Relationship between hospital specialization and health outcomes in patients with nonsurgical spinal joint disease in South Korea: A nationwide evidence-based study using national health insurance data.

ABSTRACT: Previous studies on hospital specialization in spinal joint disease have been limited to patients requiring surgical treatment. The lack of similar research on the nonsurgical spinal joint disease in specialized hospitals provides limited information to hospital executives.To analyze the relationship between hospital specialization and health outcomes (length of stay and medical expenses) with a focus on nonsurgical spinal joint diseases.The data of 56,516 patients, which were obtained from the 2018 National Inpatient Sample, provided by the Health Insurance Review and Assessment Service, were utilized. The study focused on inpatients with nonsurgical spinal joint disease and used a generalized linear mixed model with specialization status as the independent variable. Hospital specialization was measured using the Inner Herfindahl-Hirschman Index (IHI). The IHI (value ≤1) was calculated as the proportion of hospital discharges accounted for by each service category out of the hospital's total discharges. Patient and hospital characteristics were the control variables, and the mean length of hospital stay and medical expenses were the dependent variables.The majority of the patients with the nonsurgical spinal joint disease were female. More than half of all patients were middle-aged (40-64 years old). The majority did not undergo surgery and had mild disease, with Charlson Comorbidity Index score ≤1. The mean inpatient expense was 1265.22 USD per patient, and the mean length of stay was 9.2 days. The specialization status of a hospital had a negative correlation with the length of stay, as well as with medical expenses. An increase in specialization status, that is, IHI, was associated with a decrease in medical expenses and the length of stay, after adjusting for patient and hospital characteristics.Hospital specialization had a positive effect on hospital efficiency. The results of this study could inform decision-making by hospital executives and specialty hospital-related medical policymakers.

Health care utilization in medically complex people living with HIV before and after admission to an HIV-specific community facility: a pre-post comparison study.

BACKGROUND: People living with HIV and multiple comorbidities have high rates of health service use. This study evaluates system usage before and after admission to a community facility focused on HIV care. METHODS: We used Ontario administrative health databases to conduct a pre-post comparison of rates and costs of hospital admissions, emergency department visits, and family physician and home care visits among medically complex people with HIV in the year before and after admission to Casey House, an HIV-specific hospital in Toronto, for all individuals admitted between April 2009 and March 2015. Negative binomial regression was used to compare rates of health care utilization. We used Wilcoxon rank sum tests to compare associated health care costs, standardized to 2015 Canadian dollars. To contextualize our findings, we present rates and costs of health service use among Ontario residents living with HIV. RESULTS: During the study period, 268 people living with HIV were admitted to Casey House. Emergency department use declined from 4.6 to 2.5 visits per person-year (p = 0.02) after discharge from Casey House, and hospitalization rates declined from 1.4 to 1.1 admissions per person-year (p = 0.05). Conversely, home care visits increased from 24.3 to 35.6 visits per person-year (p = 0.01) and family physician visits increased from 18.3 to 22.6 visits per person-year (p < 0.001) in the year after discharge. These changes were associated with reduced overall costs to the health care system. The reduction in overall costs was not significant (p = 0.2); however, costs of emergency department visits (p < 0.001) and physician visits (p < 0.001) were significantly less. INTERPRETATION: Health care utilization by people with HIV was significantly different before and after admission to a community hospital focused on HIV care. This has implications for health care in other complex patient populations.

Impact of COVID-19 pandemic on epilepsy practice in India: A tripartite survey.

