Erlang could have told you so-A case study of health policy without maths.

Little consideration is given to the operational reality of implementing national policy at local scale. Using a case study from Norway, we examine how simple mathematical models may offer powerful insights to policy makers when planning policies. Our case study refers to a national initiative requiring Norwegian municipalities to establish acute community beds (municipal acute units or MAUs) to avoid hospital admissions. We use Erlang loss queueing models to estimate the total number of MAU beds required nationally to achieve the original policy aim. We demonstrate the effect of unit size and patient demand on anticipated utilisation. The results of our model imply that both the average demand for beds and the current number of MAU beds would have to be increased by 34% to achieve the original policy goal of transferring 240 000 patient days to MAUs. Increasing average demand or bed capacity alone would be insufficient to reach the policy goal. Day-to-day variation and uncertainty in the numbers of patients arriving or leaving the system can profoundly affect health service delivery at the local level. Health policy makers need to account for these effects when estimating capacity implications of policy. We demonstrate how a simple, easily reproducible, mathematical model could assist policy makers in understanding the impact of national policy implemented at the local level.

STUDY ON HEALTH PROFESSIONALS' PERCEPTION OF QUALITY OF HEALTHCARE PROVIDED TO PATIENTS.

UNLABELLED: The quality of the health care system is an essential condition for in improving the quality of health services and satisfying both the patients and healthcare professionals. RESEARCH OBJECTIVES: To identify the characteristics of medical profession, the factors of professional satisfaction or dissatisfaction and health care team-related factors that influence the quality of care. MATERIAL AND METHODS: Qualitative study using a SurveyMonkey online questionnaire consisting of 14 open-ended questions. The respondents were 1013 health professionals in university and non-university hospitals with various unit profiles. RESULTS: According to healthcare professionals, medical profession is defined by: humanism and personal sacrifice (33.37%) and also high professional competence (33.07%). Satisfaction factors are: patient health (40.57%), high social status (36.33) and saved lives (33.07%). Dissatisfaction may be due to: low salary (39.98%), disorganization (38.10%) and lack of procedures (33.96%). Performance may decrease as a result of: stressful working conditions, lack of adequate medical supplies, lack of recognition at work, routine, and strained relations with superiors. CONCLUSIONS: The study shows the need for correlating the medical education system and health systems, and for an integrated analysis of both systems by determining the required skills and modeling the medical team behavior in accordance with the performance variables which take into account satisfaction among both patients and health care professionals.

Effects of consumer and provider moral hazard at a municipal hospital out-patient department on Ghana's National Health Insurance Scheme.

BACKGROUND: In 2003, Ghana introduced the national health insurance scheme (NHIS) to promote access to healthcare. This study determines consumer and provider factors which most influence the NHIS at a municipal health facility in Ghana. METHOD: This is an analytical cross-sectional study at the Winneba Municipal Hospital (WHM) in Ghana between January-March 2010. A total of 170 insured and 175 uninsured out-patients were interviewed and information extracted from their folders using a questionnaire. Consumers were from both the urban and rural areas of the municipality. RESULTS: The mean number of visits by insured consumers to a health facility in previous six months was 2.48 +/- 1.007 and that for uninsured consumers was 1.18 +/- 0.387(p-value<0.001). Insured consumers visited the health facility at significantly more frequent intervals than uninsured consumers (χ(2) = 55.413, p-value< 0.001). Overall, insured consumers received more different types of medications for similar disease conditions and more laboratory tests per visit than the uninsured. In treating malaria (commonest condition seen), providers added multivitamins, haematinics, vitamin C and intramuscular injections as additional medications more for insured consumers than for uninsured consumers. CONCLUSION: Findings suggest consumer and provider moral hazard may be two critical factors affecting the NHIS in the Effutu Municipality. These have implications for the optimal functioning of the NHIS and may affect long-term sustainability of NHIS in the municipality. Further studies to quantify financial/ economic cost to NHIS arising from moral hazard, will be of immense benefit to the optimal functioning of the NHIS.

