Camelot or common sense? The logic behind the UCSF/Stanford merger.
Many academic medical centers (AMCs) throughout the United States have established their own community-based integrated delivery systems by purchasing physician groups and hospitals. Other AMCs have merged with existing nonprofit community-based delivery systems. Still other AMCs have been sold to for-profit firms. The AMCs at Stanford and the University of California, San Francisco (UCSF), chose a different strategy: to merge with each other to respond to the unique characteristics of the Bay Area marketplace. (+info)
Referrals by general internists and internal medicine trainees in an academic medicine practice.
Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed. (+info)
Physicians in training as quality managers: survival strategy for academic health centers.
Being responsible for medical education places academic health centers at a disadvantage in competing for managed care contracts. Although many suggestions have been made for changing medical education to produce physicians who are better prepared for the managed care environment, few studies have shown how physicians in training can actually contribute to the competitiveness of an academic health center. We present three examples of engaging trainees in projects with a population-based perspective that demonstrate how quality improvement for the academic health center can be operationalized and even led by physicians in training. In addition to gaining experience in a managed care skill that is increasingly important for future employment, physicians in training can simultaneously improve the quality of care delivered through the academic health center. (+info)
Subspecialist referrals in an academic, pediatric setting: rationale, rates, and compliance.
Appropriate referrals reduce healthcare costs and enhance patient satisfaction. We evaluated the subspecialty referral pattern of a managed care general pediatric office over a 4-month period. Three-hundred-forty-six referrals (267 meeting inclusion criteria) to 24 subspecialties were generated during 4,219 office visits, with five subspecialties receiving 59% of the referrals. The main objective of each referral was management (100), diagnostic assistance (75), special procedure (63), or a combination (29). Patients kept less than half of the referral appointments, with the highest (80%) and lowest (28%) compliance rates observed in cardiology and ophthalmology, respectively. Appointments made within four weeks of the referral were more likely to be kept than those with greater lag time (P = 0.001). The subspecialists prepared written, post-consultation responses to the referring physician in 73% of cases. Presumptive and post-consultation diagnoses were congruent in 78% of those cases in which both diagnoses were noted. Overall, the managed care format enabled our practice to track referral outcomes. The subspecialists' written responses also allowed for an educational exchange between physicians. Compliance with referral appointments is a substantial problem that needs to be addressed. (+info)
Predictors of acute hospital costs for treatment of ischemic stroke in an academic center.
BACKGROUND AND PURPOSE: We sought to determine predictors of acute hospital costs in patients presenting with acute ischemic stroke to an academic center using a stroke management team to coordinate care. METHODS: Demographic and clinical data were prospectively collected on 191 patients consecutively admitted with acute ischemic stroke. Patients were classified by insurance status, premorbid modified Rankin scale, stroke location, stroke severity (National Institutes of Health Stroke Scale score), and presence of comorbidities. Detailed hospital charge data were converted to cost by application of department-specific cost-to-charge ratios. Physician's fees were not included. A stepwise multiple regression analysis was computed to determine the predictors of total hospital cost. RESULTS: Median length of stay was 6 days (range, 1 to 63 days), and mortality was 3%. Median hospital cost per discharge was $4408 (range, $1199 to $59 799). Fifty percent of costs were for room charges, 19% for stroke evaluation, 21% for medical management, and 7% for acute rehabilitation therapies. Sixteen percent were admitted to an intensive care unit. Length of stay accounted for 43% of the variance in total cost. Other independent predictors of cost included stroke severity, heparin treatment, atrial fibrillation, male sex, ischemic cardiac disease, and premorbid functional status. CONCLUSIONS: We conclude that the major predictors of acute hospital costs of stroke in this environment are length of stay, stroke severity, cardiac disease, male sex, and use of heparin. Room charges accounted for the majority of costs, and attempts to reduce the cost of stroke evaluation would be of marginal value. Efforts to reduce acute costs should be monitored for potential cost shifting or a negative impact on quality of care. (+info)
Laparoscopic cholecystectomy in an academic hospital: evaluation of changes in perioperative outcomes.
OBJECTIVE: Evaluate changes in perioperative outcomes over an 82-month period in patients undergoing laparoscopic cholecystectomy by a single attending surgeon in an academic hospital. METHODS: A retrospective review of 1025 consecutive patients undergoing laparoscopic cholecystectomy from September 1992 to February 1997 was compared to the initial 600 patients from May 1990 to August 1992. Statistical analysis included Chi square with Yates correction and Fischer's exact test. RESULTS: Over the 82-month period there were no significant differences in the overall conversion rate to open cholecystectomy (p=0.26), intraoperative complications (p = 0.81), postoperative complications (p = 0.054) or mortality rates (p=0.66). There were 3 (0.5%) bile duct injuries in the initial 600 patients and only 1 (0.1%) in the group of 1025 patients (p=0.065). There was an increase (p<0.001) in laparoscopic cholecystectomies performed for acute cholecystitis and biliary dyskinesia and an increase (p<0.001) in the percentage of cases performed overall and for acute cholecystitis by the surgery residents over the last 54 months. Despite this, the conversion rates to open cholecystectomy in patients with acute cholecystitis decreased (p < 0.001) over the last 54 months. Additionally, more patients (p < 0.001) were discharged on the day of surgery in the most recent group. CONCLUSION: Laparoscopic cholecystectomy can be performed safely by surgery residents under the direct supervision of an experienced laparoscopist without significant changes in perioperative outcomes. Despite an increased percentage of cases being performed for acute cholecystitis over the last 54 months, conversion rates to open cholecystectomy and biliary tract injury rates have decreased, and the perioperative morbidity has remained the same. (+info)
Development and evaluation of a pharmacist-directed pharmacotherapy center.
This article is designed for ambulatory pharmacy specialists, pharmacy administrators, and managed care pharmacy and/or medical directors interested in developing systems for improved drug therapy outcomes. GOAL: To describe an alternative method for the effective delivery of pharmaceutical care. OBJECTIVES: 1. Identify the barriers to delivery of pharmaceutical care in current systems. 2. Describe the steps to take to implement a referral-based pharmaceutical care service. 3. Describe the financial and patient satisfaction outcomes of a referral-based pharmacy. 4. Describe the services that can be offered by a referral-based pharmacy. (+info)
Hypertension and managed care. Based on a presentation by Robert P. Jacobs, MD, MBA.
A shift in principles has accompanied the evolution of healthcare delivery from a fee-for-service system to managed care. Managed care organizations have to make decisions on the allocation of healthcare resources that will enhance the care of the entire population. Cost reduction has been a major driver for managed care, but this is increasingly being supplanted by other goals such as increasing the quality of care and the value of health services and providing accountability. As the population ages, management of chronic lifelong illness will pose an increasing challenge. Hypertension is a common chronic illness that, if left untreated, imposes an enormous economic burden on society. These and other aspects of the disease and its management make it eminently suitable for intervention in a managed care setting. Challenges and opportunities exist for disease management initiatives for hypertension in the managed care environment. As health plans enhance their data systems and begin to focus on the long-term benefits of chronic disease management, hypertension will certainly be an early target for intervention and control. (+info)