Wie steht es um die Hygiene beim Endoskopieren?

Flexible endoscopy is essential for the practice of modern medicine. However, with inadequate reprocessing of endoscopes and additional instruments, infections can be transmitted. Therefore, guidelines for reprocessing flexible endoscopes have been published in many countries. The goal of the present survey was to examine the current compliance with German Guidelines in a German urban region, covering all hospitals (15 hospitals) and private practices (23 practices) of this area, without any exception. All endoscopic units in Frankfort on the Main were visited by members of the Public Health Service, using a checklist based on the recommendations of the German Guidelines. In 2004, a reevaluation of 14 hospitals and 20 private practices took place, either by analysing the written reports of the institutions or by revisiting the institutions. In 2003, compliance with the guidelines in hospitals was satisfactory. In practices, however, many problems were identified in 2003. Between 2003 and 2004, great improvements could be seen (data of 2003 in parentheses). At the end of 2004, in 90% of the practices adequate storage of the endoscope without risk of recontamination (2003:52%), correct reprocessing the bottle and the tube for air/water channel flushing including filling with sterilized water was observed (2003:74% and 52%). In 100% of the practices, ultrasonic cleaning (2003:26%) and sterilizing of endoscopic accessories was guaranteed (2003:57%) and routine tests of endoscopes after reprocessing (2003:56%) were performed. In conclusion the relevance and the effect of the advising and control of public health have been so efficient that between 2003 and 2004 most faults have been corrected. Therefore control visits of the Public Health Services should not only cover hygiene in reprocessing the endoscopes but also hygiene in reprocessing endoscopic accessories as well.     

Aufbereitung von Cystoskopen in der Urologie. Was geschieht wirklich?

After having been informed about current guidelines, all urologic units in hospitals and private practices in Frankfurt/Main were visited in 2005/6 by members of the public health department and assessed using a checklist based on the recommendations of the German Guidelines for reprocessing medical instruments including rigid and flexible cystoscopes. In 12 hospitals and 22 private practices cystoscopy was performed using rigid cystoscopes, whereas flexible cystoscopes were used in 7 hospitals and 8 private practices. Cystoscopy with flexible instruments was more common in ambulatory than in clinic settings (about 1150/year vs. 280/year). In hospitals, reprocessing of the rigid cystoscopes was performed in special units for reprocessing (disinfection, sterilisation) using validated automatic processes, whereas reprocessing of flexible cystoscopes often was performed in the urologic units themselves, and not always in a correct manner. In the private practices, mainly manual reprocessing procedures were in use for rigid cystoscopes, in 18 out of 22 practices correct. However, only in 50 % of the private practices, sterilisation equipment was available for reprocessing rigid cystoscopes and/or endoscopic accessories. Flexible cystoscopes were reprocessed using a washer-disinfector in one practice, in the other ones, manual reprocessing was performed. In two practices only, reprocessing according to the guidelines was seen. Infection control advice and repeated control of the public health department resulted in the correction of most processing faults within some months.     

Fünf Jahre Empfehlungen der Kommission für Krankenhaushygiene zur Aufbereitung flexibler Endoskope

In a short review the national and international reception of the German guidelines for reprocessing flexible endoscopes is presented. The recommendations of the guidelines are discussed in view of recent knowledge on old problems such as prion inactivation and new infectious diseases and new microorganisms such as SARS, avian influenza and C. difficile. New disinfectants and new methods for endoscope disinfection are mentioned, the importance of careful cleaning is underlined. The German guidelines of the Robert Koch Institute and the US Multi-Society guidelines, published in 2003, are compared. The discrepancies concerning recommendations for water quality for final rinsing and need of microbiological controls of endoscope reprocessing are stressed. Aspects not mentioned in the German guidelines, e.g. duration of storage after reprocessing and risk of infection transmission by the endo-washer, are discussed.     

