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Preoperative medical tests do not improve the outcome of patients having cataract surgery. These tests include and electrocardiogram, a complete blood count, and blood levels of various compounds. Researchers randomly assigned 18,189 patients scheduled for cataract surgery to receive preoperative medical tests or no tests. The rate of surgical complications either during or after surgery was similar in both groups. The most frequent complications were hypertension and arrhythmia.

Laparoscopy done in conjunction with vaginal hysterectomy may be more expensive than vaginal hysterectomy alone or abdominal hysterectomy. This was the conclusion of researchers who studied 1,049 women who had a hysterectomy at one hospital. Although laparoscopic vaginal hysterectomy reduced the hospital stay by an average of 1 day, it cost substantially more than the other two operative procedures. The operation also took longer because the combined approach required different sets of instruments and longer operating time. Vaginal hysterectomy alone was the least expensive procedure.

The rate of cholecystectomy for gallstone disease appears to have increased in Maryland, though total death rates have not changed significantly. Cholecystectomy is the surgical removal of the gallbladder and can be performed by open or laparoscopic surgery. Researchers reviewed 1985 to 1992 hospital data from acute care hospitals in Maryland. The annual rate of cholecystectomy increased from about 1.7 per 1,000 residents in 1987-1989 to about 2.2 per 1,000 in 1992, which represents an increase of 28%. The laparoscopic cholecystectomy-related death rate from 1990 to 1992 was significantly lower than that of open cholecystectomy. The overall death rate for all cholecystectomies declined from 0.84% in 1989 to 0.56% in 1992. However, the number of patients who died during hospitalization in 1989 was not significantly different from the number who died in 1992 because of the increase in the number of cholecystectomies performed.

There is the expectation that outcomes research and the promulgation of medical practice guidelines will be able to identify and hopefully reduce the amount of unnecessary or inappropriate medical care through a variety of methods, including utilization review. However, past efforts by public and private insurers to deny claims on the basis of formal technology assessments or practice guidelines have frequently been overturned by the courts for multifarious reasons. This paper examines the court's reluctance to accept a variety of technology assessment methods in coverage policy decisions. The paper reviews the options that have been proposed to restrict judicial involvement in the formulation of coverage policy and then proposes a new option that employs a more precise taxonomy of medical practice assessment., Courts' decisions regarding the use of assessment of medical technology tend to reject insurance companies' arguments that they need not cover some treatments. These decisions favor physicians and patients despite qualifiers in insurance policies such as 'medically necessary' and 'not experimental.' These decisions may influence attempts to develop rigorous and scientifically valid guidelines that could change the delivery and costs of clinical practice and affect the introduction of standard insurance benefits packages. The development of standard coverage would be easier if insurance companies and physicians adhered to the same practice guidelines. Concern has been expressed that, by having individual disputes over public and private insurance coverage resolved by judicial means, decisions might to swayed by sympathy for patients with life-threatening conditions. Emotions might take precedence over more reasoned policy issues. Privately insured consumers should have more discretion to make such treatment decisions. The executive and legislative branches of government should set guidelines for publicly funded coverage.

The use of low-osmolality dyes in cardiac angiography can reduce the incidence of adverse reactions, but because of their greater cost, their use should be limited to those patients at greatest risk of having an adverse reaction. A survey of 505 patients undergoing cardiac angiography found that 24% had a minor or mild reaction, 10% had a moderate reaction and 2% had a severe reaction. All of the severe reactions and 85% of the moderate ones occurred in patients older than 60 years or with unstable angina. These patients were 3.5 times more likely to have a moderate reaction. The 253 patients who received high-osmolality dyes were three to four times more likely to have mild or moderate reactions than 252 patients given low-osmolality dyes. But they were no more likely to have a severe reaction than the patients given low-osmolality dyes.

