Neurosurgery in the Carolinas and Its Relation to National Neurosurgical Manpower Requirements FRANK
R.
WRENN, M.D., GORDON
H.
DEFRIESE, PH.D.,
AND ROBERT SULLIVAN, .l\;I.D. INTRODUCTION
In 1969 and 1970, early in the planning which led to the Neurosurgical Manpower Commission Study, certain matters were considered. Among these was the fact that the population of the country is estimated by the census. This population is served by a pluralistic system for its medical care. Within this system various tasks are performed by individuals whose qualifications vary. The committee's interest lay chiefly in those individuals or physicians who are or will be performing tasks related to neurosurgery. It was thought that neurosurgical diseases and related procedures could be reasonably identified. Each physician works in and out of institutions to provide care, to perform diagnostic and therapeutic procedures, to estimate disability, to participate in rehabilitation, and to provide assistance in legal matters. Finally, many physicians have teaching, research, and administrative responsibilities added to their patient oriented tasks. In a pluralistic system of health care delivery, there are said to be differences in the patterns of care observed in university hospital settings, and in dense urban, smaller urban, and rural areas. It seemed possible that various settings might impose certain constraints and that the tasks might differ for individuals in different settings. Further, there is a postulate that physician behavior in the provision of care is modified in various settings. Several studies in this country and elsewhere point to these ideas and allege a discernible difference in the quality of care rendered in various settings (1, 3, 4, 7, 11, 12). Thus a number of considerations seemed essential in an attempt to know the numbers of individuals needed to meet work requirements, and whether the necessary individuals are presently being trained for the work as it really is rather than as imperfectly understood by the training programs. Several studies of surgical manpower needs have been accomplished and others are underway (13, 15). Efforts have been made to calculate the surgical work load from observations of hospital case loads and other data (10, 14). Other efforts have attempted to look at physician to population 526
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CHAPTER 34
NEUROSURGERY IN THE
CAROLI:r~AS
527
NATIONAL PREVALENCE OF NEUROSURGICAL DISEASES AND PROCEDURES
The pluralistic system of medical care delivery in the United States has no uniform data system which compiles either ambulatory or hospital incidences of diagnoses or procedures. The largest body of inpatient data is that compiled by the Commission on Professional and Hospital Activities (CPHA) of Ann Arbor, Michigan. It is necessary at this point to explain certain features of the CPHA data.
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ratios in several modes of medical care delivery and to understand how production, death, and retirement calculations can affect such ratios (15, 16). There has been a paucity of data about what surgeons do outside the hospital because the hospital experience has, up to now, been easier to document and study. In Canada where uniform computer data are available, the distribution of the surgical work load among various specialists has been the subject of an interesting study (14). In the United States a smaller aspect of this has been studied also (7). The important questions in our study seemed to be, who does what to whom, and where does he do it? The several methodological approaches to answering these important questions as devised in the Neurosurgical Manpower Commission Study have been described elsewhere (5). One basic approach involved an effort to understand from those identified as neurosurgeons what they thought they did, by means of a mailed questionnaire. A second approach was to estimate the hospital work loads. It seemed neces-sary to estimate the dispersion of defined neurosurgical and neurological diseases within those of the population hospitalized during a unit of time. At the same time it seemed likely that an estimate of the numbers of defined procedures likely to be performed by neurosurgeons could be accomplished. As a practical matter it is commonly known that this work goes on in hospitals of varying size and capabilities and that the work applied to the defined disease processes is often performed by others and not by those designated as neurosurgeons. Our report is to be presented in three parts. The details of those studies done nationwide have been presented elsewhere (5), but pertinent portions of the study of the national prevalence in hospitals of defined neurosurgical diseases and procedures, and of the analysis of data derived from a questionnaire completed by neurosurgeons throughout the country, will be reviewed for purposes of correlation in the present report. The bulk of the report is directed toward providing a partial picture of the content and activity of neurosurgical practice as well as some knowledge of the management of defined diseases and procedures by persons other than neurosurgeons, thereby providing some answers to the who, what, to whom, and where dilemma.
528
CLINICAL NEUROSURGERY Downloaded from https://academic.oup.com/neurosurgery/article-abstract/22/CN_suppl_1/526/4099458 by guest on 25 October 2019
The system is designed for use by hospitals for studies of professional activities (Professional Activity Study, or PAS) and medical audit programs (MAP). It uses a set of codes and descriptors known as H-ICDA [Hospital Adaptation of the ICDA (18)]. The rubrics provide a large collection of aggregates of data for review so that reference to an individual hospital record is seldom necessary. These rubrics often include the neurological manifestation of a disease under a category along with other manifestations of the disease process. As an example, herpes simplex encephalitis is coded under a rubric which includes involvement of other organs. This problem can be more clearly seen when one examines the rubrics for certain neurosurgical procedures as seen in Table 34.1. There are also other vagaries which make it difficult to use these data in an epidemiological way, but the data do reflect primary and secondary diagnoses and numbers of procedures done in hospitals which keep physicians at work. The full details of this study will appear elsewhere. Data from 1971 were obtained from the CPHA for 510 selected diagnoses and 56 procedures of neurosurgical and neurological interest. These were classified by geographical region and by bed size of the hospital. From Janurary 1 to December 31, 1971, the CPHA had collected data from 1,284 hospitals with 10,207,191 individual discharges. These data were transferred to the Health Services Research Center of the University of North Carolina at Chapel Hill for analysis. The data were suitably corrected for the disproportionate distribution of hospitals by size and within geographical areas to more nearly approximate the national picture, and were then expanded by statistical methods to yield estimates of the numbers experienced nationally. From the expansion procedure it was estimated that approximately 9,929,500 hospital instances of defined neurological disease had occurred in 1971. Of this number 5,043,551 were listed as a primary diagnosis; in 8,092,560 instances both a primary and a secondary neurological diagnosis were listed. The 510 separate diagnoses, representing a very large data set, have been partially summarized into 10 categories for ease of review. These data are displayed in Table 34.2. Table 34.3 displays these diagnoses with respect to the population by census divisions and geographical regions. In general it appears that nearly equal rates of disease were reported in New England and in the Southeast and Mountain regions, with lower rates in descending order in the Midwest, Great Lakes, and Pacific regions. Except for the Mountain and Pacific regions the preponderance of the selected diseases was reported from hospitals of greater than 199 beds. There were 408,258 records which contained at least one neurosurgical procedure. There were 963,613 so-called neurosurgical procedures reported, or an average of a little more than two procedures per case. Table 34.4 dis-
TABLE 34.1 H -ICDA * Rubrics for Certain Neurosurgical Procedures
02 Other operations on brain, cerebral meninges, and skull 02.0 Cranioplasty bone flap, cranial bone graft, skull debridement, skull elevation of bone fragments open reduction of fracture opening cranial suture removal of: bone fragments granulation tissue plate repair with: bone graft plate: metal (tantalum) plastic (methyl methacrylate) strip craniectomy 03 Operations on spinal cord structures: nerve roots, spinal cord, spinal meninges 03.0 Laminectomy decompression, spinal exploration hemilaminectomy incision and drainage laminotomy rachitomy removal of foreign body reopening laminectomy site with section of spinal ligament Excludes: laminectomy with excision of herniated intervertebral disc (83.4) lumbar puncture (99.7) subarachnoid block of spinal sensory nerves (04.7) that involving further operative procedure (03.1-03.9) H-ICDA
