Teaching status and resource use for patients with acute myocardial infarction: a new look at the indirect costs of graduate medical education.

To investigate whether the process of graduate medical education increases costs in teaching hospitals by causing longer lengths of stay and greater resource use, we compared lengths of stay, hospital charges, and the use of cardiovascular procedures for patients with acute myocardial infarction admitted to the teaching and nonteaching services of a university-affiliated community hospital. After adjusting for severity of illness and demographic characteristics, patients on the teaching services had a mean length of stay that was shorter by 0.6 days (p = 0.04) and mean charges that were $2,060 lower (p = 0.15) than for patients on the nonteaching service. Patients on the teaching service also had 15 percent (95% CI: -26, -4) fewer cardiac catheterizations and 9 percent (-18, 0) fewer procedures for myocardial revascularization (angioplasty or cardiac bypass surgery). These findings suggest that graduate medical education per se may not directly increase the use of health care resources and that the cost differences between teaching and nonteaching hospitals may be largely a consequence of other factors. These factors may include epiphenomena of teaching such as a specialized organizational structure, specialized patient care services, and continuing medical education for the nursing and medical staffs. They may also include factors not related to teaching such as differences in patients' severity of illness and sociodemographic characteristics.     

Closing the gap. Funding clinical medical education in Minnesota

In recent years, decreasing funding for graduate medical education (GME) from private payers, combined with increasing competition between teaching and nonteaching hospitals for managed care contracts and cuts in federal aid to teaching hospitals, have led to a worsening financial crisis for the nation's teaching facilities. For more than a decade, Minnesota's teaching hospitals have been dealing with the same issues, and recent articles have discussed the impact that declining funding and a market increasingly dominated by managed care have had on graduate medical education. Although there is agreement that teaching hospitals have higher costs for patient care than nonteaching hospitals, relatively little research has been done to determine the magnitude of the costs of GME or to isolate their components. Using data from the Minnesota Department of Health's Medical Education and Research Costs (MERC) Fund, the author analyzes the costs to teaching facilities of providing clinical training to resident physicians and students and examines the sources of funding that are available to offset these costs.     

Estimating the mission-related costs of teaching hospitals

Academic health centers and other teaching hospitals face higher patient care costs than nonteaching community hospitals face, because of their missions of graduate medical education (GME), biomedical research, and the maintenance of standby capacity for medically complex patients. We estimate that total mission-related costs were dollar 27 billion in 2002 for all teaching hospitals, with GME (including indirect and direct GME) and standby capacity accounting for roughly 60 and 35 percent of these costs, respectively. To assure their continued ability to perform important social missions in a competitive environment, it may be necessary to reassess the way in which these activities are financed.     

Teaching hospitals and quality of care: a review of the literature

Because teaching hospitals face increasing pressure to justify their higher charges for clinical care, the quality of care in teaching and nonteaching hospitals is an important policy question. The most rigorous peer-reviewed studies published between 1985 and 2001 that assessed quality of care by hospital-teaching status in the United States provide moderately strong evidence of better quality and lower risk-adjusted mortality in major teaching hospitals for elderly patients with common conditions such as acute myocardial infarction, congestive heart failure, and pneumonia. A few studies, however, found nursing care, pediatric intensive care, and some surgical outcomes to be better in nonteaching hospitals. Some factors related to teaching status, such as organizational culture, staffing, technology, and volume, may lead to higher-quality care.     

海南省乡镇卫生院卫生人力资源现状调查

目的了解海南省乡镇卫生院卫生人力资源现状,发现其存在的问题,并提出相应的建议和对策,为卫生行政部门制定卫生人力资源发展规划提供参考依据。方法采用分层整群抽样的方法收集到176所乡镇卫生院的4 262名卫生人员信息,对海南省乡镇卫生院卫生人力资源的性别、年龄、学历和职称构成进行描述。结果海南省176所乡镇卫生院卫生人员配置和专业结构较为合理,院均24.2人,医护比为1:0.87,医防比为1:0.292;年龄构成不合理,35~44岁年龄组仅占31.1%;学历水平较低,中专学历占64.3%;高级人才短缺,高级职称人员仅占2.3%。结论卫生主管部门应该重视农村卫生人力资源的重要性,科学合理地对卫生人力资源进行配置,重点应放在提高农村卫生人员整体素质,加强卫生人才队伍的建设上。     

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Policy Points

• In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long‐term survival of cancer patients following initial diagnosis. There is also evidence that short‐term (30‐day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower.
• Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed.
• Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care.

