Different regional organisational models and the quality of health care: the case of coronary artery bypass graft surgery

OBJECTIVES

The Italian regions of Emilia-Romagna and Lombardy within the Italian National Health Service provide an opportunity to see if two different approaches to the organisation of care--one more hierarchical and planned, the other more competitive and market-like--influence its quality through examining the relationship between the number of coronary artery bypass grafts (CABGs) and the rate of in-hospital mortality using administrative data for the period 1996-1998.

METHODS

Descriptive statistics and logistic regression models were used.

RESULTS

The volume-outcome relation was statistically significant in both regions (odds ratio 0.71, P < 0.0001). Although CABG performance in Emilia-Romagna was slightly poorer than in Lombardy (OR 1.22, P < 0.05), the potential advantage in terms of the reduced risk of death for patients treated at high-volume versus low-volume hospitals was significantly greater. In Emilia-Romagna, the average performance advantage of high-volume units was more substantial in the case of private accredited hospitals than public hospitals (OR = 0.50, P < 0.0001 versus OR = 0.64, P < 0.0001). In Lombardy, the performance advantage of concentrating CABG procedures was greater in private research hospitals (OR = 0.67, P < 0.0001), whereas results were not statistically significant for the other types of hospital, indicating a good level of performance in both public and private hospitals even at low volumes. This also partially explained the lower mortality rate observed in that region.

CONCLUSIONS

The degree of hierarchical regionalisation versus market-like arrangements characterising the two systems produced contrasting effects in terms of the quality of CABG surgery. Lombardy's more competitive environment appeared to achieve better performance in terms of a slightly lower probability of adverse outcomes, in a system with no formal assessment of population need and very high per capita revascularisation rates. To improve performance in the more hierarchical system adopted in Emilia-Romagna would require considerable effort to increase CABG surgery in low-volume cardiac units, and to sharpen performance incentives.

New report card compares end-of-life care initiatives across the country

A report card from Last Acts and the Robert Wood Johnson Foundation takes a first look on a state-by-state basis at how end-of-life care and related issues are approached by healthcare organizations across the country.

[Cross-sectional study of cardiac surgery centers within the "CABG Project" (short-term outcome in patients undergoing coronary artery bypass graft surgery in Italian cardiac surgery centers)]

BACKGROUND

Italian cardiac surgery units have changed in their characteristics over time. These changes have to be monitored. At the moment, there are no regular monitoring systems that could be used to support the processes of evaluation of performance. The Italian Institute of Health has recently started a national prospective study on the short-term outcomes (within 30 days mortality) of coronary artery bypass graft procedures. This study has been preceded by a cross-sectional investigation on the general activities of the Italian cardiac surgery centers.

METHODS

A complete Italian cardiac surgery center directory has been assembled. A questionnaire on hospital characteristics, number of beds, number of yearly coronary artery bypass graft procedures, department computer systems and methods for surgery risk assessment has been sent to the person responsible for each cardiac surgery center.

RESULTS

In Italy there are 86 non-pediatric cardiac surgery centers (65% public centers, 31% accountable private and 4% not yet accountable private). Sixty-eight centers answered the questionnaire. Each cardiac surgery center has, on the average, availability of 26 beds and carries out about 400 coronary artery bypass graft procedures per year; 81% of cardiac surgery centers follow their patients until day 30 after the intervention, but only 64% of them report the cause of death when the patient dies; 75% of cardiac surgery centers regularly use surgery risk assessment systems.

CONCLUSIONS

These data indicate that a project on cardiac surgery outcome assessment can be conducted in Italy. This project will help defining standardized methodologies that will represent essential instruments for each cardiac surgery center and for regional offices in order to improve and optimize their activity.

Perineal outcomes in NSW public and private hospitals: analysing recent trends

Women using private health insurance for pregnancy care may be unaware of the impact that this choice has in increasing their risk of experiencing a range of interventions during childbirth. This paper identifies recent trends in episiotomy rates and perineal outcomes for New South Wales (NSW) public and private hospitals between 1997 and 1999. Clear and consistent differences exist in birth outcomes in NSW private hospitals in respect to greater episiotomy use and poorer overall perineal outcomes, higher caesarean section rates and higher instrumental birth rates. Given the potential health impact for women who experience intervention during childbirth, identification of clinically unjustified practices is an important step towards ensuring that women's choices provide them with optimal childbirth outcomes regardless of their health insurance status.

A randomized control trial of nursing-based case management for patients with chronic obstructive pulmonary disease

This study assessed the impact of a randomized trial of nursing-based case management for patients with chronic obstructive pulmonary disease, their caregivers, and nursing and medical staff. Sixty-six patients were matched by FEV on admission to hospital, and randomized into an intervention or control group. Intervention group patients reported significantly less anxiety at 1 month postdischarge; however, this effect was not sustained. There was little difference between groups in terms of unplanned readmissions, depression, symptoms, support, and subjective well being. Interviews with patients and caregivers found that the case management improved access to resources and staff-patient communication. Interviews with nursing and medical staff found that case management improved communication between staff and enhanced patient care.(1)

Markets for hospital services in Zambia

Hospital reforms involving the introduction of measures to increase competition in hospital markets are being implemented in a range of low and middle-income countries. However, little is understood about the operation of hospital markets outside the USA and the UK. This paper assesses the degree of competition for hospital services in two hospital markets in Zambia (Copperbelt and Midlands), and the implications for prices, quality and efficiency. We found substantial differences among different hospital types in prices, costs and quality, suggesting that the hospital service market is a segmented market. The two markets differ significantly in their degree of competition, with the high cost inpatient services market in Copperbelt relatively more competitive than that in the Midlands market. The implications of these differences are discussed in terms of the potential for competition to improve hospital performance, the impact of market structure on equity of access, and how the government should address the problem of the mine hospitals.

[The accreditation procedure: An external recognition of quality in public and private health centres in France. ]

Since early 1990, the structures and financing of various health systems have been reformed. For the first time, some western Europe countries have admitted that quality insurance within the health system can become a governmental responsibility and, as in the past, simply the responsibility of the professionals and/or the health service administrators. During the last decade of the XXth century, pressure has gradually been increased for governments to become more involved in health system quality. This focus on quality was linked to human safety. In this historical perspective, the emergence of AIDS and the difficulty to control this epidemic, and the consequences of contamination by injection needles have probably played a part in this collective awareness. In this context, quality has become a major concern in Europe.

Emergency transfer from independent hospitals to NHS hospitals: risk, reasons and cost

BACKGROUND

In view of public concern about standards of emergency care in independent hospitals and the impact of transferred patients on NHS facilities we aimed to estimate the number and risk of emergency transfers from independent hospitals to NHS hospitals; to describe the circumstances; and estimate costs to the NHS.

METHODS

Patients transferred in three months from 137 independent hospitals were identified from central records systems and local hospital enquiries. Circumstances were described by Directors of Nursing in telephone interviews. Numbers were weighted for whole year activity and non-participating hospitals to estimate total transfers in 1999. Medical Directors of NHS Trusts receiving the patients supplied durations of stay in critical care and other facilities. NHS Reference Costs were applied.

RESULTS

There were 158 emergency transfers (plus 105 planned transfers, and 18 as a result of funding problems). Proportionately more emergency transfers were from hospitals lacking intensive care facilities. Patients over 65 years old constituted 61 per cent of transfers but only 25 per cent of all cases. Transfer followed major abdominal surgery in 42 (26 per cent) cases and major orthopaedic surgery in 31 (20 per cent), although these treatments constituted only 2 per cent and 3 per cent of the caseloads. There were an estimated 749 emergency transfers in 1999 (95 per cent confidence interval 640-875), a risk of 1 in 956 (all ages) and 1 in 392 (aged over 65); 729 had been funded privately, of whom two-thirds became NHS patients after transfer, costing Pound Sterling 2.61 million.

CONCLUSIONS

The scale of emergency transfer (two per day) and resulting cost to the NHS is small. The risk is reducible if patients and interventions are matched to hospitals' critical care capabilities. Common clinical service guidelines should apply to NHS and independent hospitals.

[Assessment of the promotion of breastfeeding in public and private maternities of São Paulo city, Brazil]

OBJECTIVE

The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) carried out a study to compare and evaluate the practices of protecting, promoting and supporting breastfeeding in public and private hospitals using the "ten steps" of the Hospital Initiative (BFHI) as a reference parameter.

METHODS

Forty-five hospitals of the municipality of São Paulo participated in the study. Data on the practices of infant feeding were collected by interviewing nurseries' supervisors of all public hospitals (26), and from a random sample of private hospitals (19), corresponding to a third of the total, during the years 1996-1997.

RESULTS

More than a quarter of the public hospitals and more than one third of the private hospitals did not comply with any of the BFHI steps. Seven of the "ten steps" were observed in only two public hospitals. In general, practices of protection, promotion, and support of breastfeeding were seen at a higher frequency in public hospitals.

CONCLUSIONS

The present study shows that practices considered detrimental to the onset and progressing of breastfeeding - unnecessary separation of the mother and her newborn, restrictions regarding the length of time and frequency of breastfeeding, use of pre-lacteal foods and supplements - are still quite frequently observed in public and private hospitals within the city of São Paulo. Given the benefits of breastfeeding for both the mother's and their children's health, and the important role maternities play for an early and successful onset of breastfeeding, it is paramount that the BFHI patterns be adopted by hospitals within the municipality of São Paulo.

Length of stay as a source of bias in comparing performance in VA and private sector facilities: lessons learned from a regional evaluation of intensive care outcomes

OBJECTIVES

Compare intensive care unit (ICU) mortality and length of stay (LOS) in a VA hospital and private sector hospitals and examine the impact of hospital utilization on mortality comparisons.

RESEARCH DESIGN

Retrospective cohort study.

SUBJECTS

Consecutive ICU admissions to a VA hospital (n = 1,142) and 27 private sector hospitals (n = 51,249) serving the same health care market in 1994 to 1995.

MEASURES

Mortality and ICU LOS were adjusted for severity of illness using a validated method that considers physiologic data from the first 24 hours of ICU admission. Mortality comparisons were made using two different multivariable techniques.

RESULTS

Unadjusted in-hospital mortality was higher in VA patients (14.5% vs. 12.0%; P = 0.01), as was hospital (28.3 vs. 11.3 days; P <0.001) and ICU (4.3 vs. 3.9 days; P <0.001) LOS. Using logistic regression to adjust for severity, the odds of death was similar in VA patients, relative to private sector patients (OR 1.16, 95% CI 0.93-1.44; P = 0.18). However, a higher proportion of VA deaths occurred after 21 hospital days (33% vs. 13%; P <0.001). Using proportional hazards regression and censoring patients at hospital discharge, the risk for death was lower in VA patients (hazard ratio 0.70; 95% CI 0.59-0.82; P <0.001). After adjusting for severity, differences in ICU LOS were no longer significant (P = 0.19).

CONCLUSIONS

Severity-adjusted mortality in ICU patients was lower in a VA hospital than in private sector hospitals in the same health care market, based on proportional hazards regression. This finding differed from logistic regression analysis, in which mortality was similar, suggesting that comparisons of hospital mortality between systems with different hospital utilization patterns may be biased if LOS is not considered. If generalizable to other markets, our findings further suggest that ICU outcomes are at least similar in VA hospitals.

Integrated care pathways in the private sector

ICPs are evidence- and outcome-based. The variances they expose can be analysed along with audit data. ICPs provide a useful audit tool, provided they are acted upon.