Rückblick auf 10 Jahre Infektionsschutzgesetz

In 2001, the German Protection against Infection Act came into force, implementing a variety of new regulations. For the first time, obligatory infection control visits of the public health departments in surgical ambulatory practices were implemented, as well as optional infection control visits in all medical, dental and paramedical practices using invasive methods. Based on the data of the public health department of the city of Frankfurt am Main, Germany, an evaluation of this new regulation is given in this paper. First, prioritization of these new tasks was mandatory. First priority was given to the obligatory visits in surgical practices, second priority to the hygiene visits in practices performing endoscopy in gastroenterology as well as in urology and in practices of traditional healers, and third priority was given to all other doctors’ practices. After receiving preliminary information and further training of the doctors etc., the control visits were performed by members of the public health department, using a checklist based on the guidelines of the German Commission on Hospital Infection Prevention (“Kommission für Krankenhaushygiene und Infektionsprävention”). Since 2001, more than 1100 infection control visits in medical practices in Frankfurt am Main were documented. Not only in surgical, but also in gastroenterological and urological practices great improvement could be achieved, regarding not only hand hygiene and reprocessing surface areas, but especially in reprocessing medical devices. In practices for internal medicine and those of general practitioners, errors in hand hygiene, skin antiseptic and surface disinfection also decreased. According to our results, especially regarding the improved quality of structure as well as quality of process and with regard to the public discussion on this hygiene topic, our evaluation is absolutely positive. The new regulation proved worthwhile.     

Multi-society guideline for reprocessing flexible gastrointestinal endoscopes. Society for Healthcare Epidemiology of America.

Flexible gastrointestinal endoscopy is a valuable diagnostic and therapeutic tool for the care of patients with gastrointestinal and pancreaticobiliary disorders. Compliance with accepted guidelines for the reprocessing of gastrointestinal endoscopes between patients is critical to the safety and success of their use. When these guidelines are followed, pathogen transmission can be effectively prevented. Increased efforts and resources should be directed to improve compliance with these guidelines. Further research in the area of gastrointestinal endoscope reprocessing should be encouraged. The organizations that endorsed this guideline are committed to assisting the FDA and manufacturers in addressing critical infection control issues in gastrointestinal device reprocessing.     

Compliance with HIPAA security standards in U.S. Hospitals

With the widespread use of computer networks, the amount of information stored electronically has grown exponentially, resulting in increased concern for privacy and security of information. The healthcare industry has been put to the test with the federally mandated Health Insurance Portability and Accountability Act (HIPAA) of 1996. To assess the compliance status of HIPAA security standards, a random sample of 1,000 U.S. hospitals was surveyed in January 2004, yielding a return rate of 29 percent. One year later, a follow-up survey was sent to all previous respondents, with 50 percent replying. HIPAA officers'perceptions of security compliance in 2004 and 2005 are compared in this article. The security standards achieving the highest level of compliance in both 2004 and 2005 were obtaining required business associate agreements and physical safeguards to limit access to electronic information systems. Respondents indicated least compliance both years in performing periodic evaluation of security practices governed by the Security Rule. Roadblocks, threats, problems and solutions regarding HIPAA compliance are discussed. This information may be applied to current and future strategies toward maintaining security of information systems throughout the healthcare industry.     

Requirements for the prevention of nosocomial infections. German Guideline 2009 and reality. Current data from hospitals in Frankfurt am Main, Germany

In 2009, the new directive of the German Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionspr?vention, KRINKO) entitled Human and Organizational Requirements for the Prevention of Nosocomial Infections was published, including detailed information on the needs of hygiene professionals in hospital settings. Compared to the needs calculated according to the above policy, the current staff hygiene health professionals (HHPs) in the hospitals of Frankfurt am Main (Frankfurt/M), Germany, was on average 27.6%: 36% in the large hospitals (>600?beds), 21.6% in medium hospitals (300?C600?beds), and 19.8% in small hospitals (<300?beds). Only 1?of 14?hospitals had a full-time hygienist. The demands of the KRINKO policy have not been met by any of the hospitals. Hospitals with lower percentages of hospital hygiene staff not only had a lower rating of hygienic quality, they also showed a lower usage of hand disinfection per patient?Cday. In Germany, there is currently a lack of trained HHPs and hygienists to meet the needs of the KRINKO policy. Therefore, the reactions of the hospitals in Frankfurt/M ranged from the establishment of additional jobs for HHPs to changes in structures and organization of hospital hygiene. Thus, the new KRINKO guideline in Frankfurt/M did not result in a wave of recruitment of health professionals, but at least resulted in organizational and structural improvements in hygiene.     

