Lost opportunity cost of surgical training in the Australian private sector

Background: To meet Australia's future demands, surgical training in the private sector will be required. The aim of this study was to estimate the time and lost opportunity cost of training in the private sector. Methods: A literature search identified studies that compared the operation time required by a supervised trainee with a consultant. This time was costed using a business model. Results: In 22 studies (34 operations), the median operation duration of a supervised trainee was 34% longer than the consultant. To complete a private training list in the same time as a consultant list, one major case would have to be dropped. A consultant's average lost opportunity cost was $1186 per list ($106 698 per year). Training in rooms and administration requirements increased this to $155 618 per year. To train 400 trainees in the private sector to college standards would require 54 000 training lists per year. The consultants' national lost opportunity cost would be $137 million per year. The average lost hospital case payment was $5894 per list, or $330 million per year nationally. The total lost opportunity cost of surgical training in the private sector would be about $467 million per year. When trainee salaries, other specialties and indirect expenses are included, the total cost will be substantially greater. Conclusion: It is unlikely that surgeons or hospitals will be prepared to absorb these costs. There needs to be a public debate about the funding implications of surgical training in the private sector.     

The impact of practice environment on laparoscopic colectomy utilization following colorectal residency: a survey of the ASCRS Young Surgeons

Aim It is often thought that practice patterns are different in private (PP) vs university hospital (UH) settings. We aimed to describe the impact of practice environment on the type of laparoscopic colectomy procedures performed by graduating colorectal surgeons. Method A review was carried out of prospectively gathered self‐reported questionnaire data. Graduates of American Society of Colon and Rectal Surgeons’ (ASCRS)‐approved colorectal residencies from 2004 to 2008 underwent an on‐line survey, developed by the ASCRS Young Surgeons’ Committee. Results About 177 (52%) of 342 graduates surveyed responded. Practice setting data were available for 157 (89%) surgeons. Gender, geographical location and age were similar in both cohorts. PP surgeons utilized a laparoscopic approach more often for rectal cancer (37%vs 19%; P = 0.003). There was no significant difference in the rate of laparoscopic surgery in colon cancer, diverticular disease, inflammatory bowel disease, Clostridium difficile or emergency surgery. PP surgeons operated more often with a partner (43%vs 8%) or surgical assistant (13%vs 4%; both P < 0.001), while UH surgeons had a colorectal resident (10%vs 21%) or general surgery resident (15%vs 55%; both P < 0.001). Impediments to performing laparoscopic surgery for PP surgeons included a perceived lack of hospital equipment (33%vs 20%) and support (29%vs 17%; both P < 0.05). Perception of personal experience, access to trained assistants, financial reimbursement, length of surgery and patient availability were equivalent in both groups. Conclusion While differences such as type of assistant and impediments to laparoscopic utilization exist between PP‐ and UH‐based practices, early laparoscopic practice patterns remain similar. PP surgeons more frequently perform laparoscopic resection for rectal cancer and with hand‐assistance. Despite differences, newly trained colorectal surgeons in both settings utilize and require laparoscopic skills.     

Does hospital setting influence shoulder replacement revision rate? A national comparison of outcomes between private and public settings

Background

Australian healthcare relies on both private and public sectors to meet the demand for surgical care. Rapid growth of shoulder replacement surgery highlights a disparity in service provision, with two-thirds occurring privately. This study aimed to assess the influence of hospital setting on shoulder replacement revision rate at a national level.

Methods

All primary shoulder replacements recorded by the Australian Orthopaedic Association National Joint Replacement Registry from April 2004 to December 2020 were included. Private and public settings were compared for stemmed total shoulder replacement (sTSR) for osteoarthritis (OA), reverse total shoulder replacement (rTSR) for OA/cuff arthropathy (CA), and rTSR for fracture. The primary outcome was cumulative percent revision (CPR), with Kaplan–Meier estimates of survivorship to determine differences between private and public hospitals, recorded as hazard ratios (HR). Secondary analyses investigated differences between hospital settings, targeting hospital outliers for revision and prosthesis selection.

