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PubMed2004

Do HMO penetration and hospital competition impact quality of hospital care?

This study examines the impact of HMO penetration and competition on hospital markets. A modified structure-conduct-performance paradigm was applied to the health care industry in order to investigate the impact of HMO penetration and competition on risk-adjusted hospital mortality rates (i.e. quality of hospital care). Secondary data for 1957 acute care hospitals in the USA from the 1991 American Hospital Association's Annual Survey of Hospitals were used. The outcome variables were risk-adjusted mortality rates in 1991. Predictor variables were market characteristics (i.e. managed care penetration and hospital competition). Control variables were environmental, patient, and institutional characteristics. Associations between predictor and outcome variables were investigated using statistical regression techniques. Hospital competition had a negative relationship with risk-adjusted mortality rates (a negative indicator of quality of care). HMO penetration, hospital competition, and an interaction effect of HMO penetration and competition were not found to have significant effects on risk-adjusted mortality rates. These findings suggest that when faced with intense competition, hospitals may respond in ways associated with reducing their mortality rates.

Economic Competition↗

PubMed2000

The cost-effectiveness of teleneurology consultations for patients admitted to hospitals without neurologists on site. 1: A retrospective comparison of the case-mix and management at two rural hospitals.

We are currently evaluating the use of telemedicine for improving the care of patients admitted with neurological symptoms to hospitals that do not have specialist neurologists on site. To do this we have been comparing the outcome of patients admitted to two small hospitals. In one hospital all patients with neurological symptoms are seen by a neurologist at a distance using an interactive video-link transmitting at 384 kbit/s; in the other patients with neurological problems are managed as per usual practices. For the results of this study to be valid, it is essential that the case-mix and process of management for neurological patients are similar at the two hospitals. We therefore compared the case-mix, process of management, and outcome for all patients admitted over a four-month period to either hospital who had been coded using ICD-10 as having a final diagnosis of a neurological condition. No appreciable differences were noted between the two hospitals for measures of case-mix or outcome. Likewise, most measures of process were similar, although there was a significant difference for the overall length of hospital episode between the two hospitals. When patients with prolonged hospital episodes were excluded, or only patients with a diagnosis of headache, epilepsy or transient ischaemic attack were considered (who as a group made up the bulk of neurological admissions), the difference in the length of hospital episode was not significant. It should therefore be possible for us to estimate the effect of telemedicine on the management of patients with neurological problems.

Cohort Studies↗

PubMed1982

Medicare program; Medicare hospital reimbursement reforms: limitations on reimbursable costs and the rate of hospital cost increases--HCFA. Interim final rule with comment period.

These rules implement section 1886 of the Social Security Act (established by section 101 of the Tax Equity and Fiscal Responsibility Act of 1982). These rules amend current regulations on hospital cost limits, providing for new exemptions and exceptions. These amendments make exceptions available to hospitals consistent with the new cost limits published elsewhere in this issue of the Federal Register, and specifically exempt from those cost limits rural hospitals with less than 50 beds in existence as of the enactment of the law. These rules also set forth new regulations establishing a three-year ceiling on the allowable annual rate of increase in operating costs per case for inpatient hospital services. This ceiling takes the form of a target amount of cost per case against which a hospital's incurred cost per case will be compared. Hospitals are provided incentives to keep their cost increases below the target rate. A hospital that has costs per case less than the target amount will be paid a portion of the difference between actual cost and the target amount. A hospital that has costs per case that are greater than the target amount will be paid the target amount plus 25 percent of its costs in excess of the target for the first two years of the ceiling, and none of the excess in the third year. However, payment to a hospital under these new target rate regulations will not be greater than the amount determined under the new schedule of limits on hospital inpatient operating costs published elsewhere in this issue of the Federal Register.

Costs and Cost Analysis↗

PubMed1999

[Is it necessary to hospitalize so many children for so many days? Unnecessary pediatric hospitalization].

