Variability in GPs' referral rates in Spain

The purpose of this study is to explore the causes that mayinfluence the variations on referral rates in a sample of 242general practitioners (GPs) in Spain. We applied Poisson multivariant regression modeling to analyzethe role played by different variables related to doctors, patientsand practices. The mean referral rate was 6.92±0.22 with a variant coefficientof 50.6%. The results of the Poisson model showed a statisticallysignificant variation on the following variables: 1) doctorgender; 2) proportion of consultations to the practice madeby male patients; 3) proportion of consultations made by patientsover 65 years of age; 4) list size, 5) number of doctors inthe PCT; 6) number of practice consultations to each doctorper week; 7) accredited practice for VT; 8) location of practice;9) proportion of outpatient referrals; 10) proportion of privatereferrals; 11) proportion of emergency referrals; 12) proportionof referrals in which the patient's attitude did not influencethe doctor for the referral; 13) proportion of new referrals. The statistical significance for the final model was very high(P < 0.00001). The study draws attention to the influence of some structuralcharacteristics of health care system on the referral ratesthat could be modified to reduce the number of referrals fromPrimary to Secondary Care.     

Use of hospital mortality rates following myocardial revascularization surgery to monitor hospital care

Brazilian hospitals performing coronary artery by-pass graft surgery (CABG) from 1996 to 1998 and covered by the Ministry of Health were ranked according to their risk-adjusted hospital mortality rates. Seventy-six hospitals that performed more than 150 CABGs (total of 38,962 surgical interventions) were classified as low or high outliers according to the ratio between observed and expected hospital mortality rates. Overall hospital mortality rate was 7.20%. The rate was 3.48% among patients treated in the low outliers and 13.96% among the high outliers. The methodology was useful for discriminating Brazilian hospitals according to their post-CABG mortality rates and may be a useful tool for identifying hospitals with possible quality-of-care problems.     

In-hospital mortality after stomach cancer surgery in Spain and relationship with hospital volume of interventions

Background  

There is no consensus about the possible relation between in-hospital mortality in surgery for gastric cancer and the hospital annual volume of interventions. The objectives were to identify factors associated to greater in-hospital mortality for surgery in gastric cancer and to analyze the possible independent relation between hospital annual volume and in-hospital mortality.     

Nutritional aspects of colorectal cancer surgery care in a district general hospital

Background: Nutritional screening and support as well as early re‐introduction of enteral feeding can enhance recovery in colorectal surgical patients (Fearon & Luff, 2003; Fearon et al., 2005). Recent advances in multi‐modal surgical care have highlighted many changes that are required in practice compared to traditional approaches. The aim of this study was to compare the current nutritional practice for colorectal cancer patients undergoing elective surgery at Queen Mary's Hospital Sidcup against current evidence‐based recommendations (Fearon et al., 2005; Arends et al., 2006). Methods: Surgical and nursing notes of patients that underwent elective procedures for colorectal malignancy in 2006 were examined. Data collected included information regarding preoperative nutritional screening and anthropometrics, the use of preoperative fasting and carbohydrate loading, use of nasogastric tubes and the time to re‐introduction of oral diet and fluids. Results: Thirty‐three patients underwent elective surgery for colorectal cancer in 2006. Less than half of patients (37.2%) did not receive any form of preoperative nutritional assessment. No patients received carbohydrate loading; 93.9% were fasted for >6 h prior to surgery for liquids and solids. Post‐operatively (PO); clear fluids were commenced at a mean (SD) of 1.6 (1.1) days, free fluids at 2.7 (1.4) days PO, and diet at 3.9 (1.8) days PO. 90.9% of patients received nasogastric tube intubation; mean (SD) removal time was 4.0 (4.0) days PO.

Supply-induced demand for hospital care.

Preliminary analysis of hospital utilization data indicates that Roemer's Law may still be operative in rural Iowa: counties with more hospital beds per capita have more hospital utilization per capita. However, when patient origin data are analyzed findings are entirely different. Bed supply is not related to utilization rates in Iowa counties. Instead, the number of unique hospital services is associated with higher utilization rates. The impact of this characteristic of hospital supply, however, is much weaker than the original Roemer effect. The contradiction of these findings with Roemer's Law is apparently a result of a methods effect: use of hospital utilization data which are not derived from actual population experience reveals a relationship which is a statistical artifact. The data also reveal that suburban counties have higher utilization rates than either rural or urban (MSA core) counties.     

Perceived quality of hospital care.

Physicians, nurses, and consumers in the New York City area were asked to indicate which of 76 acute-care hospitals they would be willing to be patients in if they became seriously ill. Percentages of favorable judgments ranged from a high of 95% for one university hospital to a low of less than 10% for a community hospital. Over half of all responding physicians, nurses, and consumers indicated that they would not wish to be a patient in the majority of the 76 hospitals sampled. Although a high degree of consistency (r = .93) was observed among all three types of respondents, physicians were on the average significantly more pessimistic (X percentage of favorable judgments = 34) than nurses and consumers. All three groups indicated a statistically significant (p less than .001) preference for larger hospitals as well as institutions that were affiliated with a medical school in some way.     

Underutilization of acute care settings in a tertiary care hospital.

