The debate over specialty hospitals: how physician-hospital relationships have reached a new fault line over these "focused factories"

Within the last 20 years, the fragile symbiotic relationship between physicians and hospitals has become increasingly strained. Physicians have created new healthcare delivery systems, including a host of for-profit, physician-owned specialty hospitals. Proponents of specialty hospitals argue that they provide high quality facilities and allow for innovative treatments. Opponents, however, contend that such hospitals "cherry pick" patients who otherwise would help to subsidize general hospitals, and point to the various fraud and abuse issues raised by physician-owned specialty hospitals. This Article examines the specialty hospital phenomenon and the arguments for and against such entities. It also analyzes whether an extension of the present federal moratorium on the construction of new physician-owned specialty hospitals is in the best interests of the country's healthcare system. The author concludes that the data are unclear as the overall impact of such hospitals and that they should not be further constrained until when and if the facts are clear.

Stakeholder perspectives on outpatient services performance: what patients, clinicians and managers want to know

The development of performance measures in outpatient services is trailing in the wake of an emphasis on inpatient measures. Research was undertaken at The Royal Victorian Eye and Ear Hospital (RVEEH) to determine key areas for the development of performance measures in eye outpatient services from the perspective of three stakeholder groups: clinicians, managers and patients. The study identified four key areas for the development of performance measurement: waiting time to first outpatient appointment, patient discharge from outpatient clinics, waiting time in clinic and patient throughput. It was also shown that there are some significant differences of opinion between stakeholder groups. Such similarities and differences are unlikely to be unique to RVEEH and may serve as useful prompts for other organisations considering outpatient performance measures.

A survey of tuberculosis hospitals in India

SETTING

Hospitals with beds for tuberculosis (TB) in India.

OBJECTIVES

To assess diagnostic and treatment practices at institutions offering secondary or tertiary level care for TB patients, and to determine the resources being used at these institutions.

DESIGN

Countrywide cross-sectional survey of TB hospitals using a mailed semi-structured questionnaire sent to all 105 hospitals with 100 or more beds and to all State Directorate Health Services.

RESULTS

The 94 hospitals that returned the questionnaire had 15773 TB beds, one third of the total TB beds in the country. Nearly 1 million patients sought treatment in the TB hospitals and one third were diagnosed with TB; the ratio of smear-positive to smear-negative patients was 1:2.7. Sixty-four per cent of hospitals prescribed unobserved rifampicin in the continuation phase, and 56% of sputum smear-positive patients were hospitalised. The annual expenditure for the TB hospitals was more than the total annual budget for the TB control programme of the country.

CONCLUSIONS

In view of the high number of patients seen and the suboptimal practices observed, urgent steps should be taken to ensure implementation of correct diagnostic and treatment policies in hospitals with TB beds.

Retrospective descriptive study of adult tuberculosis in Wuhan, China

OBJECTIVE

To determine the rate and associated factors of adult tuberculosis (TB) in the central Chinese city of Wuhan.

DESIGN

A retrospective descriptive study of 417 patients registered for TB treatment from 1 January to 31 December 2001.

RESULTS

The mean age of admission was 38.47 (median 35) years, with males aged 20-40 years mostly affected; 191 (45.8%) TB patients were classified as smear-positive, 221 (53%) smear-negative and for five (1.2%) the sputum results were not known. Of all admissions, 43 (10.32%) were retreatment cases and 50 (11.99%) were diagnosed as extra-pulmonary TB. All patients were treated under the DOTS strategy, with 391 (93.76%) cures, five (1.2%) treatment completed, five (1.2%) treatment failures, four (0.96%) deaths, three (0.72%) defaults and nine (2.16%) transfers out. Cure was associated with age (chi2 = 3.92, P < 0.05), but not with sex, retreatment TB, extra-pulmonary TB, type of treatment regimen, BCG status or delay in treatment (P > 0.05).

CONCLUSION

DOTS provides high TB cure rates. The reasons for the low detection rates, high retreatment rates and the increasing number of young adults affected by TB need further elucidation. For these purposes, routine human immunodeficiency virus screening and sputum culture for multidrug-resistant tuberculosis and case detection may be required.

Evaluating rural nursing home environments: dementia special care units versus integrated facilities

Although one in four seniors currently lives in a rural area, little is known about the capacity of rural nursing homes to provide specialized dementia services. The physical and social environments are increasingly recognized as important factors in the quality of life and functional ability of persons with dementia. This study compared eight rural nursing homes (those located in centres with populations < or =15,000) that had created dementia Special Care Units (SCUs) to eight same-sized rural nursing homes that did not have SCUs. Outcomes were assessed in relation to residents, staff, family members, and the environment. In this paper we describe the overall study design and findings from the environmental assessment. Analysis of variance (ANOVA) was used to compare the SCU versus non-SCU environments on the nine dimensions of the Physical Environmental Assessment Protocol (PEAP), which was used to assess the physical environment. The SCUs were more supportive on six dimensions: maximizing awareness and orientation, maximizing safety and security, regulation of stimulation, quality of stimulation, opportunities for personal control, and continuity of the self. Analysis of variance was also used to compare the groups on the six subscales of the Nursing Unit Rating Scale (NURS), which assesses the social environment of dementia care settings. The SCUs were more supportive on the Separation and Stimulation subscales, indicating that SCUs had greater separation of residents with dementia from other residents for activities of daily living and programming, and better control of non-meaningful stimulation.

[Prevalence of mycelial fungi in hematological hospital]

AIM

To study prevalence, quantity and species of mycelial fungi in the air of a hematological hospital.

MATERIAL AND METHODS

Air samples in the hematological departments were taken monthly by PU-1B device in the volume 250 l/min. Seeding and identification of mycelial fungi were made on the Chapeck medium.

RESULTS

Tests for mycelial fungi in the air was 95%. Dominating species were the following: Penicillium spp., Cladosporium spp., Aspergillus spp. The fungal contamination was seasonal. Maximal isolation of Penicillium spp was seen in winter and autumn. Aspergillus spp. is represented with 13 species of which most frequent were A.versicolor, A. niger, A. fumigatus, A. ochraceus, A. flavus. Pathological material from 19 patients contained Aspergillus spp.: A. fumigatus, A. flavus, A. niger. The isolation peak was in autumn-winter and coincided with maximal isolation of fungal spores from the air. The analysis of air samples taken in the wards where patients had Aspergillus spp. in biomaterials showed that concentration of spores Aspergillus spp. was higher than in nearby wards and corridor: 45.6 CFU/M3 vs 18.8 CFU/m3 and 24.7 CFU/M3, respectively. However, morphologically identical strains (patient-air) were recognized only in 4 cases from the nearby wards and corridor. None of the air samples taken in the ward of the patient contained identical species. Minimal amount of the spores of micromycetes was registered in the wards furnished with ventilation with laminar air flow. Most contaminated was the air of 4 bed wards in the old building.

CONCLUSION

Mycological monitoring of the air in hematological departments determined the structure of mycelial fungi complexes. Though ambient air in the wards is full of fungi, detection of morphologically identical strains causing invasive mycosis in immunocompromised patients is rare. Further studies are necessary.

[Arrangement of specialized public health care and the work experience of the gastroenterological center]

Arrangement of consulting gastroenterological centers at multi-type clinical hospitals makes it possible to render highly qualified medical care for adults, establish schools for training patients, render significant methodical assistance to medical staff on a permanent basis, especially during the period of the public health care system reorganization.

[Promoting the efficient functioning of an ophthalmologic hospital]

A model of hospital management, i.e. a state regional ophthalmologic clinic, was designed on the basis of the Republican Clinical Hospital for Ophthalmology of the Udmurt Ministry of Health. Apart from the basic typical elements, its structure comprises the research-and-production units (as finances sources) and investment technologies. Described in the paper are related components and an analysis of the medical-and-economic efficiency of using the above model.

Establishment of primary stroke centers: a survey of physician attitudes and hospital resources

OBJECTIVES

To survey US physicians involved in acute stroke care to determine the proportion of hospitals that currently meet the recommended Brain Attack Coalition (BAC) criteria for Primary Stroke Centers (PSC) and obtain opinions regarding the value of stroke centers.

METHODS

A survey regarding the BAC guidelines for the establishment of stroke centers was mailed to 3,245 US neurologists, neurosurgeons, and emergency physicians.

RESULTS

A total of 1,032 responses were received. Seventy-nine percent (range by specialty 58 to 98%) of respondents believed there was a need for stroke centers. If formal stroke center designation were established, 81% (range 72 to 90%) would like their hospital to become a PSC. Although 77% of respondents believed that their hospital currently met recommended criteria for a PSC, only 7% actually meet all recommended elements. However, 44% of hospitals already provide most acute stroke services. The BAC criteria most frequently lacking were continuing medical education for professional stroke center staff, stroke training for emergency department staff, formal establishment of a stroke unit, and designation of a stroke center director.