OBJECTIVE: To assess the impact of ongoing COVID-19 pandemic on epilepsy care in India. METHODS: We conducted a three-part survey comprising neurologists, people with epilepsy (PWE), and 11 specialized epilepsy centers across India. We sent two separate online survey questionnaires to Indian neurologists and PWE to assess the epilepsy practice, seizures control, and access to care during the COVID-19 pandemic. We collected and compared the data concerning the number of PWE cared for and epilepsy procedures performed during the 6 months periods preceding and following COVID-19 lockdown from epilepsy centers. RESULTS: The survey was completed by 453 neurologists and 325 PWE. One third of the neurologist reported >50 % decline in outdoor visits by PWE and EEG recordings. The cumulative data from 11 centers showed 65-70 % decline in the number of outdoor patients, video-EEG monitoring, and epilepsy surgery. Working in a hospital admitting COVID-19 patients and use of teleconsultation correlated with this decline. Half of PWE had postponed their planned outpatient visits and EEG. Less than 10 % of PWE missed their antiseizure medicines (ASM) or had seizures due to the nonavailability of ASM. Seizure control remained unchanged or improved in 92 % PWE. Half of the neurologists started using teleconsultation during the pandemic. Only 4% of PWE were afflicted with COVID-19 infection. CONCLUSIONS: Despite significant decline in the number of PWE visiting hospitals, their seizure control and access to ASMs were not affected during the COVID-19 pandemic in India. Risk of COVID-19 infection in PWE is similar to general population.

Assessment patient satisfaction towards emergency medical care and its determinants at Ayder comprehensive specialized hospital, Mekelle, Northern Ethiopia.

BACKGROUND: As the healthcare industry shifts toward patient-centered models, providers will need to fully understand patient satisfaction and how they affect their practices. This study aimed to assess patient satisfaction towards the emergency medical care and factors associated with at Ayder specialized comprehensive hospital, Emergency room, Mekelle, Ethiopia. METHODS: An institution-based cross-sectional study was conducted from March 1-30, 2019. A systematic random sampling method was used to enroll 299 study participants. Data were collected using a standard Brief Emergency Department Patient Satisfaction Scale questionnaire by trained data collectors. Data was entered into EpiData 3.1 then exported and analyzed by SPSS version 22. Binary and multiple logistic regression were used to assess the factors associated with patient satisfaction. Where the p-value of <0.05 was considered significant. RESULTS: A total of 299 participants were enrolled in the study with a response rate of 99.3%. On overall patient satisfaction score majority (81.9%) of them were satisfied with the emergency medical care provided. The satisfaction rate towards emergency staff courtesy, emergency room environment, physician care satisfaction, general patient satisfaction, and patient family satisfaction was 80.3%, 37.5%, 75.9%, 70.9%, and 49.8% respectively. Those who arrived during the morning time of the day tend to be satisfied more with the emergency services (AOR = 4.8, 95% CI: 2.08, 11.4), while having low educational status (able to read and write) (AOR = 0.12, 95% CI: 0.03, 0.50) and waiting time till seen by a doctor (AOR = 1.3, 95% CI: 1.003, 1.4) was found to affect patient satisfaction negatively. CONCLUSIONS: The total patient satisfaction score towards emergency medical care was found to be good. The hospital management and emergency room staff should act on the identified factors especially on minimizing the patients waiting time to improve the quality of care in the emergency department.

Prevalence of diabetes, management and outcomes among Covid-19 adult patients admitted in a specialized tertiary hospital in Riyadh, Saudi Arabia.

This retrospective study aimed to characterize comorbidities and associated with mortality among hospitalized adults with Covid-19 managed as perthe Saudi Ministry of Health protocol in a specialized tertiary hospital in Riyadh, Saudi Arabia. Medical records of 300 adult patients with PCR-confirmed SARS-CoV2 infection and admitted in King Salman Hospital (KSH) from May 1 to July 31, 2020 were included. Medical history, management and outcomes were noted. Males significantly outnumber females (259 versus 41). South Asians comprise 41% of all admitted patients. Mortality rate was 10% and highest among Saudi males (28.9%). Type 2 diabetes mellitus (T2DM) was the most common comorbidity (45.7%). Almost all patients (99%) had pneumonia. Patients > 50 years were three times more likely to die (confidence interval, CI 1.3-6.9; p = 0.01) from Covid-19. Congestive heart failure (odds ratio OR 19.4, CI-1.5-260.0; p = 0.02) and acute kidney injury (OR 11.7, CI-4.7-28.6; p < 0.001) were significantly associated with higher mortality. Dexamethasone use significantly improved the final outcome based on net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (p < 0.05). In this single-center study, T2DM was very common among hospitalized Covid-19 patients. Patients > 50 years, those with congestive heart failure and acute kidney injury are at higher risk for worse Covid-19 outcome.

