Efficiency and scale effect of county public hospitals in Shandong Province, China: a cross-sectional study.

OBJECTIVE: To evaluate the efficiency of county public hospitals in Shandong Province following China's new medical reform and compare the efficiency of hospitals with different bed sizes for improving efficiency. DESIGN AND SETTING: This was a cross-sectional study on the efficiency and size of 68 county public hospitals in China in 2017. OUTCOME MEASURES: Data envelopment analysis was used to calculate the efficiency scores of hospitals and to analyse the slack values of inefficient hospitals. The actual number of open beds, doctors, nurses and total expenditure were selected as inputs, and the total number of annual visits, discharges and total income were selected as outputs. The Kruskal-Wallis H test was employed to compare the efficiency of hospitals with different bed sizes. The χ2 test was used to compare the returns to scale (RTS) of hospitals with different bed sizes. RESULTS: Twenty (29.41%) hospitals were efficient. There were 27 hospitals with increasing returns to scale, 23 hospitals with constant returns to scale and 18 hospitals with decreasing returns to scale (DRS). The differences in technical efficiency (p=0.248, p>0.05) and pure technical efficiency (p=0.073, p>0.05) were not statistically significant. However, the differences in scale efficiency (p=0.047, p<0.05) and RTS (p<0.001) were statistically significant. Hospitals with DRS began to appear at 885 beds. All sample hospitals with more than 1100 beds were already saturated and some hospitals even had a negative scale effect. CONCLUSIONS: The government and hospital managers should strictly control the bed size in hospitals and make hospitals resume operating in the interests of public welfare. Interventions that rationally allocate health resources and improve the efficiency of medical workers are conducive to solving redundant inputs and insufficient outputs.

SMASH standardised perioperative management of patients operated with acute abdominal surgery in a high-risk setting.

OBJECTIVE OF THE STUDY: Emergency laparotomy and other high-risk acute abdominal surgery procedures have a high mortality rate. The perioperative management of these patients is complex and poses several challenges. The objective of the study is to implement and evaluate the outcome of protocol-based standardised care for patients in need of acute abdominal surgery in a Swedish setting. NÄL is a large county hospital in Sweden serving a population of approximately 270,000 inhabitants. The study seeks to determine whether standardised protocol-based perioperative management in emergency abdominal surgical procedures leads to a better outcome measured as short- and long-term mortality and postoperative complications compared with the present standard in Swedish routine care. The study is ongoing, and this article describes the methodology used in the study and discusses the benefits and limitations the study design. RESULTS: There are no results so far. The inclusion rate for the first 22 months is as expected; 404 patients have been included and protocols have been followed and reviewed according to the study plan. 25 patients have been missed and demographic data and outcome data for these patients will be collected and analysed.

Emergent groin hernia repair at a County Hospital in Guatemala: patient-related issues vs. health care system limitations.

BACKGROUND: The rate of emergent groin hernia repair in developing countries is poorly understood. MATERIALS AND METHODS: A retrospective analysis of groin hernia repairs performed at a county hospital in Guatemala [Hospital Nacional de San Benito (HSNB)] was undertaken and compared to a literature review in developed countries. Patients with incarcerated hernias were interviewed to determine factors related to late presentation. RESULTS: Twenty-five percent of patients with groin hernias in this analysis presented at HNSB emergently (vs. 2.5-7.7% in developed countries). Most patients were male in their fifth decade of life. Ten percent of hernias were femoral. There was no delay in scheduling patients for surgery presenting for elective repair. Most patients lived within 20 miles of the hospital, but only 50% of patients returned for their follow-up appointment. Most patients with an incarcerated inguinal hernia (56%) did not seek medical attention because of family obligations, but when they did, this decision was influence by their children (66%). None of the patients presenting with an incarcerated hernia had education past secondary school. In fact, most (56%) did not have any form formal education. Nearly 90% of patients who had an incarcerated hernia repaired thought that the hospital provided good-to-excellent care. CONCLUSION: A high number of patients present emergently for groin hernia repair at a county hospital in Guatemala compared to developed countries. Our data suggest that emergent hernias are likely the result of patient-related issues rather than health care system limitations.