Diferenças regionais e custos dos procedimentos de fisioterapia no Sistema Único de Saúde do Brasil, 1995 a 2008 / Regional differences and costs of physical therapy procedures in Brazil's Unified Health System, 1995 to 2008

OBJETIVO: Descrever os atendimentos ambulatoriais fisioterßpicos prestados pelo Sistema Único de Saúde (SUS) no Brasil quanto a sua distribuição geogrßfica, custos, tipos de procedimento e tipos de prestador. MÉTODOS: Foram utilizados dados do Departamento de Informßtica do SUS (DATASUS), referentes ao período de 1995 a 2008, que incluíam a quantidade e o valor dos procedimentos aprovados para pagamento pelas Secretarias de Saúde e a quantidade e o valor dos procedimentos apresentados para pagamento. Os coeficientes de atendimento (CoA) foram calculados dividindo-se o número de atendimentos no ano em uma região pela população estimada no mesmo ano e região. RESULTADOS: O CoA no Brasil em 2008 foi de 0,19 e as regiões Norte e Centro-Oeste apresentaram os menores coeficientes (0,13 e 0,10, respectivamente). Entre 1995 e 2007 houve um crescimento no coeficiente nacional de atendimentos de 33,7 por cento, sendo que a região Norte apresentou o maior aumento, de 143,8 por cento, a Centro-Oeste, de 62,1 por cento, e a Nordeste, de 56,1 por cento. O atendimento nas alterações motoras foi o procedimento mais realizado (61,8 por cento) e os valores de pagamento aprovados foram menores que os apresentados pelos gestores dos serviços em 2008 (10,4 por cento). Estabelecimentos privados com fins lucrativos prestaram 44,5 por cento dos atendimentos fisioterßpicos pagos pelo SUS em 2008. Os estabelecimentos municipais responderam por 26,6 por cento dos atendimentos e os federais por apenas 0,9 por cento. Entre 1995 e 2007, a quantidade de atendimentos oferecidos pelos estabelecimentos municipais cresceu 278,7 por cento. CONCLUSÕES: Observou-se que a oferta de atendimento fisioterßpico ambulatorial pelo SUS ainda é pequena e geograficamente desigual, embora regiões menos desenvolvidas apresentem um maior crescimento no CoA. O SUS remunera inadequadamente os serviços prestados em fisioterapia e ainda o faz, em grande parte, por meio de convênios...

OBJECTIVE: Describe the ambulatory physical therapy treatments provided by the Unified Health System (SUS) in Brazil with regard to their geographical distribution, costs, types of procedure, and types of provider. METHODS: Data from the SUS Information Technology Department (DATASUS) were utilized, drawing from the period from 1995 to 2008, which included the quantity and the value of the procedures approved for payment by the Secretariats of Health and the quantity and value of the procedures presented for payment. The treatment coefficients (CoA) were calculated by dividing the number of treatments in a particular year and region by the estimated population of that region in that year. RESULTS: The CoA in Brazil in 2008 was 0.19 and the North and Center-West regions presented the lowest coefficients (0.13 and 0.10, respectively). Between 1995 and 2007 there was an increase in the national treatment coefficient of 33.7 percent, with the North region showing the largest increase, 143.8 percent; the Center-West 62.1 percent, and the Northeast 56.1 percent. Treatment for motor disorders was the most widely performed procedure (61.8 percent), and the values of payments approved were lower than those presented by the managers of the services in 2008 (10.4 percent). Private for-profit establishments provided 44.5 percent of the physical therapy treatments paid for by the SUS in 2008. Municipal establishments accounted for 26.6 percent of the treatments, and federal establishments for only 0.9 percent. Between 1995 and 2007, the quantity of treatments offered by municipal establishments increased 278.7 percent. CONCLUSIONS: It was observed that the provision of ambulatory physical therapy treatment by the SUS remains small and geographically unequal, although lessdeveloped regions showed a larger increase in the CoA. The SUS remunerates inadequately the physical therapy services provided and continues to do so, in large part, by means of agreements...

[Parameters of bed occupancy of intensive care units in Hungary]. / A magyarországi intenzív osztályok kihasználtságának néhány paramétere.

According to the Semmelweis Plan for Saving Health Care, "the capacity of the national network of intensive care units in Hungary is one but not the only bottleneck of emergency care at present". Author shows on the basis of data reported to the health insurance that not on a single calendar day more than 75% of beds in intensive care units were occupied. There were about 15 to 20 thousand sick days which could be considered unnecessary because patients occupying these beds were discharged to their homes directly from the intensive care unit. The data indicate that on the whole bed capacity is not low, only in some institutions insufficient. Thus, in order to improve emergency care in Hungary, the rearrangement of existing beds, rather than an increase of bed capacity is needed.