Acute Stroke Care Is at Risk in the Era of COVID-19: Experience at a Comprehensive Stroke Center in Barcelona.

BACKGROUND AND PURPOSE: The purpose of the study is to analyze how the coronavirus disease 2019 (COVID-19) pandemic affected acute stroke care in a Comprehensive Stroke Center. METHODS: On February 28, 2020, contingency plans were implemented at Hospital Clinic of Barcelona to contain the COVID-19 pandemic. Among them, the decision to refrain from reallocating the Stroke Team and Stroke Unit to the care of patients with COVID-19. From March 1 to March 31, 2020, we measured the number of emergency calls to the Emergency Medical System in Catalonia (7.5 million inhabitants), and the Stroke Codes dispatched to Hospital Clinic of Barcelona. We recorded all stroke admissions, and the adequacy of acute care measures, including the number of thrombectomies, workflow metrics, angiographic results, and clinical outcomes. Data were compared with March 2019 using parametric or nonparametric methods as appropriate. RESULTS: At Hospital Clinic of Barcelona, 1232 patients with COVID-19 were admitted in March 2020, demanding 60% of the hospital bed capacity. Relative to March 2019, the Emergency Medical System had a 330% mean increment in the number of calls (158 005 versus 679 569), but fewer Stroke Code activations (517 versus 426). Stroke admissions (108 versus 83) and the number of thrombectomies (21 versus 16) declined at Hospital Clinic of Barcelona, particularly after lockdown of the population. Younger age was found in stroke admissions during the pandemic (median [interquartile range] 69 [64-73] versus 75 [73-80] years, P=0.009). In-hospital, there were no differences in workflow metrics, angiographic results, complications, or outcomes at discharge. CONCLUSIONS: The COVID-19 pandemic reduced by a quarter the stroke admissions and thrombectomies performed at a Comprehensive Stroke Center but did not affect the quality of care metrics. During the lockdown, there was an overload of emergency calls but fewer Stroke Code activations, particularly in elderly patients. Hospital contingency plans, patient transport systems, and population-targeted alerts must act concertedly to better protect the chain of stroke care in times of pandemic.

A comparative analysis on human resources among the specialized ophthalmic medical institutions in China.

BACKGROUND: This study compares perspectives on specialized ophthalmic medical institutions, identifies the gaps in property and geographic offerings, and explores the ways that ophthalmic medical institutions can better allocate resources. The results of this research will increase patient's access to equitable and high-quality ophthalmic care in China. METHODS: The data for this research was gathered from the Survey of China National Eye Care Capacity and Resource for the year 2015. The paper specified the number, professional level of expertise, and educational background of ophthalmic health personnel. The authors of the paper analyzed and compared the differences in ophthalmic care in public vs. private and urban vs. rural regions in China. Descriptive statistics were used. RESULTS: Of the 395 specialized ophthalmic hospitals surveyed, 332 were private medical institutions (84%), and 63 were public (16%). Of the 26 607 ophthalmic personnel surveyed, working in specialized ophthalmic hospitals, 17 561 were in private hospitals (66%) and 9 046 were in public ones (34%). Furthermore, 22 578 of those personnel worked in urban ophthalmic institutions (85%) and 4 029 worked in rural ones (15%). As for regional differences, 14 090 personnel were located in eastern China (53%), 8 828 in central regions (33%), and 3 689 in the western regions (14%). CONCLUSIONS: Public ophthalmic medical institutions still face challenges in providing equitable and widespread care. The availability of well-staffed health centers varies significantly by region. These variations impact resource allocation and directly lead to inequalities and inaccessibility of health services in certain regions of China.