Evaluation of current practices in surgical antimicrobial prophylaxis in primary total hip prosthesis--a multicentre survey in private and public French hospitals

Deep wound infection is a rare but dreaded postoperative complication after total hip prosthesis (THP) procedures but its incidence can be reduced by systemic antimicrobial prophylaxis. The objective of the present study was to evaluate whether antimicrobial prophylaxis for elective primary THP in patients without any history of hip infection, in orthopaedic wards, participating on a voluntary basis, in French public hospitals and private institutions, complies with published guidelines. Three types of data were collected from anaesthetic and surgical records (November 2000-January 2001) in participating hospitals: (1) administrative data on the hospitals and orthopaedic wards, (2) data on patients, (3) data on compliance of practices with five critical criteria derived from published French guidelines. These criteria concerned administration of prophylaxis, choice of antimicrobial agent, dose of first injection, timing of administration and total length of prophylaxis. Thirty institutions sent data files on 1257 THPs to the coordination centre. Compliance exceeded 80% for all criteria except one (interval between first and second injection). Cumulative compliance with the five criteria was 66.9%. Major compliance failures were an inappropriate interval between the first injection and incision, and total antimicrobial prophylaxis exceeding 48 h. Cumulative compliance was 87.9% in teaching hospitals, 61.8% in general hospitals and 67.7% in private institutions (P<1 x 10(-6)). It was slightly higher when the annual number of interventions was > or =100 (69.4 versus 62.3%; P<0.02). Although the protocol for antimicrobial prophylaxis in THP was clear and easy, one-third of practices did not conform with all five standards. Knowledge of the results by the participating institutions should encourage them to set up working groups to draft care protocols for THP and other surgical interventions, in order to improve practice and perhaps reduce costs.     

Reprocessing and reuse of single-use medical devices: a national survey of Canadian acute-care hospitals.

A national survey investigated the current practices of reprocessing and reusing single-use medical devices in Canadian acute-care hospitals. Our response rate was 72% (413 responses), and 28% of hospitals reprocess single-use devices. The results showed that Canadian hospital practices have not changed much in the past decade.     

Hospital ownership and efficiency: a review of studies with particular focus on Germany

The German hospital market has been subject over the past two decades to a variety of healthcare reforms. Particularly the introduction of diagnosis-related groups (DRGs) in 2004 aimed to increase efficiency of hospitals. The objective of the paper is to review recent studies comparing the efficiency of German public, private non-profit and private for-profit hospitals. The results of the studies are quite mixed. However, in line with the evidence found in studies from other countries, especially the US, the evidence from Germany suggests that private ownership (i.e., private non-profit and private for-profit) is not necessarily associated with higher efficiency compared to public ownership. This may be a surprising result to many policy makers as private for-profit hospitals are often perceived the most efficient ownership type by the public.     

Impact of the "Guidelines for infection prevention in dentistry" (2006) by the Commission of Hospital Hygiene and Infection Prevention at the Robert Koch-Institute (KRINKO) on hygiene management in dental practices - analysis of a survey from 2009

Aim: To assess trends in hygiene management in dental practices in comparison to an earlier survey in 2002/2003 and to point out key aspects for future efforts. Method: The infection prevention management of all dental practices in Greifswald (n=35) was determined by a questionnaire in a personal interview in 2008/2009.Results: 26% of the dentists did not use sufficient personal protective equipment during the general examination of the patient. In conservative and prosthetic dentistry, 15% still did not use adequate measures and 9% did not even in surgical interventions. Vaccination coverage was clearly too low, as only 35% of dentists were vaccinated against influenza and coverage with other vaccinations was also quite low. 11% of the dentists did not perform a documented anamnesis and in 29% of the dental practices no appointment system for risk patients existed.There were significant deficiencies in the reprocessing of medical devices and in the equipment needed for reprocessing. The opportunity to participate in further training in this field was rejected by 23% of the dentists.In 10 dental practices, the colony count in the dental unit water-conducting system was five times higher than the limit. A contamination with P. aeruginosa was discovered in 4 practices. All units were renovated.Discussion: Overall, both the hygiene management and hygiene equipment in the practices have improved considerably compared to the previous survey in 2002/2003. This demonstrates the positive effect of the KRINKO guidelines from 2006. However, the survey again showed relevant deficiences in the hygiene management of dental practices, which agrees with a Germany-wide online survey from 2009.Conclusion: While the study revealed persistent deficiencies in hygiene management, especially in reprocessing, it confirms that the KRINKO guidelines for dental practices from 2006 led to significant improvements in hygiene management. Doubts about the impact of the guidelines are not backed by evidence.     

