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PubMed1975

The state mental hospital in transition. Illinois state mental hospitals decentralize.

In this paper, we have looked at mental hospital decentralization as it has developed in the thirteen State of Illinois mental hospitals as of June 30, 1967. The hospitals were looked at from the most centralized to the most decentralized. This was done by relating the hospitals to five descriptive model types, described at greater length elsewhere. Hospital decentralization is portrayed as a complex and highly idiosyncratic process. Attempts to place specific hospitals at point along the decentralization continuum are thus tentative and clear rules for classifying stages of decentralization have yet to be formulated. Complicating the picture still further is that hospitals in transition change rapidly and may at even intervals of a month show dramatic change. It is expected that the trend implied is stable, however, and that ultimately all Illinois state mental hospital with possible exception of ISPI and Illinois Security Hospital, will be located at the decentralized model. This is seen as necessary if they are to survive as viable treatment institutions.

Commitment of Persons with Psychiatric Disorders↗

PubMed1997

Overview of the hospital formulary systems in Hong Kong. Princess Margaret Hospital as a baseline.

OBJECTIVE: To investigate the popularity of formulary systems in all Hong Kong hospitals and to compare these with the newly introduced formulary system in a major government hospital, the Princess Margaret Hospital (PMH), as the baseline. DESIGN: Questionnaire and selected interviews by pharmacy students. SETTING: All hospital pharmacies in Hong Kong. PARTICIPANTS: Department managers (directors of pharmacy services) of hospital pharmacies. MAIN OUTCOME MEASURE: The popularity of the hospitals' formulary systems and their formulary decision-making strategies. Calculations of cost savings of the new formulary system in PMH and a comparison of the PMH system with the US standards were also made. RESULTS: Among 38 responding hospitals, 35 (92%) had a formulary handbook and 21 (55.3%) claimed to have a formulary system. The evaluation processes and formulary decision-making procedures were found to be inadequate because basic components in drug evaluation (e.g., standardized criteria for drug evaluation) were not used regularly. However, the formulary system in PMH was found to be comparable with the US standards. Substantial cost savings were made through rejection of less cost-effective drugs by the Formulary Subcommittee in PMH. CONCLUSIONS: In general, comprehensive formulary systems are still not popular in Hong Kong. This may be due to insufficient staffing and lack of administrative and physicians' support. The new formulary system in PMH can be used as a model to develop a successful formulary system in which hospital pharmacists can prove their expertise for the benefit of both hospitals and patients in Hong Kong.

Attitude of Health Personnel↗

PubMed2005

The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: a randomized controlled trial.

OBJECTIVE: To compare the safety, effectiveness, acceptability and costs of a hospital-at-home programme with usual acute hospital inpatient care. METHOD: Patients aged 55 years or over being treated for an acute medical problem were randomized to receive either standard inpatient hospital care or hospital-at-home care. Follow-up was for 90 days after randomization. Health outcome measures included physical and mental function, self-rated recovery, health status as assessed by the SF-36, adverse events and readmissions to hospital. Acceptability was assessed using satisfaction surveys and the Carer Strain Index. Costs comprised hospital care, care in the home, community services, general practitioner services and personal health care expenses. RESULTS: In all, 285 people were randomized with a mean age of 80 years. There were no significant differences in health outcome measures between the two randomized groups. Significantly more patients receiving care at home reported high levels of satisfaction, as did more of their relatives. Relatives of the care-at-home group also reported significantly lower scores on the Carer Strain Index. However, the mean cost per patient was almost twice for patients treated at home (NZ 6524 dollars) as for standard hospital care (NZ 3525 dollars). A sensitivity analysis indicated that, if the service providing care in the home had been operating at full capacity, the mean cost per patient episode would have been similar for both modes of care. CONCLUSIONS: This hospital-at-home programme was found to be more acceptable and as effective and safe as inpatient care. While caring for patients at home was significantly more costly than standard inpatient care, this was largely due to the hospital-at-home programme not operating at full capacity.