Fangcang shelter hospitals: a novel concept for responding to public health emergencies.

Fangcang shelter hospitals are a novel public health concept. They were implemented for the first time in China in February, 2020, to tackle the coronavirus disease 2019 (COVID-19) outbreak. The Fangcang shelter hospitals in China were large-scale, temporary hospitals, rapidly built by converting existing public venues, such as stadiums and exhibition centres, into health-care facilities. They served to isolate patients with mild to moderate COVID-19 from their families and communities, while providing medical care, disease monitoring, food, shelter, and social activities. We document the development of Fangcang shelter hospitals during the COVID-19 outbreak in China and explain their three key characteristics (rapid construction, massive scale, and low cost) and five essential functions (isolation, triage, basic medical care, frequent monitoring and rapid referral, and essential living and social engagement). Fangcang shelter hospitals could be powerful components of national responses to the COVID-19 pandemic, as well as future epidemics and public health emergencies.

NSCLC patient "migration" for treatment: A retrospective analysis of patient characteristics, travel patterns, and survival differences.

PURPOSE: Every year a significant population exists of those diagnosed with nonsmall cell lung cancer (NSCLC) who do not receive initial treatment upon diagnosis and then "migrate" to additional hospital before ultimately getting treatment. Migration to different hospitals may play a role in the decision to treat or not-to-treat, and we aimed to evaluate the potential factors that lead to treatment. METHODS: A retrospective review of 6212 patients with NSCLC from 29 Kentucky hospital registries from 2012 to 2014 was performed. Variables collected included hospital accreditation status, age at diagnosis, stage, overall survival (OS), and insurance status. Hospital records were matched to Kentucky Cancer Registry records to determine the number of hospitals visited for treatment. RESULTS: Most patients were treated at their initial hospital (73%). Of the remaining patients, 36% migrated to a different hospital where most received treatment (93%). Migrating to another hospital was associated with Stage I-III disease, younger age (66.4 vs 72.2 years), and longer OS (561 vs 157 days). Notably, migration was also associated with private insurance status and missing treatment modalities at the initial hospital. Treatment after migrating was associated with Stage I-II disease, younger age (65.8 vs 72.8 years), and longer OS (595 vs 153 days). After adjusting for confounders, treated migrating patients lived longer than initially treated patients (591 vs 505 days), especially among those with stage III (563 vs 495 days) and IV (379 vs 300 days) disease. CONCLUSION: This analysis demonstrates a survival benefit for initially untreated patients with advanced disease who migrate to another hospital for treatment. Migration was associated with having private insurance, thus making it noteworthy of the relationship between NSCLC survival benefit and insurance status.

Mohs Micrographic Surgery at the Skin and Cancer Foundation Australia, 20 Years Later (1997-2017).

BACKGROUND: The availability of Mohs micrographic surgery (MMS) in Australia has increased dramatically since its inception in the 1980s. OBJECTIVE: This study aimed to describe the evolution of MMS practices at the Skin and Cancer Foundation Australia (SCFA) over the past 20 years (1997-2017). METHODS: Retrospective analysis of Mohs surgery cases at SCFA in 2017, 2007, and 1997, comparing data on sex, age, tumor type and site, initial tumor and final defect size, number of surgical stages and sections, and closure management. The present study is limited by being a retrospective analysis from a single institution. RESULTS: There was a 415% increase in the number of Mohs surgery cases from 1997 to 2017, and a significant increase in Mohs surgery-treated squamous cell carcinoma. The preoperative tumor and final defect size have decreased. More side-to-side closures and fewer grafts are being performed over time. LIMITATIONS: Retrospective analysis from a single institution. CONCLUSION: Over the last 20 years, MMS has remained appropriate in its application and is being increasingly used for treatment of squamous cell carcinoma suggesting improved access.

