Hospital centers of excellence defy geographic trends.

A study of "centers of excellence" of hospitals finds that dominant hospitals of excellence-those with citations in many specialties-are in relatively smaller metropolitan areas.

[Fungemia in hospitals of the city of Buenos Aires, Argentina]. / Fungemias en hospitales de la Ciudad de Buenos Aires, Argentina.

BACKGROUND: The incidence of fungi like pathogens in hospitals varies by regions. OBJECTIVES: Our goal was not only to record the incidence and etiology of fungaemia, but also the change during the 4 years analysed, to determine the time of detection in automated blood culture and by lysis-centrifugation, and finally to assess the gender, age and underlying disease of the patients with fungaemia. METHODS: An observational multicentre study of fungaemia was conducted in hospitals in the Mycology Network of Buenos Aires. RESULTS: A total of 190,920 blood cultures were processed: 182,050 automated blood culture and 8,870 lysis-centrifugation. Fungi were recovered in 1,020 episodes. The overall incidence of fungaemia was 1.72/1,000 admissions; 683 episodes were due to Candida (68%), and 325 (32%) to other fungi: 214 Cryptococcus, 105 Histoplasma, 7 Rhodotorula, 5 Trichosporon, 2 Pichia, 2 Acremonium, one Saccharomyces and one Fusarium. The incidence of candidaemia was 1.15/1,000 admissions with a wide variation between centres (0.35 to 2.65). Most Candida isolates (97%) were detected in the first 2 days of incubation. Candida albicans was recovered in 43% of the episodes. In fungaemia other than candidaemia, the predominant fungi were Cryptococcus and Histoplasma capsulatum. CONCLUSIONS: The incidence remained stable during the study period. Fungaemia by Candida were predominant. C. albicans was involved in less than a half of the episodes. The recovery of Cryptoccocus and H. capsulatum is strongly associated with HIV patients.

Steering patients to safer hospitals? The effect of a tiered hospital network on hospital admissions.

OBJECTIVE: To determine if a tiered hospital benefit and safety incentive shifted the distribution of admissions toward safer hospitals. DATA SOURCES/STUDY SETTING: A large manufacturing company instituted the hospital safety incentive (HSI) for union employees. The HSI gave union patients a financial incentive to choose hospitals that met the Leapfrog Group's three patient safety "leaps." The analysis merges data from four sources: claims and enrollment data from the company, the American Hospital Association, the AHRQ HCUP-SID, and a state Office of the Insurance Commissioner. STUDY DESIGN: Changes in hospital admissions' patterns for union and nonunion employees using a difference-in-difference design. We estimate the probability of choosing a specific hospital from a set of available alternatives using conditional logistic regression. PRINCIPAL FINDINGS: Patients affiliated with the engineers' union and admitted for a medical diagnosis were 2.92 times more likely to select a hospital designated as safer in the postperiod than in the preperiod, while salaried nonunion (SNU) patients (not subject to the financial incentive) were 0.64 times as likely to choose a compliant hospital in the post- versus preperiod. The difference-in-difference estimate, which is based on the predictions of the conditional logit model, is 0.20. However, the machinists' union was also exposed to the incentive and they were no more likely to choose a safer hospital than the SNU patients. The incentive did not have an effect on patients admitted for a surgical diagnosis, regardless of union status. All patients were averse to travel time, but those union patients selecting an incentive hospital were less averse to travel time. CONCLUSIONS: Patient price incentives and quality/safety information may influence hospital selection decisions, particularly for medical admissions, though the optimal incentive level for financial return to the plan sponsor is not clear.

Affording what's free and paying for choice: comparing the cost of public and private hospitalizations in urban Kerala.

OBJECTIVE: To assess the cost of public and private hospitalizations in urban Kerala and discuss policy implications of social disparities in the economic burden of hospital care. METHODS: The NSSO survey on health care (1995-1996) for urban Kerala was analysed with regards to expenditure incurred by hospital episodes. Multilevel linear models were built to assess factors associated with levels of health expenditure. FINDINGS: Hospital care involves paying admission fees in 68% of cases of hospitalizations (98% in private and 20% in public sector) in urban Kerala. Poor households and those headed by casual workers show significantly lower levels of health expenditure and a higher proportion of health-related loss of income than other social groups. Although there is significant expenditure in both sectors for these groups, hospitalization on free public wards is associated with lower expenditure than other options. Factors linked with higher expenditure are: duration of stay; hospitalizations on paying public wards and in the private sector; hospitalizations for above poverty line households and hospitalizations for chronic illnesses. Expenditure for services bought from outside the hospital is important in the public sector. CONCLUSION: Hospitalization incurs significant expenditure in urban Kerala. Greater availability of free medical services in the public sector and financial protection against the cost of hospitalization are warranted.

The changing landscape of hospital capacity in large cities and suburbs: implications for the safety net in metropolitan America.

An analysis of trends in hospital use and capacity by ownership status and community poverty levels for large urban and suburban areas was undertaken to examine changes that may have important implications for the future of the hospital safety net in large metropolitan areas. Using data on general acute care hospitals located in the 100 largest cities and their suburbs for the years 1996, 1999, and 2002, we examined a number of measures of use and capacity, including staffed beds, admissions, outpatient and emergency department visits, trauma centers, and positron emission tomography scanners. Over the 6-year period, the number of for-profit, nonprofit, and public hospitals declined in both cities and suburbs, with public hospitals showing the largest percentage of decreases. By 2002, for-profit hospitals were responsible for more Medicaid admissions than public hospitals for the 100 largest cities combined. Public hospitals, however, maintained the longest Medicaid average length of stay. The proportion of urban hospital resources located in high poverty cities was slightly higher than the proportion of urban population living in high poverty cities. However, the results demonstrate for the first time, a highly disproportionate share of hospital resources and use among suburbs with a low poverty rate compared to suburbs with a high poverty rate. High poverty communities represented the greatest proportion of suburban population in 2000 but had the smallest proportion of hospital use and specialty care capacity, whereas the opposite was true of low poverty suburbs. The results raise questions about the effects of the expanding role of private hospitals as safety net providers, and have implications for poor residents in high poverty suburban areas, and for urban safety net hospitals that care for poor suburban residents in surrounding communities.