Aged↗

PubMed1981

Frequency of hospitalization among hospital employees and their families.

Using claims data from 443 employee groups in North Carolina, this study examines the acute care hospital utilization rates of hospital employees and their dependents and compares them to employee groups in non-hospital settings. Results show that hospital employee groups account for 28 per cent more hospital days than non-hospital employee groups. The significantly higher rates are due primarily to employee utilization, although hospital employee dependents also showed higher rates of use than would be expected. We hypothesize that the high utilization rates of the hospital employee groups is due to the unusual availability and accessibility of hospital services and an atypical doctor-patient relationship.

Blue Cross Blue Shield Insurance Plans↗

PubMed1996

Medicare and Medicaid program; criteria for a rural hospital to be designated as an essential access community hospital (EACH)--HCFA. Final rule with comment period.

This final rule revises the criteria that a rural hospital must meet to be designated as an Essential Access Community Hospital (EACH). The revised criteria permit HCFA to designate a hospital as an EACH if the hospital cannot be designated as an EACH by the State only because it has fewer than 75 beds and is located 35 miles or less from another hospital. Hospitals in rural areas that are designated as EACHs by HCFA are treated, for payment purposes, as sole community hospitals. The revised criteria are designed to facilitate development of network affiliations between rural EACHs and small rural facilities, known as Rural Primary Care Hospitals (RPCHs). The revisions would affect only hospitals located in rural areas of the States of California, Colorado, Kansas, South Dakota, New York, West Virginia, and North Carolina, or in an adjacent State.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2004

[Hospital family medicine. Education in an urban university hospital center].

OBJECTIVE: To describe the patients residents see in one hospital's family medicine unit and to determine whether these patients resemble family medicine patients in other Quebec hospitals. DESIGN: Descriptive study. SETTING: Urban teaching hospital. PARTICIPANTS: Patients 20 years and older who were admitted to the family medicine unit at Hôpital du St-Sacrement between April 1, 1999, and March 31, 2000, were compared with all patients admitted in general medicine to Quebec hospitals during this period. MAIN OUTCOME MEASURES: Sex, age, main diagnosis, secondary diagnoses, types of diseases, length of stay, number of consultations and specialties involved, referral after hospitalization. RESULTS: Patients hospitalized in this unit were older, had more secondary diagnoses, and stayed in hospital slightly longer than patients hospitalized in general medicine in Quebec as a whole. Residents were, therefore, exposed to patients who were more medically complex. CONCLUSION: Patients to whom residents were exposed resemble patients they will see in future hospital practice.

Adult↗

PubMed1990

The effect of hospital control strategies on physician satisfaction and physician-hospital conflict.

This article examines several strategies that hospitals use to control their medical staffs. Such strategies include placing physicians on salary, developing exclusive hospital affiliations with physicians, and involving physicians in decision-making bodies. Using regression techniques, we investigate which hospitals are more likely to utilize these strategies and whether such strategies are effective in promoting physician-hospital integration. Contrary to our expectations, corporate hospital structures (e.g., for-profit hospitals, membership in multihospital systems) generally do not employ these strategies more often and oftentimes employ them less. There is also little evidence that control strategies are effective levers for increasing physician satisfaction or decreasing physician-hospital conflict. We suggest that control strategies are useful for purposes other than promoting physician-hospital integration. Finally, hospital ownership appears to exert the biggest effect on physician satisfaction and conflict.

Age Factors↗

PubMed1983

Estimating the effect of hospital closure on areawide inpatient hospital costs: a preliminary model and application.

