The experience of Hamad General Hospital collaborative anticoagulation clinic in Qatar during the COVID-19 pandemic.

Hamad General Hospital Anticoagulation Clinic is one of the largest collaborative-practice clinics of its type in Qatar. The patients being followed at this clinic are typically complex and vulnerable. During the coronavirus disease 2019 pandemic, measures were implemented at the clinic to minimize the exposure of patients and healthcare providers to the acute respiratory syndrome coronavirus-2 and to promote social distancing. These measures included extending INR-recall period, transitioning to direct oral anticoagulant drugs whenever feasible, home visits to elderly and immunocompromised patients for INR testing, establishing an anticoagulation hotline, and relocation of warfarin dispensing from the main pharmacy to the anticoagulation clinic. In addition, the clinic shifted its multidisciplinary team meetings onto an online platform using Microsoft Teams. Telehealth consultations were extensively utilized to closely follow up with the patients and ensure that anticoagulation efficacy and safety remained optimal. The aim of this paper is to share our experience and describe the measures adopted by the clinic as part of the Hamad Medical Corporation response to the emerging situation.

Changes in Emergency General Surgery During Covid-19 in Scotland: A Prospective Cohort Study.

INTRODUCTION: Covid-19 has had a significant impact on all aspects of health care. We aimed to characterise the trends in emergency general surgery at a district general hospital in Scotland. METHODS: A prospective cohort study was performed from 23/03/20 to 07/05/20. All emergency general surgery patients were included. Demographics, diagnosis and management were recorded along with Covid-19 testing and results. Thirty-day mortality and readmission rates were also noted. Similar data were collected on patients admitted during the same period in 2019 to allow for comparison. RESULTS: A total of 294 patients were included. There was a 58.3 per cent reduction in admissions when comparing 2020 with 2019 (85 vs 209); however, there was no difference in age (53.2 vs 57.2 years, p = 0.169) or length of stay (4.8 vs 3.7 days, p = 0.133). During 2020, the diagnosis of appendicitis increased (4.3 vs 18.8 per cent, p = < 0.05) as did severity (0 per cent > grade 1 vs 58.3 per cent > grade 1, p = < 0.05). The proportion of patients undergoing surgery increased (19.1 vs 42.3 per cent, p = < 0.05) as did the mean operating time (102.4 vs 145.7 min, p = < 0.05). Surgery was performed in 1 confirmed and 1 suspected Covid-19 patient. The latter died within 30 days. There were no 30-day readmissions with Covid-19 symptoms. CONCLUSION: Covid-19 has significantly impacted the number of admissions to emergency general surgery. However, emergency operating continues to be needed at pre-Covid-19 levels and as such provisions need to be made to facilitate this.

The adjustment of neurosurgical procedures during the COVID-19 pandemic: a case study at Dr. Sardjito General Hospital as a part of an academic health system.

OBJECTIVE: The recent COVID-19 outbreak has forced notable adjustments to surgical procedure preparation, including neurosurgical services. However, due to the uniqueness of the recent situation, neurosurgical centers, especially those located in low-resource settings, are facing several challenges such as a lack of coordination, poor equipment, and shortage of medical personnel. Therefore, several guidelines from local authorities and international neurosurgical bodies have been published to help clinicians manage their patients. In addition, the academic health system (AHS), which is an integrated system containing a medical institution, universities, and a teaching hospital, may play some role in the management of patients during COVID-19. The objective of this study was to describe how each hospital in the authors' network adjusted their neurosurgical practice and how the AHS of the Universitas Gadjah Mada (UGM) played its role in the adaptation process during the pandemic. METHODS: The authors gathered both local and national data about the number of COVID-19 infections from the government's database. To assess the contribution of the AHS to the efforts of each hospital to address the pandemic, questionnaires were given to 6 neurosurgeons, 1 resident, and 2 general surgeons about the management of neurosurgical cases during the pandemic in their hospitals. RESULTS: The data illustrate various strategies to manage neurosurgical cases by hospitals within the authors' networks. The hospitals were grouped into three categories based on the transmission risk in each region. Most of these hospitals stated that UGM AHS had a positive impact on the changes in their strategies. In the early phase of the outbreak, some hospitals faced a lack of coordination between hospitals and related stakeholders, inadequate amount of personal protective equipment (PPE), and unclear regulations. As the nation enters a new phase, almost all hospitals had performed routine screening tests, had a sufficient amount of PPE for the medical personnel, and followed both national and international guidelines in caring for their neurosurgical patients. CONCLUSIONS: The management of neurosurgical procedures during the outbreak has been a challenging task and a role of the AHS in improving patient care has been experienced by most hospitals in the authors' network. In the future, the authors expect to develop a better collaboration for the next possible pandemic.