Are cost differences between specialist and general hospitals compensated by the prospective payment system?

Prospective payment systems fund hospitals based on a fixed-price regime that does not directly distinguish between specialist and general hospitals. We investigate whether current prospective payments in England compensate for differences in costs between specialist orthopaedic hospitals and trauma and orthopaedics departments in general hospitals. We employ reference cost data for a sample of hospitals providing services in the trauma and orthopaedics specialty. Our regression results suggest that specialist orthopaedic hospitals have on average 13% lower profit margins. Under the assumption of break-even for the average trauma and orthopaedics department, two of the three specialist orthopaedic hospitals appear to make a loss on their activity. The same holds true for 33% of departments in our sample. Patient age and severity are the main drivers of such differences.

Hospitalizations for Cardiovascular Disease After Liver Transplantation in the United States.

Cardiovascular disease (CVD) is a leading cause of post-liver transplant death, and variable care patterns may affect outcomes. We aimed to describe epidemiology and outcomes of inpatient CVD care across US hospitals. Using a merged data set from the 2002-2011 Nationwide Inpatient Sample and the American Hospital Association Annual Survey, we evaluated liver transplant patients admitted primarily with myocardial infarction (MI), stroke (cerebrovascular accident [CVA]), congestive heart failure (CHF), dysrhythmias, cardiac arrest (CA), or malignant hypertension. Patient-level data include demographics, Charlson comorbidity index, and CVD diagnoses. Facility-level variables included ownership status, payer-mix, hospital resources, teaching status, and physician/nursing-to-bed ratios. We used generalized estimating equations to evaluate patient- and hospital-level factors associated with mortality. There were 4763 hospitalizations that occurred in 153 facilities (transplant hospitals, n = 80). CVD hospitalizations increased overall by 115% over the decade (P < 0.01). CVA and MI declined over time (both P < 0.05), but CHF and dysrhythmia grew significantly (both P < 0.03); a total of 19% of hospitalizations were for multiple CVD diagnoses. Transplant hospitals had lower comorbidity patients (P < 0.001) and greater resource intensity including presence of cardiac intensive care unit, interventional radiology, operating rooms, teaching status, and nursing density (all P < 0.01). Transplant and nontransplant hospitals had similar unadjusted mortality (overall, 3.9%, P = 0.55; by diagnosis, all P > 0.07). Transplant hospitals had significantly longer overall length of stay, higher total costs, and more high-cost hospitalizations (all P < 0.05). After risk adjustment, transplant hospitals were associated with higher mortality and high-cost hospitalizations. In conclusion, CVD after liver transplant is evolving and responsible for growing rates of inpatient care. Transplant hospitals are associated with poor outcomes, even after risk adjustment for patient and hospital characteristics, which may be attributable to selective referral of certain patient phenotypes but could also be related to differences in quality of care. Further study is warranted.

Bladder Reconstruction Rates Differ among Centers Participating in National Spina Bifida Patient Registry.

PURPOSE: We performed an exploratory analysis of data from the NSBPR (National Spina Bifida Patient Registry) to assess variation in the frequency of bladder reconstruction surgeries among NSBPR centers. MATERIALS AND METHODS: We queried the 2009-2014 NSBPR to identify patients who had ever undergone bladder reconstruction surgeries. We evaluated demographic characteristics, spina bifida type, functional level, mobility and NSBPR center to determine whether any of these factors were associated with reconstructive surgery rates. Multivariable logistic regression was used to simultaneously adjust for the impact of these factors. RESULTS: We identified 5,528 patients with spina bifida enrolled in the NSBPR. Of these patients 1,129 (20.4%) underwent bladder reconstruction (703 augmentation, 382 continent catheterizable channel, 189 bladder outlet procedure). Surgical patients were more likely older, female, nonHispanic white, with a higher lesion level, myelomeningocele diagnosis, nonambulators (all p <0.001) and nonprivately insured (p=0.018). Bladder reconstruction surgery rates varied among NSBPR centers (range 12.1% to 37.9%, p <0.001). After correcting for known confounders NSBPR center, spina bifida type, mobility, gender and age (all p <0.001) were significant predictors of surgical intervention. Race (p=0.19) and insurance status (p=0.11) were not associated with surgical intervention. CONCLUSIONS: There is significant variation in rates of bladder reconstruction surgery among NSBPR centers. In addition to clinical factors such as mobility status, lesion type and lesion level, nonclinical factors such as patient age, gender and treating center are also associated with the likelihood of an individual undergoing bladder reconstruction.