Cost and technical efficiency of German hospitals: does ownership matter?

This paper is the first to investigate both the technical and cost efficiency of more than 1500 German general hospitals. More specifically, it deals with the question how hospital efficiency varies with ownership, patient structure, and other exogenous factors, which are neither inputs to nor outputs of the production process. The empirical results for the years from 2001 to 2003 indicate that private and non-profit hospitals are on average less cost efficient and less technically efficient than publicly owned hospitals. The hospital rankings based on estimated efficiency scores turn out to be negatively correlated with average length of stay, which is highest in private hospitals. The results are derived by conducting a Stochastic Frontier Analysis assuming both Cobb-Douglas and translog production technologies and using a newly available and multifaceted administrative German data set.     

医院所有制与效率：以德国为关注重点的研究回顾

德国医院市场在过去20年里进行了一揽子医疗改革,特别是在2004年引进了疾病诊断相关分组——以期提高医院效率。本文旨在回顾近期就比较德国公立医院、私立非营利医院和私立营利医院效率所开展的研究。尽管研究结果错综复杂,但结合其他国家,特别是美国的研究证据,德国方面的研究结果表明:与公立医院相比,私立医院(私立非营利和私立营利医院)的运营效率并不一定就高。由于私立营利医院通常都会被认为是最有效率的所有制形式,因此本研究结果对很多决策者来说也许有些意外。     

Endoscope decontamination incidents in England 2003-2004

An Endoscope Task Force was established following the report of an endoscope decontamination failure in May 2004. The Task Force reviewed endoscope decontamination incidents in England from 2003 to 2004 and made recommendations to prevent further recurrences. Twenty-one incidents were reported from 19 National Health Service (NHS) Trusts, 18 of which matched the Task Force definition of an incident. Eight incidents involved failures to decontaminate auxiliary endoscope channels, seven incidents highlighted problems with automated endoscope reprocessors, and the remaining three involved disinfection practices not recommended by the British Society of Gastroenterology Guidelines. Following an assessment of the risk of transmission from blood-borne viruses, the Task Force recommended that look-back exercises were not indicated. The nature of the incidents suggested that there were problems associated with defining roles and responsibilities for endoscope decontamination, staff training and incompatibility between endoscopes and reprocessors. The Medicines and Healthcare Products Regulatory Agency subsequently issued recommendations to all NHS Trusts carrying out endoscopies.     

MRSA in Blutkulturen in Frankfurter Krankenh?usern 2010

Since 1?July?2009 in accordance with the statuary order based on the German law for infectious diseases (Infektionsschutzgesetz), MRSA in blood and liquor must be notified to the public health authorities. The aim of extension of the notification to report is to improve the surveillance of nosocomial infections and the prevention of nosocomial MRSA infections. In addition to MRSA detection, data on symptoms and risk factors, e.g., medical devices, must also be reported. In this report, data of bloodstream MRSA infections in hospitals in Frankfurt/Main, Germany, for the first complete year (2010)were evaluated. In 2010, 58 MRSA-positive bloodstream infections were reported by the 17 hospitals in Frankfurt to the health protection authorities, i.e., 0.0360 MRSA/1,000 patient?Cdays (range: 0?C 0.109/1,000 patient?Cdays). However, 10 of these infections initially had not been reported to the public health department in charge for the hospitals, but to the health departments according to the patient??s addresses. Although most of the infections were reported from large hospitals (>100,000 patient?Cdays/year), the highest incidences (0.0416/1,000 patient?Cdays) were reported from small hospitals (<50,000 patient?Cdays/year). Of the blood specimen, 13 (22.4%) were drawn on the first day of hospital stay, thus, indicating an imported infection. While 90% of the patients with MRSA in the bloodstream suffered from fever, 80% had sepsis and 34.5% suffered from pneumonia. Medical devices, such as central venous catheters and PEG, were reported from 60% of the patients. In the MRE network Rhine?CMain region, the public health authorities asked for some more detailed information, such as risk factors for MRSA colonization (history for MRSA, recent hospital stay or antibiotic therapy, skin disorders, dialysis, residence in a retirements home), and for screening results as well as for the MRSA management, i.e., isolation of the patient and, if necessary, the contact patient. In 55% of the cases, the patients were identified by the clinics themselves as being patients with MRSA risk factors, mainly because of a history of MRSA (29%), recent hospital stay (71%), and antibiotic therapy during the last 6 months (52%). Screening was performed in 31 (53%) of the patients, most of them (71%) with positive MRSA nose swab. If the patients were screened, significantly fewer contact patients had to be screened and isolated later. Thus, to improve surveillance data on MRSA bloodstream infections, the notification route to the public health authorities responsible for the clinic hosting the patient must be strictly obeyed in order to avoid underreporting und underassessment of nosocomial infection. Although asking for clinical symptoms may be useful to validate the result in some cases, focus should be placed on risk factors and risk management, including screening and isolation. Only then can the aim of improving surveillance and reduction of nosocomial MRSA infection be achieved.     

