Reinventing the community hospital: a retrospective population-based cohort study of a natural experiment using register data.

OBJECTIVES: To investigate whether implementation of municipal acute bed units (MAUs) resulting from the Norwegian Coordination Reform (2012) was associated with reductions in hospital admissions, particularly for the elderly. DESIGN: A municipality-based retrospective comparative cohort study using monthly population-based registry data analysed with fixed-effects log-log regressions. SETTING: Norwegian municipalities and hospitals. POPULATION: All patients admitted to secondary hospital care in Norway between 2010 and 2014, excluding psychiatric admissions, with additional focus on admission type and elderly age subgroups. MAIN OUTCOME MEASURES: Monthly admission rates in total and by age group for all patients, patients admitted with acute conditions and with acute conditions at internal medicine departments. RESULTS: The introduction of MAUs was associated with a small yet significant overall negative effect on hospital admissions. The reduction in all admissions was significant for the entire population (-1.2%, 95% CI -2.0% to -0.0%) and slightly stronger for those aged 80 years and above (-1.9%, 95% CI -3.0% to -1.0%). The more detailed analysis of the elderly population aged 80 years and above revealed that effects were affected by the institutional characteristics of the MAUs. The significant effects ranged between -1.6% and -8.6%, depending on the availability of physicians on duty at the MAUs, the MAUs location or combinations thereof. CONCLUSIONS: Introduction of MAUs following implementation of the Norwegian Coordination Reform in 2012 was associated with a significant reduction in hospital admissions primarily for the elderly. Our findings suggest that this type of intermediate care is a viable option in an effort to alleviate the burden on hospitals by reducing the acute secondary care admission volume. Further examinations focused on cost-effectiveness, health status of patients, number of patients treated at the MAUs and comparing other intermediate care alternatives would all add important perspectives to the issue.

Regional health care planning: a methodology to cluster facilities using community utilization patterns.

BACKGROUND: Community-based health care planning and regulation necessitates grouping facilities and areal units into regions of similar health care use. Limited research has explored the methodologies used in creating these regions. We offer a new methodology that clusters facilities based on similarities in patient utilization patterns and geographic location. Our case study focused on Hospital Groups in Michigan, the allocation units used for predicting future inpatient hospital bed demand in the state's Bed Need Methodology. The scientific, practical, and political concerns that were considered throughout the formulation and development of the methodology are detailed. METHODS: The clustering methodology employs a 2-step K-means + Ward's clustering algorithm to group hospitals. The final number of clusters is selected using a heuristic that integrates both a statistical-based measure of cluster fit and characteristics of the resulting Hospital Groups. RESULTS: Using recent hospital utilization data, the clustering methodology identified 33 Hospital Groups in Michigan. CONCLUSIONS: Despite being developed within the politically charged climate of Certificate of Need regulation, we have provided an objective, replicable, and sustainable methodology to create Hospital Groups. Because the methodology is built upon theoretically sound principles of clustering analysis and health care service utilization, it is highly transferable across applications and suitable for grouping facilities or areal units.

An alternative facility for a stroke unit in a community hospital.

OBJECTIVE: The administration of tissue plasminogen activator (tPA) to patients with acute ischemic stroke (AIS) within three hours from onset of neurological symptoms is presently accepted as the standard treatment for suitable individuals, since it has been shown that it improves their outcome. The aim of this retrospective study was to report our experience with tPA administration in a subunit of a department of internal medicine adapted specifically for that goal. SETTING: The study was carried out in a subunit of a department of internal medicine. This subunit was equipped with all necessary items for monitoring vital signs. The patients received 0.9mg/kg of tPA intravenously and remained under around-the-clock supervision by highly trained nurses. SUBJECTS: Thirty one patients (11 women and 20 men), diagnosed with AIS between 2004 and 2008, and eligible for tPA treatment, were included in the study. RESULTS: The interval from the onset of stroke to tPA administration (onset to treat time OTT) was 145±2.2min, whereas the interval from door-to-needle was 100±4min. Two patients (6.4%) died during hospitalization because of severe intracerebral hemorrhage. Three patients with hemiparesis (9.6%) developed minor hemorrhages detected by brain CT. The mean length of stay was 8.8±0.6days. CONCLUSIONS: Our results are comparable with those obtained in stroke units in other countries. The suggested model offers a possibility for appropriate and rapid thrombolysis for AIS in a community hospital lacking special stroke unit. Moreover, the suggested alternative does not require extensive economic investment, since there is no need for additional staff, and permits the use of already existing hospital facilities.

Measuring physical accessibility to health facilities--a case study on Khulna City.

Improving health services is a crucial issue and an immense challenge for the government of any Third World country. Bangladesh lacks healthcare services, one of the basic necessities of life. This paper demonstrates a method for estimating the geographical accessibility of health facilities by population coverage, average travel time and distance to the closest hospital. This analysis was applied to community units in the research area, allowing geographical access to be linked to people. The study area was divided into hexagons of equal size, and accessibility was measured from the centre of each hexagon. Despite the abundance of evidence on the inadequacy of health services in Khulna City, this study has given us a diverse dimension of possibilities. The study found that even with existing health facilities, discontent about the unavailability of health services can be mitigated in most areas. Exceptions are some peripheral areas, where average travel time to reach the city centre and distance from hospital services is greater.

