[Chaux-de-Fonds hospital: from charity hospital to modern hospital].
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The effects of hospital-physician integration strategies on hospital financial performance.
STUDY QUESTION: This study investigated the longitudinal relations between hospital financial performance outcomes and three hospital-physician integration strategies: physician involvement in hospital governance, hospital ownership by physicians, and the integration of hospital-physician financial relationships. DATA SOURCES AND STUDY SETTING: Using secondary data from the State of California, integration strategies in approximately 300 California short-term acute care hospitals were tracked over a ten-year period (1981-1990). STUDY DESIGN: The study used an archival design. Hospital performance was measured on three dimensions: operational profitability, occupancy, and costs. Thirteen control variables were used in the analyses: market competition, affluence, and rurality; hospital ownership; teaching costs and intensity; multihospital system membership; hospital size; outpatient service mix; patient volume case mix; Medicare and Medicaid intensity; and managed care intensity. DATA COLLECTION/EXTRACTION: Financial and utilization data were obtained from the State of California, which requires annual hospital reports. A series of longitudinal regressions tested the hypotheses. PRINCIPAL FINDINGS: Considerable variation was found in the popularity of the three strategies and their ability to predict hospital performance outcomes. Physician involvement in hospital governance increased modestly from 1981-1990, while ownership and financial integration declined significantly. Physician governance was associated with greater occupancy and higher operating margins, while financial integration was related to lower hospital operating costs. Direct physician ownership, particularly in small hospitals, was associated with lower operating margins and higher costs. Subsample analyses indicate that implementation of the Medicare prospective payment system in 1983 had a major impact on these relationships, especially on the benefits of financial integration. CONCLUSIONS: The findings support the validity of hospital-physician financial integration efforts, and to a lesser extent the involvement of physicians in hospital governance. The results lend considerably less support for strategies built around direct physician ownership in hospitals, particularly since PPS implementation. RELEVANCE/IMPACT: These findings challenge prior studies that found few financial benefits to hospital-physician integration prior to PPS implementation in 1983. The results imply that financial benefits of integration may take several years after implementation to emerge, are most salient in a managed care or managed competition environment, and vary by hospital size and multihospital system membership.
Analysis of Variance↗
Comparison of pediatric hospitalization using the pediatric appropriateness evaluation protocol at three diverse hospitals in Louisiana.
The purpose of this study was to compare the number of inappropriate pediatric admissions and hospital days in three hospitals in Louisiana using Pediatric Appropriateness Evaluation Protocol (PAEP) criteria. The hospitals studied included an urban, nontertiary care, teaching hospital with 20 inpatient, pediatric beds (A); a private, tertiary care hospital with 30 beds (B); and a tertiary care, regional referral center with 133 pediatric beds (C). The study prospectively observed all nonintensive care pediatric admissions (> six months of age) between May 1 and June 30, 1993. Admissions and subsequent hospital days were labeled as appropriate or inappropriate based on PAEP criteria. A significantly shorter hospital stay (days) was demonstrated at hospital C (4.41 +/- 1.01, p < .05) compared to A (5.98 +/- 4.95) or B (5.78 +/- 1.21). Similarly, hospital B had significantly more patients admitted electively (19%, p < .05) compared to A (4%) or C (15%). The percentage of inappropriate admissions for hospitals A, B, and C were 11.0, 10.0, and 2.0 (p < .05) and hospital days 18.0, 22.0, and 12.0 (p < .05), respectively. A significant proportion of inappropriate hospital days came from trauma admissions in hospital A (18%, p < .05) and elective admissions in hospital B (36%, p < .05). Hospital A had 99% of patients with either Medicaid or uninsured payor status compared to 35% and 84% at hospital B and C, respectively. Significant differences in the rate of inappropriate admission or subsequent hospital days were demonstrated in the three hospitals studied. Finally, the rates of inappropriate hospitalization demonstrated in this study of Louisiana hospitals were similar to previous studies using the PAEP in other regions.