Barriers to adoption of laparoscopic cholecystectomy in a county hospital in Guatemala.

BACKGROUND: Despite international efforts to increase performance of laparoscopic cholecystectomy (LC) in rural Guatemala, the vast majority of cholecystectomies are still performed via the open cholecystectomy (OC) approach. Our goal was to explore barriers to the adoption of LC in Guatemala as well as possible mechanisms to overcome them. METHODS: We reviewed 9402 cholecystectomies performed over 14 years by surgeons at the Hospital Nacional de San Benito (HNSB) in El Peten, Guatemala, with either an open or a laparoscopic approach. We conducted personal interviews with all the surgeons who perform cholecystectomies at HNSB to determine current practice and barriers to adopting LC. RESULTS: Overall, seven general surgeons were interviewed who regularly perform cholecystectomy. Of the total number of cholecystectomies reviewed, 8440 (90%) were open and 962 (10%) were laparoscopic. The mean number of cholecystectomies performed per surgeon was 1341.1 ± 1244.9, with OC at 1205.7 ± 1194.9, and LC at 137.4 ± 188.0. Lack of formal training in laparoscopy was identified in 57% of surgeons. Lack of government funds to implement a laparoscopic program was noted by 71% of surgeons (29% felt there was insufficient ancillary staff, 29% poor allocation of hospital funding to purchase laparoscopic equipment/training). Lack of sufficient laparoscopic equipment was identified by 71% of surgeons. CONCLUSIONS: Ninety percent of cholecystectomies performed by surgeons at HNSB continue to be OC. The major limitation is the lack of funding to provide sufficient equipment or ancillary staff. The majority of surgeons preferred to perform LC if these problems could be addressed.

County and Physician Variation in Benzodiazepine Prescribing to Medicare Beneficiaries by Primary Care Physicians in the USA.

BACKGROUND: Physicians widely prescribe benzodiazepines (BZD) despite well-recognized harms. OBJECTIVE: To determine county and provider characteristics that predict high-intensity BZD prescribing by primary care physicians (PCPs) to Medicare beneficiaries. DESIGN: Cross-sectional analysis of the 2015 Medicare Part D Public Use Files (PUF). SUBJECTS: n = 122,054 PCPs who prescribed 37.3 billion medication days. MAIN MEASURES: Primary outcome was intensity of BZD prescribing (days prescribed/total medication days) at the county- and physician levels. PCP and county characteristics were derived from the Part D PUF, Area Health Resources Files, and County Health Rankings. Logistic regression determined the characteristics associated with high-intensity (top quartile) BZD prescribing. KEY RESULTS: Beneficiaries were prescribed over 1.2 billion days of BZD in 2015, accounting for 2.3% of all medication days prescribed in Part D. Top quartile counties had 3.1 times higher BZD prescribing than the lowest (3.4% vs. 1.1%; F = 3293.8, df = 3, p < 0.001). Adjusting for county-level demographics and health care system characteristics (including supply of mental health providers), counties with more adults with at least some college had lower odds of high-intensity prescribing (per 5% increase, adjusted odds ratio [AOR] 0.80, 99% confidence interval (CI) 0.73-0.87, p < 0.001), as did higher income counties (per US$1000 increase, AOR 0.93, CI 0.91-0.95, p < 0.001). Top quartile PCPs prescribed at 6.5 times the rate of the bottom (3.9% vs. 0.6%; F = 63,910.2, df = 3, p < 0.001). High-intensity opioid prescribing (AOR 4.18, CI 3.90-4.48, p < 0.001) was the characteristic most strongly associated with BZD prescribing. CONCLUSIONS: BZD prescribing appears to vary across counties and providers and is related to non-patient characteristics. Further work is needed to understand how such non-clinical factors drive variation.

Balanced scorecard-based performance evaluation of Chinese county hospitals in underdeveloped areas.