=
Hospital Adaptation of the ICDA (18). 529
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01 Incision and excision of skull, brain, and cerebral meninges 01.0 Craniotomy burr holes craniectomy decompression, cranial exploration, cranial removal of: extradural hematoma foreign body, except plate sequestrum reopening of craniotomy site trephination Excludes: decompression of fracture (02.0) exploratory puncture (01.2) removal of foreign body (02. 9) removal of plate (02.0) strip craniectomy (02.0) that involving further operative procedure (01.2-02.9)
530
CLINICAL NEUROSURGERY
34.2
Rubric
Disease Category
No. of Hospital Instances
430-596.6 710-739 780-797.4 800-848 850-873.1 170-238.9 740-759.8 001-136 350-354 950-959.9
Cerebrovascular disease Disease of musculoskeletal system Physical signs and symptoms Injuries and adverse effects, fractures Intracranial injury Neoplasms Congenital anomalies Infections and parasitic disease Diseases of peripheral nerves and ganglia Inj ury to nerves and spinal cord
1,949,807 1,634,482 980,263 929,815 806,955 213,845 184,527 162,889 146,994 84,926
* PAS = Professional Activity Study program of the Commission on Professional and Hospital Activities. TABLE
34.3
Ratio of Neurological Diagnoses to Population by U. S. Census Divisions and Geographical Regions Designated in Present Study*
u.s. Census Division
Middle New England Atlantic
East East West West South South North North South MounCentral Atlantic Central Central Central tain
u. S. Pacific Average
--- --- -- -- - - -- - - --
Diagnoses per 1000 population
57
46
45
50
62
52
45
57
42
--
51
-- -- -Study Region
Diagnoses per 1000 population
New England
Great Lakes
Southeast
Midwest
57.0
45.5
56.0
48.5
Mountain
U. s. Pacific Average
--
-- --
57.0
42.0
51
* Diagnostic data were derived from expansion of national PAS statistics and population data from the Statistical Abstract of the United States: 1971 (17). plays these procedures with respect to the population by census divisions and geographical regions; Table 34.5 lists the percentages of the total number of procedures before and after the expansion of the PAS data was carried out. These procedures may be grouped in several ways. One way is to group by criteria which attempt to distinguish between major and minor surgical procedures or as to requirements for general or local anesthesia. A second grouping used in this presentation is based upon assumptions of whether the procedure is likely to be performed only by neurosurgeons or may com-
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TABLE
Prevalence of Selected Diseases of Neurosurgical Interest after Expansion of P AS* Data
TABLE 34.4 Ratto of Neurosurgical Procedures to Population by U. S. Census Divisions and Geographical Regions Designated in Present Study*
Divison
East East West West South South North North South MounCentral Atlantic Central Central Central tain
New Middle England Atlantic
u. s. Pacific Average
--- --- --- --- --- --- --- ---
Procedures per 1000 population Study Region
32
42
28
35
37
29
34
27
New England
Great Lakes
Southeast
Midwest
Mountain
42
30
36
28
34
Procedures per 1000 population
--- ---
24
32
---
---
U. S. Pacific Average ---
---
24
32
* Procedures data were derived from expanded PAS data and population data from the Statistical Abstract of the United States: 1971 (17). TABLE 34.5 Percentage Distribution of Neurosurgical Procedures by U. S. Census Divisions and Geographical Study Regions before and after National Expansion of PAS Data* •
I
Middle New England Atlantic
---
Before National Expansion of PAS Data
---
East North Central
South Atlantic
--- ---
East South Central
West North Central
--- ---
---
17.8% 29.3% 13.4% 1.9%
8.2%
West South Mountain Pacific Central
8.8%
4.4%
--- ---
5.3%
10.9%
---
---
New England
Great Lakes
Southeast
Midwest
---
Mountain
Pacific
--- ---
47.1%
8.2%
13.2%
15.4%
5.3%
10.9%
--- ---
New Middle England Atlantic
East North Central
South Atlantic
East South Central
West North Central
West South Mountain Central
--- --- --- ------ --- ---
After National Expansion of PAS Data
19.0% 18.1% 16.9% 7.3%
7.8%
7.4%
8.5%
4.9%
Pacific
---
10.1%
I
;
I
--- --New England
Great Lakes
Southeast
Midwest
7.8%
37.1%
24.2%
15.9%
Mountain Pacific --- ---
4.9%
10.1%
* Data from 1971 were provided by the Commission on Professional and Hospital Activities, Ann Arbor, Mich. 531
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u. s. Census
TABLE 34.6 Distribution of Neurosurgical Activity among Three Categories of Neurosurgical Procedures in the United States, 1971*
--Type 1 094.6 099.7 093.1 095.0 094.8 093.0 004.7 ------
No. of Procedures
Per Cent of Total
Radioisotope scanning/brain, unspecified Spinal puncture Myelography and disography Arteriography of head and neck UItrasonic radiography/brain, unspecified Encephalography and ventriculography Nerve block, peripheral
2,517,900 1,330,647 646,808 416,050 246,388 146,930 23,324
39.316 20.768 10.095 6.493 3.846 2.293 0.364
Sub-total
5,328,047
83.175
329,094
5.136
116,862 83,352 66,263 40,585 31,294 29,578 25,534 24,600 14,684 14,010 12,273 8,999 7,286 6,590
1.823 1.300 1.030 0.633 0.488 0.461 0.398 0.383 0.229 0.218 0.191 0.140 0.114 0.103
6,298
0.098
6,167
0.096
6,131
0.096
4,204 2,458 2,302
0.065 0.038 0.035
1,503
0.023
854
0.013
736 185
0.011 0.003
841,842
13.125
Procedure
---Type 2
083.4 084.4 003.0 005.1 034.1 004.0 004.6 002.0 004.4 005.2 004.5 004.1 001.2 004.8 034.8 034.5 034.9 034.0 005.3 004.9 034.2 007.5 002.9 005.0 034.7
----
Excision/intervertebral cartilage, prolapsed disc Spinal fusion Laminectomy Sympathectomy or ganglionectomy Endarterectomy of head, neck, base of brain Exploration of peripheral nerve Neurolysis Cranioplasty Neurorrhaphy Sympathetic nerve block N europlasty Section of peripheral nerve Cranial puncture Nerve transplantation Suture and ligation/blood vessel/neck, head, brain base Graft reconstruction/artery/head, neck, brain base Other operation/blood vessels/head, neck, brain base Incision/blood vessel/head, neck, base of brain Periarterial sympathectomy Other operations on peripheral nerves Excision/blood vessel/head, neck, base of brain Hypophysectomy, trans-sphenoidal approach Other operations on brain and cerebral meninges Section of sympathetic nerve or ganglion Venous anastomosis/head, neck, base of brain Sub-total 532
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Category H-ICDA Code
533
NEUROSURGERY IN THE CAROLINAS
Category H-ICDA Code
Type 3
001.0 001.6 001.3 004.3 002.3 002.4 034.3 003.3 003.2 003.1 003.5 001.8 003.4 002.1 003.9 001.5 002.2 034.6 001.4 003.8 034.4
----
001.7 001.9 007.6
34.6-Continued No. of Procedures
Procedure
Craniotomy Excision of tissue of brain and cerebral meninges Incision with drainage Neurectomy or avulsion of peripheral nerve Ventricular shunt or anastomosis Revision or removal of shunt Repair of aneurysm/head, neck, base of brain Excision and destruction of lesion of cord and meninges Cordotomy Rhizotomy and radiculectomy Lysis of adhesions of cord and spinal nerve roots Biopsy of brain and cerebral meninges Plastic operations on spinal cord and spinal meninges Repair cerebral meninges Other operations on spinal cord structures Excision of lesion of skull Ventriculostomy Arterial anastomosis/head, neck, base of brain Incision or division of brain tissue Biopsy of spinal cord and spinal meninges Repair/ arteriovenous fistula/head, neck, brain base Operations on thalamus and globus pallidus Biopsy of skull Other operations on pituitary gland Sub-total
Per Cent of Total
55,259 32,442
0.862 0.506
25,006 22,578 16,409 12,228 11,268 8,437
0.390 0.352 0.256 0.191 0.176 0.132
8,241 5,897 5,881
0.128 0.092 0.092
5,598 4,528
0.087 0.070
4,508 3,620 3,523 3,350 1,873
0.070 0.056 0.055 0.052 0.029
1,612 1,499 1,281
0.025 0.023 0.019
1,211 535 434
0.019 0.008 0.006
237,228
3.700
6,407,117
100.000
---
Total
* Estimates based on expanded PAS data. monly be performed by other practitioners as well. This approach is arbitrary and the likelihood of neurosurgeon involvement is subject to documentation. However, using these approaches three categories of procedures were identified. Type 1 procedures are considered minor (usually performed for diagnostic purposes and requiring in most cases either local anesthesia or no anesthesia) and are often performed by non-neurosurgeons. Type 2 procedures are considered major and are commonly performed by neurosurgeons and non-neurosurgeons. Type 3 procedures are considered major and are nearly always performed by neurosurgeons. Table 34.6 displays
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TABLE
534
CLINICAL NEUROSURGERY
TABLE
34.7
Number of Selected Specialists and Their Ratio to Population Specialty*
Neurosurgery Neurology Orthopedics Otolaryngology Ophtha mology Thoracic surgery General surgery General practice Plastic surgery Urology Internal medicine Pediatrics
* Reliable
. . . . . . . . . . . .
Numberj
Ratio to Population
2,614 3,494 10,074 5,483 10,117 1,798 29,850 54,558 1,732 6,128 43,118 19,160
1:78,840 1:59,980 1:20,460 1:37,590 1:20,370 1:114,620 1:6,900 1:3,780 1:118,990 1:33,630 1:4,780 1:10,760
numbers for neuroradiologists have not been found.
t Data taken from Reference Data on Profile of Medical Practice (2).
