An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola.

BACKGROUND: The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014-2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country's maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). METHODS: Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible. RESULTS: Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1-3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided. CONCLUSIONS: Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.

A Closer Look Into Global Hospital Beds Capacity and Resource Shortages During the COVID-19 Pandemic.

BACKGROUND: As the COVID-19 pandemic continues, there is a question of whether hospitals have adequate resources to manage patients. We aim to investigate global hospital bed (HB), acute care bed (ACB), and intensive care unit (ICU) bed capacity and determine any correlation between these hospital resources and COVID-19 mortality. METHOD: Cross-sectional study utilizing data from the World Health Organization (WHO) and other official organizations regarding global HB, ACB, ICU bed capacity, and confirmed COVID-19 cases/mortality. Descriptive statistics and linear regression were performed. RESULTS: A total of 183 countries were included with a mean of 307.1 HBs, 413.9 ACBs, and 8.73 ICU beds/100,000 population. High-income regions had the highest mean number of ICU beds (12.79) and HBs (402.32) per 100,000 population whereas upper middle-income regions had the highest mean number of ACBs (424.75) per 100,000. A weakly positive significant association was discovered between the number of ICU beds/100,000 population and COVID-19 mortality. No significant associations exist between the number of HBs or ACBs per 100,000 population and COVID-19 mortality. CONCLUSIONS: Global COVID-19 mortality rates are likely affected by multiple factors, including hospital resources, personnel, and bed capacity. Higher income regions of the world have greater ICU, acute care, and hospital bed capacities. Mandatory reporting of ICU, acute care, and hospital bed capacity/occupancy and information relating to coronavirus should be implemented. Adopting a tiered critical care approach and targeting the expansion of space, staff, and supplies may serve to maximize the quality of care during resurgences and future disasters.

Improving Quality of Carotid Interventions: Identifying Hospital-Level Structural Factors that can Improve Outcomes.

BACKGROUND: "Structural factors" relating to organization of hospitals may affect procedural outcomes. This study's aim was to clarify associations between structural factors and outcomes after carotid endarterectomy (CEA) and carotid endarterectomy stenting (CAS). METHODS: A systematic review of studies published in English since 2005 was conducted. Structural factors assessed were as follows: population size served by the vascular department; number of hospital beds; availability of dedicated vascular beds; established clinical pathways; surgical intensive care unit (SICU) size; and specialty of surgeon/interventionalist. Primary outcomes were as follows: mortality; stroke; cardiac complications; length of hospital stay (LOS); and cost. RESULTS: There were 11 studies (n = 95,100 patients) included in this systematic review. For CEA, reduced mortality (P < 0.0001) and stroke rates (P = 0.001) were associated with vascular departments serving >75,000 people. Larger hospitals were associated with lower mortality, stroke rate, and cardiac events, compared with smaller hospitals (less than 130 beds). Provision of vascular beds after CEA was associated with lower mortality (P = 0.0008) and fewer cardiac events (P = 0.03). Adherence to established clinical pathways was associated with reduced stroke and cardiac event rates while reducing CEA costs. Large SICUs (≥7 beds) and dedicated intensivists were associated with decreased mortality after CEA while a large SICU was associated with reduced stroke rate (P = 0.001). Vascular surgeons performing CEA were associated with lower stroke rates and shorter LOS (P = 0.0001) than other specialists. CAS outcomes were not influenced by specialty but costless when performed by vascular surgeons (P < 0.0001). CONCLUSIONS: Structural factors affect CEA outcomes, but data on CAS were limited. These findings may inform reconfiguration of vascular services, reducing risks and costs associated with carotid interventions.

Efficiency and profitability in US not-for-profit hospitals.

