Managing acute cholecystitis among Medicaid insured in New York State: opportunities to optimize care.

BACKGROUND: Identifying sources of unnecessary cost within Medicaid will help focus cost containment efforts. This study sought to identify differences in surgical management and associated costs of cholecystitis between Medicaid and privately insured in New York State. METHODS: The New York State all-payer mandatory discharge database from 2003 to 2013, had 297,635 patients with Medicaid (75,512) and privately (222,123) insurance who underwent cholecystectomy for cholecystitis. Patients were stratified by insurance. Four surgical management approaches were delineated based on cholecystectomy timing: primary, interval, emergency, and delayed cholecystectomy. Delayed cholecystectomy was defined as more than one hospital visit from diagnosis to definitive cholecystectomy. Medicaid and privately insured patients were propensity score matched. Surgical management approach and associated costs were compared between matched cohorts. RESULTS: A greater proportion of Medicaid patients underwent delayed cholecystectomy compared to matched privately insured patients, 8.5 versus 4.8%; P < 0.001. Primary initial cholecystectomy was performed in fewer Medicaid compared to privately insured patients, 55.4 versus 66.0%, P < 0.001. Primary initial cholecystectomy was the cheapest surgical management approach, with the median cost of $3707, and delayed cholecystectomy was the most expensive, $12,212, P < 0.001. The median cost per Medicaid patient was $6170 versus $4804 per matched privately insured patient, P < 0.001. The annual predicted cost savings for New York State Medicaid would be $13,097,371, if the distribution of surgical management approaches were proportionally similar to private insurance. CONCLUSIONS: Medicaid patients with cholecystitis were more frequently managed with delayed cholecystectomy than privately insured patients, which had substantial cost implications for the New York Medicaid Program.

The journal: a retrospective.

With this issue, The Mount Sinai Journal of Medicine moves from being a general medical publication to one specializing in translational and personalized medicine. This article traces the history of The Journal from its beginning in 1934 to the present day. The Editors and their editorial policies are discussed, with mention of many articles over the years that have made the Journal truly a part of Mount Sinai's history.

How time affects the risk of rupture in appendicitis.

BACKGROUND: Increasing time between symptom onset and treatment may be a risk factor for a ruptured appendix, but little is known about how the risk changes with passing time. This study aimed to determine the changes in risk of rupture in patients with appendicitis with increasing time from symptom onset to treatment to help guide the swiftness of surgical intervention. STUDY DESIGN: We conducted a retrospective chart review of physician office, clinic, emergency room, and inpatient records of a random sample of 219 of 731 appendicitis patients operated on between 1996 and 1998 at 2 inner-city tertiary referral and municipal hospitals. Conditional risks of rupture were calculated using life table methods. Logistic regression was used to assess factors associated with rupture, and linear regression was used to assess factors affecting time from first examination to treatment. RESULTS: Rupture risk was < or = 2% in patients with less than 36 hours of untreated symptoms. For patients with untreated symptoms beyond 36 hours, the risk of rupture rose to and remained steady at 5% for each ensuing 12-hour period. Rupture was greater in patients with 36 hours or more of untreated symptoms (estimated relative risk [RR]=6.6; 95% CI: 1.9 to 8.3), age 65 years and older (RR=4.2; 95% CI: 1.9 to 6.1), fever > 38.9 degrees C (RR=3.6; 95% CI: 1.2 to 5.7), and tachycardia (heart rate > or = 100 beats/minute; RR=3.4; 95% CI: 1.8 to 5.4). Time between first physician examination and treatment was shorter among patients presenting to the emergency department (median, 7.1 hours versus 10.9 hours; p<0.0001), and those for whom a physician's leading diagnostic impression was appendicitis (6.3 hours versus 11.3 hours; p<0.0001). Patients sent for CT scan experienced longer times to operation (18.6 hours versus 7.1 hours; p<0.0001). CONCLUSIONS: Risk of rupture in ensuing 12-hour periods rises to 5% after 36 hours of untreated symptoms. Physicians should be cautious about delaying surgery beyond 36 hours from symptom onset in patients with appendicitis.

