Burnout among American surgeons Campbell, Darrell A.; Sonnad, Seema S.; Eckhauser, Frederic E. ...
Surgery,
10/2001, Letnik:
130, Številka:
4
Journal Article
Recenzirano
Background. The long-term consequences of stress on the surgeon are unknown. One manifestation of stress is burnout. The purpose of this study was to measure the prevalence of burnout in actively ...practicing American surgeons. Methods. The Maslach Burnout Inventory and a questionnaire of our own design were sent to 1706 graduates of various University of Michigan surgical residencies (1222) and members of the Midwest Surgical Association (484). The response rate was 44%. Responses from 582 actively practicing surgeons were the sample used for analysis. Results. Thirty-two percent of actively practicing surgeons showed “high” levels of emotional exhaustion, 13% showed “high” levels of depersonalization, and 4% showed evidence for low personal accomplishment. Younger surgeons were more susceptible to burnout (r = −0.28, P <.01). Burnout was not related to caseload, practice setting, or percent of patients insured by a health maintenance organization. Important etiologic factors were a sense that work was “overwhelming” (r = 0.61, P <.01), a perceived imbalance between career, family, and personal growth (r = −0.56), P <.01), perceptions that career was unrewarding (r = −0.42, P <.01), and lack of autonomy or decision involvement (r = −0.39, P <.01). A strong association was noted between burnout elements and a desire to retire early (r = 0.50, P <.01). Conclusions. Burnout is an important problem for actively practicing American surgeons. These data could be used to modify existing surgical training curricula or as an aid to surgical leadership when negotiating about the surgical work environment. (Surgery 2001;130:696-705.)
Clinical Research Methods for Surgeons is a comprehensive guide for the surgical scientist, and serves as both a critical review of existing literature and a reference guide for clinical research ...methodologies as they apply to surgery. The text addresses the clinical research questions facing 21st century surgeons, and provides clear direction on how to incorporate sophisticated research techniques into practice. In addition to the surgical generalist, this practical volume is specifically oriented to surgeons who treat unique diseases, yet have no single resource to facilitate clinical research in these specific areas.This comprehensive and easy-to-use guide encompasses the entire process of clinical study design, application, and assessment. Part One is aimed at the young surgeon about to engage in new studies, and gives a general overview of the infrastructure of clinical research. Parts Two and Three are geared towards experienced investigators interested in pursuing clinical research and surgeons reviewing the literature for practical application. Part Two focuses on study design and related statistical issues, while Part Three is concerned with measuring and assessing the outcome of clinical studies. Part Four presents topics of interest to the active investigator, such as quality of care and cost-effectiveness analyses. Clinical Research Methods for Surgeons is relevant to both beginning investigators and established researchers, and addresses the unique concerns of surgical diseases and acknowledges that they require special approaches to deal with clinical questions. Written for:General Surgeons, Urologists, Cardiac Surgeons, Neurosurgeons
Deep venous thrombosis (DVT) and pulmonary embolism (PE) are common complications in trauma patients. These diagnoses can be difficult and expensive to make. Recent studies report that a negative
...d-dimer test excludes thrombotic complications. We questioned the predictive value of a
d-dimer test to exclude DVT and PE.
Adult trauma patients admitted March 1999 to March 2001, with an Injury Severity Score ≥9 and expected length of stay >3 days, were approached for enrollment. Bilateral lower extremity duplex ultrasounds and
d-dimer levels were performed within 36 hours of admission, day 3-4, day 7, and weekly until discharge.
Twenty-three patients were diagnosed with DVTs, with 18 DVTs detected within the first week of admission. Five DVT patients had normal
d-dimer levels. One of three PE patients tested had a normal
d-dimer level. The false negative rate for DVT by
d-dimer assay was 24%, and the sensitivity was 76%. The negative predictive value for
d-dimers was 92%. All false negative
d-dimer tests occurred in patients diagnosed with DVT or PE within the 4 days after admission.
In the early postinjury phase, a negative
d-dimer test does not exclude DVT or PE. However, the negative predictive value of a
d-dimer test after the first 4 days from admission rose to 100%. Patients with clinical signs and symptoms of DVT or PE in the immediate postinjury phase should undergo further screening to exclude thromboembolic complications.