ContextThe relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a “must.” For traditional fee‐for‐service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy.MethodsComplementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy‐oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers.FindingsQuality of care as measured in process of care studies and in longitudinal studies of long‐term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range''s lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures.ConclusionsBased on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.     

广西基层妇幼保健院卫生技术人员流失情况分析

目的:分析广西基层妇幼保健院卫生技术人员流失情况,为新医改进程中妇幼保健机构的建设和发展提供参考依据。方法:采用分层随机抽样方法对广西28家县级妇幼保健院进行调查。结果:5年中广西县级妇幼保健院进入与流失人员比为3.9∶1;总体上流失人员年龄、职业技能、学历和职称均比进入人员高(P<0.05);流失人员主要是流向其他医疗卫生机构,占89.9%;人员流失的首要原因是报酬和待遇低,其次是不能入编制,缺乏保障,以及专业发展受限,不能发挥个人能力和特长,感觉不受重视,没有发展前途也占一定比例。结论:广西基层妇幼保健院高层次、高素质卫生技术人员流失严重,应采取各种有效措施吸引人才、留住人才、激励人才,以提高基层妇幼保健院人才队伍建设水平。     

四省基层医疗卫生机构传染病监测人力资源现状调查

目的了解基层医疗卫生机构传染病监测岗位人力资源现状,为相关部门制定卫生规划提供依据。方法对4个省基层医疗卫生机构采用分层抽样的方法抽取调查单位,对抽取的单位所有传染病监测人员全部自填问卷进行调查。结果4个省基层医疗卫生机构传染病预防控制和防保人员746人,传染病诊疗医生285人,检验人员166人。县级疾控机构、县级医院和乡镇卫生院／社区卫生服务机构的传染病监测人员中有专业学历者分别占94．6％、97．8％、89．5％;县级疾控机构传染病预防控制人员中,公共卫生专业的人员占42．7％,县级医院和乡镇卫生院／卒土区卫生服务机构传染病诊疗医生中,临床医学或中医学／中西医结合专业的人员分别占88．8％和79．3％,检验人员中医学检验（或临床检验）和卫生检验专业分别占30．7％和30．1％,无专业学历人员占13．3％（22／166）;职称以初级为主,占48．5％;其次为中级职称占39．9％;各类传染病监测人员具备执业证书者占81．2％,13．3％的人员无任何执业证书。结论4省基层医疗卫生机构传染病监测人员中,学历、职称、专业构成不合理,部分人员没有学历、不具备执业医师（助理医师）或执业护士资格。     

Small, nonteaching, and rural hospitals continue to be slow in adopting electronic health record systems

To achieve the goal of comprehensive health information record keeping and exchange among providers and patients, hospitals must have functioning electronic health record systems that contain patient demographics, care histories, lab results, and more. Using national survey data on US hospitals from 2011, the year federal incentives for the meaningful use of electronic health records began, we found that the share of hospitals with any electronic health record system increased from 15.1 percent in 2010 to 26.6 percent in 2011, and the share with a comprehensive system rose from 3.6 percent to 8.7 percent. The proportion able to meet our proxy criteria for meaningful use also rose; in 2011, 18.4 percent of hospitals had these functions in place in at least one unit and 11.2 percent had them across all clinical units. However, gaps in rates of adoption of at least a basic record system have increased substantially over the past four years based on hospital size, teaching status, and location. Small, nonteaching, and rural hospitals continue to adopt electronic health record systems more slowly than other types of hospitals. In sum, this is mixed news for policy makers, who should redouble their efforts among hospitals that appear to be moving slowly and ensure that policies do not further widen gaps in adoption. A more robust infrastructure for information exchange needs to be developed, and possibly a special program for the sizable minority of hospitals that have almost no health information technology at all.     

Ethics in health care marketing: the Twin Cities perspective

Do hospital-based marketers have a common perspective on what practices are ethical for the promotion of health services to consumers? Do they find adequate guidance in making ethical decisions on marketing practices from the mission statements of their institutions? The author sought answers to these questions through a survey of marketers and other health care professionals in the highly competitive Twin Cities health care environment.     

