Discharge against medical advice from a Mission tertiary hospital, South-West, Nigeria.

BACKROUND: The fiduciary duty of a managing physician makes paediatric discharges against medical advice (DAMA) particularly challenging as children lack the legal power or authority to make their health decisions. Aim: It is aimed in the present study to determine the prevalence of paediatric DAMA in a mission tertiary hospital. METHODS: This was a prospective descriptive study carried out from June 2018 to May 2019 among paediatric inpatients at the Bowen University Teaching Hospital, Ogbomoso, Nigeria whose parent/ care giver signed DAMA, despite adequate counselling. Data was analysed using SPSS version 23. RESULTS: The prevalence of DAMA in the study was of 4.1%, and the neonatal group accounted for the largest bulk of DAMA. Birth asphyxia was the commonest diagnosis among this group. There was a slight female predominance among the patients whose parents signed DAMA. Financial constraint was the commonest reason [13(30.2%)] given for DAMA and none of the children whose parents signed DAMA was enrolled on the National Health Insurance Scheme (NHIS). CONCLUSION: Rate of DAMA in a private mission tertiary hospital was lower than previously reported from government tertiary hospitals in the present-day Nigeria.

Morbidity Pattern and Choice of Care in an Urban Slum of a Metropolitan State, Southwestern Nigeria.

BACKGROUND: An increased population growth has led to the proliferation of slums in urban areas. Urban slum dwellers are susceptible to ailments which may be worsened from reduced access to health facilities or weak institutional capacity. Understanding the pattern of morbidity and choice of care among slum dwellers can inform appropriate health interventions among this group. This study was conducted to investigate and document the morbidity patterns and choice of care within an urban slum community of South-western Nigeria. METHODS: The study was a descriptive cross-sectional survey involving 480 respondents selected through a random sampling technique in Idikan community of Southwestern Nigeria. The survey was conducted using a pre-tested semi-structured interviewer administered questionnaire on morbidity pattern and choice of care. Data were analyzed using SPSS Vs version 13 to generate frequencies and association between independent variables and choice of care using Chi-square at 5% level of significance. RESULTS: Among those that were ill, slightly over half of the respondents, 254 (52.9%) used self-medication while only 226 respondents (47.1%) sought medical care Majority of the respondents that sought care did so from Christian based health facilities (66.8%). A significantly higher proportion, (74.3%) of those in the higher occupational class compared with those of low occupational class (55.1%) (p = 0.001) sought care in a health facility. Also, a significantly higher proportion of those with tertiary education (69.0%) sought care in facilities compared to other cadres (p = 0.033). CONCLUSION: Disparities in morbidity patterns and access to care still persists in the surveyed community which requires urgent attention in the urban slums. This is evidently linked to educational and socio-economic status. Re-distribution of national funds to educational institutions and creation of jobs in the slums are advocated to improve the health seeking behaviours of slum dwellers in Ibadan and Nigeria at large.

Scaling up Maternal and Child Healthcare Delivery among Mission Hospitals in Southeast Nigeria: An Empirical Application of Data Envelopment Analysis for Setting Benchmarks and Targets.

The health system in many parts of Nigeria has been dysfunctional in several domains including financing, human resources, infrastructure, health management information system and hospital services. In an attempt to scale up Maternal and Child Health (MCH) services and ensure efficiency, Ebonyi State Government in Southeast Nigeria provided funding to mission hospitals across the State as a grant. This study used nonparametric method to assess the effect of this public financing on the efficiency of the mission hospitals. Operational cost and number of hospital beds were used as the input variables, while antenatal registrations, number of immunization doses and hospital deliveries were the output variables. The hospitals were disaggregated into 15 hospital-years. The mean overall technical efficiency of the mission hospitals was 84.05 22.45%. The mean pure technical efficiency was 95.56±6.9% and the scale efficiency was 88.05±22.20%. About 46.67% of all the hospital-years were technically and scale efficient. Although, 55.33% were generally inefficient, only 33.33% of hospital-years exhibited pure technical inefficiency. Low immunization coverage was the major cause of inefficiency. The study showed increased maternal health service output as result of public funding or intervention; however, the mission hospitals could have saved 16% of input resources if they had performed efficiently. It also shows that data envelopment analysis can be used in setting targets/benchmarks for relatively inefficient health facilities, and in monitoring impact of interventions on efficiency of hospitals over-time.

Impact of the closure of a large urban medical center: a qualitative assessment (part I).

