Surgical Care Driving Miss Daisy

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Surgical Care Driving Miss Daisy

• Issue Provision, Funding, Ethics and Quality of
  Medical Care
• Sarah Cording, Stephanie Williams, Zoe
  Keon-Cohen, Frank Giorlando

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Mrs Daisy Q

• 65 yo lady
• Severe bilateral osteoarthritis for 8 years
• Mobility seriously impaired
• No other comorbidites

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Presentation

• On 15th February
• Elective surgery recommended
• Placed on St Elsewheres waiting list
• Classed as Category 2 patient (non urgent, within
  90 days)
• Procedure delayed a further 6 weeks extra (long
  waiting lists)

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Pre Admission Clinic

• 7th April
• Discharge planning discussed
• 8th May
• Attended St Elsewheres for Right Total Hip
  replacement
• 9th May
• Surgery Completed without complications

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Post Operative

• Daisy remained in hospital for 10 days as per
  discharge plan
• Hip pain experienced but not reported
• Returned Home under the care of her Elderly
  Husband and RDNS
• Refuses to Ambulate due to pain
• Feels she is a burden on her husband

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4 Days Post Discharge

• Mentions to nurse
• R leg is hot, swollen and feels doughy
• Readmitted to St Elswheres
• Diagnosed with DVT
• Heparin commenced
• Develops hospital aquired pneumonia
• Remains in hospital for 12 days

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Discharged Again!

• Didnt return to premorbid functioning
• Refuses to consider further surgery or surgery on
  left hip

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How much will Daisys hip operation cost?

• (A) 6,000
• (B) 9,000
• (C) 12,000
• (D) 18,000

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Answer

• (D) 18,000!

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What is the medicare benefits schedule fee for
the operation?

• (A) 666.40
• (B) 1,041.35
• (C) 2,224.10

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Answer

• (B) 1,041.52

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What is the average length of stay for a hip
replacement?

• (A) 7.4 days
• (B) 13.2 days
• (C) 8.5 days

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Answer

• (C) 8.5 days

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Who funds elective surgery?

• Combination of federal and state governments
• How is the funding allocated?
• By the case-mix system

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What is case-mix funding?

• Introduced in 1993 to Victoria
• Allocation of funds to hospitals based on the
  NUMBER and TYPE of patients treated within an
  overall CAPPED budget
• Allows hospitals to decide as to the mix of
  services offered within this capped budget

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For example

• A surgical procedure falls into a diagnostic
  related group (DRG) and has variable costing
  components
• A STANDARD UNIT RATE
• Covers medical, nursing, theatre, pharmaceutical
  and equipment costs of a procedure
• The COST WEIGHT is
• Cost of procedure / average cost of all
  procedures
• Ie appendicectomy 1500
• Average cost of all procedures is 2000
• Appendicectomy has a CW of 0.75

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Do all appendectomies cost 1500?

• If the hospital can do an appendectomy for less
  than the standard unit price
• It keeps the CASH!

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Average length of stay.

• The length of stay is a KEY determinant of
  funding for procedures
• If a patient EXCEEDS the average length of stay
  for a procedure the hospital is NOT reimbursed
  for these additional costs
• However if the patient stays longer b/c of a
  complication the hospital will receive a little
  bit of extra cash (not really enough) for this
  patient

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Consequences of case-mix funding

• The good, bad and ugly
• Reduced government spending on health and
  improved public hospital efficiency
• Surgery has become a focus for hospitals b.c of
  its higher earning capacity --- waiting list
  times?
• The emphasis on length of stay has encouraged
  forward planning for earlier discharge

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Ethical Issues Case-mix and Daisy

• Hospital efficiency helps to reduce waiting lists
• case-mix was introduced largely on this premise
• However, it addresses only the in-patient
  component of patient management
• A patient becomes a case
• Patients readmitted after 30 days are a new case

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Who can we discharge today?

• Funding is not tied to outcome beyond 30 days
• Therefore, the simplest way for a hospital to
  improve efficiency is with early discharge
• However, there is not enough post-acute care
  available in the community

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Daisy becomes a Yo-Yo

• Daisy was discharged 10 days post operative
• But she returned 4 days later with a DVT
• She spent an extra 12 days in hospital
• Did the pressure to clear her bed mean that she
  was discharged too early or discharged to an
  inappropriate care environment?

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Where do the funds go?

• A Health Dollar can be spent many different ways
• Primordial Prevention
• Preventive Medicine and health maximisation
• Community Medicine
• Acute Care
• Post-acute Care
• Palliative Care

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Patient Outcomes

• Health is a state of complete
  physical, mental, and social
  well-being and not merely the absence
  of disease or infirmity.
• A truly efficient health system
• Works at societal level to maintain health
• Treats patients in need
• Reintegrates patients into the community

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Conclusions

• Case mix funding emphasises the imperative of
  reducing expenses by more efficient use of
  hospital beds
• For beneficial patient outcomes, it relies on
  effective post discharge care that is not always
  available
• Funding needs to be tied to assessments of the
  quality of care outcomes to better serve
  community health