农村在岗卫生人员临床医学专业专科教育教学质量保障实践

农村在岗卫生技术人员成人大专学历教育,是安徽省加快农村卫生人才培养所采取的一种特殊而有效的形式,如何开展教学并保证其教学质量,备受社会各界的关注。鉴于培养对象的特殊性,我们组织力量针对农村在岗卫生技术人员的特点,通过加强教学管理,并积极开展教育教学改革,有效保证了教育教学质量。     

Nutrition Competencies in Health Professionals’ Education and Training: A New Paradigm

Most health care professionals are not adequately trained to address diet and nutrition-related issues with their patients, thus missing important opportunities to ameliorate chronic diseases and improve outcomes in acute illness. In this symposium, the speakers reviewed the status of nutrition education for health care professionals in the United States, United Kingdom, and Australia. Nutrition education is not required for educating and training physicians in many countries. Nutrition education for the spectrum of health care professionals is uncoordinated, which runs contrary to the current theme of interprofessional education. The central role of competencies in guiding medical education was emphasized and the urgent need to establish competencies in nutrition-related patient care was presented. The importance of additional strategies to improve nutrition education of health care professionals was highlighted. Public health legislation such as the Patient Protection and Affordable Care Act recognizes the role of nutrition, however, to capitalize on this increasing momentum, health care professionals must be trained to deliver needed services. Thus, there is a pressing need to garner support from stakeholders to achieve this goal. Promoting a research agenda that provides outcome-based evidence on individual and public health levels is needed to improve and sustain effective interprofessional nutrition education.     

北京市海淀区2003-2009年中小学校卫生保健人员状况

目的 分析2003 -2009年海淀区中小学校卫生保健人员状况,为制定更加科学合理的政策提供依据.方法 采用问卷调查结合访谈的方式,于2009年对海滨区内中小学校的卫生保健人员进行调查,并将结果分别与2003及2008年进行比较.结果 海淀区中小学校卫生保健人员配备状况总体发展良好,小学配备比例明显提高,卫生保健人员年龄结构趋于年轻化,医学专业人员有所增加;但小学卫生保健人员配备率仅为22.2％,中小学校校医及保健教师工作年限5 a以下的占58.0％,且更换频繁;卫生保健人员医学专业结构有待完善.结论 教育行政部门应加强对学校卫生保健队伍的管理,特别是加强小学医务室及专职卫生保健人员配备.     

Evaluation of Viewpoints of Health Care Professionals on the Role of Ethics Committees and Hospitals in the Resolution of Clinical Ethical Dilemmas Based on Practice Environment

We sought to evaluate whether health care professionals’ viewpoints differed on the role of ethics committees and hospitals in the resolution of clinical ethical dilemmas based on practice location. We conducted a survey study from December 21, 2013 to March 15, 2014 of health care professionals at six hospitals (one tertiary care academic medical center, three large community hospitals and two small community hospitals). The survey consisted of eight clinical ethics cases followed by statements on whether there was a role for the ethics committee or hospital in their resolution, what that role might be and case specific queries. Respondents used a 5-point Likert scale to express their degree of agreement with the premises posed. We used the ANOVA test to evaluate whether respondent views significantly varied based on practice location. 240 health care professionals (108—tertiary care center, 92—large community hospitals, 40—small community hospitals) completed the survey (response rate: 63.6 %). Only three individual queries of 32 showed any significant response variations across practice locations. Overall, viewpoints did not vary across practice locations within question categories on whether the ethics committee or hospital had a role in case resolution, what that role might be and case specific queries. In this multicenter survey study, the viewpoints of health care professionals on the role of ethics committees or hospitals in the resolution of clinical ethics cases varied little based on practice location.     

The professional chaplain

In this technological age, when hospitals run the risk of becoming frightening and impersonal places, pastoral care departments have an obligation to ensure that they provide high-quality, professional service. One of the common themes of contemporary mission statements is the call for "holistic care"-- meeting the physical, emotional, social, and spiritual needs of patients. A second theme is the importance of providing high-quality care. In the past 20 years, the National Association of Catholic Chaplains has developed education and accreditation programs that have led to stronger, more effective pastoral care service and education. Although credentialing is not a panacea for all problems and conflicts, when persons work at developing personal, professional, and theological competencies, they are more successful in resolving conflict. In fact, well-prepared, certified chaplains enhance all aspects of the healthcare ministry. Finally, the effort to improve pastoral care provides an opportunity for all involved to "live the mission." Today's greater emphasis on team ministry allows the pastoral care department to be a model of community and dialogic relationship for the rest of the healthcare facility.     

