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Teixeira et al. showed that patients admitted to the intensive care unit of a teaching hospital in a non-metropolitan region needed more support, had worse prognostic indices, and had a higher nursing workload in the first 24 hours of admission. In addition, worse outcomes, including mortality, need for dialysis, pressure injury, infection, prolonged mechanical ventilation, and prolonged hospital stay, were observed in the teaching hospital. Worse outcomes were more prevalent in the teaching hospital. Understanding the importance of teaching hospitals to implement well-established care protocols is critical., Objective: To compare the clinical outcomes of patients admitted to the intensive care unit of teaching (HI) and nonteaching (without an academic affiliation; H2) hospitals., Methods: In this prospective cohort study, adult patients hospitalized between August 2018 and July 2019, with a minimum length of stay of 24 hours in the intensive care unit, were included. Patients with no essential information in their medical records to evaluate the study outcomes were excluded. Resuslts: Overall, 219 patients participated in this study. The clinical and demographic characteristics of patients in H1 and H2 were similar. The most prevalent clinical outcomes were death, need for dialysis, pressure injury, length of hospital stay, mechanical ventilation >48 hours, and infection, all of which were more prevalent in the teaching hospital., Conclusion: Worse outcomes were more prevalent in the teaching hospital. There was no difference between the institutions concerning the survival rate of patients as a function of length of hospital stay; however, a difference was observed in intensive care unit admissions.

Introduction: The incidence of peptic ulcer disease (PUD) has been decreasing over time with Helicobacter pylori eradication and use of acid-suppressing therapies. However, PUD remains a common cause of hospitalization in the United States. We aimed to evaluate contemporary national trends in the incidence, treatment patterns, and outcomes for PUD-related hospitalizations and compare care delivery by hospital rurality., Methods: Data from the National Inpatient Sample were used to estimate weighted annual rates of PUD-related hospitalizations. Temporal trends were evaluated by joinpoint regression and expressed as annual percent change with 95% confidence intervals (CIs). We determined the proportion of hospitalizations requiring endoscopic and surgical interventions, stratified by clinical presentation and rurality. Multivariable logistic regression was used to assess independent predictors of in-hospital mortality and postoperative morbidity., Results: There was a 25.8% reduction (P < 0.001) in PUD-related hospitalizations from 2005 to 2014, although the rate of decline decreased from -7.2% per year (95% CI: 13.2% to -0.7%) before 2008 to -2.1% per year (95% CI: 3.0% to -1.1%) after 2008. In-hospital mortality was 2.4% (95% CI: 2.4%-2.5%). Upper endoscopy (84.3% vs 78.4%, P < 0.001) and endoscopic hemostasis (26.1% vs 16.8%, P < 0.001) were more likely to be performed in urban hospitals, whereas surgery was performed less frequently (9.7% vs 10.5%, P < 0.001). In multivariable logistic regression, patients managed in urban hospitals were at higher risk for postoperative morbidity (odds ratio 1.16 [95% CI: 1.04-1.29]), but not death (odds ratio 1.11 [95% CI: 1.00-1.23])., Discussion: The rate of decline in hospitalization rates for PUD has stabilized over time, although there remains significant heterogeneity in treatment patterns by hospital rurality., (Copyright © 2020 by The American College of Gastroenterology.)

Importance: Emergency department (ED) visits are common and increasing. Whether outcomes associated with care in the ED are improving over time is largely unknown to date., Objective: To examine trends in 30-day mortality rates associated with ED care among Medicare beneficiaries aged 65 years or older., Design, Setting, and Participants: This cross-sectional study used a random 5% sample in 2009 and 2010 and a 20% sample from 2011 to 2016, for a total of 15 416 385 ED visits from 2009 to 2016 among Medicare beneficiaries aged 65 years or older., Exposures: Time (year) as a continuous variable., Main Outcomes and Measures: The primary outcome was 30-day mortality, overall and stratified by illness severity and hospital characteristics. Secondary outcomes included mortality rates on the day of the ED visit (day 0) as well as at 7 and 14 days. Changes in disposition from the ED (admission, observation, transfer, died in the ED, and discharged) over time were also examined., Results: The sample included 15 416 385 ED visits (60.8% women and 39.2% men; mean [SD] age, 78.6 [8.5] years) at 4828 acute care hospitals. The percentage of patients discharged from the ED increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality declined from 5.1% in 2009 to 4.6% in 2016 (-0.068% per year; 95% CI, -0.074% to -0.063% per year; P < .001). After adjusting for hospital random effects, patient demographics, and chronic conditions, the adjusted 30-day mortality trend was -0.198% per year (95% CI, -0.204% to -0.193% per year; P < .001). The magnitude of this trend was greatest for patients with a high severity of illness (-0.662%; 95% CI, -0.681% to -0.644%; P < .001), followed by those with a medium severity of illness (-0.103% per year; 95% CI, -0.108% to -0.097% per year; P < .001) and those with a low severity of illness (-0.009% per year; 95% CI, -0.006% to -0.011% per year; P < .001). Declines in mortality were seen in each category of ED disposition, including visits resulting in admission (-0.356% per year; 95% CI, -0.368% to -0.343% per year; P < .001) as well as those resulting in discharge (-0.059% per year; 95% CI, -0.064% to -0.055% per year; P < .001). The decline was greater for major teaching hospitals (compared with nonteaching hospitals), nonprofit hospitals (compared with for-profit hospitals), and urban hospitals (compared with rural hospitals)., Conclusions and Relevance: Among Medicare beneficiaries receiving ED care in the United States, mortality within 30 days of an ED visit appears to have declined in recent years, particularly for patients with the highest severity of illness, even as fewer patients are being admitted from an ED visit. This study's findings suggest that further study is needed to understand the reasons for this decline and why certain types of hospitals are seeing greater improvements in outcomes.