This article examines the relationship between hospital profitability and efficiency. A cross-section of 1317 U.S. metropolitan, acute care, not-for-profit hospitals for the year 2015 was employed. We use a frontier method, stochastic frontier analysis, to estimate hospital efficiency. Total margin and operating margin were used as profit variables in OLS regressions that were corrected for heteroskedacity. In addition to estimated efficiency, control variables for internal and external correlates of profitability were included in the regression models. We found that more efficient hospitals were also more profitable. The results show a positive relationship between profitability and size, concentration of output, occupancy rate and membership in a multi-hospital system. An inverse relationship was found between profits and academic medical centers, average length of stay, location in a Medicaid expansion state, Medicaid and Medicare share of admissions, and unemployment rate. The results of a Hausman test indicates that efficiency is exogenous in the profit equations. The findings suggest that not-for-profit hospitals will be responsive to incentives for increasing efficiency and use market power to increase surplus to pursue their objectives.

Association between variations in the number of hospital beds and inpatient chemo/radiotherapy for breast cancer: a study using a large claim database.

OBJECTIVE: Chemo/radiotherapy for breast cancer patients does not require hospitalisation in most cases. We investigated the relationship between the proportion of hospitalisation for chemo/radiotherapy over total hospitalisation and the number of hospital beds per capita among breast cancer cases. DESIGN: A retrospective observational study. SETTING: Hospitals in Japan. PARTICIPANTS: In total, 561,165 records of hospitalisation of breast cancer cases were extracted from the Japanese Diagnosis Procedure Combination database from April 2012 to March 2016.Intervention(s) and main outcome measure(s): A multivariable beta regression model accounting for the clustering effect within each prefecture was used to examine the relationship between the number of hospital beds per capita in each prefecture and the proportion of hospitalisation for inpatient chemo/radiotherapy treatment or the number of surgical operations for breast cancer patients in each prefecture. RESULTS: The proportion of hospitalisation for inpatient chemo/radiotherapy treatment varied from 2.6% to 61.8% in 2016. The logit proportion of hospitalisation for inpatient chemo/radiotherapy treatment was significantly higher for every additional hospital bed per capita (0.0027, 95% confidence interval (95% CI) 0.0014-0.0040). In contrast, no significant relationship was observed between the number of surgical operations for breast cancer per capita and the number of hospital beds per capita. CONCLUSIONS: We found that a higher number of regional hospital beds were associated with a higher proportion of hospitalisation for chemo/radiotherapy treatment, suggesting that inpatient chemo/radiotherapy may be a provider-induced practice.

The Vital Role of a Full Continuum of Psychiatric Care Beyond Beds.

The authors make the case for expanding the national discussion of inpatient psychiatric beds to recognize and incorporate other vital components of the continuum of care in order to improve outcomes for individuals with serious mental illness. They review the varied terminology applied to psychiatric beds and describe how the location of these beds has changed from primarily state hospitals to the criminal justice system, emergency departments, inpatient units, and the community. The authors propose 10 recommendations related to beds or to contextual issues regarding them. The recommendations address issues of mental illness terminology, criminal and juvenile justice diversion, the Emergency Medical Treatment and Labor Act, mental health technology, and the mental health workforce, among others. Each recommendation is based on findings from publicly available data and clinical observation and is intended to reduce the human and economic costs associated with severe mental illness by promoting a robust, interconnected, and evidence-based system of care that goes beyond beds.

A Generic Simulation Model of the Relative Cost-Effectiveness of ICU Versus Step-Down (IMCU) Expansion.

BACKGROUND: Many jurisdictions are facing increased demand for intensive care. There are two long-term investment options: intensive care unit (ICU) versus step-down or intermediate care unit (IMCU) capacity expansion. Relative cost-effectiveness of the two investment strategies with regard to patient lives saved has not been studied to date. METHODS: We expand a generic system dynamics simulation model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to estimate the long-term effects of expanding ICU versus IMCU beds on patient lives saved under a common assumption of 2.1% annual increase in hospital arrivals. Two alternative policies of expanding ICU by two beds versus introducing a two-bed IMCU are compared over a ten-year simulation period. Russel equation is used to calculate total cost of patients' hospitalization. Using two possible values for the ratio of ICU to IMCU cost per inpatient day and four possible values for the percentage of patients transferred from ICU to IMCU found in the literature, nine scenarios are compared against the baseline scenario of no capacity expansion. RESULTS: Expanding ICU capacity by two beds is demonstrated as the most cost-effective scenario with an incremental cost-effectiveness ratio of 3684 (US $) per life saved against the baseline scenario. Sensitivity analyses on the mortality rate of patients in IMCU, direct transfer of IMCU-destined patients to the ward upon completing required IMCU length of stay in the ICU, admission of IMCU patient to ICU, adding two ward beds, and changes in hospital size do not change the superiority of ICU expansion over other scenarios. CONCLUSIONS: In terms of operational costs, ICU beds are more cost effective for saving patients than IMCU beds. However, capital costs of setting up ICU versus IMCU beds should be considered for a complete economic analysis.