Medical costs, Cesarean delivery rates, and length of stay in specialty hospitals vs. non-specialty hospitals in South Korea.

BACKGROUND: Since 2011, specialty hospitals in South Korea have been known for providing high- quality care in specific clinical areas. Much research related to specialty hospitals and their performance in many such areas has been performed, but investigations about their performance in obstetrics and gynecology are lacking. Thus, we aimed to compare specialty vs. non-specialty hospitals with respect to mode of obstetric delivery, especially the costs and length of stay related to Cesarean section (CS) procedures, and to provide evidence to policy-makers for evaluating the success of hospitals that specialize in obstetric and gynecological (OBGYN) care. METHODS: We obtained National Health Insurance claim data from 2012 to 2014, which included information from 418,141 OBGYN cases at 214 hospitals. We used a generalized estimating equation model to identify a potential association between the likelihood of CS at specialty hospitals compared with other hospitals. We also evaluated medical costs and length of stay in specialty hospitals according to type of delivery. RESULTS: We found that 150,256 (35.9%) total deliveries were performed by CS. The odds ratio of CS was significantly lower in specialty hospitals (OR: 0.95, 95% CI: 0.93-0.96compared to other hospitals Medical costs (0.74%) and length of stay (1%) in CS cases increased in specialty hospitals, although length of stay following vaginal delivery was lower (0.57%) in specialty hospitals compared with other hospitals. CONCLUSIONS: We determined that specialty hospitals are significantly associated with a lower likelihood of CS delivery and shorter length of stay after vaginal delivery. Although they are also associated with higher costs for delivery, the increased cost could be due to the high level of intensive care provided, which leads to improve quality of care. Policy-makers should consider incentive programs to maintain performance of specialty hospitals and promote efficiency that could reduce medical costs accrued by patients.

Prevalence and management status of urologic diseases in geriatric hospitals in South Korea: A field research.

PURPOSE: We aimed to investigate the current management status of urologic diseases in geriatric hospitals in South Korea. MATERIALS AND METHODS: Questionnaire surveys and in-depth person-to-person interviews were conducted at 13 hospitals within the Seoul and Incheon areas. RESULTS: The study was carried out from July to December 2014; 75.6% of patients (1,858/2,458) and 77.5% (779/1,031) of medical personnel responded to our survey. All surveys and interviews were performed by urology specialists, fellows, residents, or nurses. The hospitals included in the study had an average of 215.2 beds (range, 110-367), 189.1 patients (range, 90-345), and 40.2 nurses (range, 10-83). The average number of physicians was 6.2 (range, 3-11), but none of these were certified urologists. Only 4 hospitals provided consultation services for urological disorders. In total, 64% of patients had urological disorders, although only 20.7% of patients were receiving medication. Most patients were being treated using urological interventions; diapers (49.7%), indwelling catheters (19.5%), clean intermittent catheters (12.2%), and external collection urinary drainage (7.9%). However, most interventions were inadequately implemented, and only 17% of the patients had been examined by a certified urologist. Urological complications were found in 20.2% of patients, and secondary complications occurred in 18.8%. Excluding redundant cases, the total prevalence of urological complications was 39.0%. CONCLUSIONS: Urologic diseases are poorly managed, and no certified urologists work in geriatric hospitals. Therefore, more designated urologists are needed in geriatric hospitals.

