Geographical variation in hospital admission rates: an analysis of workload in the Oxford region, England.

OBJECTIVE--To measure variation in hospital admission rates between health districts in part of the English NHS, comparing a wide range of medical and surgical conditions. DESIGN--Retrospective analysis of interdistrict variation using linked routine hospital admission data. Comparisons were also made with levels of variation reported from the USA. SETTING--Oxford Regional Health Authority, 1979-86. SUBJECTS--Six district health authorities--total study population 2.1 million people, 1.6 million hospital admissions. MAIN MEASURES--Age and sex standardised hospital admission rates for resident populations for individual operations and diagnoses; systematic components of variation (SCV). RESULTS--Of 118 standard operation groups, 38 (26% of surgical workload) showed high variation (SCV 16 or more) and 40 (36% of surgical workload) showed low variation (SCV < 4). Operations (SCV) with very low levels of variation included prostatectomy (0.1), inguinal herniorraphy (0.9), and cholecystectomy (1.3). Rates were more variable for myringotomy (3.7), hysterectomy (4.3), dilatation and curettage (5.6), and tonsillectomy (6.2). The SCV was high for only four of the 40 commonest medical causes of admission, and was low for 18 of them. CONCLUSIONS--Most admissions in the Oxford region were for conditions that did not show a great deal of variation in admission rates. The level of variation for many surgical procedures was less than that reported in studies from the USA. Variation was no greater for medical causes of admission than for surgical conditions. Large scale variation may not be an inevitable consequence of autonomous clinical practice.     

Capital intensive hospital technology and illness: an analysis of American state data

This paper: describes the development of a 'hospital technology index' to measure the level of capital intensive medical technology in each of the 50 U.S. states and the District of Columbia, reports differences between states in scores on this index, and tests the hypothesis that there is a low but significant negative correlation between the level of capital intensive medical technology and the level of illness. The three subscales of the hospital technology index have high alpha coefficients of reliability, are reasonably orthogonal, and there is at least some evidence of construct and discriminant validity for each. The multiple regression analysis suggests that there is either no relation between capital intensive medical technology and the rate of illness or that there is a slight tendency for the illness rate to increase as the level of technology increases. Eight possible explanations for the findings are discussed.     

Social class,ethnicity, and mental illness: the importance of being more than earnest.

This paper revisits a landmark study of the prevalence of mental illness in the state of Massachusetts conducted by Edward Jarvis in the 19th century. Jarvis drew an improper conclusion about the relationship between social class, ethnicity, and insanity, asserting that the Irish foreign-born had a higher prevalence of insanity in each social stratum. A reanalysis of Jarvis'' data shows that in both the pauper and independent social classes in Massachusetts, the prevalence of insanity was significantly lower among foreign-born persons than among native-born persons. On the basis of his misperception, Jarvis constructed elaborate etiological theories. These theories made a strong impact on the mental health service policies of his day. The effects of incomplete examination of data on etiological theories and mental health policy in current times are highlighted in this article.     

Social class, smoking and the severity of respiratory symptoms in the general population

STUDY OBJECTIVE: The prevalence of respiratory symptoms has been found in some studies to vary with social class. One explanation of this link may be the effect of exposure to cigarette smoke. To investigate this, the relation between social class, smoking and respiratory symptoms was explored in a population based survey. DESIGN: A cross sectional survey using a validated questionnaire. SETTING: Two general practices in Staffordshire, United Kingdom. PATIENTS: A random sample of 4237 patients aged 16 and over from two general practices in Staffordshire were mailed a questionnaire enquiring about respiratory symptoms and their severity. MAIN RESULTS: The severity of respiratory symptoms increased with increasing exposure to cigarette smoke and was greater among manual social classes. Current smokers (odds ratio (OR) = 2.9, 95% confidence limits (CI) 2.3, 3.6), past smokers (OR = 1.5, 95% CI 1.2, 1.8) and passive smokers (OR = 1.4, 95% CI 1.0, 1.8) were more likely to report the more severe respiratory symptoms compared with non-smokers. Responders from social class V (OR = 2.4, 95% CI 1.3, 4. 4) were more likely to report the more severe respiratory symptoms compared with social class I, as were responders from social classes IIIM (OR = 1.3, 95% CI 0.9, 1.9) and IV (OR = 1.4, 95% CI 0.9, 2.1). These effects were independent of each other. CONCLUSIONS: This study has shown that social class is linked to the severity of respiratory symptoms, independently of smoking. Although the need to reduce and quit smoking in manual class households remains a crucial preventive issue, other mechanisms by which social class differences may influence symptom occurrence and severity need to be explored.     

