Service mix and financial performance in rural hospitals: A contingency theory perspective.

BACKGROUND: Rural hospitals are increasingly at risk of closure. Closure reduces the availability of hospital care in rural areas, resulting in a disparity in health between rural and urban citizens, and it has broader economic impacts on rural communities as rural hospitals are often large employers and are vital to recruiting new businesses to a community. To combat the risk of closure, rural hospitals have sought partnerships to bolster financial performance, which often results in a closure of services valuable to the community, such as obstetrics and certain diagnostic services, which are viewed as unprofitable. This can lead to poor health outcomes as community members are unable to access care in these areas. PURPOSE: In this article, we explore rural hospital service offerings and financial performance, with an aim to illuminate if specific service offerings are associated with positive financial performance in a rural setting. METHODS: Our study used hospital organization data, as well as county-level demographics with periods of analysis from 2015 and 2019. We employed a pooled cross-sectional regression analysis with robust standard errors examining the association between total margin and service lines among rural hospitals in the United States. RESULTS: The findings suggest that some services deemed unprofitable in urban and suburban hospital settings-such as obstetrics and drug/alcohol rehabilitation-are associated with higher margins in rural hospitals. Other unprofitable service lines-such as psychiatry and long-term care-are associated with lower margins in rural hospitals. CONCLUSION: Our results suggest the need of rural hospitals to choose services that align with environmental circumstances to maximize financial performance. PRACTICE IMPLICATION: Hospital administrators in rural settings need to take a nuanced look at their environmental and organizational specifics when deciding upon the service mix. Generalizations regarding profitability should be avoided to maximize financial performance.

Understanding Barriers to Telemedicine Implementation in Rural Emergency Departments.

STUDY OBJECTIVE: Telemedicine has potential to add value to the delivery of emergency care in rural emergency departments (EDs); however, previous work suggests that it may be underused. We seek to understand barriers to telemedicine implementation in rural EDs, and to describe characteristics of rural EDs that do and do not use telemedicine. METHODS: We performed a secondary analysis of data from the 2016 National Emergency Department Inventory survey, identifying rural EDs that did and did not use telemedicine in 2016. All rural EDs that did not use telemedicine were administered a follow-up survey asking about ED staffing, transfer patterns, and perceived barriers to telemedicine use. We used a similar instrument to survey a sample of EDs that did use telemedicine, but we replaced the question about barriers with questions related to telemedicine use. Data are presented with descriptive statistics. RESULTS: We identified 977 rural EDs responding to the 2016 National Emergency Department Inventory-USA survey; 453 (46%; 95% confidence interval 43% to 50%) did not use telemedicine. Among rural nonusers, 374 EDs (83%; 95% confidence interval 79% to 86%) responded to our second survey. Of the 177 rural EDs using telemedicine that we surveyed, 153 responded (86%; 95% confidence interval 80% to 91%). Among rural EDs not using telemedicine, 235 (67%) reported that their ED, hospital, or health system leadership had considered it. Cost was the most commonly cited reason for lack of adoption (n=86; 37%). CONCLUSION: Among US rural EDs, cost is a commonly reported barrier that may be limiting the extent of telemedicine adoption.

Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids' Inpatient Database.

BACKGROUND: Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment. METHODS: A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids' Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates. RESULTS: A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P<0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P<0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P<0.001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012. CONCLUSIONS: Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications. LEVEL OF EVIDENCE: Level III-case series, database study.

Capital Expenditures Increased at Rural Hospitals That Merged Between 2012 and 2015.

EXECUTIVE SUMMARY: The number of rural hospital mergers has increased substantially in recent years. A commonly reported reason for merging is to increase access to capital. However, no empirical evidence exists to show whether capital expenditures increased at rural hospitals after a merger. We used a difference-in-differences approach to determine whether total capital expenditures changed at rural hospitals after a merger. The comparison group (rural hospitals that did not merge during the 2012 through 2015 study period) was weighted using inverse probability of treatment weights. The key outcome measure was logged total capital expenditures.Merging resulted in a 26% increase in capital expenditures and also was associated with a significant improvement in plant age. The postmerger improvement in plant age may have been partially attributable to merger-related accounting changes and partially attributable to increased capital expenses, possibly on long-term asset renovations and replacement.These findings suggest that through mergers, rural hospital board members and executives who have accepted or are considering a merger may improve a hospital's ability to increase capital expenditures. Further, increased capital investments in rural hospitals may be an important signal to the community that the acquirer intends to keep the rural hospital open and continue providing some volume and level of services within the community. Future research should determine how capital is spent after a merger.