Increased use of computed tomography does not harm patients with acute appendicitis.

The increased use of computed tomography (CT) in patients with appendicitis may cause a delay in surgery and, therefore, higher perforation rates. We examined the use of CT, delay in time to surgery, and perforation rates in appendicitis patients operated on in two periods: Phase 1, 1996 through 1998 and Phase 2, 2001 through 2002. CT was performed in 18 per cent of the Phase 1 group compared with 62 per cent in the Phase 2 group. In the Phase 1 group, patients undergoing CT had a delay to surgery compared with those without CT (18.6 hours vs 7 hours; P < 0.0001). In the Phase 2 group, time to surgery was reduced (median time = 12 hours with CT vs 6 hours without CT; P < 0.001). CT was more accurate in the later group; there were less false-negative and equivocal studies. There was no difference in perforation rates between the Phase 1 and 2 groups. Over time, the increased use, efficiency, and accuracy of CT in patients with acute appendicitis were associated with reduced delays to surgery. The use of CT did not harm patients, but did not translate to better overall outcomes in this group of patients.

Influence of time on risk of bowel resection in complete small bowel obstruction.

BACKGROUND: Little is known about the effect of passing time on risk of resection among patients with complete small bowel obstruction. We sought to provide a benchmark of the relationship of time from symptom onset to surgical treatment on the need for resection in patients with complete small bowel obstruction. STUDY DESIGN: We performed an observational study of patients with surgically treated complete small bowel obstruction at an inner-city urban tertiary referral center and a municipal hospital. Patients were sampled randomly retrospectively (n=60), and prospectively (n=81), for a final sample of 141. Detailed clinical and time data were abstracted from medical records including out-of-hospital examinations. Risk of resection was calculated using actuarial life table methods. Linear regression was used to determine factors affecting time to treatment. RESULTS: All patients were treated surgically for obstruction; 45% underwent resection. Resected patients had longer (11 days versus 8 days; p=0.01) and more complicated (31% versus 14% in ICU; p=0.01) hospital stays. The risk of resection was 4% among patients with 24 hours of unresponsive symptoms; it increased to 10% to 14% through 96 hours, then dropped slightly but did not disappear. Patients treated first with a tube had longer times between first examination and operation, system-time (40.6 hours versus 10.2 hours; p=0.0007), but this was not associated with an increased resection risk. System-times were shorter among patients seen first in the emergency department (median: 25.7 hours versus 59.7 hours; p=0.0001). CONCLUSIONS: Physicians should be cautious in postponing surgery beyond 24 hours in patients with unresponsive symptoms from complete obstruction. The risk of resection rises dramatically, remains elevated through 96 hours of unresolved symptoms, then declines but does not disappear.

Hip fracture in the older patient: reasons for delay in hospitalization and timing of surgical repair.

OBJECTIVES: To quantify the interval between injury and hospitalization in older hip fracture patients, to quantify the time from hospital arrival to surgical repair of hip fracture, and to describe factors contributing to extended intervals between injury, hospitalization, and surgical repair of hip fracture. DESIGN: Prospective cohort study. SETTING: Four hospitals in the New York City metropolitan area. PARTICIPANTS: Consecutive patients aged 50 and older admitted with diagnosis of hip fracture to these four hospitals between August 1997 and August 1998. MEASUREMENTS: Time of injury, time of arrival to the emergency room, and time of surgery were recorded and used to calculate intervals between injury and hospital arrival and between hospital arrival and surgical repair. RESULTS: Of the 571 patients enrolled, 99 (17%) arrived at the hospital more than 24 hours after injury. After hospital arrival, 17 (3%) patients did not have surgery, 166 (29%) had surgery within 24 hours of arrival, and 388 (68.0%) had surgery more than 24 hours after arrival (median 41 hours, range 25-584). For those patients who had surgery after 24 hours, 163 (29.4%) had surgery 25 to 36 hours after hospital arrival, 102 (18.4%) had surgery 37 to 48 hours after arrival, and 123 (22.2%) had surgery more than 48 hours after arrival. The primary reasons for delaying surgery more than 24 hours after hospital arrival were waiting for routine medical clearance (52%) and unavailability of the operating suite or surgeon (29%). Stabilization of associated medical conditions resulted in the lengthiest periods of delay. CONCLUSION: A wait time of more than 24 hours from hospitalization to surgical repair of hip fracture in older patients is common. Some of this delay time is patient related and some occurs because of systems factors and may be avoidable. The extent to which surgical timing affects survival and functional recovery needs more detailed examination.

