Barriers to adoption of laparoscopic cholecystectomy in a county hospital in Guatemala.

BACKGROUND: Despite international efforts to increase performance of laparoscopic cholecystectomy (LC) in rural Guatemala, the vast majority of cholecystectomies are still performed via the open cholecystectomy (OC) approach. Our goal was to explore barriers to the adoption of LC in Guatemala as well as possible mechanisms to overcome them. METHODS: We reviewed 9402 cholecystectomies performed over 14 years by surgeons at the Hospital Nacional de San Benito (HNSB) in El Peten, Guatemala, with either an open or a laparoscopic approach. We conducted personal interviews with all the surgeons who perform cholecystectomies at HNSB to determine current practice and barriers to adopting LC. RESULTS: Overall, seven general surgeons were interviewed who regularly perform cholecystectomy. Of the total number of cholecystectomies reviewed, 8440 (90%) were open and 962 (10%) were laparoscopic. The mean number of cholecystectomies performed per surgeon was 1341.1 ± 1244.9, with OC at 1205.7 ± 1194.9, and LC at 137.4 ± 188.0. Lack of formal training in laparoscopy was identified in 57% of surgeons. Lack of government funds to implement a laparoscopic program was noted by 71% of surgeons (29% felt there was insufficient ancillary staff, 29% poor allocation of hospital funding to purchase laparoscopic equipment/training). Lack of sufficient laparoscopic equipment was identified by 71% of surgeons. CONCLUSIONS: Ninety percent of cholecystectomies performed by surgeons at HNSB continue to be OC. The major limitation is the lack of funding to provide sufficient equipment or ancillary staff. The majority of surgeons preferred to perform LC if these problems could be addressed.

County and Physician Variation in Benzodiazepine Prescribing to Medicare Beneficiaries by Primary Care Physicians in the USA.

BACKGROUND: Physicians widely prescribe benzodiazepines (BZD) despite well-recognized harms. OBJECTIVE: To determine county and provider characteristics that predict high-intensity BZD prescribing by primary care physicians (PCPs) to Medicare beneficiaries. DESIGN: Cross-sectional analysis of the 2015 Medicare Part D Public Use Files (PUF). SUBJECTS: n = 122,054 PCPs who prescribed 37.3 billion medication days. MAIN MEASURES: Primary outcome was intensity of BZD prescribing (days prescribed/total medication days) at the county- and physician levels. PCP and county characteristics were derived from the Part D PUF, Area Health Resources Files, and County Health Rankings. Logistic regression determined the characteristics associated with high-intensity (top quartile) BZD prescribing. KEY RESULTS: Beneficiaries were prescribed over 1.2 billion days of BZD in 2015, accounting for 2.3% of all medication days prescribed in Part D. Top quartile counties had 3.1 times higher BZD prescribing than the lowest (3.4% vs. 1.1%; F = 3293.8, df = 3, p < 0.001). Adjusting for county-level demographics and health care system characteristics (including supply of mental health providers), counties with more adults with at least some college had lower odds of high-intensity prescribing (per 5% increase, adjusted odds ratio [AOR] 0.80, 99% confidence interval (CI) 0.73-0.87, p < 0.001), as did higher income counties (per US$1000 increase, AOR 0.93, CI 0.91-0.95, p < 0.001). Top quartile PCPs prescribed at 6.5 times the rate of the bottom (3.9% vs. 0.6%; F = 63,910.2, df = 3, p < 0.001). High-intensity opioid prescribing (AOR 4.18, CI 3.90-4.48, p < 0.001) was the characteristic most strongly associated with BZD prescribing. CONCLUSIONS: BZD prescribing appears to vary across counties and providers and is related to non-patient characteristics. Further work is needed to understand how such non-clinical factors drive variation.

Variation in and risk factors for paediatric inpatient all-cause mortality in a low income setting: data from an emerging clinical information network.

