Policy proposal for correcting the imbalance in general surgical manpower.

The Graduate Medical Education National Advisory Committee's 1980 report on physician manpower estimated that 23,500 general surgeons would be required in 1990 and that there would be a surplus of 11,800 trained general surgeons by then. Using the GMENAC estimates of need and our analysis of supply, we project a surplus of only about half that number. To balance the supply of general surgeons to anticipated needs by the year 2000, it is estimated that the number of physicians beginning their residency training in general surgery between 1984 and 1995 should be reduced by 20% in relation to the number of first-year general surgery residents in 1982-1983.

Incidental appendectomy in the elderly? No.

This study examines the appropriateness of incidental appendectomy in the elderly. By examining the incidences of appendicitis and incidental appendectomy in 1977 in Wisconsin's elderly, this study calculated the chances that a citizen undergoing incidental appendectomy would have required otherwise an operation for appendicitis in his remaining lifetime. The 1977 incidences of appendicitis procedures and incidental appendectomy in citizens greater than or equal to 65 years were 0.78 and 1.59 per 1,000 population at risk. During 1977, 3.73 persons were spared an appendicitis operation in their remaining lifetimes because 3.82 incidental procedures were performed. This represents over 100 incidental procedures to avoid a single case of appendicitis. At a 1977-78 mortality rate of 3.5% for appendicitis in patients greater than or equal to 65 years, nearly 3,000 incidental procedures must be performed to save a life which would be lost to appendicitis otherwise. We doubt that incidental appendectomy in the elderly can be performed to better this threshold of risk. Therefore, we believe that incidental appendectomy is not indicated in the elderly, since it would appear that the risk of incidental appendectomy would outweigh its potential benefits.

Late appearance of arterial emboli: diagnosis and management.

Although the occurrence of an arterial embolus is usually a cataclysmic event prompting emergency presentationand early diagnosis, we have managed 22 patients who presented more than 48 hours after the onset of symptoms. The diagnosis was apparent in only six patients. The remainder had subacute limb ischemia, and arteriography was used to help delineate the diagnosis in 14 of these patients. In most instances arteriograms were atypical of chronic occlusive disease, rather than diagnostic of arterial emboli. Embolectomy was performed a mean of 13 days after the onset of symptoms, with retrieval of thromboembolic material in all instances. Two patients died (mortality rate of 9%), and the limb salvage rate for the 25 limbs explored was 88%. Among 22 lower extremity embolectomies, foot pulses were restored in 13 patients (59%), and four patients (18%) had viable extremities without pulses. Adjunctive arterial reconstruction was required in three patients.

Digital subtraction angiography and B-mode ultrasonography for abdominal and peripheral aneurysms.

Thirty-two patients suspected of having intraabdominal and/or peripheral aneurysms were evaluated by digital subtraction angiography (DSA) and B-mode ultrasonography to determine whether diagnostic accuracy and operative management could be improved by this combination of preoperative studies. Abdominal B-mode ultrasonography accurately diagnosed most primary aortic aneurysms and correctly determined their size (93%) but missed iliac artery aneurysms in 75% of cases. Failures resulted from severe ileus and the inability to scan the intrapelvic iliac vessels. Abdominal ultrasound studies were false positive for aortic pseudoaneurysms in two of four cases. DSA correctly identified all but one intra-abdominal aneurysm but did not always correctly determine their size because of intraluminal clot. DSA identified a number of associated peripheral vascular lesions, which ultrasonography could not. All primary peripheral aneurysms were correctly diagnosed by ultrasound, but nearly half of the ultrasound studies were false positive for femoral pseudoaneurysms. DSA correctly identified all peripheral aneurysms and at the same time provided anatomic information about vessels proximal and distal to these lesions needed for surgical planning. Digital subtraction angiography combined with ultrasonography is diagnostically accurate and provides adequate anatomic information for planning surgical management of these aneurysms.

Intra-arterial digital angiography: a new diagnostic method for determining limb salvage bypass candidates.

