The dialysis facility levels and sizes are associated with outcomes of incident hemodialysis patients.

The outcomes of patients with incident kidney failure who start hemodialysis are influenced by several factors. Whether hemodialysis facility characteristics are associated with patient outcomes is unclear. We included adults diagnosed as having kidney failure requiring hemodialysis during January 1, 2001 to December 31, 2013 from the Taiwan National Health Insurance Research Database to perform this retrospective cohort study. The exposures included different sizes and levels of hemodialysis facilities. The outcomes were all-cause mortality, cardiovascular death, infection-related death, hospitalization, and kidney transplantation. During 2001-2013, we identified 74,406 patients and divided them in to three groups according to the facilities where they receive hemodialysis: medical center (n = 8263), non-center hospital (n = 40,008), and clinic (n = 26,135). The multivariable Cox model demonstrated that a larger facility size was associated with a low mortality risk (hazard ratio [HR] 0.991, 95% confidence interval [95% CI] 0.984-0.998; every 20 beds per facility). Compared with medical centers, patients in non-center hospitals and clinics had higher mortality risks (HR 1.13, 95% CI 1.09-1.17 and HR 1.11, 95% CI 1.06-1.15, respectively). Patients in medical centers and non-center hospitals had higher risk of hospitalization (subdistribution HR [SHR] 1.11, 95% CI 1.10-1.12 and SHR 1.22, 95% CI 1.21-1.23, respectively). Patients in medical centers had the highest rate of kidney transplantation among the three groups. In patients with incident kidney failure, a larger hemodialysis facility size was associated with lower mortality. Overall, medical center patients had a lower mortality rate and higher transplantation rate, whereas clinic patients had a lower hospitalization risk.

Significance of Hospital Size in Outcomes of Single-Level Elective Anterior Cervical Discectomy and Fusion: A Nationwide Readmissions Database Analysis.

OBJECTIVE: To elucidate risk factors for 90-day readmission in anterior cervical discectomy and fusion (ACDF) for small, medium, and large hospitals. To assess differences in length of stay, charges, and complication rates across hospitals of different size. METHODS: A retrospective analysis was performed using elective, single-level ACDF data from 2016 to 2018 in the Healthcare Cost and Utilization Project Nationwide Readmissions Database. Elective single-level ACDF cases were stratified into 3 groups by hospital bed size (small, medium, and large). All-cause complication rates, mean charges, length of stay, and 90-day readmission rates were compared across hospital size. Frequencies of specific comorbidities were compared between readmitted and nonreadmitted patients for each hospital size. Comorbidities significant on univariate analysis were evaluated as independent risk factors for 90-day readmission for each hospital size using multivariate regression. RESULTS: The overall 90-day readmission rate was 6.43% in 36,794 patients, and the rates for small, medium, and large hospitals were 6.25%, 6.28%, and 6.56%, respectively (P = 0.537). Length of stay increased significantly with hospital size (P < 0.001), and small hospitals had the lowest charges (P < 0.001). Although different independent predictors of 90-day readmission were identified for each hospital size, cardiac arrhythmia, chronic pulmonary disease, neurologic disorders, and rheumatic disease were identified as risk factors for hospitals of all sizes. CONCLUSIONS: Hospital size is a determining factor for charges and length of stay associated with elective single-level ACDF. Variation in risk factors for readmission exists across hospital size in context of similar 90-day readmission rates.

Hospital admission volume does not impact the in-hospital mortality of acute pancreatitis.