Analysis of Variance↗
Hospital outcomes in major teaching, minor teaching, and nonteaching hospitals in New York state.
PURPOSE: The possible benefit that hospital teaching status may confer in the care of patients with cardiovascular disease is unknown. Our purpose was to determine the effect of hospital teaching status on in-hospital mortality, use of invasive procedures, length of stay, and charges in patients with myocardial infarction, heart failure, or stroke. SUBJECTS AND METHODS: We analyzed a New York State hospital administrative database containing information on 388 964 consecutive patients who had been admitted with heart failure (n = 173 799), myocardial infarction (n = 121 209), or stroke (n = 93 956) from 1993 to 1995. We classified the 248 participating acute care hospitals by teaching status (major, minor, nonteaching). The primary outcomes were standardized in-hospital mortality ratios, defined as the ratio of observed to predicted mortality. RESULTS: Standardized in-hospital mortality ratios were significantly lower in major teaching hospitals (0.976 for heart failure, 0.945 for myocardial infarction, 0.958 for stroke) than in nonteaching hospitals (1.01 for heart failure, 1.01 for myocardial infarction, 0.995 for stroke). Standardized in-hospital mortality ratios were significantly higher for patients with stroke (1.06) but not heart failure (1.0) or myocardial infarction (1.06) in minor teaching hospitals than in nonteaching hospitals. Compared with nonteaching hospitals, use of invasive cardiac procedures and adjusted hospital charges were significantly greater in major and minor teaching hospitals for all three conditions. The adjusted length of stay was also shorter for myocardial infarction in major teaching hospitals and longer for stroke in minor teaching hospitals. CONCLUSION: Major teaching hospital status was an important determinant of outcomes in patients hospitalized with myocardial infarction, heart failure, or stroke in New York State.
Aged↗
Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients.
BACKGROUND: Acutely ill older persons often experience adverse events when cared for in the acute care hospital. OBJECTIVE: To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home. DESIGN: Prospective quasi-experiment. SETTING: 3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center. PARTICIPANTS: 455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. INTERVENTION: Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital. MEASUREMENTS: Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care. RESULTS: Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P = 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care (5081 dollars vs. 7480 dollars) (P < 0.001). LIMITATIONS: Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences. CONCLUSIONS: The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.
Acute Disease↗
In-hospital cardiopulmonary resuscitation: organization, management and training in hospitals of different levels of care.
BACKGROUND: : During recent years in-hospital cardiopulmonary resuscitation (CPR) management has received much attention. This can be attributed to the Utstein model for in-hospital CPR developed in 1997. The present status of in-hospital resuscitation management in Finnish hospitals is not known. Therefore, a study was designed to describe the organization of training and clinical management of CPR in Finnish hospitals of different levels of care. METHODS: : In the summer of 2000, we performed a cross-sectional mail survey throughout Finland, including all district, central and university hospitals. The questionnaire outlined in detail in-hospital resuscitation management and training. For analysis the hospitals were divided into primary, secondary and tertiary groups, depending on levels of care. RESULTS: : Most hospitals (72%) reported having a physician or a nurse in charge of resuscitation management and training. Training in advanced life support was more common among nurses (80%) than among physicians (53%). Surprisingly, a majority of respondents (75%) reported that they felt training in CPR was insufficient. On the general wards and on wards treating cardiac patients, defibrillation was in most cases performed by a physician (91% and 51%, respectively), and less often by a nurse (16% and 31%, respectively). In the secondary and tertiary hospitals cardiac arrest was managed by a cardiac arrest team (53% and 62%, respectively) and in the primary hospitals by the ward physician (56%), anesthesiologist or emergency physician on call (44%). Most hospitals used do-not-resuscitate orders (83%) but only 33% of the hospitals had a unified style of notation. Systematic data collection was practised in 55% of hospitals, predominantly by using a model of their own. Only a few hospitals (11%) used the in-hospital Utstein model. CONCLUSION: : Our study showed that more attention needs to be paid to CPR management in Finnish hospitals. At present, 25% of hospitals do not have an appointed physician or nurse in charge of organizing CPR management. The study also revealed a lack of regular organized training in resuscitation for physicians. Fifty-five per cent of hospitals practise systematic data collection, but only 11% according to the Utstein template; and without which further quality assurance is difficult.