Crohn's & Colitis Australia inflammatory bowel disease audit: measuring the quality of care in Australia.

BACKGROUND: Australia has among the highest prevalence of Crohn disease and ulcerative colitis in the world. Management of the chronic gastrointestinal disorders results in significant societal costs and the standard of care is inconsistent across Australia. AIM: To audit the quality of care received by patients admitted for inflammatory bowel disease (IBD) across Australia against national IBD standards. METHODS: A retrospective cross-sectional survey and clinical audit was undertaken assessing organisational resources, clinical processes and outcome measures. This study was conducted in Australian hospitals that care for inpatients with Crohn disease or ulcerative colitis. The main outcome measures were adherence to national IBD standards and comparison of quality of care between hospitals with and without multidisciplinary IBD services. RESULTS: A total of 71 hospitals completed the organisational survey. Only one hospital had a complete multidisciplinary IBD service and 17 had a partial IBD service (IBD nurse, helpline and clinical lead). A total of 1440 inpatient records was reviewed from 52 hospitals (mean age 37 years; 51% female, 53% Crohn disease), approximately 26% of IBD inpatient episodes over a 12-month period in Australia. These patients were chronically unwell with high rates of anaemia (30%) and frequent readmissions (40% within 2 years). In general, care was inconsistent, and documentation was poor. Hospitals with a partial IBD service performed better in many processes and outcome measures: for example, 22% reduction in admissions through emergency departments and greater adherence to standards for safety monitoring of biological (89% vs 59%) and immunosuppressive drugs (79% vs 55%) in those hospitals than those without. CONCLUSION: Patients admitted to hospital suffering from IBD are young, chronically unwell and are subject to substantial variations in clinical documentation and quality of care. Only one hospital met accepted standards for multidisciplinary care; hospitals with even a minimal IBD service provided improved care.

Impact of shortened length of stay for delivery on the required bed capacity in maternity services: results from forecast analysis on administrative data.

BACKGROUND: We examine the implications of reducing the average length of stay (ALOS) for a delivery on the required capacity in terms of service volume and maternity beds in Belgium, using administrative data covering all inpatient stays in Belgian general hospitals over the period 2003-2014. METHODS: A projection model generates forecasts of all inpatient and day-care services with a time horizon of 2025. It adjusts the observed hospital use in 2014 to the combined effect of three evolutions: the change in population size and composition, the time trend evolution of ALOS, and the time trend evolution of the admission rates. In addition, we develop an alternative scenario to evaluate the impact of an accelerated reduction of ALOS. RESULTS: Between 2014 and 2025, we expect the number of deliveries to increase by 4.41%, and the number of stays in maternity services by 3.38%. At the same time, a reduction in ALOS is projected for all types of deliveries. The required capacity for maternity beds will decrease by 17%. In case of an accelerated reduction of the ALOS to reach international standards, this required capacity for maternity beds will decrease by more than 30%. CONCLUSIONS: Despite an expected increase in the number of deliveries, future hospital capacity in terms of maternity beds can be considerably reduced in Belgium, due to the continuing reduction of ALOS.

Evolving trends in the surgical management of renal masses over the past two decades: A contemporary picture from a large prospectively-maintained database.

OBJECTIVES: To investigate the trends in the presentation and surgical management of renal tumors at Singapore General Hospital, Singapore. METHODS: We accessed our uro-oncological registry to extract the clinicopathological data of patients with renal tumors who underwent nephrectomy from 2000 to 2015. Binary logistic regression was used to identify predictors of nephron-sparing surgery utilization, Clavien-Dindo grade ≥III complications and progression to stage ≥3 chronic kidney disease. Cox regression models were created to evaluate the proportional hazards of the risk factors for overall survival and cancer-specific survival. RESULTS: A total of 1208 cases of nephrectomy were carried out between 2000 and 2015. The proportion of cT1a tumors increased from 2000-2004 to 2010-2015, which was accompanied by the doubling of utilization rates of nephron-sparing surgery and minimally invasive surgery. Charlson Comorbidity Index score <2, asymptomatic presentation, clinical T1a tumors and having an estimated glomerular filtration rate ≥30 mL/min/1.73 m2 were all independent predictors of nephron-sparing surgery utilization. Age, symptomatic presentation and nephron-sparing surgery utilization were all significantly associated with greater odds of having Clavien-Dindo grade ≥III complications, whereas minimally invasive surgery was associated with decreased risk. The utilization of partial nephrectomy and minimally invasive surgery was significantly associated with a decreased risk of developing postoperative stage ≥3 chronic kidney disease. Both overall survival and cancer-specific survival were not significantly affected by whether nephron-sparing surgery was utilized. CONCLUSIONS: There has been an increasing proportion of small renal masses diagnosed incidentally with a shift towards nephron-sparing surgery for clinically localized tumors. With the adoption of nephron-sparing surgery, progression to stage 3 chronic kidney disease has decreased, without any compromise in oncological and survival outcomes.