Objective Since the Guangxi government implemented public county hospital reform in 2009, there have been no studies of county hospitals in this underdeveloped area of China. This study aimed to establish an evaluation indicator system for Guangxi county hospitals and to generate recommendations for hospital development and policymaking. Methods A performance evaluation indicator system was developed based on balanced scorecard theory. Opinions were elicited from 25 experts from administrative units, universities and hospitals and the Delphi method was used to modify the performance indicators. The indicator system and the Topsis method were used to evaluate the performance of five county hospitals randomly selected from the same batch of 2015 Guangxi reform pilots. Results There were 4 first-level indicators, 9 second-level indicators and 36 third-level indicators in the final performance evaluation indicator system that showed good consistency, validity and reliability. The performance rank of the hospitals was B > E > A > C > D. Conclusions The performance evaluation indicator system established using the balanced scorecard is practical and scientific. Analysis of the results based on this indicator system identified several factors affecting hospital performance, such as resource utilisation efficiency, medical service price, personnel structure and doctor-patient relationships.

Variation in and risk factors for paediatric inpatient all-cause mortality in a low income setting: data from an emerging clinical information network.

BACKGROUND: Hospital mortality data can inform planning for health interventions and may help optimize resource allocation if they are reliable and appropriately interpreted. However such data are often not available in low income countries including Kenya. METHODS: Data from the Clinical Information Network covering 12 county hospitals' paediatric admissions aged 2-59 months for the periods September 2013 to March 2015 were used to describe mortality across differing contexts and to explore whether simple clinical characteristics used to classify severity of illness in common treatment guidelines are consistently associated with inpatient mortality. Regression models accounting for hospital identity and malaria prevalence (low or high) were used. Multiple imputation for missing data was based on a missing at random assumption with sensitivity analyses based on pattern mixture missing not at random assumptions. RESULTS: The overall cluster adjusted crude mortality rate across hospitals was 6 · 2% with an almost 5 fold variation across sites (95% CI 4 · 9 to 7 · 8; range 2 · 1% - 11 · 0%). Hospital identity was significantly associated with mortality. Clinical features included in guidelines for common diseases to assess severity of illness were consistently associated with mortality in multivariable analyses (AROC =0 · 86). CONCLUSION: All-cause mortality is highly variable across hospitals and associated with clinical risk factors identified in disease specific guidelines. A panel of these clinical features may provide a basic common data framework as part of improved health information systems to support evaluations of quality and outcomes of care at scale and inform health system strengthening efforts.

The Burden of Tunneled Central Venous Catheters for Hemodialysis in a County Hospital.

Prolonged use of central venous catheters (CVCs) for hemodialysis (HD) is associated with greater morbidity and mortality when compared with autogenous arteriovenous fistulas (AVF). The objective was to assess compliance with CVC guidelines in adults referred for hemoaccess at a county teaching hospital. Out of 256 patients, 172 (67.2%) were male, with a mean age of 50.0 ± 12.4 years. Overall 62.5 per cent initiated dialysis via CVC. Patients were divided into two groups (those with CVC (62.5%) and those without (37.5%)). Male gender was associated with initiation of dialysis via CVC versus no CVC (72.5 vs 58.3%, P = 0.02), as was a history of prior vascular access (P < 0.01). There were no significant differences between the groups regarding age, diabetes, smoking, ambulatory status, or insurance status. There were no differences in gender, age, insurance status, or prior vascular access between prolonged CVC use (≥90 days) and short-term CVC use (<90 days). We conclude that most patients initiated HD with CVC and exceed the recommended CVC duration. Men are more likely to initiate HD via CVC. Insurance status was not associated with CVC use. Multidisciplinary action may address barriers to reducing CVC duration.

Variation and Trends in Lower Extremity Amputation Rates in Los Angeles County Hospitals 2000-2010.