The intermediate care unit as a cost-reducing critical care facility in tertiary referral hospitals: a single-centre observational study.

OBJECTIVES: To determine whether and to what extent the surgical intermediate care unit (IMCU) reduces healthcare costs. DESIGN: Retrospective cohort study. SETTING: The mixed-surgical IMCU of a tertiary academic referral hospital. PARTICIPANTS: All admissions (n=2577) from 2012 to 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcome measure was the hypothetical cost savings due to the presence of the IMCU. For this, each admission day was classified as either low-acuity or high-acuity, based on the Therapeutic Intervention Scoring System-28, the required specific nursing interventions and the indication for admission at the IMCU. Costs (2018) used were €463 per hospital ward, €1307 per IMCU and €2224 per intensive care unit (ICU) admission day. Savings were calculated by subtracting the actual IMCU costs from the hypothetical costs in the absence of the IMCU. RESULTS: There were 9037 admission days (n=2577 admissions) at the IMCU. The proportion of high-acuity admissions was 87.6%. Total costs at the IMCU were €11.808 888. Total hypothetical costs in absence of the IMCU were €18.115 284. Total cost savings were thus €6.306 395, or €1.576 599, per year. CONCLUSIONS: The surgical IMCU may substantially reduce societal healthcare costs, making it a cost saving alternative to ICU care. Constant adequate triage is essential to optimise its potential.

[Give the due value to the end of life: the systematic underfunding of specialised palliative care in the Swiss DRG system]. / Der Wert des Lebensendes: am Beispiel der Finanzierung der stationären spezialisierten Palliative Care in der Schweiz.

Give the due value to the end of life: the systematic underfunding of specialised palliative care in the Swiss DRG system Abstract. Palliative care is an integral part of modern medicine, improving quality of life, treatment satisfaction, and reducing the costs of care in severe disease. Patients' access should be early, regardless of age, diagnosis and setting, when incurable or advanced disease has been diagnosed. The public expenditure for specialised palliative care units in hospitals can be seen as yardstick for an appropriate palliative care supply, but in Switzerland only a mere fraction of revenues is dedicated to the palliative care units. Every year, 66'000 patients die in Switzerland, 38 % of them in a hospital. Health care costs for the last year of life account for 1.9 billion Swiss francs, but palliative care units receive only estimated 51 million Swiss francs per year. Reasons are a too little number of palliative care units, a systemic underfunding of their services and a fragmentary supply chain for severely ill or dying patients. This leads to ethically conflicting situations for clinicians. They have to deal with shortage of supply and, due to economic reasons, are forced to transfer severely ill or dying patients into inadequate settings. Based on international recommendations, Switzerland is in need of further 500 beds for specialised palliative care (actually 335), and at least 11'000 patients per year need access to a specialised palliative care service (actually about 3'500). Under the actual tariffing system, units for palliative care in hospitals are endangered in their existence. Corrections of the remuneration system are urgently warranted. On the long run, a national legal basis should be elaborated to safeguard adequate palliative care supply for all patients in need and as a base for monitoring, formation and research in palliative care.

Early Effects of Medicare's Bundled Payment for Care Improvement Program for Lumbar Fusion.