Cardiopulmonary Resuscitation↗
GPs' motives for referrals to general hospitals: does access to GP hospital beds make any difference?
OBJECTIVES: We aimed to explore the relative impact of medical and other situational motives on GP's decisions to refer patients to specialist care in a general hospital, and to assess whether having access to a GP hospital influences the decisions. METHODS: We carried out a prospective study of consecutive doctor-patient contacts during one week. The effects of main motives, medical, social/nursing, general hospital advice, distance from the nearest general hospital and access to GP hospitals on referral decisions were explored by logistic regression. The motives for different referral decisions were also explored through frequency analyses. The study was set in general practices in the county of Finnmark in North Norway, which included 40 GPs from rural practices with access to a GP hospital and eight GPs working closer to a general hospital without access to GP hospital. We studied 2496 doctor-patient contacts, which resulted in 411 patients being considered for any kind of referral, of which 205 were referred to the general hospital. RESULTS: Medical needs were recorded as the only referral motive of major importance in about half of the cases considered for referral, while additional motives were recorded in the other half. The rationale for admissions to general hospitals and GP hospitals (in-patient care) was compatible in terms of the relative importance of the medical arguments. The GP hospital option was mainly chosen because of the long distance from the general hospital, nursing needs and the preferences of the patient and the family, and resulted in a lower proportion of patients being referred to general hospitals from GPs with access to a GP hospital. CONCLUSION: Medical motives dominate the decision to refer patients to general hospitals, but access to a GP hospital, in cases where nursing needs and long distances to the general hospital are supplementary considerations, reduces the proportion of patients being referred to general hospitals.
Adolescent↗
Does the implementation of responsibility centers, total quality management, and physician fee programs improve hospital efficiency? Evidence from Taiwan hospitals.
OBJECTIVES: This study evaluates whether the implementation of various types of hospital-physician integration strategies, such as the responsibility centers system, total quality management, and physician fee programs, enhance efficiency for Taiwan hospitals. Because hospitals in Taiwan are structurally similar to staff-model HMOs, the study has implications beyond Taiwan. RESEARCH DESIGN: The Data Envelopment Analysis model is applied to measure hospital efficiency. Hospital efficiency refers to the ability to produce more outputs (eg, ambulatory and emergency visits, inpatient days, and inpatient visits) with the same inputs (eg, physicians, nurses, ancillary labor, and hospital beds). The sample consists of 90 general hospitals in Taiwan from 1994 to 1996. In addition, multitobit regression analysis is used to simultaneously estimate the effects of the hospital-physician integration strategies and provide better control for the effect of other factors (eg, size, degree of competition, ownership structure, teaching status, and the change in regulatory regime) that may also affect hospital efficiency. RESULTS: When evaluating the hospital-physician integration strategies individually, hospitals that implemented the responsibility centers system, total quality management, and physician fee programs were more efficient than hospitals that did not. Controlling for other factors using the multitobit model, hospitals that implemented physician fee programs remained significantly more efficient than others. In addition, hospitals that implemented total quality management were more efficient when they had implemented the strategy for at least 2 years. Hospitals that implemented the responsibility centers system were more efficient but only when integrating the system with formal incentive schemes. CONCLUSIONS: Physician fee programs seem to provide the most direct and robust incentives to enhance hospital efficiency under a fee-for-service regime like that in Taiwan. Because of time-lagged effects, hospitals that implemented the total quality management programs were more efficient but only when the programs had been implemented for at least 2 years. The responsibility centers system can also be effective when the system was associated with formal incentive schemes. The results indicate the importance of having both the individual-based and team-based incentives in place. Finally, the hospital-physician integration strategies appear to be effective individually, but the results change significantly when they are evaluated simultaneously, together with other control variables, in the tobit model. This indicates the importance of investigating hospital-physician integration strategies as a portfolio instead of a single tool.
