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Incisional endometriosis
LETTERS TO THE EDITOR
Controversy: Length of Stay
preserve safety. I further note that those who are proponents of longer stays as assuring greater patient safety might well look at the incidence of adverse events and conclude that hospitals are not the safest places to be when you are moderately well, irrespective of the “cheapness” of the bed day. I look forward to this article being a stimulus to more detailed or general work on the subject, and hope that the dimension of outcomes will also be included, but I am wary to use these conclusions in a general context.
Stan Goldstein, MB, BS, MHA Sydney, Australia I would like to provide feedback on the article appearing in the August issue of the Journal of the American College of Surgeons, “Length of Stay Has Minimal Impact on the Cost of Hospital Admission” by Paul A Taheri, MD, MBA, FACS, David A Butz, PhD, and Lazar J Greenfield, MD, FACS.1 I believe this sort of work is a valuable contribution to improving the way in which administrative drivers are influencing patient management processes. But I also believe that bias should be avoided or acknowledged, where possible. The general concept is interesting. But that this is a study on emergency department patients leaves a degree of nervousness in trying to conclude anything from the study. It is not a new concept that the last day of care is the cheapest day. It is not new that emergency department patients have an intense expense in the first days. It is not new that when a patient requires management in ICU this skews the costs of care even further toward those first days of intensive management. Yet most patients in hospital never see an ICU, and the majority of care is not provided to patients gaining access to that care through the emergency department. In fact, if I were trying to predict areas of hospital care where research might reveal just such outcomes, this and cardiac surgery would probably be the two areas I might look to, and then only if cardiac surgery didn’t look at marginal cost of ICU days. Although the message on process change is of vital importance, and I would commend and not condemn that message, I would also hope that an objective commentator would qualify any conclusion to be drawn from this study because of the sample selected. These conclusions cannot be extrapolated to the whole system of hospital management or the payment systems. Even so, on the issue of process change, I agree with the authors that there is an inordinate concentration on the idea of length of stay as being the primary driver of efficiency, and agree that looking to process change is far more likely to give efficient and effective outcomes, and
© 2001 by the American College of Surgeons Published by Elsevier Science Inc.
REFERENCES 1. Taheri PA, Butz DA, Greenfield LJ. Length of stay has minimal impact on the cost of hospital admission. J Am Coll Surg 2000; 191:123–130.
Reply Paul A Taheri, MD, MBA, FACS Ann Arbor, MI I wish to respond to Dr Goldstein’s letter to the editor. It is critically important to clarify the issues presented in this manuscript. Dr Goldstein asserts that this is a study of “emergency patients.” Yet our analysis included more than 12,000 patients, and in particular, all surviving discharged patients who had a length of stay of at least 4 days from our entire inpatient health system during fiscal year 1998. A subset of this population (n⫽665) included only trauma patients. Dr Goldstein also incorrectly states that our sample included only patients in the ICU who had high resource consumption early in their stays (eg, specific specialties such as cardiac surgery). The patient population in this study included both critically ill patients and patients who did not have ICU stays. As such, I am puzzled by Dr Goldstein’s comments. Our sample encompassed the entire hospital. There is no broader sampling unless we include multiple health systems. (Although we examined a single health system, our results were quite consistent across specialties, suggesting that they reflect the experience of clinicians across the United States, and throughout academic health systems). Although certain local, regional, and
142
ISSN 1072-7515/01/$21.00 PII S1072-7515(00)00767-5
Vol. 192, No. 1, January 2001
institutional effects may play a role in the sampling and distribution of patients, this type of analysis provides physicians with critical information to better manage their individual health systems and patient populations.
Incisional Endometriosis James H McClenathan, MD, FACS Santa Clara, CA Kim Edward Koger, MD Durham, NC We enjoyed reading the lead article on incisional endometriosis, in the April issue of the Journal.1 In this article, Nirula and Greaney reviewed their experience with 10 patients with surgical scar endometriosis and reported that only 32 patients had been described in the general surgical literature before 2000. This letter is written to update that number to at least 76 by adding our own institution’s experience with 44 patients who have been treated for scar endometriosis over the past 28 years. Twenty-two of these patients were previously described in the Journal of the American College of Surgeons (then titled Surgery, Gynecology and Obstetrics) as part of a series of 24 patients reported by Koger and associates in 1993.2 Of our 44 patients, 39 had endometriosis in a cesarean section scar. A single patient had bilateral endometriosis. Typically, scar endometriosis presents as a firm mass adherent to the fascia
Letters to the Editor
143
and located lateral to the midline. If there is pain, it may or may not vary with the menstrual cycle. Four patients had endometriosis in an episiotomy scar. One of our patients had endometriosis in an appendectomy scar. All of our patients were treated operatively. The majority of our patients were treated by general surgeons. The topic of surgical scar endometrioma has been included in our continuing education program for the past 10 years. Most of the patients treated during the past 10 years have been diagnosed correctly preoperatively. In general, surgical treatment has included complete removal of the endometrioma. None of our patients has had a recurrence of endometriosis within their scars during followup of up to 28 years. In conclusion, we believe that scar endometriosis is even more common than indicated by the article by Nirula and Greaney. Usually seen in cesarean section scars, endometriosis may also be seen in other scars, such as those formed by episiotomy or other abdominal incisions. Our experience suggests that recurrent scar endometriosis is rare if excision is complete. Acknowledgment: The Medical Editing Department, Kaiser Foundation Research Institute, provided editorial assistance.
REFERENCES 1. Nirula R, Greaney GC. Incisional endometriosis: an underappreciated diagnosis in general surgery. J Am Coll Surg 2000;190:404–407. 2. Koger KE, Shatney CH, Hodge K, McClenathan JH. Surgical scar endometrioma. Surg Gynecol Obstet 1993;177:243–246.