Prevalence of insomnia symptoms and their associated factors in patients treated in outpatient clinics of four general hospitals in Guangzhou, China.

BACKGROUND: Data on the prevalence of insomnia symptoms in medical outpatient clinics in China are lacking. This study examined the prevalence of insomnia symptoms and their socio-demographic correlates in patients treated at medical outpatient clinics affiliated with four general hospitals in Guangzhou, a large metropolis in southern China. METHOD: A total of 4399 patients were consecutively invited to participate in the study. Data on insomnia and its socio-demographic correlates were collected with standardized questionnaires. RESULTS: The prevalence of any type of insomnia symptoms was 22.1% (95% confidence interval (CI): 20.9-23.3%); the prevalence of difficulty initiating sleep was 14.3%, difficulty maintaining sleep was 16.2%, and early morning awakening was 12.4%. Only 17.5% of the patients suffering from insomnia received sleeping pills. Multiple logistic regression analysis revealed that male gender, education level, rural residence, and being unemployed or retired were negatively associated with insomnia symptoms, while lacking health insurance, older age and more severe depressive symptoms were positively associated with insomnia symptoms. CONCLUSIONS: Insomnia symptoms are common in patients attending medical outpatient clinics in Guangzhou. Increasing awareness of sleep hygiene measures, regular screening and psychosocial and pharmacological interventions for insomnia are needed in China. TRIAL REGISTRATION: ChiCTR-INR-16008066 . Registered 8 March 2016.

Pediatric Hospitalization Trends at Children's and General Hospitals, 2000-2019.

This study examines whether pediatric inpatient care has been redistributed from general hospitals into children's hospitals.

Mental health literacy about schizophrenia and depression: a survey among Chinese caregivers of patients with mental disorder.

OBJECTIVE: To investigate the knowledge of schizophrenia and depression among caregivers of patients with mental disorder in China. METHOD: A convenience sample of 402 caregivers at the Department of Psychiatry of a general hospital in China was investigated (response rate 95.7%), using vignettes based investigation methodology. RESULTS: The number of caregivers using the term "depression" to describe the depression vignette was 43.6%, which was significantly higher than the number of caregivers using the term "schizophrenia" to describe the schizophrenia one (28.5%). A high percentage of caregivers believed that "psychiatrist", "psychologist" and "close family members" would be helpful, and the top three most helpful interventions were "becoming more physically active", "getting out and learning more" and "receiving psychotherapy". The number of caregivers endorsed "antipsychotics" and "antidepressants" as helpful for the schizophrenia and the depression vignettes were 82.0 and 80.7%, respectively. Regarding the causes of mental illness, items related to psychosocial factors, including "daily problems" and "work or financial problems", and "weakness of character" were highly rated, with half considered genetic or chemical imbalance causes. CONCLUSION: Caregivers expressed a high knowledge about treatments and interventions of mental disorders. But there are still some areas, particularly regarding the recognition and causes of mental disorders, that are in need of improvement. This is particularly the case for schizophrenia.

Emergency psychiatry: a product of circumstance or a growing sub-speciality field?

OBJECTIVES: This article reviews recent trends in the provision of psychiatric services to the emergency departments of tertiary hospitals in Australia, involving the establishment of specialised in-reach or liaison services as well as various forms of short stay unit attached to emergency departments. The Emergency Psychiatry Service at Flinders Medical Centre, South Australia, is described as a case example. Its specialised models of assessment and clinical care are described, highlighting how these are differentiated from more traditional models in inpatient, community and general hospital consultation-liaison psychiatry. CONCLUSIONS: Emergency psychiatry, and in particular the application of specialised psychiatric models of in-reach service and short stay units, is an increasingly important and growing field of psychiatry that warrants further exploration in research. The Emergency Psychiatry Service at Flinders Medical Centre has developed a distinct group of assessment and treatment approaches that exemplifies this growing field.