Lower extremity amputation (LEA) is a preventable complication of diabetes and peripheral vascular disease. Hospital-related factors associated with higher LEA are low hospital LEA revascularization volume, rural setting, and nonteaching status. In this study, we describe LEA rates in health care systems and hospitals in Los Angeles County from 2000 to 2010. Data on hospital discharges in Los Angeles County from 2000 to 2010 were obtained from the California Office of Statewide Health Planning and Development. LEA rates were adjusted for clinical and demographic variables including age, sex, race, source of health care payment, diabetes, and peripheral vascular disease. Adjusted LEA rates over the study period were analyzed by category of hospital (municipal, nonprofit/non-Kaiser, Kaiser, and private), and for changes in rates in each hospital over the study period. Over the 11-year study period the LEA rates increased for municipal hospitals, while decreasing for the other 3 categories of hospitals. Among the 84 hospitals included in the final analysis, 41 hospitals had higher than average relative risk for LEA in 2007-2010. Among these hospitals 12 had higher than average decline in LEA rate between 2000-2003 and 2007-2010. The other 29 hospitals had not lowered the LEA rate as much as the whole County over the study period. After adjusting for demographic and clinical variables, the relative risk for LEA among hospitals varied by 7.5-fold. Significant variability was found both within each of the 4 types of hospitals, and between the 4 types. Hospitals also varied in the degree that they lowered their LEA rates. This study demonstrated that health care systems and hospitals are associated with significant disparity in LEA rates among socioeconomic groups and geographical regions.

A hospital-centered approach to improve emergency obstetric care in South Sudan.

OBJECTIVE: To assess provision of emergency obstetric care (EmOC) in Greater Yirol, South Sudan, after implementation of a hospital-centered intervention with an ambulance referral system. METHODS: In a descriptive study, data were prospectively recorded for all women referred to Yirol County Hospital for delivery in 2012. An ambulance referral system had been implemented in October 2011. Access to the hospital and ambulance use were free of charge. RESULTS: The number of deliveries at Yirol County Hospital increased in 2012 to 1089, corresponding to 13.3% of the 8213 deliveries expected to have occurred in the catchment area. Cesareans were performed for 53 (4.9%) deliveries, corresponding to 0.6% of the expected number of deliveries in the catchment area. Among 950 women who delivered a newborn weighing at least 2500 g at the hospital, 6 (0.6%) intrapartum or very early neonatal deaths occurred. Of 1232 women expected to have major obstetric complications in 2012 in the catchment area, 472 (38.3%) received EmOC at the hospital. Of 115 expected absolute obstetric indications, 114 (99.1%) were treated in the hospital. CONCLUSION: A hospital-centered approach with an ambulance referral system effectively improves the availability of EmOC in underprivileged remote settings.

[One third of Danish doctors specializing in diagnostic radiology do not feel sufficiently equipped in terms of medical expertise]. / Hver tredje hoveduddannelseslæge i diagnostisk radiologi føler sig ikke rustet til rollen som medicinsk ekspert.

An internet-based survey among Danish doctors specializing in diagnostic radiology revealed differences with respect to the length of internships at regional and university hospitals as well as the educational environment. The university hospitals were generally evaluated to have the best educational facilities except within practical skills. Therefore, it seems necessary to optimize the educational environment at regional hospitals, especially within medical expertise and scientific skills which are key elements regarding continuous development and quality assurance within radiology.

Prescription pattern and its influencing factors in Chinese county hospitals: a retrospective cross-sectional study.

OBJECTIVE: This study aimed to investigate prescription patterns and influencing factors in Chinese county hospitals. METHODS: Prescription quality was evaluated by five indicators proposed by WHO/INRUD. A questionnaire for doctors was designed by our research group. All internists, surgeons, obstetricians, gynecologists and pediatricians from 10 county hospitals in Anhui province were asked to fill the questionnaire. Their prescriptions from May 2011 to April 2012 were analyzed. RESULTS: Three-hundred and thirty-seven doctors completed valid questionnaires, and 5099 prescriptions were analyzed. The average number of drugs per prescription was 3.52±2.31; the average percentage of generic drugs, antibiotic usage, injection drug usage, and drugs prescribed from the national essential drug list were 96.12%, 29.90%, 20.02% and 48.85%, respectively. Differences in final academic degree and specialty led to differences in all of the five prescription quality indicators. The older doctors tended to use more antibiotics. Doctors with more education, more training on rational drug use, and better acquisition of medicine knowledge prescribe a lower percentage of generic drugs. Moreover, the more supportive the doctor's attitude to national essential medicine policy, the higher the percentage of generic drugs were prescribed. A higher level of medical knowledge was associated with a higher percentage of drugs prescribed from the essential drugs list. CONCLUSIONS: Promoting the education of medical knowledge on doctors, reinforcing the publicity of rational drug use to doctors, and initiating the performance evaluation for doctors are effective ways for improving prescription quality in Chinese county hospitals.