Twenty patients with chronic arterial disease of a lower extremity underwent standard angiography to determine whether distal bypass surgery could be performed for limb salvage (seven had pain at rest and 13 had breakdown of ischemic skin). Standard angiography provided anatomic detail of the aortoiliac and proximal femoral arteries in all cases, but even with 7 minutes of cuff-induced reactive hyperemia, angiography failed to demonstrate the status of the tibial vessels and the plantar arcade.l Digital subtraction angiography (with intra-arterially injected contrast medium) demonstrated a patent popliteal artery with at least one patent tibial vessel communicating with the distal arcade in 14 of 20 ischemic extremities (70%). Intra-arterial digital angiography (IDA) confirmed absent distal runoff or unreconstructable tibial arterial segments with absent plantar arch communications in six limbs (30%). Fourteen patients underwent distal artery bypass because of additional information provided by IDA (femoropopliteal, 7; femorotibial-peroneal, 4; sequential, 3). Three of the remaining six patients with occluded or unreconstructable distal disease had amputations, and three underwent local profundoplasty. Intraoperative angiograms confirmed the patency of occult arteries in the distally reconstructed limbs. This small series suggests that failure to visualize distal vasculature in ischemic patients by standard angiography is usually a technical problem and that bypass surgery is possible in many patients who might otherwise be considered for amputation.

The future of the IAIMS in a managed care environment: a call for private action and public investment.

A national public and private "grand challenge" initiative should be undertaken to assure the American public that the telecommunications and computing revolutions improve health care, health education, and biomedical and health services research, and secure accountability for cost, quality, and access. The initiative should focus on meeting the needs of the patient and society at large. It needs to be a national vision, but it also ought to have regional focus. A plan for action would include a health-infrastructure strategy, a service strategy, an education strategy, a research and development strategy, and an international-linkages strategy. Without this type of initiative, health care will lack the basic building blocks it needs to more effectively deal with the transformational forces that have already been unleashed. These forces will strengthen or weaken health care in the next century depending on whether and how the nation--including the leadership in health care and the informatics community--responds to this challenge.

Arterial graft infections. Delayed v immediate vascular reconstruction.

We evaluated the treatment and clinical outcome of 20 patients with major abdominal vascular graft infections and found that immediate reconstruction of arterial inflow to the lower extremities after complete removal of contaminated graft material may not always be necessary or advisable. Patients were treated by the following categories: group 1, graft removal with immediate vascular reconstruction (seven patients, two aortoiliac and five aortofemoral grafts); group 2, graft removal with delayed vascular reconstruction (13 patients, three aortoiliac, five aortofemoral, and five extra-abdominal grafts). The mortality (57%) and the incidence of major amputation (14%) were highest when immediate vascular reconstruction was attempted. Patient survival, the incidence of recurrent graft infection, and the need for major amputation were favorably altered with delayed reconstruction even when prosthetic material was used.

Chronic shin splints. Classification and management of medial tibial stress syndrome.

A clinical classification and treatment programme has been developed for chronic medial tibial stress syndrome. Medial tibial stress syndrome has been reported to be either tibial stress fracture or microfracture, tibial periostitis, or distal deep posterior chronic compartment syndrome. Three chronic types exist and may coexist: Type I (tibial microfracture, bone stress reaction or cortical fracture); type II (periostalgia from chronic avulsion of the periosteum at the periosteal-fascial junction); and type III (chronic compartment syndrome syndrome). Type I disease is treated nonoperatively. Operations for resistant types II and III medial tibial stress syndrome were performed in 41 patients. Bilaterality was common (type II, 50% type III, 88%). Seven had coexistent type II/III; one had type I/II. Preoperative symptoms averaged 24 months in type II, 6 months in type III, and 33 months in types II/III. Mean age was 22 years (15 to 51). Resting compartment pressures were normal in type II (mean 12 mm Hg) and elevated in type III and type II/III (mean 23 mm Hg). Type II and type II/III patients received fasciotomy plus periosteal cauterisation. Type III patients had fasciotomy only. All procedures were performed on an outpatient basis using local anaesthesia. Follow up was complete and averaged 6 months (2 to 14 months). Improved performance was as follows: type II, 93%, type III, 100%; type II/III, 86%. Complete cures were as follows: type II, 78%; type III, 75%; and type II/III, 57%. This experience suggests that with precise diagnosis and treatment involving minimal risk and cost the athlete has a reasonable chance of return to full activity.

Veterans Affairs residency realignment and National Graduate Medical Education policy.

The supply of physicians in the United States is affected by a variety of complex factors. Given the current abundance, if not oversupply, of physicians and the dramatic changes under way in the US health care delivery system, policy makers have renewed efforts to implement strategies that will lead to an appropriate balance of physicians in the United States. Several organizations have recommended specific strategies for achieving that goal. The Veterans Health Administration has already decided to change the number and distribution of its residency training positions. These changes cannot, however, be viewed in isolation. The Veterans Health Administration plays an important role in the graduate medical education of many physicians in the United States, and the magnitude of the intended changes could have a significant impact on residency opportunities.

