[Rates of caesarean sections tn two types of private hospitals: restriced-access and open-access]. / Tasa de cesáreas en dos hospitales privados con normativas diferentes: abierto y cerrado.

BACKGROUND: In recent years, rising rates of caesarean section are of concern in the medical community in many countries, especially in Latin America. OBJECTIVE: Determine if there is a difference in the rate of Caesarean sections in a restricted-access hospital (HC) and an open-access hospital (HA) using the Robson classification to explain potential differences. MATERIAL AND METHOD: A prospective cohort study was conducted. This in volved all patients that attended the obstetrics sector in the two hospitals in Buenos Aires where they gave birth between 1 June 2009 and 25h January 2010. The open-access hospital is open to doctors with varying professional training and differing clinical practice. The restricted-access hospital, on the other hand, can only be attended by specified doctors with certain professional training; their medical) conduct is based on service standards and clinical practice. RESULTS: Over the study period 762 patients who fulfilled the study criteria were included from the open-access hospital and 768 from the restricted-access hospital. The global rate of caesarean sections in the HAwas 53.5%, and 48.7% in the HC, RR 1.09 (CI 0.99-1.21) a difference that was not statistically significant (p = 0.058). The onset of spontaneous labour in the HAwas significantly more than in the HC (74.9% vs. 41.8%) RR 2.66 (CU.98-3.57). The induced labour was significantly lower in HA (9,7% vs. 28,3%); RR 0.34 (CI 0.27-0.44). Elective caesarean sections were significantly lower in the HA (15.3% vs. 29.9%) RR 0.51 (CI 0.42-0.62). CONCLUSION: This study reveals a similar rate of caesarean sections in two private hospitals with different systems of care. However, it observed that the HA has a greater tendency to operate on patients at the onset of spontaneous labour and the HC has a greater number of induced labour and elective caesarean section.

Socioeconomic impact on device-associated infections in limited-resource neonatal intensive care units: findings of the INICC.

PURPOSE: To evaluate the impact of country socioeconomic status and hospital type on device-associated healthcare-associated infections (DA-HAIs) in neonatal intensive care units (NICUs). METHODS: Data were collected on DA-HAIs from September 2003 to February 2010 on 13,251 patients in 30 NICUs in 15 countries. DA-HAIs were defined using criteria formulated by the Centers for Disease Control and Prevention. Country socioeconomic status was defined using World Bank criteria. RESULTS: Central-line-associated bloodstream infection (CLA-BSI) rates in NICU patients were significantly lower in private than academic hospitals (10.8 vs. 14.3 CLA-BSI per 1,000 catheter-days; p < 0.03), but not different in public and academic hospitals (14.6 vs. 14.3 CLA-BSI per 1,000 catheter-days; p = 0.86). NICU patient CLA-BSI rates were significantly higher in low-income countries than in lower-middle-income countries or upper-middle-income countries [37.0 vs. 11.9 (p < 0.02) vs. 17.6 (p < 0.05) CLA-BSIs per 1,000 catheter-days, respectively]. Ventilator-associated-pneumonia (VAP) rates in NICU patients were significantly higher in academic hospitals than in private or public hospitals [13.2 vs. 2.4 (p < 0.001) vs. 4.9 (p < 0.001) VAPs per 1,000 ventilator days, respectively]. Lower-middle-income countries had significantly higher VAP rates than low-income countries (11.8 vs. 3.8 per 1,000 ventilator-days; p < 0.001), but VAP rates were not different in low-income countries and upper-middle-income countries (3.8 vs. 6.7 per 1,000 ventilator-days; p = 0.57). When examined by hospital type, overall crude mortality for NICU patients without DA-HAIs was significantly higher in academic and public hospitals than in private hospitals (5.8 vs. 12.5%; p < 0.001). In contrast, NICU patient mortality among those with DA-HAIs was not different regardless of hospital type or country socioeconomic level. CONCLUSIONS: Hospital type and country socioeconomic level influence DA-HAI rates and overall mortality in developing countries.

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.

Top 100 hospitals: the best-run hospitals. For-profits spur efficiency.

For-profit hospital companies are spurring the industry's all-out drive toward efficiency. That's one of the principal findings of an analysis of 1994 Medicare cost and discharge data from 4,000 acute-care hospitals by HCIA and William M. Mercer. The analysis produced a list of ¿100 Top Hospitals: Benchmarks for Success.¿

Development of a maternity hospital classification for use in perinatal research.