Results

Primary sTSR (OA) demonstrated a higher revision rate in private hospitals compared to public hospitals (HR = 1.27; P = 0.001), as did rTSR (OA/CA) after 3 months (HR = 1.33; P = 0.003). However, no significant difference was observed for primary rTSR (fracture) (HR = 1.10; P = 0.484). Restricting rTSR (OA/CA) to the best performing prosthesis combinations eliminated the difference between private and public outcomes (HR 1.10; P = 0.415). No other secondary analysis altered the primary result.

Conclusions

Differences exist between private and public hospitals for revision rate following primary shoulder replacement. Prosthesis selection accounts for some of the variation. Further analysis into patient specific characteristics is necessary to better understand these disparities.     

Outcome of metabolic evaluation and medical treatment for calcium nephrolithiasis in a private urological practice

PURPOSE: We determine if medications that have been proven effective for kidney stone prevention in prospective controlled trials can reduce kidney stone recurrence in a private practice of urology better than life-style advice, including hydration. MATERIALS AND METHODS: Between July 1, 1995 and December 31, 1996, 203 patients with stones received care from 1 private practice. Physicians chose to evaluate these patients metabolically based on clinical judgement. Thiazide, potassium citrate and allopurinol are recognized in this study as active treatments, and drug treatment intervals were calculated. Relapse and recurrent stones were counted as those stones manifesting after the initial index event. A stone was called a relapse stone if its date was included in the active treatment interval. RESULTS: The association between use of active therapy and ordering of metabolic evaluation was highly significant. Using survival tables, we separately considered all patients and only those who had formed more than 1 stone. For both populations active treatment reduced stone recurrence significantly more than diet advice and hydration. CONCLUSIONS: Medications validated in trials and guided by metabolic evaluation lower stone recurrence when used in a private practice setting as they do in trials.     

新建综合民营医院医院感染病原菌分布与细菌耐药性

目的探讨新建综合民营医院医院感染病原菌的分布及耐药性情况,为临床合理使用抗菌药物提供客观依据。 方法对2008年1月1日～2011年12月30日河南宏力医院院内感染病原菌的构成、分布和耐药性进行χ²检验,并与2010年中国CHINET细菌耐药性监测及国内新建三级甲等综合医院的医院感染情况进行比较,对特定环境下细菌耐药进行分析。 结果所分离的3 728株病原菌中,革兰阴性菌占79.8%,革兰阳性菌占20.2%;革兰阴性菌中大肠埃希菌、铜绿假单胞菌、克雷伯菌属和不动杆菌属为最常见病原菌,其中克雷伯菌属对头孢哌酮-舒巴坦、亚胺培南和美罗培南高度敏感,耐药率均为0%,显著低于2010年我国CHINET细菌耐药监测结果,3种药物耐药率差异具有统计学意义（P均< 0.01）。大肠埃希菌对以上3种药物的耐药率分别为1.52%、1.2%和1.39%,均低于2010年我国CHINET监测结果,较头孢哌酮-舒巴坦的耐药率差异具有统计学意义（P < 0.01）,而较亚胺培南和美罗培南的耐药率差异无统计学意义（P值分别为0.315和0.988）。铜绿假单胞菌对以上3种药物的耐药率分别为16.96%、22.84%和29.3%,除美罗培南外均低于CHINET监测结果,头孢哌酮-舒巴坦耐药率差异无统计学意义（P = 0.536）;对亚胺培南和美罗培南耐药率差异具有统计学意义（P分别< 0.01和< 0.05）。不动杆菌属对以上3种药物的耐药率分别为4.5%、47.5%和39.9%,均低于CHINET监测结果,3种药物耐药率差异具有统计学意义（P均< 0.01）。革兰阳性菌中以金黄色葡萄菌、凝固酶阴性葡萄球菌为主要的感染病原菌,革兰阳性球菌对万古霉素、替考拉宁和利奈唑胺高度敏感,耐药率均为0%,与CHINET监测结果相同,差异无统计学意义。与首都医科大学附属北京朝阳医院京西院区耐药率监测相比,铜绿假单胞菌对庆大霉素、哌拉西林-他唑巴坦和美罗培南的耐药率分别为67.45%、36.69%和29.3%,均显著高于该院区的监测结果,差异具有统计学意义（P均< 0.01）;大肠埃希菌耐药率相近,差异无统计学意义（P > 0.05）。与首都医科大学附属北京朝阳医院京西院区革兰阳性球菌耐药性相比,本院葡萄球菌属耐药率普遍较低,差异具有统计学意义（P均< 0.01）。 结论新建民营综合医院环境下医院感染菌株在构成、菌种分布及耐药性等方面,与国内新建三甲医院及相关研究结果基本一致。     