A preliminary model is developed for estimating the extent of savings, if any, likely to result from discontinuing a specific inpatient service. By examining the sources of referral to the discontinued service, the model estimates potential demand and how cases will be redistributed among remaining hospitals. This redistribution determines average cost per day in hospitals that receive these cases, relative to average cost per day of the discontinued service. The outflow rate, which measures the proportion of cases not absorbed in other acute care hospitals, is estimated as 30 percent for the average discontinuation. The marginal cost ratio, which relates marginal costs of cases absorbed in surrounding hospitals to the average costs in those hospitals, is estimated as 87 percent in the base case. The model was applied to the discontinuation of all inpatient services in the 75-bed Chelsea Memorial Hospital, near Boston, Massachusetts, using 1976 data. As the precise value of key parameters is uncertain, sensitivity analysis was used to explore a range of values. The most likely result is a small increase ($120,000) in the area's annual inpatient hospital costs, because many patients are referred to more costly teaching hospitals. A similar situation may arise with other urban closures. For service discontinuations to generate savings, recipient hospitals must be low in costs, the outflow rate must be large, and the marginal cost ratio must be low.

Boston↗

PubMed1994

[Integrated struggle against aspergillosis at the level of a single hospital or a hospital cluster].

Invasive nosocomial aspergillosis (INA) has become an increasing public health problem in hospitals whose inpatients are severely immunocompromised, i.e. in case of aplasia, bone marrow or organ transplants. The hospital's responsibility is engaged, all the more so since numerous INA cases have been reported during hospital construction work. Prevention measures must be implemented at the time of high risk activities (bone marrow graft, transplantation) or as soon as predisposed patients (aplastic) are admitted in hospitals. In case of hospital construction work, those measures must be adapted to the type of work and to the localization of the exposed patients. The first step of an integrated control strategy is to identify the aspergillus risk units in the hospital according to the immunocompromised state of their patients. The second step consists in the implementation, for those units, of effective protection measures concerning the control of hospital contamination sources, the patient's food, the architecture, the air treatment facilities, the staff organization and training. The third step is to apply a triple surveillance: epidemiological for the disease, technical for the air treatment facilities, mycological for the patients environment. In case of construction work, in or near the hospital, an evaluation of the Aspergillus risk level according to the construction work plan must be undertaken for each high risk unit. This risk level conditions the specific measures which have to be implemented. In the network of epidemiological INA surveillance of the Assistance Publique hospitals in Paris, those measures have been published as a recommendation guide.

Air Microbiology↗

PubMed1995

Uncertain demand, the structure of hospital costs, and the cost of empty hospital beds.

In this paper we reformulate the theory of cost and production to take account of uncertain demand facing a firm. In the reformulated theory the duality between cost and production no longer obtains, and demand distribution parameters enter the cost function as well as the traditional outputs and input prices. We then estimate a short run cost function for a hospital facing uncertain demand using data from a national sample of over 5000 hospitals for the years 1983-1987. The traditional cost model is strongly rejected in favor of the reformulated model. This model is used to calculate the cost of empty hospital beds, controlling for the effect of uncertain demand on the structure of hospital costs. The cost of an empty hospital bed is calculated as $36,443 in 1987 dollars. We estimate that a one percent decrease in the number of hospital beds would decrease hospital costs by slightly over one-third of one percent. Increasing the occupancy rate from the average 1992 level (65 percent) back to the average 1980 level (76 percent) is estimated to save the average hospital over $2 million, or 9.5 percent of costs.

American Hospital Association↗

PubMed2000

Assessing the operating efficiencies of teaching hospitals by an enhancement of the AHA/AAMC method. American Hospital Association/Association of American Medical Colleges.