Decision Making, Organizational↗
U.S. hospital care for HIV-infected persons and the role of public, private, and Veterans Administration hospitals.
Hospitals are a major provider of medical care for human immunodeficiency virus (HIV)-infected persons. Although utilization and patterns of care profiles in public and private hospitals have been evaluated for acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), one of the most costly and common severe complications of AIDS, information from Veterans Administration (VA) hospitals has not been reported previously. This article reports on inpatient care for PCP patients by obtaining data from VA, private, and public hospitals. Cost and resource utilization data were obtained from reviews of medical records, claims, and provider bills from 26 non-VA hospitals and 18 VA hospitals in 10 cities in the United States. Data on severity of illness, patterns of care, and outcomes for PCP were obtained from medical record reviews from 2,174 PCP cases treated in 82 non-VA and 14 VA hospitals in five U.S. cities. Estimates were made of the average costs and the rates of use of diagnostic tests, anti-PCP medications, and intensive care units for samples of public hospital, private hospital, and VA patients with PCP. With mean charges for a single PCP episode of $14,500 to $16,060, PCP remains one of thea most costly complications of AIDS. Although the severity of PCP illness at admission was greatest at public hospitals, the intensity of care was lowest: for frequency of cytologic diagnosis (48% at public, 62% at VA, and 66% at private hospitals), bronchoscopy (45% at public, 60% at VA, and 66% at private hospitals), and intensive care unit use (11% at public, 22% at VA, and 19% at private hospitals). In-hospital mortality rates for PCP also differed in the three types of hospitals (20% at public, 24% at VA, and 18% at private hospitals). Patterns of PCP care differ among VA, public, and private hospitals. Future studies on the HIV epidemic should include data collected from uniform data sources from VA hospitals, in addition to public and private hospitals, to provide insight on the processes of care and outcomes for HIV-infected persons.
AIDS-Related Opportunistic Infections↗
In-hospital mortality following coronary artery bypass graft surgery in Veterans Health Administration and private sector hospitals.
OBJECTIVES: Compare severity-adjusted in-hospital mortality in patients undergoing coronary artery bypass graft surgery (CABG) in VA and private sector hospitals in two geographic regions. RESEARCH DESIGN: Retrospective Cohort Study. SUBJECTS: Consecutive male patients undergoing CABG from October 1993 to December 1996 in: 43 VA hospitals with cardiac surgery programs (n = 19,266); 32 hospitals in New York (NY) State (n = 44,247); and 10 hospitals in Northeast (NE) Ohio (n = 9696). METHODS: Demographic and clinical data were abstracted from medical records. Logistic regression analysis identified 10 independent patient-level predictors (P <0.01) of in-hospital mortality: age, prior CABG, angioplasty before CABG, ejection fraction, diabetes, peripheral vascular disease, congestive heart failure (CHF), cerebrovascular disease, renal insufficiency, and chronic obstructive pulmonary disease (COPD). RESULTS: Unadjusted mortality was higher in VA patients than in NY or NE Ohio patients (3.5% vs. 2.0%, and 2.2%, respectively). Mortality decreased (P <0.001) with increasing volume (3.6% in low [<500 cases], 3.0% in moderate [500-1000 cases], and 2.0% in high [>1000 cases] volume hospitals). Median volume was lower in VA than private sector hospitals (410 vs. 1520), and no VA hospitals were classified as high volume. Adjusting for patient-level predictors and volume, the odds of death was higher in VA patients, relative to private sector patients (OR, 1.34; 95% CI, 1.11-1.63; P <0.001). In stratified analyses, the odds of death in VA patients was similar in low volume hospitals (OR, 0.86; P = 0.39), but higher in moderate volume hospitals (OR, 1.50; P = 0.01). CONCLUSIONS: VA hospitals had lower CABG volume than private sector hospitals in NY and NE Ohio, and higher in-hospital mortality. However, the difference in mortality was limited to moderate-volume hospitals. These findings suggest that hospital volume is an important modifier in comparisons of CABG mortality in VA and private sector hospitals. The higher mortality in VA hospitals may, in part, be caused by differences in surgical capacity and patient demand that lead to lower volume cardiac surgery programs.