Managing health services organizations with an educational mission: the case of Canada

Teaching hospitals represent a major segment of the Canadian health system, accounting for a disproportionate number of beds, patient days, and separations. Thus, although only six percent of hospitals are classified as teaching hospitals, they are responsible for about 36 percent of total hospital operating expenses. While affiliation with a medical school presents unique opportunities for the teaching hospital and increases its prestige, there are clear costs associated with affiliation. Administrators have less control over resource allocation decisions, including the types of teaching programs offered. Teaching hospitals cannot unilaterally design their own teaching programs around specialties and subspecialties of their own choosing; decisions related to teaching programs have a direct impact on the services provided by the hospital and may negatively affect the hospital's ability to fulfill its patient care mission. As education budgets are constrained, teaching hospitals are expected to assume outstanding teaching-related expenses. Teaching hospitals are also expected to shift some of their teaching to alternative settings, such as the community. Thus, teaching hospital administrators will require a strong background in finance as well as negotiation and political skills.     

Education in reproductive health: proposal or reality in the Family Health Program?

As supervisors of primary health care units in the State of Ceará, Brazil, we have observed a low supply of health education services. As part of the activities under the Family Health Program (FHP), we attempted to investigate the causes of this short supply and identify flaws in the development of such activities. Interviews and participatory observation were adopted as the research method. The following causes were defined in the lack of health education practices: disorganization of demand, insufficient coverage of the population by FHP teams, resistance by both health professionals and the population to educational activities, absence of adequate floor space for conducting such activities, and lack of support materials. The following flaws were identified in the implementation of activities: limited exchange of experiences among participants; limited focus on the group's needs; frequent use of scientific language; transfer of outdated information; and inadequate utilization of teaching materials. The conclusion is that there is a need to retrain health professionals and to improve the availability of physical resources and teaching materials in order for education in reproductive health to become a reality in the FHP.     

Endemic bacteremia in Columbia, South Carolina

Between 1977 and 1981, there were 4.9 episodes of community-acquired bacteremia and 5.1 episodes of hospital-acquired bacteremia per 1,000 patients in the four major hospitals of one metropolitan area. Case fatality rates were 30.1 per cent based on deaths due to all causes and 14.7 per cent based on deaths attributed specifically to bacteremia. Patients who experienced bacteremia had a 12-fold excess in mortality compared with other patients. Bacteremia occurred more frequently and was associated with greater case fatality rates at university-affiliated teaching hospitals compared with nonteaching community hospitals. At the nonteaching community hospitals, the odds of mortality for patients with bacteremia were lower even after adjustment for age, sex, severity of underlying medical problems, and severity of infection. Patients on private services at a teaching municipal hospital experienced greater odds of mortality compared with private patients at two nonteaching community hospitals. These latter observations may reflect, at least in part, limitations in the standard parameters used for determining severity of underlying medical problems and severity of infection.     

Should professional ethics education incorporate single-professional or interprofessional learning?

Since ethical issues in the contemporary delivery of health care involve doctors, nurses, technicians, and members of other health professions, the authors consider whether members of diverse health care occupations might benefit from studying ethics in a single classroom. While interprofessional courses may be better at teaching the ethics of the relationships between and among the various health professions, single-professional courses may be better at teaching the ethics of relationships between particular kinds of professionals and patients. An ethics instructor’s professional discipline affects his/her credibility with the students, and the course readings may not always be relevant to the actual work of a given discipline. With these challenges in mind, the authors suggest that the boundaries of ethics education in the health professions be reconceived to accommodate the professional mission of a specific discipline as well as the interdependence and collaboration that marks high quality health care.     

Competition and screening with motivated health professionals

Two hospitals compete for the exclusive services of health professionals, who are privately informed about their ability and motivation. Hospitals differ in their ownership structure and in the mission they pursue. The non-profit hospital sacrifices some profits to follow its mission but becomes attractive for motivated workers. In equilibrium, when both hospitals are active, the sorting of workers to hospitals is efficient and ability-neutral. Allocative distortions are decreasing in the degree of competition and disappear when hospitals are similar. The non-profit hospital tends to provide a higher amount of care and offer lower salaries than the for-profit one.