We aimed to develop a maternity hospital classification, using stable and easily available criteria, that would have wide application in maternity services research and allow comparison across state, national and international jurisdictions. A classification with 13 obstetric groupings (12 hospital groups and home births) was based on neonatal care capability, urban and rural location, annual average number of births and public/private hospital status. In a case study of early elective birth we demonstrate that neonatal morbidity differs according to the maternity hospital classification, and also that the 13 groups can be collapsed in ways that are pragmatic from a clinical and policy decision-making perspective, and are manageable for analysis.

Cardiovascular responses of peripheral artery disease patients during resistance exercise / Respostas cardiovasculares durante o exercício de força em pacientes com doença arterial periférica

Resistance training has been used for the treatment of patients with peripheral artery disease (PAD). However, cardiovascular responses during this type of exercise have not been fully elucidated in these patients. OBJECTIVES: To analyze the cardiovascular responses during resistance exercise and to verify whether there are any correlations between these responses and disease severity or blood pressure levels in patients with PAD. METHODS: Seventeen PAD patients performed one set of 10 repetitions of knee extension exercise with an intensity of 50% of one repetition maximum. The responses of systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were continuously monitored using the finger photoplethysmography technique. The rate-pressure product (RPP) was obtained by multiplication of SBP and HR. RESULTS: During the resistance exercises there were significant increases in SBP (126 ± 14 vs. 184 ± 20 mmHg, p<0.001), DBP (68 ± 8 vs. 104 ± 14 mmHg, p<0.001), HR (76 ± 18 vs. 104 ± 30 bpm, p<0.001) and RPP (9523 ± 2115 vs. 19103 ± 6098 mmHg x bpm, p<0.001). A negative correlation was observed between relative change (Δ) in SBP and SBP at rest (r =-0.549, p=0.022). On the other hand, there was no relationship between Δ SBP and the ankle-brachial index (r=0.076, p=0.771). CONCLUSION: Increases in cardiovascular variables were observed during resistance exercise in PAD patients. The highest increases occurred in patients with lower SBP levels at resting...

O treinamento de força vem sendo utilizado para o tratamento de pacientes com doença arterial periférica (DAP). No entanto, as respostas cardiovasculares durante a realização desse tipo de exercício ainda não são claras nesses pacientes. OBJETIVOS: Analisar as respostas cardiovasculares durante a realização do exercício de força e verificar se existe alguma correlação entre essas respostas e a severidade da doença e o nível de pressão arterial em pacientes com DAP. MÉTODOS: Dezessete pacientes com DAP realizaram uma série de dez repetições com intensidade de 50% de uma repetição máxima do exercício extensão do joelho. As respostas da pressão arterial sistólica (PAS) e diastólica (PAD), e da frequência cardíaca (FC) foram continuamente registradas pela técnica de fotopletismografia de dedo. O duplo produto (DP) foi obtido pela multiplicação da PAS pela FC. RESULTADOS: Durante a realização do exercício de força, houve aumento significante dos seguintes parâmetros: PAS (126 ± 14 vs. 184 ± 20 mmHg; p < 0,001); PAD (68 ± 8 vs. 104 ± 14 mmHg; p < 0,001); FC (76 ± 18 vs. 104 ± 30 bpm; p < 0,001), e DP (9523 ± 2115 vs. 19103 ± 6098 bpm x mmHg; p < 0,001). Foi observada correlação negativa entre o delta (Δ) relativo da PAS com a PAS de repouso (r = -0,549; p = 0,022). Por outro lado, não foi observada relação entre o Δ relativo da PAS e o índice tornozelo braço (r = 0,076; p = 0,771). CONCLUSÃO: Foram observados aumentos das variáveis cardiovasculares durante o exercício de força em pacientes com DAP. Os maiores aumentos ocorreram nos pacientes com menor nível de PAS em repouso...

National audit of critical care resources in South Africa - unit and bed distribution.

OBJECTIVE: To determine the national distribution of intensive care unit (ICU)/high care (HC) units and beds. DESIGN AND SETTING: A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICU and high care units in South Africa was undertaken. RESULTS: A 100% sample was obtained; 23% of public and 84% of private hospitals have ICU/HC units. This translates to 1,783 public and 2,385 private beds. Only 18% of all beds were HC beds. The majority of units and beds (public and private) were located in three provinces: Gauteng, KwaZulu-Natal and the Western Cape. The Eastern Cape and Free State had less than 300 beds per province; the remaining four provinces had 100 or fewer beds per province. The public sector bed: population ratio in the Free State, Gauteng and Western Cape was less than 1:20,000. In the other provinces, the ratio ranged from 1:30,000 to 1:80,000. The majority of units are in level 3 hospitals. The ICU bed: total hospital bed ratio is 1.7% in the public sector compared with 8.9% in the private sector. The ratio is more when the comparison is made only in those hospitals that have ICU beds (3.9% v. 9.6% respectively). In the public and private sector 19.6% beds are dedicated to paediatric and neonatal patients with a similar disparity across all provinces. Most hospitals admit children to mixed medical surgical units. Of all ICU beds across all provinces 2.3% are commissioned but not being utilised. CONCLUSION: The most compelling conclusion from this study is the need for regionalisation of ICU services in SA.

Differences in characteristics of hospitals with sustained high and sustained low profitability.

The organizational and operational characteristics of 140 private Florida hospitals with sustained high profitability and sustained low profitability were compared using pretax operating margin (PTOM) and pretax return on assets (PROA) measures. Approximately 15 to 20 percent of hospitals were defined as PTOM or PROA high-profit or low-profit for the years 1990, 1991, and 1992. The PTOM or PROA high-profit groups had a lower adjusted average length of stay and debt utilization, and a higher labor yield, occupancy rate, and percent with high hospital accreditation ratings (p < .05). In addition, the PROA high-profit group had a higher case-mix index and Medicare mix (p < .05). Characteristics that were different for high-profit and low-profit groups were within the scope of management.

Pronóstico de pacientes con cáncer de mama tratadas con cirugía en un sistema privado extra de salud / Prognosis of patients with breast cancer treated with definitive surgery in a private health insurance system

Introducción: Muchas usuarias del sistema público de salud español contratan además un seguro privado para mejorar los controles ginecológicos y exploraciones rutinarias como mamografía anual. Analizamos retrospectivamente el pronóstico de estas pacientes cuando son diagnosticadas de cáncer de mama y se tratan con cirugía de intención curativa. Material y métodos: Se analizan la supervivencia global y los factores pronósticos de pacientes diagnosticadas de cáncer de mama sin metástasis tratadas con cirugía curativa en el contexto de un tratamiento multidisciplinario, remitidas a una consulta de oncología médica dentro de un sistema sanitario privado extra. Resultados: Entre 1994 y 2009 se analizaron 395 pacientes con cáncer de mama. Treinta y ocho tenían metástasis al diagnóstico y 357 pudieron tratarse con cirugía curativa: conservadora en 265 casos y mastectomía en 92. Con mediana de seguimiento de 64 meses, la tasa de supervivencia a 5 años era 91%: 97% para estadios I, 94% para estadios II, y 77% para estadios III. En las que se diagnosticaron por mamografía sistemática fue del 96 frente al 86% en las que acudieron al ginecólogo por autopalpación de tumor u otros síntomas (p = 0,0159). En el 74% se realizo ́ tratamiento conservador con mejor supervivencia frente al 26% que se realizó mastectomía (p = 0,0024). Pacientes con receptores positivos tuvieron mejor supervivencia que con receptores negativos (p = 0,0264) y este fue el único factor pronóstico independiente en el análisis multivariado de Cox. Conclusiones: Las pacientes con cáncer de mama tratadas con cirugía de intención curativa en un sistema sanitario privado tienen alta tasa de curación probablemente por tener un diagnóstico en fase precoz (AU)

Introduction: Many women enrolled in the Spanish National Health Service also take out private health insurance to improve gynecological follow-up and complementary examinations, such as annual mammograms. We analyzed the cure rate of these patients when diagnosed with breast cancer and treated with surgery with curative intent. Material and methods: Both overall survival and prognosis were analyzed in patients with breast cancer without metastases referred to a private oncology facility and treated with definitive surgery in the context of multidisciplinary treatment. Results: Between 1994 and 2009, 395 patients with breast cancer were analyzed. Thirty- eight had metastases at diagnosis and 357 could be treated with definitive surgery: conservative in 265 patients and mastectomy in the remaining 92. The median follow-up was 64 months and the 5-year survival rate was 91%: 97% for stage I, 94% for stage II and 77% for stage III. In women diagnosed by mammography, the 5-year survival rate was 96% versus 86% for women consulting a gynecologist after self palpation or for other symptoms (p = 0.0159). Treatment was conservative in 74%, with better survival than in the remaining 26% who were treated with mastectomy (p = 0.0024). Survival was greater in patients with positive hormone receptors than in those with negative hormone receptors (p = 0.0264). Hormone receptor status was the only independent prognostic factor in multivariate Cox analysis. Conclusions: Patients with breast cancer treated with definitive surgery in a private health insurance system have high cure rate, possibly because they are diagnosed in an early stage (AU)