Length of stay and imminent discharge probability distributions from multistage models: variation by diagnosis,severity of illness,and hospital

Multistage models have been effective at describing length of stay (LOS) distributions for diverse patient groups. Our study objective was to determine whether such models could be used for patient groups restricted by diagnosis, severity of illness, or hospital in order to facilitate comparisons conditioned on these factors. We performed a retrospective cohort study using data from 317,876 hospitalizations occurring over 2 years in 17 hospitals in a large, integrated health care delivery system. We estimated model parameters using data from the first year and validated them by comparing the predicted LOS distribution to the second year of data. We found that 3- and 4-stage models fit LOS data for either the entire hospital cohort or for subsets of patients with specific conditions (e.g. community-acquired pneumonia). Probability distributions were strongly influenced by the degree of physiologic derangement on admission, pre-existing comorbidities, or a summary mortality risk combining these with age, sex, and diagnosis. The distributions for groups with greater severity of illness were shifted slightly to the right, but even more notable was the increase in the dispersion, indicating the LOS is harder to predict with greater severity of illness. Multistage models facilitate computation of the hazard function, which shows the probability of imminent discharge given the elapsed LOS, and provide a unified method of fitting, summarizing, and studying the effects of factors affecting LOS distributions. Future work should not be restricted to expected LOS comparisons, but should incorporate examination of LOS probability distributions.     

Nutritional status on admission and hospital mortality of under-five year old children with infectious diseases in Ouagadougou,Burkina Faso

BACKGROUND: It is known that malnutrition in childhood interacting with infectious diseases contributes to increase mortality. In Burkina Faso, infectious pathologies and malnutrition are public health problems. We examined the impact of malnutrition status, using the Weight-for-age (WA) index, on mortality of children hospitalized for infectious diseases. METHODS: This retrospective study uses a systematic sample derived from the year 1999 hospital register. In total data of 1573 children from 0 to 59 months were analyzed. The association between mortality and dependent variables was measured by relative risks (RR) in univariate analysis. A logistic regression was realized and attributable risk percent (etiologic fraction among exposed) of death was calculated. RESULTS: The total intra-hospital lethality amounted to 15.3%. Age, diagnosis, type of care recourse and malnutrition (low WA index) on admission were associated to mortality. The logistic regression model confirmed the high risks of deaths for young children (0-11m), children in malnutrition (low WA index) and those with severe malaria. The attributable risk percent of death indicates that, 87% of deaths are statically attributable to severe malnutrition (WA Z-score<=-3) and 64.3% of deaths are statically attributable to moderate malnutrition (WA Z-score]-3, -2]). CONCLUSION: Nutritional status evaluation would allow to select children at risk and reduce mortality by including nutritional intervention in standard treatment of children hospitalized for infectious diseases.     

The impact of migration in all-cause mortality: the Turin Longitudinal Study, 1971-2005

North-western Italy has a long history of domestic influx, however little is known on how migrant mortality compares to mortality at the local level. While geographic mortality gradients may play a role, conceptualizations developed for international migration may also be relevant. Using this theoretical framework, the study investigated immigrant-native differentials in the north-western city of Turin through a 34-year follow-up that was facilitated by the Turin Longitudinal Study. The study population comprised inhabitants of age 30-74 years at the 1971 census. Survival trajectories were modelled through the Gompertz distribution and were examined for nativity status, birthplace, length of stay and age at arrival (the last two variables were combined). All estimates were adjusted for socio-economic factors. Overall, the risk of dying for internal migrants was lower, compared to locals, and consistent with geographic gradients. However, this pattern hid significant differences mediated by both age at arrival and length of stay. The advantage appeared to be exclusive to young and adult migrants, despite differentials narrowing over time. Immigrants who arrived after age 44 suffered instead a progressively greater excess risk, compared to natives, as residence increased. The dissipation of the health advantage found in internal migrants, along with poor health outcomes amongst people older at arrival, raises concern about immigrants from developing countries who need to endure a more demanding journey and adjustment to the new environment. The study indicated, through lengthy longitudinal data, that immigrant-native differentials were best explained by the stratified variable 'length of stay by age at arrival' and this should inform future studies.     

Cause-specific hospital admission and mortality among working men: association with socioeconomic circumstances in childhood and adult life, and the mediating role of daily stress

