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OBJECTIVE Absent from an analysis of supply is consideration of the geographic distribution of pediatric neurosurgeons. Several patient socioeconomic metrics are known to be associated with outcome in pediatric neurosurgical diseases, such as hydrocephalus. The purpose of this study was to determine current geographic proximity to pediatric neurosurgical care using professional society databases. This study also sought to establish how socioeconomic factors are related to distance to care, using federal government-collected data. METHODS A list of currently practicing American Board of Pediatric Neurological Surgery (ABPNS)-certified neurosurgeons was compiled (ABPNS group). A separate list of practicing members of the Joint Pediatric Section (JPS) of the American Association of Neurological Surgeons/Congress of Neurological Surgeons was prepared (JPS group). Current primary practice locations were collected from each professional society database for each ABPNS or JPS neurosurgeon and were charted using ArcGIS mapping software (ESRI, version 10.3) on a United States Census Bureau map. The straight distance from the centroid of each zip code tabulation area (ZCTA) to the nearest neurosurgeon was determined by group type of neurosurgeon (ABPNS vs ABPNS + JPS). ZCTA-level data on demographic and socioeconomic factors were acquired from the American Community Survey, including data in children and young adults (0-18 or 0-24 years old) and the general population. These data were compared by distance to care and by groups of neurosurgeons (Pearson's chi-square analysis; the threshold of significance was set at 0.05). RESULTS Three hundred fifty-five practicing neurosurgeons providing pediatric care were located, of whom 215 surgeons were certified by the ABPNS and 140 were JPS members only. The analysis showed that 1 pediatric neurosurgeon is in practice for every 289,799 persons up to the age of 24 years. The average distance between a ZCTA and the nearest pediatric neurosurgeon is 63.3 miles (SE 0.3, range 0.0-499.7 miles). Geographic analysis showed that 27.1% of children live farther than 60 miles from an ABPNS-certified neurosurgeon and 19.7% from either an ABPNS-certified neurosurgeon or a JPS member. ZCTAs with children who live farther than 60 miles from a neurosurgeon providing pediatric care had a marginally higher rate of uninsured children, a higher percentage of families with children living below the federal poverty level, and a higher proportion of persons living in rural areas compared with ZCTAs with children who live within 60 miles of care (p < 0.005 for each finding). CONCLUSIONS The results of this study indicate that there is considerable variation in proximity to pediatric neurosurgical subspecialty care by geographic region. In addition, there is a relationship between distance to neurosurgical care and socioeconomic indicators. Optimization of access to pediatric neurosurgical care may involve strategies to overcome long geographic distances, particularly in rural and underserved areas. Such areas may have disproportionately lower socioeconomic levels, which may further limit access to care and affect outcomes. Both the total number of pediatric neurosurgeons per pediatric population and their geographic distribution could be important in determining appropriate subspecialty supply factors (e.g., the number of accredited pediatric neurosurgical fellowship training programs), as well as being important drivers of neurosurgical patient outcomes.

Introduction: Economic disadvantage may adversely influence the outcomes of infants with gastroschisis (GS). Gastroschisis International (GiT) is a network of seven paediatric surgical centres, spanning two continents, evaluating GS treatment and outcomes., Material and Methods: A 2-year retrospective review of GS infants at GiT centres. Primary outcome was mortality. Sites were classified into high, middle and low income country (HIC, MIC, and LIC). MIC and LIC were sometimes combined for analysis (LMIC). Disability adjusted life years (DALYs) were calculated and centres with the highest mortality underwent a needs assessment., Results: Mortality was higher in the LICs and LMICs: 100% in Uganda and Cote d'Ivoire, 75% in Nigeria and 60% in Malawi. 29% and 0% mortality was reported in South Africa and the UK, respectively. Septicaemia was the commonest cause of death. Averted and non-avertable DALYs were nil in Uganda and Cote d'Ivoire (no survivors). In the UK (100% survival) averted DALYs (met need) was highest, representing death and disability prevented by surgical intervention. Performance improvement measures were agreed: a prospectively maintained GS register; clarification of the key team members of a GS team and management pathway., Conclusions: We propose the use of GS as a bellwether condition for assessing institutional capacity to deliver newborn surgical care. Early access to care, efficient multidisciplinary team working, appropriate resuscitation, avoidance of abdominal compartment syndrome, stabilization prior to formal closure and proactive nutritional interventions may reduce GS-associated burden of disease in low resource settings., (Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.)