In the ongoing effort to control costs, comparisons among hospitals' efficiency levels, if valid, can help identify "best practices" across institutions and uncover situations that need corrective intervention. The authors present an extension of the "adjusted cost per equivalent discharge" approach, which incorporates case-mix-severity differences, regional labor cost differentials, and inpatient/outpatient mix, but does not take into account such factors as the differences in hospital sizes, extents of the teaching mission, or quality of care delivered. The alternative approach yields information that suggests where an institution's total operating costs might be reduced with no change in any of the hospital's outputs or operating environment, through comparison with a "peer group" of other hospitals, matched according to the subject hospital's number of beds, the quality of care the hospital delivers, the extent of medical education carried out, the level of case-mix-adjusted discharges, and outpatient activities. A difficulty with this approach (as with others) is that measurement of some of the additional facets (e.g., quality of care) is still evolving, so its main contribution at this time is to provide a construct and method capable of incorporating these important added considerations. Hospital rankings achieved by applying the current and alternative approaches to a real set of teaching hospitals operating in FY 1987 are compared. While the rankings produced by the two approaches are loosely similar, the authors show that some significant differences do appear and can be at least partially explained by the incorporation of the additional factors mentioned above.

Ambulatory Care↗

PubMed2007

Does the patient's payer matter in hospital patient safety?: a study of urban hospitals.

BACKGROUND: Previous studies have documented that hospitals decrease costs in response to reimbursement cutbacks. However, research concerning how this may affect quality of care has produced mixed results. Until recently, the ability to study changes in patient safety and payment has been limited. OBJECTIVE: The objective of the study was to determine whether changes in 4 hospital patient safety indicator (PSI) rates are related to changes in the generosity of payers over time. DATA AND METHODS: Study data are drawn from 1995-2000 hospital discharges in 11 states in the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Database. Following the same organizations over time, we estimate hospital fixed-effects regression models of the association of payer-specific time and post Balanced Budget Act (BBA) payment changes with risk-adjusted hospital PSI rates controlling for patient, organizational, and market characteristics. Four PSIs relevant to a large number of patients and hospitals that reflect general care processes are studied. RESULTS: The time trend during 1995-2000 is consistently significantly positive for private and Medicare hospital PSI rates. Thus, after controlling for patient characteristics and organizational and market factors, performance worsened. The trend is less consistent for Medicaid and does not exist for self-pay hospital PSI rates. After adjusting for multiple comparisons, we also find that the Medicare trend is fairly consistently higher than that of the other payers. In contrast, there is a less consistent BBA effect, especially for Medicare.

Financing, Personal↗

PubMed1996

Do community hospitals reduce the use of district general hospital inpatient beds?

Community hospitals have been supported by the general public and by professionals as one means of increasing choice between local, low technology, care and high technology care at the district general hospital. However, there is no information on the impact of community hospitals on district general hospital use subsequent to NHS and community care reforms. Examination of routinely gathered activity data in the Bath Health District revealed that availability of community hospital beds was associated with reduced use of central inpatient services in the city of Bath. The reduction was most apparent for medical and geriatric beds. Decrease in the use of surgical beds was small. However, total inpatient bed use (including central and community hospital beds) was higher in the population with access to community hospital beds. We conclude that community hospitals offer one option for accessible health care and, as such merit systematic evaluation of costs and benefits. This study presents some evidence that savings could be achieved through improved efficiency.

Adolescent↗

PubMed2006

[Evaluation of risk-adjusted hospital mortality after coronary artery bypass graft surgery in the Catalan public healthcare system. Influence of hospital management type (ARCA Study)].

