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PubMed2005

Profiling hospital performance of laparoscopic cholecystectomy based on the administrative data of four teaching hospitals in Japan.

Over the last decade in Japan, laparoscopic cholecystectomy (LC) has replaced traditional open cholecystectomy as the standard of elective surgery for cholelithiasis. The laparoscopic approach has a clinical course relatively easier to standardize among the different types of intraabdominal surgery. However, significant practice variation is suspected in Japan, but there has been little demonstration or discussion based on empirical data. Through the analysis of 1589 elective LC cases from four leading teaching hospitals in Japan between 1996 and 2000, this study aims to demonstrate the surgical variations and to investigate their determinants regarding the length of hospital stay and the health care charge. Substantially and significantly large variation existed among the hospitals in terms of the length of hospital stay and the total health care charge, even after the differences in patient factors were adjusted. Particularly, the combined drug and exam charge per day was strikingly different among the four hospitals, which indicated that the daily process also varied widely, as did the total course of inpatient care. In addition, intra-hospital variation was also remained very large even after adjusting for all the potential correlates studied. This study alarmingly points out great room for improvement in the efficiency of health care resource use and potentially in the quality of care through standardization of LC. It has serious implications for the national policy and individual providers under the on-going health care reforms directed toward higher efficiency and quality.

Aged↗

PubMed2005

Analysis of Clostridium difficile-associated diarrhea among patients hospitalized in tertiary care academic hospital.

The frequency of Clostridium difficile strains in stool samples of patients with diarrhea hospitalized in the hematology/oncology, surgery, orthopedics, transplantology ward, and emergency room of Davis Medical Center was analyzed. A total of 786 stool samples collected from patients with diarrhea and 180 samples taken from the hospital environment were cultured for C. difficile by routine methods. There were 119 strains of C. difficile isolated: 97 (12.3%) strains from patients' stools (no enteropathogen other than C. difficile was detected in these stool samples) and 22 (12.2%) strains from the hospital environment. It was confirmed that hospital environment plays an important role in transmission of C. difficile by AP-PCR and PCR ribotyping. Among 97 C. difficile strains isolated from patient' stools 25 were nontoxigenic (A-/B-), 67 were toxigenic (A+/B+), and 5 strains were toxin B-positive/toxin A-negative. Analysis of concomitant symptoms among hospitalized patients with diarrhea demonstrated significantly longer duration of diarrhea caused by nontoxigenic strains than in cases of diarrhea caused by toxigenic strains. On the other hand, among patients infected by toxigenic strains, significantly higher leukocytosis and longer duration of fever were observed. The resistance of isolated C. difficile strains to erythromycin and clindamycin indicated the possibility of transmission in the hospital strains with macrolide-lincosamide-streptogramin B resistance type.

Bacterial Proteins↗

PubMed2004

Pain prevalence and predictors among inpatients in a major Italian teaching hospital. A baseline survey towards a pain free hospital.

Pain prevalence among inpatients is an important indicator of quality care; it may reach over 80% in various clinical settings. A cross-sectional survey was conducted in a teaching hospital to depict benchmark data regarding pain prevalence and predictors among the entire inpatient population. Overall 892 patients, 6 years old and hospitalized for at least 24 h in 57 hospital wards were interviewed using an internationally applied questionnaire. Patients self-reported their pain intensity at the time of the interview (T(0)) and worst pain perceived during the previous 24 h (T(-1)), using a numerical rating scale (NRS) and indicated current pain duration. Specific pain predictor data (hospital stay, gender, age and marital status) were obtained from patient medical charts. Pain prevalence at T(0) was 38% and 52% at T(-1). Pain was moderate to severe (NRS4) in approximately 25% of the patients at T(0) and in 40% at T(-1). High pain prevalence was found (at T(0) and T(-1), respectively) in Radiotherapy (63%;77%), Obstetrics (68%;54%), and Surgery (59%;45%) wards. Gender was a prominent determinant as pain was significantly associated with females. Pain prevalence was high among young adults or divorced/separated individuals and low among pediatric patients ( approximately 20%). Protracted hospitalization and prolonged pain duration were associated with major pain severity. Results yield Quality Assurance interventions to ameliorate pain undertreatment. Predictor analysis suggests that attention should be paid to pain management in young adults, socially vulnerable patients and those with protracted hospitalization and pain.

