[Local, central and regional functions. Obsolete concepts?]

As a consequence of the regionalization of the health services in Norway hospitals were given either local, central or regional responsibility. This system was intended to improve the availability of expertise and costly equipment, and at the same time reduce the growth of expenditures on health care. In the last few years, however, many of the smaller hospitals have improved their technical and medical skills to such an extent that this classification system has become less meaningful. Aker hospital in Oslo carries out local, central and regional functions. In a prospective study at this hospital we found that 88% of 980 consecutive medical admissions could be classified as local hospital admissions. Only 5% of the patients needed service at the central level, and 5% at the regional level. In our opinion it would suffice to have two types of hospital ("treatment levels"), standard hospitals and referral hospitals.

Outcomes of care within a multiple-case study in the evaluation of the experimental National Health Service nursing homes

This paper reports outcome data from a multiple-case study of the three experimental NHS nursing homes and six hospital wards undertaken as part of the evaluation of the experimental NHS nursing homes. While all subjects were very frail, NHS nursing home residents were found to be less frail than those in hospital wards. Significant differences in favour of the NHS nursing homes were found in the proportion of subjects engaged in meaningful activity during the mornings and afternoons, in the amount of activity and contact with others during the hour preceding lunchtime, and in amount of verbal interactions over lunchtime, particularly when choices were offered. These outcome data support the findings of other studies carried out as part of the evaluation that there is no evidence to imply that continuing-care accommodation should not be provided in NHS nursing homes.

[Centralized treatment of extensive burns in Norway]

About 800 patients are admitted annually to Norwegian hospitals for burn injuries. Among these, about 5% (40) patients have extensive burns, and 80-110 have special burns (skinburns combined with inhalation injuries, burns of the hands and burns of the face). The National Burn Center at Haukeland Hospital was opened in October 1984. In our experience decreased mortality, reduced disability and quicker rehabilitation are achieved when extensive and special burns are treated in specialized burn units.

[Can surgeons be in charge of an obstetric department?]

At Rana sykehus there are neither obstetricians nor pediatricians. The obstetric ward is run by the surgeons. Pregnant women suspected of being at increased risks are transferred to Nordland Sentralsykehus before the expected delivery. The following data were obtained by analyzing 1,009 deliveries. 19.2% of all the deliveries needed emergency assistance by a doctor. Emergency cesarean section was performed in 6.2% of the cases, and vacuum extraction was needed in 3.2%. Elective cesarean section was done in 4.9% of all births. Emergency and elective cesarean section together made up 11.1% of the 1009 deliveries. The cesarean section rates were lower than the average number in Nordland and in the country as a whole. The perinatal death rate was lower than the average rate for the rest of the country (0.49% versus 0.8%). Infants with potential dangerous conditions were transferred for pediatric care at Nordland Sentralsykehus (3.96%). Our conclusion is that general surgeons can be responsible for an obstetric ward, when it is done voluntary, and it is approved by a responsible obstetrician. In our area there is a need for an obstetric ward, and the surgeons here have built a certain expertise in obstetrics. In difficult cases, however, the surgeons always consult the obstetricians and pediatricians at Nordland Sentralsykehus for evaluation of the patients.

[Reflections on the timeliness and utility of an ambulatory glaucoma center as part of the Colţea Ophthalmologic Clinic and the Bucharest Municipal Hospital]

The paper presents several remarks on opportunity and usefulness of the centre for outpatient follow up of glaucoma within the "Colţea" Ophthalmology Clinic and of the Bucharest Municipal Hospital. The unconfirmed, suspected patients were not considered glaucomatous. The exam of the eye has to be complete, to include the systematic investigation of the ocular tension, and of the visual field, by evidencing scotoma in Bjerrum's area photometric disharmonies and chromatic alterations. A special attention must be paid to the low pressure glaucoma, as a peculiar evolution form of glaucoma with open angle.

[Has regionalization fulfilled administrative expectations? Work load, utilization and therapeutic costs at somatic hospitals in Oslo]

Regionalization of the health system in Oslo has equalized pressure of work in the hospitals and improved utilization of available hospital beds. The Local Authorities have succeeded in restricting the increase in hospital costs through improved economic control. The study documents a considerable overcapacity of acute care beds and large differences between the hospitals in regard to waiting lists for surgical operations. Health care planners are recommended to give priority to the home care services and nursing homes, and at the same time reduce the number of acute care beds.

[Regionalization in Oslo. Attitude of health personnel]

A mail survey conducted among physicians, nurses and ambulance personnel in Oslo revealed considerable support for regionalization of the city's hospital services. The physicians would prefer to reduce the larger hospital regions and increase the smaller ones in order to improve collaboration between hospitals and other public health services. All health care workers strongly emphasized a need for a more flexible practice of the system with regard to regional boundaries.

[Attitudes of the population and patients to regionalization in Oslo]

A representative sample of the population of Oslo was interviewed, and a sample of patients discharged from Oslo-hospitals were surveyed using a standardized questionnaire which focused on their attitudes towards the regionalization of the health services in Oslo. The results clearly demonstrate that the patients and the population at large both have full confidence in Oslo's hospitals. In general, the patients felt secure that their regional hospital had both the capacity and expertise to take proper care of them. Only a small minority would have changed hospital if this had been possible. The majority were in favour of the present regionalization principle, and prefer this to an arrangement where they could choose a hospital themselves.

[Is regionalization disadvantageous for patients? A registration study based on ambulance transports in Oslo]

The number of transferrals between Oslo hospitals has been doubled since the hospital system was regionalized in 1982. Essentially, this development may be explained by the increased need to refer patients to the highly specialized hospitals because of recent years advances in medical technology. During a two month period in 1988, 4,841 admissions to hospitals in Oslo were registered, and 917 transferrals between hospitals. We found that patient-transport was adequate in 92% of the cases. However, ambulance personnel reported 389 cases (8%) of delayed admissions and unnecessary transferrals between the hospitals. In most cases, the real cause of the problems was a too rigid attitude among health workers. The inflexibility of the present system seems to be a major threat to the principle of regionalization. We propose a simple set of rules which will protect the principle and also the requests of the patients.

[Should hospitals be allowed to transfer surplus patients? A study of the patient load situation at medical and surgical wards in regionalized hospitals in Oslo]

The regionalization arrangements in Oslo are based on each regional hospital having a clearly defined geographical catchment area. This paper considers the patient load in these four regional hospitals during the course of a year and discusses whether a cooperative arrangement should be introduced so that overloaded hospitals are permitted to transfer surplus patients to other hospitals. This arrangement is not considered advisable for the following reasons: Firstly, there is rarely enough space; secondly, peak loads usually occur at the same time; and finally, such an arrangement would tend to undermine the advantages of each regional hospital having its own defined sphere of responsibility.

Quality assurance for HIV-related care

Now that models of care for numerous HIV-related conditions have been defined, a knowledge base exists for developing protocols of appropriate, high-quality care for HIV-infected patients. Bronx Municipal Hospital Center in New York City plans to implement a monitoring and evaluation program for HIV-related care that would establish protocols and indicators of quality and appropriateness, monitor compliance with protocols, and generate recommendations for improving care. At present, Bronx Municipal's AIDS consultation service has drafted guidelines for developing indicators of appropriate diagnosis, clinical course, and drug usage for HIV-infected patients, as well as guidelines for reviewing medical records.

The need for a do-not-resuscitate policy in a public city hospital

Data were collected over a six-month period from in-hospital cardiopulmonary resuscitation (CPR) patients (aged 18 years and older) who were admitted to a public hospital. The sample population was mostly male (55.4 percent), primarily black (90.6 percent), with a mean age of 61 years. Medical expenses for these patients were largely covered by public funds or medical charities, reflecting the predominately low socioeconomic status of the population. The proportion of patients discharged alive after in-hospital CPR was 6.1 percent. The CPR sample contains a large proportion of patients in the terminal phase of diseases such as metastatic cancer, acquired immune deficiency syndrome (AIDS), and end-stage liver disease. Chart reviews revealed that do-not-resuscitate (DNR) orders were not presented as a therapeutic option to either patient or family in the majority of instances. These findings indicate a need to develop standards and strategies for decision making about the use of CPR specific to this population.

Measuring hospital performance. A non-parametric approach

In this paper a technique for assessing the relative performance of firms is introduced and applied to a sample of hospitals in California. Hospitals are compared on the basis of their relative technical efficiency. The reference technology is constructed from observed outputs and inputs (including physicians) using programming techniques, and efficiency is assessed relative to the frontier of the technology using measures similar to those suggested by Farrell. The technique used here imposes no prespecified functional form, allows for multiple outputs and inputs (allowing for differences in case mix), and yields information on the productive performance of individual hospitals. This technique can also be used to determine whether different types of hospitals use different technologies. Our results, although illustrative rather than definitive, suggest that ownership affects 'efficiency' as measured here: public and NFP hospitals have 'different' best practice frontiers, and public hospitals appear to use relatively fewer resources. These results could reflect differences in quality of care by ownership.