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the distribution among the 56 procedures of numbers which were estimated after expansion to total 6,407,117 throughout the nation. Note that Type 1 procedures account for 83.2 per cent of the total, whereas Type 3 procedures represent only 3.7 per cent of the work done. If these procedures represent tasks available for neurosurgeons, how many neurosurgeons will be required? If Type 3 procedures are reduced to monthly values and one assumes eight procedures per neurosurgeon per month, one concludes that there is a requirement of 2471 neurosurgeons. Data published by the American Medical Association in 1973 indicated that there were 2753 self designated neurosurgeons of whom 2614 were involved in patient care in the year 1971 (2). This figure along with the numbers of certain other selected specialists with their ratio to population are shown in Table 34.7. These numbers represent physicians involved in patient care. Because the 1970 census of 206,092,026 is a fairly recent estimate of the population of the United States the ratios have probably not changed significan tly. The data in Table 34.8 have been rearranged in yet a third way by categories of procedures and rounded totals per year which could be obtained if every procedure were done by a neurosurgeon. As in Table 34.7 the number of neurosurgeons used in the calculation was 2614. Obviously several types of physicians take care of patients with these conditions and perform many of these procedures. Table 34.8 displays a great deal of work to be done, but one must consider, for example, that the number of discs removed is shared with 10,000 orthopedists among others. Similar sharing is evident among many of the other procedures studied as well.
535
NEUROSURGERY IN THE CAROLINAS
34.8 No. of Procedures No. of Procedures per Neurosurgeon per Year
Procedure
134,607
51.3
Operations on or wi thin the cranial vault For trauma craniotomy cranioplasty For tumor For aneurysm Repair A-V fistula Hypophysectomy (trans-sphenoidal) Other operations on pituitary
. . . . . . . .
55,259 25,534 39,328 11,268 1,281 1,503 434
Other operations on blood vessels to brain Endarterectomy Suture ligation blood vessel Graft reconstruction Other operations Incision Excisioa Arterial anastomosis Venous anastomosis
. . . . . . . . .
70,131 40,585 6,590 6,298 6,167 6,131 2,302 1,873 185
26.6
Spinal operations Excision of herniated nucleus pulposus Spinal fusion Laminectomy (excluding disc operations) Spinal cord lesion, excision Lysis adhesions cord and roots Other operations cord Biopsy cord and meninges
. . . . . . . .
548,745 329,094 116,862 83,352 8,437 5,881 3,620 1,499
209.6
Operations for hydrocephalus and spinal cord coverings . Plastic operation on meninges . Ventricular shunt . Revision of shunt . Ventriculostomy .
31,525 4,528 16,409 12,228 3,360
13.7
Operations for pain control Cordotomy Rhizotomy Neurectomy or peripheral avulsion
36,716 8,241 5,897 22,578
14.0
. . . .
21.0 10.0 15.0 4.0 0.5 0.6 0.2 15.5 2.5 2.4 2.3 2.3 0.9 0.7 0.0 125.8 44.7 32.0 3.1 2.1 1.4 0.5
1.7 6.0 5.0 1.0 3.4 2.0 8.6
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TABLE
Estimated Numbers if Procedures were Performed Solely by N eurosurgeons*
536
CLINICAL NEUROSURGERY
34.8-Continued No. of Procedures No. of Procedures per Neurosurgeon per Year
Procedure
Operations on peripheral nerves Exploration (includes carpal tunnel) Neurolysis Neurorrhaphy N europlasty Section Transplantation Other operations
. . . . . . . .
126,499 31,294 29,578 29,600 14,010 12,273 7,286 2,458
46.3
Contrast studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1,209,788 Myelogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646,808 Arteriogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416,050 Ventriculogram or pneumoencephalogram. . . . . . . . . 146,930
462.0
11.9 11.3 9.4 5.3 4.7 2.8 0.9 247.0 159.0 56.0
* Estimates based on expanded 1971 PAS data, using 2,614 as the number of neurosurgeons (2). THE CAROLINAS STUDY
The preceding has delineated some dimensions of the hospital work loads available throughout the nation. This section of this presentation attempts to assess how the neurosurgeon attends to his tasks, how he views his working milieu, especially its relationship to the constraints upon what he does and how he does it, how long he works, and something of his rewards. It is possible to examine some differences in the patterns of care rendered in various settings and by various specialists, but this will be the subject of an analytical effort to be reported at another time. In the Carolinas a unique opportunity existed for examining many of the questions of concern to the Neurosurgical Manpower Commission that did not exist elsewhere, South Carolina had a 1970 census of 2,590,516 and North Carolina, 5,082,059. Figure 34.1 shows the locations of the Standard Metropolitan Statistical Areas (19). The Carolinas have changed in the last three decades, with a steep decline in the proportion of population in remote or rural areas. In 1970, 45 per cent of the North Carolina population and 47.6 per cent of the South Carolina population were clustered in urban areas compared with 73.5 per cent of the United States population as a whole. North Carolina is approximately 400 miles from East to West; in South Carolina this distance is about 250 miles. North-South distances are about equal in the two states. All of the neurosurgeons were known who were at work in the area. These numbered 55 at the time of the study and their locations are shown in Figure 34.2. The ratio of neurosurgeons to population in the two states was 1: 142,084 whereas the national ratio was 1: 78,840.
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TABLE
FIG. 34.2. Locations of the 39 practicing neurosurgeons In North Carolina, and the 16 practicing neurosurgeons in South Carolina, 1971.
537
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FIG. 34.1. The Standard Metropolitan Statistical Areas in North Carolina and South Carolina, depicted in black. A standard metropolits n statistical area is defined by The Bureau of the Census as a county or group of contiguous counties which contains at least one city of 50,000 inhabitants or more, or twin cities with a combined population of at least 50,000 (19).
538
CLINICAL NEUROSURGERY
Figure 34.3 shows the numbers and locations of the neurologists then active in both states. All other specialties were also represented in the area. Specialist to population ratios in the two states were all below the national levels by about the same proportion as for neurosurgery. Each of the neurosurgeons was approached by a personal interview which was accomplished by an individual representing the Health Services Research Center. The relatively short geographic distances made this feasible. The Carolinas interview study was an outgrowth of and supplementary to a national questionnaire survey of all neurosurgeons listed in the Congress of Neurological Surgeons Directory for 1971 (6). For the Carolinas interview study additional questions were designed to yield information about referral patterns and patient movement. Both sets of information were subjected to intensive analysis and where possible the mailed study was compared to the interview study. Selected results of this effort appear here. Within the two states there were four medical schools with attached university hospitals: Duke University in Durham, Bowman Gray School of Medicine in Winston-Salem, University of North Carolina at Chapel Hill, and the Medical University of South Carolina in Charleston. For several years the Duke Endowment, through its Hospital Section, had substantially contributed to the participation of Carolina hospitals in the PAS-MAP pro-
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FIG. 34.3 Locations of the 31 practicing neurologists in North Carolina, and the 19 practicing neurologists in South Carolina, 1971.
NEUROSURGERY IN THE CAROLINAS
539
Surveys of Participating N eurosurgeons
From this information we now know something of the way neurosurgeons view their practice situation, including some of the constraints; the relationships these men have to other practitioners; the patient care activities in which they are engaged; and the relationship of their work to income. This is the only part of the Manpower Study which provides some analysis of the neurosurgeon's participation in ambulatory care. Certain portions of these studies are presented here. Full details will appear elsewhere. Table 34.10 displays the office practice arrangements found both in the Carolinas and nationwide in 1973-1974. Roughly one-quarter of neurosurgeons in the Carolinas were in solo practice. Equivalent numbers were in medical school or teaching hospitals. Single specialty groups in the Carolinas had predominantly three or less members, perhaps a reflection of community size. There were very few multispecialty groups in the Carolinas (two neurosurgeons practicing in association with neurologists at the time of the study). A second aspect of practice settings concerned the numbers and types of hospitals in which neurosurgical care was provided. Table 34.11 displays the data in this regard. N ationwide, 45 per cent of neurosurgeons worked in three or four hospitals, but Carolina neurosurgeons had better fortune in this regard. Both of the question surveys included a question as to the staff and facili-
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grams of CPHA. For the year 1971 CPHA had abstracted 75 per cent of hospital discharges in North Carolina and 53 per cent in South Carolina. Because CPHA matches a physician code with the final diagnosis explaining admission and with the most important and other operative procedures, it seemed possible to obtain some information which related how a physician with known qualifications cared for a patient with a given diagnosis or procedure. Sixteen diagnostic entities were selected for study. These entities with accompanying H-ICDA codes are displayed in Table 34.9. Selected items of data on the CPHA abstract form were selected for retrieval. It was necessary to obtain a release from each hospital for these data. In 1971, 112 Carolina hospitals partcipated in CPHA; 101 releases were obtained. Certain exceptions other than the university hospitals must be mentioned with respect to hospitals known to be used by neurosurgeons. In Charlotte, North Carolina, the three major hospitals used their own, not CPHA, data service. In Raleigh, North Carolina, in the largest standard metropolitan statistical area (Sl\1SA), the neurosurgeons did consent to the interview, but the hospitals in which they worked did not release data. This represents the only such incident in the study. It is believed that all other hospitals used by neurosurgeons were studied.