[Regional differences and costs of physical therapy procedures in Brazil's Unified Health System, 1995 to 2008]. / Diferenças regionais e custos dos procedimentos de fisioterapia no Sistema Único de Saúde do Brasil, 1995 a 2008.

OBJECTIVE: Describe the ambulatory physical therapy treatments provided by the Unified Health System (SUS) in Brazil with regard to their geographical distribution, costs, types of procedure, and types of provider. METHODS: Data from the SUS Information Technology Department (DATASUS) were utilized, drawing from the period from 1995 to 2008, which included the quantity and the value of the procedures approved for payment by the Secretariats of Health and the quantity and value of the procedures presented for payment. The treatment coefficients (CoA) were calculated by dividing the number of treatments in a particular year and region by the estimated population of that region in that year. RESULTS: The CoA in Brazil in 2008 was 0.19 and the North and Center-West regions presented the lowest coefficients (0.13 and 0.10, respectively). Between 1995 and 2007 there was an increase in the national treatment coefficient of 33.7%, with the North region showing the largest increase, 143.8%; the Center-West 62.1%, and the Northeast 56.1%. Treatment for motor disorders was the most widely performed procedure (61.8%), and the values of payments approved were lower than those presented by the managers of the services in 2008 (10.4%). Private for-profit establishments provided 44.5% of the physical therapy treatments paid for by the SUS in 2008. Municipal establishments accounted for 26.6% of the treatments, and federal establishments for only 0.9%. Between 1995 and 2007, the quantity of treatments offered by municipal establishments increased 278.7%. CONCLUSIONS: It was observed that the provision of ambulatory physical therapy treatment by the SUS remains small and geographically unequal, although less developed regions showed a larger increase in the CoA. The SUS remunerates inadequately the physical therapy services provided and continues to do so, in large part, by means of agreements with private establishments.

Affording what's free and paying for choice: comparing the cost of public and private hospitalizations in urban Kerala.

OBJECTIVE: To assess the cost of public and private hospitalizations in urban Kerala and discuss policy implications of social disparities in the economic burden of hospital care. METHODS: The NSSO survey on health care (1995-1996) for urban Kerala was analysed with regards to expenditure incurred by hospital episodes. Multilevel linear models were built to assess factors associated with levels of health expenditure. FINDINGS: Hospital care involves paying admission fees in 68% of cases of hospitalizations (98% in private and 20% in public sector) in urban Kerala. Poor households and those headed by casual workers show significantly lower levels of health expenditure and a higher proportion of health-related loss of income than other social groups. Although there is significant expenditure in both sectors for these groups, hospitalization on free public wards is associated with lower expenditure than other options. Factors linked with higher expenditure are: duration of stay; hospitalizations on paying public wards and in the private sector; hospitalizations for above poverty line households and hospitalizations for chronic illnesses. Expenditure for services bought from outside the hospital is important in the public sector. CONCLUSION: Hospitalization incurs significant expenditure in urban Kerala. Greater availability of free medical services in the public sector and financial protection against the cost of hospitalization are warranted.

[Study of socioeconomic home environment of children hospitalised at the Department of Paediatrics of Municipal Hospital in Lodz]. / Analiza srodowiska spolecznego pacjentów oddzialu Pediatrycznego Szpitala Miejskiego w Lodzi. Doniesienie wstepne.

UNLABELLED: One of types of child abuse is lack of proper care concerning health and development. This was the motivation to carry out this study in hospitalised children in our Department. AIM: analysis of socioeconomic home environment of children hospitalised in the Department of Paediatrics of municipal hospital, situated in the centre of Lodz city. MATERIAL AND METHOD: the analysis was carried out in 618 children (326 girls and 292 boys), aged from 3 to 18 years, hospitalised in the Department of Paediatrics during the year 2006. The following factors were analysed, cause of admission, family structure, parental legal situation, parents education, parents (or guardians) occupation, number of siblings, living conditions. RESULTS: concerning living conditions: 9.2% studied children lived in one room with 4 or more persons, 5% children were from residential care, the homes of 40% families locked basic sanitary standards. Data concerning mothers: 63% had primary education, 41.7% were working, 2.9% were either dead or did not live with the family, 4.5% had reduced or no parental rights. Data concerning fathers: 50.2% had primary education, 26.5% were not working, 17.2% were dead or were not living with the family, 7.4% had reduced or no parented rights. Analysis of cause of admission and number of hospitalisations of these children may be related to insufficient care for their well being and development, in a significant on part of parents or other care gives. CONCLUSIONS: In the home setting of a large part of children treated in our Paediatric Department of the Lodz Municipal Hospital the study indicated gross evidence of poverty, which may have led to health neglect. This shows the need for more precise studies. The present results will serve as guidelines for elaboration and implementation of a more complex and effective programme for prevention of factors of health neglect, which is one of the elements of child abuse.