Background: There are gaps in understanding the challenges with the establishment of pediatric cardiac surgical practices in Nigeria. The aim of this study was to examine the prospects and challenges limiting the establishment of pediatric cardiac surgical practices in Nigeria from the perspectives of cardiothoracic surgeons and resident doctors., Methods: A descriptive study was carried out to articulate the views of the cardiothoracic surgeons and cardiothoracic resident doctors in Nigeria. A self-administered questionnaire was used to generate information from the participants between December 2014 and January 2015. Data were analyzed using the SPSS version 21 statistical software package., Result: Thirty-one of the 51 eligible participants (60.7%) took part in the survey. Twenty-one (67.7%) were specialists/consultants, and 10 (32.3%) were resident doctors in cardiothoracic surgical units. Most of the respondents, 26 (83.9%) acknowledged the enormity of pediatric patients with cardiac problems in Nigeria; however, nearly all such children were referred outside Nigeria for treatment. The dearth of pediatric cardiac surgical centers in Nigeria was attributed to weak health system, absence of skilled manpower, funds, and equipment. Although there was a general consensus on the need for the establishment of open pediatric cardiac surgical centers in the country, their set up mechanisms were not explicit., Conclusions: The obvious necessity and huge potentials for the establishment of pediatric cardiac centers in Nigeria cannot be overemphasized. Nevertheless, weakness of the national health system, including human resources remains a daunting challenge. Therefore, local and international partnerships and collaborations with country leadership are strongly advocated to pioneer this noble service., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Retinal detachment (RD) is a potentially blinding condition. Delay in management is a major prognostic factor. In our study, we analyzed the treatment delay for retinal detachments in the Midi-Pyrenees area, and factors which may influence it., Material and Methods: Observational, cross-sectional, multicentric study, carried out over a 6-month period., Primary Outcome: time between diagnosis and surgery. Secondary outcome: time between first symptoms and surgery. Non-parametric tests were used to analyze the influence of sociodemographic features, clinical features, distance between home and surgical center, and occurrence over a weekend., Results: One hundred and fiftty-nine patients were included. The mean time between diagnosis and surgery was 4.4 ± 12.3 days (2.7 ± 4.3 for recent RD, less than 1 month), and was increased by the presence of a weekend (P<0.001), or of a weekend with public holiday (P=0.023), and by macular detachment (P=0.008). The mean time between first symptoms and surgery was 12.0 days and was increased by the absence of RD history (P=0.023), and by macular detachment (P=0.046). No association was observed between these times to surgery and the distance between the patient's home address and the place of surgery., Conclusion: The time between diagnosis and surgery was relatively short in the Midi-Pyrénées area, but we often noted a delayed diagnosis, which may be due to the patient's lack of awareness of the symptoms and difficult access to specialty consultations. However, no relationship was found between this time-to-surgery and the distance between the patient's home and the surgical center., (Copyright © 2015. Published by Elsevier Masson SAS.)

Hypertrophic cardiomyopathy (HCM), a heterogeneous genetic heart disease with global distribution, is an important cause of heart failure disability at any age. For 50 years, surgical septal myectomy has been the preferred and primary treatment strategy for most HCM patients with progressive, drug refractory functional limitation due to left ventricular (LV) outflow tract obstruction. With very low surgical mortality at experienced centres, septal myectomy reliably abolishes impedance to LV outflow and heart failure-related symptoms, restores quality of life, and importantly is associated with long-term survival similar to that in the general population. Nevertheless, alternatives to surgical management are necessary for selected HCM patients. For example, after a brief flirtation with dual-chamber pacing 20 years ago, percutaneous alcohol septal ablation has garnered a large measure of enthusiasm and a dedicated following in the interventional cardiology community, achieving benefits for patients, paradoxically, by virtue of producing a transmural myocardial infarct. However, an unintended consequence has been the virtual obliteration of the surgical option for HCM patients in Europe, where several robust myectomy programmes once existed. Therefore, clear differences are now evident internationally regarding management strategies for symptomatic obstructive HCM. The surgical option is now unavailable to many patients based solely on geography, including some who would likely benefit more substantially from surgical myectomy than from catheter-based alcohol ablation. It is our aspiration that this discussion will generate reconsideration and resurgence of interest in surgical septal myectomy as a treatment option for severely symptomatic obstructive HCM patients within Europe.