Background: Approximately 40,000 newborns die each year in Tanzania. Regional differences in outcome are common. Reviewing current local data, as well as defining potential causal pathways leading to death are urgently needed, before targeted interventions can be implemented., Objective: To describe the clinical characteristics and potential causal pathways contributing to newborn death and determine the presumed causes of newborn mortality within seven days, in a rural hospital setting., Methods: Prospective observational study of admitted newborns born October 2014-July 2017. Information about labour/delivery and newborn management/care were recorded on data collection forms. Causes of deaths were predominantly based on clinical diagnosis., Results: 671 were admitted to a neonatal area. Reasons included prematurity n = 213 (32%), respiratory issues n = 209 (31%), meconium stained amniotic fluid with respiratory issues n = 115 (17%) and observation for < 24 hours n = 97 (14%). Death occurred in 124 infants. Presumed causes were birth asphyxia (BA) n = 59 (48%), prematurity n = 19 (15%), presumed sepsis n = 19 (15%), meconium aspiration syndrome (MAS) n = 13 (10%) and congenital abnormalities n = 14 (11%). More newborns who died versus survivors had oxygen saturation <60% on admission (37/113 vs 32/258; p≤0.001) respectively. Moderate hypothermia on admission was common i.e. deaths 35.1 (34.6-36.0) vs survivors 35.5 (35.0-36.0)°C (p≤0.001). Term newborns who died versus survivors were fourfold more likely to have received positive pressure ventilation after birth i.e. 4.57 (1.22-17.03) (p<0.02)., Conclusion: Intrapartum-related complications (BA, MAS), prematurity, and presumed sepsis were the leading causes of death. Intrapartum hypoxia, prematurity and attendant complications and presumed sepsis, are major pathways leading to death. Severe hypoxia and hypothermia upon admission are additional contributing factors. Strategies to identify fetuses at risk during labour e.g. improved fetal heart rate monitoring, coupled with timely interventions, and implementation of WHO interventions for preterm newborns, may reduce mortality in this low resource setting., Competing Interests: The authors have declared that no competing interests exist.

Background To manage overcrowding and bed shortages in Canadian hospitals, same-day discharge (SDD) after percutaneous coronary intervention (PCI) has emerged as a solution to improve resource utilization. However, limited information exists regarding current trends, hospital variation, and safety of SDD PCI in Canada. Methods and Results We evaluated outpatients undergoing elective PCI in Ontario, Canada, from October 2008 to March 2016. SDD was defined when patients were discharged on the day of PCI, and non-SDD was defined as those patients who had 1 overnight stay. The primary outcome was 30-day all-cause death or hospitalization for acute coronary syndrome. Inverse probability of treatment weighting with propensity score was used to account for differences in baseline and clinical characteristics between SDD and non-SDD groups. Among 35 972 patients who underwent elective PCI at 17 PCI centers in Ontario, 10 801 patients (30%) had SDD PCI and 25 121 patients (70%) had non-SDD PCI. Substantial hospital variation for SDD PCI was observed, ranging from 0% to 87% during the study period. In the propensity-weighted cohort, SDD patients had no significant difference in 30-day rates of death or hospitalization for acute coronary syndrome (1.3% versus 1.6%; hazard ratio: 0.84 [95% CI, 0.65-1.08]; P=0.17) compared with non-SDD patients. SDD and non-SDD patients also had no significant difference in 30-day rates of mortality or coronary revascularization. Conclusions In this large population-based cohort of elective PCI patients, we demonstrated the safety of SDD PCI. Increased adoption of this strategy could lead to improved bed-flow efficiency and substantial savings for the Canadian healthcare system without comprising outcomes.