This community health needs assessment-the first part of a mixed-methods project-sought to qualitatively examine the impact of the closure of St. Vincent's Catholic Medical Center, a large not-for-profit hospital in NYC, on individuals who used its services. Key informant interviews with organizational leaders and focus groups with residents were conducted to understand hospital utilization, unmet health care needs, health care utilization and experiences post closure, perceptions of the most significant effect of the closing, and recommendations for improving health care in the community. Most respondents spoke positively of the hospital's accessibility, comprehensive, high-quality services, and its close relationship with the community. Conversely, experiences post-closure were largely negative, including decreased access, interrupted care, and loss of emergency and specialty care. Lack of information concerning medical records reflected a larger problem of poor planning and community outreach. Another issue was widespread anxiety in a community now lacking a hospital. Further, while the hospital's closure might cause inconveniences, these effects were described as more daunting to vulnerable groups. Our findings provide a consistent picture of a hospital highly regarded by residents, patients, and leaders of several health and social services organizations. Regardless of whether it should have been permitted to close (as raised by many respondents), the lack of advance planning and outreach to community members and patients remains a major criticism. Coordinated efforts to provide the community with information about health and social services in the area will respond to a clear need while reducing some of the complexity encountered with utilizing local health care services.

Impact of insurance and hospital ownership on hospital length of stay among patients with ambulatory care-sensitive conditions.

PURPOSE Some studies suggest proprietary (for-profit) hospitals are maximizing financial margins from patient care by limiting therapies or decreasing length of stay for uninsured patients. This study examines the role of insurance related to length of stay once the patient is in the hospital and risk for mortality, particularly in a for-profit environment. METHODS We undertook an analysis of hospitalizations in the National Hospital Discharge Survey (NHDS) of the 5-year period of 2003 to 2007 for patients aged 18 to 64 years (unweighted n = 849,866; weighted n = 90 million). The analysis included those who were hospitalized with both ambulatory care-sensitive conditions (ACSCs), hospitalizations considered to be preventable, and non-ACSCs. We analyzed the transformed mean length of stay between individuals who had Medicaid or all other insurance types while hospitalized and those who were hospitalized without insurance. This analysis was stratified by hospital ownership. We also examined the relationship between in-hospital mortality and insurance status. RESULTS After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a significantly shorter length of stay. Across all hospital types, the mean length of stay for ACSCs was significantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days, P = .04) or Medicaid (3.19, P <.01). Among hospitalizations for ACSCs, in-hospital mortality rate for individuals with either private insurance or Medicaid was not significantly different from the mortality rate for those without insurance. CONCLUSIONS Patients without insurance have shorter lengths of stay for both ACSCs and non-ACSCs. Future research should examine whether patients without insurance are being discharged prematurely.

Grand Junction, Colorado: how a community drew on its values to shape a superior health system.

For the past decade, the high-quality, relatively low-cost health care delivered in Grand Junction, Colorado, has led that community to outperform most others in the United States. Medicare patients in Grand Junction have fewer hospitalizations, shorter hospitalizations, and lower mortality rates after hospitalization than do Medicare patients in comparison hospitals. Effective, efficient care is delivered in Grand Junction through separate, self-governing organizations that perceive health care as a community resource. This article describes how the various stakeholders in Grand Junction have addressed problems and set standards for the system. The lessons could apply to broader health reform efforts in communities around the country.

Catholic hospital services for vulnerable populations: are system values sufficient determinants?

BACKGROUND: Catholic hospitals and health systems comprise a substantial segment of nonprofit, mission-driven, health care services, with accountability to institutional pressures of the Roman Catholic Church as well as economic pressures for solvency. Values are the way in which the organization expresses its faith-based institutional identity, which may used to select services that represent those values. PURPOSE: The purpose of this study was to identify whether Catholic health systems' explicit values of justice or compassion (and derivatives of those words, known to have similar meaning) were associated with a greater number of system member hospitals' services aimed at vulnerable populations. METHODOLOGY: Using information from Web sites of 41 Catholic health systems in 2007 and data describing their 452 hospitals from the American Hospital Association Annual Survey, the relationship of health system values with hospital services for vulnerable populations was examined while controlling for organizational, market, and demand variables. FINDINGS: Although Catholic hospitals as a whole are more likely to provide services to vulnerable populations than to other ownership types, the results show that among Catholic hospitals, values of justice or compassion are not associated with more services (defined in this study) that reflect those values. System hospitals likely to have more services that represent the values of justice and compassion are larger, have a higher Medicaid payer mix, are located in less dense urban areas, and are members of geographically dispersed systems. PRACTICE IMPLICATIONS: Hospitals select services that may represent symbolic system values, but community need and financial means are stronger determinants. To bolster community benefit to justify tax exempt status, Catholic hospitals and systems may benefit from further defining, analyzing, and reporting the impact of access to relatively unprofitable services for previously underserved vulnerable populations.