BACKGROUND: Hospital mortality data can inform planning for health interventions and may help optimize resource allocation if they are reliable and appropriately interpreted. However such data are often not available in low income countries including Kenya. METHODS: Data from the Clinical Information Network covering 12 county hospitals' paediatric admissions aged 2-59 months for the periods September 2013 to March 2015 were used to describe mortality across differing contexts and to explore whether simple clinical characteristics used to classify severity of illness in common treatment guidelines are consistently associated with inpatient mortality. Regression models accounting for hospital identity and malaria prevalence (low or high) were used. Multiple imputation for missing data was based on a missing at random assumption with sensitivity analyses based on pattern mixture missing not at random assumptions. RESULTS: The overall cluster adjusted crude mortality rate across hospitals was 6 · 2% with an almost 5 fold variation across sites (95% CI 4 · 9 to 7 · 8; range 2 · 1% - 11 · 0%). Hospital identity was significantly associated with mortality. Clinical features included in guidelines for common diseases to assess severity of illness were consistently associated with mortality in multivariable analyses (AROC =0 · 86). CONCLUSION: All-cause mortality is highly variable across hospitals and associated with clinical risk factors identified in disease specific guidelines. A panel of these clinical features may provide a basic common data framework as part of improved health information systems to support evaluations of quality and outcomes of care at scale and inform health system strengthening efforts.

Liberian surgical and anesthesia infrastructure: a survey of county hospitals.

BACKGROUND: There is a significant burden of disease in low-income countries that can benefit from surgical intervention. The goal of this survey was to evaluate the current ability of the Liberian health care system to provide safe surgical care and to identify unmet needs in regard to trained personnel, equipment, infrastructure, and outcomes measurement. METHODS: A comprehensive survey tool was developed to assess physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, equipment and medications, and the capacity of the surgical system to collect and evaluate surgical outcomes at district-level hospitals in Africa. This tool was implemented in a sampling of 11 county hospitals in Liberia (January 2011). Data were obtained from the Ministry of Health and by direct government-affiliated hospital site visits. RESULTS: The total catchment area of the 11 hospitals surveyed was 2,313,429--equivalent to roughly 67 % of the population of Liberia (3,476,608). There were 13 major operating rooms and 34 (1.5 per 100,000 population) physicians delivering surgical, obstetric, or anesthesia care including 2 (0.1 per 100,000 population) who had completed formal postgraduate training programs in these specialty areas. The total number of surgical cases for 2010 was 7,654, with approximately 43 % of them being elective procedures. Among the facilities that tracked outcomes in 2010, a total of 11 intraoperative deaths (145 per 100,000 operative cases) were recorded for 2009. The 30-day postoperative mortality at hospitals providing data was 44 (1,359 per 100,000 operative cases). Metrics were also used to evaluate surgical output, safety of anesthesia, and the burden of obstetric disease. CONCLUSIONS: A significant volume of surgical care is being delivered at county hospitals throughout Liberia. The density and quality of appropriately trained personnel and infrastructure remain critically low. There is strong evidence for continued development of emergency and essential surgical services, as well as improved surgical outcomes tracking, at county hospitals in Liberia. These results serve to inform the international community and donors of the ongoing global surgical and anesthesia crisis.

Efficiency and scale effect of county public hospitals in Shandong Province, China: a cross-sectional study.

OBJECTIVE: To evaluate the efficiency of county public hospitals in Shandong Province following China's new medical reform and compare the efficiency of hospitals with different bed sizes for improving efficiency. DESIGN AND SETTING: This was a cross-sectional study on the efficiency and size of 68 county public hospitals in China in 2017. OUTCOME MEASURES: Data envelopment analysis was used to calculate the efficiency scores of hospitals and to analyse the slack values of inefficient hospitals. The actual number of open beds, doctors, nurses and total expenditure were selected as inputs, and the total number of annual visits, discharges and total income were selected as outputs. The Kruskal-Wallis H test was employed to compare the efficiency of hospitals with different bed sizes. The χ2 test was used to compare the returns to scale (RTS) of hospitals with different bed sizes. RESULTS: Twenty (29.41%) hospitals were efficient. There were 27 hospitals with increasing returns to scale, 23 hospitals with constant returns to scale and 18 hospitals with decreasing returns to scale (DRS). The differences in technical efficiency (p=0.248, p>0.05) and pure technical efficiency (p=0.073, p>0.05) were not statistically significant. However, the differences in scale efficiency (p=0.047, p<0.05) and RTS (p<0.001) were statistically significant. Hospitals with DRS began to appear at 885 beds. All sample hospitals with more than 1100 beds were already saturated and some hospitals even had a negative scale effect. CONCLUSIONS: The government and hospital managers should strictly control the bed size in hospitals and make hospitals resume operating in the interests of public welfare. Interventions that rationally allocate health resources and improve the efficiency of medical workers are conducive to solving redundant inputs and insufficient outputs.