OBJECTIVE: A tendency exists towards an increase in hospital admissions of children whereas evidence shows that some of the admissions could have been avoided or the length of stays reduced. The aim of this study was to identify the proportion of unnecessary pediatric stays and the motive behind them. PATIENTS AND METHODS: Three hundred eighty-eight hospital stays of 151 children between 6 months and 14 years of age which were discharged by the local pediatric hospital service have been reviewed. Patients and stays were selected at random. Admissions were stratified by age group and stays by episode length. The Pediatric Appropriateness Evaluation Protocol (PAEP) was used to evaluate the necessity of the hospital stay. RESULTS: Of the admissions, 27.8% (42/151) were evaluated as unnecessary, as were 48.7% (189/388) of the hospital stays. Long stays (except for hospitalizations longer than 9 days), programmed admissions (93.5%), first admissions to a hospital (59.9%) and admissions evaluated as unnecessary (80.6%) were significantly associated with unnecessary stays. Hospital organization and doctors' style of practice accounted for 74.1% of the unnecessary stays and children familiar circumstances for 21.7%. CONCLUSIONS: The high proportion of unnecessary stays and the motives, which explained them, justify the great concern about the criteria for the hospitalization of children and early discharge planning. To improve coordination among hospitals, central services, primary health care services and social services is probably required.

Adolescent↗

PubMed2000

Area income as a predictor of preventable hospitalizations in the Harris County Hospital District, Houston.

This study assesses whether geographical area income based on census data is a good predictor of preventable (or ambulatory care-sensitive) hospitalizations in a large public hospital system in Texas, and how area income correlates with the socioeconomic status reported by patients. Documenting a correspondence between area and individual-level income, as well as meaningful variation in rates of avoidable hospitalizations across subgroups and areas with varying concentrations of low-income persons, points to the validity and utility of this approach for monitoring how well public hospital systems in Texas address the needs of those they most directly serve. Area income may not fully reflect the disproportionately lower socioeconomic status of patients seen in the public hospital system. Nonetheless, living in lower-income zip codes was associated with higher preventable hospitalization rates for the predominantly low-income population served by the public hospital system. A tenfold difference found in the adjusted rates of hospitalizations for preventable conditions compared with control (or marker) conditions among persons living in low-income areas signals the likelihood of substantial unmet needs in this population. Small-area analysis and related comparisons of rates of preventable hospitalizations in high- and low-income areas provide useful indicators for monitoring and assessing the performance of public hospital systems in Texas.

Ambulatory Care↗

PubMed2003

Involuntary hospitalizations of patients with mental disorders in Vrapce Psychiatric Hospital: five years of implementation of the first Croatian law on protection of persons with mental disorders.

AIM: To analyze data on the practice of involuntary hospitalizations of patients with mental disorders in Vrapce Psychiatric Hospital from January 1, 1998, when the Law on Protection of Persons with Mental Disorders came into power, to December 31, 2002; with particular reference to the changes and supplements to the Law on December 1999. METHOD: The data on patient's sex, age, and diagnosis were collected from the medical records. Patients were diagnosed according to ICD-10 criteria. When a patient had two or more diagnoses, he or she was placed in category of the primary diagnosis. Results were statistically analyzed by descriptive statistics and chi-square test. Statistical significance was set to p<0.01. RESULTS: The rate of involuntarily hospitalized patients increased by significantly from 1998 to 1999 (from 30.8% to 39.6%; p<0.01, chi square test). This rate decreased to 5.6% in 2000 (p<0.01), and continued to decrease in 2002 (3.5%). There was no difference between involuntarily hospitalized patients regarding sex in 1998 (p=0.302) and 1999 (p=0.136). Men were significantly more often involuntarily hospitalized than women in 2000, 2001, and 2002 (p<0.01). Schizophrenia and other psychotic disorders were the most common diagnoses among involuntarily hospitalized patients in each of the observed years. CONCLUSION: Changes and supplements to the Law on Protection of Persons with Mental Disorders from December 1999, which abolished the necessity for a written consent for hospitalization and the necessity for prescribed procedure of hospitalized persons who were mentally incompetent to consent for hospitalization, led to significant decrease in the number of involuntary hospitalizations.