Trauma-related disorders in psychiatrists' and general practitioners' private practice in Switzerland

A questionnaire addressing traumatic stress related issues was mailed to every third psychiatrist in private practice and to every fifth general practitioner in Switzerland (N=1406, number of returns 517 (37%). Trauma-related disorders seem to be underdiagnosed. Patients suffering from rape, accidents and war related trauma were most often mentioned. Psychiatrists knew more about specific treatment possibilities than general practitioners. Only 14% of the responding clinicians were satisfied with the existing therapeutic services for trauma victims; more psychiatrists voiced a need for their improvement. A majority suggested interdisciplinarity and the cooperation of institutions and therapists in private practice for the treatment of trauma-related disorders. It is proposed that further education should be tailored according to the target professional group.     

Time to treatment for patients receiving BCS in a public and a private university hospital in Atlanta

Delays in treatment for breast cancer can lead to poorer patient outcome. We analyzed time to treatment among female patients receiving breast-conserving surgery in two different hospital settings, public versus private. Retrospective chart review revealed 270 patients diagnosed during 2004-2008. Three consecutive time intervals were defined (Initial abnormal imaging [I] to core biopsy [II] to surgery /pathology staging [III] to oncology evaluation for adjuvant treatment). Multivariate analyses investigated hospital type and demographic factors. Overall median treatment time was 83 days, Interval II accounting for the longest (43 days). Only 55% of patients received the entire spectrum of care within 90 days; for each consecutive 30-day interval, percentages varied dramatically: 80.7%, 31.1%, and 68.9%.Public hospital patients experienced longer overall time to treatment than private patients (94 versus 77 days, p < 0.001); these differences persisted throughout the intervals. Longer wait times were experienced by African Americans versus Caucasians (89 versus 64 days, p = 0.003), unmarried versus married patients (93 versus 70 days, p < 0.001), and Medicaid-insured patients, p < 0.001. In multivariate analyses, hospital type, race, marital status, and insurance predicted timely treatment within one or more intervals. For patients undergoing breast-conserving therapy, time to treatment differs between private and public settings. However, barriers to timely treatment arise from both system-based issues and patient socio-demographic factors. Studies are needed to evaluate and intervene on this intricate connection.     

三级民营医院新入职护士岗前培训需求及影响因素分析

目的了解三级民营医院新入职护士岗前培训需求及其影响因素,为制定科学可行的新入职护士岗前培训方案提供科学参考。方法采用自制新入职护士岗前培训需求问卷,调查分析98名新入职护士及35名护理管理人员对岗前培训的需求。结果三级民营医院新入职护士岗前培训需求得分(4.44±0.45)分;新入职护士培训需求与护士长认为其应接受培训的需求程度比较,在护理安全、疾病知识、专业技能、医院文化、护士礼仪、护理专业思想、教育服务理念7个方面差异有统计学意义(P0.05,P0.01);年龄、职称、学历、职业发展需求是新入职护士培训需求的影响因素(P0.05,P0.01)。结论新入职护士培训需求程度较高,护士长更关注新入职护士的医院发展需求培训;低年龄、低职称、高学历及有职业发展规划的护士其培训需求更高。护理管理者应制定系统全面、具有针对性、与能级对应的分层次培训。     

Prostate cancer: socio-economic, geographical and private-health insurance effects on care and survival