Controversy: Length of Stay
preserve safety. I further note that those who are proponents of longer stays as assuring greater patient safety might well look at the incidence of adverse events and conclude that hospitals are not the safest places to be when you are moderately well, irrespective of the “cheapness” of the bed day. I look forward to this article being a stimulus to more detailed or general work on the subject, and hope that the dimension of outcomes will also be included, but I am wary to use these conclusions in a general context.
Stan Goldstein, MB, BS, MHA Sydney, Australia I would like to provide feedback on the article appearing in the August issue of the Journal of the American College of Surgeons, “Length of Stay Has Minimal Impact on the Cost of Hospital Admission” by Paul A Taheri, MD, MBA, FACS, David A Butz, PhD, and Lazar J Greenfield, MD, FACS.1 I believe this sort of work is a valuable contribution to improving the way in which administrative drivers are influencing patient management processes. But I also believe that bias should be avoided or acknowledged, where possible. The general concept is interesting. But that this is a study on emergency department patients leaves a degree of nervousness in trying to conclude anything from the study. It is not a new concept that the last day of care is the cheapest day. It is not new that emergency department patients have an intense expense in the first days. It is not new that when a patient requires management in ICU this skews the costs of care even further toward those first days of intensive management. Yet most patients in hospital never see an ICU, and the majority of care is not provided to patients gaining access to that care through the emergency department. In fact, if I were trying to predict areas of hospital care where research might reveal just such outcomes, this and cardiac surgery would probably be the two areas I might look to, and then only if cardiac surgery didn’t look at marginal cost of ICU days. Although the message on process change is of vital importance, and I would commend and not condemn that message, I would also hope that an objective commentator would qualify any conclusion to be drawn from this study because of the sample selected. These conclusions cannot be extrapolated to the whole system of hospital management or the payment systems. Even so, on the issue of process change, I agree with the authors that there is an inordinate concentration on the idea of length of stay as being the primary driver of efficiency, and agree that looking to process change is far more likely to give efficient and effective outcomes, and
© 2001 by the American College of Surgeons Published by Elsevier Science Inc.
REFERENCES 1. Taheri PA, Butz DA, Greenfield LJ. Length of stay has minimal impact on the cost of hospital admission. J Am Coll Surg 2000; 191:123–130.
Reply Paul A Taheri, MD, MBA, FACS Ann Arbor, MI I wish to respond to Dr Goldstein’s letter to the editor. It is critically important to clarify the issues presented in this manuscript. Dr Goldstein asserts that this is a study of “emergency patients.” Yet our analysis included more than 12,000 patients, and in particular, all surviving discharged patients who had a length of stay of at least 4 days from our entire inpatient health system during fiscal year 1998. A subset of this population (n⫽665) included only trauma patients. Dr Goldstein also incorrectly states that our sample included only patients in the ICU who had high resource consumption early in their stays (eg, specific specialties such as cardiac surgery). The patient population in this study included both critically ill patients and patients who did not have ICU stays. As such, I am puzzled by Dr Goldstein’s comments. Our sample encompassed the entire hospital. There is no broader sampling unless we include multiple health systems. (Although we examined a single health system, our results were quite consistent across specialties, suggesting that they reflect the experience of clinicians across the United States, and throughout academic health systems). Although certain local, regional, and
142
ISSN 1072-7515/01/$21.00 PII S1072-7515(00)00767-5
Vol. 192, No. 1, January 2001
institutional effects may play a role in the sampling and distribution of patients, this type of analysis provides physicians with critical information to better manage their individual health systems and patient populations.
Incisional Endometriosis James H McClenathan, MD, FACS Santa Clara, CA Kim Edward Koger, MD Durham, NC We enjoyed reading the lead article on incisional endometriosis, in the April issue of the Journal.1 In this article, Nirula and Greaney reviewed their experience with 10 patients with surgical scar endometriosis and reported that only 32 patients had been described in the general surgical literature before 2000. This letter is written to update that number to at least 76 by adding our own institution’s experience with 44 patients who have been treated for scar endometriosis over the past 28 years. Twenty-two of these patients were previously described in the Journal of the American College of Surgeons (then titled Surgery, Gynecology and Obstetrics) as part of a series of 24 patients reported by Koger and associates in 1993.2 Of our 44 patients, 39 had endometriosis in a cesarean section scar. A single patient had bilateral endometriosis. Typically, scar endometriosis presents as a firm mass adherent to the fascia
Letters to the Editor
143
and located lateral to the midline. If there is pain, it may or may not vary with the menstrual cycle. Four patients had endometriosis in an episiotomy scar. One of our patients had endometriosis in an appendectomy scar. All of our patients were treated operatively. The majority of our patients were treated by general surgeons. The topic of surgical scar endometrioma has been included in our continuing education program for the past 10 years. Most of the patients treated during the past 10 years have been diagnosed correctly preoperatively. In general, surgical treatment has included complete removal of the endometrioma. None of our patients has had a recurrence of endometriosis within their scars during followup of up to 28 years. In conclusion, we believe that scar endometriosis is even more common than indicated by the article by Nirula and Greaney. Usually seen in cesarean section scars, endometriosis may also be seen in other scars, such as those formed by episiotomy or other abdominal incisions. Our experience suggests that recurrent scar endometriosis is rare if excision is complete. Acknowledgment: The Medical Editing Department, Kaiser Foundation Research Institute, provided editorial assistance.
REFERENCES 1. Nirula R, Greaney GC. Incisional endometriosis: an underappreciated diagnosis in general surgery. J Am Coll Surg 2000;190:404–407. 2. Koger KE, Shatney CH, Hodge K, McClenathan JH. Surgical scar endometrioma. Surg Gynecol Obstet 1993;177:243–246.