To define the relevance of treating renal artery aneurysms (RAAs) surgically.
Most prior definitions of the clinical, pathologic, and management features of RAAs have evolved from anecdotal reports. ...Controversy surrounding this clinical entity continues.
A retrospective review was undertaken of 168 patients (107 women, 61 men) with 252 RAAs encountered over 35 years at the University of Michigan Hospital. Aneurysms were solitary in 115 patients and multiple in 53 patients. Bilateral RAAs occurred in 32 patients. Associated diseases included hypertension (73%), renal artery fibrodysplasia (34%), systemic atherosclerosis (25%), and extrarenal aneurysms (6.5%). Most RAAs were saccular (79%) and noncalcified (63%). The main renal artery bifurcation was the most common site of aneurysms (60%). RAAs were often asymptomatic (55%), with a diagnosis made most often during arteriographic study for suspected renovascular hypertension (42%).
Surgery was performed in 121 patients (average RAA size 1.5 cm), including 14 patients undergoing unilateral repair with contralateral RAA observation. The remaining 47 patients (average RAA size 1.3 cm) were not treated surgically. Operations included aneurysmectomy and angioplastic renal artery closure or segmental renal artery reimplantation, aneurysmectomy and renal artery bypass, and planned nephrectomy for unreconstructable renal arteries or advanced parenchymal disease. Eight patients underwent unplanned nephrectomy, being considered a technical failure of surgical therapy. Dialysis-dependent renal failure occurred in one patient. There were no perioperative deaths. Late follow-up (average 91 months) was available in 145 patients (86%). All but two arterial reconstructions remained clinically patent. Secondary renal artery procedures included percutaneous angioplasty, branch embolization, graft thrombectomy, and repeat bypass for late aneurysmal change of a vein conduit. Among 40 patients with clearly documented preoperative and postoperative blood pressure measurements, 60% had a significant decline in blood pressure after surgery while taking fewer antihypertensive medications. Late RAA rupture did not occur in the nonoperative patients, but no lessening of this group's hypertension was noted.
Surgical therapy of RAAs in properly selected patients provides excellent long-term clinical outcomes and is often associated with decreased blood pressure.
How DRGs hurt academic health systems Taheri, Paul A; Butz, David A; Dechert, Ron ...
Journal of the American College of Surgeons,
07/2001, Letnik:
193, Številka:
1
Journal Article
Recenzirano
BACKGROUND:
Academic health centers continue their mission of clinical care, education, and research. This mission predisposes them to accept patients regardless of their individual clinical ...variation and financial risk. The purpose of this study is to assess the variation in costs and the attendant financial risk associated with these patients. In addition, we propose a new reimbursement methodology for academic health center high-end DRGs that better aligns financial risks.
STUDY DESIGN:
We reviewed clinical and financial data from the University of Michigan data warehouse for FY1999 (n = 39,804). The diagnosis-related groups were classified by volume (group 1, low volume to group 4, high volume). The coefficient of variation for total cost per admission was then calculated for each DRG classification. A regression analysis was also performed to assess how costs in the first 3 days estimated total costs. A hybrid methodology to estimate costs was then determined and its accuracy benchmarked against actual Medicare and Blue Cross reimbursements.
RESULTS:
Low-volume DRGs (< 75 annual admissions) had the highest coefficient of variation relative to each of the three other DRG classifications (moderate to high volume, groups 2, 3, and 4). The regression analysis accurately estimated costs (within 25% of actual costs) in 64.7% of patients with a length of stay ≥ 4 days (n = 16,287). This regression fared well compared with actual FY 1999 DRG-based Medicare and Blue Cross reimbursements (n = 9,085 with length of stay ≥ 4 days), which accurately reimbursed the University of Michigan Health System in only 43.9% of cases.
CONCLUSIONS:
Academic health centers receive a disproportionate number of admissions to low-volume, high-variation DRGs. This clinical variation translates into financial risk. Traditional risk management strategies are difficult to use in health care settings. The application of our proposed reimbursement methodology better distributes risk between payers and providers, and reduces adverse selection and incentive problems (“moral hazard”).
Trauma services: a profit center? Taheri, Paul A; Butz, David A; Watts, Charles M ...