STUDY DESIGN: Retrospective analysis of Medicare claims linked to hospital participation in the Center for Medicare and Medicaid Innovation's episode-based Bundled Payment for Care Improvement (BPCI) program for lumbar fusion. OBJECTIVE: To describe the early effects of BPCI participation for lumbar fusion on 90-day reimbursement, procedure volume, reoperation, and readmission. SUMMARY OF BACKGROUND DATA: Initiated on January 1, 2013, BPCI's voluntary bundle payment program provides a predetermined payment for services related to a Diagnosis-Related Group-defined "triggering event" over a defined time period. As an alternative to fee-for-service, these reforms shift the financial risk of care on to hospitals. METHODS: We identified fee-for-service beneficiaries over age 65 undergoing a lumbar fusion in 2012 or 2013, corresponding to the years before and after BPCI initiation. Hospitals were grouped based on program participation status as nonparticipants, preparatory, or risk-bearing. Generalized estimating equation models adjusting for patient age, sex, race, comorbidity, and hospital size were used to compare changes in episode costs, procedure volume, and safety indicators based on hospital BPCI participation. RESULTS: We included 89,605 beneficiaries undergoing lumbar fusion, including 36% seen by a preparatory hospital and 7% from a risk-bearing hospital. The mean age of the cohort was 73.4 years, with 59% women, 92% White, and 22% with a Charlson Comorbidity Index of 2 or more. Participant hospitals had greater procedure volume, bed size, and total discharges. Relative to nonparticipants, risk-bearing hospitals had a slightly increased fusion procedure volume from 2012 to 2013 (3.4% increase vs. 1.6% decrease, P = 0.119), did not reduce 90-day episode of care costs (0.4% decrease vs. 2.9% decrease, P = 0.044), increased 90-day readmission rate (+2.7% vs. -10.7%, P = 0.043), and increased repeat surgery rates (+30.6% vs. +7.1% points, P = 0.043). CONCLUSION: These early, unintended trends suggest an imperative for continued monitoring of BPCI in lumbar fusion. LEVEL OF EVIDENCE: 3.

Baby Boomers and Beds: a Demographic Challenge for the Ages.

The United States is facing a significant demographic transition, with about 10,000 baby boomers turning age 65 each day. At the same time, the nation is experiencing a similarly striking transition in hospital capacity, as the supply of hospital beds has declined in recent decades. The juxtaposition of population aging and hospital capacity portends a potentially widening divergence between supply and demand for hospital care. We provide a closer look at current hospital capacity and a rethinking of the future role of hospital beds in meeting the needs of an aging population.

Improving the Hospital Quality of Care during Winter Periods by Optimizing Budget Allocation Between Rotavirus Vaccination and Bed Expansion.

BACKGROUND: During each winter the hospital quality of care (QoC) in pediatric wards decreases due to a surge in pediatric infectious diseases leading to overcrowded units. Bed occupancy rates often surpass the good hospital bed management threshold of 85%, which can result in poor conditions in the workplace. This study explores how QoC-scores could be improved by investing in additional beds and/or better vaccination programs against vaccine-preventable infectious diseases. METHODS: The Cobb-Douglas model was selected to define the improvement in QoC (%) as a function of two strategies (rotavirus vaccination coverage [%] and addition of extra hospital beds [% of existing beds]), allowing improvement-isocurves to be produced. Subsequently, budget minimization was applied to determine the combination of the two strategies needed to reach a given QoC improvement at the lowest cost. Data from Jessa Hospital (Hasselt, Belgium) were chosen as an example. The annual population in the catchment area to be vaccinated was 7000 children; the winter period was 90 days with 34 pediatric beds available. Rotavirus vaccination cost per course was €118.26 and the daily cost of a pediatric bed was €436.53. The target QoC increase was fixed at 50%. The model was first built with baseline parameter values. RESULTS: The model predicted that a combination of 64% vaccine coverage and 39% extra hospital beds (≈ 13 extra beds) in winter would improve QoC-scores by 50% for the minimum budget allocation. CONCLUSION: The model allows determination of the most efficient allocation of the healthcare budget between rotavirus vaccination and bed expansion for improving QoC-scores during the annual epidemic winter seasons.