[Current problems for outpatients undergoing cancer chemotherapy in Ehime Priority Hospitals of Cancer Care Network (Ehime Cancer Kyoten Hospitals)].

Ehime Priority Hospitals of Cancer Care Network(Ehime Cancer Kyoten Hospitals)regularly have meetings to discus the current problems in cancer care in Ehime Prefecture. We established three subcommittees:"Registration of Cancer Incident," "Critical Paths for the Management of Patients with Cancer,"and"Palliative Care for Patients with Advanced Cancer"to exchange our opinions. We recently set up a new subcommittee related to the physical and spiritual care of patients undergoing chemotherapy treatment,"A Subcommittee dealing with Cancer Chemotherapy and its Management"."This subcommittee has tried to identify current problems with chemotherapy for outpatients in each institution through questionnaire and analysis. As a result of this survey, it was found that Ehime Priority Hospitals have total of seventy-three beds for outpatients undergoing chemotherapy, and that they performed chemotherapy 19, 671 times in 2008. A total of eight oncology physicians and sixteen oncology nurses were engaged in performing chemotherapy in this system. The questions patients most frequently asked during chemotherapy concerned the management of therapy-related complications, dealing with problems at night and during holidays after chemotherapy, and financial problems related to the costs of treatment. In this study we found three issues that need to be managed in Ehime Priority Hospitals. First, for the nursing of outpatients undergoing chemotherapy, more staff engaged in different types of care is required. Second, a new system to deal with emergencies at night and during holidays after chemotherapy is necessary, because Ehime Priority Hospitals use the same system to deal with chemotherapy patients as for other patients. Third, cooperation between pharmacies and out-clinics is important for patient compliance during chemotherapy, especially for the administration of oral anti-tumor agents. Ehime Priority Hospitals of Cancer Care Network is trying to improve each institution while dealing with these problems.

The other building boom.

Reminding the community that hospitals are vital, valued resources that merit their support can help build strong bonds of trust.

Availability of safety net providers and access to care of uninsured persons.

OBJECTIVE: To understand how proximity to safety net clinics and hospitals affects a variety of measures of access to care and service use by uninsured persons. DATA SOURCES: The 1998-1999 Community Tracking Study household survey, administered primarily by telephone survey to households in 60 randomly selected communities, linked to data on community health centers, other free clinics, and safety net hospitals. STUDY DESIGN: Instrumental variable estimation of multivariate regression models of several measures of access to care (having a usual source of care, unmet or delayed medical care needs, ambulatory service use, and overnight hospital stays) against endogenous measures of distances to the nearest community health center and safety net hospital, controlling for characteristics of uninsured persons and other area characteristics that are related to access to care. The models are estimated with data from a nationally representative sample of uninsured people. PRINCIPAL FINDINGS: Shorter distances to the nearest safety net providers increase access to care for uninsured persons. Failure to account for the endogeneity of distance to safety net providers on access to care generally leads to finding little or no safety net effects on access. CONCLUSIONS: Closer proximity to the safety net increases access to care for uninsured persons. However, the improvements in access to care are relatively small compared with similar measures of access to care for insured persons. Modest expansion of the safety net is unlikely to provide a full substitute for insurance coverage expansions.

Back to the basics. Number of general hospitals grows for the first time in years despite slim margins, lagging reimbursements and a tight market.

After slipping 16.5% in the past quarter-century, the number of community hospitals is on the rise despite slim margins, lagging reimbursements and a tight capital market. Growth is spurred by the attractive demographics of fast-growing suburban areas, changing consumer tastes and the lure of big business from baby boomers and the elderly. One new facility is Florida Hospital-Flagler, left.

[How community oriented is psychiatric care in Germany?]. / Wie gemeindenah ist die psychiatrische Versorgung in der Bundesrepublik Deutschland?

OBJECTIVE: Following 25 years of psychiatric reform in West and 12 years in East Germany the status of community orientation of German psychiatry is investigated. METHOD: Analysis of secondary data. RESULT: Community orientation in hospital care is better realised in the smaller western states and in the eastern German states. In the large western states inpatient care is still dominated by the structures of the large regional hospitals. Outpatient care, dominated by psychiatrists and psychotherapists in private practise, is less densely provided in East Germany. Sheltered accommodation is provided predominantly in hostels. The states with better community orientation in hospital care offer fewer sheltered accommodation. CONCLUSION: The process of psychiatric reform is not accomplished yet, particularly concerning hospital care in the large western states and sheltered accommodation in general. A possible cause for the weak implementation of community orientation in hospital services in the large western states might be the strong position of hospital responsables that oppose the closing down of hospitals. Incentives for implementing supported housing are weak. The under-serving with sheltered accommodation might pose risks to the persons concerned.

Facilities and equipment for the care of pediatric patients in a community hospital.

Many children who require hospitalization are admitted to community hospitals that are more accessible for families and their primary care physicians but vary substantially in their pediatric resources. The intent of this clinical report is to provide basic guidelines for furnishing and equipping a pediatric area in a community hospital.

Community hospitals for the new millennium.

There is a lack of basic information regarding the numbers of and facilities offered by community hospitals. This survey identified 471 community hospitals in the United Kingdom containing 18,579 beds with 20% of general practitioners having admitting rights. The majority of hospitals provide a comprehensive range of rehabilitation services and consultant outpatient clinics. Community hospitals are potentially an important resource in providing intermediate care in the community.