OBJECTIVE: To estimate underutilization of acute care settings in a tertiary care hospital. DESIGN: A retrospective and concurrent cohort study using chart reviews and the Intensity of service, Severity of illness, Discharge screen for Acute Care (ISD-AC(R)) tool to measure appropriateness of acute care for patients who were receiving care in a less acute setting, as an indicator of underutilization. SETTING: A 450-bed tertiary care teaching hospital. STUDY PARTICIPANTS: Patients discharged from the emergency department, patients discharged from acute care inpatient units and patients in acute, non-critical care settings. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The percentage of patients discharged from the emergency department who did not meet the criteria for acute care discharge screens; the percentage of patients discharged from an acute care inpatient unit who did not meet the criteria for discharge screens; and the percentage of patients who were in acute, non-critical care beds and who met the criteria for critical care. RESULTS: It was found that six out of 168 patients [3.57%; 95% confidence interval (CI), 1.32-7.61%] did not meet the discharge screens at the time of discharge from the emergency department. Four out of 156 patients (2.56%; 95% CI, 0.70-6.43%) did not meet the discharge screens at the time of discharge from an acute care inpatient service and two out of 156 acute care patients (1.33%; 95% CI, 0.02-4.73%) who were in non-critical care beds met the criteria for critical care. CONCLUSION: These findings of underutilization may help to quantitate an unmet need in health care.     

Uncompensated care and hospital conversions in Florida.

Hospital conversions to for-profit ownership have prompted concern about continuing access to care for the poor or uninsured. This DataWatch presents an analysis of the rate of uncompensated care provided by Florida hospitals before and after converting to for-profit ownership. Uncompensated care declined greatly in the converting public hospitals, which had a significant commitment to uncompensated care before conversion. Among converting nonprofit hospitals, uncompensated care levels were low before conversion and did not change following conversion. The study suggests that policymakers should assess the risk entailed in a conversion by considering the hospital's historic mission and its current role in the community.     

Evaluation of a health care programme with nursing tutor in a hospital traumatological facility in a hospital, Granada, Spain, 2004

BACKGROUND: The current trend in patient care is towards a more humanized and higher-quality healthcare. The objective of the present study was to evaluate the results of implementing a programme of healthcare with a reference nurse who welcomes the patient at hospital admission, visits regularly during hospital stay, and resolves doubts and problems. METHODS: Quasi-experimental study (149 cases and 454 non-tutored controls) in patients admitted for scheduled trauma surgery at the Virgen de las Nieves University Hospital, Granada. Sociodemographic and clinical data were gathered at admission. At 15 days after discharge, patients were administered with an interviewer-administered Zung score and an ad hoc questionnaire on satisfaction with different healthcare aspects during hospital stay and understanding of information received. Bivariate analyses and linear and multivariate logistic regression analyses were performed with a study of confounding variables. RESULTS: For the outcome variable anxiety level non-tutored patients had a B coefficient of 2.64 (p<0,01) in the multivariate linear regression analysis controlling for the other variables in the final model: sex, presence of informal career, professional activity, days of hospital stay and understanding of health information. For the outcome variable inadequate understanding information non-tutored patients showed an odds ratio of 3.48 in the multivariate analysis controlling for educational level and presence of informal career. Satisfaction with he friendliness of health care personnel and with the hospital setting did not significantly difference, although the percentage of dissatisfied patients was higher in the non-tutored group: 15% vs 11% (p= 0.34) and 18% vs 12 % (p= 0.11) respectively. CONCLUSIONS: The implemented continued care programme proved effective for these patients, increasing their understanding of information received and reducing anxiety levels.     

Trends in hospital care

This paper analyses trends in the delivery of hospital services in Brazil, considering the setting, the current situation and its challenges, examining what still remains to be done. The variables studied for the analysis of the setting are: demography, epidemiological profile, human resources, technology, medicalization, costs, review of the role of the citizen, legislation, equity, hospital-centricity and regionalization, care fractioning and bed availability. The Brazilian setting was studied through the supplementary healthcare model, financing and the healthcare area production chain. The observations of the current situation present external evaluation models, outsourcing, public-private relationships, de-hospitalization and financing. The analysis of the challenges examines the need for long range planning, the quest for new legal models for the 'business', the use of information and information systems, cost controls and the need for enhanced efficiency and compliance with legal directives, guaranteed universal access to full healthcare facilities, the inclusion of primary prevention in healthcare procedures, integrating the public and private sectors and engaging physicians in solving problems.     

Substituting emergency services: primary care vs. hospital care

Overcrowding in emergency departments (EDs) is inefficient, especially if it is caused by inappropriate visits for which primary care physicians could be equally effective as a hospital ED. Our paper investigates the extent to which both ambulatory ED visits and inpatient ED admissions are substitutes for primary care emergency services (PCES) in Germany. We use extensive longitudinal data and fixed effects models. Moreover, we add interaction terms to investigate the influence of various determinants on the strength of the substitution. Our results show significant substitution between PCES and ambulatory ED visits. Regarding the determinants, we find the largest substitution for younger patients. The more accessible the hospital ED is, the significantly larger the substitution. Moreover, substitution is larger among better-educated patients. For inpatient ED admission, we find significant substitution that is eight times smaller than the substitution for ambulatory ED visits. With regard to the determinants, we find the strongest substitution for non-urgent, short-stay admission and elderly patients. Countries with no gate-keeping system (such as Germany) have difficulties redirecting the patients streaming to EDs. Our estimated elasticities can help policy makers to resolve this issue, as our findings indicate where incentivizing the utilization of PCES is particularly effective.