Adolescent↗

PubMed2006

Impact of hospital and physician characteristics on medical expenditures for acute myocardial infarction hospitalization.

This study aims to examine the impact of length of stay, hospital characteristics, physician characteristics and other factors on the expenditures of hospitalization for acute myocardial infarction (AMI) under Taiwan's National Health Insurance program. This study uses data collected from the Taiwan's National Health Research Institute's 2001-2003 National Health Insurance Research Database. We estimated contributors to increased expenditures of hospitalization using three-stage least square regression model. The hospital expenditures for the treatment of AMI averaged NT$126,366 (US$3829, US$1=NT$33) per discharge, with the largest proportion (27%) spent on room expenditures. They were strongly impacted by length of stay, increasing around 4.8% per day. We conclude that hospital expenditures for the treatment of AMI patients may vary widely depending on the characteristics of the hospital and physicians that provide them care.

Adult↗

PubMed2002

The effects of introducing prospective payments to general hospitals on length of stay, quality of care, and hospitals' income: the early experience of Israel.

A new reimbursement system for general hospitals in Israel was introduced in July 1990. The new system specified that for 15 selected procedures, hospitals would be paid by the insurers prospectively, rather than by the traditional per-diem arrangement. The rates were determined by the Ministry of Health. Henceforth, the number of selected procedures has increased and by now 40 procedures are included. In line with the ever-lasting interest in the effect of financial incentives on suppliers of medical care, the purpose of this paper is to examine the first-year effect of this change on the volume of activity, length of stay, quality of care, and hospitals' real income. We focused on five selected procedures (cholecystectomy, hysterectomy, hip replacement, operations on lens and heart surgeries) performed in the four largest Israeli medical centers (Sheba, Sorasky, Rambam, and Hadassah). The analysis includes more than 17,000 hospitalizations occurring during two years prior to the change (July 1988-June 1990) and the first year after its implementation (July 1990-June 1991). We, therefore, examined, the short-term effects, wherein changes in the hospitals' behavior are reflected mainly in the above-mentioned hospitalization characteristics. Further analysis will be required to examine the long-run implications of the change as well as its effect on the rest of the general inpatient sector in Israel.

Arthroplasty, Replacement, Hip↗

PubMed2000

Successful out-of-hospital cardiopulmonary resuscitation: what is the optimal in-hospital treatment strategy?

UNLABELLED: The aim of the study was to evaluate prognostic factors in patients after successful out-of-hospital resuscitation (sOHR) within 30 min after admission. A prognostic scoring scale in patients surviving OHR was analysed. We also studied the effect of these predictive factors and the in-hospital treatment (percutaneous transluminal coronary angioplasty (PTCA) vs. thrombolysis) on mortality. We performed a retrospective analysis of the emergency medical system forms and medical files of 72 consecutive patients aged > or =18 years with sOHR. Of these 72 patients 37 (51%) met the electrocardiographic and enzymatic criteria for acute myocardial infarction (AMI). Ten of the 37 AMI patients (27%) underwent acute PTCA as primary treatment and seven patients (19%) received thrombolytic therapy for AMI despite prolonged (mean 24+/-13 min) cardiopulmonary resuscitation (CPR). The remaining 20 patients had no specific infarct treatment. Despite successful PTCA, in eight out of ten patients, their mortality in hospital was 60% (6/10). Mortality in the thrombolysis group was 57% (4/7). For the remaining 20 MI-patients the mortality was 65% (13/20). Univariate and multivariate analyses were performed to design a weighted prognostic scoring system. The Glasgow coma scale (GCS) was the strongest independent predictor (r=0.76, P< or =0.001) for in-hospital death. CONCLUSIONS: in-hospital mortality after successful OHR seems to largely depend on neurological status at admission and much less on the specific treatment of myocardial infarction. The prognostic scoring system accurately predicted the in-hospital mortality and can be used for early treatment stratification; however, it should be proven in a prospective study.