OBJECTIVE: To examine the effects of demographic, geographical and socio-economic factors, and the influence of private health insurance, on patterns of prostate cancer care and 3-year survival in Western Australia (WA). PATIENTS AND METHODS: The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of men diagnosed with prostate cancer between 1982 and 2001. The likelihood of having a radical prostatectomy (RP) was estimated using logistic regression, and the likelihood of death 3 years after diagnosis was estimated using Cox regression. RESULTS: The proportion of men undergoing RP increased six-fold, from 3.1% to 20.1%, over the 20 years, whilst non-radical surgery (transurethral, open or closed prostatectomy) simultaneously halved to 29%. Men who had RP were typically younger, married and with less comorbidity. Patients with a first admission to a rural hospital were much less likely to have RP (odds ratio 0.15; 95% confidence interval, CI, 0.11-0.21), whereas residence alone in a rural area had less effect (0.54, 0.29-1.03). A first admission to a private hospital increased the likelihood of having RP (2.40, 2.11-2.72), as did having private health insurance (1.77, 1.56-2.00); being more socio-economically disadvantaged reduced RP (0.63, 0.47-0.83). The 3-year mortality rate was greater with a first admission to a rural hospital (relative risk 1.22; 95% CI 1.09-1.36) and in more socio-economically disadvantaged groups (1.34, 1.10-1.64), whereas those admitted to a private hospital (0.77, 0.71-0.84) or with private health insurance (0.82, 0.76-0.89) fared better. Men who had RP had better survival than those who had non-radical surgery (4.85, 3.52-6.68) or no surgery (6.42, 4.65-8.84), although this may be an artefact of a screening effect. CONCLUSION: The 3-year survival was poorer and the use of RP less frequent in men from socio-economically and geographically disadvantaged backgrounds, particularly those admitted to rural or public hospitals, and those with no private health insurance.     

磁性医院管理对基层托管二级民营医院护士离职率的影响

目的 探讨磁性医院管理在基层托管二级民营医院的实践效果.方法 将磁性医院管理应用于托管二级民营医院:培养护理管理者领导力、建立有效激励机制、构建支持性工作环境、打造磁性医院关爱文化等,增强临床护士凝聚力.比较实施前后护士职业价值观、离职意愿及离职率状况.结果 实施磁性医院管理实践后,临床护士职业价值观评分显著高于实施前,离职意愿评分显著低于实施前(均P＜0.05);离职率由2017年33.05％降至2020年6.19％ (P＜0.01).结论 磁性医院管理能引导临床护士建立正确的职业价值观,降低护士离职意愿及离职率.     

Universitätskliniken im Spannungsfeld des Krankenhausmarktes

Zusammenfassung In den letzten Jahren manifestierte sich im deutschen Gesundheitssystem ein Trend zu stärkerer Ökonomisierung. Damit ist eine Intensivierung des Wettbewerbs zwischen den Krankenhäusern verbunden. Die Folge ist, dass Krankenhäuser ihre Position am Markt erkämpfen und behaupten müssen. Bei den Universitätskliniken kommt erschwerend hinzu, dass sie als Forschungs- und Lehreinrichtungen in diesem Wettbewerb mit ungünstigen Kostenstrukturen arbeiten müssen. Zusätzlich wird dieser Wettbewerbsnachteil durch die gesetzlich vorgegebene Verpflichtung zur Sicherung der Maximalversorgung der Bevölkerung verschärft. Diese Verpflichtung bringt eine ungünstige Erlössituation mit sich. Vor dem Hintergrund knapper Finanzmittel werden daher in jüngster Zeit auch Universitätskliniken zur Privatisierung ausgeschrieben.Eine Alternative zur Privatisierung von Kliniken ist die Änderung der Rechtsform zur Kapitalgesellschaft oder zur Stiftung öffentlichen Rechts nach amerikanischem Vorbild. Darüber hinaus bieten public private partnerships (PPPs) eine Alternative, um externes Kapital an die Klinik zu führen, ohne auf Mitspracherechte zu verzichten. Schließlich können Universitätskliniken auch eine strategische Neuausrichtung durchführen und vergleichbar zu privaten Trägern Rationalisierungspotenziale durch Restrukturierungen, z. B. in den Segmenten medizinische Versorgung, Forschung und Personal, realisieren. Entscheidend ist jedoch, dass Universitätskliniken eigene Initiativen und Entwicklungen starten. Dafür werden in diesem Beitrag mehrere Handlungsoptionen aufgezeigt.     

