Resource-intensive Procedures Research Articles

Revenue from single-balloon enteroscopy is driven by anesthesia: experience from a tertiary care facility.

Resource-intensive endoscopic procedures have shown to generate more costs than revenue under the current reimbursement system in the USA. Single-balloon enteroscopy (SBE), a resource-intensive procedure, has never been evaluated for its financial impact at tertiary care hospitals, and thus, our aim was to determine the sources of revenue that SBE procedures generate. Retrospective review of all procedures performed using the SBE system during the first year of implementation at a single tertiary referral center. Financial data from two subspecialties in the form of revenues for physician and facility fees were collected and analyzed. Revenues were analyzed in total and as a function of payer (insurance) and physician type. Fifty-two procedures using the SBE system were identified during the first year of implementation at a single tertiary care center. Total revenue generated for all SBE procedures was $123,714 including $64,475 dollars from physician fees and $59,239 dollars from the facility fees. Revenue generated by anesthesia physician fees was higher from Medicare cases compared to private insurance cases (p < 0.01); however, revenues from facility fees were higher for private insurance cases compared to Medicare (p < 0.01). Revenues from anesthesiology physician fees were significantly more than revenues from GI physician fees (p < 0.01). Of the three referred cases, one generated additional downstream revenues from other non-SBE-related services totaling $4727. A large proportion of revenues generated from SBE cases come in the form of ancillary services provided by anesthesia. Projected revenue generation (and it sources) should be considered when establishing a device-assisted enteroscopy program.

A Microfluidic Device for Multiplex Single-Nucleotide Polymorphism Genotyping.

Single-nucleotide polymorphisms (SNPs) are the most abundant type of genetic variations; they provide the genetic fingerprint of individuals and are essential for genetic biomarker discoveries. Accurate detection of SNPs is of great significance for disease prevention, diagnosis and prognosis, and for prediction of drug response and clinical outcomes in patients. Nevertheless, conventional SNP genotyping methods are still limited by insufficient accuracy or labor-, time-, and resource-intensive procedures. Microfluidics has been increasingly utilized to improve efficiency; however, the currently available microfluidic genotyping systems still have shortcomings in accuracy, sensitivity, throughput and multiplexing capability. To address these challenges, we developed a multi-step SNP genotyping microfluidic device, which performs single-base extension of SNP specific primers and solid-phase purification of the extension products on a temperature-controlled chip. The products are ready for immediate detection by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), providing identification of the alleles at the target loci. The integrated device enables efficient and automated operation, while maintaining the high accuracy and sensitivity provided by MS. The multiplex genotyping capability was validated by performing rapid, accurate and simultaneous detection of 4 loci on a synthetic template. The microfluidic device has the potential to perform automatic, accurate, quantitative and high-throughput assays covering a broad spectrum of applications in biological and clinical research, drug development and forensics.

Steady-state emulation of a diesel engine air charging system through real-time turbocharger modelling

Engine downsizing is an important route to meeting tightening emission regulations and improving engine efficiency. However, when a new air charging system such as a turbocharger is selected to enable downsizing of an internal-combustion engine for increased specific power and efficiency, extensive resource-intensive optimization procedures are currently required. In this paper, a method of emulating an engine charge system is developed on the basis of a charge air-handling unit and a real-time turbocharger model comprising map based compressor and turbine models with improved data density and range via numerical and analytical approaches. Variables such as the boost pressure, back pressure, turbocharger speed and the mass flow rate of air are used to compare the response of the charge system emulation with the real turbocharger. The emulation method achieves considerable accuracy when compared with the real turbocharger hardware. This approach will enable future engine developments to be assessed prior to the prototype hardware phase, resulting in significantly lower costs and shorter time frames for the development process.

Fluoroscopy-guided, transcervical, selective salpingography and fallopian tube recanalisation

This study is a retrospective review of the transcervical fluoroscopy-guided fallopian tube recanalisation (FTR) procedures done in a multi-ethnic south-east Asian population, over 9 years. A total of 100 patients with infertility and documented proximal tubal obstruction (PTO) were referred for FTR. On-table hysterosalpingography under sedation demonstrated true PTO in 96 patients. At selective-salpingography, the PTO cleared in 16 patients; 78 required FTR and two had fimbrial blockage. The technical success rate of FTR was 86.8% and the post-FTR pregnancy rate was 36.84% at a mean follow-up interval of 12.2 months. There were no major, immediate procedure-related complications. There was an ectopic pregnancy in a single treated patient. Fluoroscopy-guided FTR is a safe treatment option in patients with infertility from PTO, with high technical success rate, low complication rate and increased chances of pregnancy; therefore it should be preferred before attempting more expensive and resource-intensive procedures.

Advanced endoscopy procedures in private practice: is the juice worth the squeeze?

Advanced endoscopy procedures in private practice: is the juice worth the squeeze?