540
CLINICAL NEUROSURGERY
Entity Name
Study Diagnoses Included in the Diagnostic Entity
H-ICDA Code
1. Cervical disc
Herniated nucleus pulposus
725.0
2. Lumbar disc
Herniated nucleus pulposus
725.1
3. Spinal trauma without paralysis
Fractured vertebra without paralysis
805.0-9
4. Spinal trauma with paralysis
Fractured vertebra with paralysis
806.0-9
5. Cerebral trauma
Concussion Laceration Subarachnoid hemorrhage Intracerebral hemorrhage
850.0 & 9 851.0-1 &'"'9 852. 0-1 &~:9 853.0-1 & 9
6. Cerebral tumor
Benign tumor Malignant tumor
225.0-.6, 225.9 191.0-9
7. Spinal tumor
Benign tumor Malignant tumor
225.3-4 192.2-3
8. Epilepsy
Minor epilepsy, maj or epilepsy
345.0-5 & 9
9. Headaches
Migraine headache Headache Tension headache
346.0 791.0 316.8
Cerebral thrombosis with and without paralysis Cerebral hemorrhage Cerebral vascular occlusion Cerebral embolism Cerebral ischemia Cerebral vascular disease
433.0-1
11. Spontaneous subarach- Spontaneous subarachnoid hemornoid hemorrhage rhage, with and without paralysis
430.0-1
12. Peripheral nerve injury Arm, upper, nerve injury Arm, fore, nerve injury Wrist & hand, nerve injury Leg, thigh, nerve injury Leg, lower, nerve injury Foot, nerve injury
952.0-1 953.0-1 954.0-1 955.0-1 956.0-1 957.0-1
10. Cerebrovascular accident
431.0-1 432.0-1 434.0-1 435.0-1 436.0-1
&9 & 9 & 9
&9 & 9 & 9
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TABLE 34.9 Neurosurgical and Neuroloqical Conditions Assessed in the Carolinas N eurosurgical Manpower Study
541
NEUROSURGERY IN THE CAROLINAS
Entity Name
34.9--Continued
Study Diagnoses Included in the Diagnostic Entity
H-ICDA Code
13. Birth defects
Spina bifida Hydrocephalus Encephalocele
741.0 & .9 742.0 743.0
14. eNS abscess
Brain abscess Spine abscess
322.0 322.1
15. Aseptic meningitis
Brain meningitis, aseptic Spine meningitis, aseptic
320.0-4 320.8-9
16. Paralysis agitans
Parkinson's disease
342.0
TABLE
34.10
Frequency and Percentage Distributions of N eurosurgeons among Types of Office Practice Settings ,. National and Carolinas Surveys, 1973-197.4 National Survey
Carolinas Survey
No.
No.
Per Cent
13 22 4 2 13
24.1 40.7 7.4 3.7 24.1
-
-
Office Practice Setting Per Cent
Solo practice ............................... Group practice (3 or less) ................... Group practice (4 or more) . . . . . . . . . . . . . . . . Multispecialty group ... . . . . . . . . . . . . . . . . . . . . Medical school and/or teaching hospital. .. Government service ........................ Other ......................................
297 281 119 60 206 38 10
29.4 27.8 11.8 5.9 20.4 3.7 1.0
Totals ......................................
1,011
100.0
~
54
100.0
ties available at the principal hospital in which the neurosurgeon worked. Those surveyed were asked whether each of these items was available: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Special neurosurgery operating room, Intensive care unit, Serial film changer for angiography, N euroradiologist, Neuropathologist, Other neurosurgeons not in your practice, Neurologists, Neurosurgical residents, General surgery residents, Orthopedic surgery residents, and Neurology residents.
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TABLE
542
CLINICAL NEUROSURGERY
National Survey
Carolinas Survey
Number of Hospitals No.
1 2 3
>4 Totals
283 277 218 235
I
I !
1,013
Per Cent
No.
Per Cent
27.9 27.4 21.5 23.2
27 17 9 1
50.0 31.5 16.7 1.8
100.0
54
100.0
I
Mean number of hospitals
2.53
1.70
These eleven traits were scored for each respondent as present or absent in their primary hospital. Of the eleven items, two (intensive care unit and serial film changer) were excluded because all neurosurgeons reported these available. Three other items were also removed (neuroradiologist, neurology residents, and other neurosurgeons) because their distributions were identical to those of other items. The six items remaining were subjected to the statistical process known as Guttman scaling in order to develop a single score index of the hospitals' capability of facilitating neurosurgical care. Using this score each respondent could be scored with respect to a hospital type, a distinction among hospitals "more" or "less" equipped to deliver neurosurgical care. Table 34.12 displays the distributions of neurosurgeons among these hospital types in the two surveys. It appears that a significant number of neurosurgeons work without the best hospital facilities and almost certainly with less than was available where they were trained. The Carolinas survey also provided data on the patterns of patient referrals and the relationship of neurosurgeons to their own and other disciplines. Three types of information was requested: basic sources of referral (emergency, self referral, referral by other physicians); whether referrals were within or without the same town; and information about the specific type of physician making the referral. Table 34.13 displays these data by characteristics of office practice and Table 34.14 by type of hospital. N eurosurgeons seemed to get few self referrals from patients. Clearly neurosurgeons received the bulk of their patients from other physicians. Those who worked alone and in the less well equipped hospitals seemed more dependent upon their in-town colleagues. Such neurosurgeons received almost all of their referrals from primary care physicians and few from specialists such as neurologists or orthopedists. N eurosurgeons in more systematized prac-
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TABLE 34.11 Frequency and Percentage Distributions of N eurosurqeons among Numbers of Hospitals in which They Practice; National and Carolinas Surveys, 1973-197J,.
543
NEUROSURGERY IN THE CAROLINAS
National Survey
Hospital Neurosurgical Facility Score*
No.
Carolinas Survey
Per Cent
No.
0 1 2 3 4 5 6
197 101 98 150 169 183 57
20.6 10.6 10.3 15.7 17.7 19.1 6.0
13 3 6 11 13 3 1
Totals
955
100.0
50
Per Cent
26.0 6.0 12.0 22.0 26.0 6.0 2.0 ------
2.81
Mean hospital score *Guttman scale: 0
=
100.0
most equipped, 6
2.42 least equipped.
TABLE 34.13 Mean Percentages* of Patients Referred to Carolina N eurosurqeons from Various Sources by Type of Office Practice Setting; Carolinas Survey, 1973-1974
Type of Office Practice Setting Source of Referral (N
Emergency ................ Self (patient) .............. Other M.D ................ General practitioner ..... Internist .............. Pediatrici an . . . . . . . . . . . . General surgeon ......... Neurologist ............. Orthopedist. . ........... Other ................... In-town ...................
Solo
=
13)
15.6 5.8 93.5 38.8 25.0 5.1 9.2 9.7 11.7 0.2 61.1
Small Group
(N
=
22)
18.2 4.1 95.9 42.5 19.3 5.8 4.9 17.6 9.3 1.8 52.5
Large Group
(N
=
4)
10.0 0.0 100.0 15.0 30.0 10.0 10.0 25.0 10.0 0.0 30.0
Multispecialty Group (N
=
2)
10.0 0.0 95.0 30.0 15.0 5.0 10.0 12.5 27.5 0.0 50.0
Medical School
(N
=
Totals
13)
21.2 3.5 90.7 26.5 19.2 10.4 10.6 18.1 12.5 1.3 20.8
17.4 3.9 94.4 35.3 21.3 7.0 7.9 16.2 11.4 1.0 45.1
* Data in table are means of percentage estimates given verbally by respondents. Columns and rows do not, therefore, sum to 100 per cent.