Beneficial Effects of Implementing Stroke Protocols Require Establishment of a Geographically Distinct Unit.

BACKGROUND AND PURPOSE: Usefulness of multidisciplinary stroke units in acute stroke patients is well established. There is extensive western literature on usefulness of stroke units in outcome, but limited evidence from the rest of the world. We aim to evaluate the impact of establishing a stroke unit on outcome in patients presenting to a tertiary care facility. METHODS: This is a retrospective study of 1003 patients with acute stroke admitted to Hamad General Hospital, Qatar, between January 2014 and February 2015. Patients directly admitted to intensive care unit (132) were excluded. We compared outcomes of pre- and poststroke ward (SW) establishment and in SW patients versus those of general medical wards. RESULTS: Before the establishment of the SW, 175 patients were admitted to the hospital. From April 2014 to February 2015, 696 patients were admitted (SW, 545; medical ward, 151). There was a significant reduction in length of stay from 14.7±27.7 to 6.2±20.2 days (P=0.0001) and incidence of complications (23.6% versus 6.4%, P=0.0001) after implementation of stroke-specific protocols. Prognosis at discharge (modified Rankin Scale 0-2 in 56.0% versus 70.4%, P=0.001) and at 90 days (modified Rankin Scale 0-2 in 70.6% versus 95.0%, P=0.001) also significantly improved. Compared with medical ward patients, outcome was significantly better in SW patients with fewer complications (10.9% versus 5.0%, P=0.013) and shorter length of stay (8.9±30.7 versus 5.4±16.1 days, P=0.05). CONCLUSIONS: Establishing a distinct SW is essential for achieving full benefits of stroke protocols implementation. SW patients have significantly fewer complications and better prognosis when compared with patients in medical wards.

Late-life depression and quality of life in a geriatric evaluation and management unit: an exploratory study.

BACKGROUND: Late-life depression is common among elderly patients. Ignorance of the health problem, either because of under-diagnosis or under-treatment, causes additional medical cost and comorbidity. For a better health and quality of life (QoL), evaluation, prevention and treatment of late-life depression in elderly patients is essential. METHODS: This study examined (1) the differences of clinical characteristics, degree of improvement on QoL and functionality on discharge between non-depressed and depressed elderly inpatients and (2) factors associated with QoL on discharge. Four hundred and seventy-one elderly inpatients admitted to a geriatric evaluation and management unit (GEMU) from 2009 to 2010 were enrolled in this study. Comprehensive geriatric assessment including the activities of daily living (ADL), geriatric depression scale, and mini-mental state examination were conducted. QoL was assessed using the European Quality of Life-5 Dimensions and the European Quality of Life-5 Dimensions Visual Analog Scale on discharge. Information on hospital stay and Charlson comorbidity index were obtained by chart review. Chi-square tests, independent t-tests, Mann-Whitney U tests and multiple linear regressions were used in statistical analysis. RESULTS: Worse QoL and ADL on discharge were found among the depressed. Depressive symptoms, female gender, duration of hospital stay, and rehabilitation were significant factors affecting QoL on discharge in linear regression models. CONCLUSIONS: The importance of the diagnosis and treatment of depression among elderly inpatients should not be overlooked during hospital stay and after discharge. Greater efforts should be made to improve intervention with depressed elderly inpatients.

Relationship between in-hospital location and outcomes of care in patients of a large general medical service.

BACKGROUND: The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted under the care of a general medical service can be placed in other departments' wards. These patients are called 'outliers', and their outcomes are unknown. AIMS: To examine the relation between the proportion of time each patient spent in their 'home ward' during an index admission and the outcomes of that hospital stay. METHODS: Data from Flinders Medical Centre's patient journey database were extracted and analysed. The analysis was carried out on the patient journeys of patients admitted under the general medicine units. RESULTS: Outlier patients' length of stay was significantly shorter than that of the inlier patients (110.7 h cf 141.9 h; P < 0.001).They had a reduced risk of readmission within 28 days of discharge from hospital. Outlier patients' discharge summaries were less likely to be completed within a week (64.3% cf 78.0%; P < 0.001). Being an outlier patient increased the risk-adjusted risk of in-hospital mortality by over 40%. Fifty per cent of deaths in the outlier group occurred within 48 h of admission. Outlier patients had spent longer in the emergency department waiting for a bed (6.3 h cf 5.3 h; P < 0.001) but duration of emergency department stay was not an independent predictor of mortality risk. CONCLUSION: Outlier patients had significantly shorter length of stay in hospital but significantly greater in-patient death rates. Surviving outlier patients had lower rates of readmission but lower rates of discharge summary completion.