SMASH standardised perioperative management of patients operated with acute abdominal surgery in a high-risk setting.

OBJECTIVE OF THE STUDY: Emergency laparotomy and other high-risk acute abdominal surgery procedures have a high mortality rate. The perioperative management of these patients is complex and poses several challenges. The objective of the study is to implement and evaluate the outcome of protocol-based standardised care for patients in need of acute abdominal surgery in a Swedish setting. NÄL is a large county hospital in Sweden serving a population of approximately 270,000 inhabitants. The study seeks to determine whether standardised protocol-based perioperative management in emergency abdominal surgical procedures leads to a better outcome measured as short- and long-term mortality and postoperative complications compared with the present standard in Swedish routine care. The study is ongoing, and this article describes the methodology used in the study and discusses the benefits and limitations the study design. RESULTS: There are no results so far. The inclusion rate for the first 22 months is as expected; 404 patients have been included and protocols have been followed and reviewed according to the study plan. 25 patients have been missed and demographic data and outcome data for these patients will be collected and analysed.

Emergent groin hernia repair at a County Hospital in Guatemala: patient-related issues vs. health care system limitations.

BACKGROUND: The rate of emergent groin hernia repair in developing countries is poorly understood. MATERIALS AND METHODS: A retrospective analysis of groin hernia repairs performed at a county hospital in Guatemala [Hospital Nacional de San Benito (HSNB)] was undertaken and compared to a literature review in developed countries. Patients with incarcerated hernias were interviewed to determine factors related to late presentation. RESULTS: Twenty-five percent of patients with groin hernias in this analysis presented at HNSB emergently (vs. 2.5-7.7% in developed countries). Most patients were male in their fifth decade of life. Ten percent of hernias were femoral. There was no delay in scheduling patients for surgery presenting for elective repair. Most patients lived within 20 miles of the hospital, but only 50% of patients returned for their follow-up appointment. Most patients with an incarcerated inguinal hernia (56%) did not seek medical attention because of family obligations, but when they did, this decision was influence by their children (66%). None of the patients presenting with an incarcerated hernia had education past secondary school. In fact, most (56%) did not have any form formal education. Nearly 90% of patients who had an incarcerated hernia repaired thought that the hospital provided good-to-excellent care. CONCLUSION: A high number of patients present emergently for groin hernia repair at a county hospital in Guatemala compared to developed countries. Our data suggest that emergent hernias are likely the result of patient-related issues rather than health care system limitations.

Identification of limited English proficient patients in clinical care.

BACKGROUND: Standardized means to identify patients likely to benefit from language assistance are needed. OBJECTIVE: To evaluate the accuracy of the U.S. Census English proficiency question (Census-LEP) in predicting patients' ability to communicate effectively in English. DESIGN: We investigated the sensitivity and specificity of the Census-LEP alone or in combination with a question on preferred language for medical care for predicting patient-reported ability to discuss symptoms and understand physician recommendations in English. PARTICIPANTS: Three hundred and two patients > 18 who spoke Spanish and/or English recruited from a cardiology clinic and an inpatient general medical-surgical ward in 2004-2005. RESULTS: One hundred ninety-eight (66%) participants reported speaking English less than "very well" and 166 (55%) less than "well"; 157 (52%) preferred receiving their medical care in Spanish. Overall, 135 (45%) were able to discuss symptoms and 143 (48%) to understand physician recommendations in English. The Census-LEP with a high-threshold (less than "very well") had the highest sensitivity for predicting effective communication (100% Discuss; 98.7% Understand), but the lowest specificity (72.6% Discuss; 67.1% Understand). The composite measure of Census-LEP and preferred language for medical care provided a significant increase in specificity (91.9% Discuss; 83.9% Understand), with only a marginal decrease in sensitivity (99.4% Discuss; 96.7% Understand). CONCLUSIONS: Using the Census-LEP item with a high-threshold of less than "very well" as a screening question, followed by a language preference for medical care question, is recommended for inclusive and accurate identification of patients likely to benefit from language assistance.

Case study: enhancing effective and efficient congestive heart failure management at Columbus Regional Hospital.

For left ventricular function assessment, angiotensin converting enzyme inhibitor at discharge, smoking cessation education, and congestive heart failure (CHF) discharge instructions, a CHF team developed interventions to improve current practices.

Balanced scorecard-based performance evaluation of Chinese county hospitals in underdeveloped areas.

Objective Since the Guangxi government implemented public county hospital reform in 2009, there have been no studies of county hospitals in this underdeveloped area of China. This study aimed to establish an evaluation indicator system for Guangxi county hospitals and to generate recommendations for hospital development and policymaking. Methods A performance evaluation indicator system was developed based on balanced scorecard theory. Opinions were elicited from 25 experts from administrative units, universities and hospitals and the Delphi method was used to modify the performance indicators. The indicator system and the Topsis method were used to evaluate the performance of five county hospitals randomly selected from the same batch of 2015 Guangxi reform pilots. Results There were 4 first-level indicators, 9 second-level indicators and 36 third-level indicators in the final performance evaluation indicator system that showed good consistency, validity and reliability. The performance rank of the hospitals was B > E > A > C > D. Conclusions The performance evaluation indicator system established using the balanced scorecard is practical and scientific. Analysis of the results based on this indicator system identified several factors affecting hospital performance, such as resource utilisation efficiency, medical service price, personnel structure and doctor-patient relationships.

The Burden of Tunneled Central Venous Catheters for Hemodialysis in a County Hospital.

Prolonged use of central venous catheters (CVCs) for hemodialysis (HD) is associated with greater morbidity and mortality when compared with autogenous arteriovenous fistulas (AVF). The objective was to assess compliance with CVC guidelines in adults referred for hemoaccess at a county teaching hospital. Out of 256 patients, 172 (67.2%) were male, with a mean age of 50.0 ± 12.4 years. Overall 62.5 per cent initiated dialysis via CVC. Patients were divided into two groups (those with CVC (62.5%) and those without (37.5%)). Male gender was associated with initiation of dialysis via CVC versus no CVC (72.5 vs 58.3%, P = 0.02), as was a history of prior vascular access (P < 0.01). There were no significant differences between the groups regarding age, diabetes, smoking, ambulatory status, or insurance status. There were no differences in gender, age, insurance status, or prior vascular access between prolonged CVC use (≥90 days) and short-term CVC use (<90 days). We conclude that most patients initiated HD with CVC and exceed the recommended CVC duration. Men are more likely to initiate HD via CVC. Insurance status was not associated with CVC use. Multidisciplinary action may address barriers to reducing CVC duration.

Variation and Trends in Lower Extremity Amputation Rates in Los Angeles County Hospitals 2000-2010.

Lower extremity amputation (LEA) is a preventable complication of diabetes and peripheral vascular disease. Hospital-related factors associated with higher LEA are low hospital LEA revascularization volume, rural setting, and nonteaching status. In this study, we describe LEA rates in health care systems and hospitals in Los Angeles County from 2000 to 2010. Data on hospital discharges in Los Angeles County from 2000 to 2010 were obtained from the California Office of Statewide Health Planning and Development. LEA rates were adjusted for clinical and demographic variables including age, sex, race, source of health care payment, diabetes, and peripheral vascular disease. Adjusted LEA rates over the study period were analyzed by category of hospital (municipal, nonprofit/non-Kaiser, Kaiser, and private), and for changes in rates in each hospital over the study period. Over the 11-year study period the LEA rates increased for municipal hospitals, while decreasing for the other 3 categories of hospitals. Among the 84 hospitals included in the final analysis, 41 hospitals had higher than average relative risk for LEA in 2007-2010. Among these hospitals 12 had higher than average decline in LEA rate between 2000-2003 and 2007-2010. The other 29 hospitals had not lowered the LEA rate as much as the whole County over the study period. After adjusting for demographic and clinical variables, the relative risk for LEA among hospitals varied by 7.5-fold. Significant variability was found both within each of the 4 types of hospitals, and between the 4 types. Hospitals also varied in the degree that they lowered their LEA rates. This study demonstrated that health care systems and hospitals are associated with significant disparity in LEA rates among socioeconomic groups and geographical regions.

Low survival rate after cardiopulmonary resuscitation in a county hospital.

BACKGROUND: The standard of practice in hospitals in the United States is to perform cardiopulmonary resuscitation on all patients who suffer a cardiac arrest unless a specific order has been written to the contrary. In recent decades, however, data showing a low rate of survival to discharge under certain conditions have accumulated, leading some to question this policy. The objective of this study was to examine variables predictive of patient survival following cardiopulmonary resuscitation using standardized methods of measuring severity of illness. METHODS: All patients were identified who underwent cardiopulmonary resuscitation on the medicine service at Los Angeles County (California) Hospital from August 15, 1990, to February 15, 1991. Severity of illness was evaluated by examining diagnosis, Acute Physiology and Chronic Health Evaluation II score, and organ system failure. Cases were followed up prospectively until death or hospital discharge, and data concerning post-arrest mental status, utilization of resources, and disposition were gathered. RESULTS: Of the 131 patients identified, 22 patients (16.8%) survived for 24 hours but died before discharge; only four patients (3.1%) survived to discharge. CONCLUSIONS: This study suggests that in some settings (eg, institutions that are for sick patients under conditions where monitoring is limited because of scarcity of resources), survival after full cardiopulmonary arrest may be even lower than previously documented.

Design and implementation of a performance measurement system in Swedish health care services: a multiple case study of 6 development teams.

Performance measurement is considered to be an important part in improving and controlling contemporary organizations. Despite the increased interest in using and improving performance measurement systems, the number of researchers investigating the design and implementation process in more detail is still very small. The purpose of this article is to increase the understanding of how a performance measurement system, called the flow model, is designed and implemented by development teams in Swedish health care. The purpose of the flow model is to follow up the requirements in the National Care Guarantee through 8 measures. From a multiple case study of 6 local development teams, we conclude that the performance measurement system of the flow model is designed and implemented in Swedish County Councils through 3 development tracks, which are reflected in close interaction between the local development team and people in clinical departments. Enabling factors in the design and implementation are (1) the recognition of a need to change the current situation, (2) the teams' interaction with people in the clinical departments, (3) the national network meetings arranged by the financier, (4) the struggle to motivate and inform the top management, and (5) the establishment of contact with other development teams and ongoing projects.

A hospital-centered approach to improve emergency obstetric care in South Sudan.

OBJECTIVE: To assess provision of emergency obstetric care (EmOC) in Greater Yirol, South Sudan, after implementation of a hospital-centered intervention with an ambulance referral system. METHODS: In a descriptive study, data were prospectively recorded for all women referred to Yirol County Hospital for delivery in 2012. An ambulance referral system had been implemented in October 2011. Access to the hospital and ambulance use were free of charge. RESULTS: The number of deliveries at Yirol County Hospital increased in 2012 to 1089, corresponding to 13.3% of the 8213 deliveries expected to have occurred in the catchment area. Cesareans were performed for 53 (4.9%) deliveries, corresponding to 0.6% of the expected number of deliveries in the catchment area. Among 950 women who delivered a newborn weighing at least 2500 g at the hospital, 6 (0.6%) intrapartum or very early neonatal deaths occurred. Of 1232 women expected to have major obstetric complications in 2012 in the catchment area, 472 (38.3%) received EmOC at the hospital. Of 115 expected absolute obstetric indications, 114 (99.1%) were treated in the hospital. CONCLUSION: A hospital-centered approach with an ambulance referral system effectively improves the availability of EmOC in underprivileged remote settings.