Chi-Square Distribution↗

PubMed2005

Intussusception in Taiwanese children: analysis of incidence, length of hospitalization and hospital costs in different age groups.

BACKGROUND AND PURPOSE: This study investigated the characteristics of intussusception in Taiwanese children of different age groups, including the incidence, length of hospitalization and hospital costs. METHODS: Children with a diagnosis of intussusception who were hospitalized from 1999 through 2001 were identified from a nationwide health insurance claims database. The incidence of intussusception was calculated by age, gender, and season. Length of hospitalization and hospital costs were also analyzed. RESULTS: A total of 6988 cases of intussusception were identified in Taiwan from 1999 to 2001. Among them, 4859 cases occurred in children below 15 years of age. The average incidence among children below age 15 years was 34.5 per 100,000, with a peak incidence of 118.8 per 100,000 observed among children younger than 24 months old. The highest incidence of intussusception in Taiwanese children occurred between 12 and 24 months of age. According to the data for patients below 15 years of age hospitalized for intussusception in year 2000, males were more likely to be affected than females (61.3% vs 38.7%). Intussusception-related hospitalizations were rare in infants in the first few months of life, increased in those 6 to 12 months old, and peaked among children 1 to 3 years old. Among the 952 patients with intussusception admitted to hospitals in 2000, 297 (31.2%) received surgery, incurring higher median medical costs (New Taiwan Dollars [NT dollars] 42,265 or US dollars 1234) and longer median hospital stay (6.2 days) than the 655 patients who did not require surgery (NT dollars 6290 or US dollars 185 for hospitalization of 2.4 days). CONCLUSIONS: The study found that the incidence of intussusception peaked in the second year of life in Taiwanese children. There was also a male predominance and lack of seasonal variation in incidence.

Adolescent↗

PubMed2005

[The relationship between in-hospital breastfeeding rates and hospital type].

The objective of this study was to examine the impact of hospital environment on breastfeeding rates during maternal hospitalization. This study applied a descriptive correlational design. The study population consisted of mothers who had given birth to infants in the Taiwan area between June and October 2003. A proportional probability sampling method was used. Samples were drawn based on the mother's residence in one of six regions: eastern, central, southern, and northern Taiwan, Taipei City, or Kaohsiung City. The rates of exclusive and mixed breastfeeding during hospitalization were found to be 17.9% and 47%, respectively. Bi-variable analysis showed that higher-level hospitals, certified baby-friendly hospitals, teaching hospitals, hospitals with higher annual birth numbers, and public hospitals all had higher rates of breastfeeding. Logistic regression results demonstrated the positive influence of institutional factors associated with breastfeeding (any and exclusive breatfeeding) when social demographic and perinatal variables were controlled in the model. Baby-friendly and higher-level hospitals had the highest breastfeeding rates. Women who delivered at baby-friendly and teaching hospitals had higher exclusive breastfeeding rates. The results of this research can serve as a reference to the government and medical institutions in relation to efforts to promote breastfeeding.

Adult↗

PubMed2006

Hospital choice by rural medicare beneficiaries: does hospital ownership matter?--a Colorado case.

About 45 percent of rural patients in Colorado bypassed their local rural hospitals during the 1990s. The effect of this phenomenon is a reduction in occupancy rates and a decrease in the competitiveness of rural hospitals, thereby ultimately causing rural hospitals to close and adversely affecting the communities that they were designed to serve. This study tests whether hospital ownership affects hospital choice by patients after controlling for institutional and individual dimensions. A conditional logistic regression is used to analyze Colorado Inpatient Discharge Data (CIDD) on 85,529 patients in addition to hospital data. Rural Medicare beneficiaries are influenced to choose a particular hospital by a combination of hospital characteristics (the number of beds, the number of services, accreditation, ownership type, and distance from patient residence) and patient characteristics (medical condition, age, gender, race, and total charge for services). Increasing rural hospitals' survivability, collaborating with other rural hospitals, expanding the number of available services, making strategic alliance with other providers are possible strategies that may help ward off encroachment by urban competitors.