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TABLE 34.12 Frequency and Percentage Distributions of N eurosurqeons among Primary Hospitals Having Selected Types of Neurosurgical Facilities,. National and Carolinas Surveys, 1973-1974
544
CLINICAL NEUROSURGERY
34.14
I
Type of Primary Hospital t Source of Referral
Emergency ............... Self (patient) ............. Other M.D ................ General practitioner .... Internist ............... Pediatrician ............ General surgeon ........ Neurologist ............. Orthopedist ............ Other .................. In-town ..................
0 (N = 13) --
21.2 3.5 90.7 26.5 10.2 10.4 10.6 18.1 12.5 1.3 20.8
1 (N = 3)
I
2
(N = 6)
-- --
20.0 20.0 80.0 45.0 25.0 5.0 0.0 25.0 0.0 0.0 27.0
11.7 0.5 99.5 20.0 30.0 8.3 8.3 20.8 12.5 1.3 32.2
Totals
3 (N = 11)
4 (N = 13)
5 (N = 3)
- -
--
- -
---
---
13.3 3.3 96.7 50.0 18.3 6.7 5.0 6.7 13.3 0.0 66.7
5.0 0.0 100.0 85.0 5.0 0.0 0.0 0.0 10.0 0.0 75.0
17.7 4.0 94.2 36.2 21.4 7.2 7.8 15.2 11.4 1.0 43.4
16.4 1.4 98.6 44.5 17.3 5.7 8.5 10.3 12.7 2.9 48.2 i
19.5 5.1 93.8 37.3 24.2 5.8 7.1 14.7 10.9 0.0 64.8
(N
6
=
1)
* Data in table are means of percentage estimates given verbally by respondents. Columns and rows do not, therefore, sum to 100 per cent. t Guttman score of hospital neurosurgical facilities: 0 = most equipped, 6 = least equipped. tice settings (groups who worked in the better equipped hospitals) received their patients from a wider variety of other specialists. Thus one can speculate as to how these referral patterns relate to the overlaps of care provided in various settings. In the Carolinas a significant proportion of care is being provided by non-neurosurgeons. Further, it is obvious that much of the pattern of a neurosurgical practice can be predicted from knowledge of the office and hospital settings. This will subsequently be compared with the distribution of diseases managed in several hospital settings by neurosurgeons and by other types of physicians. Further studies of the characteristics of neurosurgical practice were made by examining the hours worked and the division of these hours between patient care, administration, teaching, and research, as "Tell as the daily hospital census, number of procedures performed per month, and the number of professional meetings attended. These data are arranged by office setting in Table 34.15 and by hospital type in Table 34.16. Because of the personal contact afforded by the data gathering arrangement in the Carolinas study, these data are thought to be a reasonable, valid representation of the variables they purport to measure. N eurosurgeons all seem to work long hours. Solo practitioners and those working in medical schools reported the longest hours. Those in partnerships or groups handled a few more inpatients, and virtually all spent more
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TABLE
Jl,I ean Percentages* of Patients Referred to Carolina Neurosurqeons from Various Sources by Type of Primary Hospital; Carolinas Survey, 1973-1974
TABLE
34.15
Characteristics of Neurosurgical Practice by Type of Ottiice Practice Setting
Type of Office Practice Setting
Patient Care Work Hours Outpatient
Daily Hospital Census
Procedures per Month
Nonneurosurgical Patients Seen per Year
49.76 43.36 39.5 23.00 31.61
13.30 19.43 19.25 11.00 14.76
44.46 45.51 44.5 61. 40.92
243.95 155.83 168.00 140.00 156.14
34.21 35.73 36.19 32.46 40.07 45.32
4.94 5.18 6.93 4.27 18.48 9.36
40.79 43.63 43.45 41.95 39.80 38.90
298.51 326.65 248.26 246.40 184.28 387.68
I patient In-
Carolinas Survey
69.30 65.81 57.50 60.00 69.00
Solo ... , ... , ............ Small group ............. Large group ............ Multispecialty .......... Medical school ..........
13 22 4 2 13
Solo ...... , .... '" ...... Small group ............. Large group ............. Multispecialty .......... Medical school .......... Government service .....
281-287 259-271 108-116 58-59 173-190 31-33
16.92 19.90 13.75 35.00 10.00
National Survey
* Not
30.59 28.59 25.94 31.69 16.02 22.21
65.32 65.16 65.21 64.64 67'.19 59.11
all respondents answered all the questions. TABLE
34.16
Characteristics of Neurosurgical Practice by Type of Primary Hospital Type of of Neuro- Hours Worked Primary No.surgeons] per Week Hospital"
Patient Care Work Hours Outpatient
IInpatient
Daily Hospital Census
Procedures per Month
Non-neurosurgical Patients Seen per Year
14.76 20.00 16.83 19.86 14.07 25.00 15.00
40.92 51.00 43.50 43.87 48.12 42.66 49.00
156.14 142.33 175.40 165.66 187.18 255.00 355.00
17.32 12.17 6.20 6.46 4.83 3.47 2.20
41.08 39.94 42.89 41.96 42.03 42.16 41.08
209.69 231.78 247.56 342.92 283.74 313.84 360.27
Carolinas Survey
0 1 2 3 4 5 6
13 3 6 11
13 3 1
69.00 65.00 56.66 69.63 66.30 65.33 60.00
10.00 35.00 17.90 16.26 20.23 15.66 10.00
31.61 30.00 41.10 50.09 43.00 48.00 50.00
National Survey
0 1 2
3 4 5 6
169-188 I 90-93 138-145 137-141 150-161 171-173 55
66.95 63.31 67.09 64.22 64.59 64.99 65.51
18.08 23.11 26.05 26.12 30.23 30.25 37.86
42.54 44.89 54.03 55.52 54.75 57.12 51.68
* Guttman score of hospital neurosurgical facilities: 0 least equipped. t Not all respondents answered all the questions. 545
most equipped, 6
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Hours Worked per \Veek
No. of Neurosurgeons"
546
CLINICAL NEUROSURGERY
34.17
Income Groups*
No. of Neurosurgeons]
Hours Worked per Week
Patien t Care Work Hours
Outpatient
Daily Hospital Census
I patient In-
Procedures per Month N. S. Only
I
N.S. Plus
Nonneurosurgical Patients Seen per Year
182.97 148.53 185.62 210.78 131.83
Carolinas Survey
30,000-40,000 40,000--50,000 50,000-75,000 75,000-100,000 100,000 plus
5 11 20 12 6
62.20 63.63 68.10 67.50 69.16
30,000--40,000 40,000-50,000 50,000-75,000 75,000-100,000 100,000 plus
121-131 147-154 267-282 206-213 170-176
60.59 63.84 65.39 67.44 67.78
13.80 12.62 17.70 21.33 15.83
30.60 41.63 39.45 43.83 48.33
12.30 18.00 15.73 18.25 16.50
24.00 22.10 25.01 26.69 21.50
16.00 16.81 16.78 19.55 20.00
10.90 9.63 7.90 7.01 6.05
18.54 19.81 20.96 21.09 21.56
16. 17
National Survey
24.59 26.30 26.81 26.58 27.35
52 46. 46.68
1
52.15 07
54. 56.52
1
16.39
1
221.09
229.38
18.75
19.34 20.69
303.44 357.18 1262.19
* Income in dollars per year. t Not all respondents answered all the questions. time on inpatients than outpatients. All saw a significant number of patients without neurosurgical disease during their work periods, as well as a significant amount of disease not yielding a surgical procedure. It is ·suggested that there was greater efficiency in patient care with non-solo practice and with single hospital settings. Incidentally, nearly all reported that they are well compensated. As with other endeavors, one seems to work longer hours for somewhat more money (Table 34.17). This variable with several others will be reported in detail later. Among these variables are the following: Table 34.18 displays the variations in choice or availability of operating room assistants arranged by type of practice organization. Table 34.19 rearranges these by type of primary hospital. Table 34.20 shows certain differences between board certified and noncertified practitioners. Note that noncertified neurosurgeons work longer hours, but perform approximately the same number of procedures as board certified neurosurgeons. The national estimates indicate that noncertified neurosurgeons see larger numbers of non-neurosurgical patients. The mix of these patients is not clear. It is suspected, but not documented, that this may reflect inadequate triage and the unavailability of other specialists, perhaps neurologists. The differences in the numbers of meetings attended is significant.
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TABLE
Characteristics of Neurosurgical Practice by Income
547
NEUROSURGERY IN THE CAROLINAS
Type of Office Practice Setting Type of Operating Room Assistant
Survey]
Solo
-- ---
Small Group
Large Group
--- ---
Multi- Medical specialty School
Govt. Service
--- ---
-
C N
3.5 2.9
1.7 1.8
1.0 1.9
1.0 2.8
3.3 3.1
2.9
Neurosurgical resident
C N
4.0 3.2
4.0 3.3
4.0 2.4
4.0 3.4
1.0 1.6
3.1
Other M.D.