MRSA bloodstream infections in hospitals in Frankfurt/Main, Germany, 2010 : Results of the mandatory notification and suggestions for improvement

Since 1?July?2009 in accordance with the statuary order based on the German law for infectious diseases (Infektionsschutzgesetz), MRSA in blood and liquor must be notified to the public health authorities. The aim of extension of the notification to report is to improve the surveillance of nosocomial infections and the prevention of nosocomial MRSA infections. In addition to MRSA detection, data on symptoms and risk factors, e.g., medical devices, must also be reported. In this report, data of bloodstream MRSA infections in hospitals in Frankfurt/Main, Germany, for the first complete year (2010)were evaluated. In 2010, 58 MRSA-positive bloodstream infections were reported by the 17 hospitals in Frankfurt to the health protection authorities, i.e., 0.0360 MRSA/1,000 patient-days (range: 0- 0.109/1,000 patient-days). However, 10 of these infections initially had not been reported to the public health department in charge for the hospitals, but to the health departments according to the patient's addresses. Although most of the infections were reported from large hospitals (>100,000 patient-days/year), the highest incidences (0.0416/1,000 patient-days) were reported from small hospitals (<50,000 patient-days/year). Of the blood specimen, 13 (22.4%) were drawn on the first day of hospital stay, thus, indicating an imported infection. While 90% of the patients with MRSA in the bloodstream suffered from fever, 80% had sepsis and 34.5% suffered from pneumonia. Medical devices, such as central venous catheters and PEG, were reported from 60% of the patients. In the MRE network Rhine-Main region, the public health authorities asked for some more detailed information, such as risk factors for MRSA colonization (history for MRSA, recent hospital stay or antibiotic therapy, skin disorders, dialysis, residence in a retirements home), and for screening results as well as for the MRSA management, i.e., isolation of the patient and, if necessary, the contact patient. In 55% of the cases, the patients were identified by the clinics themselves as being patients with MRSA risk factors, mainly because of a history of MRSA (29%), recent hospital stay (71%), and antibiotic therapy during the last 6 months (52%). Screening was performed in 31 (53%) of the patients, most of them (71%) with positive MRSA nose swab. If the patients were screened, significantly fewer contact patients had to be screened and isolated later. Thus, to improve surveillance data on MRSA bloodstream infections, the notification route to the public health authorities responsible for the clinic hosting the patient must be strictly obeyed in order to avoid underreporting und underassessment of nosocomial infection. Although asking for clinical symptoms may be useful to validate the result in some cases, focus should be placed on risk factors and risk management, including screening and isolation. Only then can the aim of improving surveillance and reduction of nosocomial MRSA infection be achieved.     