Choice Behavior↗

PubMed1991

[Reduction in length of stay in Federal German acute hospitals between 1980 and 1989 in connection with hospital size].

This investigation was conducted on the basis of data collected by the German opinion poll company Infratest (whose health research division created a DTI = diagnosis and therapy index) to find out whether the reduced length of stay of patients in Federal german hospitals for acute disease that took place during the past decade, showed any kind of distribution pattern in respect of hospital size. First of all, the average age distribution and diagnostic patterns of the patients in the individual size ranges of the hospitals for acute diseases were determined. Secondly, the investigation aimed at determining how the development of multimorbidity was distributed among the individual size ranges of hospitals. The reduced length of hospital stay between 1980 and 1989 took an almost uniform course in all hospital size groups. The largest hospitals (over 1,000 beds) have the lowest average duration of stay over the investigated period, whereas the small hospitals with 100-200 beds have the highest. The only mavericks were the smallest hospitals with less than 100 patients, where the length of stay had been highest in 1980, the reduction being subsequently the strongest despite the fact that the patient structure had become less favourable. Thus, the very smallest hospitals had overall a less-than-average length of stay in 1989.

Adolescent↗

PubMed1995

Appropriateness of admissions and hospitalization days in an acute-care teaching hospital.

A cross-sectional study was made of the appropriateness of admissions and hospitalization days in an high-technology, acute-care teaching hospital. This 952-bed institution with 31 hospital services is a reference center for the metropolitan area of Barcelona. A systematic random sampling (1:11) of the registers of hospital discharges was carried out during the months of January, February and March 1991 (n = 7,142) excluding discharges from the pediatric, obstetrics and psychiatric departments. A retrospective analysis was made of 639 patients' medical records using the Appropriateness Evaluation Protocol (AEP). The rate of inappropriate hospital admissions was 9.1% (58/639) (95% confidence interval: 6.9-11.5). Inappropriate admissions were primarily attributable to hospitalizations for diagnostic and/or therapeutic services that could have been rendered on an ambulatory basis (70.7% of cases). Overall 29.2% of hospitalization days (1,963/6,731) were inappropriate (95% confidence interval: 28.1-30.3). Inappropriate admissions to hospital, an optimizable health care planning and a conservative physician's attitude (postponed discharge) were the most frequent reasons for unnecessary days of care. The interrater reliability in the use AEP criteria for appropriateness of admission showed a kappa index of 0.5 and that for appropriateness of hospitalization days 0.67. In summary, instruments, such as the AEP protocol, that allow us to determine which patients can be attended at other levels of the health care system and which levels are the most appropriate, are key elements in improving the appropriateness of hospital use in public health care systems.

Acute Disease↗

PubMed1995

[Assessment by the primary care physician of his influence on the patient's hospital choice and of his own ability to evaluate hospital quality].

We report a mail survey (1993) of 677 primary care physicians employed by Israel's 4 sick funds of their influence on the patient's choice of hospital. In the light of the far-reaching changes currently taking place in the health system in Israel, factors considered by physicians in recommending a hospital were studied. About 50% reported having a high degree of influence over patient choice of hospital for elective procedures. Most reported themselves able to evaluate the quality of hospital care, especially results of clinical treatment (89%). Multivariate analysis revealed the physicians who reported a high degree of influence on patient hospital choice were men under the age of 65, independently employed by a smaller sick fund or by several sick funds. They considered themselves capable of evaluating hospital quality and were in regular professional contact with at least 1 hospital. The main factors considered in recommending a hospital were quality of its physicians and medical care, the way in which the hospital staff related to patients, and the level of equipment and technology available. Little importance was given to sick fund hospitalization policy. The survey findings had implications for primary care physicians, and for policymakers of the sick funds and the government.

Choice Behavior↗

PubMed1997

[Week-long hospitalization in a Department of Internal Medicine: patients and care patterns. Description and comparison with standard hospitalization].