M1524: Downstream Revenue Stream From Resource Intensive Small Bowel Endoscopies (Single Balloon Enteroscopy, Spiral Balloon Enteroscopy, and Wireless Capsule Endoscopy)

Much of the recent advances in gastroenterology has focused on the small bowel. Reimbursement is generally poor considering the time, expertise, and equipment required. Our current billing system lags behind technology and as a result, many of these newer procedures operate at a net loss in income. Previous studies have shown that downstream revenue generation from other resource intensive procedures such as ERCP, EUS, and EMR attenuates the loss of income from the procedure itself. No studies to date have specifically analyzed small bowel-directed endoscopies and their revenue generating profile.

Technique for repair of suprarenal and thoracoabdominal aortic aneurysms

Suprarenal and thoracoabdominal aortic aneurysms represent significant surgical challenges. For patients with associated aortic dissections, current endovascular technology has not been matured to address branch reconstructions that derive from separate lumens, making open surgical reconstruction the only proven method for repair. The required exposures of the thoracoabdominal aorta are expansive, and the extent of aortic replacement mandates efficient technique. Furthermore, a well-orchestrated team of surgeons, nurses, anesthesiologists, and perfusionists are all integral to achieving good outcomes and keeping operative courses tightly managed. Techniques to address extensive aneurysms of the thoracoabdominal aorta are reviewed in detail here, and videos are provided on The Journal website to show relevant anatomical features.

Resource-intensive endoscopy: revenue source or cash drain?

Recent research has demonstrated that resource-intensive endoscopic procedures are not financially viable if performed without the need for further clinical care. To determine whether the net income from downstream clinical activities makes resource-intensive endoscopy a financially viable activity. Retrospective database review. Tertiary-referral medical center. Patients whose initial contacts with the medical center were as outpatients who underwent EUS, EMR, or ERCP in 2004. Hospital charges, the cost of providing services, revenue, and net income from all services provided through June 2006. A total of 120 patients were reviewed whose initial procedure was EUS (48), ERCP (53), or EMR (19). Although income was lost by performing the endoscopic procedures, revenue was generated by the subsequent clinical care derived from EUS (mean $7093 per patient, standard deviation [SD] $23,686, range $12,316-$117,984 per patient); a loss of revenue was incurred in the clinical care of both patients who underwent ERCP (mean -$5028 per patient, SD $12,565, range -$33,648-$47,481) and patients who underwent EMR (mean -$931 per patient, SD $6515, range -$11,245-$12,196). The most lucrative activity arising from initial endoscopic referral was surgery. Revenue was lost for these procedures in Medicare patients compared with non-Medicare patients. Indirect costs are institution specific and may not be generalizable to other centers. EUS is the most remunerative resource-intensive endoscopic procedure. Centralizing these resource-intensive procedures into multispecialty practice sites that provide surgical and oncologic care allows downstream revenue from patient treatment to offset procedural losses. Even taking account of downstream revenues, performing these procedures on Medicare patients is not financially viable. Any future cuts in Medicare physician payment rates will further increase this Medicare/non-Medicare reimbursement imbalance and likely have consequences on the performance of these procedures.

Resource-intensive endoscopic procedures: do the dollars make sense?

The rapid development of endoscopic technologies over the past decade has led to an increased utilization of resource-intensive endoscopic procedures in clinical practice. These procedures are technically challenging, time consuming, and typically involve major equipment-related costs. To determine the economics associated with performing resource-intensive endoscopic procedures in a tertiary-referral center A retrospective practice database review. A single, North American tertiary-referral medical center. All the patients whose initial contacts with the medical center were as outpatients for an EUS, EMR, or ERCP between July and November 2004. Hospital charges, the cost of providing services, revenue, and net income from all services provided through June 2006. Seventy patients were tracked. During the review period, these 70 patients generated a total of $2.9 million, or $42,126 per patient, in hospital charges. The net profit was $407,263 ($5790 per patient). Endoscopic services alone resulted in a loss of $424 per patient. Surgical services generated just over $300,000 in net profit. Economics for only resource-intensive endoscopic procedures are not financially viable under the current health care reimbursement system. The first step to removing disincentives to performing these cost-effective procedures would appear to be an insistence that reimbursement be weighted equitably to ensure reasonable profitability.

Program characteristics and organizational factors affecting the implementation of a school-based indicated prevention program

Reconnecting Youth (RY) is a school-based drug prevention program designed to address academic, substance use and mood management goals among youth at risk of dropping out of high school. This paper presents the organizational factors and RY program characteristics that either promoted or hindered the implementation of the program during a randomized controlled effectiveness trial in 10 schools in two school districts in the United States. Data were collected using surveys and interviews from teachers and school and district staff who participated in the implementation of the RY program in these schools. Results suggest that certain RY program characteristics made it difficult to implement. Small class size, resource-intensive procedures for student selection and recruitment and special training, qualities and skills needed to be an effective RY teacher meant that schools had to significantly change their usual practices to implement the program. Organizational barriers included a lack of financial resources and leadership support for program implementation, and low priority for non-academic courses for high-risk students. Transient student populations, staff turnover and district-wide scheduling and curriculum changes all resulted in high levels of organizational turbulence at most schools, further hindering program implementation.