Anesthesiologists and surgeons at Mount Sinai: a partnership in excellence.

Although anesthesia was available to patients when the doors of The Jews Hospital opened in 1855, "professional anesthetists" were not appointed to the staff until 1902. This article traces the history of the anesthesiology staff and department, and documents their accomplishments over the past century.

Characteristics and costs of surgical scheduling errors.

BACKGROUND: Errors that increase the risk of wrong-side/-site procedures not only occur the day of surgery but also are often introduced much earlier during the scheduling process. The frequency of these booking errors and their effects are unclear. METHODS: All surgical scheduling errors reported in the institution's medical event reporting system from January 1, 2011, to July 31, 2011, were analyzed. Focus groups with operating room nurses were held to discuss delays caused by scheduling errors. RESULTS: Of 17,606 surgeries, there were 151 (.86%) booking errors. The most common errors were wrong side (55, 36%), incomplete (38, 25%), and wrong approach (25, 17%). Focus group participants said incomplete and wrong-approach bookings resulted in the longest delays, averaging 20 minutes and costing at least $320. CONCLUSIONS: Although infrequent, scheduling errors disrupt operating room team dynamics, causing delays and bearing substantial costs. Further research is necessary to develop tools for more accurate scheduling.

Factors associated with delays to emergency care for bowel obstruction.

BACKGROUND: Our objective was to determine factors associated with delays to first treatment for emergency department (ED) patients diagnosed with small-bowel obstruction (SBO). METHODS: This was a retrospective study of ED patients with SBO. Data were collected from medical records, administrative databases, and staffing schedules at an urban, tertiary care medical center from June 1, 2001, to November 30, 2002. Patient-related characteristics and processes of ED and hospital care were evaluated. Outcomes studied were time to first treatment (nasogastric tube or surgery) and risk of surgical resection. RESULTS: A total of 193 patients were diagnosed with confirmed intestinal obstruction. Patients with longer times to first treatment arrived during ED clinician hand-offs (adjusted hazard ratio, .40; 95% confidence interval, .17-.98). Patients with longer times to surgery consult (ref. first quartile) had greater odds of surgical resection (second quartile adjusted odds ratio, 6.91; 95% confidence interval, 1.85-24.80). CONCLUSIONS: Remediable ED and hospital factors were associated with longer times to treatment for patients with bowel obstruction.

Student perceptions of medical errors: incorporating an explicit professionalism curriculum in the third-year surgery clerkship.

Among medical educators, there is a universal call for curricula that emphasize development of character, compassion, and integrity. A unique challenge to the development of such curricula is the lack of tools with which to assess student progress. To these ends, we created a curriculum designed to inculcate the values of the surgical profession alongside both fact-based and skill-based learning within the triad of medical school education. Our purposes were 1) the acknowledgment of student fears regarding committing medical errors during their third-year surgical clerkship and 2) the design of curricular content aimed toward a more comprehensive understanding of professionalism using medical error as a paradigm. Third-year clerks on the surgical service were assigned readings, participated in formalized discussions regarding medical errors and ethics, and were required to complete questionnaires that contained open-ended questions pertaining to their concerns, observations, and reactions toward any perceived or actual medical errors they encountered during the third-year surgical clerkship. Questionnaires were analyzed according to themes contained within the students' responses. Most students expressed an initial fear of committing primarily technical medical errors and subsequently causing harm to patients. The dilemma as to whether to speak up against a superior regarding unaddressed medical errors appeared as a frequent theme among the students. New prerotation and postrotation questionnaires have been designed to allow for both quantitative and qualitative analysis of the students' understanding of the gravity of varying types of medical errors and how they relate to medical professionalism.