INTRODUCTION AND OBJECTIVES: Previous studies suggest that the effectiveness of coronary surgery is influenced by the type of management at the healthcare centre where the intervention is performed. The present study assessed the risk-adjusted hospital mortality of coronary surgery in the Catalan healthcare system in hospitals under either private or public management. METHODS: We carried out a prospective study of all consecutive patients receiving a first coronary artery bypass graft, with public financial support, in a period of 2 years at 5 hospitals under either public or private management. Preoperative risk was assessed using the EuroSCORE and Catalan Agency for Health Technology Assessment (CAHTA) predictive models. RESULTS: Overall, 1605 patients underwent interventions, 21% of which were at private hospitals. The percentage of patients undergoing non-elective surgery was higher at private hospitals (64% vs 50%), as was the percentage needing intravenous nitrates (17% vs 11%) and the percentage in functional class IV (20% vs 11%). The odds ratio for in-hospital mortality in private compared with public hospitals was 0.56 (95% CI, 0.29-1.06) when adjusted for EuroSCORE, 0.56 (95% CI, 0.29-1.07) when adjusted for CAHTA score, and 0.43 (95% CI, 0.21-0.87) when adjusted for patient characteristics. The mortality observed, 4.8% (95% CI 3.8-5.6), was not significantly higher than that predicted. CONCLUSIONS: a) Hospital mortality was equivalent to or lower than that expected after adjustment for the 2 risk scores; b) after adjustment for baseline patient characteristics, the results favored privately managed centers; and c) comparison with previous results suggests that coronary surgery effectiveness has improved in recent years.

Adult↗

PubMed2006

[Is the incidence of schizophrenia declining?: an investigation of the examination rates in the psychiatric clinics of a medical school hospital and a general hospital].

PURPOSE: Some researchers in Europe, America and Oceania have recently reported that the incidence of schizophrenia is declining. We investigated changes in the proportion of schizophrenic patients to the total number of patients in two Japanese hospitals during the last decade. SUBJECTS AND METHODS: The subjects were patients who first consulted the psychiatric clinic of Jichi Medical School or the psychiatric clinic of Kamitsuga General Hospital between December 1993 and November 1994 or between December 2003 and November 2004. Both clinics accepted new patients without prior appointments. Patients were classified using ICD-10 criteria (F0-F9, G40). The sex distribution of the patients and the mean age at first contact were compared for the two time periods. The proportion of schizophrenia (F2 in the ICD-10 criteria) to the total number of patients was compared for the two time periods after standardizing the populations with regard to age using the "1985 model population in Japan." RESULTS: A decade ago, 398 patients first contacted the psychiatric clinic of the medical school hospital, compared with 958 patients in the recent investigation. A decade ago, 166 patients first contacted the psychiatric clinic of the general hospital, compared with 407 patients in the recent investigation. No differences in the sex ratios of the two groups were noted. The mean age of the patients visiting the medical school significantly increased by 3.5 years (36.9 to 40.4 years), while that of the patients visiting the general hospital significantly increased by 10.0 years (46.2 to 56.2 years). The proportion of schizophrenia patients in the medical hospital decreased from 8.5% to 6.9%, while that in the general hospital decreased from 11.0% to 5.4%. Only the change in the proportion of schizophrenia patients at the general hospital was significant. CONCLUSION AND DISCUSSION: The facts that the mean age of first-contact patients has risen and that the number of first-contact patients has increased approximately 2.5-fold suggests a change in the composition of first-contact patients in the last decade. We have some reservations regarding the comparison of these two groups. Although the actual number of first-contact patients with schizophrenia increased in both clinics, we found that the proportions of schizophrenia patients decreased in both clinics after standardizing the populations with regard to age. This finding must be investigated in view of other factors, including the overall age distribution of first-contact patients, increases in the proportions of affective disorders and organic mental disorders, and so on.

Age Distribution↗

PubMed2005

[Variations in the management of patients with acute myocardial infarction in alpine hospitals compared to other French hospitals. Secondary analysis of the USIC 2000 study data].