Journal of the American College of Surgeons,
04/1999, Letnik:
188, Številka:
4
Journal Article, Conference Proceeding
Recenzirano
Background: Previous studies have demonstrated inadequate reimbursement for severely injured patients with a resultant negative economic impact for the trauma service and hospital. The purpose of ...this study was to assess the total cost of care for all injured patients discharged from the trauma service in fiscal year 1997, and to determine the proportion of costs for the most severely injured on total cost. In addition, we assessed the total service costs and the revenue for treatment of the most severely ill. The final result was the determination of the profit (loss) margin for the entire service.
Study Design: All patients discharged from our Level I Trauma Center in fiscal year 1997 were included (n = 696). The population was then stratified into 2 subgroups using the Injury Severity Score (ISS). Patient grouping was facilitated by integration of the trauma registry with the hospital cost accounting system. The population was sub-divided into 2 distinct groups. Group A represented all patients with an ISS > 15 (n = 192). Group B contained all patients with an ISS < 15 (n = 504). Length of stay and mortality of each group was recorded. Cost of care was determined by the hospital cost accounting system TSI (Transition System Incorporated, Boston, MA), which is designed to generate cost center data on a cost per patient basis. Total costs were determined for the entire population and Groups A and B. The proportion of costs consumed by each group was then calculated. Reimbursement was determined by calculating expected payments for each patient. These calculations are based on previously agreed upon allowances from each insurer and are reconciled at the end of each fiscal year to ensure accuracy.
Results: The average length of stay for the population and Groups A and B were 7.5, 9.8, and 6.7 days respectively. Mortality in each group was 9.7%, 19.3%, and 6%. Over 92% of the population sustained blunt mechanism injury and only 8% were penetrating. When controlled for length of stay, the profit margin for Group A is $1,242/day and for Group B is $519/day. Comparison of mean cost/patient between Group A and Group B was $35,727 versus $17,623, respectively.
Conclusion: Trauma centers can be profitable. Group A is responsible for 44% of the total service cost while accounting for only 28% of the discharges. Moreover, this group is responsible for 57% of the profit, and yields the greatest return. The ability to care for the sickest patients, while enormously costly, is essential to the economic viability of the trauma center and its future growth.
Purpose: This study tested the hypothesis that a subset of secondary infrainguinal arterial reconstructions show prohibitive failure rates. Methods: Records of 79 consecutive patients, 44 men and 35 ...women, with a mean age of 60 years, who underwent secondary infrainguinal bypass from 1992 to 2000 at the University of Michigan Hospital, were reviewed. Data were analyzed with life-table analysis, logistic regression, and descriptive statistics. Results: Secondary infrainguinal reconstructions were performed in patients who had undergone earlier ipsilateral bypasses once (n = 35) or twice (n = 44). Among the prior procedures, 68% (n = 54) were done at an institution other than the authors'. Comorbidities included coronary artery disease (72%), tobacco use (77%), and diabetes mellitus (34%), but no patient had hemodialysis-dependent renal failure. Disabling claudication, with average ankle brachial index of 0.48, had been the indication for the primary operation in 77% of cases. Femoral-popliteal bypass was the primary procedure in 67%, with a prosthetic graft used in 62%. The mean patency duration of these earlier bypasses was 25 months. The indication for the final bypass was rest pain or tissue loss in 51% of patients, with an average ankle brachial index of 0.37. The most common procedure was a femoral-distal bypass with autologous vein (63%). Mean patency duration of the secondary bypasses was 30 months. Graft failure within 30 days of operation occurred in 22 patients (28%), and amputation was necessitated in 86% of these patients. The presence of rest pain or tissue loss, when accompanied with a history of early prior graft thrombosis in female patients, correlated with worse mean patency rates, recurrent graft failure (P ≤.05), and a 94% amputation rate. Men in a similar setting incurred a 57% amputation rate. No association of final patency existed with regard to age, number of prior bypasses, conduit types, tobacco use, or diabetes. Conclusion: Secondary infrainguinal bypasses are associated with an increased rate of graft failure and significant limb loss, particularly in those with a history of rest pain or tissue loss, female gender, and early prior graft failure. More appropriate initial operations in carefully selected patients and aggressive postoperative graft surveillance is speculated to improve these outcomes. (J Vasc Surg 2002;35:902-9.)
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