Hospital‐based health systems 20 years later: A taxonomy for policy research and analysis

ObjectiveBuilding on the original taxonomy of hospital‐based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments.Data SourcesThe 2016 American Hospital Association''s (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017‐2018 National Survey of Healthcare Organizations and Systems (NSHOS).Study DesignCluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital‐based health systems.Data CollectionPrincipal components factor analysis with varimax rotation generating the factors used in the cluster algorithms.Principal FindingsAmong the four cluster types, 54% (N = 202) of systems are decentralized (−0.35) and relatively less differentiated (−0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (−0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (−1.35) and most decentralized (−0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system.ConclusionsThe new taxonomy of hospital‐based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value‐based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.     

Steady-state kinetics of imipramine in patients

Steady-state plasma level kinetics were studied in 76 patients given imipramine (IP) 150 to 225 mg/day for 2–5 weeks. IP was given in three divided doses at 8.00 a.m., 1.00 p.m. and 5.00 p.m. Plasma concentrations of IP and its active metabolite desipramine (DMI) were determined by quantitative in situ thin-layer chromatography. The plasma levels of IP and DMI showed pronounced flucutations throughout the day with a ratio of about 2 between highest and lowest level. Patients with steady-state levels of IP and/or DMI below 50 g/l reached this within 1 week of treatment. Patients with higher steady-state levels reached steady-state concentrations within 2–3 weeks. There were some intraindividual fluctuations in plasma levels from week to week after steady state had been reached (coefficient of variation: 10–20%). Interindividually, the steady-state levels corrected to a dose of 3.5 mg/kg per day varied considerably: IP: 6–356 g/l, DMI: 24–659 g/l and IP+DMI: 58–809 g/l. The steady-state plasma levels showed a skew distribution that became normal by logarithmic transformation. The IP/DMI ratio ranged from 0.07 to 5.5 with a median value of 0.47. Compared to data from amitriptyline treated patients the IP/DMI ratios had significantly lower median value and larger variation than the corresponding plasma level ratios of amitriptyline/nortriptyline. Several statistically significant differences in steady-state levels between age groups were found. For IP: Women aged 30–39 had lower levels than women aged 20–29, 40–49, and 50–59, and men aged 50–59 and 60–65; men aged 30–39 had lower levels than men aged 60–65. For DMI: Women aged 30–39 had lower levels than women aged 50–59.     

医院管理公司对中国医疗产业发展影响探讨

医院管理公司是继国有医院集团以后新兴的医院联合的模式,这种模式可以充分利用医疗产业现有的机会,通过产业集中和完善医院的治理结构,对当前的产业总体结构进行调整.医疗产业经过调整后,会产生新的产业分工,并通过市场调节机制发挥卫生资源重新配置的职能.     

如何正确运用t检验——两几何均值比较一般差异性t检验及SAS实现

本文目的是介绍几何均数以及两组近似对数正态分布数据几何均数的一般差异性t检验及SAS实现。首先对几何均数的概念、适用条件和计算公式进行介绍;并且将几何均数与统计学中常用的算术均数的特点进行比较;其次,呈现两组药物浓度数据,该数据近似服从对数正态分布,符合几何均数的适用条件,使用SAS的TTEST过程对两组几何均数的一般差异性进行t检验,并对相关结果进行解释和比较;最后,讨论几何均数使用时的注意事项。     

A comparison of visual acuity measured by ETDRS chart and Standard Logarithmic Visual Acuity chart among outpatients

AIM:To compare the results of visual acuity(VA)measured by Early Treatment Diabetic Retinopathy Study(ETDRS)chart,5 m Standard Logarithm Visual Acuity(5 SL)chart,and 2.5 m Standard Logarithm Visual Acuity(2.5 SL)chart in outpatients of age 12-80 y.METHODS:Each patient(totally 2000 outpatients)had both eyes tested with ETDRS chart at 4 m,5 SL chart at 5 m,and 2.5 SL chart at 2.5 m in random order.The VA values of outpatients were categorized by ages.VA values were expressed by log MAR recording method.RESULTS:The mean VA results of ETDRS charts,5 SL,and 2.5 SL chart were 0.52±0.28,0.50±0.30,and 0.46±0.28 log MAR,respectively.There was a statistically significant difference in the three eye charts in the whole group(P<0.001).For all subjects,the correlation of VA tested with three charts was statistically significant(Spearman correlation coefficient=0.944,0.937,0.946,all P<0.001).Bland–Altman analysis shows the 95%limits of agreement between the 5 SL and 2.5 SL chart were-0.182 to 0.210,-0.139 to 0.251,and-0.151 to 0.235 log MAR,respectively.CONCLUSION:The agreement between the three eye charts is not high.The VA measured by 5 SL chart is slightly better than that by ETDRS chart and 5 SL chart would be a suitable alternative when ETDRS chart are not available in the clinical situation.The VA measured by 2.5 SL chart is about 0.5 line better than VA tested with ETDRS chart,which may overestimate VA.     

一种几何分级对数记录的图形视力表

本视力表所用视标为:鸟、鱼、房子、剪子、茶杯、苹果、雨伞、花和鸭子。采用10 10~(1/2)的几何增率及五分视力记录法。与缪氏对数视力表所测视力值呈高度相关(r=0.98, P<0.01;r=0.76,P>0.01),儿童对本视力表及缪氏视力表的不合作率间差异有非常显著意义(X~2=52.85,P<0.01)。测试结果初步表明本视力表适用于不能接受E视标检查的儿童,对三岁以下幼儿尤为适用。     

Ulnar growth patterns in radial longitudinal deficiency

PURPOSE: To determine the association between centralization surgical procedures and the longitudinal growth of the ulna in radial longitudinal deficiency (RLD). METHODS: The charts of 90 patients with 124 affected limbs were reviewed. Thirty-four patients were affected bilaterally and 56 were affected unilaterally. Based on the Bayne and Klug classification there were 5 type I, 3 type II, 9 type III, and 107 type IV deformities. Seventy-two limbs had available radiographs, which were measured for ulnar length. We plotted 384 ulnar length measurements in 72 limbs and compared these with both normative ulnar length data and ulnar length data in RLD. The average ulnar length was compared for the group (n = 46) treated with surgical centralization versus the nonsurgically treated group (n = 22). RESULTS: The nonsurgically treated group attained 64% of normal ulnar length whereas the nonnotched centralization group attained 58% of normal ulnar length. The notched centralization group attained 48% of normal ulnar length. Ulnar growth for the surgically treated group averaged 0.54 cm/y and the for the nonsurgically treated group averaged 0.71 cm/y, which showed no statistical significance. CONCLUSIONS: Wrist centralization procedures effectively increase the overall length of the limb by centralizing the hand and carpus over the shortened ulna; this must be weighed against the high rate of recurrent radial deviation deformity and some loss of ulnar growth.