The cost of water hyacinth control in South Africa: a case study of three options

The aquatic plant water hyacinth (Eichhornia crassipes) was first recorded in South Africa during the early part of the 20th century. The plant has since spread across the country and is found in water bodies in both sub-tropical and temperate areas. The biology, ecology and impacts of water hyacinth are well studied, but sound and cost-effective management of it remains an enormous challenge in South Africa. Since the 1970s, control programmes have focused on the use of herbicides, with some success, while biological and integrated control have historically received less effort and investment, despite the successes of the latter control approaches in other parts of Africa and elsewhere in the world. The reasons for the relative successes and challenges associated with the various control approaches vary substantially. Herbicidal control has been an effective short-term solution with highly visible results. However, the cases used in this study show that herbicidal control is approximately five times (R1 481/ha) less costeffective than either biological or integrated control, mainly because it requires resource-intensive follow-up procedures. The effectiveness of large-scale herbicidal control has mainly been influenced by inappropriate field application, plus management and institutional inconsistencies. Biological control offers a longer term, cheaper (R309/ha and potentially R3.60/ha) and less resource-intensive solution compared to herbicidal treatment, but the effectiveness of this approach relies heavily on the successful release of control agents, the ability of biocontrol agents to thrive under a range of climatic conditions and the extent to which affected water bodies are nutrient-enriched. Based on the analysis here, integrated control was the most cost-effective control option at an average cost of R277/ha. This approach enables managers to integrate selected aspects of herbicidal and biological control and it is also more likely to facilitate the development of partnerships in water hyacinth control programs. Discussion of a possible ‘no control’ option suggests that the economic and environmental costs of no control may be far greater than any control. Recommendations include: the selection of appropriate management option/s should be based on management needs across different time scales and on objective cost-benefit information—this will help to determine how the costs and benefits of different control approaches could be distributed amongst those who pay for and benefit from the management of water hyacinth. Successful management will also rely on selecting appropriate and sound ecological approaches suited to local conditions; management will also need to facilitate the integration of control efforts at the catchment level as well as institutional and partnership integration to ensure continuity in the ownership of water hyacinth control.

Mother and Teacher Reports of ADHD Symptoms: DSM‐IV Questionnaire Data

Diagnosis of attention-deficit/hyperactivity disorder (ADHD) is thought to be best accomplished by a multimodal approach. In many research and clinical settings, such extensive procedures may not be feasible. A screening instrument that could identify children meeting necessary (but not sufficient) criteria would permit selection of subgroups for more resource-intensive diagnostic procedures. The Diagnostic Rating Scale (DRS) was completed by the mothers and teachers of 124 children referred to hospital-based clinics and 225 nonreferred children. The authors performed principal components analysis (PCA) on the questionnaire, compared the scores obtained by children from the 2 samples, and examined age and gender effects. Diagnoses derived from the DRS were not validated against structured diagnostic interviews. PCAs replicated the DSM-IV symptom combinations. Children from the referred sample exhibited more symptoms (p < .001) than children from the community sample. Boys were overrepresented among the children who received DRS-derived ADHD diagnoses. Girls were more likely (92%) to receive a diagnosis of ADHD, predominantly inattentive subtype, than other ADHD diagnoses. The results of this study provide preliminary support for the validity of the parent and teacher DRS as time- and resource-efficient screening instruments for examining symptoms associated with ADHD.

LIFE WITHOUT DISEASE: THE PURSUIT OF MEDICAL UTOPIA

In the next 50 years genetic intervention will shift the focus of medicine in the United States from repairing the ravages of disease to preventing the onset of disease. Understanding the role of genes in human health, says William B. Schwartz, is the driving force that will change the direction of medical care, and the age-old dream of life without disease may come close to realization by the middle of the next century. Medical care in 2050 will be vastly more effective, Shwartz maintains, and it may also be less expensive than the resource-intensive procedures such as coronary bypass surgery that medicine relies on today. Shwartz's prospect of a medical utopia raises urgent questions, however. What are the scientific and public policy obstacles that must be overcome if such a goal is to become a reality? Restrictions on access imposed by managed care plans, the corporatization of charitable health care institutions, the increasing numbers of citizens without health insurance, the problems with malpractice insurance, and the threatened Medicare bankruptcy - all are the legacy of medicine's great progress in mastering the human body and society's inability to assimilate that mastery into existing economic, ethical, and legal structures. And if the average American life span is 130 years, a genuine possibility by 2050, what social and economic problems will result? Shwartz examines the forces that have brought America to the current health care state and shows how those same forces will exert themselves in the decades ahead. Focusing on the inextricable link between scientific progress and health policy, he encourages a careful examination of these two forces in order to determine the kind of medical utopia that awaits us. The decisions we make will affect not only our own care, but also the system of care we bequeath to our children.