Impact on and use of an inner-city London Infectious Diseases Department by international migrants: a questionnaire survey.

BACKGROUND: The UK has witnessed a considerable increase in immigration in the past decade. Migrant may face barriers to accessing appropriate health care on arrival and the current focus on screening certain migrants for tuberculosis on arrival is considered inadequate. We assessed the implications for an inner-city London Infectious Diseases Department in a high migrant area. METHODS: We administered an anonymous 20-point questionnaire survey to all admitted patients during a 6 week period. Questions related to sociodemographic characteristics and clinical presentation. Analysis was by migration status (UK born vs overseas born). RESULTS: 111 of 133 patients completed the survey (response rate 83.4%). 58 (52.2%) were born in the UK; 53 (47.7%) of the cohort were overseas born. Overseas-born were over-represented in comparison to Census data for this survey site (47.7% vs 33.6%; proportional difference 0.142 [95% CI 0.049-0.235]; p = 0.002): overseas born reported 33 different countries of birth, most (73.6%) of whom arrived in the UK pre-1975 and self-reported their nationality as British. A smaller number (26.4%) were new migrants to the UK (< or =10 years), mostly refugees/asylum seekers. Overseas-born patients presented with a broad range and more severe spectrum of infections, differing from the UK-born population, resulting in two deaths in this group only. Presentation with a primary infection was associated with refugee/asylum status (n = 8; OR 6.35 [95% CI 1.28-31.50]; p = 0.023), being a new migrant (12; 10.62 [2.24-50.23]; p = 0.003), and being overseas born (31; 3.69 [1.67-8.18]; p = 0.001). Not having registered with a primary-care physician was associated with being overseas born, being a refugee/asylum seeker, being a new migrant, not having English as a first language, and being in the UK for < or =5 years. No significant differences were found between groups in terms of duration of illness prior to presentation or duration of hospitalisation (mean 11.74 days [SD 12.69]). CONCLUSION: Migrants presented with a range of more severe infections, which suggests they face barriers to accessing appropriate health care and screening both on arrival and once settled through primary care services. A more organised and holistic approach to migrant health care is required.

Impact on and use of health services by international migrants: questionnaire survey of inner city London A&E attenders.

BACKGROUND: Changing immigration trends pose new challenges for the UK's open access health service and there is considerable speculation that migrants from resource-poor countries place a disproportionate burden on services. Data are needed to inform provision of services to migrant groups and to ensure their access to appropriate health care. We compared sociodemographic characteristics and impact of migrant groups and UK-born patients presenting to a hospital A&E/Walk-In Centre and prior use of community-based General Practitioner (GP) services. METHODS: We administered an anonymous questionnaire survey of all presenting patients at an A&E/Walk-In Centre at an inner-city London hospital during a 1 month period. Questions related to nationality, immigration status, time in the UK, registration and use of GP services. We compared differences between groups using two-way tables by Chi-Square and Fisher's exact test. We used logistic regression modelling to quantify associations of explanatory variables and outcomes. RESULTS: 1611 of 3262 patients completed the survey (response rate 49.4%). 720 (44.7%) were overseas born, representing 87 nationalities, of whom 532 (73.9%) were new migrants to the UK (< or =10 years). Overseas born were over-represented in comparison to local estimates (44.7% vs 33.6%; p < 0.001; proportional difference 0.111 [95% CI 0.087-0.136]). Dominant immigration status' were: work permit (24.4%), EU citizens (21.5%), with only 21 (1.3%) political asylum seekers/refugees. 178 (11%) reported nationalities from refugee-generating countries (RGCs), eg, Somalia, who were less likely to speak English. Compared with RGCs, and after adjusting for age and sex, the Australians, New Zealanders, and South Africans (ANS group; OR 0.28 [95% CI 0.11 to 0.71]; p = 0.008) and the Other Migrant (OM) group comprising mainly Europeans (0.13 [0.06 to 0.30]; p = 0.000) were less likely to have GP registration and to have made prior contact with GPs, yet this did not affect mode of access to hospital services across groups nor delay access to care. CONCLUSION: Recently arrived migrants are a diverse and substantial group, of whom migrants from refugee-generating countries and asylum seekers comprise only a minority group. Service reorganisation to ensure improved access to community-based GPs and delivery of more appropriate care may lessen their impact on acute services.