C N
3.2 1.6
3.3 2.5
4.0 2.9
3.0 2.9
3.4 3.0
2.5
C N
3.1 2.5
3.3 3.0
3.3 2.7
3.0 2.7
4.0 3.3
3.0
C N
1.8 3.1
3.1 3.2
4.0 3.2
3.0 2.3
4.0 3.3
3.4
Neurosurgeon
Nurse
Technician
* Where 1 = usually,2 = often, 3 = rarely, 4 = t C = Carolinas Interview Study Panel; N =
Total for Study Panel
-
-
-
-
2.0 2.6 3.3 3.0 3.3 2.5 3.3 3.1 3.2 3.4
never. National Questionnaire Study
Panel.
Whether this reflects solo practice, lack of interest, or the unavailability of continuing educational programs or forums is not clear. This matter requires further study and analysis for it has obvious and fundamental importance. Management of Certain Neurosurgical Diseases Table 34.21 displays the frequency and percentage distributions of diagnostic and treatment procedures applied to the 38,981 diagnoses retrieved from the 101 participating hospitals in the Carolinas. In the totals column the numbers are actual diagnoses and the percentages are the per cent of the total number of diagnoses. These figures do not reflect the true incidence of such diseases but only of those observed in the hospitals studied. It is striking that in 67.7 per cent of these diagnoses, no neurosurgical procedure was performed during that hospital admission. The criteria for establishing each diagnosis or for the case being coded as such were not clear from the data. The usual procedure requires the physician to specify the diagnosis which is then coded using the governing rubric by a medical records person. It is conceivable that the diagnosis was obtained from one of the smaller hospitals and that the patient was transferred to a second or
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TABLE 34.18 Median* Scores on Use of Selected Types of Operatinq Room Assistants by N eurosurqeons by Type of Office Practice Setting, National and Carolinas Surveys, 1973-197J,.
548
CLINICAL NEUROSURGERY
34.19
Type of Primary Hospitalf
Type of Operating Room Assistant
0
Neurosurgeon Neurosurgical
Total for Study Panel
Survey]
resident
C N
3.3 3.1
2.0 2.8
1.8 2.3
1.6 2.5
2.5 2.3
1.0 2.4
4.0 2.7
2.0 2.6
e
1.0 1.5
4.0 1.8
4.0 3.2
4.0 3.3
4.0 3.4
4.0 3.4
4.0 3.5
3.3 3.0
3.4 3.2
4.0 2.9
3.3 2.8
3.3 2.0
3.5 1.9
3.5 1.8
4.0 1.9
3.3 2.5
N
4.0 3.3
4.0 3.1
3.4 3.0
3.2 2.4
3.5 3.0
3.5 2.9
1.0 1.9
3.3 3.1
C N
4.0 3.3
4.0 3.1
3.4 2.8
3.3 2.9
2.0 3.3
3.5
3.0
1.0 3.1
3.2 3.4
N
e
Other M.D.
N
e
Nurse Technician
1 2 4 5 6 3 ---- -- -- -- -- ----
I
.
* Where 1 = usually, 2 = often, 3 = rarely, 4 = never. t C = Carolinas Interview Study Panel; N = National Questionnaire Study Panel.
t Guttman score of hospital neurosurgical facilities: 0 = most equipped, 6 = least equipped. TABLE
34.20
Characteristics of Neurosurgical Practice by Board Certification No. of Neurosurgeons
Board Certification
Hours Worked per Week
Patien t Care Work Hours
Out-
pa tien t
I
I pa Intient
Procedures per Month N.S. Only
I
N. S. Plus
Non-neurosurgical Patients Seen per Year
Professional Meetings Attended per Year
Carolinas Survey Yes No
40 14
65.02 71.07
[15.17141.20 124.11 21.85 40.57 24.85
1
17 . 50 18.21
176.81 179.20
1.92 0.64
1
18 .49 1 276.62 18.70 388.29
2.21 1.69
I
National Survey Yes No
797 159
65.18 66.39
126.46150.80 120.81 26.60 56.68 19.52
larger hospital where a procedure was subsequently done. It is hoped that some insight into this type of discharge outcome will be available later. Criteria for the classification of a procedure as diagnostic or therapeutic are, of necessity, arbitrary. Lumbar punctures, brain scans, skull x-rays,
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TABLE
Median * Scores on Use of Selected Types of Operating Room Assistants by N eurosurgeons by Type of Primary Hospital, National and Carolinas Surveys, 1973-1974-
549
NEUROSURGERY IN THE CAROLINAS
34.21
Type of Neurosurgical Procedure Performed No Neurosurgical Procedures Procedure I TherDiagnostic Dx and Rx Considered Performed apeutic Procedure Procedure Procedures Both Dx and Rx
Diagnostic Entity
Row Per No. Cent
No.
._-
-
Row Per No. Cent
Row Per No. Cent
Row Per Cent
-
-
-
-
-
1 Cervical disc .......... 19912.7 100 6.4 30119.2 9 Lumbar disc ........... 799 13.5 557 9.6 157427.3 Spinal trauma with 3 paralysis ............ 78 3.1 64 2.5 23 0.9 Spinal trauma without 4 paralysis ............ 16 4.1 39 9.9 11 2.8 5 8.8 610.5 2645.6 Spinal tumor .......... 2 0.4 9 Peripheral nerve inj ury 19 3.6 22642.4 ........................................ e. .......
Epilepsy ............... Headaches ............. Cerebrovascular accident ............. Cerebral trauma ....... ..
a
......................................
-.
......
..
...... ..
67927.7 2003 40.8
..
e
...
6 0.2 15 0.3
...
.. ...... ..
. ....
.....
..
......
..
-
-
......
..
....
..
......
..
......
..
..
........
..
-
-
-- -- -0.1 970 61.7 1571 4.0 0.2 2857 49.5 5796 14.8 0.1 2381 93.4 2549
6.5
32282.1 2035.1 27752.0
1.0 0.2 1.4
1.0 -
1.7 ......
..
.
..
........
..
......
392 57 533
.. ........ .. ..........
-- -
6.3 12.0
5 49 2 20 1
..
1.0 13325.9 514 8.9 28652.1 549 10 27.8 36 5.6 3.4 81 13.7 590 0.1 1303 87.6 1488
...... ...... .. ...... .. ......
17 3.2 18735.0
Column Per Cent
21 0.2 884274.1 11934 30.6 25 0.5 4273 84.3 5069 13.0 ...... ...... .. ........ .. ...... . .... 'I. . ........
65 12.6 72 13.1 1438.9 27 4.6 2 0.1
4 0.8 92 16.8 3 8.3 4 0.7 1 0.1 ......
Row Row Per Cent No.
15 0.6 7 0.3 1747 71.2 2454 23 0.5 155 3.2 2718 55.3 4914
2759 23.1 85 0.7 227 1.9 471 9.3 153 3.0 147 2.9
Spontaneoussubarachnoid hemorrhage .... 30759.7 Birth defects .......... 50 9.1 719.4 CNS abscess ........... Aseptic meningitis .... 45877.6 Paralysis agitans ...... 18112.2 ............................................ .. .... .. ...... .. Cerebral tumor ........ 12423.2
No.
Totals
-
..
34 6.4 --
..
......
1.3 1.4 0.2 1.5 3.8
.. ...... .......... .. ..........
17332.3
-- -
535
1.4
-- --
345 26393 38981 1372 2716 Totals: column no ... 8155 7.0 0.9 100.0 3.5 67.7 20.9 row per cent ..... , 1
electroencephalograms, electromyograms, and spinal and cranial contrast studies are generally diagnostic. By the same token, removal of a herniated disc, removal of a spinal or brain tumor, spinal fusion, peripheral nerve operation, or operation for cranial trauma is hopefully therapeutic. Yet, a stellate block or nerve block might be either. Five procedures were classified in the present study as either diagnostic or therapeutic. These particular data do not display procedures done for the relief of pain.