Risk factors of stroke patients admitted to a general hospital in Kuwait.

There are limited data on stroke incidence in the Middle East, and only one study from Kuwait. The aim of this study was to establish a baseline status of stroke in Kuwait. We performed a retrospective chart review of all patients admitted from January 1st to December 31st, 2008 to the Amiri Hospital, Kuwait, who either were discharged or passed away with a diagnosis of stroke. Documented risk factors for stroke were analyzed for the total cohort and for male and female subgroups. Stroke subtypes were defined in accordance with the Trial of Org 10172 in acute stroke treatment (TOAST) criteria. There were 151 cases of stroke, of which 90.1% were ischemic. Eighty-five (56.3%) of the patients had diabetes mellitus, 86 (57.0%) had hyperlipidemia, and 104 (68.9%) had hypertension. Statins were used by 42.4% of the 86 hyperlipidemic patients prior to their presentation, and only 66 hypertensive patients (63.5%) were receiving treatment for hypertension prior to their presentation. Atrial fibrillation was diagnosed in 4% of the patients prior to their presentation, and 4% more were diagnosed afterward. History of ischemic heart disease was present in 28.5% of the subjects. This study shows similar rates of risk factors to regionally published reports and provides an updated picture of stroke in Kuwait.

A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005-2010).

A review of all medication incidents reported to the National Reporting and Learning System (NRLS) in England in Wales between 1 January 2005 and 31 December 2010 was undertaken. The 526,186 medication incident reports represented 9.68% of all patient safety incidents. Medication incidents from acute general hospitals (394,951) represented 75% of reports. There were relatively smaller numbers of medication incident reports (44,952) from primary care, representing 8.5% of the total. Of 86,821 (16%) medication incidents reporting actual patient harm, 822 (0.9%) resulted in death or severe harm. The incidents involving medicine administration (263,228; 50%) and prescribing (97,097; 18%) were the process steps with the largest number of reports. Omitted and delayed medicine (82,028; 16%) and wrong dose (80,170; 15%) represented the largest error categories. Thirteen medicines or therapeutic groups accounted for 377 (46%) of the incidents with outcomes of death or severe harm. The National Patient Safety Agency (NPSA) has issued guidance to help minimize incidents with many of these medicines. Many recent incidents could have been prevented if the NPSA guidance had been better implemented. It is recommended that healthcare organizations in all sectors establish an effective infrastructure to oversee and promote safe medication practice, including an annual medication safety report. In the future, preventable harms from medication incidents can be further minimized by; the continued use of the NRLS to identify and prioritize important actions to improve medication safety, a central organization continuing to issue medication safety guidance to the service and better methods to ensure that the National Health Service has implemented this guidance.

Hip resurfacing in a district general hospital: 6-year clinical results using the ReCap hip resurfacing system.

BACKGROUND: The purpose of our study was to prospectively report the clinical results of 280 consecutive hips (240 patients) who received a ReCap Hip Resurfacing System implant (Biomet Inc., Warsaw, USA) in a single district general hospital. Literature reports a large variation in clinical results between different resurfacing designs and published results using this particular design are scarce. METHODS: Mean follow up was 3.3 years (1.0 to 6.3) and four patients were lost to follow-up. All patients were diagnosed with end-stage hip osteoarthritis, their mean age was 54 years and 76.4% of all patients were male. RESULTS: There were 16 revisions and four patients reported a Harris Hip Score <70 points at their latest follow up. There were no pending revisions. Kaplan-Meier implant survival probability, with revision for any reason as endpoint, was 93.5% at six years follow-up (95%-CI: 88.8-95.3). There were no revisions for Adverse Reactions to Metal Debris (ARMD) and no indications of ARMD in symptomatic non-revised patients, although diagnostics were limited to ultrasound scans. CONCLUSIONS: This independent series confirms that hip resurfacing is a demanding procedure, and that implant survival of the ReCap hip resurfacing system is on a critical level in our series. In non-revised patients, reported outcomes are generally excellent. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00603395.