Liberian surgical and anesthesia infrastructure: a survey of county hospitals.

BACKGROUND: There is a significant burden of disease in low-income countries that can benefit from surgical intervention. The goal of this survey was to evaluate the current ability of the Liberian health care system to provide safe surgical care and to identify unmet needs in regard to trained personnel, equipment, infrastructure, and outcomes measurement. METHODS: A comprehensive survey tool was developed to assess physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, equipment and medications, and the capacity of the surgical system to collect and evaluate surgical outcomes at district-level hospitals in Africa. This tool was implemented in a sampling of 11 county hospitals in Liberia (January 2011). Data were obtained from the Ministry of Health and by direct government-affiliated hospital site visits. RESULTS: The total catchment area of the 11 hospitals surveyed was 2,313,429--equivalent to roughly 67 % of the population of Liberia (3,476,608). There were 13 major operating rooms and 34 (1.5 per 100,000 population) physicians delivering surgical, obstetric, or anesthesia care including 2 (0.1 per 100,000 population) who had completed formal postgraduate training programs in these specialty areas. The total number of surgical cases for 2010 was 7,654, with approximately 43 % of them being elective procedures. Among the facilities that tracked outcomes in 2010, a total of 11 intraoperative deaths (145 per 100,000 operative cases) were recorded for 2009. The 30-day postoperative mortality at hospitals providing data was 44 (1,359 per 100,000 operative cases). Metrics were also used to evaluate surgical output, safety of anesthesia, and the burden of obstetric disease. CONCLUSIONS: A significant volume of surgical care is being delivered at county hospitals throughout Liberia. The density and quality of appropriately trained personnel and infrastructure remain critically low. There is strong evidence for continued development of emergency and essential surgical services, as well as improved surgical outcomes tracking, at county hospitals in Liberia. These results serve to inform the international community and donors of the ongoing global surgical and anesthesia crisis.

Assessing trauma care at the district and provincial hospital levels: a case study of hospitals in Kenya.

Trauma is a major cause of death and disability worldwide, of which more than 90% occur in low- and middle-income countries. Given the magnitude of this inequality, there is a need to devise and use tools to assess the capacity of facility-based trauma care. This study used two tools, hospital flowcharts and the World Health Organization's Trauma Care Checklist, to describe trauma care capacity at two hospitals in Kenya and ways in which this capacity can be strengthened. We found these hospitals had a large volume of trauma, but due to the lack of intensive care units, specialized trauma units, and axillary services, such as orthopedics and neurosurgery, the hospitals had a limited ability to provide definitive care for injured patients in critical condition. Additionally, organizational capabilities, such as trauma registries, trauma-specific training, and quality improvement programmes were lacking. The state of trauma care at district and provincial levels in Kenya demonstrates a strong case for national and global investment in clinical and systemic interventions.

Are there differences in access to care, treatment, and outcomes for children with appendicitis treated at county versus private hospitals?

INTRODUCTION: We conducted a study to determine whether hospital type (county [ie, safety-net] vs private) affects health care access (appendiceal perforation [AP] rates), treatment (laparoscopic appendectomy [LA] rates), and outcomes in children with appendicitis. METHODS: A review of cases involving children who had appendicitis between 1998 and 2007 was performed. Data from county and private hospitals were compared. Outcomes were AP rates, LA rates, need for postoperative abscess drainage, length of hospitalization (LOH), and cost. RESULTS: Multivariate analysis confirmed that among 7902 patients, (county = 682; private = 7220), county-hospital patients had lower incomes, higher AP rates, higher LA rates, lower postoperative abscess drainage rates, and longer LOH than did private-hospital patients. The longer LOH at the county institution led to higher costs. Within the county hospital, outcomes were similar across all ethnic groups and income levels. CONCLUSIONS: Children with appendicitis treated at a county hospital were of lower socioeconomic background and had higher AP rates, longer LOH, and higher costs than their counterparts at private hospitals, but were more likely to undergo LA and require less abscess drainage. Within the county hospital, ethnic and socioeconomic disparities were not apparent; thus, these differences between institutions might have been caused by underlying disparities in ethnicity, income, and health care access.