Costs and Trends of Emergency Department Utilization Pre-ACA and Post-ACA: Evidence From a Rural Georgia Hospital.

BACKGROUND: A high volume of emergency department (ED) visits in the rural United States may be the result of barriers to accessing primary care. The Affordable Care Act (ACA) increased the number of insured, which may improve patient access to primary care and therefore reduce ED utilization. The objective of this study is to estimate the trends and cost of ED utilization pre-ACA and post-ACA implementation in a rural United States. DATA AND METHODS: We use 2009-2013 ED utilization data from a rural Georgia hospital to estimate trends and costs by demographic characteristics, referring source, and payor information. T tests and log-linear regression models are used to assess the sociodemographic factors impacting ED inflation-adjusted costs before (2009-2010) and after ACA (2011-2013) implementation. RESULTS: During 2009-2013, 39,970 ED encounters were recorded with an average cost (AC) of $2002 per visit. Results indicate that during pre-ACA, on average, 8702 encounters were recorded per year with an AC of $1759. During post-ACA, there were 7521 annual visits, with an annual AC of $2241. Regression model results indicate that AC were significantly higher for men, older adults, nonblack patients, those with private insurance, and during the post-ACA period. CONCLUSIONS: Results suggest that post-ACA, declining ED visits may be due to more patients with insurance accessing primary care instead of ED. We further hypothesize that increased AC during this period may be due to ED visits being of an emergent nature, which require more resources to treat. Further comprehensive investigation is warranted to study the impact of ACA on ED utilization for nonemergency purposes among rural and nonrural hospitals.

Economic efficiency versus accessibility: Planning of the hospital landscape in rural regions using a linear model on the example of paediatric and obstetric wards in the northeast of Germany.

BACKGROUND: Costs for the provision of regional hospital care depend, among other things, on the population density and the maximum reasonable distance to the nearest hospital. In regions with a low population density, it is a challenge to plan the number and location of hospitals with respect both to economic efficiency and to the availability of hospital care close to residential areas. We examined whether the hospital landscape in rural regions can be planned on the basis of a regional economic model using the example which number of paediatric and obstetric wards in a region in the Northeast of Germany is economically efficient and what would be the consequences for the accessibility when one or more of the three current locations would be closed. METHODS: A model of linear programming was developed to estimate the costs and revenues under different scenarios with up to three hospitals with both a paediatric and an obstetric ward in the investigation region. To calculate accessibility of the wards, geographic analyses were conducted. RESULTS: With three hospitals in the study region, there is a financial gap of €3.6 million. To get a positive contribution margin for all three hospitals, more cases have to be treated than the region can deliver. Closing hospitals in the parts of the region with the smallest population density would lead to reduced accessibility for about 8% of the population under risk. CONCLUSIONS: Quantitative modelling of the costs of regional hospital care provides a basis for planning. A qualitative discussion to the locations of the remaining departments and the implementation of alternative healthcare concepts should follow.

Effect of a typical systemic hospital reform on inpatient expenditure for rural population: the Sanming model in China.

BACKGROUND: Considering catastrophic health expenses in rural households with hospitalised members were unproportionally high, in 2013, China developed a model of systemic reform in Sanming by adjusting payment method, pharmaceutical system, and medical services price. The reform was expected to control the excessive growth of hospital expenditures by reducing inefficiency and waste in health system or shortening the length of stay. This study analyzed the systemic reform's impact on the financial burden and length of stay for the rural population in Sanming. METHODS: A total of 1,113,615 inpatient records for the rural population were extracted from the rural new cooperative medical scheme (NCMS) database in Sanming from 2007 to 2012 (before the reform) and from 2013 to 2016 (after the reform). We calculated the average growth rate of total inpatient expenditures and costs of different medical service categories (medications, diagnostic testing, physician services and therapeutic services) in these two periods. Generalized linear models (GLM) were employed to examine the effect of reform on out-of-pocket (OOP) expenditures and length of stay, controlling for some covariates. Furthermore, we controlled the fixed effects of the year and hospitals, and included cluster standard errors by hospital to assess the robustness of the findings in the GLM analysis. RESULTS: The typical systemic reform decreased the average growth rate of total inpatient expenditures by 1.34%, compared with the period before the reform. The OOP expenditures as a share of total expenditures showed a downward trend after the reform (42.34% in 2013). Holding all else constant, individuals after the reform spent ¥308.42 less on OOP expenditures (p < 0.001) than they did before the reform. Moreover, length of stay had a decrease of 0.67 days after the reform (p < 0.001). CONCLUSIONS: These results suggested that the typical systemic hospital reform of the Sanming model had some positive effects on cost control and reducing financial burden for the rural population. Considering the OOP expenditures as a share of total expenditures was still high, China still has a long way to go to improve the benefits rural people have enjoyed from the NCMS.

Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing.

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.

Does the agglomeration effect occur in the hospital sector? The impact of agglomeration economies on the financial performance of hospitals-An evidence from Poland.

The main aim of the article is to analyze the occurrence of agglomeration effect in the hospital sector on the basis of financial performance. The considerations are made on the example of hospitals in Poland-the country that survived the latest economic crisis relatively well, usually generating positive values of GDP, but where still there is an ongoing discussion on the final shape of healthcare financing model. The article is based on the assumption that there occur significant differences in financial performance between hospitals according to their location. The research hypothesis is as follows: Hospitals operating in big cities are featured by better financial condition than their counterparts operating in smaller towns. To verify the hypothesis, the methods of financial analysis and statistical hypothesis testing are used. As it is emphasized in the article, the assumption is true and the hypothesis can be verified positively.

Telehealth Decreases Rural Emergency Department Wait Times for Behavioral Health Patients in a Group of Critical Access Hospitals.

Background: Telehealth has been proposed as an important care delivery strategy to increase access to behavioral health care, especially in rural and medically-underserved settings where mental health care provider shortage areas predominate, to speed access to behavioral health care, and reduce health disparities.Introduction: This study was conducted to determine the effects of telehealth-based care delivery on clinical, temporal, and cost outcomes for behavioral health patients in rural emergency departments (EDs) of four Midwestern critical access hospitals (CAHs).Materials and Methods: Observational matched cohort study of adult (age ≥18 years) behavioral health patients treated in participating CAH EDs from 2015 to 2017 (N = 287). Telehealth cases were matched 2:1 retrospectively to nontelehealth control cases based on gender, age ±10 years, diagnosis group, and CAH, before implementation of telehealth in the rural hospitals (2005-2013; N = 153).Results: The greatest number of behavioral health cases evaluated was in the mood, anxiety, and other mental health disorders category. The majority of patients in the telehealth (74%) and nontelehealth (68%) cohorts were 18-44 years. Mean ED wait time for the telehealth cohort was significantly shorter at 12 min (95% CI 11-14 min) (p < 0.001) compared to a mean time of 27 min (95% CI 22-32 min) for the nontelehealth case controls (local provider only). The ED length of stay (LOS) for the telehealth cohort was significantly longer (M = 318 min vs. 147 min, p < 0.001) compared to the nontelehealth cohort. The end of telehealth visit to departure (EOTVtD) from the ED in minutes was evaluated to highlight factors potentially influencing delivery of behavioral health care in the ED. Across three behavioral diagnostic categories, time in minutes from end of telehealth visit to disposition/discharge was significantly longer for suicide and intentional self-injury cases (n = 100; 113 min, 95% CI 88-145; p = 0.004) compared to anxiety, mood, and other mental health disorders (n = 126; 66 min, 95% CI 52-83). There was a clinically meaningful difference in EOTVtD in minutes for substance abuse-related cases, which were shorter in length on average (n = 58; 71 min, 95% CI 54-94). Total ED costs for substance abuse-related cases for the telehealth (n = 58; $4556, 95% CI $3963-$5238) cohort were significantly higher than for the two other behavioral diagnostic groups (p < 0.001).Conclusions: Telehealth consultation in the ED for behavioral health cases was associated with decreased wait time and longer ED LOS. Similar to recent studies, the most common behavioral health cases involved mood and anxiety disorders. Costs related to treatment were highest for substance abuse-related cases, likely due to the additional interventions needed, especially related to resuscitation There are opportunities to improve ED efficiencies and post-telehealth visit protocols related to the timeframe extending from the EOTVtD from the ED, which continues to be a focus of future research. Additional research is also needed to determine if telehealth lends itself more effectively to specific categories of behavioral health cases.

Medicare Access and CHIP Reauthorization Act and Rural Hospitals.

