Conclusions: The correct preoperative diagnosis of appendicitisappears statistically more accurate with CT scan compared to his-tory and physical examination alone (PPV 96.4% vs 90.8%, p�0.045).For those with a clinical suspicion of perforated appendicitis, CTevaluation may help direct therapy towards an initial non-operativemanagement. The efficacy of initial non-operative management ofperforated appendicitis warrants further investigation.

QS253. THE BUSINESS PRACTICES IN AN ACADEMIC DE-PARTMENT OF SURGERY: CAN WE SURVIVE? C.Daniel Smith; Mayo Medical School, Jacksonvile, FL

Background: Reimbursement for general surgery has been steadilyfalling over the past decade. At the same time the business of billingand collecting for the care a general surgeon provides has becomevery complex, especially in an academic practice where many of thenewest procedures are offered in advance of the existence of standardbilling codes and reimbursement amounts. To maintain profit mar-gins, academic surgeons must simultaneously increase the volumeand decrease operating expenses, all in the face of the requirement ofestablishing efficient business practices. Academic general surgerypractices are not well suited to make these changes. The aim of thework is to evaluate the business practices of an academic generalsurgeon’s practice through assessing billing and coding. Methods: Adetailed prospective analysis of the coding, billing and paymentresults for a single surgeon’s practice was undertaken. All of thecases of an established general surgeon (over 10 years in practice andaverage �450 cases/year over past 5 year; � $2 million in billing/year) were identified and the precertification data, operative reports,IDX billing summary, and pricing for each case analyzed. The insti-tution’s contracted pricing schedule and the 2006 CPT Code Bookdata were used. Each case was specifically analyzed for missed bills,incorrect codes, missed procedures, rejections, or payment variancefrom contracted or Medicare pricing. The total $ variance from ex-pected was calculated. Data was analyzed by month and total for3-month period. Results: During the three months analyzed, 104operative procedures were performed. Correct bills were submittedfor 62 procedures (60%). Reasons for incorrect billing are detailed intable below. Conclusion: Current business practices are not captur-ing all possible revenue of a busy general surgeon in an academicpractice. Missing procedures, cases not billed and use of wrong codesare easily correctable problems accounting for over 20% of incorrectbills. Practices where surgeons are offering the newest proceduresare particularly vulnerable to these problems.

QS254. THE USE OF LOCUM TENENS SURGEONS AT RU-RAL HOSPITALS. Randall S. Zuckerman, David Borg-strom, Mark Andres, Brit Doty, Albert Blankley; MIBH,Cooperstown, NY

Purpose: There is a shortage of general surgeons practicing inrural America. Our preliminary work indicates that approxi-mately half of hospitals in the smallest rural areas do not have afull-time surgeon. Therefore, it appears likely that some of theserural hospitals are using alternative arrangements to fulfill theirsurgical needs including hiring locum tenens surgeons. Given theimportance of providing surgical care for their rural residents, wehypothesize that a substantial number of rural hospitals are usinglocum tenens surgeons to provide surgical care. No research hasbeen done to date examining this question. We presume that ruralhospitals that use locum tenens services do so for one of thefollowing reasons: 1) They are unable to recruit and retain apermanent surgeon, 2) They need coverage for their surgeon’svacation, CME time, or on-call coverage or 3) They are unable tooffer full-time comprehensive surgical care but have a need for apart-time surgeon on an ongoing basis. We propose to ascertainwhether and describe the degree to which rural hospitals areusing locum tenens surgeons to provide surgical services. Meth-ods: Administrators at 100 randomly selected rural hospitals weresurveyed by telephone. The survey instrument is comprised of ques-tions addressing different topic areas including whether the hospitalprovides surgical services, if the hospital is recruiting a surgeon,whether the hospital uses locum tenens surgeons and if so for whatpurposes. A list of rural hospitals was obtained from the AmericanHospital Association. Rural designation was determined using rural-urban commuting area (RUCA) codes. These codes classify US cen-sus tracts using measures of population density, urbanization anddaily commuting patterns. For the purposes of this project, thehospitals randomly selected to complete the survey were located insmall and isolated small rural communities (RUCA codes 7 - 10).Results: Preliminary results as of August 2007 show that 74% ofresponding hospitals have critical access designation and 79% ofthese hospitals offer surgical services. Of those hospitals providingsurgical care, 52% have recruited a surgeon in the past five years and22% have used locum tenens surgeons. Significance: By determin-ing whether rural hospitals are using locum tenens surgeons, we willbetter understand how surgical care is delivered in rural areas.Given the shortage of surgeons in rural America, it is critical todevelop strategies to address this problem. Some hospitals are usinglocum surgeons to provide surgical care. While this strategy mayallow rural hospitals to offer surgical services, the quality of surgicalcare may be compromised partly due to fragmentation of care. Othermeans for delivering surgical services at rural hospitals that cannotrecruit or retain a surgeon should be explored in order to ensure thatrural residents have access to high quality surgical care.

QS255. BARRIERS TO COMPLIANCE WITH SURGICALSITE INFECTION PREVENTION GUIDELINES. Lil-lian S. Kao1, Matthew M. Carrick2, Debbie F. Lew1, DerekW. Meeks1, Eric J. Thomas1, Kevin P. Lally1; 1University ofTexas Health Science Center, Houston, TX; 2Baylor Collegeof Medicine, Houston, TX

Background: Compliance with evidence-based guidelines to pre-vent surgical site infections (SSIs) is suboptimal. Simple measures toimprove compliance such as passive dissemination of guidelines areoften unsuccessful. Multi-faceted, complex intervention packages areusually necessary to change delivery systems and provider behav-iors. The purpose of this study is to determine the barriers to com-pliance with guidelines so as to develop a targeted interventionprogram. Methods: Structured interviews were performed by twotrained research coordinators at two county hospitals in the samedistrict. Responses to open-ended questions about SSI preventionwere audiotaped and transcribed. Two reviewers independently an-alyzed each transcript using iterative data analysis to identify re-current themes. Discrepancies were resolved by a third reviewer.Results: Forty-nine interviews of operating room team memberswere conducted. A broad range of issues contribute to non-

368 ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS