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PubMed2005

Hospital at home versus in-patient hospital care.

BACKGROUND: Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period. OBJECTIVES: To assess the effects of hospital at home compared with in-patient hospital care. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (November 2004), MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995) and the Medical Care supplement on economic literature (1970 to 1990). SELECTION CRITERIA: Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Twenty two trials are included in this update of the review. Among trials evaluating early discharge hospital at home schemes we found an odds ratio (OR) for mortality of 1.79 95% CI 0.85 to 3.76 for elderly medical patients (age 65 years and over) (n = 3 trials); OR 0.58; 95% CI 0.29 to 1.17 for patients with chronic obstructive pulmonary disease (COPD) (n = 5 trials); and OR 0.78; 95%CI 0.52 to 1.19 for patients recovering from a stroke (n = 4 trials). Two trials evaluating the early discharge of patients recovering from surgery reported an OR 0.43 (95% CI 0.02 to 10.89) for patients recovering from a hip replacement and an OR 1.01 (95% CI 0.37 to 2.81) for patients with a mix of conditions at three months follow-up. For readmission to hospital we found an OR 1.76; 95% CI 0.78 to 3.99 at 3 months follow-up for elderly medical patients (n = 2 trials); OR 0.81; 95% CI 0.55 to 1.19 for patients with COPD (n = 5 trials); and OR 0.96; 95% CI 0.63 to 1.45 for patients recovering from a stroke (n = 3 trials). No significant heterogeneity was observed. One trial recruiting patients following surgery for hernia or varicose veins reported 0/117 versus 2/121 patients were re admitted (Ruckley 1978); another that 2/37 (5%) versus 1/49 (2%) (difference 3%, 95% CI -5% to 12%) of patients recovering from a hip replacement, 4/47 (9%) versus 1/39 (3%) (difference 6%, 95% CI -3% to 15%) of patients recovering from a knee replacement, and 7/114 (6%) versus 13/124 (10%) (difference -4% 95% CI -11% to 3%) of patients recovering from a hysterectomy were readmitted. A third trial analysing surgical and medical patients together reported that 42/159 versus 17/81 patients were readmitted at 3 months (OR 1.34 95% CI 0.66 to 2.20). Allocation to hospital at home resulted in a small reduction in hospital length of stay, but hospital at home increased overall length of care. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital, while the view of carers was mixed. AUTHORS' CONCLUSIONS: Despite increasing interest in the potential of hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. For these clinical groups hospital length of stay is reduced, although this is offset by the provision of hospital at home. Future primary research should focus on rigorous evaluations of admission avoidance schemes and standards for original research should aim at assisting future meta-analyses of individual patient data from these and future trials.

Adult↗

PubMed2006

Analysis on antimicrobial resistance of clinical bacteria isolated from county hospitals and a teaching hospital.

The distinction of antimicrobial resistance of clinical bacteria isolated from county hospitals and a teaching hospital was investigated. Disc diffusion test was used to study the antimicrobial resistance of isolates collected from county hospitals and a teaching hospital. The data was analyzed by WHONET5 and SPSS statistic software. A total of 655 strains and 1682 strains were collected from county hospitals and a teaching hospital, respectively, in the year of 2003. The top ten pathogens were Coagulase negative staphylococci (CNS), E. coli, Klebsiella spp., S. areus, P. aeruginosa, Enterococcus spp., Enterobacter spp., otherwise Salmonella spp., Proteus spp., Shigella spp. in county hospitals and Streptococcus spp., Acinetobacter spp., X. maltophilia in the teaching hospital. The prevalence of multi-drug resistant bacteria was 5% (4/86) of methicillin-resistant S. areus (MRSA), 12% (16/133) and 15.8% (9/57) of extended-spectrum beta-lactamases producing strains of E. coli and Klebsiella spp., respectively, in county hospitals. All of the three rates were lower than that in the teaching hospital and the difference was statistically significant (P < 0. 01). However, the incidence of methicillin-resistant CNS (MRCNS) reached to 70% (109/156) in the two classes of hospitals. Generally, the antimicrobial resistant rates in the county hospitals were lower than those in the teaching hospital, except the resistant rates of ciprofloxacin, erythromycin, clindamycin, SMZco which were similar in the two classes of hospitals. There were differences between county hospitals and the teaching hospital in the distribution of clinical isolates and prevalence of antimicrobial resistance. It was the basis of rational use of antimicrobial agents to monitor antimicrobial resistance by each hospital.

Anti-Bacterial Agents↗

PubMed1998

Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes.

OBJECTIVES: To compare hospital at home care with inpatient hospital care in terms of patient outcomes. DESIGN: Randomised controlled trial with three month follow up. SETTING: District general hospital and catchment area of neighbouring community trust. SUBJECTS: Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32). INTERVENTIONS: Hospital at home care or inpatient hospital care. MAIN OUTCOME MEASURES: Dartmouth COOP chart to measure patients' general health status; SF-36 to measure possible limitations in physical functioning of patients with hysterectomy; disease specific measures-chronic respiratory disease questionnaire, Barthel index for elderly medical patients, Oxford hip score, and Bristol knee score; hospital readmission and mortality data; carer strain index to measure burden on carers; patients' and carers' preferred form of care. RESULTS: At follow up, there were no major differences in outcome between hospital at home care and hospital care for any of the patient groups except that those recovering from hip replacement reported a significantly greater improvement in quality of life with hospital at home care (difference in change from baseline value 0.50, 95% confidence interval 0.13 to 0.88). Hospital at home did not seem suitable for patients recovering from a knee replacement, as 14 (30%) of patients allocated to hospital at home remained in hospital. Patients in all groups preferred hospital at home care except those with chronic obstructive airways disease. No differences were detected for carer burden. Carers of patients recovering from knee replacement preferred hospital at home care, while carers of patients recovering from a hysterectomy preferred hospital care. CONCLUSIONS: Few differences in outcome were detected. Thus, the cost of hospital at home compared with hospital care becomes a primary concern.

Adult↗

PubMed2004

Hospitalizations for tuberculosis in the United States in 2000: predictors of in-hospital mortality.

STUDY OBJECTIVES: Despite curative therapy, mortality remains high for hospitalized patients with tuberculosis (TB) in the United States. The purpose of this study was to describe the characteristics of hospitalized patients with TB and to identify patient characteristics associated with in-hospital mortality. DESIGN, SETTING, AND PATIENTS: Using the 2000 Nationwide Inpatient Sample, representing 20% of US hospital admissions, we identified 2,279 hospital admissions with a primary diagnosis of TB (International Classification of Diseases, ninth revision, codes, 010.xx to 018.xx). MEASUREMENTS AND RESULTS: Mortality was the main outcome measure. Logistic regression analyses were performed including age, gender, race, insurance status, income, Deyo-adapted Charlson comorbidity index (DCI), HIV status, hospital admission source, and hospital characteristics as explanatory variables. A disproportionate number of patients hospitalized with TB were men (64%), nonwhite (72%), lived in areas with median incomes of < $35,000 (50%), and had publicly funded health insurance (49%) or no health insurance (17%). The mortality rate for patients hospitalized for TB was greater than that for non-TB hospital admissions (4.9% vs 2.4%, respectively; p < 0.001). Patients with TB who died during hospitalization were older (mean age, 65.1 vs 49.4 years, respectively; p < 0.001), had greater comorbid illness (DCI, 1.1 vs 0.55, respectively; p < 0.001), required longer hospitalizations (19.9 vs 13.9 days, respectively; p < 0.001), and accumulated substantially higher charges ($79,585 vs $31,610, respectively; p < 0.001) than did patients with TB who were alive at hospital discharge. In a multivariable analysis, older age, comorbid illnesses, and emergency department admissions were independently associated with mortality. The total charges for TB hospitalizations in the United States in 2000 exceeded $385 million. CONCLUSIONS: Despite public health efforts, patients who are hospitalized with TB are frequently admitted through emergency care settings, have a high risk of in-hospital mortality, and incur substantial hospital charges. To improve TB health outcomes, more vigorous clinical management and prevention strategies should especially target older patients and those with comorbid medical conditions.

Comorbidity↗

PubMed2006

In-hospital mortality for children with hypoplastic left heart syndrome after stage I surgical palliation: teaching versus nonteaching hospitals.

OBJECTIVES: Teaching hospitals are perceived to provide a higher quality of care for the treatment of rare disease and complex patients. A substantial proportion of stage I palliation for hypoplastic left heart syndrome (HLHS) may be performed in nonteaching hospitals. This study compares the in-hospital mortality of stage I palliation between teaching and nonteaching hospitals. METHODS: The authors conducted a retrospective cohort study using the Kids' Inpatient Database 1997 and 2000. Patients with HLHS undergoing stage I palliation were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. RESULTS: Seven hundred fifty-four and 880 discharges of children with HLHS undergoing stage I palliation in 1997 and 2000, respectively, were identified. The in-hospital mortality for the study population was 28% in 1997 and 24% in 2000. Twenty percent of stage I palliation operations were performed in nonteaching hospitals in 1997. Two percent of operations were performed in nonteaching hospitals in 2000. In 1997 only, in-hospital mortality remained higher in nonteaching hospitals after controlling for stage I palliation hospital volume and condition-severity diagnoses. Low-volume hospitals performing stage I palliation were associated with increased in-hospital mortality in 1997 and 2000. CONCLUSIONS: Patients with HLHS undergoing stage I palliation in nonteaching hospitals experienced increased in-hospital mortality in 1997. A significant reduction in the number of stage I palliation procedures performed in nonteaching hospitals occurred between 1997 and 2000. This centralization of stage I palliation into teaching hospitals, along with advances in postoperative medical and surgical care for these children, was associated with a decrease in mortality. Patients in low-volume hospitals performing stage I palliation continued to experience increased mortality in 2000.

Adolescent↗

PubMed1995

Comparison of initial laparoscopic cholecystectomy at a community hospital versus a teaching hospital.

OBJECTIVE: To compare the initiation of laparoscopic cholecystectomy at a community hospital versus a tertiary-care teaching hospital. DESIGN: Retrospective chart review. SETTINGS: A general community hospital in Prince George, BC, and a tertiary-care teaching hospital in Vancouver. PATIENTS: One hundred and eighty-two patients in the community hospital and 318 patients in the tertiary-care centre. INTERVENTION: Laparoscopic cholecystectomy for symptomatic gallbladder disease. MAIN OUTCOME MEASURES: Preparation of surgeons for the new technique, complication rates, operating time, conversion rates to open cholecystectomy and duration of hospitalization. RESULTS: All community surgeons took didactic and laboratory courses in preparation for the new procedure and assisted each other for their first 10 cases, but surgeons at the teaching hospital had more varied preparation that included additional extensive laboratory work and preceptorships with surgeons experienced with the procedure. The rates of major complications of laparoscopic cholecystectomy were 6.5% at the community hospital compared with 5% at the tertiary-care centre. The rates of minor complications were 5.5% at community hospital and 5.3% at the tertiary-care centre. The rates of conversion to open cholecystectomy were 6.6% for the community hospital versus 4.7% for teaching hospital. The mean (and standard deviation) operating time was shorter at the community hospital than at the teaching hospital: 72.3 (30) minutes versus 106 (32) minutes (p < 0.0001). The mean (SD) length of stay was 2.5 (1.8) days at the community hospital and 3.4 (1.9) days at the teaching hospital. CONCLUSIONS: The introduction of laparoscopic cholecystectomy during a 2-year period was achieved safely at both hospitals. The complication rates were similar. The length of stay and operating times were shorter in the community hospital.

Adult↗

PubMed2000

The association between hospital type and mortality and length of stay: a study of 16.9 million hospitalized Medicare beneficiaries.

OBJECTIVES: To examine the association between hospital type and mortality and length of stay using hospitalized Medicare beneficiaries for a 10-year period. METHODS: The retrospective cohort study included 16.9 million hospitalized Medicare beneficiaries > or = 65 years of age admitted for 10 common medical conditions and 10 common surgical procedures from 1984 to 1993. A total of 5,127 acute-care hospitals in the United States were grouped into 6 mutually exclusive hospital types based on teaching status and financial structure (for-profit [FP], not-for-profit [NFP], osteopathic [OSTEO], public [PUB], teaching not-for-profit [TNFP], and teaching public [TPUB]) as reported in the 1988 American Hospital Association database. Logistic and linear regression methods were used to examine risk-adjusted 30-day and 6-month mortality and length of stay. RESULTS: During the 10-year study period, 10.6 million patients were admitted with 1 of the 10 selected medical conditions, and 6.3 million patients were hospitalized for 1 of the 10 selected surgical procedures. Patients at TNFP hospitals had significantly lower risk-adjusted 30-day mortality rates than patients at other hospital types when all diagnoses or procedures were combined (combined diagnoses: RR(TNFP) = 1.00 [reference], RR(TPUB) = 1.40, RR(OSTEO) = 1.14, RR(PUB) = 1.07, RR(FP) = 1.03, RR(NFP) = 1.02; combined procedures: RR(TNFP) = 1.00 [reference], RR(OSTEO) = 1.36, RR(TPUB) = 1.30, RR(PUB) = 1.16, RR(FP) = 1.13, RR(NFP) = 1.08). The results were mostly consistent when diagnoses and procedures were examined separately. After adjustment for patient characteristics, patients at other hospital types had 10% to 20% shorter lengths of stay (LOS) than patients at TNFP hospitals for most diagnoses and procedures studied. CONCLUSION: As measured by the risk-adjusted 30-day mortality, TNFP hospitals had an overall better performance than other hospital types. However, patients at TNFP hospitals had relatively longer LOS than patients at other hospital types, perhaps reflecting the medical education and research activities found at teaching institutions. Future research should examine the empirical evidence to help elucidate the adequate LOS for a given condition or procedure while maintaining the quality of care.

Aged↗

PubMed2003

Hospitalizations for arthritis and other rheumatic conditions: data from the 1997 National Hospital Discharge Survey.

OBJECTIVE: To describe the impact of arthritis and other rheumatic conditions on hospitals by describing the magnitude and characteristics of these hospitalizations. METHODS: Data from the 1997 National Hospital Discharge Survey were used to examine this impact. Arthritis was defined using International Classification of Diseases, 9th Revision, Clinical Modification, codes specified by the National Arthritis Data Workgroup. Arthritis-related hospitalizations were analyzed by principal diagnosis of arthritis and by any-listed arthritis diagnosis. RESULTS: In 1997, there were an estimated 744,000 hospitalizations with a principal arthritis diagnosis (3% of hospitalizations). Compared with nonarthritis hospitalizations, persons hospitalized with a principal arthritis diagnosis were older, had fewer comorbidities, had shorter hospital stays, were more likely to undergo a procedure, and were more likely to be discharged to short- and long-term care facilities. The most common diagnoses and procedures related to osteoarthritis. This profile was consistent with a healthier-than-average hospital population electively admitted for specific procedures and subsequent rehabilitation. There were an estimated 2.5 million hospitalizations with an any-listed arthritis diagnosis (>9% of hospitalizations). Persons hospitalized with an any-listed arthritis diagnosis were older, had more comorbidities, and had longer hospital stays than those with principal arthritis or nonarthritis hospitalizations. This profile was consistent with a sicker-than-average hospital population nonelectively admitted for reasons other than their arthritis, especially cardiovascular disease. CONCLUSION: Arthritis has a sizable impact on the hospital care system. As our population ages, this impact, in both human and economic terms, is likely to increase.

Adolescent↗

PubMed2006

Variation in hospital length of stay: do physicians adapt their length of stay decisions to what is usual in the hospital where they work?

OBJECTIVE: To test the hypothesis that physicians who work in different hospitals adapt their length of stay decisions to what is usual in the hospital under consideration. DATA SOURCES: Secondary data were used, originating from the Statewide Planning and Research Cooperative System (SPARCS). SPARCS is a major management tool for assisting hospitals, agencies, and health care organizations with decision making in relation to financial planning and monitoring of inpatient and ambulatory surgery services and costs in New York state. STUDY DESIGN: Data on length of stay for surgical interventions and medical conditions (a total of seven diagnosis-related groups [DRGs]) were studied, to find out whether there is more variation between than within hospitals. Data (1999, 2000, and 2001) from all hospitals in New York state were used. The study examined physicians practicing in one hospital and physicians practicing in more than one hospital, to determine whether average length of stay differs according to the hospital of practice. Multilevel models were used to determine variation between and within hospitals. A t-test was used to test whether length of stay for patients of each multihospital physician differed from the average length of stay in each of the two hospitals. PRINCIPAL FINDINGS: There is significantly (p<.05) more variation between than within hospitals in most of the study populations. Physicians working in two hospitals had patient lengths of stay comparable with the usual practice in the hospital where the procedure was performed. The proportion of physicians working in one hospital did not have a consistent effect for all DRGs on the variation within hospitals. CONCLUSION: Physicians adapt to their colleagues or to the managerial demands of the particular hospital in which they work. The hospital and broader work environment should be taken into account when developing effective interventions to reduce variation in medical practice.

Decision Making↗

PubMed2005

Effects of payment incentives, hospital ownership and competition on hospitalization decisions for ambulatory surgical procedures.

OBJECTIVE: To test the hypotheses that (1) for-profit (FP) and not-for-profit (NFP) hospitals are less likely than public hospitals to admit cases reimbursed by prospective payment favoring ambulatory over inpatient care; (2) admission odds of public, FP and NFP hospitals will converge under increasing hospital competition. METHODS: Retrospective, population-based, cross-sectional study covering 29,699 cases of unilateral, femoral/inguinal hernia operation (major surgical procedure) and 60,626 cases of cataract surgery (local surgical procedure), from Taiwan's National Health Insurance database was used. Diagnosis-wise logistic regression analysis were done to examine associations between admission propensities of FP versus public and NFP hospitals (large teaching hospitals with > or = 250 beds versus district hospitals with < 250 beds) under high and low competition, adjusted for clinical complications, and patient as well as physician demographics. RESULTS: Large public teaching hospitals are significantly more likely than FP district hospitals to admit hernia patients (ORs = 1.9 and 2.6, respectively, under high and low competition), and cataract surgery patients (ORs = 5.0 and 5.4, respectively, under high and low competition). The corresponding odds ratios for public district hospitals (relative to FP district hospitals) are 1.2 and 3.9 for hernia and 4.9 and 2.7 for cataract surgery. Odds ratios show convergence of admission odds across hospital ownership under high competition relative to low competition for hernia (OR range for different hospital types under high competition, 1.0-1.9; and under low competition, 1.0-3.9). Cataract cases show high divergence of admission odds between public and FP/NFP hospitals regardless of competition level (OR range for different hospital types under high competition, 0.3-5.0; and under low competition, 0.3-5.4). CONCLUSION: Overall, our data support the study hypotheses. Differences in the relevance of inpatient care for hernia and cataract surgery may account for the lack of admission convergence of public hospitals and FPs under high competition among cataract surgery group.

Ambulatory Surgical Procedures↗

PubMed1994

A time-insensitive predictive instrument for acute hospital mortality due to congestive heart failure: development, testing, and use for comparing hospitals: a multicenter study.

The purpose of this study was to develop a "time-insensitive" predictive instrument (TIPI) for acute hospital mortality due to congestive heart failure. In Phase 1, based on prospectively collected data on 401 congestive heart failure patients among 5,773 study patients who presented to six New England hospitals over a 2-year period whose chief complaints were chest pain, shortness of breath, or other cardiac symptoms, a multivariable logistic regression was used to develop the TIPI for acute mortality. Discrimination between patients who lived and those who died was reflected by receiver-operating characteristic (ROC) curve area of 0.90. Predicted mortality was found to not vary significantly from actual mortality rates across deciles of predicted probabilities from 0% to 100%. In Phase 2, the six hospitals' actual mortality rates for their congestive heart failure patients were compared to their respective rates predicted by the TIPI. Actual hospital mortality rates ranged from 3.6% to 11.3%, with no hospital having a statistically significantly higher rate. Predicted mortality rates ranged from 4% to 9%, with one hospital having a significantly lower predicted rate (P = .01), and one hospital having a borderline significantly higher predicted rate (P = .07). Individual hospitals' differences between actual and predicted mortality ranged from -3.8% to +4.7% (all NS). When grouped by hospital type, respectively for urban teaching, smaller city teaching, and rural non-teaching hospitals, the actual mortality rates were 5.1%, 10.5%, and 5.4%, (NS). The predicted mortality rates were 8.3%, 6.1%, and 5.4%, respectively, with the rate for urban major teaching centers being significantly higher (P = .03). No hospital type had significant differences between their actual and predicted mortality rates (NS). This congestive heart failure mortality TIPI (CHFM-TIPI) shows potential for risk-adjusted studies of hospitals, mortality for multi-hospital groups, hospital-to-hospital comparisons, and potentially for within-hospital assessment and if further validated, potentially also for real-time clinical use.

Acute Disease↗

PubMed2003

[Hospitalizations of hemodialysis patients (data of Kaunas University of Medicine Hospital in 2001)].

The number of patients with end-stage renal disease is increasing, therefore the need of renal replacement therapy is increasing. Rising cost of treating end stage renal disease patients includes not only the cost of dialysis procedure but also the cost of hospitalizations and ambulatory medicamental treatment. There is no analysis done of hospitalizations of end-stage renal disease patients in Lithuania. Our purpose--to examine hospitalization rate, causes and duration in end-stage renal disease patients dialyzed in Kaunas University of Medicine Hospital. We analyzed ambulatory case records of all end-stage renal disease patients dialyzed in our clinic in November 2001. Retrospective data about diabetes, ischemic heart disease, Karnofsky score, hospitalization rate and causes of hospitalizations were collected. Hospitalizations of the year 2001 analyzed separately. The study included 111 patients. There were 123 hospitalizations in 75 patients, 1967 total hospital days. Admission rate was 1.34+/-1.5 per patient year, 19.82+/-25.96 hospital days per patient year, the mean length of each hospitalization--16.26+/-11.57. Most frequent causes of hospitalization--start of hemodialysis, infections, other causes, rare cause - hemodialysis complications. Karnofsky score correlated negatively with duration of hospitalizations per patient year. No statistically significant correlation was found between duration of hospitalizations and the presence of diabetes, ischemic heart disease, the way of starting hemodialysis (urgent or not). In comparison with other countries, in our center there were less hospitalizations but longer hospital days per admission.

Adult↗

PubMed1999

Risk-adjusted in-hospital death rates for peer hospitals in rural and urban regions.

The purpose of this research project was to compare inpatient mortality rates for rural hospitals with mortality rates of urban hospitals of given sizes and ranges of service. Statistical adjustments for risk were made in the probability of death during hospitalization for 43,000 patients across 166 hospitals by age, gender, principal diagnosis, principal surgical procedure, characteristics of the secondary diagnoses, and whether or not cancer was a secondary diagnosis. Eighty-three small hospitals that had a relatively unspecialized range of services constituted the study group. Patient characteristics of this study group were moderately representative of the national population. A standardized score was calculated for each hospital using a formula based on the actual hospital death rate and the death rate expected for a given hospital with patients of the same demographic and medical characteristics. Patients admitted to hospitals in nonmetropolitan areas had a mortality rate of 0.41 percent compared with a mortality rate of 0.66 percent in peer hospitals in metropolitan areas. After mortality rates were risk-adjusted and converted to z scores, nonmetropolitan areas had an average z of +0.16, and metropolitan areas had an average z of -0.25, where positive z scores reflect a lower-than-average adjusted mortality rate. The metropolitan-nonmetropolitan (urban-rural) difference was not statistically significant, but it is meaningful in that rural hospitals tended to have a lower adjusted mortality rate than urban hospitals of the same size and type, indicating that rural hospitals had the same or lower adjusted mortality rates. The possibility of urban hospitals having riskier patients was minimized but could not be definitively ruled out. Taken together with other studies, the data are consistent with the view that small rural hospitals generally make appropriate transfer decisions for severely ill patients and provide quality care for retained patients.

Adolescent↗

PubMed1965