Hygiene und Infektionsprävention in Zahnarztpraxen

Recommendations for prevention of infection in dentistry have been published in many countries and in Germany as well. In a pilot project in collaboration with the Public Health Service of the City of Frankfurt and the chamber of dentists in Hesse, compliance with these recommendations was studied in dental practices in Frankfurt/M in 2005. After being informed about the recommendations, more than 50% of the 560 Frankfurt dentists agreed to participate in this project, and 127 of these practitioners were visited by experts of the dentist chamber. Hygienic standards in the practices were examined using a checklist. A proper hygiene schedule was observed in 84% of the practices. Facilities for hand hygiene such as dispensers for soap, disinfectant and towels were available in 98, 93 and 92% of the practices, and personal protective equipment such as gloves, masks, eye wear and gowns was found in 98, 100, 98 and 88% of the practices, respectively. Reprocessing of dental instruments was done either manually (52%), manually in combination with ultrasonic cleaning (48%) or by using special reprocessing machines (32%). Steam sterilization was used in all practices; in some practices gravity displacement sterilizers were used (14%), whereas in most of the practices (61%) a high-speed prevacuum sterilizer was available -- especially in dental surgeon practices (77%). Monitoring and documentation of the sterilization process was done automatically (33%) or by hand (55%). In 80% of the practices, pressure, temperature, time and person responsible were documented. Documents of routine maintenance and regular biological testing of the sterilizers could be shown in 93 and 84% of the practices. The Frankfurt pilot project based on information and advice in combination with control has proven to be successful in the majority of practices enrolled. Encouraged by this experience, the chamber of dentists wants to implement this project all over the state of Hesse. The intention is to inform and to visit all 4,500 dental practices in agreement with the local public health services, which in turn could reduce their own control visits in dental practices. Thus, hygiene control visits of the public health services could focus on other practices such as ambulatory surgery or endoscopy.     

常州市医疗机构内镜清洗消毒质量调查

目的了解常州市医院中内镜消毒现状,提高内镜消毒质量,为有效控制院内感染提供科学依据。方法根据《内镜清洗消毒技术操作规范》(2004年版)和《消毒技术规范》(2002年版)要求,对医院内镜及其相关用品的消毒质量进行调查。结果 37家不同级别医院共检测内镜及其相关用品527份,总合格率为74.9%,市级医院消毒质量结果好于县级医院,县级医院好于乡镇医院。内镜检测合格率为69.7%,清洗消毒槽内表面检测合格率为66.9%,消毒剂有效成分含量合格率为75.7%。结论常州市内镜清洗消毒质量有待进一步提高,应加强内镜消毒质量管理,规范操作过程,加大内镜消毒工作的指导和监控力度。     

Quality of birth care in maternity hospitals of Rio de Janeiro, Brazil

OBJECTIVE: To evaluate the quality of birth care based on the World Health Organization guidelines. METHODS: A case-control study was carried out in a public and a private maternity hospitals contracted by the Brazilian Health System in the city of Rio de Janeiro, Brazil, from October 1998 to March 1999. The sample comprised 461 women in the public maternity hospital (230 vaginal deliveries and 231 Cesarean sections) and 448 women in the private one (224 vaginal deliveries and 224 Cesarean sections). Data was collected through interviews with puerperal women and review of medical records. A summarization score of quality of delivery care was constructed. RESULTS: There was low frequency of practices that should be encouraged, such as having an accompanying person (1% in the private hospital for both vaginal delivery and C-sections), freedom of movements throughout labor (9.6% of C-sections in the public hospital and 9.9% of vaginal deliveries in the private hospital) and breastfeeding in the delivery room (6.9% of C-sections in the public hospital and 8.0% of C-sections in the private hospital). There was a high frequency of known harmful practices such as enema administration (38.4%); routine pubic shaving; routine intravenous infusion (88.8%); routine use of oxytocin (64.4%), strict bed rest throughout labor (90.1%) and routine supine position in labor (98.7%) in vaginal deliveries. The best summarizing scores were seen in the public maternity hospital. CONCLUSIONS: The two maternity hospitals have a high frequency of interventions during birth care. In spite of providing care to higher risk pregnant women, the public maternity hospital has a less interventionist profile than the private one. Procedures carried out on a routine basis should be pondered based on evidence of their benefits.     

On the efficiency of public, welfare and private hospitals in Germany over time: a sectoral data envelopment analysis study.

This paper examines the efficiency of the German hospital sector over time and the relative efficiency of public, welfare (both nonprofit) and private (for-profit) hospital sectors using data from the Federal Statistics Office of German hospitals. Efficiency scores were computed using data envelopment analysis. The absolute efficiency of the hospital sector as a whole was found to have improved between 1991 and 1996. In this comparison, the empirical results showed that the hospitals in the public and welfare sector are relatively more efficient than private hospitals. Our results suggest that public, welfare and private hospital sectors have different best-practice frontiers; and that public and welfare hospital sectors appear to use relatively fewer resources than private hospitals. These results suggest differences in quality of care arising from ownership.