BACKGROUND: The aim of this study was to investigate the association of childhood and adulthood social class with the occurrence of specific diseases, including those not associated with a high mortality rate, and to investigate daily stress as the mechanism for that part of any association which cannot be accounted for by established risk factors. METHODS: This was a prospective cohort study with 25 years of follow-up for cause-specific morbidity and mortality. A total of 5577 Scottish men were recruited from 27 workplaces in the West of Scotland. Childhood social class was determined from the occupation held by the individual's father, and adulthood social class from the individual's occupation at enrolment. Daily stress was measured at enrolment using the Reeder Stress Inventory. RESULTS: Health differentials were found for cardiovascular diseases, lung cancer, peptic ulcer, asthma, accidents and violence, alcohol-related diseases, and perhaps psychiatric illness. Adulthood circumstances were associated with the incidence of most diseases in adulthood, the exception being stroke, which was strongly associated with less privileged circumstances in childhood. Both childhood and adulthood circumstances contributed to the incidence of coronary heart disease. Daily stress did not underlie any of these associations once the influence of established risk factors had been taken into account. CONCLUSIONS: Socioeconomic circumstances in childhood and adulthood both contribute to health differentials in adulthood, the relative contributions depending upon the particular disease. Where known risk factors explained only part of the excess of a disease among individuals raised or living in less-privileged circumstances, there was no evidence to suggest that daily stress was the reason for the unexplained excess.     

Excess child mortality after discharge from hospital in Kilifi, Kenya: a retrospective cohort analysis

Objective

To explore excess paediatric mortality after discharge from Kilifi District Hospital, Kenya, and its duration and risk factors.

Methods

Hospital and demographic data were used to describe post-discharge mortality and survival probability in children aged < 15 years, by age group and clinical syndrome. Cox regression models were developed to identify risk factors.

Findings

In 2004–2008, approximately 111 000 children were followed for 555 000 person–years. We analysed 14 971 discharges and 535 deaths occurring within 365 days of discharge. Mortality was higher in the post-discharge cohort than in the community cohort (age-adjusted rate ratio, RR: 7.7; 95% confidence interval, CI: 6.6–8.9) and declined little over time. An increased post-discharge mortality hazard was found in children aged < 5 years with the following: weight-for-age Z score < −4 (hazard ratio, HR: 6.5); weight-for-age Z score > −4 but < −3 (HR: 3.4); hypoxia (HR: 2.3); bacteraemia (HR: 1.8); hepatomegaly (HR: 2.3); jaundice (HR: 1.8); hospital stay > 13 days (HR: 1.8). Older age was protective (reference < 1 month): 6–23 months, HR: 0.8; 2–4 years, HR: 0.6. Children with at least one risk factor accounted for 545 (33%) of the 1655 annual discharges and for 39 (47%) of the 83 discharge-associated deaths.

Conclusion

Hospital admission selects vulnerable children with a sustained increased risk of dying. The risk factors identified provide an empiric basis for effective outpatient follow-up.     

Occupational risk factors for mortality from stomach and lung cancer among rubber workers: an analysis using internal controls and refined exposure assessment

OBJECTIVES: To determine occupational risk factors for stomach and lung cancer among workers in the German rubber industry. METHODS: A cohort of all male German rubber workers (n = 11,633) who had been employed for at least one year in one of five study plants and who were alive and actively employed or retired on 1 January 1981 was followed for mortality from 1 January 1981 through December 1991. A subcohort of n = 8,933 workers who were hired after 1 January 1950 was defined to focus on working conditions in the more recent rubber industry. Work histories were reconstructed using routinely documented 'cost centre codes' and classified into six work areas as well as subgroups of some work areas. The work areas are: 1. preparation of materials, 2. production of technical rubber goods, 3. production of tyres, 4. storage and dispatch, 5. maintenance, 6. others. Standardized mortality ratios (SMR) and Cox proportional hazards models were calculated for each of the work areas (>1 year of employment in the respective work area). Hazard rate ratios were adjusted for age (time marker) and stratified for year of hire (1950-1959, > or =1960) and years of employment in the respective work area (1-9 years, > or =10 years); years of employment were lagged 10 years to account for latency. RESULTS: Compared to the national reference population mortality from cancer of stomach (observed 44, SMR = 117; 95% CI: 85-157) and lung (observed 154, SMR = 123; 95% CI: 104-144) was slightly increased. Using internal controls we observed excess deaths from stomach cancer in work area 1 (relative risk [RR] = 2.3; 95% CI: 1.2-4.2) and from lung cancer in work areas 1 (RR = 1.7; 95% CI: 1.2-2.3), 2 (RR = 1.5; 95% CI: 1.1-2.1), and 3 (RR = 1.3; 95% CI: 0.9-1.8). On the basis of cumulative years of employment an exposure response relationship was observed for mortality from both cancer sites among a subcategory of work area 1: weighing and mixing. Increased risks were also seen for lung cancer among workers employed in production of technical rubber goods. CONCLUSION: Our results support an association between an excess mortality from stomach and lung cancer and employment in early production stages of rubber manufacturing, especially weighing and mixing. This may point to an aetiologic role of asbestos or carbon black. For stomach cancer additional risk factors, e.g. exposure to dust and talc, deserve further investigation. The results of the present study do not support a causal role of nitrosamines for stomach or lung cancer.     