OBJECTIVES: The objective of this study was to determine the inpatient and care pathway predictive factors of week hospitalization (week-end excluded = HDS) compared to classical short term hospitalization (HC). METHODS: We compared 340 HDS stays to 65 HC stays. We analyzed the major in-patient sociodemographic and medical characteristics, and their care pathways. RESULTS: HDS inpatients were younger, more living in couples, had a higher educational level, better social insurance, more cancer, less associated diagnosis, less general health impairment than HC in-patients. More chemotherapies and endoscopies were performed in HDS. Hospital physicians were more often involved in HDS admissions than in HC admissions and general practitioners were more often involved in outpatient hospital visits for advice before HDS hospitalization than before HC hospitalization. HDS hospitalizations per in-patient were more numerous than HC hospitalizations. HDS inpatients were discharged directly to their home more often. After logistic regression modeling, most of these factors remained independently associated with HDS hospitalization, except for sociodemographic characteristics, age excluded, admission rates and home discharge. CONCLUSIONS: Type of hospitalization (HDS vs. HC) was mainly determined by medical characteristics of patients and by care pathways. Limiting factors were mainly due to organization of care.

Day Care, Medical↗

PubMed2005

Ability of hospitalized older adults to use their call bell: a pilot study in a tertiary care teaching hospital.

BACKGROUND AND AIMS: Cognitive impairment, visual loss and decreased mobility may make it difficult for older patients to use a hospital call bell when they need help. Inability to call for help may cause harm that could potentially be modified. Despite the importance of this issue, to date no study has determined the ability of older hospitalized adults to use their call bell. The aim of this study was to determine what percentage of hospitalized patients, aged 70 and older, are capable of using their call bell. METHODS: The study used a cross-sectional design. Patients were enrolled from two different clinical units in a tertiary care teaching hospital. Subjects participated in a structured interview to determine whether or not they could use the hospital call bell. RESULTS: Thirty-seven patients were interviewed. Of these, eleven patients were unable to use the call bell, seven because it was out of reach and four because they were unaware of how to use it. Only two of the four patients diagnosed with dementia were aware of their hospital call bell, compared with 31 of 33 patients without dementia (p = 0.050). CONCLUSIONS: The present system of hospital care is based on the assumption that patients are able to get help by activating their call bell. However, a large percentage of hospitalized patients are unable to use this device. Ensuring that call bells are positioned within reach of patients and providing increased supervision to patients with dementia may reduce the rate of adverse events in hospital.

Aged↗

PubMed1984

The effect of a mental hospital strike on general hospital psychiatric services.

Data collected from 6043 psychiatric in-patient records were analysed to assess the impact of a strike at a mental hospital on in-patient services in general hospital psychiatric units in St John's, Newfoundland, Canada. As a whole, during the strike general hospital units showed an increase in the number of involuntary admissions, the number of prior mental hospital admissions of patients, and indications of violent or suicidal behaviour; and a decrease in the occupational status of patients admitted and the prescription of minor tranquillizers. There was also evidence of considerable variation between general hospitals in the extent to which their admission pattern changed during the strike and the permanence of some of the strike effects. The data indicate that all patients showing violent or suicidal behaviour who would normally have been admitted to the mental hospital were treated in the general hospital units during the strike. On the other hand, a large number of patients diagnosed with schizophrenia, personality disorder or mental retardation, who normally would have been admitted to the mental hospital, apparently went without hospitalization during the strike. A substantial proportion of this latter group would usually have been admitted involuntarily.

Delivery of Health Care↗

PubMed2003

Mortality and length of stay in a veterans affairs hospital and private sector hospitals serving a common market.