Retrospective study of pressure ulcer prevalence in Dutch general hospitals since 2001.

OBJECTIVE: To investigate whether factors such as patient characteristics, pressure ulcer (PU) prevention strategies and the structural quality indicators used by institutions and wards can explain an apparent decline in PU prevalence from 2001 to 2008. METHOD: The Dutch National Prevalence Survey of Care Problems (known as LPZ) database from 2001 to 2008 was used to explore differences in patient characteristics, PU prevention strategies and structural quality indicators used by institutions and wards between two periods, 2001-2004 (PU as an internal health-care quality indicator) and 2005-2008 (PU as an external health-care quality indicator). RESULTS: Compared with 2001-2004, fewer participants with CVA /hemiparesis (OR 0.485), infectious diseases (OR 0.861), surgery lasting >2 hours (OR 0.637), at-risk Braden scale scores (OR 0.844), and more participants with diabetes mellitus (OR 1.693) were found in the 2005-2008 group. More special beds/mattresses (OR 2.216) and special cushions in wheelchairs (OR 2.277) were used in the 2005- 2008 period, as well as slightly more repositioning, dehydration/malnutrition prevention and PU prevention and treatment information. More institutions had information leaflets (OR 5.894), PU prevention guidelines (OR 4.625), a PU committee (OR 2.503), and a PU-wound care nurse at ward level (OR 2.434) in the 2005-2008 period. CONCLUSION: The decline in PU prevalence at Dutch general hospitals after 2004 may be partly explained by differences in patient characteristics, improved structural quality indicators and a slight improvement in PU prevention. Further research is needed to find evidence of which individual factors can explain the decline in PU prevalence after 2004 and whether any changes in health care policy have impacted on these prevalence rates.

Teledermatology via a social networking web site: a pilot study between a general hospital and a rural clinic.

Teledermatology via a free public social networking Web site is a practical tool to provide attention to patients who do not have access to dermatologic care. In this pilot study, a general practitioner sent consults to a dermatology department at a general hospital via Facebook(®). Forty-four patients were seen and treatment was installed. We identified both simple-to-treat, common skin diseases and rare congenital diseases that require genetic counseling and more complex treatment. The majority of patients (75%) benefited with the diagnoses and treatments offered, thus avoiding unnecessary expenses or transportation to urban areas.

[Some aspects of outpatient care in the modem world].

The problems of improvement of outpatient care are considered, methodology of more active implementation of hospitalization technologies, the use of day care, hospital at home is proposed. It is emphasized that the introduction of hospitalization technology makes it less than treatment in hospital costs to improve quality of life for huge numbers of patients.

Specialty hospital market proliferation: Strategic implications for general hospitals.

BACKGROUND: Since the early 1990s, specialty hospitals have been continuously increasing in number. A moratorium was passed in 2003 that prohibited physicians' referrals of Medicare patients to newly established specialty hospitals if the physician has ownership stakes in the hospital. Although this moratorium expired in effect in 2007, many are still demanding that the government pass new policies to discourage the proliferation of specialty hospitals. PURPOSE: This study aimed at examining the regulatory and environmental forces that influence specialty hospitals founding rate. Specifically, we use the resource partitioning theory to investigate the relationship between general hospitals closure rates and the market entry of specialty hospitals. This study will help managers of general hospitals in their strategic thinking and planning. METHODOLOGY: We rely on secondary data resources, which include the American Hospital Association, Area Resource file, census, and Center for Medicare and Medicaid Services data, to perform a longitudinal analysis of the founding rate of specialty hospital in the 48 states. Specifically, we use the negative binomial generalized estimating equation approach available through Stata 9.0 to study the effect of general hospitals closure rate and environmental variables on the proliferation of specialty hospitals. FINDINGS: Specialty hospitals founding rate seems to be significantly related to general hospitals closure rates. Moreover, results indicate that economic, supply, regulatory, and financial conditions determine the founding rate of specialty hospitals in different states. PRACTICE IMPLICATIONS: The results from this study indicate that the closure of general hospitals creates market conditions that encourage the market entry of specialized health care delivery forms such as specialty hospitals. Managers of surviving general hospitals have to view the closure of other general hospitals not just as an opportunity to increase market share but also as a threat of competition from new forms of health care organizations.