CONCLUSIONS

The majority of emergency medicine and neuroscience physician respondents involved in acute stroke care support the designation of primary stroke centers. Although respondents globally overestimated the extent to which their facilities currently meet BAC recommended criteria for PSC, detailed responses suggested that over 40% of hospitals possess substantial existing acute stroke care resources and are poised to function as PSC with modest additional administrative and financial commitment.

Is ophthalmology evidence based? A clinical audit of the emergency unit of a regional eye hospital

AIM

To evaluate the proportion of interventions that are evidence based in the acute care unit of a regional eye hospital.

METHODS

A prospective clinical audit was carried out at Hong Kong Eye Hospital in July 2002 to investigate the extent to which ophthalmic practices were evidence based. The major diagnosis and intervention provided were identified through chart review. A corresponding literature search using Medline and the Cochrane Library was performed to assess the degree to which each intervention was based on current, best evidence. Each diagnosis intervention pair was accordingly analysed and graded. The level of best, current evidence supporting each intervention was graded and analysed.

RESULTS

A total of 274 consecutive consultation episodes were examined. 22 cases were excluded since no diagnosis or intervention was made during the consultation. 108 (42.9%) patient interventions were found to be based on evidence from systematic reviews, meta-analyses, or randomised controlled trials (RCT). Evidence from prospective or retrospective observational studies supported the interventions in 86 (34.1%) patients. In 58 (23.0%) cases, no evidence or opposing evidence was found regarding the intervention. The proportion of evidence based on RCT or systematic reviews was higher for surgical interventions compared with non-surgical interventions (p=0.007). The proportion of interventions based on RCT or systematic reviews was higher for specialist ophthalmologists than trainee ophthalmologists (p=0.021).

CONCLUSION

This study demonstrated that the majority of interventions in the ophthalmic unit were evidence based and comparable to the experience of other specialties.

Delivery of photocoagulation treatment for diabetic retinopathy at a large Australian ophthalmic hospital: comparisons with national clinical practice guidelines

OBJECTIVE

To determine if the delivery of photocoagulation for diabetic retinopathy at a large Australian ophthalmic hospital conforms with Australian National Health and Medical Research Council clinical practice guidelines.

METHODS

A retrospective medical record review was conducted of all patients who had initial laser treatment for diabetic retinopathy at the Royal Victorian Eye and Ear Hospital from January 1997 to December 1998.

RESULTS

The study included 322 eyes from 203 patients. The mean age was 65.8 years (range 18-89 years) and the mean duration of diabetes was 14.7 years (range 1-40 years). Panretinal photocoagulation (PRP) alone was performed in 37 eyes over a mean number of 2.6 sessions. The median waiting time for these procedures was 14 days (range 0-146 days) and the median follow-up time was 7.1 weeks (range 1-25 weeks). Focal treatment was performed (without PRP) in 238 eyes and 55.5% of these cases required repeat focal treatment for persistent clinically significant macular oedema. Median waiting time for focal treatment was 20 days (range 0-302 days) and the median follow-up time after treatment was 12.1 weeks (range 1.7-42.0 weeks). Focal and PRP treatment was used in 47 eyes that had maculopathy concurrently with proliferative retinopathy. Focal treatment was applied before (or at the same session as) the PRP wherever possible.

CONCLUSIONS

The study indicates that the application of photocoagulation and follow up for diabetic retinopathy at this tertiary referral institution conforms closely with Australian clinical practice guidelines.

[Quality management at the University Hospital and Orthopedic Hospital of French-speaking Switzerland: coherence in diversity]

All hospitals in Switzerland will have to set up and run a quality management system, according to legal and contract requirements. However, their context and characteristics are quite different, and will have an impact on the type of system they will select and implement. The University Hospital in Lausanne and the Hôpital Orthopédique de la Suisse Romande are neighbour hospitals, which run an orthopaedic ward on both locations. Despite their different sizes, they need a common philosophy and collaboration to set up and run their quality management system. The different stages, strengths and difficulties of both projects are described and compared. The illustrate how coherent the two projects can be despite their initial diversity.

Three specialty hospitals discover 'special' formats

Each of the winning entries in this category presents a high volume of information in a unique format. First place winner Woman's Hospital, Baton Rouge, La., uses a stand-up desk calendar. Miami Children's Hospital, Miami, Fla., uses a magazine format to round up the hospital's 50th anniversary activities. And, third place winner La Rabida Children's Hospital, Chicago, uses an information-packed set of note cards to spread the good word.