Emergency department as the main source of asthma care.

Many asthma patients use the emergency department (ED) as the sole source of asthma care. This is considered inadequate and poor practice. This prospective study revealed that young age, lack of evening clinic, forgetting to keep the appointment, conflicting priorities of daily life, and easy access to the ED on an as-needed basis for urgent care, medications, and prescriptions, and failure to use inhaled corticosteroids were significant while lack of insurance or access to asthma clinic were not significant factors in exclusive use of the ED. Establishing ED asthma education programs or an after hours asthma clinic may alleviate the practice.

Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program.

BACKGROUND: Patient falls in hospitals are common and may lead to negative outcomes such as injuries, prolonged hospitalization and legal liability. Consequently, various hospital falls prevention programs have been implemented in the last decades. However, most of the programs had no sustained effects on falls reduction over extended periods of time. METHODS: This study used a serial survey design to examine in-patient fall rates and consequent injuries before and after the implementation of an interdisciplinary falls prevention program (IFP) in a 300-bed urban public hospital. The population under study included adult patients, hospitalized in the departments of internal medicine, geriatrics, and surgery. Administrative patient data and fall incident report data from 1999 to 2003 were examined and summarized using frequencies, proportions, means and standard deviations and were analyzed accordingly. RESULTS: A total of 34,972 hospitalized patients (mean age: 67.3, SD +/- 19.3 years; female 53.6%, mean length of stay: 11.9 +/- 13.2 days, mean nursing care time per day: 3.5 +/- 1.4 hours) were observed during the study period. Overall, a total of 3,842 falls affected 2,512 (7.2%) of the hospitalized patients. From these falls, 2,552 (66.4%) were without injuries, while 1,142 (29.7%) falls resulted in minor injuries, and 148 (3.9%) falls resulted in major injuries. The overall fall rate in the hospitals' patient population was 8.9 falls per 1,000 patient days. The fall rates fluctuated slightly from 9.1 falls in 1999 to 8.6 falls in 2003. After the implementation of the IFP, in 2001 a slight decrease to 7.8 falls per 1,000 patient days was observed (p = 0.086). The annual proportion of minor and major injuries did not decrease after the implementation of the IFP. From 1999 to 2003, patient characteristics changed in terms of slight increases (female gender, age, consumed nursing care time) or decreases (length of hospital stay), as well as the prevalence of fall risk factors increased up to 46.8% in those patients who fell. CONCLUSION: Following the implementation of an interdisciplinary falls prevention program, neither the frequencies of falls nor consequent injuries decreased substantially. Future studies need to incorporate strategies to maximize and evaluate ongoing adherence to interventions in hospital falls prevention programs.

Randomized clinical trial of a postdischarge pharmaceutical care program vs regular follow-up in patients with heart failure.

OBJECTIVE: To assess the efficacy of a multifactorial educational intervention carried out by a pharmacist in patients with heart failure (HF). METHOD: A randomized, prospective, open clinical trial in patients admitted for HF. The patients assigned to the intervention group received information about the disease, drug therapy, diet education, and active telephone follow-up. Visits were completed at 2, 6, and 12 months. Hospital re-admissions, days of hospital stay, treatment compliance, satisfaction with the care received, and quality of life (EuroQol) were evaluated; a financial study was conducted in order to assess the possible impact of the program. The intervention was performed by the pharmacy department in coordination with the cardiology unit. RESULTS: 134 patients were included, with a mean age of 75 years and a low educational level. The patients of the intervention group had a higher level of treatment compliance than the patients in the control group. At 12 months of follow-up, 32.9% fewer patients in the intervention group were admitted again vs. the control group. The mean days of hospital stay per patient in the control group were 9.6 (SD=18.5) vs. 5.9 (SD=14.1) in the intervention group. No differences were recorded in quality of life, but the intervention group had a higher score in the satisfaction scale at two months [9.0 (SD=1.3) versus 8.2 (SD=1.8) p=0.026]. Upon adjusting a Cox survival model with the ejection fraction, the patients in the intervention group had a lower risk of re-admission (Hazard ratio 0.56; 95% CI: 0.32-0.97). The financial analysis evidenced savings in hospital costs of euro 578 per patient that were favorable to the intervention group. CONCLUSIONS: Postdischarge pharmaceutical care allows for reducing the number of new admissions in patients with heart failure, the total days of hospital stay, and improves treatment compliance without increasing the costs of care.