Private Bundles: The Nuances of Contracting and Managing Total Joint Arthroplasty Episodes

In recent years, bundled payment reimbursement models have been used to address the unsustainable rising cost of healthcare. Centers for Medicare and Medicaid Services initiatives, such as Bundled Payment for Care Improvement Program, have already demonstrated their ability to create financial and performance accountability in the public sector. More recently, these value-based models have been introduced among private payers to increase coordination, quality, and efficiency. Bundled payment strategies provide incentives for physicians and healthcare professionals to eliminate unnecessary services and reduce costs. This article discusses our experience at a private institution with transitioning to a bundled payment program, while identifying the challenges and strategies associated with a successful implementation.     

Unequal access to breast-conserving surgery in Western Australia 1982-2000

BACKGROUND: The purpose of the present study was to examine the effects of demographic, locational and social disadvantage and the possession of private health insurance in Western Australia on the likelihood of women with breast cancer receiving breast-conserving surgery rather than mastectomy. METHODS: The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of women with breast cancer in Western Australia from 1982 to 2000 inclusive. Comparisons between those receiving breast-conserving surgery and mastectomy were made after adjustment for covariates in logistic regression. RESULTS: Younger women, especially those aged less than 60 years, and those with less comorbidity were more likely to receive breast-conserving surgery (BCS). In lower socio-economic groups, women were less likely to receive BCS (OR 0.73; 95% CI 0.60-0.90). Women resident in rural areas tended to receive less BCS than those from metropolitan areas (OR 0.84; 95% CI 0.55-1.29). Women treated in a rural hospital had a reduced likelihood of BCS (OR 0.74; 95% CI 0.61-0.89). Treatment in a private hospital reduced the likelihood of BCS (OR 0.70; 95% CI 0.54-0.90), while women with private health insurance were much more likely to receive BCS (OR 1.39; 95% CI 1.08-1.79). CONCLUSION: Several factors were found to affect the likelihood of women with breast cancer receiving breast-conserving surgery, in particular, women from disadvantaged backgrounds were significantly less likely to receive breast-conserving surgery than those from more privileged groups.     

Surgical malpractice: staying out of trouble

This article discusses why surgeons get into trouble more than most specialties and reviews data from the National Clinical Assessment Authority and the General Medical Council National Training Survey. It explores some of the areas that are known to be associated with the highest risk of suspension and malpractice claims, including working in the private and independent sectors, the introduction of new procedures and use of novel devices, consent and documentation, peri-procedural precautions, lack of resources and support, and medicolegal work. In each of these areas, he highlights pitfalls to avoid. The article concludes by emphasizing the importance of teamworking, an adequate workload, regular peer review, thorough counselling of patients, meticulous record keeping and attention to detail.     

Colorectal cancer surgical care and survival: do private health insurance,socioeconomic and locational status make a difference?

BACKGROUND: The purpose of the present paper was to examine patterns of surgical care and the likelihood of death within 5 years after a diagnosis of colorectal cancer, including the effects of demographic, locational and socioeconomic disadvantage and the possession of private health insurance. METHODS: The Western Australian Data Linkage System was used to extract all hospital morbidity, cancer and death records for people with a diagnosis of colorectal cancer from 1982 to 2001. Demographic, hospital and private health insurance information was available for all years and measures of socioeconomic and locational disadvantage from 1991. A logistic regression model estimated the probability of receiving colorectal surgery. A Cox regression model estimated the likelihood of death from any cause within 5 years of diagnosis. RESULTS: People were more likely to undergo colorectal surgery if they were younger, had less comorbidity and were married/defacto or divorced. People with a first admission to a private hospital (odds ratio (OR) 1.31, 95% confidence interval (CI): 1.16-1.48) or with private health insurance (OR 1.27, 95% CI: 1.14-1.42) were more likely to undergo surgery. Living in a rural or remote area made little difference, but a first admission to a rural hospital reduced the likelihood of surgery (OR 0.76, 95% CI: 0.66-0.87). Residency in lower socioeconomic areas also made no difference to the likelihood of having surgical treatment. The likelihood of death from any cause was lower in those who were younger, had less comorbidity, were elective admissions and underwent surgery. Residency in lower socioeconomic status and rural areas, admission to a rural hospital or a private hospital and possession of private health insurance had no effect on the likelihood of death. CONCLUSIONS: The present study demonstrates that socioeconomic and locational status and access to private health care had no significant effects on surgical patterns of care in people with colorectal cancer. However, despite the higher rates of surgery in the private hospitals and among those with private health insurance, their survival was no better.