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TABLE
Frequency and Percentage Distributions of Diagnostic (Dx) and Therapeutic (Rx) Neurosurgical Procedures Performed for Various Diagnoses in North and South Carolina PAS Hospitals, 1971
550
CLINICAL NEUROSURGERY Downloaded from https://academic.oup.com/neurosurgery/article-abstract/22/CN_suppl_1/526/4099458 by guest on 25 October 2019
Nevertheless, it would appear that patients with the diseases studied were admitted to hospitals and in some instances no procedures were performed. Presumably hospital visits and supervision of care represented the physician's work load in these cases. Of the remaining 32.3 per cent of the cases the data were divided into those cases with only a diagnostic procedure or a therapeutic procedure done during the admission. A third grouping was made of those cases with both types of procedures done during the same admission. In a relatively small number of cases clear distinctions were not possible as to the intent of the procedure. A further grouping is evident in Table 34.21. One can envision the work load above the first interrupted line as shared with orthopedists. The next two sections can be viewed as shared with a variety of practitioners, including neurologists. All cerebral tumors hopefully would at some time be evaluated by a neurosurgeon and certainly we did not expect any operations requiring incisions to be done in significant numbers by physicians other than surgeons. The major diseases reported in descending order in the Carolinas study were cerebrovascular accidents, lumbar disc disease, cerebral trauma, headaches, spinal trauma with paralysis, epilepsy, and cervical disc disease. These accounted for 34,287 cases or 88.0 per cent of the total. This is generally equivalent to the national prevalences. The reported number of spinal cord injuries seems somewhat high; this is not understood at this time as related to the particular sample peculiarities, but perhaps it can be explained with further data analysis. The figure for subarachnoid hemorrhage should not be taken as representing aneurysms because the rubric includes meningeal hemorrhage as well as aneurysms. The primary hospitals in which Carolina neurosurgeons worked were identifiable from the interview study and could be matched to the patient care data obtained from CPHA. The exceptions have been mentioned. It was possible, therefore, to separate out the cases managed and/or procedures done in hospitals not serviced by neurosurgeons. Table 34.22 displays the dispersion of procedures of the several types by the type of hospital in which neurosurgeons worked. It is evident that a smaller percentage of the work was done in the less well equipped hospitals. No statement as to the quality of the work done can be made from these data. The frequency and proportion of the various types of procedures done in those hospitals without neurosurgeons are shown in Table 34.23. Cerebral tumors, spinal tumors, birth defects, peripheral nerve injuries, central nervous system (CNS) abscesses, and by narrow margins aseptic meningitis and the two types of disc disease were managed predominantly in hospitals staffed by neurosurgeons. But it is obvious that a great deal of work in these
551
NEUROSURGERY IN THE CAROLINAS
Type of Neurosurgical Procedure Performed TheraDiagnostic peutic Diagnostic Entity by Type Procedure Procedure of Primary Hospital"
No.
Row Per No. Cent
-- --
Cervical disc
0 3 4 5
Row Per No. Cent
Row Per Cent
-- -- --
No.
-
Row Per Cent
No Neurosurgical Procedure Performed
No.
Row Per Cent
Totals
Row No.
Column Per Cent
-- -- -- -- --
19 19.2 11 11.1 46 46.5 58 31.4 16 8.6 46 24.9 1 0.2 72 14.3 44 8.7 176 35.0 4 33.3 541.7 -
23 65 210 3
23.2 35.1 41.7 25.0
2 0.5 71 16.9 59 14.0 207 49.2 21421.2 12612.5 460 45.5 1 0.1 22015.7 15310.9 405 28.9 3 0.2 62 27.6 15 6.7 102 45.3 -
82 209 619 46
19.5 421 13.8 20.7 1010 33.1 44.2 1400 45.8 20.4 225 7.4 -- --3056 100
77 215 385 26
67.5 88.5 86.3 96.3
0 3 4 5
Lumbar disc
Dx and Rx Procedures
Procedure Considered Both Dx andRx
99 12.4 185 23.2 503 63.0 12 1.5 ----799 100
Spinal trauma without paralysis
0 3 4
17 14.9 14 12.3 6 5.3 16 6.6 8 3.3 4 1.6 20 4.5 31 7.0 10 2.2 1 3.7 -
5
-
114 13.7 243 29.3 446 53.7 27 3.3 --- ---
830 100 Spinal trauma with paralysis
0 3 4 5
6 9.5 411.8 1 2.3 -
-
11 17.5 5 7.9 514.7 2 5.9 19 44.2 3 7.0 125.0 -
-
* Guttman score of hospital neurosurgical facilities: 0 least equipped.
41 23 20 3
65.1 67.1 46.5 75.0
63 34 43 4 -144
43.8 23.6 29. 9 2. & 100
most equipped, 6
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TABLE 34.22 Frequency and Percentage Distributions of Diagnostic (Dx) and Therapeutic (Rx) Neurosurgical Procedures Performed for Various Diagnoses in North and South Carolina PAS Hospitals, 1971, According to Type of Primary Hospital
552
CLINICAL NEUROSURGERY 34.22-Continued
Type of Neurosurgical Procedure Performed TheraDiagnostic peutic Diagnostic Entity by Type Procedure Procedure of Primary Hospital"
No.
Row Per No. Cent
Dx and Rx Procedures
Row Per No. Cent
-- -- -- -
Spinal tumor
0 3 4 5
1 5.3 -
315.8 125.0 210.0
-
315.0 -
-
-
-
Row Per Cent
Procedure Considered Both Dx and Rx No.
Row Per Cent
No Neurosurgical Procedure Performed
Row Per Cent
No.
-- -- -- -- --
11 3 10 1
57.9 75.0 50.0 50.0
-
-
-
4 21.1 -
-
5 25.0
1 50.0
Totals
Row No.
Column Per Cent
-- --
19 4 20 2
42.2 8.9 44.4 4.4
-- ---
45 100 Peripheral nerve injury
0 3 4 5
6 3.9 3 3.7 4 3.6 325.0
2 1.3 9 5 9 57 37.3 33 40.2 68 61.8 541.7 -
79 46 38 4
51.6 56.1 34.5 33.3
153 42.8 82 23.0 110 30.8 12 3.4 -- ---
357 100 Epilepsy
0 3 4 5
21360.0 5 1.4 12 1 73 46.5 2 15642.7 12 48.0 -
3.4 6 1.7 0.6 1 0.6 0.5 -
-
-
119 82 207 13
33.5 52.2 56.7 52.0
355 39.4 157 17.4 365 40.5 25 2.8 -- ---
9021 100 Headaches
0 3 4 5
33559.9 4 0.7 39149.9 2 0.3 52259.9 6 0.7 34 50.0 -
4 5 5
1
0.7 5 0.9 0.6 146 18.6 0.6 3 0.3 1.5 -
211 240 355 33
37.7 30.6 38.5 48.5
559 24.5 784 34.4 871 38.2 68 3.0 -- ---
2282 100 CNS abscess
0 3 4
233.3 116.7 240.0 1 7.7 1 7.7
1 16.7 2 33.3 3 60.0 2 15.4 1 7.7 8 61.5
6 5 13
25.0 20.8 54.2
-----
24 100
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TABLE
553
NEUROSURGERY IN THE CAROLINAS 34.22-Continued
Type of Neurosurgical Procedure Performed TheraDiagnostic peutic Diagnostic Entity by Type Procedure Procedure of Primary Hospital*
No.
Row Per No. Cent
0 3 4 5
Cerebral tumor
0 3 4 5
Cerebral trauma
0 3 4 5
Row Per Cent
N tr:
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34.29
BC
0.5
14
1. 1
O.1
8.3
6
8
9
7 7
19 29 19
No.
9. 0
22.2
9.3 3.9 3.2
40.0
6.9 10.8 9.4 50.0 6.7 11. 4 13.8 3.0
Neurosurgery BE or N
No.
I I
General Surgery Other
O.5
1.9
0.4 2.0
66.71-
62.3 84 56.3 85 39.6 90 7.1 3 42.9 50 39.2 39 58.6 16 48.5 8 66.7 1 20.0 2 25.0 1 53.5 13 33.3 27 54.8 25 2 60.0 1 55.6 8 55.0 20.0, 90.0 11
50.1
3 100.0 2 100.0 -
172 151 80 1 45 31 34 16 2 1 3 23 17 34 3 5 11 1 9 2
35. 3
10.0
30.4 31. 7 44.6 21.4 47.6 49.4 27.6 24.2 33.3 40.0 ' 8.3 53.5 52.9 40.3 40.0 11.1 40.0
1. 6
60.0
11.1
2.3 2.0 1.6
6.1
2.2 0.4 1.0 14.3
14 1 4
1. 9
5.0 20.0
2.3 2.0
1.0
5.1 0.4 2.0
Row Row Row Per INo. Per No.1 Row Per No. Row Per INo. Per Cent Cent Cent Cent Cent
- - - - - - : - - - - 1 - - , - - , - - _..-
Neurosurgery BC
2
3
79 58 33 3 5 12 43 51 62 5 9 20 5 10 3
14 lOB
296 269 202
Row No.