Age Distribution↗
Randomised controlled trial of effectiveness of Leicester hospital at home scheme compared with hospital care.
OBJECTIVE: To compare effectiveness of patient care in hospital at home scheme with hospital care. DESIGN: Pragmatic randomised controlled trial. SETTING: Leicester hospital at home scheme and the city's three acute hospitals. PARTICIPANTS: 199 consecutive patients referred to hospital at home by their general practitioner and assessed as being suitable for admission. Six of 102 patients randomised to hospital at home refused admission, as did 23 of 97 allocated to hospital. INTERVENTION: Hospital at home or hospital inpatient care. MAIN OUTCOME MEASURES: Mortality and change in health status (Barthel index, sickness impact profile 68, EuroQol, Philadelphia geriatric morale scale) assessed at 2 weeks and 3 months after randomisation. The main process measures were service inputs, discharge destination, readmission rates, length of initial stay, and total days of care. RESULTS: Hospital at home group and hospital group showed no significant differences in health status (median scores on sickness impact profile 68 were 29 and 30 respectively at 2 weeks, and 24 and 26 at 3 months) or in dependency (Barthel scores 15 and 14 at 2 weeks and 16 for both groups at 3 months). At 3 months' follow up, 26 (25%) of hospital at home group had died compared with 30 (31%) of hospital group (relative risk 0. 82 (95% confidence interval 0.52 to 1.28)). Hospital at home group required fewer days of treatment than hospital group, both in terms of initial stay (median 8 days v 14.5 days, P=0.026) and total days of care at 3 months (median 9 days v 16 days, P=0.031). CONCLUSIONS: Hospital at home scheme delivered care as effectively as hospital, with no clinically important differences in health status. Hospital at home resulted in significantly shorter lengths of stay, which did not lead to a higher rate of subsequent admission.
Adult↗
Delays in suspicion and isolation among hospitalized persons with pulmonary tuberculosis at public and private US hospitals during 1996 to 1999.
BACKGROUND: While prior studies have shown that public and private hospitals differ in their rates of suspicion and isolation of patients who are at risk for tuberculosis (TB), no study has investigated whether this variation is due to differences in the impact of patient case-mix on hospitals or to variations attributable to specific hospital practice patterns. OBJECTIVE: To investigate patient-level and hospital-level factors associated with delays in TB suspicion and isolation among inpatients with pulmonary TB disease. DESIGN: Retrospective cohort study of patients hospitalized with culture-positive pulmonary TB during 1996 to 1999. SETTING: Patients with culture-proven pulmonary TB treated at three public hospitals (765 patients) and seven not-for-profit private hospitals (172 patients) in Chicago, Los Angeles, and southern Florida that provided care for five or more patients with TB per year during the study period. MEASUREMENTS: Two-day rates (within 48 h from admission) of acid-fast bacilli (AFB) smear orders and 1-day rates (within 24 h from admission) of TB isolation. RESULTS: Two-day rates of ordering AFB smears were > 80% at three public and two private hospitals vs 65 to 75% at five private hospitals. One-day rates of TB isolation at the three public hospitals were 64%, 79%, and 86%, respectively, vs 39 to 58% at the seven private hospitals. Delays of > 2 days in ordering AFB smears were associated with patient-level factors: absence of cough (adjusted odds ratio [AOR], 6.02; 95% confidence interval [CI], 3.82 to 9.52), cavitary lung lesion (AOR, 5.17; 95% CI, 1.98 to 13.50), night sweats (AOR, 3.38; 95% CI, 1.90 to 5.99), chills (AOR, 1.70; 95% CI, 1.01 to 2.88), and female gender (AOR, 1.66; 95% CI, 1.06 to 2.60). Delays of > 1 day in ordering pulmonary isolation were associated with patient-level factors: absence of cough (AOR, 3.40; 95% CI, 2.31 to 5.03), cavitary lung lesion (AOR, 2.66; 95% CI, 1.57 to 4.50), night sweats (AOR, 1.98; 95% CI, 1.35 to 2.92), and history of noninjecting drug use (AOR, 1.86; 95% CI, 1.16 to 2.99) and one hospital-level factor: receiving care at a nonpublic hospital. Even after adjustment for patient-level factors, TB patients at private hospitals were half as likely as those at public hospitals to be placed in pulmonary isolation (AOR, 0.47; 95% CI, 0.30 to 0.72), while odds of suspecting TB in these same patients were similar at both hospitals. CONCLUSION: Private hospitals should order TB isolation for all patients for whom AFB smears are ordered, a policy that has been instituted previously at public hospitals in our study.
Adult↗
Keeping children with asthma out of hospitals: parents' and physicians' perspectives on how pediatric asthma hospitalizations can be prevented.
BACKGROUND: A total of 196,000 hospitalizations occur each year among the 9 million US children who have been diagnosed with asthma. Not enough is known about how to prevent pediatric asthma hospitalizations. OBJECTIVES: To identify the proportion of preventable pediatric asthma hospitalizations and how such hospitalizations might be prevented, according to parents and physicians of hospitalized children with asthma. METHODS: A cross-sectional survey was conducted of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of all children who were admitted for asthma to an urban hospital in a 14-month period. RESULTS: The 230 hospitalized children had a median age of 5 years; most were poor (median annual family income: 13,356 dollars), were nonwhite (93%), and had public (74%) or no (14%) health insurance. Compared with children who were hospitalized for other ambulatory care-sensitive conditions, hospitalized children with asthma were significantly more likely to be African American (70% vs 57%), to be older, and not to have made a physician visit or telephone contact before admission (52% vs 41%). Only 26% of parents said that their child's admission was preventable, compared with 38% of PCPs and 43% of IAPs. The proportion of asthma hospitalizations that were assessed as preventable varied according to the source or combination of sources, from 15% for agreement among all 3 sources to 54% as identified by any 1 of the 3 sources. PCPs (83%) and IAPs (67%) significantly more often than parents (44%) cited parent/patient-related reasons for how hospitalizations could have been prevented, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (27%) and IAPs (26%) significantly more often than PCPs (11%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child's condition, and better quality of care. Multivariate analyses revealed that an age > or =11 years and no physician contact before the hospitalization were associated with approximately 2 times the odds of a preventable asthma hospitalization. CONCLUSIONS: The proportion of asthma hospitalizations assessed as preventable varies from 15% to 54%, depending on the source. Adolescents and families who fail to contact physicians before hospitalization are at greatest risk for preventable hospitalizations. Many pediatric asthma hospitalizations might be prevented if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers.
Allergens↗
Costs of poison-related hospitalizations at an urban teaching hospital for children.