BACKGROUND: Multiple factors influence mortality in Acute Pancreatitis (AP). METHODS: To evaluate the association of demographic, clinical, and hospital factors with the in-hospital mortality of AP using a population-based administrative database. The Maryland HSCRC database was queried for adult (≥18 years) admissions with primary diagnosis of AP between 1/94-12/10. Organ failure (OF), interventions, hospital characteristics and referral status were evaluated. RESULTS: There were 72,601 AP admissions across 48 hospitals in Maryland with 885 (1.2%) deaths. A total of 1657 (2.3%) were transfer patients, of whom 101 (6.1%) died. Multisystem OF was present in 1078 (1.5%), of whom 306 (28.4%) died. On univariable analysis, age, male gender, transfer status, comorbidity, OF, all interventions, and all hospital characteristics were significantly associated with mortality; however, only age, transfer status, OF, interventions, and large hospital size were significant in the adjusted analysis. Patients with commercial health insurance had significantly less mortality than those with other forms of insurance (OR 0.65, 95% CI: 0.52, 0.82, p = 0.0002). CONCLUSION: OF is the strongest predictor of mortality in AP after adjusting for demographic, clinical, and hospital characteristics. Admission to HV or teaching hospital has no survival benefit in AP after adjusting for OF and transfer status.

Designated Stroke Center Status and Hospital Characteristics as Predictors of In-Hospital Mortality among Hemorrhagic Stroke Patients in New York, 2008-2012.

BACKGROUND: Although designated stroke centers (DSCs) improve the quality of care and clinical outcomes for ischemic stroke patients, less is known about the benefits of DSCs for patients with intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). HYPOTHESIS: Compared to non-DSCs, hospitals with the DSC status have lower in-hospital mortality rates for hemorrhagic stroke patients. We believed these effects would sustain over a period of time after adjusting for hospital-level characteristics, including hospital size, urban location, and teaching status. METHODS AND RESULTS: We evaluated ICH (International Classification of Diseases, Ninth Revision; ICD-9: 431) and SAH (ICD-9: 430) hospitalizations documented in the 2008-2012 New York State Department of Health Statewide Planning and Research Cooperative System inpatient sample database. Generalized estimating equation logistic regression was used to evaluate the association between DSC status and in-hospital mortality. We calculated ORs and 95% CIs adjusted for clustering of patients within facilities, other hospital characteristics, and individual level characteristics. Planned secondary analyses explored other hospital characteristics associated with in-hospital mortality. In 6,352 ICH and 3,369 SAH patients in the study sample, in-hospital mortality was higher among those with ICH compared to SAH (23.7 vs. 18.5%). Unadjusted analyses revealed that DSC status was related with reduced mortality for both ICH (OR 0.7, 95% CI 0.5-0.8) and SAH patients (OR 0.4, 95% CI 0.3-0.7). DSC remained a significant predictor of lower in-hospital mortality for SAH patients (OR 0.6, 95% CI 0.3-0.9) but not for ICH patients (OR 0.8, 95% CI 0.6-1.0) after adjusting for patient demographic characteristics, comorbidities, hospital size, teaching status and location. CONCLUSIONS: Admission to a DSC was independently associated with reduced in-hospital mortality for SAH patients but not for those with ICH. Other patient and hospital characteristics may explain the benefits of DSC status on outcomes after ICH. For conditions with clear treatments such as ischemic stroke and SAH, being treated in a DSC improves outcomes, but this trend was not observed in those with strokes, in those who did not have clear treatment guidelines. Identifying hospital-level factors associated with ICH and SAH represents a means to identify and improve gaps in stroke systems of care.

Increase in Utilization of Afterhours Medical Imaging: A Study of Three Canadian Academic Centers.

OBJECTIVES: The objectives of our study were to assess trends in afterhours medical imaging utilization for emergency department (ED) and inpatient (IP) patient populations from 2006-2013, including analysis by modality and specialty and with adjustment for patient volume. METHODS: For this retrospective study, we reviewed the number of CT, MRI, and ultrasound studies performed for the ED and IP patients during the afterhours time period (5pm - 8am on weekdays and 24 hours on weekends and statutory holidays) from 2006-2013 at three different Canadian academic hospitals. We used the Jonckheere-Terpstra (JT) test to determine statistical significance of imaging and patient volume trends. A regression model was used to examine whether there was an increasing trend over time in the volume of imaging tests per 1000 patients. RESULTS: For all three sites from 2006-2013 during the afterhours time period: There was a statistically significant increasing trend in total medical imaging volume, which also held true when the volumes were assessed by modality and by specialty. There was a statistically significant increasing trend in ED and IP patient volume. When medical imaging volumes were adjusted for patient volumes, there was a statistically significant increasing trend in imaging being performed per patient. CONCLUSION: Afterhours medical imaging volumes demonstrated a statistically significant increasing trend at all three sites from 2006-2013 when assessed by total volume, modality, and specialty. During the same time period and at all three sites, the ED and IP patient volumes also demonstrated a statistically significant increasing trend with more medical imaging, however, being performed per patient.