Objective: To assess the effect of Maryland's 2010 Total Patient Revenue (TPR) global budget reform in eight rural hospitals on population-level hospital rates of utilization three years after implementation., Data Sources/study Setting: Data on all inpatient discharges and outpatient department visits from the Health Services Cost Review Commission, population data from Claritas Demographic Reports, and county-level data from the Area Health Resource File., Study Design: We use a difference-in-differences approach to compare changes in utilization rates over time in the reform areas comprising 125 Zip Code Tabulation Areas (ZCTAs) and in two control hospital areas (66 ZCTAs and 327 ZCTAs, respectively). We examine several inpatient and outpatient measures and distinguish between relatively discretionary and nondiscretionary utilization., Data Collection: Admissions data are hospital-reported discharge abstracts of all encounters in Maryland during 2008-2013. Population data are derived from the US Census., Principal Findings: We find no statistically significant changes in admissions, either overall or discretionary. We find a statistically significant 8.9 percent (95%CI = [1.8, 16.0]) reduction in outpatient visits, with a statistically significant reduction of 14.8 percent (95%CI = [5.3, 24.3]) visits not to the Emergency Department., Conclusions: We find that the TPR reform decreased outpatient utilization but did not affect inpatient utilization., (© Health Research and Educational Trust.)

In 2010 Maryland replaced fee-for-service payment for some rural hospitals with "global budgets" for hospital-provided services called Total Patient Revenue (TPR). A principal goal was to incentivize hospitals to manage resources efficiently. Using a difference-in-differences design, we compared eight TPR hospitals to seven similar non-TPR Maryland hospitals to estimate how TPR affected hospital-provided services. We also compared health care use by "treated" patients in TPR counties to that of patients in counties containing control hospitals. Inpatient admissions and outpatient services fell sharply at TPR hospitals, increasingly so over the period that TPR was in effect. Emergency department (ED) admission rates declined 12 percent, direct (non-ED) admissions fell 23 percent, ambulatory surgery center visits fell 45 percent, and outpatient clinic visits and services fell 40 percent. However, for residents of TPR counties, visits to all Maryland hospitals fell by lesser amounts and Medicare spending increased, which suggests that some care moved outside of the global budget. Nonetheless, we could not assess the efficiency of these shifts with our data, and some care could have moved to more efficient locations. Our evidence suggests that capitation models require strong oversight to ensure that hospitals do not respond by shifting costs to other providers.

Aim: To analyse differences in children and adolescents aged ≤18 years admitted to the leprosy ward in a rural Ethiopian hospital >16 years., Methods: We retrospectively collected data from leprosy admission registry books on patients with leprosy who were admitted to a referral hospital from September 2000 to September 2016., Results: There were 2129 admissions for leprosy during the study period: 180 (8.4%) patients were s ≤ 18 years old. Of these, 98 (54.4%) were male and 82 (45.6%) were female. The proportion of new diagnoses in children and adolescents was 31.7%, significantly higher than in adults (11.7%; p < 0.001). There were also significant differences in the prevalence of lepromatous ulcers (46.9 vs. 61.7%), leprosy reaction (29.4 vs. 13.0%) and neuritis (16.9 vs.5.3%) between these age groups., Conclusions: There were more new diagnoses, leprosy reactions and neuritis, and fewer lepromatous ulcers, in children and adolescents compared with adults, with younger patients being referred more frequently to reference centres.

In a substantial shift in payment policy, the State of Maryland implemented a global budget program for acute care hospitals in 2010. Goals of the program include controlling hospital use and spending. Eight rural hospitals entered the program in 2010, while urban and suburban hospitals joined in 2014. Prior analyses, which focused on urban and suburban hospitals, did not find consistent evidence that Maryland's program had contributed to changes in hospital use after two years. However, these studies were limited by short follow-up periods, may have failed to isolate impacts of Maryland's payment change from other state trends, and had limited generalizability to rural settings. To understand the effects of Maryland's global budget program on rural hospitals, we compared changes in hospital use among Medicare beneficiaries served by affected rural hospitals versus an in-state control population from before to after 2010. By 2013-three years after the rural program began-there were no differential changes in acute hospital use or price-standardized hospital spending among beneficiaries served by the affected hospitals, versus the within-state control group. Our results suggest that among Medicare beneficiaries, global budgets in rural Maryland hospitals did not reduce hospital use or price-standardized spending as policy makers had anticipated.