Identifying homelessness at an urban public hospital: a moving target?

Hospitals do not routinely collect data about homelessness. The objectives of the present study were to (1) describe rate of patient reports of homelessness among inpatients at a public hospital, (2) assess the agreement between patient report of housing status on a study questionnaire with clinical and administrative data about homelessness, and (3) assess changes in housing status during hospitalization. We conducted a cross-sectional survey of inpatients at an urban public hospital to assess housing status; we then examined subjects' medical charts to assess agreement with the questionnaire on housing status. Of inpatients, 25.6% were homeless at discharge. An additional 19.4% were marginally housed. One third of homeless persons had their housing status change during their hospitalization. Administrative data identified 25.6% and physicians' notes identified 22.5% as homeless. Clinical, administrative, and survey data did not agree. Homelessness and changes in housing status are common among inpatients at an urban public hospital. Poor agreement on who is homeless limits the usefulness of data.

The role of U.S. public hospitals in urban health.

Public hospitals in the United States play a key role in urban health. In many metropolitan communities, public hospitals maintain the health care safety net. Most urban public hospitals have evolved to not only provide care for the indigent but also to serve their communities in other ways, including serving as major providers for tertiary services such as trauma and those that support homeland security; serving as the foundation for primary care services; continuing to train a significant number of physician, nurses, and other medical personnel; and providing laboratories for clinical medical research. Federal budget cuts such as those in the Balanced Budget Act of 1997, recent state budget deficits, competition for Medicaid Managed Care, and the growth in the number of uninsured have led to a decline in revenues among urban public hospitals. To be better stewards of scarce resources, public hospitals have moved to reduce inpatient demand by adopting prevention strategies that are aimed at addressing the determinants of health, the complex interactions among social and economic factors, the physical environment, and individual behavior. These factors contribute to health status and offer opportunities to intervene and improve community health. Urban public hospitals, to be successful in the next stage of their evolution, need to learn to manage the "in-betweens"--partnering with governmental and nongovernmental entities to identify and work together on common health and safety issues. If public hospitals engage the community successfully, building trust and establishing new capability and capacity, urban public hospitals will survive, evolve, and continue their tradition of service.

A management information system to plan and monitor the delivery of health-care services in government hospitals in India.

Governments all over the world are getting increasingly concerned about their ability to meet their social obligations in the health sector. In this paper, we discuss the design and development of a management information system (MIS) to plan and monitor the delivery of healthcare services in government hospitals in India. Our MIS design is based on an understanding of the working of several municipal, district, and state government hospitals. In order to understand the magnitude and complexity of various issues faced by the government hospitals, we analyze the working of three large tertiary care hospitals administered by the Ahmedabad Municipal Corporation. The hospital managers are very concerned about the lack of hospital infrastructure and resources to provide a satisfactory level of service. Equally concerned are the government administrators who have limited financial resources to offer healthcare services at subsidized rates. A comprehensive hospital MIS is thus necessary to plan and monitor the delivery of hospital services efficiently and effectively.

Assessment of some performance indicators of medical departments in tertiary hospitals.

The present study assesses the performance of 37 medical departments from 12 tertiary hospitals in Iasi town during year 2001 through the following indicators: average hospital stay, utilization rate and hospital bed turnover rate. The first indicator has been analyzed by comparing the values recorded in various medical departments with those recommended by the Ministry of Health for tertiary hospitals. The highest value was recorded in the nephrology department, with a ratio 2001 value/optimal value of 2.76. Long average hospital stay has been recorded in 14 of the 37 assessed departments (37.8%). During year 2001, the following utilization rates have been found: normal rates of 300-365 inpatient days per hospital bed in 14 departments, high rates (over 365 days) in 11 departments, and low rates (less than 300) in 12 departments. Bed turnover rate varied with department's specialty profile and length of hospital stay from 11 inpatients per hospital bed in the acute mental disorders department to 146 in C intensive care unit.

Motor city blues.

With its safety net hospital in peril, Detroit had a choice: fundamentally reform its public health system or watch it collapse. Cities nationwide face a similar dilemma.