Measuring the impact of influenza on the hospital admission rates of the elderly in Ontario: a five-year admission rate analysis, 1988-1993

OBJECTIVE: A retrospective study was conducted to compare age- and sex-specific rates of hospital admission of the elderly in Ontario for five influenza seasons from 1988-1993 for pneumonia, congestive heart failure and chronic respiratory disease. RESULTS: Significant increases in admissions were found for pneumonia in each influenza season for both sexes. Admissions were significantly increased for congestive heart failure for the oldest males in all years; and for four of five years for the youngest two age groups of males. For females significant increases in admissions occurred in the oldest two age groups in each influenza season; and for three of five seasons for the youngest age group. For chronic respiratory disease, significant increases in admissions were found for each influenza season for all years for the two youngest age groups of males and females. CONCLUSION: The impact of influenza is substantial in terms of morbidity in the elderly.     

The role of expectations in patient assessments of hospital care: an example from a university hospital network, Turkey

PURPOSE: The aim of this paper is to document a study, in which the SERVQUAL scale was used to evaluate hospital services, conducting a preliminary assessment of patient attitudes regarding the important aspects of service dimensions. DESIGN/METHODOLOGY/APPROACH: The SERVQUAL scale was implemented into routine use at the Baskent University Hospitals Network in Baskent, Turkey. The study consisted of 550 randomly chosen patients who presented to any member hospital in that network during January and February 2006 and received treatment as inpatients or outpatients at those healthcare facilities. The SERVQUAL scale was utilised to evaluate hospital services. FINDINGS: A questionnaire was completed by a total of 472 (86.0 per cent) patients. The perceived scores of the patients were higher than expected for an ordinary hospital but lower than expected for a high-quality hospital. The highest difference between the perceived service score and the expected service score was found at the Alanya Application and Research Center in Alanya, Turkey. ORIGINALITY/VALUE: The paper demonstrates the use of the SERVQUAL scale in measuring the functional quality of the hospitals assessed.     

Consolidations and closures: an empirical analysis of exits from the hospital industry

This paper investigates the pre-exit characteristics of hospital mergers, acquisitions, and closures. We estimate competing risk hazard models using an 18-year national data set that spans the wave of closures in the 1980s and of mergers in the 1990s. Evidence shows that weak productivity of the hospital is a strong determinant for closures while competitive pressures are more influential in the decision to consolidate. Thus, increased market power, relative to cost reductions, appears to play a larger role in the merger decision. Our results also provide insight into possible correlations between mergers and closures.     

Household-acquisition of measles and illness severity in an urban community in the United States.

Studies from developing countries suggest that persons with household-acquired (HA) measles are at greater risk of severe illness than persons with community-acquired (CA) infection. Reported measles cases occurring among Milwaukee residents from May 1989 to June 1990 were used to assess whether household-acquisition was a risk factor for severe measles in the United States. A case was classified as HA if onset of rash occurred 7-18 days after onset of rash in another case in the same household. Hospitalization rates were similar for 128 patients with HA measles (27%) and for 1004 patients with CA measles (26%). Multiple logistic regression was used to evaluate the association between hospitalization and household-acquisition after controlling for socioeconomic status, measles vaccination history, age, race, and date of onset of rash. Patients with HA measles were no more likely to be hospitalized than patients with CA measles (odds ratio 0.9, 95% confidence interval 0.6, 1.5). HA measles cases were not more severe than CA measles cases during this urban outbreak in the United States.     

An analysis of the link between behavioural, biological and social risk factors and subsequent hospital admission in Scotland

OBJECTIVE: To determine the association between risk factors and hospital admission. METHODS: The 1998 Scottish Health Survey was linked to the Scottish hospital admission database. FINDINGS: Smoking was the most important behavioural risk factor (hazard ratio: 1.90, 95% CI: 1.59-2.27). Other behavioural risk factors yielded small but largely anticipated results. Hazard ratios for biological risks increased predictably but with some exceptions (blood pressure and total cholesterol). The top quintile for C-reactive protein showed almost double the risk of admission compared with the bottom quintile (hazard ratio: 1.93, 95% CI: 1.52-2.46). Elevated body mass index (BMI) increased the risk of serious admission (hazard ratio: 1.23, 95% CI: 1.03-1.47) and raised gamma-GT increased this risk by 20% (hazard ratio: 1.20, 95% CI: 1.04-1.38). Forced expiratory volume was the 'biological' factor with the largest risk (hazard ratio for lowest category: 1.82, 95% CI: 1.49-2.22). All the measures of social position showed variable effects on the risk of hospital admission. Large effects on risk were associated with self assessed health, longstanding illness and previous admission. CONCLUSION: The linkage of national surveys with a prospective hospitalization database will develop into an increasingly powerful tool.