The impact of carperitide usage on the cost of hospitalization and outcome in patients with acute heart failure: High value care vs. low value care campaign in Japan.

BACKGROUND: The usefulness of carperitide in patients with acute heart failure (AHF) has not been confirmed; carperitide is expensive, and thus, its routine use has not been shown to add much value in clinical settings. We analyzed the impact of carperitide usage on the outcome and cost of hospitalization in AHF patients. METHODS: Data obtained from the Diagnosis Procedure Combination (DPC) database from July 2014 until June 2015 from 371 hospitals were analyzed. Emergent patients with acute heart failure (ICD code I50* and DPC code 050130) who did not undergo any surgical procedures were enrolled. We compared the outcomes and cost between the carperitide group and non-carperitide group using propensity score matched analysis. RESULTS: In 37,891 heart failure patients (52.2% male; 79.2±11.9years), 13,421 pairs were selected according to the propensity score matching. In-hospital death occurred more frequently in the carperitide group (n=997; 7.4%) than in the non-carperitide group (n=844; 6.3%; p<0.01). Carperitide use was also related with higher costs of hospitalizations, and total dose of carperitide administered during hospitalization decreased with the increasing case volume (p<0.01). On the other hand, carperitide usage was frequently recognized in hospitals with larger annual case volumes (32.1%, Q1; 37.3%, Q2; 40.7%, Q3, p-value<0.01). CONCLUSIONS: Carperitide usage negatively affected patient outcomes and cost of hospitalization. In hospitals with lower annual case volume, clinicians should pay attention to the total dose and duration of carperitide. On the other hand, in hospitals with larger annual case volumes, clinicians should pay attention to the thresholds/indications to prescribe carperitide in AHF patients.

Ebola Preparedness Resources for Acute-Care Hospitals in the United States: A Cross-Sectional Study of Costs, Benefits, and Challenges.

OBJECTIVE To assess resource allocation and costs associated with US hospitals preparing for the possible spread of the 2014-2015 Ebola virus disease (EVD) epidemic in the United States. METHODS A survey was sent to a stratified national probability sample (n=750) of US general medical/surgical hospitals selected from the American Hospital Association (AHA) list of hospitals. The survey was also sent to all children's general hospitals listed by the AHA (n=60). The survey assessed EVD preparation supply costs and overtime staff hours. The average national wage was multiplied by labor hours to calculate overtime labor costs. Additional information collected included challenges, benefits, and perceived value of EVD preparedness activities. RESULTS The average amount spent by hospitals on combined supply and overtime labor costs was $80,461 (n=133; 95% confidence interval [CI], $56,502-$104,419). Multivariate analysis indicated that small hospitals (mean, $76,167) spent more on staff overtime costs per 100 beds than large hospitals (mean, $15,737; P<.0001). The overall cost for acute-care hospitals in the United States to prepare for possible EVD cases was estimated to be $361,108,968. The leading challenge was difficulty obtaining supplies from vendors due to shortages (83%; 95% CI, 78%-88%) and the greatest benefit was improved knowledge about personal protective equipment (89%; 95% CI, 85%-93%). CONCLUSIONS The financial impact of EVD preparedness activities was substantial. Overtime cost in smaller hospitals was >3 times that in larger hospitals. Planning for emerging infectious disease identification, triage, and management should be conducted at regional and national levels in the United States to facilitate efficient and appropriate allocation of resources in acute-care facilities. Infect Control Hosp Epidemiol 2017;38:405-410.

Tonsillectomy is not a procedure of limited value - the unseen costs of tonsillitis and quinsy on hospital bed consumption.