Guidelines for surgical residents' working hours. Intent vs reality.

To comply with voluntary California medical school guidelines, our general surgery residency program reduced in-house call to 1 in 4 nights, and scheduled a 72-hour work-week. We assessed the effectiveness of these changes by prospectively surveying the actual working hours of surgical house staff through completion of a daily schedule for 1 month. Actual in-hospital hours averaged 98 per week, significantly exceeding the scheduled hours, and were greater for interns (100 hours) and junior residents (97 hours) than for chief residents (95 hours). Twenty hours (22%) of nonconference waking hours were spent on so-called scut work. Significant reduction of intern work hours could be accomplished by expansion of ancillary care, allowing more time for direct patient care. The effect on senior house staff hours would be less dramatic but might be sufficient to bring hours into compliance with proposed limits.

Satisfaction of patients attending an arthritis clinic in a county teaching hospital.

OBJECTIVE: To gather information about the satisfaction of medically indigent arthritis patients with their health care. METHODS: Patients attending a university-affiliated county hospital arthritis clinic were surveyed using a questionnaire about their satisfaction with various aspects of the clinic. RESULTS: Two hundred thirty-two out of 283 questionnaires were completed. Patients were most satisfied with the care given by doctors, and least satisfied with the waiting times; accessibility, environment, and information received intermediate responses. Although most patients said that they were satisfied with their overall care, only 53% would continue to attend the clinic if they had full insurance. CONCLUSION: A number of aspects of health care delivery were sources of dissatisfaction for medically indigent arthritis patients. Attention to these concerns could increase overall satisfaction and perhaps improve compliance in this group of patients.

Use of medical resources, complications and long-term outcome in patients hospitalized with acute chest pain. A comparison between a city university hospital and a county hospital.

OBJECTIVE: The primary aim was to test the hypothesis that there is a difference in long-term outcome after hospital discharge among patients hospitalized with acute chest pain in a university hospital and a county hospital. Secondary aims were to compare these two hospitals with regard to use of medical resources, occurrence of complications and risk indicators for death. PATIENTS: All patients hospitalized at Sahlgrenska University Hospital in Göteborg (with a catchment population of 706 inhabitants/km(2)) and Uddevalla County Hospital (with a catchment population of 34 inhabitants/km(2)) due to symptoms of acute chest pain during a period of 6 months. RESULTS: Complications, use of medical resources and mortality during the subsequent 2 years after discharge were compared among 1,592 hospitalizations in a city hospital and 822 in a county hospital due to acute chest pain. Angina pectoris after the first event, congestive heart failure and various arrhythmias were more frequently reported in the county hospital. The use of medical resources differed. Thus, the use of betablockers, heparin, antiarrhythmics, diuretics and nipride was more frequent in the county hospital, whereas the use of nitrates, digitalis, coronary angiography, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) was more frequent in the city hospital. Despite these differences, the mortality 2 years after hospital discharge was similar (14.7% in the city hospital and 12.8% in the county hospital, P=0.26). Two factors, intravenous digitalis in hospital and a prescription of insulin at discharge, were significantly more associated with death in the county hospital compared with the city hospital. CONCLUSIONS: When comparing a city university hospital with a county hospital with regard to patients admitted with chest pain, major differences in terms of complications and use of medical resources were found. Thus, various complications were reported more frequently in the county hospital. The use of medical resources varied, some being used more frequently in the county hospital, whereas others were used more frequently in the university hospital. Despite these differences the mortality 2 years after hospital discharge was similar in the two cohorts.