Introduction: There is scarce information on the profiles of patients attended in the Emergency Departments (ED) in rural Angola., Methods: Retrospective descriptive study including all the patients treated in the ED in Hospital Nossa Senhora da Paz (Cubal) during 6 months (December 2014- May 2015). The epidemiological and clinical data collected were: age, sex, shift, service assignment, reason for consultation and outcome (discharge, admission, referral or death)., Results: A total of 2384 patients (53.4% women) were attended. The median age was 10 years (range: 0 - 96 years); 57.9% and 40.2% of them were under 17 and 5 years, respectively. No differences were observed regarding the assistance per shift, weekdays, weekends, or mean age per shift. The reason for consultation was registered in 69.9% of the patients; the most common were respiratory tract infections (20.5%), fever (14%), digestive diseases (13.6%) and malaria (10.4%). Up to 47.2% of the patients required in-hospital treatment and 1.3% were transferred to other hospitals. The patients admitted were significantly younger than the patients discharged (median age of 4 vs.16 years, p < 0.01). The mortality rate within the ED was 0.5%., Conclusion: Young patients were those who mostly required assistance in the ED. Infectious diseases were the most frequent reason for consultation. Pulmonary tuberculosis was suspected in one third of respiratory infections. The admission rate was high, especially in children under 5 years and in cases of malaria and malnutrition. Low referral rate and low mortality within the ED were observed.

Background: In response to urban-rural disparities in healthcare resources, China recently launched a healthcare reform with a focus on improving rural care during the past decade. However, nationally representative studies comparing medical care and patient outcomes between urban and rural areas in China during this period are not available., Methods and Results: We created a nationally representative sample of patients in China admitted for ST-segment-elevation myocardial infarction in 2001, 2006, and 2011, using a 2-stage random sampling design in 2 urban and 3 rural strata. In China, evidence-based treatments were provided less often in 2001 in rural hospitals, which had lower volume and less availability of advanced cardiac facilities. However, these differences diminished by 2011 for reperfusion therapy (54% in urban versus 57% in rural; P =0.1) and reversed for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (66% versus 68%; P =0.04) and early β-blockers (56% versus 60%; P =0.01). The risk-adjusted rate of in-hospital death or withdrawal from treatment was not significantly different between urban and rural hospitals in any study year, with an adjusted odds ratio of 1.13 (0.77-1.65) in 2001, 0.99 (0.77-1.27) in 2006, and 0.94 (0.74-1.19) in 2011., Conclusions: Although urban-rural disparities in evidence-based treatment for myocardial infarction in China have largely been eliminated, substantial gaps in quality of care persist in both settings. In addition, urban hospitals providing more resource-intensive care did not achieve better outcomes., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883., (© 2017 American Heart Association, Inc.)

Data are lacking on the extent and distribution of injuries in rural areas. This study aimed at comparing injury-related hospitalizations between 2002 and 2012 at a rural hospital of northern Mexico focusing on differences between indigenous (IP) and non-indigenous patients (NIP). A retrospective design based on the review of records of patients hospitalized with injury diagnoses was used. Information extracted included ethnicity, sex, age, hospital duration, surgical procedures, complications and discharge outcome. Injury data comprised of main diagnosis, mechanism and body part affected. Patterns were stratified by year and ethnicity. Logistic regression was used to determine the probability of being hospitalized for >1 day. Injury-related mortality increased from 0.4% in 2002 to 3.1% in 2012. The proportion of non-indigenous patients hospitalized also increased by 4.5%. Men accounted for two-thirds of all inpatients. Weapon involvement doubled from 16.6% to 33.6%. Almost half of the patients in 2012 were victims of interpersonal violence. Indigenous patients had a 2.7 higher adjusted odds ratios of being hospitalized for >1 day in 2002 (95% CI 1.2-5.7), though the gap was reduced to 1.9 (1.1-3.5) in 2012. While indigenous patients continue to be more disadvantaged than the non-indigenous, the gaps closed in 2012; the reasons behind these disparities need to be further investigated.