Percutaneous transluminal angioplasty is a surgical procedure to reopen blood vessels blocked by disease. The procedure is safer and cheaper than bypass surgery, and is often used to treat diseased arteries of the heart. The same procedure is often used to treat artery disease in the arms and legs. Although the procedure results in an impressive improvement in the period after surgery, concern has been expressed that the improvement does not last. Numerous reports have been published in the medical literature on the effectiveness of transluminal angioplasty for arteries in the arms or legs, but most have been small studies on patients at one medical center. A major study was therefore conducted to review the cases in which angioplasty was used in 52 hospitals, as well as evaluating cases of peripheral vascular disease in which bypass surgery or limb amputation was performed. A total of 30,637 cases of peripheral vascular disease were identified between 1979 and 1989. An additional 36,715 cases were identified in which peripheral vascular disease was likely. A total of 5,791 angioplasty procedures, 37,660 bypass operations, and 23,901 amputations were performed during this period. A review of the data indicated that the increasing use of angioplasty during the period from 1979 to 1989 was not associated with a decrease in the rate of bypass procedures. Indeed, the adoption of angioplasty for peripheral vascular disease was associated with an increase in bypass operations. Furthermore, the necessity of amputation was not reduced by the use of angioplasty as an accepted procedure. The available data do not permit the analysis of how individual cases progressed. Therefore, while the overall outcome of peripheral vascular disease has not been appreciably affected by the introduction of transluminal angioplasty, it is not possible to determine how the quality of life of the patients might have improved after treatment. (Consumer Summary produced by Reliance Medical Information, Inc.)

Patients with medical insurance receive a different kind of medical care than those without it; one research study found that uninsured patient hospital stays were 7 percent shorter and included 7 percent fewer procedures than those with insurance. To learn more concerning hospital care as it is associated with patient insurance status, a study was carried out using a large database (592,598 discharges), compiling data from patients who were between the ages of 1 and 64 with one of five specified insurance statuses. These were: no charge, or self-pay (both considered uninsured), Blue Cross, insurance company, or Medicaid. Several variables were examined, including: the Risk-Adjusted Mortality Index (RAMI), a higher value represents a sicker patient; the probability of a weekend admission (weekend admissions are more urgent); average length of stay; probability of a high-cost or high-discretion procedure (uninsured were hypothesized to have a lower probability); probability of a specific procedure associated with a particular diagnosis (for 28 selected diagnoses); and probability of a 'not abnormal' or normal biopsy result (higher probability should represent more aggressive health care). Results showed that the uninsured had a higher RAMI for 13 of 16 cohorts (organized according to age, race, and sex). They also had a shorter length of hospital stay for the five diagnoses examined; a much lower probability of undergoing five high-cost or high-discretion procedures (such as coronary artery bypass graft and total knee replacement); a lower probability of undergoing certain other procedures; and a probability of a normal tissue biopsy report that was less than half that of an insured patient (for five of seven procedures studied). For 15 of 16 groups organized according to age, race, and sex, and corrected for RAMI and other variables, uninsured patients had a higher probability of suffering an in-hospital death. The difference in probabilities was statistically significant for 10 of the 16 cohorts. The data indicate that condition on admission, use of resources during hospitalization, and likelihood of in-hospital death, vary significantly depending on patients' insurance coverage. Insurance coverage should be considered as a variable in predicting the cost, and outcome, of medical care in the US. (Consumer Summary produced by Reliance Medical Information, Inc.)

Numerous proposals have been suggested to revise the current adjusted annual per capita cost (AAPCC) method for paying HMOs in the Medicare program. Several evaluations of the various alternatives conclude that including a prior utilization variable is the most promising alternative. In this paper, using statistical and other criteria, we compare the current AAPCC method with three different prior utilization models. The results suggest that all three prior utilization models can predict expenditures for either individuals or a group--drawn from a cross section and a risk selected sample of aged Medicare beneficiaries--more accurately than the AAPCC method. Of the three prior utilization measures, Payment Amount for Capitated Systems (PACS) predicts actual expenditures most accurately.