[HSF] post op mediastinitis discussion

[Michael Firstenberg]

It is probably not unreasonable to limit payments for complications.   
The issue that I/we (at our hospital) struggle with is the entire DRG/ 
Global system.  We - as in everyone on this forum - takes care of a  
lot of very sick patients - some typically refused by other centers.   
Part of the reason other centers do not want to do the cases is not  
that they can't but they do not have the resources or infrastructures  
to take care of the patients post-operatively.  Having spoken with  
surgeons in private practice in the "communities" for the global  
payments that they get it is difficult to justify the amount of time  
they would need to invest in caring for these patients post- 
operatively.  Clearly many of them can do the cases but the post- 
operative medical/social/etc management is too much of a time drain  
on a system which can't afford to "waste" time, energy, people,  
resources on activities with limited or no re-embursement.  It is one  
thing to do a CABG and have the patients go home in 4 days - it is  
another to do a CABG and have the patients spend a month in the  
hospital - we don't get payed any more and that is a problem.

So, while at many places these new rules may not change our practices  
per say - it may mean we deal with a lot more of other's  
complications - and I dont mean that in a negative way as most  
surgeons want to deal with their own problems - but the systems they  
work for may not want them "wasting their time".  In fact, we may  
even get sent more "high risk" patients which would only further  
limit the development and growth of smaller practices - which is a  
shame.

-michael


On Oct 4, 2007, at 6:53 PM, hgrmd at aol.com wrote:

> Chuck,
>   I guess you've finally realized Ani is the "master debater" on HSF.
>
> Hal
> Sent from my Verizon Wireless BlackBerry
>
> -----Original Message-----
> From: "Douville, Chuck" <ecdouville at orclinic.com>
>
> Date: Thu, 4 Oct 2007 15:08:22
> To:<OpenHeart-L at lists.hsforum.com>
> Subject: RE: [HSF] post op mediastinitis discussion
>
>
> Ben I agree, that if the rule is left as is, this will be the  
> result. Great discussion around a tough issue: Ani is an excellent  
> debater, though I maintain that is a bad policy to penalize an  
> institution for a rare complication, if the institution has  
> demonstrable quality measures and compliance in evidence, and  
> results that match that. chuckdouville
>
> ________________________________
>
> From: openheart-l-bounces at lists.hsforum.com on behalf of Ben Bidstrup
> Sent: Wed 10/3/2007 12:36 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] post op mediastinitis discussion
>
>
>
>> This discussion is relevant to our cardiac surgery colleagues around
>> the world, although it is a financial issue only in the USA. CMS
>> (center for medicare services), the agency responsible for medicare
>> healthcare funding in the US recently announced it would no longer
>> pay hospitals for costs due to postoperative mediastinitis in
>> cardiac surgery patients effective within the next year. Despite
>> perfect glucose control, antibiotic timing etc, my own recent
>> morbidly obese re-do AVR pt had his chest open 7 hours due to
>> difficult adhesions. S. epi wound infection on day 6 required
>> opening his sternum, VAC therapy and IV antibiotics and an extra
>> week in the hospital. The only way to avoid the infection in this pt
>> that I can think of is to deny the operation to a 60 yr old man with
>> critical AS after previous CABG 6 years earlier.  I do not believe
>> the incidence of this problem can ever be zero. Thoughts?
>> _______________________________________________
>
> Well, the best way would be to use the NNECVSG risk tool for DSWI and
> exclude from surgery any patients with a greater than 2% risk. This
> is double the incidence mist units would see. Then tell them why, and
> let them discuss with their senator or congressman.
>
> Tough measure need tough solutions!
>
> Or call it something else.
> --
> Ben Bidstrup FRACS FRCSEd FEBCTS
> Consultant Cardiothoracic Surgeon
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