Background: Distinct strains of methicillin resistant Staphylococcus aureus (MRSA) have been identified on livestock and livestock workers. Industrial food animal production may be an important environmental reservoir for human carriage of these pathogenic bacteria. The objective of this study was to investigate environmental and occupational exposures associated with nasal carriage of MRSA in patients hospitalized at Vidant Medical Center, a tertiary hospital serving a region with intensive livestock production in eastern North Carolina., Methods: MRSA nasal carriage was identified via nasal swabs collected within 24 hours of hospital admission. MRSA carriers (cases) were gender and age matched to non-carriers (controls). Participants were interviewed about recent environmental and occupational exposures. Home addresses were geocoded and publicly available data were used to estimate the density of swine in residential census block groups of residence. Conditional logistic regression models were used to derive odds ratio (OR) estimates and 95% confidence intervals (CI). Presence of the scn gene in MRSA isolates was assessed. In addition, multi locus sequence typing (MLST) of the MRSA isolates was performed, and the Diversilab® system was used to match the isolates to USA pulsed field gel electrophoresis types., Results: From July - December 2011, 117 cases and 119 controls were enrolled. A higher proportion of controls than cases were current workforce members (41.2% vs. 31.6%) Cases had a higher odds of living in census block groups with medium densities of swine (OR: 4.76, 95% CI: 1.36-16.69) and of reporting the ability to smell odor from a farm with animals when they were home (OR: 1.51, 95% CI: 0.80-2.86). Of 49 culture positive MRSA isolates, all were scn positive. Twenty-two isolates belonged to clonal complex 5., Conclusions: Absence of livestock workers in this study precluded evaluation of occupational exposures. Higher odds of MRSA in medium swine density areas could reflect environmental exposure to swine or poultry.

Background: Although severe malaria is an important cause of mortality among children in Burkina Faso, data on community-acquired invasive bacterial infections (IBI, bacteremia and meningitis) are lacking, as well as data on the involved pathogens and their antibiotic resistance rates., Methods: The present study was conducted in a rural hospital and health center in Burkina Faso, in a seasonal malaria transmission area. Hospitalized children (<15 years) presenting with T≥38.0°C and/or signs of severe illness were enrolled upon admission. Malaria diagnosis and blood culture were performed for all participants, lumbar puncture when clinically indicated. We assessed the frequency of severe malaria (microscopically confirmed, according to World Health Organization definitions) and IBI, and the species distribution and antibiotic resistance of the bacterial pathogens causing IBI., Results: From July 2012 to July 2013, a total of 711 patients were included. Severe malaria was diagnosed in 292 (41.1%) children, including 8 (2.7%) with IBI co-infection. IBI was demonstrated in 67 (9.7%) children (bacteremia, n = 63; meningitis, n = 6), 8 (11.8%) were co-infected with malaria. Non-Typhoid Salmonella spp. (NTS) was the predominant isolate from blood culture (32.8%), followed by Salmonella Typhi (18.8%), Streptococcus pneumoniae (18.8%) and Escherichia coli (12.5%). High antibiotic resistance rates to first line antibiotics were observed, particularly among Gram-negative pathogens. In addition, decreased ciprofloxacin susceptibility and extended-spectrum beta lactamase (ESBL) production was reported for one NTS isolate each. ESBL production was observed in 3/8 E. coli isolates. In-hospital mortality was 8.2% and case-fatality rates for IBI (23.4%) were significantly higher compared to severe malaria (6.8%, p<0.001)., Conclusions: Although severe malaria was the main cause of illness, IBI were not uncommon and had higher case-fatality rates. The high frequency, antibiotic resistance rates and mortality rates of community acquired IBI require improvement in hygiene, better diagnostic methods and revision of current treatment guidelines.

Objective: The aim of this study was to determine if there is regionalization of orthognathic surgeries to teaching hospitals during the study period., Study Design: The Nationwide Inpatient Sample for years 2000-2008 was used. Every hospitalization that had an orthognathic surgery was selected. Patient and hospital level variables were examined. The odds of an orthognathic surgery procedure being performed in a teaching hospital over the study period was computed with the use of a multivariable logistic regression model., Results: During the study period, a total of 108,264 hospitalizations underwent orthognathic surgeries in the United States. The average age ranged from 27 years during the years 2006-2008 to 28.2 years during the years 2000-2002. After adjusting for multiple patient and hospital level factors, the year of procedure was not a significant predictor of increasing odds of an orthognathic surgery being performed in a teaching hospital., Conclusions: There is no evidence of concentration of orthognathic surgical procedures in teaching hospitals., (Copyright © 2013 Elsevier Inc. All rights reserved.)