Quality of care for acute myocardial infarction at urban safety-net hospitals.

Safety-net hospitals are experiencing increasing financial strains, possibly affecting their quality of care. We compare quality at safety-net and non-safety-net urban hospitals for Medicare beneficiaries admitted with acute myocardial infarction (AMI). Although safety-net hospitals had modestly higher risk-standardized thirty-day all-cause mortality rates and modestly lower adherence to quality-of-care performance measures than non-safety-net hospitals, there was much heterogeneity among safety-net hospitals and substantial overlap with non-safety-net hospitals. We examine the implications of these findings for the millions of vulnerable Americans who rely on safety-net hospitals for their care.

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The contribution by medical radiology departments to dental radiology in general dental practice in Scotland.

AIM: To determine the availability of the services of medical radiology departments to general dental practitioners in Scotland. METHODS: Fifty-seven hospitals were identified as likely to have services available to general dental practitioners; 41 were within central urbanised areas (the 'Central Belt') and 16 in the more remote rural areas, (the 'Borders, Highlands and Islands'). The available services were identified by questionnaire. RESULTS: All 57 questionnaires were returned. Although there were significantly fewer larger hospitals in the 'Borders, Highlands and Islands', there was no significant difference in availability of services to general dental practitioners between the two parts of Scotland. CONCLUSION: The services of medical radiology departments are generally available to general dental practitioners in both the 'Central Belt' and the 'Borders, Highlands and Islands'.

Suburban versus urban: does it matter where the residency interview begins?

Geographic location is an important factor in students' ranking of residency programs. Our program's inner city location has a negative impact on our recruitment efforts. In an attempt to assess the impact of geography, we started half of the residency interview days at our suburban community medical center and then measured the effect on the applicant's perception of the program. During the 1998-1999 residency interview season we alternated the site at which the day began. Students were randomly assigned based on interview date requests to starting the day at the urban hospital or at the community hospital. At the conclusion of the day the students completed a questionnaire regarding various components of the interview day and how their perception of the program was influenced by the experience. Of 206 students asked to complete the questionnaire, 188 (91%) completed the survey. The degree to which the students' perception of the program was affected was remarkably similar regardless of where the interview day began; however, significant differences were found between the Chairman's Talk, the Teaching Session, and talking with current residents when compared by univariate analysis. We concluded that students' perception of the program at the conclusion of the interview day was similar regardless of whether the interview day began at an urban or suburban medical center.

The impact of health maintenance organization penetration on the use of hospitals that serve minority communities.

OBJECTIVES: Health maintenance organization (HMO) penetration has made hospital markets more price competitive. Hospitals in minority communities may be at a competitive disadvantage because they serve patients who are, on average, sicker and more likely to be uninsured or underinsured. This study estimated the impact of HMO penetration on the use of hospitals in minority communities during 1987 to 1992. METHODS: Using a sample of 1,413 short-term general hospitals from the 85 largest metropolitan statistical areas, the determinants of hospitals' patient volumes were estimated. Hospitals located in predominately nonwhite neighborhoods were designated minority hospitals, and other hospitals were designated nonminority hospitals. Using regression analysis, the impact of HMO penetration and concentration on hospitals' patient volumes were estimated. By interacting the HMO penetration and concentration variables with a minority hospital indicator variable, HMOs' impact on minority hospitals was calculated. RESULTS: Health maintenance organization penetration was correlated with lower patient volumes in minority hospitals and higher patient volumes in nonminority hospitals. Competition in HMO markets was correlated with lower patient volumes for all hospitals. This effect was stronger for minority hospitals. CONCLUSIONS: These findings suggest that minority hospitals may be at risk of losing patients as HMO penetration increases.

Geographic classification of hospitals: alternative labor market areas.

Medicare hospital payments are adjusted to reflect variation in hospital wages across geographic areas by grouping hospitals into labor market areas. By only recognizing the average wage in an area, Medicare encourages hospitals to contain costs. Labor market area definitions have recently received renewed attention because of their impact on hospital payments. Alternative labor market areas were evaluated using several criteria, including ability to explain wage variation and impact on payment equity. Rural labor market areas can be improved using county population size; however, further research on urban labor market areas is needed.

Ownership and organizational performance. A comparison of technical efficiency across hospital types.

Using a national data base of urban hospitals, the effect of ownership (government, nonprofit, and for-profit) on the technical efficiency of hospitals was examined. Efficiency scores were computed using a method called data envelopment analysis. Controlling for environmental and hospital characteristics, for-profit hospitals were found somewhat less frequently and government hospitals consistently more frequently in the efficient category. When examining highly inefficient hospitals as a percentage of those receiving inefficient scores, for-profit hospitals appeared to be highly inefficient relative to the other ownership forms. Government and nonprofit hospitals were somewhat indistinguishable from one another regarding their percentages of highly inefficient scores. For-profit hospitals also tended to use supply and capital asset (hospital size) inputs less efficiently, and service and labor inputs more efficiently than hospitals in the other ownership categories.