OBJECTIVES: To assess the impact of the introduction of the SIGN Clinical guidelines in 1999 and subsequent revision in 2005 on tonsillectomy, hospital admission with tonsillitis and peritonsillar abscess rates in four countries. METHODS: Retrospective analysis using English, Welsh, Australian and New Zealand National healthcare hospital admission databases between 2000 and 2013. Primary outcomes measures included tonsillectomy rates and hospital admission rates for tonsillitis and peritonsillar abscess. Secondary outcome measures included bed-day usage in England and Wales. Linear forecasting was used to identify the potential impact of any trends. RESULTS: Following guideline introduction for tonsillectomy, a significant decline in tonsillectomy rates in England (P < 0.01) and Wales (P < 0.05) was seen. Hospital admissions for acute tonsil infections increased in England (P < 0.01) and Wales (P < 0.01). In Australia and New Zealand, tonsillectomy and admission for tonsillitis rates both increased (P < 0.01). During this time, the increased rate of admission for tonsillitis in England and Wales was significantly greater than Australasia (P < 0.01). CONCLUSIONS: Following the introduction of these Clinical guidelines, there was a decrease in the rate of tonsillectomy in England and Wales and a presumed associated increase in admissions with tonsillitis. This did not occur in Australasia where tonsillectomy rates rose over time. If these trends continue, it is likely that they will have a significant deleterious impact on healthcare spending in the future.

Unmet need for specialised rehabilitation following neurosurgery: can we maximise the potential cost-benefits?

OBJECTIVE: To identify the needs for specialised rehabilitation provision in a cohort of neurosurgical patients; to determine if these were met, and to estimate the potential cost implications and cost-benefits of meeting any unmet rehabilitation needs. METHODS: A prospective study of in-patient admissions to a regional neurosurgical ward. Assessment of needs for specialised rehabilitation (Category A or B needs) was made with the Patient Categorisation Tool. The number of patients who were referred and admitted for specialised rehabilitation was calculated. Data from the unit's submission to the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database 2012-2015 were used to estimate the potential mean lifetime savings generated through reduction in the costs of on-going care in the community. RESULTS: Of 223 neurosurgical in-patients over 3 months, 156 (70%) had Category A or B needs. Out of the 105 patients who were eligible for admission to the local specialised rehabilitation service, only 20 (19%) were referred and just 11 (10%) were actually admitted. The mean transfer time was 70.2 (range 28-127) days, compared with the national standard of 42 days. In the 3-year sample, mean savings in the cost of on-going care were £568 per week. Assuming a 10-year reduction in life expectancy, the approximate net lifetime saving for post-neurosurgical patients was estimated as at least £600K per patient. We calculated that provision of additional bed capacity in the specialist rehabilitation unit could generate net savings of £3.6M/bed-year. CONCLUSION: This preliminary single-centre study identified a considerable gap in provision of specialised rehabilitation for neurosurgical patients, which must be addressed if patients are to fulfil their potential for recovery. A 5-fold increase in bed capacity would cost £9.3m/year, but could lead to potential net savings of £24m/year. Our findings now require confirmation on a wider scale through prospective multi-centre studies.

Geographic distribution of hospital beds throughout China: a county-level econometric analysis.

BACKGROUND: Geographical distribution of healthcare resources is an important dimension of healthcare access. Little work has been published on healthcare resource allocation patterns in China, despite public equity concerns. METHODS: Using national data from 2043 counties, this paper investigates the geographic distribution of hospital beds at the county level in China. We performed Gini coefficient analysis to measure inequalities and ordinary least squares regression with fixed provincial effects and additional spatial specifications to assess key determinants. RESULTS: We found that provinces in west China have the least equitable resource distribution. We also found that the distribution of hospital beds is highly spatially clustered. Finally, we found that both county-level savings and government revenue show a strong positive relationship with county level hospital bed density. CONCLUSIONS: We argue for more widespread use of disaggregated, geographical data in health policy-making in China to support the rational allocation of healthcare resources, thus promoting efficiency and equity.

Regional variation in acute stroke care organisation.

BACKGROUND: Few studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST). METHODS: HeadPoST is an on-going international multicenter crossover cluster-randomized trial of 'sitting-up' versus 'lying-flat' head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification. RESULTS: 94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13%; P<0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5%; P=0.002) compared to MIC hospitals. CONCLUSIONS: Although all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes.