Breaking down barriers. Cambridge Hospital ensures access to care for diverse community groups

The American Hospital Association and the Baxter Foundation present the Foster G. McGaw Prize annually to a hospital that distinguishes itself in meeting the diverse health and social needs of its community. The winner receives $75,000; the three finalists each receive $10,000. This year's winner and finalists were chosen from more than 100 entries. Applicants were judged by a panel of 77 hospital executives and a nine-member prize committee of health care experts.

[The status of the rheumatology service of the city of Kiev]

An analysis is presented of the dynamics of morbidity, incidence and working losses due to the main rheumatological diseases in the city of Kiev. Data are presented on the structure of the city rheumatological service, its activities in out- and inpatient departments. The current status and perspectives of the rheumatological service are analysed.

Atlanta's Grady renovating for the future

Grady Memorial Hospital in Atlanta has opened a new emergency-care center, designed around a fast-track system. It's only part of a massive $318 million renovation affecting nearly every department in the public hospital. When the project is completed in 1995, it will allow Grady to meet building codes, increase its total number of beds to 1,024 and eliminate duplicative services.

Evaluation of prophylaxis against hepatitis B in a large municipal hospital

BACKGROUND

Perinatal transmission of hepatitis B can be interrupted by the administration of hepatitis B vaccine and hepatitis B globulin to the infants of carrier mothers. Universal screening of pregnant women makes this strategy possible.

METHODS

To evaluate the implementation of universal hepatitis B surface antigen screening of women giving birth at Kings County Hospital Center during 1988, we reviewed laboratory records to find all women with a positive test result who might give birth. We also randomly reviewed records of women who gave birth to live infants to determine the percentage of screening in the population. Infants' charts were reviewed for documentation of maternal hepatitis B surface antigen status and administration of hepatitis B immune globulin and vaccine.

RESULTS

Sixty infants who lived long enough to receive antihepatitis B prophylaxis were distinguished out of a total of 5146 births. Screening was done for from 66.8% to 80.4% (95% confidence interval) of the mothers of these infants. Although 44 of 60 infants received hepatitis B immune globulin and 39 of 60 infants received vaccine, only 27 of 60 received vaccine within 12 hours in combination with immune globulin (Centers for Disease Control-recommended therapy).

CONCLUSIONS

Documentation of hepatitis B surface antigen in the infant's delivery room record was present in 23 of 60 infants. Those infants all received hepatitis B immune globulin and vaccine; 21 received hepatitis B immune globulin within 12 hours. Hepatitis B immune globulin was given within 12 hours to 8 of 37 infants who lacked documentation of hepatitis B surface antigen status on the delivery room record. These differences were highly significant (p less than 0.001) even when only the 40 patients who had documented prenatal screening at Kings County Hospital Center (21/23 vs 4/17). Prenatal care did not have any effect on outcome.

[The systems analysis of anesthesiological activities in a general hospital]

Using an information mathematical model of anesthesiological service suggested, the authors have performed system analysis of anesthesia management in a multi-profile hospital in Arkhangelsk. Changes in the scope and structure of anesthesia, indexes of anesthesiological activity, frequency of procedures, asepsis, incidence of complications have been analysed. The analysis performed demonstrates the possibility of the control and management of anesthesiological service and forms the necessary prerequisites for its further development on the basis of economic parameters and criteria.

Improving public health care: lessons on governance from five cities

Policy-oriented investigations into public health care delivery have been limited, especially during the Reagan era of competition and profit-based health care, when the inner city was essentially forgotten. In this study, policymakers toured five urban public health care systems in different parts of the country to promote consideration of a new governance for Chicago and Cook County's complicated and uncoordinated care for the medically indigent. A comparison of patterns of governance revealed strengths and weaknesses of each model. Local leadership and the political will to evolve a system of care, with clear connections between the public and private sectors, account for each city's relative success in addressing mounting needs of inner-city populations.

Organizing the Metro Firm System for research

During the mid-1970s, four similar groups of patients and providers were created with the institution of the Firm System at Cleveland Metropolitan General Hospital (Metro). In the early 1980s, ongoing randomization was initiated for patients and physicians, setting the stage for the performance of randomized controlled trials. Techniques such as stratification and blocking are used with randomization to ensure that equivalent numbers and characteristics of patients and physicians are distributed among the firms. Comparability of key patient and physician features across firms has been documented during the baseline periods of several recent firm studies. Dissimilarities among firms can occur secondary to differential drop-out of patients (residue cohort effect), or to administrative decisions that adversely affect the structural or operational integrity of the system. Prestudy evaluations of equivalence and vigilant system maintenance programs are methods to identify and minimize important differences among firms.

Randomized, controlled trials using the Metro Firm System

The Firm System at MetroHealth Medical Center was begun almost two decades ago to foster improved continuity of patient care and teaching of medical students and residents in Internal Medicine. For the past 8 years, these parallel teams of providers and patients also have been used to conduct clinical, educational, and health care delivery research. Randomized, controlled trials are made possible by ongoing random assignment of patients and providers to the three teams, or small group practices. Each group practice has equivalent inpatient and outpatient areas supported by nonrotating nursing, paramedical, and clerical staff. The system's current relationships were established after a controlled trial established both decreased costs and increased effectiveness of the "group practice model" as compared to more traditional approaches to patient care by residents in an academic medical center. Other trials, both on the inpatient and outpatient settings, have been used to guide ongoing institutional change. The unique advantages of the randomized controlled trial are high-lighted by contrasting the results of within-group changes during an intervention with results that incorporate control group changes. A variety of methodologic and logistical issues must be addressed when conducting controlled trials that use ongoing randomization within a single institution. These include determination that the groups are equivalent for all important parameters preintervention, choosing an analytic approach that accounts for potential differences among providers and patients, and, in trials designed to affect behavior, assurance that a "steady state" exists prior to initiating another trial designed to affect similar behavior. Consideration also must be given to the possibilities of cross-team contamination, the Hawthorne effect, the "dominant attending effect," and ethical issues related to informed consent. Clinical trials in a single institution may be performed for common problems and those with well defined stages of severity. Since the costs of maintaining the ongoing randomization are relatively small, the incremental costs of conducting randomized controlled trials are low by comparison to traditional approaches. The establishment of analogous systems at other institutions will permit multisite trials for less common clinical problems, enhance the generalizability of findings, and permit new types of health services research, including the rigorous evaluation of practice guidelines.

[Small hospitals--future tasks and functions]

We review the small municipal hospitals included in our study of hospitals serving less than 50,000 persons. We identified the following problems: These hospitals are resource-intensive to a greater degree than expected, measured in terms of beds, doctors, health services and per capita costs in the area served by the hospital. Moreover, their quality is questionable, due to problems of recruitment and lack of continuity, a weak infrastructure, and insufficient patients to maintain a high level of competence, especially in taking care of patients with complicated and acute conditions. We foresee, and recommend, a new and different future for small hospitals, emphasizing closer links with primary health care and closer collaboration with the larger county hospitals. Key words are: Outpatient services, including perhaps ambulatory specialist services from the larger hospitals, elective services in fields of special competence, possibly covering a larger area, rehabilitation services, municipal psychiatric services; and finally, the traditional acute services should be changed to a first-aid service, preferably as part of emergency care in the municipality.

Managing the unmanageable: public hospital systems

There are significant challenges to those who work in large public health care delivery systems: political imperatives; resource constraints; sometimes rigid personnel systems; and, the reality that everything occurs in a public forum. The fact that many nations are reviewing and, in some instances, restructuring their national health care systems, has added to the complexity and feeling of continual turbulence experienced by their managers. State run systems like that in the United Kingdom are introducing market forces to increase effectiveness and value for money; while market systems, like that in the United States, are increasing regulatory interventions to achieve the kind of cost control available to countries with large public systems which operate with global budgets. Public hospitals in the United States offer examples of public institutions operating in a highly competitive market environment. A decade of management changes undertaken to enhance the efficiency and effectiveness of the New York City Health and Hospitals Corporation (HHC), the largest public hospital system in the United States, is presented as a case study of public health services and public management in a market environment.

[Experience in organizing medical care for the victims of the accident at the Chernobyl Atomic Electric Power Station at a specialized hospital]

Organization of health care for victims of radiation accidents requires well-adjusted organizational activities, including an inpatient clinic with well-equipped reception, dosimetric, karyological and bacteriological laboratories, an intensive care department, a surgical (burn) department, a blood transfusion laboratory and equipment for plasmapheresis and hemosorption. Therapy of such patients should be developed along the following lines: 1) prevention and therapy of infectious complications: 2) blood cell substitution therapy; 3) bone marrow transplantation; 4) detoxicating therapy; 5) correction of water-electrolyte metabolism; 6) therapy of local radiation injuries.