Prevalence of skin diseases in hospitalized geriatric patients : Association with gender, duration of hospitalization and geriatric assessment.

BACKGROUND: Improvement of quality of life in old age and prevention of age-associated diseases have become the main focus of research into aging; however, information regarding the skin health status of geriatric patients still remains sparse. GOAL: To investigate the extent of dermatological diseases in hospitalized geriatric patients, map the most prevalent ones, check for any gender differences and document any correlations with duration of hospitalization and results of geriatric assessments. PATIENTS AND METHODS: A total of 110 hospitalized geriatric patients underwent a complete dermatological examination at the Evangelical Geriatric Hospital (Evangelisches Geriatriezentrum) Berlin. The collected information was stratified according to dermatological diagnosis, results of geriatric assessments, duration of hospitalization, age and gender of the patients. RESULTS: The average number of diagnosed skin diseases per patient was 3.7 ± 1.8 for the female population and 4.3 ± 2.0 for the male population. After categorizing all diagnosed skin diseases, infectious diseases were found to be most common in both female and male patients (55 % and 58 %, respectively) followed by vascular diseases (46.7 % and 54 %, respectively). Precancerous skin lesions and epithelial skin cancer were more frequent in men than in women (20 % vs. 6.7 %, p < 0.037 and 34 % vs. 13.3 %, p < 0.010, respectively). Pruritus showed a positive correlation with the duration of hospitalization and a negative correlation with the Barthel index and Tinetti score on the day of discharge, indicating that pruritus may have a significant impact on the physical condition of elderly multimorbid patients and on the static and dynamic balance abilities. CONCLUSION: Our results demonstrate that skin health in the elderly is compromised and disregarded and this should constitute one of the top priorities of healthcare specialists and physicians in the future.

Spending on Bariatric Surgery in the Unified Health System from 2010 to 2014: a Study Based on the Specialist Hospitals Authorized by the Ministry of Health.

BACKGROUND: The aim of this study is to analyze the production of 76 specialist hospitals for the morbidly obese in Brazil's public healthcare system (SUS) from 2010 to 2014 in terms of quantity and costs of bariatric surgery and its complications. METHODS: Secondary data from the SUS Hospital Information System and the National Healthcare Establishments Registry were used. Current spending on bariatric surgery and its medical and postoperative complications were analyzed. RESULTS: There was a 60 % rise in the number of surgeries between 2010 and 2014. This increase was not homogeneous among the hospitals studied, since only 19 performed the minimum number of surgeries required. Women accounted for 85 % of the surgeries carried out, and 32 % were aged between 35 and 44 years. The Roux-en-Y technique was the most widely used (93.7 % of the total), followed by sleeve gastrectomy. The ratio between the occurrence of medical complications and total number of surgeries performed in each hospital varied significantly (between 0 and 5.97 %) but was lower for postoperative complications, ranging from 0 to 1.7 %. There was a nominal increase of 44 % in average expenditure on postoperative complications between 2013 and 2014, while the average cost of medical complications decreased by 8.7 % in the same period. CONCLUSIONS: Despite the rise in the number of bariatric surgeries in Brazil, there is still a high demand for surgeries that is not being met, while most specialist hospitals fail to perform the minimum number of surgeries stipulated by the Ministry of Health.

Initial Report on the Results of the Kidney Transplant Program at the Bajio Regional High Specialty Hospital.

