Journal of the American College of Surgeons
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Historical Article
Physician reimbursement for general surgical procedures in the last century: 1906-2006.
The last century has seen revolutionary changes in health-care delivery and treatment of surgical diseases. Equally dramatic has been the changes in health-care economics, including the creation of the Medicare and Medicaid programs in 1965. To better characterize the impact to surgical billing, we have undertaken an analysis of physician fees for common general surgical procedures during the past century. ⋯ There has been a substantial decline in payments for general surgical procedures during the past century. The influences of government regulations and increased productivity are likely to continue to apply downward pressure on surgical reimbursement.
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Burn patients constitute approximately 5% of casualties injured in support of US military operations in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]). Since the onset of these conflicts, there have been numerous casualties infected with multidrug-resistant bacteria. It is currently unclear if bacteremia with these multidrug-resistant organisms in OIF/OEF burn casualties is associated with increased mortality. ⋯ Casualties of OIF/OEF with burn injuries did not have different outcomes than patients whose burns were not associated with military operations. Bacteremia, especially with a multidrug-resistant organism, causes increased mortality in burn patients. Of all the pathogens causing bacteremia, K pneumonia appears to have the greatest impact on mortality.
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Randomized Controlled Trial Comparative Study
A randomized controlled trial comparing acetaminophen plus ibuprofen versus acetaminophen plus codeine plus caffeine after outpatient general surgery.
Narcotics are used extensively in outpatient general surgery but are often poorly tolerated with variable efficacy. Acetaminophen combined with NSAIDs is a possible alternative. The objective of this study was to compare the efficacy of acetaminophen, codeine, and caffeine (Tylenol No. 3) with acetaminophen and ibuprofen for management of pain after outpatient general surgery procedures. ⋯ When compared with Tylenol No. 3, AcIBU was not an inferior analgesic and was associated with fewer side effects and higher patient satisfaction. AcIBU is an effective, low-cost, and safe alternative to codeine-based narcotic analgesia for outpatient general surgery procedures.
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Daily spontaneous-breathing trials (SBTs) are promulgated as the best method for assessing readiness for discontinuation of mechanical ventilation. SBT protocols have also been shown to improve outcomes as opposed to wild-type implementation of daily SBT recommendations. Here we determine whether implementation of a mandatory, protocol-driven daily SBT on all ventilated patients in the ICU improves extubation rates and accelerates liberation from mechanical ventilation. ⋯ Implementation of a daily SBT protocol resulted in improvement of extubation rates during the year of implementation without a change in the reintubation rate. Requesting that physicians enumerate reasons for continuing mechanical ventilation in the face of a passing breathing trial was associated with a sustained improvement in extubation rate.