The utilization of surgical physician assistants: policy implications for the future.

It is anticipated that there will be a major growth in the role of surgical physician assistants in the immediate future. The authors believe that this trend will improve the quality of surgical care in the United States, reduce the number of surgeons being trained, and enable practicing surgeons to be more productive and hence more proficient.

Improved results in acute appendicitis care following areawide review.

The Wisconsin Professional Review Organization compared acute appendectomies being performed in 1981 to those done in 1978 in 32 Wisconsin hospitals. In both years approximately 75 percent of primary appendectomies were in patients 5 to 30 years of age, one-fourth were in patients 15 to 19 years of age, and the majority were in males. Incidence of normal appendices dropped from 16.1 percent in 1978 to 11.4 percent in 1981 (p less than 0.005). The number of patients with normal appendices who did not meet symptom criteria dropped from 37.3 percent to 9.5 percent (p less than 0.05). Incidence of normal appendices was highest in small hospitals. Severity and ruptures or perforations increased, but not significantly. Postoperative complications and mortality decreased. Average length of stay decreased overall, but increased for patients with complications and ruptures or perforations. These data suggest that areawide reviews assure quality and help contain costs. Physician self-regulation using areawide studies may produce desirable change.

A decision theoretic methodology for severity index development.

Severity indices are a key element in evaluation of health programs. But the methodologies used in development of such indices are rarely clearly defined. Moreover, there have been no tests of transportability of the index development methodologies that do exist, so there is no guarantee that panels of physicians convened by different facilitators would produce indices with similar performance characteristics. This paper describes a replicable index development strategy, a heart disease severity index developed by using that methodology, and a test of that methodology's transportability.

Chronic compartment syndrome: diagnosis, management, and outcomes.

A consecutive operative series of 100 patients with chronic compartment syndrome involving 233 compartments is reported. Seven of every eight were athletes, and runners predominated. Exercise-induced symptoms of consistently recurring tightness, aching (in some, sharp pains) in anatomically defined compartments were pathognomonic. Mean months of symptoms prior to operation was 22; median age was 26 years. Bilaterality occurred in 82. The distribution of compartments was: anterior, 39%; lateral, 12%; and posterior, 48%. Incidental compartment pressures were elevated (mean = 23 mmHg). Fasciotomy using local anesthesia was performed on 70 outpatients. At a median of 4.5 months, over 90% were cured or significantly improved in symptoms and/or function. Median time to walking unassisted was 2 days, and to resumption of conditioned running 21 days. Fasciotomy can be a safe, effective, and economical treatment for chronic compartment syndrome.

Factors affecting the use of surgical physician assistants.

The actual use of surgical physician assistants in 1979 and the expected use of them in 1984 by 552 general hospitals in the United States with 400 or more beds was assessed by means of a questionnaire mailed to the hospitals' surgical department chairmen. The influence of geographic and institutional variables upon this use was determined by multiple regression analysis. The most important determinants of actual use were the complexity of surgical care in the institution and its geographic location. Institutions with more complex surgical care and those located outside of the West were more likely to have used surgical physician assistants in 1979. Important determinants of the expected use of surgical physician assistants in 1984 appeared to be the complexity of surgical care and the degree of reliance upon foreign medical graduates (FMGs) in the surgical housestaff training program within the institution. Those surgical department chairmen in hospitals with a greater concentration of FMGs on their surgical housestaffs in 1979 anticipated a greater future role for surgical physician assistants.

Possible platelet thrombi formation in dog and human femoral arteries.