BACKGROUND: We present the first results of our program, which is characterized by its acceptance of any candidate with chronic renal failure. Therefore, we serve all patients, regardless of their social security and socioeconomic status. METHODS: We conducted a retrospective, descriptive, cross-sectional study describing the characteristics of patients who received kidney transplants in the period from 2008 to 2015. Descriptive statistics were used to evaluate our findings. RESULTS: A total of 708 transplants were performed, with 377 (53%) involving a living donor and 331 (47%) involving deceased donors. The patients' mean age was 26 years (±12.7 SD), with a range of 5 to 69 years. Of these patients, 488 were male (68.9%), and 423 (59.7%) had no social security. The replacement therapy prior to transplantation was peritoneal dialysis in 40% of cases, hemodialysis in 57% of cases, and 3% of patients had no prior therapy. The blood group distribution was 436 (61%) type O; 177 (25%) type A; 78 (11%) type B; and 8 (1%) type AB. The average hospital stay for a living donor transplant was 9 days and 13 days in the case of a deceased donor. CONCLUSIONS: This study describes the basic clinical and epidemiological characteristics of our transplant population. These results can be used as a basis for future descriptive and prospective studies at our institution or in other inter-agency and national projects. We also highlight the rapid development of the kidney transplant program at the Bajio Regional High Specialty Hospital.

Finding the Value in 'Value' Designation: Evidence and Opportunity in the United States.

PURPOSE: Centers of Excellence (COE) designations have been used to distinguish high-quality facilities. Originally based on quality metrics alone, published evidence failed to consistently show improvements in measurable quality markers. COE development has since shifted to a value-based framework incorporating cost of care, providing greater transparency. This study evaluated the patient outcomes of such value-designated facilities certified under one of the larger U.S. commercial provider networks. DESIGN: Retrospective, observational study using 2009-2013 commercial administrative claims data. METHODOLOGY: Analysis included 33,827 adults (≥18 years) who received spine surgery at value-designated (n=6,141, 22%) vs. other facilities (n=27,686, 78%). Multivariate regression models were used to compare 90-day episodic costs and quality outcomes, adjusted for patient characteristics and comorbidities. RESULTS: Adjusted episodic cost per surgery was lower in value-designated facilities by $3,157 (16%) for lumbar discectomy/decompression, $6,784 (19%) for cervical simple fusion, and $11,134 (18%) for lumbar simple fusion (all P<.05). Adjusted complication rate was lower (1.5% vs. 2.0%; P<.05) at value-designated facilities, while other quality measures were similar. Value-designated facilities tended to be large, in metropolitan areas, affiliated with medical schools, and performed more surgical procedures and provided more nursing hours. CONCLUSIONS: To our knowledge, this is the first large-scale study evaluating value-designated COE. Value-designated COE programs represent an advance over a cost- or quality-alone designation in the ability to identify facilities with lower costs and equal or better quality outcomes. Value designation offers patients transparency for selecting care providers. Future efforts should continue to refine quality criteria used in designations to distinguish patient outcomes.

Optimization modeling to maximize population access to comprehensive stroke centers.

OBJECTIVE: The location of comprehensive stroke centers (CSCs) is critical to ensuring rapid access to acute stroke therapies; we conducted a population-level virtual trial simulating change in access to CSCs using optimization modeling to selectively convert primary stroke centers (PSCs) to CSCs. METHODS: Up to 20 certified PSCs per state were selected for conversion to maximize the population with 60-minute CSC access by ground and air. Access was compared across states based on region and the presence of state-level emergency medical service policies preferentially routing patients to stroke centers. RESULTS: In 2010, there were 811 Joint Commission PSCs and 0 CSCs in the United States. Of the US population, 65.8% had 60-minute ground access to PSCs. After adding up to 20 optimally located CSCs per state, 63.1% of the US population had 60-minute ground access and 86.0% had 60-minute ground/air access to a CSC. Across states, median CSC access was 55.7% by ground (interquartile range 35.7%-71.5%) and 85.3% by ground/air (interquartile range 59.8%-92.1%). Ground access was lower in Stroke Belt states compared with non-Stroke Belt states (32.0% vs 58.6%, p = 0.02) and lower in states without emergency medical service routing policies (52.7% vs 68.3%, p = 0.04). CONCLUSION: Optimal system simulation can be used to develop efficient care systems that maximize accessibility. Under optimal conditions, a large proportion of the US population will be unable to access a CSC within 60 minutes.