In recent years, the prevalence of myocardial infarction (MI) has increased among women and decreased among men aged 35 to 54 years. To determine the extent to which changes in incidence account for recent variations in prevalence, we assessed the temporal trends in gender-specific hospitalization rates for MI. Using the Nationwide Inpatient Sample, we identified patients aged 35 to 64 years admitted to United States hospitals with a primary discharge diagnosis of MI from 1997 to 2006 (n = 2,824,615). The age-standardized MI hospitalization rates per 100,000 subjects were assessed for men and women aged 35 to 44, 45 to 54, and 55 to 64 years. The MI hospitalization rates per 100,000 subjects decreased by 26% from 168 to 126 for men and by 18% from 56 to 46 for women (both p <0.001). The reductions in the MI hospitalization rates were greatest among men aged 45 to 54, men aged 55 to 64, and women aged 55 to 64 years (standardized rates of change -3%, -4%, and -3% annually, p <0.001). The MI hospitalization rates decreased slightly for women aged 45 to 54 years and men aged 35 to 44 years (standardized rate of change -2% annually, p <0.001) and increased for women aged 35 to 44 years (standardized rate of change 2% annually, p = 0.008). In conclusion, from 1997 to 2006, men and women aged 35 to 64 years experienced an overall decrease in MI hospitalization rates; the reductions were more pronounced in men than in women. The slight increase in MI hospitalizations among women aged 35 to 44 years might have played a small role in the previously noted increases in MI prevalence among middle-age women., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Introduction: In population-based studies, transfers into hospitals and hospital deaths are typically considered to be indicators of potentially inappropriate care settings at the end of life. Despite a plethora of research into where people die, few studies have examined whether hospital transfers at the end of life differ in rural versus urban areas. In the present study hospitalizations in the last month before death in one mid-Western Canadian province were examined. The study had three main objectives, to: (1) compare hospitalizations in rural/remote with urban regions; (2) examine the role of healthcare resources in hospitalizations; and (3) explore more specifically whether day-to-day patterns of hospitalization shortly before death differ between rural/remote and urban areas., Methods: The source of data was administrative healthcare records, with the study including all adults (aged over 19 years; excluding nursing home residents) who died in the province of Manitoba in 2003-2004 (n = 6523). Whether the decedents were hospitalized in the 30 days before death was determined from hospital files. The number of hospital days incurred was counted. Region of residence was defined along regional health authority boundaries, with 7 regions identified as rural/remote and 2 as urban. Healthcare resources were measured in terms of the number of: physicians, hospital beds, nursing home beds, and home care services per 1000 population. Age, sex and trajectory groups, which categorized decedents according to their cause of death, were included in all analyses., Results: Residents of 4 of the 7 rural/remote regions had increased odds of being hospitalized relative to the comparison, the larger urban region (adjusted odds ratios [AOR] ranged from 1.25 to 1.70). Hospital days did not differ across regions. Further analyses showed that having more physicians (AOR = .75) and more hospital beds per 1000 population (AOR = .95) both significantly reduced the odds of being hospitalized. Nursing home beds and home care services were not related to hospitalizations. Growth curve models indicated that daily patterns of hospitalizations generally did not differ across rural/remote versus urban regions., Conclusion: The findings suggest that residents of some rural/remote regions were at a disadvantage in terms of access to an appropriate care setting at the end of life. The regional variation in hospitalization can, at least in part, be attributed to the availability of healthcare resources, specifically the number of physicians and hospital beds (per 1000 population). However, the variation that emerged across regions also suggests that conclusions should not be over-generalized to all rural/remote regions; rather, local differences in healthcare resources should be considered when examining healthcare usage at the end of life.

Study Objective: Federal policy changes and tightened state budgets may reduce Medicaid enrollment in many states. In March 2003, the Oregon Health Plan (Oregon's Medicaid expansion program) made substantial changes in its benefit package that resulted in the disenrollment of more than 50,000 beneficiaries. We sought to study the impact of these Oregon Health Plan policy changes on statewide emergency department (ED) use., Methods: In this observational study, hospital billing data on 2,680,954 visits to 26 Oregon EDs were obtained, sampled up to 24 months before and 24 months after the cutbacks. These visits represent approximately 62% of all visits to Oregon's 58 EDs. We ascertained counts of ED visits by payer group before and after the Oregon Health Plan cutback date, plus hospital admissions from the ED as a measure of acuity., Results: After the Oregon Health Plan policy changes, ED visits by the uninsured underwent an abrupt and sustained increase, from 6,682 per month in 2002 to 9,058 per month in 2004. Oregon Health Plan-sponsored and commercially insured visits decreased, resulting in a slight decrease in overall ED visits. Multivariable models adjusting for secular trends and seasonality showed a 20% (95% confidence interval 13% to 28%) increase in uninsured ED visits, whereas the adjusted number of Oregon Health Plan-sponsored visits decreased. The proportion of uninsured ED visits resulting in hospital admission increased (odds ratio 1.50; 95% confidence interval 1.39 to 1.62)., Conclusion: Oregon's Medicaid cutbacks were followed by increases in ED use and hospitalizations by the uninsured. Recent federal legislation facilitating similar Medicaid changes in other states may lead to replication of these events elsewhere.