Atherosclerosis is a ubiquitous condition that commonly produces vessel stenosis and progresses ultimately to vascular occlusion. It is thought by many that platelets collect on sites of atherosclerosis and exacerbate its progression. We have previously shown that platelet thrombi can form within 10 minutes in the stenosed coronary arteries of a dog and can produce acute cyclical reduction in blood flow measured with an electromagnetic flowmeter (EMF). This is followed by sudden restoration of flow as the platelet thrombus breaks loose and is carried distally (Circulation 54:365-370, 1976). In five dogs, blood flow was measured simultaneously in a femoral artery stenosed 70%, exposed proximally with an EMF, and monitored distally over intact skin with a Doppler ultrasonic flowmeter (DUF). Cyclical reductions in blood flow were detected by both the EMF and the DUF, presumably due to platelet thrombi forming in the stenosed femoral artery and then breaking loose and moving distally. These flow reductions could be consistently abolished with aspirin (ASA). In ten patients with angiographically proven substantial stenoses of the femoral or popliteal arteries who were not taking ASA, the popliteal blood flow velocity was measured with a DUF. Six of the ten patients showed cyclical blood flow velocity reductions during 30 minutes of observation. These flow velocity reductions were similar to those observed in the stenosed dog femoral arteries. One hour after taking 600 mg ASA orally, five of the six patients no longer showed flow velocity reductions. Eight male control subjects who were not on ASA and had no known stenoses had no flow velocity reductions when studied with the DUF. Since many factors, such as cigarette smoking, diabetes, and elevated plasma lipids, are known to increase human platelet aggregation, we postulate that platelet thrombi may form in stenosed peripheral arteries, hasten the development of atherosclerosis, and reduce blood flow. This postulate would be compatible with the increased incidence and accelerated development of clinically significant atherosclerosis noted in such patients. Claudication may be more than just the response to "increased demand"; thrombus degeneration may lead to the elaboration of vasospastic substances. If these findings are confirmed by further investigations, the potential for successful therapeutic intervention may be quite significant.

Epidemiology and prevention of blood and body fluid exposures among emergency department staff.

Emergency Department (ED) staff are vulnerable to occupational exposure to infectious blood and body fluids (BBF). Universal precautions are often ignored in the ED setting. Identification of body locations at high risk of BBF exposure may allow development of site specific protective garments that minimize risk and inconvenience. All permanent staff (92) in a 58,000 visit public university hospital ED with potential for BBF exposure were surveyed. Respondents estimated the number of BBF contacts sustained during the past year, describing their most recent contact in detail. Seventy-eight of 91 (85%) responded, reporting average rates of 54.1 intact skin, 1.5 nonintact skin, and .87 mucous membrane BBF contacts per full-time employee per year. Of the most recent incidents, 94% involved blood, 22% involved vomit or urine, and 11% involved saliva. Eighty-eight percent of BBF contacts were to unprotected skin or mucous membranes, either when no barrier was worn or at the gap between gloves and sleeves. Most (66%) were distal to the elbow; 13% involved the face. Use of long gloves or another continuous protective barrier from the fingers to the elbow, in addition to increased use of face masks or shields, would markedly reduce the rate of ED BBF contacts with a minimum of inconvenience.

A new health system and its quality agenda.

This article reviews recent work on healthcare quality, highlights findings and recommendations of the Institute of Medicine (IOM) reports on medical errors and quality, and describes response to the reports to date. In it, Detmer, chair of the IOM's Board of Health Care Services and a member of its Committee on Quality of Health Care in America, identifies implications of the reports for healthcare delivery organizations and professionals and outlines ways organizations and professionals can improve the six dimensions of patient quality defined by the IOM. Sustained efforts at the point of care and in policy development are needed to overcome cultural inertia, realign incentives, support innovation, and address technical and human resource issues. Success requires that healthcare executives embrace the goal of transforming the healthcare sector into a true system and provide leadership for their organizations and communities in this most fundamental of challenges for twenty-first century healthcare.

Whither primary care in the academic health science center?

Five forces that shape the form and function of the future academic health center are a mandate to decrease health care costs, a surplus of physicians, intense competition for the provision of tertiary medical care, a suboptimal diagnosis-related group (DRG) case mix, and decreasing funding for manpower training and research. All five forces cause the academic health center to be much more in need of strong primary medical care services. This article describes the current relationship between primary care and the academic medical center, new contributions that primary care can make to the academic medical center, and the benefits that would accrue to both the academic medical center and primary care should a closer working relationship develop. These benefits include increased outpatient volume and revenue, a more balanced inpatient case mix, better primary medical care education, an enhanced community reputation, and greater influence by primary care on academic medical center policies. Published and personal case study experiences that show some of the potential problems with a closer working relationship between primary care and the academic medical center are described.

Diagnosis related groups (DRGs): efficiency and/or quality producing? Some evidence from surgical patients.

Hospital charges and length of stay for inguinal hernia and acute appendicitis patients were examined in a university hospital to determine the degree of variation with DRGs. Evidence presented here suggests that DRGs may lead to a reduction in medical care costs without a reduction in patient outcomes. Mode/year DRGs to take account of source of admission and maintaining outliers payments may be desirable to avoid patient selectivity and incentives for lowering quality of care of the most severely ill patients.