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As with any joint venture in any given industry, positive and negative impacts are felt. Tulane University School of Medicine experienced impacts on its academic and clinical missions as a result of the joint venture between Tulane University and HCA, a for-profit public company. The laws of business had entered the halls of medicine. Although patients, personnel, and physicians experienced culture shock and inconveniences, Tulane University School of Medicine has been able to maintain viable training programs, and its faculty physicians have a hospital and corporately run clinics across the street. In addition, multidisciplinary centers of excellence, long spoken of in the academic realm, came to fruition through the corporate world. This may not have been the case, had Tulane University not entered into ajoint venture with HCA. Is it worth the effort? For Tulane University, whether one likes the entire package or not, the answer must be yes. The greatest impact is that the orthopaedic surgeons still are in a position to fulfill their academic and clinical missions.

A stratified, unselected sample of 30 patients who underwent revision total hip arthroplasty between 1990 and 1992 for whom complete clinical and financial data were available was studied. Clinical data included age, gender, diagnosis, length of stay, operative time and blood loss. Financial data included cost of implants, bone graft and accessories, hospital charge, and surgeon reimbursement. Results were compared with the results of an analogous group of 50 patients who underwent revision total hip arthroplasty at the same institution between 1995 and 1997. Cases were classified as simple (involving revision of only acetabular liner and/or femoral head), routine (revision of acetabular and/or femoral components), or complex (major structural graft, antiprotrusio cage, impacted grafting). For patients undergoing routine revision total hip arthroplasty, a dramatic decline of 52% occurred in length of stay during the 5-year span (10.7 days to 5.1 days). The average operative time also declined significantly (238 minutes to 199 minutes) as did the average implant cost ($4349 to $2827). Despite this, the average hospital charge increased 16% ($29,666 to $34,328). There was a significant and dramatic 35% decline in surgeon reimbursement ($3240 to $2178). There was no significant difference in surgeon reimbursement between simple, routine, and complex total hip arthroplasty. Patients who underwent complex procedures had a significantly greater length of stay (7.3 versus 5.1 days) and operative time (297 versus 199 minutes). The hospital charge was dramatically higher for patients undergoing complex procedures ($51,290 versus $34,328) but the surgeon reimbursement was lower on average, although not statistically significant ($1926 versus $2178). There was a significant increase in the number and complexity of revision total hip arthroplasties between the two periods. Significant decreases were achieved in length of stay, operating room time, and implant cost. Benefits from these changes were accrued to the hospital but not the surgeon because hospital costs decreased significantly whereas surgeon reimbursements declined dramatically.

Objective: To determine the prevalence of gunshot wound related orthopaedic injuries in an urban trauma center and outline the socioeconomic background of this patient population., Design: Retrospective study conducted from January 1, 1994, through December 30, 1994., Setting: University-affiliated level 1 trauma center., Patients: Strict inclusion and exclusion criteria were established., Inclusion Criteria: All patients were admitted through the emergency room with a gunshot wound for which the orthopaedic surgery service was consulted. The study group consisted of 284 patients., Exclusion Criteria: Those individuals excluded from the study were patients with an orthopaedic injury who died during or before attempts at resuscitation in the emergency room and patients treated on an outpatient basis., Main Outcome Measures: Orthopaedic and nonorthopaedic diagnoses, etiology, procedures performed, number of hours from admission to the first surgical procedure, average daily hospital census, drug and alcohol screen results, and patient financial status., Results: The orthopaedic service was consulted on 284 patients admitted with gunshot wounds. This group comprised 24% of all orthopaedic admissions, 33% of the average daily orthopaedic census, and 14% of all orthopaedic surgery cases performed. Ninety-four percent were African American and 87% were male, with a mean age of 27 years. Approximately half were tested for alcohol and/or drugs, 45% of whom were positive for alcohol and 65% for drugs. Only 4% of the patients were privately insured., Conclusions: During the period of this study, gunshot wound injuries required more orthopaedic trauma resources than any other single diagnosis.

One hundred twenty stratified nonselected cases of primary and revision total joint arthroplasties performed between 1990 and 1992 in which complete financial and clinical data were available were reviewed. All cases were performed at a single university hospital. Compared with primary total joint arthroplasty, revision surgery involved significantly more operative time, greater blood loss, increased length of stay, and a much higher complication rate. The actual physician reimbursement was not significantly more than for primary procedures. Physician reimbursement constituted 18% of the total fees collected compared with 24% for the actual prosthesis cost. Surgeons performing revision surgery devote significantly more time and are at a higher liability than when performing primary total joint arthroplasty.