[Target controlled infusion (TCI) anesthesia using propofol. Assessment of training and practice in the operating room]

OBJECTIVE

To evaluate overall awareness of TCI and the need for training in the TCI technique. To assess, among trained anaesthetists, the value of the session and the impact of TCI technique on their working practice.

STUDY DESIGN

Two prospective domestic surveys during the first quarter of 1999.

METHODS

Three hundred anaesthetists representative of French anaesthetists as a whole, and 336 anaesthetists who had taken part in a training course.

RESULTS

The notoriety of TCI was high and greater in the public sector compared with the private sector. Almost 3/4 of anaesthetists believed that training was necessary but only four anaesthetists out of ten TCI users said they had taken part in training sessions. After the training session nine anaesthetists out of ten became TCI users and would have recommended the training course despite the low number and variety of anaesthetic procedures observed during the practical part of training. The main difficulties reported during initial use were the choice of target concentrations and the management of drug interactions. Familiarisation to the technique was rapid (less than 20 procedures). Despite the lack of long experience (< 6 months for more than 2/3 of them), TCI appeared to be more likely used for anaesthesia of average duration.

CONCLUSIONS

TCI was perceived to be an innovative concept with a requirement of a specific training. This preliminary appraisal of training sessions was generally satisfactory but underline a need for future training sessions focused on practical aspects.

ACHS Quality Awards 2000. Quality is the way we do business

Hollywood Private Hospital recognized that the use of quality management processes can achieve numerous benefits; however, for this to occur quality must be regarded as normal business practice rather than a separate programme. Therefore, the means of ensuring a quality service must be embedded in the strategic plans of both the organization and individual departments. The Hollywood Private Hospital Executive committed the organization to this approach further building on the 'core values' of the hospital by: integrating quality into the Strategic Planning of the organization; integrating risk management into the existing quality system; further embedding of the core values into the culture of the organisation; introducing systems thinking into the organization; taking a process improvement approach to improving quality; involving staff in Quality Action Teams and utilizing the Evaluation and Quality Improvement Programme as the management framework to co-ordinate all the above.

[Regional program to improve the quality of blood transfusions in hospitals: experience of the Poitou-Charentes region]

In the Poitou-Charentes area, a regional pilot program was implemented over a two year-period to improve transfusion safety in public and private hospitals. This program consisted in: (i) an evaluation of the transfusion chain in hospitals; (ii) a regional program to guide hospitals in improving the quality process. Five workgroups were set up. Three persons in each hospital should participate in the workgroup: one representing the administration, one the medical staff and one the nursing staff. After a six months follow-up several hospitals were prompted to implement corrective and preventive measures to improve transfusion safety; (iii) a letter was regularly published to contribute to set-up a regional haemovigilance network. Such a quality improvement program revealed to be a relevant method to steer the changing blood transfusion process in hospitals.

Private healthcare. Let's drink to that

The Commission for Health Improvement will have authority to monitor private hospitals treating NHS patients. The private sector will be subject to the NHS complaints procedure. The issue of medical staffing for private hospitals needs to be addressed. The uneven spread of private facilities across the country undermines the partnership. Arrangements to cut NHS waiting lists will reduce demand for private medical insurance.

Preventive services advertised to the public by private hospitals in Hong Kong

To evaluate the preventive activities offered to the public by private hospitals in Hong Kong, we obtained information from 11 of the 12 private hospitals about their screening programmes and evaluated them against the standards of the Canadian and United States task forces on preventive health care. We found that not all proven preventive activities are being offered, and many unproven or even possibly harmful actions are provided. The services focus on the application of technology rather than on behaviour change and immunisation, which are the most effective preventive strategies. This focus on testing may give the wrong impression to the public and divert effort from these worthwhile actions. A clear guideline focused on Hong Kong epidemiology and health care would be helpful.