OBJECTIVE: To compare processes of care for acute myocardial infarction among patients admitted to alpine vs other French hospitals. METHODS: Prospective observational study of patients with ST-elevation and non ST-elevation myocardial infarction of less than 48 hours hospitalized in 369 intensive care units in November 2000. RESULTS: Fifty-five patients were enrolled in nine alpine hospitals and 2265 patients in 360 other French hospitals. Patients baseline characteristics did not differ between the two groups with the exception of ST-elevation myocardial infarction which was less frequent in patients admitted to alpine hospitals (71 vs. 83%, P = 0.02). Patients living in the alpine area were less likely to be admitted to hospitals with on-site cardiac catheterization facilities (42 vs. 60%, P < 0.01) although the use of primary (20%) and rescue (24%) percutaneous coronary intervention did not differ significantly between the two groups. There were no differences in the use of medical treatments between the two groups with the exception of low-molecular-weight heparin. The risk of in-hospital death and complications did not differ significantly between the two groups while the risk of death at one year was lower in patients admitted to alpine hospitals (5 vs. 16%, P = 0.04). CONCLUSION: In 2000, a lower proportion of patients living in the alpine area had access to hospitals with cardiac catheterization facilities compared to other French patients. This finding supports the creation of an additional cardiac catheterization laboratory with experienced operators performing percutaneous coronary interventions 24 hours/7 days and the implementation of an emergency medical care network for acute coronary syndromes in the alpine area.

Aged↗

PubMed2005

[Malnutrition screening in hospitalized children: influence of the hospital unit on its management].

OBJECTIVES: The aims of this study were to assess the prevalence of malnutrition in a pediatric population hospitalized in a French regional hospital and to evaluate the influence of type of hospital unit (pediatric or not) in the screening and the management of malnutrition. PATIENTS AND METHODS: This one-day cross-sectional survey was performed in three different seasons during 2003. Every child aged 2 months to 16 years old, hospitalized for more than 48 hours was included. Weight for height, Z-score and Body Mass Index Z-score were used for nutritional assessment. Type of hospitalisation unit, date of admission, associated diagnosis, screening and treatment of malnutrition were also taken into account. RESULTS: Two hundred and eighty hospitalized children were undernourished (11%) and thirty-one children were obese (11%) with no difference in prevalence of malnutrition between pediatric and non-pediatric units. At the time of the study, malnutrition was recognized in one third of the children, at a similar rate whatever the type of hospitalized unit. The children hospitalized in pediatrics wards benefited more frequently from nutritional intervention, i.e. dietician care (43 vs. 16% P < 0.01). CONCLUSION: Prevalence of malnutrition in hospitalized children is low and the same in pediatric or non-pediatric units. Screening of malnutrition remains unsatisfactory in hospital. However, malnutrition is more frequently treated in pediatric unit compared with non-pediatric unit.

Adolescent↗

PubMed2005

A history of diabetes is associated with an adverse outcome among patients admitted to hospital alive after an out-of-hospital cardiac arrest.

BACKGROUND: Factors of importance for the outcome among patients who are admitted to hospital alive after an out-of-hospital cardiac arrest are not well described in the literature. The importance of a history of diabetes for the outcome among these patients has not been reported in detail previously. This survey aims to describe the outcome among patients who were admitted to hospital after an out-of-hospital cardiac arrest in relation to whether they had a history of diabetes. METHODS: All patients who were admitted to hospital alive after an out-of-hospital cardiac arrest in the two city hospitals in the Municipality of Göteborg between 1980 and 2002 were included in the survey. RESULTS: In all, 1377 patients fulfilled the inclusion criteria and 187 (14%) of them had a history of diabetes. Patients with diabetes differed from those without diabetes by having a previous history of myocardial infarction, angina pectoris, hypertension and heart failure more frequently. Furthermore, they were older, with a mean age of 70 years versus 66 years for patients without diabetes. Among patients with diabetes, 25% were discharged alive, as compared with 37% of patients without diabetes (p=0.002). When adjusting for differences at baseline, the adjusted odds ratio for diabetic patients being discharged alive (versus no diabetes) was 0.57 (95% confidence interval, 0.39-0.80). CONCLUSION: Among patients admitted to hospital after an out-of-hospital cardiac arrest, 14% had a history of diabetes. These patients had a lower survival rate compared with those without diabetes, even after correcting for dissimilarities at baseline. It remains to be determined whether an early metabolic intervention in these patients will improve survival.

Age Distribution↗