years, no cases required revision, and radiologically, the bone graft had united. Our results support the use of bulk femoral-head autografting in patients with acetabular dysplasia requiring hip arthroplasty.