[ 100
22.9 20.9 15.7 1.1 8.2 6.1 4.5 2.6 0.2 0.4 0.9 3.3 4.0 4.8 0.4 0.7 1.6 0.4 0.8 0.2 0.2 0.2
Col. Per Cent
Totals
-1--1~1-1-7I--I-;;I--I~I---I-;~I---i-;~I--I~;-'--
No.
-1
I
1--1-1--
33.3
5.9
58.3
3.0
0.5 7.1
Per Cent
Row Per Cent
Neurology BE or N
• Type 3 procedures = those usually performed by neurosurgeons and requiring general anesthesia. t Be = board certified, BE = board eligible, N = not board eligible.
6
2.3
1.0
0.4 0.4 1.0
No.
Row
Row Per Cent
BE or N
Row No.1 Per Cent
BC
I Orthopedics I Orthopedics I Neurology
Primary Care
Craniotomy Excision brain, meninges Incision, drainage Neurectomy Ventricular shunt Revision shunt Repair aneurysm Excision cord Cordotomy Rhizotomy Lysis adhesions cord & roots ' Biopsy brain Meningeal repair cord Meningeal repair cerebral Other Opt cord Excision skull lesion Ventriculostomy Arterial anastomosis Tncision brain Biopsy cord meninges Repair A-V fistula Operations thalamus Biopsy skull Other pituitary op.
Brief Description
Totals: column no. row per cent
001.0 001.6 001.3 004.3 002.3 002.4 034.3 003.3 003.2 003.1 003.5 001. 8 003.4 002.1 003.9 001.5 002.2 034.6 001.4 003.8 034.4 001.7 001.9 007.6
H-.JCDA Code
Type 3 Procedures*
Primary Specialty]
Disiriindion of N eurosurqical Activtty in N ortli and South Carolina P AS Hospitals amonq Type 3 JVeurosurqical Proccdurcs, 1971
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~ ~
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~ ~
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Z
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o
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NEUROSURGERY IN THE CAROLINAS
563 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/22/CN_suppl_1/526/4099458 by guest on 25 October 2019
always pass on to the neurosurgeon all of what the neurosurgeon has probably been more extensively trained than others to do. This indicates the competition that exists among specialties for the same diseases. It is obvious that efforts to restructure the system become philosophical exercises even if one is wholly convinced that the system is inefficient and deserves to be changed. The issues are complex indeed. Obviously one aspect of the manpower question is the efficient use of resources, both people and facilities. It seems evident that in the present pluralistic mode of medical care delivery the present arrangements produce encroachments upon the neurosurgeon's domain of work and push the neurosurgeon into non-neurosurgical work of significant proportions. If one accepts the concept of further development of primary care physicians such as family practitioners, pediatricians, and internists, it follows that perhaps the guidelines under which these practitioners operate the screening process which passes on the patient to second and third levels need serious reexamination. This suggests the need for stronger neurosurgical input into the medical teaching which develops these types of physicians. It also suggests a need to examine more of the efficiency of the system in so far as both physicians and patients are concerned. As a corollary one should also attempt some estimates of the quality of care rendered. Both are important. In planning it is said that the key to success is flexibility and the ability to react to change and contingency. Certain trends can be looked at now but these will need subsequent monitoring. The distribution problems are obvious. An effort must be made to fit the present numbers of neurosurgeons to the tasks available under the present system. That there are more tasks available and in the hands of others is obvious. This will always be true in a loose nonsystem in a relatively free society. Obviously, the problem relates directly to the whole issue of physician manpower requirements which are expected to vary with a differing mode of prepayment and with increasing regulation. It is far from clear what these requirements might be, as indicated by discrepancies between estimates currently made. Dr. Charles Edwards of the Department of Health, Education, and Welfare has suggested that we are threatened with overproduction of physicians and this has been countered by the release of a different report suggesting a serious shortage of physicians and a decline in number of those involved in primary care and office based practice (8, 9). Both cannot be correct. It is suggested that neurosurgeons need to look at their relationship with primary care physicians and with other specialists. It seems evident that the present system will have difficulty in absorbing neurosurgeons at the present rate of production unless changes within the system can shift the work load back and forth among the various specialties. If the system changes there is a new set of considerations.
564
CLINICAL NEUROSURGERY
REFERENCES 1. Ament, R. P., Gustafson, P. G., Holtz, C. L., Jr., and Teich, K. W. Cholecystectomy mortality. PAS Reporter, 8: No. 8:1-6, April 20, 1970. 2. American Medical Association, Center for Health Services Research and Development. Reference Data on Profile of Medical Practice, 166 pp. AMA, Chicago, 1973. 3. Arnold, D. J. 28,621 cholecystectomies in Ohio. Results of a survey in Ohio hospitals by the Gallbladder Survey Committee, Ohio Chapter, American College of Surgeons. Am. J. Surg., 119: 714-717, 1970. 4. Child, C. G. An assessment of the quality of surgical services in the United States. Surgery, 70: 53.5-537, 1971. 5. Clark, W. K. Report of the Neurosurgery Manpower Commission. Presented at the 42nd Annual Meeting of the American Association of Neurological Surgeons, St. Louis, Mo., April 1974. 6. Congress of Neurological Surgeons, Directory Committee. Directory of Neurological Surgeons in the United States of America, 1971. 7. Drake, H. Changing educational needs for graduate training of the general surgeon. Am. J. Surg., 119: 363-364, 1970. 8. Edwards, C. C. A candid look at health manpower problems. J. Med. Educ., 49: 19-26, 1974. 9. HEW study sees a shift from office practice. Hospital Tribune, 8: 15, 24, August 19, 1974. 10. Hughes, E. F. X., Fuchs, V. R., Jacoby, J. E., and Lewit, E. M. Surgical work loads in a communi ty practice. Surgery, 71: 315-327,1972. 11. Lee, J. A., Morrison, S. L., and Morris, J. N. Fatality from three common surgical conditions in teaching and non-teaching hospitals. Lancet, 2: 785-791, 1957. 12. Lee, J. A., Morrison, S. L., and Morris, J. N. Case-fatality in teaching and nonteaching hospitals. Lancet, 1: 170-171, 1960. 13. Mason, H. R. Manpower needs by specialty. J. A. M. A., 219: 1621-1626, 1972.
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If our present pluralistic system obtains and if those giving primary care can be trained to do a better job of screening and to give up the patient at an appropriate time to make efficient use of the neurosurgeon we do not appear to need more neurosurgeons. If the delivery system changes or if neurosurgeons succeed in some "ray in wrestling away from their competitors some of the work they are prepared to do, we may need more. N eurosurgeons seem to want different things in and from their practices. Socio-political considerations may subsequently narrow these choices. N eurosurgeons currently need to define their roles, to take affirmative action in various ways to design a good system for the delivery of neurosurgical care to the citizenry of this country, and to develop the appropriate numbers of neurosurgeons to do the task. It would appear risky to continue the present proliferation of neurosurgeons without further consideration of how the system might be changed, either now or in the future, to provide the highest level of care for all those afflicted with those disease processes in which neurosurgeons should be interested.
NEUROSURGERY IN THE CAROLINAS
565 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/22/CN_suppl_1/526/4099458 by guest on 25 October 2019
14. McPhedran, N. T., and Ekstrand, C. Study of surgical practice in Alberta for 1970. Can. J. Surg., 16: 77-83, 1973. 15. Moore, F. D., Boyden, C. M., Sabiston, D., Warren, R., Peterson, 0., Zeppa, R., Herr, D., and Murthy, N. The production, attrition, and biologic life-time of surgeons in relation to the population of the United States: a look into the future through the clouded computer crystal. Ann. Surg., 176: 457-468,1972. 16. Program of the Seventeenth Annual Meeting of The Allen O. Whipple Surgical Society. Surgery, 70: 486-554, 1971. 17. United States Department of Commerce, Bureau of the Census. Statistical Abstract of the United States: 1971, Ed. 92,1008 pp. U. S. Government Printing Office, Washington, D. C., 1971. 18. United States Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics. Eighth Revision International Classification of Diseases, Adapted for Use in the United States, Vol. 1, Tabular List, 671 pp. Public Health Service Publication No. 1693. U. S. Government Printing Office, Washington, D. C., 1972. 19. United States Office of Management and Budget. Standard Metropolitan Statistical Areas, 1971. U. S. Government Printing Office, Washington, D. C., 1971.