Economics of upper extremity replantation: national and local trends.

BACKGROUND: Reimbursements have fallen for reconstructive surgery. The purpose of this study was to show that not only are large teaching hospitals performing more of the reconstructive surgery procedures, specifically upper extremity replantation, they are also getting paid less to do so. METHODS: The authors examined trends in reimbursement, teaching status, and hospital size in both a national and a local database of patients who had undergone upper extremity replantation. Specifically, they used the 1993 to 2002 Nationwide Inpatient Sample as well as the local replant database from the past 5 years at Yale New Haven Hospital. RESULTS: A total of 3219 upper extremity replantations were coded in the Nationwide Inpatient Sample, representing 16,128 replantations performed in the United States from 1993 to 2002. The percentage of replantations performed at teaching hospitals increased over two-fold (44 percent versus 89 percent). Those performed at nonteaching hospitals declined (56 percent versus 11 percent). Also, a larger percentage of replantations were being performed at large hospitals (64 percent versus 82 percent). At Yale New Haven Hospital, the percentage of the professional fee that was actually paid dropped (100 percent in 2000 versus 32 percent in 2005). CONCLUSIONS: With respect to upper extremity replantation, teaching hospitals are bearing the proportionally largest economic burden of managed care's declining reimbursements for reconstructive procedures. The authors believe that these replantation data are representative of trends in reconstructive surgery, and that the model of ever-increasing volume and diminishing reimbursements in large academic medical centers may not be sustainable.

Analysis of hospital facility growth: are we super-sizing healthcare?

A retrospective analysis of space planned for selected clinical areas in acute healthcare facilities between the years 1980-2008 was conducted. Findings revealed that, during the 28-year period, incremental growth occurred in both room size and departmental square feet in adult inpatient units as well as interventional services. This observed growth and-in many instances- super-sized or excessive growth may be attributed to various factors, depending on the year of construction, regional variability, or level of urbanization. However, at a macro level, growth may be attributed to changes in patient care and operational models; consumer-driven healthcare and market competition; demographics and patient acuity; technology; and regulations and building codes. In the future, forces including but not limited to capital availability, an increased desire for efficiency, and continued escalation in the cost of construction are likely to play an increasing role in offsetting the desire for sizing excess.

Clinical and human resource planning for the downsizing of psychiatric hospitals: the British Columbia experience.

Riverview Hospital, B.C.'s only and Canada's largest remaining provincial psychiatric hospital began a formal planned "downsizing" process in 1992. This initiative was an important element in the Province's strategic plan to shift to a more community-focused mental health system and to bring tertiary psychiatric services "closer to home" by redeveloping Riverview Hospital on three sites. The paper summarizes the literature pertaining to the "downsizing" of psychiatric hospital services in relation both to clinical and human resource planning. It describes the mental health system in B.C. and the service system context in which this exercise is occurring. It is based on the first three years of experience in identifying the major challenges and the strategies developed to meet these challenges. It draws some conclusions about the effectiveness of these strategies and it speculates about the likely future challenges as the "downsizing" process continues.

Hospital downsizing and patients' assaults on staff.

Although the downsizing and closing of state mental hospitals is occurring with increasing frequency nationwide, there appears to be only one case study of the clinical impacts of downsizing state hospitals. In this study, Snyder reported a four-fold increase in frequency of assaults on staff as the hospital census decreased. The present paper is a second case study of state hospital downsizing and closing in which the frequency of assaults on staff decreased by 63%. Possible explanations for the two differing outcomes are considered, and some general guidelines for the downsizing and closing of state hospitals are proposed.