The cost of health care within the United States has continued to increase, whereas the quality of patient care has generally decreased in some areas. With the continued use of Medicare's former physician reimbursement algorithm, termed sustainable growth rate, national expenditures within the United States have been expected to increase 5.6% annually. To modernize the delivery and financing of care, Congress has introduced the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which has permanently eliminated and replaced the sustainable growth rate. The purpose of this study was to review MACRA and its implementation to determine how it would financially impact rural hospitals. Two reimbursement pathways have been created for physicians under the MACRA. In addition, the financing and competition among facilities created by the act have been expected to impact physicians and health care organizations. Rural hospitals have been set to receive reduced government reimbursements and have been predicted to compete poorly with larger hospitals and health care corporations. Furthermore, the payment tracks available through the act have been projected to impact solo and small practice physicians negatively.

The impact of the introduction of a point-of-care haematology analyser in a New Zealand rural hospital with no onsite laboratory.

INTRODUCTION: Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital. METHODS: This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost-benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted. RESULTS: Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ2 tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ2 tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to 'make it work'. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost-benefit analysis showed a clear cost saving to the health system as a whole. CONCLUSIONS: This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-from-laboratory context.

An evaluation of mini-laparotomy cholecystectomy in the laparoscopic era: a rural experience.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard for the management of symptomatic cholelithiasis and complications of gallstone disease. Mini laparotomy cholecystectomy (MOC) may be a more appropriate option in the resource constrained rural setting due to its widespread applicability and comparable outcome with LC. The study aimed to provide an epidemiological analysis of gallstone disease in the rural population and to evaluate the outcome of MOC in a rural hospital. METHOD: A retrospective chart analysis of 248 patients undergoing cholecystectomy in a rural regional referral hospital in KwaZulu-Natal from January 2009 to December 2013 was undertaken. RESULTS: Of the 248 patients, the majority were females (n = 211, [85%]). The most frequent indications for cholecystectomy included: biliary colic (n = 115, [46.3%]); acute cholecystitis (n = 80, [32.3%]); gallstone pancreatitis (n = 27, [10.8%]). Forty cases (16.1%) were converted to open cholecystectomy (OC). The median operative time was 40 minutes (range18-57). Twenty-three morbidities (9.3%) occurred including: bile leaks (n = 6, [2.4%]); bleeding from drain site (n = 1, [0.4%]), incisional hernia (n = 8 [3.2%]) and wound sepsis (n = 8 [3.2%]). The median length of hospital stay in patients who underwent MOC was 48 hours (range: 24-72 hours) and the median time to return to work was 10 days (range: 4-14 days). There was one mortality in the entire cohort. CONCLUSION: MOC is a safe and feasible operation for symptomatic cholelithiasis when cholecystectomy is indicated. The low operative morbidity and mortality in the context of a high risk patient profile and complicated gallstone disease makes this procedure an alternative to LC where LC is inaccessible.

Medicare Program; Temporary Exception for Certain Severe Wound Discharges From Certain Long-Term Care Hospitals Required by the Consolidated Appropriations Act, 2016; Modification of Limitations on Redesignation by the Medicare Geographic Classification Review Board. Interim final rule with comment period.

This interim final rule with comment period (IFC) implements section 231 of the Consolidated Appropriations Act of 2016 (CAA), which provides for a temporary exception for certain wound care discharges from the application of the site neutral payment rate under the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for certain long-term care hospitals. This IFC also amends our current regulations to allow hospitals nationwide to reclassify based on their acquired rural status, effective with reclassifications beginning with fiscal year (FY) 2018. Hospitals with an existing Medicare Geographic Classification Review Board (MGCRB) reclassification would also have the opportunity to seek rural reclassification for IPPS payment and other purposes and keep their existing MGCRB reclassification. We would also apply the policy in this IFC when deciding timely appeals before the Administrator under our regulations for FY 2017 that were denied by the MGCRB due to existing regulations, which do not permit simultaneous rural reclassification for IPPS payment and other purposes and MGCRB reclassification. These regulatory changes implement the decisions in Geisinger Community Medical Center v. Secretary, United States Department of Health and Human Services, 794 F.3d 383 (3d Cir. 2015) and Lawrence + Memorial Hospital v. Burwell, No. 15-164, 2016 WL 423702 (2d Cir. Feb. 4, 2015) in a nationally consistent manner.

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals. Final rule.

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and making technical corrections and changes to regulations relating to costs to related organizations and Medicare cost reports; we are providing notice of the closure of three teaching hospitals and the opportunity to apply for available GME resident slots under section 5506 of the Affordable Care Act. We are finalizing the provisions of interim final rules with comment period that relate to a temporary exception for certain wound care discharges from the application of the site neutral payment rate under the LTCH PPS for certain LTCHs; application of two judicial decisions relating to modifications of limitations on redesignation by the Medicare Geographic Classification Review Board; and legislative extensions of the Medicare-dependent, small rural hospital program and changes to the payment adjustment for low-volume hospitals.

Influence of the New Cooperative Medical Scheme on hospitalization cost of patients with nephrotic syndrome in rural China.

INTRODUCTION: Rural residents are benefitting from the current New Cooperative Medical Scheme (NCMS) in China. Treatment of diseases has improved and the total cost of hospitalization has decreased significantly because of the application of NCMS. Most articles in this area have mainly focused on the policy of NCMS, but few studies have been relevant to the influence of NCMS on a specific disease and the cost. In the present study, the impact of NCMS on hospitalization costs of patient with nephrotic syndrome from the countryside was investigated and discussed. METHODS: Three hundred and ninety patients from China and with nephrotic syndrome were enrolled into the present study and were divided into two groups according to whether they had joined the NCMS. The total hospitalization cost, check cost (such as laboratory testing and ultrasound), drugs cost, length of stay in hospital and ratio of renal biopsy in all patients were analyzed. RESULTS: The expenses for individuals decreased significantly in patients who were part of the NCMS, in contrast with the patients without the NCMS (p<0.001). The ratio of renal biopsy increased significantly in patients who were part of the NCMS (p<0.01). There was no significant difference in cost and length of stay between the two groups. CONCLUSIONS: The NCMS contributes to reducing personal expenses and therapy of disease.

Hospital closures and the current healthcare climate: the future of rural hospitals in the USA.

Hospital closures occur from time to time. These closures affect not only the patients that depend on the hospitals but also the economy in many rural areas. Many factors come into play when a hospital decides to shut off services. Although influencing reasons may vary, hospital closures are likely to be caused by financial shortfalls. In the USA recently, several rural hospitals have closed and many are on the verge of closing. The recent changes in the healthcare industry due to the new reforms are believed to have impacted certain small community and rural hospitals by putting them at risk of closure. In this article, we will discuss some of the highlights of the healthcare reforms and the events that followed, to relate how they may have affected the hospitals. We will also discuss what the future of these hospitals may look like and the necessary steps that the hospitals need to adopt to sustain themselves.

Burden, causes, and outcomes of people with epilepsy admitted to a rural hospital in Kenya.

OBJECTIVE: People with epilepsy (PWE) develop complications and comorbidities often requiring admission to hospital, which adds to the burden on the health system, particularly in low-income countries. We determined the incidence, disability-adjusted life years (DALYs), risk factors, and causes of admissions in PWE. We also examined the predictors of prolonged hospital stay and death using data from linked clinical and demographic surveillance system. METHODS: We studied children and adults admitted to a Kenyan rural hospital, between January 2003 and December 2011, with a diagnosis of epilepsy. Poisson regression was used to compute incidence and rate ratios, logistic regression to determine associated factors, and the DALY package of the R-statistical software to calculate years lived with disability (YLD) and years of life lost (YLL). RESULTS: The overall incidence of admissions was 45.6/100,000 person-years of observation (PYO) (95% confidence interval [95% CI] 43.0-48.7) and decreased with age (p < 0.001). The overall DALYs were 3.1/1,000 (95% CI, 1.8-4.7) PYO and comprised 55% of YLD. Factors associated with hospitalization were use of antiepileptic drugs (AEDs) (odds ratio [OR] 5.36, 95% CI 2.64-10.90), previous admission (OR 11.65, 95% CI 2.65-51.17), acute encephalopathy (OR 2.12, 95% CI 1.07-4.22), and adverse perinatal events (OR 2.87, 95% CI 1.06-7.74). Important causes of admission were epilepsy-related complications: convulsive status epilepticus (CSE) (38%), and postictal coma (12%). Age was independently associated with prolonged hospital stay (OR 1.02, 95% CI 1.00-1.04) and mortality (OR, 1.07, 95% CI 1.04-1.10). SIGNIFICANCE: Epilepsy is associated with significant number of admissions to hospital, considerable duration of admission, and mortality. Improved supply of AEDs in the community, early initiation of treatment, and adherence would reduce hospitalization of PWE and thus the burden of epilepsy on the health system.