Adult↗

PubMed1998

Hospital infection prevention and control: a model for improving the quality of hospital care in low- and middle-income countries.

Continuous quality improvement (CQI) is a powerful methodology for improving clinical outcomes and patient satisfaction while reducing inefficiency and costs. However, most hospitals in low- and middle-income countries have little experience with CQI methods. Hospital infection prevention is an ideal model for nascent efforts to improve the quality of hospital care because of its proven efficacy in reducing the occurrence of infections that compromise patient outcomes and increase costs. This article describes the design and implementation of a demonstration project to reduce the incidence of surgical-site infections (SSIs) for hospitals with little experience with quality-improvement methods. The project has a high likelihood of producing measurable reductions in SSI rates and hospital costs related to inefficient use of perioperative antimicrobial prophylaxis. Moreover, participating staff will gain experience that can be applied to efforts to improve the quality of other aspects of hospital care.

Developing Countries↗

PubMed1979

Hospital malnutrition. A prospective evaluation of general medical patients during the course of hospitalization.

Nutrition status was evaluated in 134 consecutive admissions to a general medical service and throughout hospitalization among patients hospitalized 2 weeks or longer. Likelihood of malnutrition was determined using eight nutrition-related parameters: serum folate and vitamin C, triceps skinfold, weight/height, arm muscle circumference, lymphocyte count, serum albumin, and hematocrit. On admission 48% of patients had a high likelihood of malnutrition, which correlated with a longer hospital stay (20 versus 12 days for patients with a low likelihood of malnutrition) and an increased mortality rate (13 versus 4%). Likelihood of malnutrition increased with hospitalization in 69% of patients with paired determinations. Compared to admission, at final follow-up a greater proportion of patients fell into the depleted range of values for folate, triceps skinfold, weight/height, arm muscle circumference, lymphocyte count, and hematocrit. These parameters worsened in over 75% of patients admitted with normal values. Hematocrit fell in all patients with normal admission levels. These findings demonstrate and association between nutrition status and hospital course and a worsening trend during hospitalization.

Anthropometry↗

PubMed2003

Validating California teachers study self-reports of recent hospitalization: comparison with California hospital discharge data.

Determining an accurate method of obtaining complete morbidity data is a long-standing challenge for epidemiologists. The authors compared the accuracy and completeness of existing California hospital discharge data with self-reports of recent hospitalizations and surgeries from participants in the California Teachers Study. Self-reports were collected by questionnaire in 1997 from 91433 female teachers and administrators residing in California. Of the 13430 hospital discharge diagnoses identified for these women, cohort members reported 58%. Self-reporting was highest for neoplasms and musculoskeletal and connective tissue diseases and was most accurate for scheduled admissions, more recent admissions, longer lengths of stay, and less severe disorders. Hospitalizations for mental health and infectious disease were not as well reported. Among the 26383 self-reports-including outpatient surgeries, which are not captured by the hospital discharge database-confirmation was lower, as expected, especially for disorders of the nervous system and sense organs and skin and subcutaneous tissue. Confirmation was highest for childbirth admissions. The hospital discharge database was more specific, but the self-reports were more comprehensive, since many conditions are now treated in outpatient settings. The combination of self-reports and secondary medical records provides more accurate and complete morbidity data than does use of either source alone.

Aged↗

PubMed1995

Nursing home residents at risk of hospitalization and the characteristics of their hospital stays.

Little national data have been available to guide the design of programs aimed at reducing the hospitalization of nursing home residents. This article uses the 1987 National Medical Expenditure Survey to identify elderly nursing home residents with an elevated risk of hospitalization and the reasons for and outcomes of residents' hospital stays. Study findings include an elevated risk of hospitalization for residents with one of several different primary diagnoses and a rise in risk as ADL dependence increases. An infection was the main medical reason for roughly 27% of hospital stays. The results suggest possible target groups for two types of programs aimed at reducing hospitalization.

Activities of Daily Living↗

PubMed1979

Patient race and physician performances: quality of medical care, hospital admissions and hospital stays.

The study has attempted to determine the extent of the relationship between patient race and physicians' performances in patient care. The sample of the study consisted of 3175 hospital episode of patients discharged from 22 short-term general hospitals in the state of Hawaii. The episodes were derived from 15 major diagnostic categories. Physicians performances were measured on the basis of the quality of medical care provided, the appropriateness of hospital admissions, and the appropriateness of hospital stays, including understays and overstays. The study has found: 1) that patient race had very limited influence on physicians' performances: the quality of medical care, the appropriateness of hospital admissions, and the appropriateness of hospital stays; 2) that Asian-Americans receive medical care equal to that of the white Americans (once they had access to the health care systems), at least in the state of Hawaii; 3) that among Asian-Americans, there was no distinct difference in medical care received by Japanese, Chinese, and Filipino; 4) that there was clear evidence of racial mutual selection between patients and physicians; and 5) that patients treated by the physicians with the same racial/ethnic backgrounds received care neither superior nor inferior to the care received by patients from the physicians with different backgrounds.

Analysis of Variance↗

PubMed1989

The epidemiology of delays in a teaching hospital. The development and use of a tool that detects unnecessary hospital days.

This study's purpose was to develop a tool that detects, quantifies, and assigns causes for medically unnecessary hospital delays and use it to describe the epidemiology of delays at a teaching tertiary care hospital. Based on observational data, a taxonomy of delays was constructed that included nine major categories and 166 subcategories. This formed the basis for an instrument for detecting inefficiency in hospital care: the Delay Tool. Initially designed for real-time concurrent assessment, in retrospective use it was also reliable, requiring about 6 minutes per medical record. In using the Delay Tool over a 6-month period on general internal medical and gastrointestinal services, it was discovered that 30% of 960 patients experienced delays, the average length of which was 2.9 days. This represented 17% of all hospital days. The most frequent causes of delays were scheduling of tests (31%), unavailability of post-discharge facilities (18%), physician decision-making (13%), discharge planning (12%), and scheduling of surgery (12%). Because of the longer lengths of the delays involved with awaiting postdischarge facilities (primarily nursing home beds), this was the most important cause of delays and represented 41% of all delay days. The general medicine and gastrointestinal services had significantly different distributions of delay types related to their different kinds of patients and care. The Delay Tool should be helpful in addressing hospital, and hospital-related, inefficiencies in health care delivery.

Appointments and Schedules↗

PubMed1992

Participation of informal caregivers in the hospital care of elderly patients and their evaluations of the care given: pilot study in three different hospitals.

This action research is an ongoing study which will last from 1991 to 1993. The main purpose of the study is to increase the participation of informal caregivers in the hospital care of elderly patients without decreasing the quality of care. The data reported here are from a pilot study. This study had three aims: (a) to test reliability and validity of the measure used, (b) to investigate the current participation of informal caregivers in the hospital care of elderly patients (aged over 75), and (c) to evaluate and compare the quality of care from both the patients' and the informal caregivers' point of view in three different hospitals. The measure of quality of care was developed on the basis of need theories, mainly those of Maslow and Alderfer. Patients and caregivers were also asked to rate the participation of the caregivers in the hospital care of elderly patients. Participation consisted of 18 activities of daily living. The pilot test with 18 elderly hospital patients and seven family members or significant others showed differences between the two groups in perception of care received. Statistically significant differences (P < 0.001) were found in the following categories: mainly social needs, psychic and spiritual needs and totals. The results supported earlier findings that elderly patients are satisfied with and do not criticize their care. The younger generation (i.e. their children) is more demanding and has precise perceptions about the care given. Relatives could be used more in planning, evaluation and even implementation of care; however, their current participation in patient hospital care is minimal.

Activities of Daily Living↗

PubMed2004

Home-based care after a shortened hospital stay versus hospital-based care postpartum: an economic evaluation.

OBJECTIVES: To compare the cost effectiveness of early postnatal discharge and home midwifery support with a traditional postnatal hospital stay. DESIGN: Cost minimisation analysis within a pragmatic randomised controlled trial. SETTING: The University Hospital of Geneva and its catchment area. POPULATION: Four hundred and fifty-nine deliveries of a single infant at term following an uncomplicated pregnancy. METHODS: Prospective economic evaluation alongside a randomised controlled trial in which women were allocated to either early postnatal discharge combined with home midwifery support (n= 228) or a traditional postnatal hospital stay (n= 231). MAIN OUTCOME MEASURES: Costs (Swiss francs, 2000 prices) to the health service, social services, patients, carers and society accrued between delivery and 28 days postpartum. RESULTS: Clinical and psychosocial outcomes were similar in the two trial arms. Early postnatal discharge combined with home midwifery support resulted in a significant reduction in postnatal hospital care costs (bootstrap mean difference 1524 francs, 95% confidence interval [CI] 675 to 2403) and a significant increase in community care costs (bootstrap mean difference 295 francs, 95% CI 245 to 343). There were no significant differences in average hospital readmission, hospital outpatient care, direct non-medical and indirect costs between the two trial groups. Overall, early postnatal discharge combined with home midwifery support resulted in a significant cost saving of 1221 francs per mother-infant dyad (bootstrap mean difference 1209 francs, 95% CI 202 to 2155). This finding remained relatively robust following variations in the values of key economic parameters performed as part of a comprehensive sensitivity analysis. CONCLUSIONS: A policy of early postnatal discharge combined with home midwifery support exhibits weak economic dominance over traditional postnatal care, that is, it significantly reduces costs without compromising the health and wellbeing of the mother and infant.

Adult↗

PubMed2006

Replicating the Hospital Elder Life Program in a community hospital and demonstrating effectiveness using quality improvement methodology.

OBJECTIVES: To evaluate a replication of the Hospital Elder Life Program (HELP), a quality-improvement model, in a community hospital without a research infrastructure, using administrative data. DESIGN: A pretest/posttest quality-improvement study. SETTING: A 500-bed community teaching hospital in western Pennsylvania. PARTICIPANTS: Four thousand seven hundred sixty-three hospitalized patients aged 70 and older admitted to one nursing unit over 3.5 years. INTERVENTION: Application of the HELP multicomponent intervention targeting patients at risk for delirium. MEASUREMENTS: A proxy measure for delirium was developed using administrative data to calculate delirium rate and differences in variable costs of care and length of stay for patients before and after the intervention. Similar calculations were used in delirious patients for variable costs and length of stay before and after the intervention. Satisfaction surveys were administered to nursing staff and patient families before and after the intervention. RESULTS: The intervention reduced the absolute rate of delirium according to proxy report 14.4% from baseline, which represented a relative reduction in risk of 35.3% (P=.002). Total costs on this 40-bed nursing unit were reduced $626,261 over 6 months. Satisfaction of nursing staff and families was high in the intervention group. In addition, the intervention showed sustained benefits over time and remains funded by the hospital. CONCLUSION: HELP can be successfully replicated in a community hospital, yielding clinical and financial benefits.

Activities of Daily Living↗

PubMed2004

[An outbreak of rubella among hospital personnel and measures taken against hospital infection--cost-benefits of the measure].

There is no nationwide outbreak of rubella after 1992 in Japan, but a local outbreak remains. Recently, some cases of congenital rubella syndrome (CRS) were reported after a local outbreak. An outbreak of rubella among hospital personnel occurred in our hospital located on Tanegashima Island on March and April 2003 after a visit of one rubella patient. Fifteen employees, including 7 clerks, 6 nurses, one doctor, and one radiologist, experienced rubella. A total of 259 employees in our hospital employees were examined for anti rubella hemagglutination inhibition (HI) tests with informed consent and recommended to take rubella vaccines. Sixty-seven employees (26%) among 257 examined for tests were found susceptible to rubella, and 53 employees were vaccinated. After vaccination, the outbreak was stamped out immediately. There was no rubella patient infected from employee. Nine among the 15 infected employees had declared to have a history of rubella or rubella vaccines before onsets, suggesting interviews are not reliable. There were many susceptible persons and rubella patients among elderly women and male personnel; therefore, measures are needed for elderly personnel as well as younger employees. In addition, adequate measures should be taken to prevent CRS, because many female personnel capable of pregnancy work in hospitals. The cost of the rubella HI tests and vaccination was approximately yen 200,000 (about dollar 1,600). The absence due to illness per one person was 6 days, and the wage per one day was about yen 12,000 (about dollar 100) on the average. The overall cost required in the outbreak was estimated to be approximate yen 1,400,000 (about dollar 12,000). Considering that an outbreak of rubella causes not only a large amount of expenditure but also loss of hospital income, the investment to prevent a rubella outbreak is quite valuable in the management of a hospital.

Adult↗

PubMed1984

Postmortem radiographic, histological and bacteriological studies of terminal respiratory infections and other pulmonary lesions in hospital and non-hospital necropsies.

One lung from 109 unselected hospital and 43 unselected non-hospital necropsies was studied using postmortem radiography with histological verification. Signs of acute bacterial infection, including bronchiolitis or bronchopneumonia, were present in 42.2% of the hospital necropsies and infection was the immediate cause of death in 8.3%. There was only one case of incipient bronchopneumonia among the non-hospital necropsies. Emphysema was the most common other pulmonary lesion in both groups. Gram negative bacteria were found significantly more often in the bronchial mucus of lungs with any pulmonary lesion, particularly those with signs of bacterial infection, than in the bronchial mucus of morphologically normal lungs in both groups of patients. In addition, the frequency of infections was associated with length of stay in hospital. This may reflect the prevalence of Gram negative infections in hospitals.

Adolescent↗

PubMed2005

Determinants of hospital length of stay among patients with pneumonia admitted to a large Canadian hospital from 1991 to 2001.

BACKGROUND: Pneumonia is a common reason for hospital admission, and the cost of treatment is primarily determined by length of stay (LOS). OBJECTIVES: To explore the changes to and determinants of hospital LOS for patients admitted for the treatment of community-acquired pneumonia over a decade of acute hospital downsizing. METHODS: Data were extracted from the database of Vancouver General Hospital, Vancouver, British Columbia, on patients admitted with community-acquired pneumonia (International Classification of Diseases, Ninth Revision, Clinical Modification codes 481.xx, 482.xx, 483.xx, 485.xx and 486.xx) from January 1, 1991 to March 31, 2001. The effects of sociodemographic factors, the specialty of the admitting physician (family practice versus specialist), admission from and/or discharge to a long-term care facility (nursing home) and year of admission, adjusted for comorbidity, illness severity measures and other potential confounders were examined. Longitudinal changes in these factors over the 10-year period were also investigated. RESULTS: The study population (n=2495) had a median age of 73 years, 53% were male and the median LOS was six days. Adjusted LOS was longer for women (10% increase, 95% CI 3 to 16), increasing age group (7% increase, 95% CI 4 to 10), admission under a family physician versus specialist (42% increase, 95% CI 32 to 52) and admission from home with subsequent discharge to a long-term care facility (75% increase, 95% CI 47 to 108). Adjusted hospital LOS decreased by an estimated 2% (95% CI 1 to 3) per annum. The mean age at admission and the proportion admitted from long-term care facilities both increased significantly over the decade (P<0.05). CONCLUSIONS: Results suggest that the management of hospitalized patients with pneumonia changed substantially between 1991 and 2001. The interface of long-term care facilities with acute care would be an important future area to explore potential efficiencies in caring for patients with pneumonia.

Adolescent↗