Hospital religious affiliation and emergency contraceptive prescribing practices.

With access to reproductive health care eroding, examination of prescribing of contraception, including emergency contraception (EC), is important. We examined whether working in a family practice affiliated with a religious institution changes the likelihood of a provider prescribing EC. Our survey asked about EC prescribing practices in a range of situations. As predicted, practitioners in non-religiously affiliated practices reported higher rates of prescribing EC than those in religiously affiliated practices. In both cases, however, the practitioners' prescribing patterns were inadequate.

Hospital service offerings: does Catholic ownership matter?

Controlling for market and organizational characteristics, Catholic hospitals in 2001 offered more stigmatized and compassionate care services than investor-owned hospitals, and more stigmatized services than public hospitals. There were no differences between Catholic hospitals and other nonprofit hospitals, however, in the number of compassionate, stigmatized, and access services offered. This may reflect growing isomorphism in the nonprofit hospital sector.

Accessibility of emergency contraception in California's Catholic hospitals.

BACKGROUND: Access to emergency contraception (EC) is an important option for women wanting to prevent an unintended pregnancy. In California, emergency rooms (ERs) are required to provide survivors of sexual assault with information about and access to EC. This study assessed the likelihood that a woman calling a Catholic hospital in California to inquire about EC could access the medication. METHODS: During September 2003, we contacted an ER staff member in each of California's Catholic hospitals (n = 45) using a mystery caller approach. Following a written script, trained female researchers asked ER staff whether they dispense EC at their facility and under what circumstances. If respondents initially stated that their facility would not dispense EC, the caller asked whether EC was available to women who had been raped. If staff confirmed that their facility would not provide EC under any circumstances including rape, callers requested a referral to another facility that would provide the medication. RESULTS: Sixty-six percent of staff contacted stated that their hospital would not provide EC under any circumstances, including rape. Of those that would not dispense EC, fewer than half of respondents (48%) provided a referral. Of the 14 referrals given, only about one third (n = 5) led to a facility that provides EC. CONCLUSIONS: Our findings suggest that access to EC in California's Catholic hospitals is minimal, even for victims of sexual assault. As many as two-thirds of these hospitals may be violating state legislation requiring hospitals to provide EC to sexual assault survivors upon request.

Under-use of emergency contraception for victims of sexual assault.

BACKGROUND: Approximately 700,000 women in the reproductive age group are victims of sexual assault in the United States per year. Between 1% and 5% of sexual assaults result in pregnancy, for a total of 32,000 pregnancies per year. Of these, 14,000 are aborted because of incest or rape. OBJECTIVE: To determine the percent of emergency departments in the state of Pennsylvania offering routine counseling and provision of emergency contraception to victims of sexual assault. Secondary objectives were to compare provision practices for Catholic versus non-Catholic hospitals, and to compare these practices with other services, such as sexually transmitted disease prophylaxis and sexual assault counseling. METHODS: A 15-item survey instrument was designed to determine the volume of sexual assault patients seen per year, routinely offered services, and emergency contraception protocols. Three telephone callers administered surveys, using a pre-designed script for each call. RESULTS: Of the 165 eligible hospitals, 125 (76%) replied. Less than half (42%) of all hospitals routinely offer emergency contraception counseling, and 16% of the hospitals did not offer any counseling regarding emergency contraception. CONCLUSION: Provision of emergency contraception to victims of sexual assault is inconsistent and insufficient. It is important that sexual assault patients not be further victimized by a system that fails to meet their needs.

Conflicting interests in private hospital care.

This article looks at key changes impacting on private hospital care: the increasing corporate ownership of private hospitals; the Commonwealth Government's support for private health; the significant increase in health fund membership; and the contracting arrangements between health funds and private hospitals. The changes highlight the often conflicting interests of hospitals, doctors, Government, health funds and patients in the provision of private hospital care. These conflicts surfaced in the debate around allegations of 'cherry picking' by private hospitals of more profitable patients. This is also a good illustration of the increasing entanglement of the Government in the fortunes of the private health industry.

Multi-unit Providers Survey. For-profits report decline in acute-care hospitals ... newcomers to top 10.

For-profit hospital systems cleaned house last year. After years of adding hospitals, investor-owned operators shed facilities in 1998, recording the first decline in the number of acute-care hospitals they've owned or managed since 1991, according to our 23rd annual Multi-unit Providers Survey.