Rheumatologists' quality of care for lupus: comparison study between a university and county hospital.

OBJECTIVE: Quality of care received from physicians may impact health outcomes in systemic lupus erythematosus (SLE). We compared physician quality of care (P-QOC), health-related quality of life (HRQOL), and disease activity and damage between SLE patients receiving outpatient care at a university and a county rheumatology clinic. METHODS: Forty-two university and 41 county clinic SLE patients provided data on 5 P-QOC parameters and HRQOL health outcomes (Short Form 36 [SF-36] health survey and EuroQol 5-domain instrument [EQ-5D]). Disease activity and damage were measured. Chi-square analysis and Student's t-tests were used for comparisons. RESULTS: Overall satisfaction with medical care was similar; however, university patients had higher P-QOC scores than county patients in "perception of doctor's understanding of impact of SLE on patient's life" (P = 0.02) and "providing education/educational information to understand their disease" (P = 0.05). HRQOL, disease activity, and damage were similar in the 2 groups. Overall satisfaction with medical care was directly related SF-36 general health (r = 0.34, P = 0.03) and EQ-5D visual analog scale on state of health (r = 0.39, P = 0.01), and inversely related EQ-5D pain (r = -0.37, P = 0.02). CONCLUSION: Patient perceptions of P-QOC differed across the 2 centers despite similar demographics, clinical and HRQOL outcomes, and significant overlap in the physicians serving each clinic. Patients' overall satisfaction with medical care is associated with better HRQOL.

Implementing Liberia's poverty reduction strategy: An assessment of emergency and essential surgical care.

OBJECTIVE: To document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. DESIGN: Survey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. SETTING: Sixteen county hospitals in Liberia. MAIN OUTCOME MEASURES: Infrastructure, personnel, procedures performed, and supplies and equipment available. RESULTS: Uniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified. CONCLUSIONS: The World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

A tale of 2 hospitals: a staggered cohort study of targeted interventions to improve compliance with antibiotic prophylaxis guidelines.

BACKGROUND: The purpose of this prospective study was to determine the effectiveness of targeted interventions to improve compliance with antibiotic prophylaxis guidelines (timing, spectrum, and discontinuation) at 2 university-affiliated hospitals. METHODS: Based on barriers identified previously, hospital-specific interventions were developed such as educational conferences, standardized forms, an extended time-out, and feedback. Guideline compliance and surgical site infection (SSI) data were recorded on all patients who underwent elective laparotomies for colorectal procedures, vascular operations, and hysterectomies during four 6-month study periods. Prestudy data from July to December 2006 served as a baseline. One year later, a prospective cohort study was performed. The interventions were introduced to the 2 hospitals in a staggered fashion with 2-month implementation periods before reassessing compliance during the 6-month study periods. General linear modeling was performed (P < .05 significant). RESULTS: Compliance with all 3 guidelines combined improved during the year preceding the study, after attention only, at both hospitals. Hospital-specific differences were found in the effectiveness of the intervention package on individual guidelines. Hospital 2 but not 1 improved in timing after the interventions; both hospitals improved in spectrum, and neither hospital improved in discontinuation. Overall compliance with all 3 antibiotic prophylactic measures was greater at hospital 1, but hospital 2 had lower SSI rates. CONCLUSION: Simply increasing attention to a quality problem can result in a significant and sustained improvement. Quality improvement interventions should be evaluated rigorously for effectiveness given hospital-specific differences in effectiveness and for correlation of guideline compliance with outcome.