We studied children admitted to Kilifi District Hospital, Kenya, between 1997 and 2005 with haemolytic uraemic syndrome (HUS) and reviewed their records in order to determine the clinical features and outcomes of the disease. Thirty-one children fulfilled the criteria: 21 (68%) had diarrhoea-associated HUS (D + HUS), the remainder did not (D-HUS); five had involvement of the central nervous system. Those with D-HUS had lower haemoglobin and platelet counts when compared with those with D + HUS. The overall mortality rate was 55% (17/31) with no significant difference between the two groups. Severe hyponatraemia ([Na(+)] <120 mmol/L) predicted a poor outcome. Shigella dysenteriae was the most common isolated organism in the stool and Escherichia coli and S. dysenteriae were the most common blood isolates. HUS carries a high mortality rate and D-HUS is as common as D + HUS.

In this policy brief, we estimate and document the national magnitude of charges associated with hospitalizations due to ambulatory care sensitive conditions (ACSCs) in rural hospitals. The brief also reports this type of charge by hospital size. This research will inform policy makers about the magnitude of rural preventable hospitalizations and the associated potential savings in hospital resource utilization.

In this policy brief, we estimate and document the regional magnitudes of charges associated with hospitalizations due to ambulatory care sensitive conditions (ACSCs) in rural hospitals. This research will inform policy makers about the regional magnitudes of rural preventable hospitalizations and the associated potential savings in hospital resource utilization when rural patients receive timely and effective primary care.

Background: This analysis provides an insight into bed demand for adults for oral health related conditions in Western Australia., Methods: Data were obtained from the Western Australian Hospital Morbidity Data System for the four financial years 1999-2000 to 2002-2003. This retrospective study analysed the principal diagnosis (ICD-10AM) obtained for all 53 646 adult patients diagnosed with an oral health related condition. Primary place of residency, gender and Indigenous status were analysed., Results: More males (52.6 per cent) were hospitalized than females and Indigenous patients were hospitalized 1.5 times more than non-Indigenous patients. "Caries" were most common in non-Indigenous patients, with "jaw fractures" most prevalent in Indigenous patients. The majority of patients were hospitalized in a private metropolitan hospital (57.2 per cent). Total costs of hospitalization, both public and private, were in excess of dollar 85 million over four years with dollar 44 million in the public sector., Conclusions: This study indicates the burden of oral health related conditions on the Western Australian population and the hospital system in terms of health and economical impact.

Aim: To provide a description of the role and function of Otago Province's three main rural hospitals, utilising analysis of hospital discharge data for the period July 2001 to June 2002., Methods: Calculation of hospitalisation rates based on analysis of information contained in the National Minimum Dataset (Hospital Events); Census data from Statistics New Zealand; and local knowledge of hospital utilisation by geographical district., Results: A comparison between the rural Otago population and New Zealand (as a whole) show age-standardised hospitalisation rates of 19,847 vs 19,930 per 100,000, and a mean length of hospital stay of 4.5 days vs 6.8 days respectively. Patients aged over 75 years account for 49% of the work of rural Otago hospitals calculated by total bed days; 9% of patients account for 28% of the total discharges., Conclusions: Results show that Otago's rural hospitals (when compared to the New Zealand average) provide an efficient and appropriate service for their communities when judged by hospitalisation rates, mean length of stay, and patient groups cared for. There are serious difficulties encountered in using the National Minimum Dataset to analyse the workload of a rural hospital. An agreed methodology to overcome these difficulties is needed as they have significant implications for service planning and resource allocation for rural hospitals in New Zealand.

In Australia, pancreatitis has been associated with gallstones in approximately 35% of cases and alcohol in approximately 25% of cases. The present study was performed to analyse the aetiology of pancreatitis in patients admitted to a remote Australian hospital that has a population base comprising both indigenous and non-indigenous people. A retrospective study was conducted of all cases of pancreatitis admitted to the Alice Springs Hospital from August 1993 to August 1999. One hundred and two patient records were examined, and 77% of these patients were Aboriginal. Alcohol was the most common aetiological factor (64%), with gallstone disease being the next most common. Aboriginal patients with pancreatitis were younger than non-Aboriginal patients ( P = 0.0304) and were also more likely to have alcohol as their cause of pancreatitis ( P = 0.035), especially if they were male. In males, alcohol was implicated in at least 70% of cases. In females, the causes were gallstone disease (41%) and alcohol (49%). Patients with gallstone disease were significantly older than patients with other causes of pancreatitis ( P = 0.000). There was an overall 30% increase in admission rate per year, which was primarily due to an increase in the number of Aboriginal admissions (36% per year) ( P = 0.000). The present study highlights a difference in the aetiology of pancreatitis in Aboriginal and non-Aboriginal people from a remote Australian population.

