Who Pays?

1. Who Pays? Economic beneficence in the healthcare environment: fact or fiction?

2. “People engage in trade – exchanging things, time, favor, money and information because it makes them better off” (Gletzen, T.E., 2007).

3. Surgical infections – a real patient safety concern “Surgical site infection (SSI) complicated 2%-5% of all surgeries in the United States, resulting in a total of 300,000 -500,000 infections each year (Engemann, J. et al, 2003; Martone, WJ. et al, 2001; & Weinstein, RA,1998).

4. Just a simple surgery… • 28 yr old female with HX of endometriosis, PCOS and pelvic & abdominal adhesions presents for out-patient surgery on a Friday morning. Surgical plans included laparoscopic adhesiolysis, endometrial implant diathermy, and left oophorectomy. • Surgery was performed without complications except noted oozing at the primary umbilical port. Scraping was performed to stop oozing and incision was closed using surgical glue. • Patient was sent to post-op and, once stable, was discharged.

5. What went wrong - timeline • 2 days post-op: patient presents with fever & hardening & tenderness around umbilical region. • 3 days post-op: redness presents around the umbilical region with odorous yellow pus seeping from the wound. Patient pages surgeon & discovers surgeon left for vacation 2 days ago. On-call physician is unaware of patient’s surgery and/or potential complications that may have been noted. Physician sends patient to urgent care where she is turned away because the operating physician is not affiliated with that institution.

6. And it continues… • 5 days post-op: Patient’s fever increases is not longer reducing with Tylenol, abdomen is firm with a fist-sized area of redness around umbilicus and extending down to encompass a good portion of the pelvis. Patient walks-in at physician’s office and demands to be seen. Post-op staph infection is later confirmed. • Patient is given antibiotic therapy and recovers a week later. • 1 month post-op: Patient acquired surgical notes report the discovery of oozing at the primary port and the failure to remove the left ovary.

7. “Misaligned incentives inherent in payment approaches are the primary cause of the poor quality and excess cost that characterize the current system” (O’Kane et al, 2008). • Where was the post-op SBAR? • Economic outcome finds for the surgeon? Economic Impact Why does the patient pay?

8. References Engemann, J, Carmeli, Y, Consgrove, S, Fowler, V, Bronstein, M, Trivette, S, Briggs, J, Sexton, D, & Kaye, K. (2003). Adverse clinical and economic outcomes attributable to methicillin resistance among patients with staphylococcus aureus surgical site infection. CID, 36. Retrieved from http://www.carefusiondev.com/pdf/Adverse_clinical_and_economic_outcomes_attributable_to_SSI_Engemann_ClinInfDis_030103.pdf Getzen, T. E. (2007). Chapter 1: The flow of funds through the health care system. In Getzen, T. E., & Moore, J., Wiley Pathway Health Care Economics (pp. 1–28). Hoboken, NJ: John Wiley & Sons.

9. Martone, WJ, & Nichols, RL. (2001). Recognition, prevention, surveillance, and management of surgical site infections: introduction to the problem and symposium overview. CID, 33 (Suppl 2): S67-8. O’Kane, M, Corrigan, J, Foote, S, Tunis, S, Isham, G, Nichols, L, Fisher, E, Ebeler, J, Block. J, Bradley, B, Cassel, C, Ness, D, & Tooker, J. (2008). Crossroads in quality. Health Affair, 27(3), 749-758. Weinstein, RA. (1998). Nosocomial infection update. Emerg Infect Dis. 4:416-20.