Emergency department performances during overcrowding: the experience of the health protection agency of Brianza.

Background: Hospital emergency departments (ED) can contribute to improve health outcomes and reduce costs of health care system. This study evaluated ED admissions during a twelve months period, analyzing characteristics of patients who underwent to emergency care in order to understand factors involved in ED overcrowding and promote adequate management. Methods: This retrospective study analyzed a twelve months window, with in-depth focus on December/January when almost all EDs reported overcrowding. All ED admissions were recorded in electronic schedules including: demographic characteristics, time/date of the access, incoming triage code, diagnosis, performed procedures, discharge, time/date of discharge. A backward multivariable logistic regression model was used to estimate relationships between investigated variables and ED pattern mortality. Results: A total of 416,299 ED admissions were analyzed. During the overcrowded period there was an increase in patients admissions (+32 patients per day, p = 0.0079) with a statistically significant rise of critical patients (+1.7% yellow codes and +0.7% red codes, p < 0.001) and older subjects (+1.4% patients aged 75 or more years, p < 0.001). Moreover, there were statistically significant increases in waiting times and in length of visits, a higher percentage of patients who were hospitalized (13.3% vs. 12.2%, p < 0.001), left ED (4.46% vs. 4.15%, p < 0.001) and died (0.27% vs. 0.17%, p < 0.0001). This latter result maintained a marginal statistical significance (OR = 1.16, 95% CI = 0.98-1.38, p = 0.075) after adjustment for confounding. Conclusion: Our study highlights that ED crowding can determine measurable worsening in ED services and patient outcomes as mortality, waiting times, lengths of stay, percentage of abandonment without being seen and, probably, costs. Thus, address ED crowding has to be considered an important public health priority requiring policymakers involvement.

Efficiency and quality of care in nursing homes: an Italian case study.

This study investigates efficiency and quality of care in nursing homes. By means of Data Envelopment Analysis (DEA), the efficiency of 40 nursing homes that deliver their services in the north-western area of the Lombardy Region was assessed over a 3-year period (2005-2007). Lombardy is a very peculiar setting, since it is the only Region in Italy where the healthcare industry is organised as a quasi-market, in which the public authority buys health and nursing services from independent providers-establishing a reimbursement system for this purpose. The analysis is conducted by generating bootstrapped DEA efficiency scores for each nursing home (stage one), then regressing those scores on explanatory variables (stage two). Our DEA model employed two input (i.e. costs for health and nursing services and costs for residential services) and three output variables (case mix, extra nursing hours and residential charges). In the second-stage analysis, Tobit regressions and the Kruskall-Wallis tests of hypothesis to the efficiency scores were applied to define what are the factors that affect efficiency: (a) the ownership (private nursing houses outperform their public counterparts); and (b) the capability to implement strategies for labour cost and nursing costs containment, since the efficiency heavily depends upon the alignment of the costs to the public reimbursement system. Lastly, even though the public institutions are less efficient than the private ones, the results suggest that public nursing homes are moving towards their private counterparts, and thus competition is benefiting efficiency.