Women's experiences with low-risk singleton in-hospital delivery in Switzerland.

OBJECTIVE: To assess maternal and neonatal clinical short-term outcomes and women's experiences with singleton low-risk in-hospital deliveries in a routine care setting. METHODS: In 13 community hospitals in the Cantons of Zurich (10), St. Gallen (2) and Schwyz (1), participating in the "Canton of Zurich Outcomes Project", trained hospital staff recorded clinical outcome data. Patients completed a questionnaire at the end of the hospital stay. Over two measurement cycles, 3395 eligible women entered the study and 2079 (61%) returned the questionnaire. RESULTS: Sixty-seven percent of women had spontaneous and 11% had assisted vaginal deliveries, 12% delivered by emergency, and 10% by elective Caesarean section. The episiotomy rate in vaginal deliveries was 46% (95% CI 44-48%). Ten percent of neonates had umbilical cord artery pH < or =7.15 (95% CI 9-11%) and Apgar scores at five minutes were < or = 7 in 3% (95% CI 2.5-3.6%). Reporting negative experiences with hospital care and an insufficient state of knowledge at discharge were strongly associated with mode of delivery. The top three issues new mothers were most likely to report about feeling little or not informed about were postpartum pelvic floor exercises (22%), management of vaginal bleedings (12%), and alternatives of infant feeding (10%). CONCLUSION: In a setting of routine care poor short-term outcomes were rare in women giving birth in hospitals, and neonates and most mothers were discharged with a level of information that at least ensured a smooth transition to follow-up maternal care. Poor clinical results and patient-reported negative experiences concentrate in few individuals. Restrictive approaches that reduce the frequency of instrumental vaginal delivery, and routine episiotomy remain an important objective for quality improvement.

Incidence and costs of osteoporosis-associated hip fractures in Austria.

This study is an investigation into the epidemiologic and socioeconomic impact of osteoporosis-associated hip fractures in Austria. We determined age- and gender-specific incidence rates of osteoporosis-associated hip fractures for all patients treated in hospitals in 1995 and calculated mortality rates, hospitalization days and direct costs of hospitalization. The data were obtained from the hospital discharge statistics for all general hospitals and for all hospitals of the General Austrian Accident Insurance. To calculate the portion of hip fractures attributable to osteoporosis in a given age-group, a basic, non-osteoporotic incidence of hip fractures was determined for ages 20-39, using gender-specific regression models. 11,379 patients with osteoporotic hip fractures underwent treatment in Austrian hospitals in 1995, accounting for 79 percent of all hip fracture patients treated. 82 percent of those were female, with the highest incidence among women aged 95 years and older with a rate of 3,000/100,000. For male patients the highest incidence was observed for the age-group of 90-94 years with 1,743/100,000. International comparisons indicate these incidence rates to be similar to those reported for the Swiss population. In 1995, 778 patients or 6.8 percent of all patients with osteoporotic hip fractures died during hospitalization. Hospital care of patients with osteoporotic hip fractures required an overall 250,268 bed-days with an age-group-specific length of stay between 8.5-27 days for female and 16-23 days for male patients. The total cost of hospital treatment of osteoporotic hip fractures in Austria was ATS 1,043,379,000 (US$ 103,509,800), with average costs per patient of ATS 91,700 (US$ 9,097). Due to the aging of the population in the years to come, an increase of osteoporotic hip fractures among individuals aged 50 years and older must be expected. The economic importance of this development and its impact on the health care system must be considered as significant.

Using a hypothetical case to measure differences in treatment aggressiveness among physicians in Canada, Germany and the United States.

Variations in physician practice style, within and between countries, account for much of the differences in the utilization of scarce health care resources. Practice style differences are particularly important at the end of life, when a substantial amount of resources are consumed. We use a hypothetical case of a severely ill elderly patient to identify factors associated with aggressive treatment and to test whether physicians in the US practice differently from their counterparts in other countries. Data come from a random sample of practicing physicians in three industrialized countries, the United States, Canada and Germany (N = 1369). Although the case stated that the chance of survival of the patient was low, 73% of all physicians selected the aggressive treatment. Physicians from the United States were the most aggressive (86%), followed by Germany (68%) and Canada (61%). Practicing in the United States was the strongest predictor of aggressiveness in the multiple linear logistic regression; German and Canadian physicians were one fourth as likely to use aggressive treatment. Specialty training, older age and being a resident all increased the likelihood of selecting the more aggressive treatment. The fear of being sued for malpractice and income did not have an effect on treatment decisions.

Use of administrative personnel in hospitals: a three nation comparison.

Differences in the costs of health care systems among industrialized countries has been the focus of several studies. Labor costs, specifically the amount of resources used for administration, are considered to contribute to differences in overall health care costs. To determine differences in the use of labor resources, especially administrative and managerial, among American, Austrian and German hospitals, we use a convenience sample of one Austrian, one German and two United States (US) tertiary care centers. In our analysis we used payroll data of the four hospitals. First, we categorized job titles and created job categories. Subsequently, we calculated full time equivalents (FTEs) per job category and compared them across countries. Adjustments were made for differences in health systems. The main outcome measures were FTEs per patient day and per discharge in each job category. In the US hospitals > 19% of FTEs were in administrative categories as compared with < 8% in the European hospitals. For administrative managers, US hospitals used > 11 times the labor per patient day of the European institutions. Among administrative areas, the largest absolute FTE difference was in financial operations. US hospitals used > 5 FTEs of personnel per 10,000 patient days versus < 1.0 FTE in the European hospitals. Given the kinds of administrative work done in US hospitals compared to Austria and Germany, differences in the organization and financing of these countries' health care systems may account for an important part of the higher number of US personnel.

Pulse oximetry in ventilated preterm newborns: reliability of detection of hyperoxaemia and hypoxaemia, and feasibility of alarm settings.

The aim of our study was to evaluate the reliability of pulse oximetry in detecting both hyper- and hypoxaemic states and to create clinically feasible alarm limits. A total of 792 readings of a pulse oximeter and corresponding values of arterial oxygen tension from 146 (79M, 67F) artificially ventilated preterm newborns with indwelling umbilical artery catheters were compared. Predictive value analysis of pulse oximeter readings related to arterial oxygen tension confirmed the ability of the pulse oximeter to identify both hypoxaemia and hyperoxaemia. However, a clinically feasible and safe range of alarm limits for maintenance of arterial oxygen tension of 40-90 mmHg (5.3-12 kPa) could only be established at a sensitivity level less than 0.9. At a level of 0.85, the alarm range on the pulse oximeter was 92.5-95%. Based on these findings, we are concerned about using pulse oximetry as the sole means of oxygen monitoring for preterm infants receiving supplementary oxygen. A combination of the pulse oximetry with other methods of blood-gas monitoring seems mandatory.