OBJECTIVE: To compare severity-adjusted in-hospital mortality and length of stay (LOS) in a Veterans Administration (VA) hospital and private sector hospitals serving the same health care market. DESIGN: Retrospective cohort study. SETTING: A large VA hospital and 27 private sector hospitals in the same metropolitan area. PATIENTS: Consecutive VA (N = 1,960) and private sector (N = 157,147) admissions in 1994 to 1995 with 9 high-volume diagnoses. MEASUREMENTS: Severity of illness was measured using validated multivariable models that were based on data abstracted from medical records. Outcomes were adjusted for severity and compared in VA and private sector patients using multiple logistic or linear regression analysis. MAIN RESULTS: Unadjusted mortality was similar in VA and private sector patients (5.0% vs 5.6%, respectively; P =.26), although mean LOS was longer in VA patients (12.7 vs 7.0 days; P <.001). Adjusting for severity, the odds of death in VA patients was similar (odds ratio [OR] 1.07; 95% confidence interval [95% CI], 0.74 to 1.54; P =.73). However, a larger proportion of deaths in VA patients occurred later during hospitalization (P <.001), and the odds of death in VA patients were actually lower (P <.05) in analyses limited to deaths during the first 7 (OR, 0.56) or 14 (OR, 0.63) days. Adjusted LOS was longer (P <.001) in VA patients for all 9 diagnoses. CONCLUSIONS: If the current findings generalizable to other markets, hospital mortality, a widely used performance measure, may be similar or lower in VA and private sector hospitals serving the same markets. The longer LOS of VA patients may reflect differences in practice patterns and may be an important source of bias in comparisons of VA and private sector hospitals.

Aged↗

PubMed2006

Hospital staff perceptions of parental involvement in paediatric hospital care.

AIM: This paper reports a study of hospital staff perceptions of parental involvement in children's hospital care. BACKGROUND: Previous research has shown that parents are expected and encouraged by hospital staff to be actively involved in the care of their hospitalized children. At the same time, parents have expressed a need for improved communication with paediatric hospital staff to clarify both parental and staff expectations and preferences about this involvement. Few studies, however, have studied hospital staff perceptions of parental involvement in the care of hospitalized children and their implications for clinical work. METHODS: A cross-sectional questionnaire study was conducted among paediatric hospital staff in October of 2003. Questionnaires were distributed to a total of 338 staff, including all physicians, Registered Nurses and nursing auxiliaries working on oncology, surgery and neurology units in three university children's hospitals in Sweden. RESULTS: A total of 207 questionnaires were returned, yielding a response rate of 61%. Exploratory and confirmatory factor analyses of the 26-item questionnaire resulted in the creation of two indices, Work Routines and Work Strain. Oncology staff reported having better work routines for involving parents in their children's care and they experienced less strain from parental demands compared with staff on other paediatric units. Staff perceptions and workplace routines regarding parental involvement did not differ statistically significantly by profession or by length of work experience. CONCLUSION: Staff perceptions of parental involvement may be related to clinical specialty. Oncology units may find it easier to establish routines for parental involvement, thereby experiencing less work strain in their interactions with parents. There is a need to further study staff perceptions of parental involvement and their implications for the staff work situation in both Sweden and other countries.

Adult↗

PubMed2004

Comparison of selected reasons for hospitalization of children among children's/tertiary hospitals, Australia, 1996-97 and 1997-98.

OBJECTIVES: To describe the major characteristics of admissions to children's/tertiary hospitals (compared to other hospitals) and to compare characteristics of local and non-local admissions to specialist children's hospitals. METHODS: A cross-sectional analysis of a routinely collected data set of hospitalizations in Australia in 1996-97 and 1997-98. RESULTS: Hospital-specific proportions of asthma and bronchitis, tonsillectomy and/or adenoidectomy and gastroenteritis varied considerably. Multivariate analysis comparing the characteristics of admitted patients by locality showed that non-local admissions of patients with asthma and bronchitis and gastroenteritis to selected children's hospitals were significantly more likely to be Indigenous children and/or children who had been transferred from another hospital. Non-local admissions of tonsillectomy and/or adenoidectomy patients to selected hospitals were significantly more likely to be public patients. CONCLUSIONS: Differences in the characteristics of admitted patients to children's hospitals by locality raise issues about equality of access and availability of appropriate services for these children and their families.

Adolescent↗