Predictors of hospital bypass for rural residents seeking common elective surgery.

BACKGROUND: Surgical bypass occurs when rural residents receive surgical care at a nonlocal hospital. Given limited knowledge of current bypass rates, we evaluated rates and predictors of bypass for common procedures. METHODS: We used 2014 to 2016 all-payer claims data from the Healthcare Cost and Utilization Project State Inpatient Databases to study rural patients from 13 states who underwent 1 of 11 common elective surgical procedures. Bypass was measured by whether a patient received elective surgical care at the closest hospital offering the requested procedure or another nonlocal hospital. Bypass probability was then modeled as a function of patient-level and hospital-level characteristics. RESULTS: Of the 121,297 rural elective surgery visits in our sample, 78,268 (64.5%) bypassed their local hospital. Bypass rate was greatest for coronary artery bypass graft or valve replacement (74.8%) and lowest for laparoscopic cholecystectomy (53.7%). In addition, average bypass rate was greatest for surgeries with the highest risk of intraoperative blood loss and postoperative complications. The probability of bypass significantly (P < .001) increased for patients who were younger, privately insured, and lived farther from the closest hospital. In addition, the probability of bypass significantly (P < .001) increased for patients whose local hospital had fewer full-time equivalents, lower operating margin, and fewer recommendations from previous patients. CONCLUSION: Among rural patients seeking elective surgery, bypass of the local hospital was common among both low-risk and high-risk procedures. These findings suggest that there is a substantial amount of bypass, which may negatively impact a hospital's financial performance and, hence, wellbeing of the local community.

Pay-for-performance in publicly financed healthcare: some international experience and considerations for Canada.

Recent reports in the United States and Canada provide evidence that healthcare systems routinely fail to deliver safe and high-quality healthcare services. Governments and other healthcare payers have begun to experiment with pay-for-performance programs that offer healthcare providers and organizations financial incentives for quality. The purpose of this paper is (1) to provide an overview of the design of major pay-for-performance programs in the United States, the United Kingdom, and Australia, with specific focus on government-sponsored programs, and (2) to articulate some considerations for potential implementation of pay-for-performance in Canada.

Acute care hospital strategic priorities: perceptions of challenges, control, competition and collaboration in Ontario's evolving healthcare system.

To explore the current and pending strategic agenda of Ontario hospitals (the largest consumers of the provincial healthcare budget), a survey of Ontario acute care hospital CEOs was conducted in January 2004. The survey, with an 82% response rate, identifies 29 strategic priorities under seven key strategic themes consistent across different hospital types. These themes include (1) human resources cultivation, (2) service integration and partnerships, (3) consumer engagement, (4) corporate governance and management, (5) organizational efficiency and redesign, (6) improved information use for decision-making, (7) patient care management. The extent to which an individual hospital's control over strategic resolutions is perceived may affect multilevel strategic priority-setting and action-planning. In addition to supporting ongoing development of meaningful performance measures and information critical to strategic decision-making, this study's findings may facilitate a better understanding of hospitals' key resource commitments, the extent of competition and collaboration for key resources, the perceived degree of individual control over strategic issue resolution and where systemic resolutions may be required.

Nurse staffing and work status in medical, surgical and obstetrical units in Ontario teaching hospitals.

This article reports on the staff mix and work status of nurses in the adult medical, surgical and obstetrical units in Ontario's teaching hospitals. While staff nurses have extensive career experience, most have been on their unit a much shorter period of time. More than one-third of the nursing staff in the study were employed on a part-time or casual basis, with few indicating an interest in moving into full-time positions. The need for enhanced retention strategies on these units is identified, as well as the development of a better understanding of motivating factors for nurses' regarding full-time, part-time or casual work options.