BACKGROUND: Childhood poisonings continue to exact a notable toll in injury-related morbidity and economic cost. Because a substantial portion of this morbidity and economic cost is associated with hospitalization, an analysis of the cost of poisoning hospitalizations might help to identify areas in which medical care could be improved and costs could be reduced. OBJECTIVE: To assess the aggregate cost of poison-related hospitalizations and to analyze the trends in categorical poisoning costs during a 4-year period. DESIGN: Cost-benefit analysis of charge data and length of stay (LOS) for poison-related hospitalizations. SETTING: Admissions to one urban children's hospital. PATIENTS: Case mix data were reviewed to identify those children whose hospitalizations had a primary discharge diagnosis related to poisoning in fiscal years 1992 to 1995. MAIN OUTCOME MEASURES: Mean aggregate hospital charges and LOS for poisonings were compared for each of the 4 years of the study. Comparisons were also made with charges and LOS for hospitalizations for all other diagnoses during the same period. Trends in hospital charges and LOS for the most common specific types of poisoning were analyzed individually. Linear regression statistics were used to compare the costs and LOS of specific types of poisoning. RESULTS: There were 638 poison-related hospitalizations during the 4-year study (0.9% of all pediatric hospital admissions). Charges per case decreased from $7934 in fiscal year 1992 to $4968 in fiscal year 1995 (z = -2.74, P = .006); mean LOS decreased from 5.85 days in 1992 to 3.45 days in 1995 (z = 2.84, P = .005). These trends exceeded smaller trends toward decreasing charges and LOS seen also for non-poison-related hospitalizations. Acetaminophen, lead, and antidepressant medications were the most common and most costly specific agents implicated in poison-related hospitalizations during the study period. Linear regression analysis showed a significant decrease in charges (F = 6.35, R2 = 0.09, P = .014) and LOS for acetaminophen (F = 4.30, R2 = 0.063, P < .04) but not for lead or antidepressant poison-related hospitalizations. CONCLUSIONS: Despite an increasing number of children hospitalized for poisoning at one institution during a 4-year period, per case hospital charges decreased substantially. The cost savings were associated with a marked decrease in LOS. Still, poison-related admissions to a single pediatric facility accounted for almost $1 million in hospital charges in fiscal year 1995. A few agents are overrepresented; new poisoning prevention measures aimed at these toxic agents are warranted. We conclude that further outcomes studies are needed to delineate cost-effective improvements in patient care targeted toward poisonings owing to those agents.
Adolescent↗
Counting in-hospital deaths in England: a comparison of hospital computer systems and mortuary registers.
OBJECTIVES: In-hospital death counts derived from hospital computer systems have been used in England by an independent company, 'Dr Foster', to rank the quality of care of hospitals, but the validity of the underlying data remains unclear. This study compares counts of in-hospital deaths using two different sources - the hospital computer system and the mortuary register - to determine: whether the counts of in-hospital deaths from these two sources differed; qualitative explanations for possible sources of discrepancy; the direction and magnitude of any differences; and the possible impact of any differences on the Dr Foster rankings. METHODS: The four highest and the four lowest National Health Service (NHS) hospitals in the West Midlands, as ranked by Dr Foster, participated. Each hospital was asked to compare the monthly counts of in-hospital deaths from the hospital computer system and the hospital mortuary register for the fiscal year 1999/2000. RESULTS: One hospital, with a computerised mortuary register, had identical counts of in-hospital deaths. Two hospitals reported 4-5% more deaths and four hospitals reported fewer deaths (0.4-7%) from their hospital computer system than from their mortuary register. These differences were not large enough to change their Dr Foster rankings. Wide discrepancies were noted on a monthly basis (range: -13.9% to +15.9%). DISCUSSION: The differences between the two sources of in-hospital death counts were not large enough to influence the Dr Foster ranks but were sufficient to raise concern about the validity and completeness of mortality data in the NHS.
Attitude of Health Personnel↗
[Hospitalization of peritoneal dialysis patients: the impact of peritonitis episodes on the hospitalization rate].
Peritonitis is still a frequent complication in peritoneal dialysis patients. Medical guidelines have been established to manage this infection. These guidelines do not provide any information regarding the requirement for hospitalization. The main objective of this study was to evaluate the impact of peritonitis episode on the hospitalization rate and on the hospitalization duration in a centre where peritoneal dialysis patients were hospitalized in case of peritonitis. This was a retrospective study of incident peritoneal patients over a six years period. Among 101 peritoneal dialysis patients 65% were hospitalized. Two hundred and twenty hospital stays were registered. The total duration of hospital stays was 2091 days. The hospitalization rate was 2 per patient and per year, the hospital duration was 19 days per patient per year. Of the 220 hospital stays, 67 (30%) were due to a peritoneal infection. Peritonitis episodes represent 581/2091 (28%) days of hospitalization. The mean duration of hospitalization for peritonitis was 8.7+/-7 days. Among the patients hospitalized for a peritonitis episode, 57% were assisted by a nurse at home to perform their peritoneal dialysis exchanges. Of the 67 peritonitis episodes, 91% were discharged from the hospital without any complication. This study emphases the fact that peritonitis has an important impact on the hospitalization rate and on the hospitalization duration in peritoneal dialysis patients. In an attempt to decrease the rate of hospitalization, educational programs are clearly needed in order to treat more peritonitis without any hospitalization requirement.
Adult↗
Hospital experience and expected mortality in patients with systemic lupus erythematosus: a hospital level analysis.
OBJECTIVE: To determine whether a hospital's experience in treating patients with systemic lupus erythematosus (SLE) is associated with the risk of in-hospital mortality among these patients. METHODS: The California Hospital Discharge Database, which contains information on all discharges from acute care hospitals in California, was used to identify patients with SLE hospitalized on an emergent or urgent basis from 1991 to 1994 (n = 9,989). For each of the 413 hospitals at which these patients were hospitalized, expected mortality risks were computed based on a model that included patient demographic and clinical characteristics, and differences between the observed and expected numbers of deaths were calculated. This difference was then associated with the average annual number of patients with SLE admitted to each hospital on an emergent or urgent basis. Similar analyses were performed for the subset of 2,372 patients hospitalized on an emergent basis (at 293 hospitals), and the subset of 405 patients hospitalized on an emergent basis due to SLE (at 122 hospitals). RESULTS: In all 3 patient subsets, there was an inverse association between the average annual number of patients with SLE hospitalized on an urgent or emergent basis at a hospital and the difference between the observed and expected number of deaths at that hospital. Highly experienced hospitals had fewer than expected deaths, while there was little association between the difference between the observed and expected number of deaths among less experienced hospitals. CONCLUSION: Hospitals that treat larger numbers of patients with SLE have fewer than the expected number of deaths among such patients.
Adult↗
Variation in Michigan hospital use rates: do physician and hospital characteristics provide the explanation?
Previous small area analysis studies have shown that hospital admission rates (total, medical and surgical) vary among hospital service areas. Using 1983 Michigan hospital inpatient data from 53 nonmetropolitan Detroit lower peninsula hospital service areas, one physician characteristic and 13 hospital characteristics (in the categories of resource supply, services offered and organization) were tested for their association with and explanation of 14 hospital use rates. Registered nurses per bed and the weighted proportion of board certified physicians to total physicians were inversely related to and offered significant contribution to the explanation of the variation in total use rates and in four medical causes for admission rates (circulatory, respiratory, digestive and genito-urinary). Physician and hospital variables provided significant explanation for six of the seven surgical procedure rates tested (appendectomy, hemorrhoidectomy, cholecystectomy, inguinal hernia repair, prostatectomy and hysterectomy). Four causative factors derived from the characteristics studied were postulated to influence the hospital use rates. The first factor was the small rural nature of the average high use hospital service area. High use areas had a lower proportion of board certified physicians and fewer RNs per bed, beds per hospital, and house staff per 10,000 population than did low use areas. Another factor was the inequality in the distribution of high technology diagnostic services. High use hospital service areas had fewer diagnostic services than did low use areas. The third factor was the inequality in the rural hospital environment produced by the presence or absence of medical education programs. The fourth factor was the impact of the definition and size of a hospital service area. Current small area analysis methodology assigns every small area to a hospital service area, no matter what the probability of the population using the hospital(s) within the service area. This research questions that methodology, suggests the need for hospital service area definitions based upon the specific diagnosis or procedure being studied and postulates that some rural hospital distance decay curves may turn upward at farther distances when the immediate availability of treatment is too critical to allow patients to return to distant residences.
Catchment Area, Health↗