Using metropolitan statistical area (MSA) panel data from 1992-2001 constructed from the 2002 Medicare Online Survey Certification and Reporting (OSCAR) System, we estimate the market effects of health maintenance organization (HMO) penetration and hospital competition on the growth of freestanding ambulatory surgery centers (ASCs). Our regression models with MSA and year fixed effects suggest that a 10-percentage-point increase in HMO penetration is associated with a decrease of 3 ASCs per 1 million population. A decrease from 5 to 4 equal-market-shared hospitals in a market is associated with an increase of 2.5 ASCs per 1 million population.

For plastic surgeons, independent development of outpatient surgical centers and specialty facilities is becoming increasingly common. These facilities serve as important avenues not only for increasing access and efficiency but in maintaining a sustainable, competitive specialty advantage. Certificate of Need regulation represents a major hurdle to plastic surgeons who attempt to create autonomy in this fashion. At the state level, Certificate of Need programs were initially established in an effort to reduce health care costs by preventing unnecessary capital outlays for facility expansion (i.e., managing supply of health care resources) in addition to assisting with patient safety and access to care. The purpose of this study was to examine the effect of Certificate of Need regulations on health care costs, patient safety, and access to care and to discuss specific implications of these regulations for plastic surgeons. Within Certificate of Need states, these regulations have done little, if anything, to control health care costs or affect patient safety. Presently, Certificate of Need effects coupled with recent provisions in the Medicare Modernization Act banning development of specialty hospitals may restrict patient access to ambulatory surgical and specialty care. For the plastic surgeon, these effects not only act as an economic barrier to entry but can threaten the efficiencies gained from providing surgical care in an ambulatory setting. An appreciation of these effects is critical to maintaining specialty autonomy and access to fiscal policy.

Using data from Round Four of the Community Tracking Study site visits, this paper describes the recent rapid increase in physician-owned specialty hospitals and ambulatory surgery centers, reasons for this increase, possible impacts, and potential policy options. These facilities could lead to excess capacity, provision of unnecessary services, and lower quality because of decreased volume at some facilities. They also could reduce community hospitals' net revenue and thus their ability to subsidize socially necessary but unprofitable services. But regulatory intervention should be cautious, because data on impact are inconclusive, and these facilities could have the potential to function as "focused factories" that improve quality and reduce costs.

Traditionally one of hospitals' most lucrative service lines, orthopedics is under pressure these days, as federal reimbursement policies make certain procedures less profitable and hospitals face new challenges from physicians. It remains a strong market to court, but hospitals are increasingly seeking to protect, rather than expand, their business.

Physicians are angry, that that's bad news for hospitals. Increasingly, doctors are unable to pay soaring liability insurance premiuyms, are refusing to accept new Medicaid and Medicare patients, and are balking at taking ED calls. What's more, many physicians are setting up niche facilities that compete directly with hospitals in the most lucrative service lines.

Although the concept of outpatient care is not a new one, the growth in ambulatory facilities has revolutionized medical care in the United States. The growth in ambulatory surgery centers, imaging centers, and cancer centers in Florida is explored in detail. With the many changes forthcoming in health care, ambulatory care will play an increasing role in delivering good health care at a reasonable cost.

Ambulatory surgery can be a win-win proposition for patients, physicians, payers, and even for hospitals. The main elements at risk are high costs and the traditional models of hospital-based surgical care. If hospitals delay their responses to the challenges of the free-standing surgicenter, the latter will become as common as the multispecialty group practice. Health care institutions need to address some questions in responding to this trend: how hospitals should act to transform their bureaucratic, inefficient systems; who should assume the leadership role; and how much autonomy and pluralism will be appropriate.