Objective: To describe the epidemiology of community-acquired bacteremia in children admitted to a rural hospital in central Africa and to identify useful diagnostic signs or symptoms., Methods: On admission, a blood culture was obtained from all children admitted to Children's Hospital of Lwiro between 1989 and 1990. Clinical and biologic signs of infection and nutritional status were recorded., Results: Among the 779 children included in the study, 15.9% were bacteremic on admission. The rate of bacteremia was the highest among children with jaundice (20/56; 35.7%) and fever (119/487; 24.4%). In contrast, children with severe malnutrition had a lower rate of bacteremia (13.2%) than weight growth retarded or well-nourished children (19.5%) (P = 0.046). Fever was the most useful diagnostic criteria (sensitivity and negative predictive value of 96.0% and 97.8%, respectively) even in severely malnourished children (sensitivity and negative predictive value of 96.4% and 99.1%, respectively). Enterobacteriacea, mostly Salmonella spp, caused 73% of the bacteremia. There was a high rate of resistance to ampicillin and chloramphenicol among the responsible organisms. Only 31 (47.7%) of 65 bacteremic children responded to the combination of ampicillin and gentamicin. The presence of bacteremia on admission did not significantly increase the risk of morality during hospitalization (19.4% compared with 13.5%; P = 0.088). Age less than 12 months and jaundice were independent risk factors for deaths in bacteremic children., Conclusions: Community-acquired bacteremia caused by multiresistant Enterobacteriacea is an important problem of hospitalized well-nourished and malnourished children in central Africa. Fever on admission is a sensitive diagnostic sign, even in malnourished children.

The Bwamanda hospital insurance scheme in Zaire was launched in the mid-eighties and is one of the few well-established and documented initiatives in the field of district-based insurance schemes in sub-Saharan Africa. It was established that hospital utilization in Bwamanda is significantly higher among the insured population. A higher hospital utilization is however not a goal in itself: it is a positive phenomenon if it takes place for problems where the hospital's know-how and technology are needed to solve the patient's problem. This paper investigates the effect of the insurance scheme on hospital utilization patterns. More specifically, the distribution of this higher utilization over the different hospital departments, as well as its spatial distribution in the entire district area are analyzed. The impact of the insurance scheme on the effectiveness, equity and efficiency of hospital utilization are discussed. The relevance and possible implications of these findings on the design of the Bwamanda insurance scheme are discussed. Finally, it is argued that the methods used in the present study contribute to a coherent framework for the evaluation of similar initiatives.

A retrospective microbiological analysis of ophthalmia neonatorum among the hospital-born babies of a rural multispecialty hospital over a period of 2 years was made. Diagnostic cultures were performed in all the affected babies and 30 cases were found to be culture positive for bacterial species. The spectrum of various bacterial isolates and their antibiotic sensitivity patterns were studied. Pseudomonas aeruginosa was found to be the commonest causative organism according to this study and newer fluoroquinolones like ciprofloxacin and norfloxacin were the antibiotics that showed the best sensitivity pattern.

This study analyses routine data from Kasongo, Zaire in order to assess the influence of coverage with a network of health centres delivering primary care on hospitalisation patterns. Admission rates are 2.1 times higher for non-covered than for covered areas. For non-justified hospitalisations (false positives) distance decay is marked both in covered and non-covered areas, but at consistently lower levels in covered areas. For justified hospitalisations (true positives), hospitalisation rates are markedly lower in covered than in non-covered areas if one considers areas with reasonable (less than 40-50 km) access to the hospital. In more remote areas the relationship is inversed, and populations from non-covered areas do not use the hospital at all, whilst some people from covered areas do reach the hospital. Reduction of hospitalisation rates is for diseases for which standardised technical solutions of known efficacy are available at the health centres. Hospitalisation rates for the diseases usually targetted by selective PHC programmes are reduced by 86% in the covered areas as compared to the non-covered areas. Reduction in hospitalisation rates for those diseases accounts for 29% of the total coverage-related reduction.