The return of Chinese nurses from overseas (2009–2023): a mixed-method study on influencing factors

Cardiometabolic multimorbidity (CMM) has emerged as a global health challenge with a high mortality risk. This study aimed to explore the association between the metabolic score for insulin resistance (METS-IR) and the incidence of CMM. This study included 6,977 individuals in the CHARLS database. We used multiple cox proportional hazards regression and restricted cubic splines (RCS) analysis to evaluate the association between METS-IR and CMM. Subgroup analyses and interaction tests were also performed. During a median 109 (108-109) months of follow-up, 745 (10.7%) participants were diagnosed with new-onset CMM. The incidences of CMM among participants in quartiles (Q) 1-4 of METS-IR were 4.99, 7.51, 10.67, and 19.54%, respectively. METS-IR was significantly higher in individuals with CMM compared to those without CMM (p < 0.001). After multivariate adjustment, a higher METS-IR was significantly associated with an increased risk of CMM. Compared to participants in Q1 of METS-IR, the hazard ratios (HRs) (95% confidence intervals [CIs]) using cox proportional hazards regression analysis for those in Q2-4 were 1.52 (1.15-2.00), 2.02 (1.56-2.63), and 3.61 (2.80-4.64), respectively. RCS analysis revealed a significant nonlinear association between METS-IR and CMM (nonlinear p < 0.05). The association between METS-IR and the incidence of CMM was present in almost all the subgroups. Furthermore, the predictive ability of METS-IR for CMM was 0.669, which surpassed that of both the triglyceride to high-density lipoprotein cholesterol ratio and the triglyceride glucose index. A higher METS-IR was closely associated with an increased risk of CMM. Further studies on METS-IR could be beneficial for preventing and treating CMM.

Acute pancreatitis (AP) is a sudden inflammatory condition of the pancreas that can lead to severe systemic complications and high mortality, especially in critically ill patients. Red cell distribution width-to-hematocrit ratio (RDH) has emerged as a potential prognostic biomarker in critical care. This study aimed to explore the association between RDH and 28-day mortality in intensive care unit (ICU) patients with AP. This retrospective observational cohort study utilized data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV, v3.1) database. Cox proportional hazards regression and restricted cubic spline analyses were used to assess the relationship between RDH and 28-day all-cause mortality. Receiver operating characteristic curve analysis, along with area under the curve (AUC), net reclassification improvement, and integrated discrimination improvement, was performed to evaluate the incremental prognostic value of RDH beyond sequential organ failure assessment (SOFA) and SAPSⅡ scores. Survival curves and subgroup analyses were performed based on pertinent covariates. A total of 1126 ICU patients with AP were included. RDH were significantly associated with 28-day all-cause mortality. In multivariable Cox models, the highest RDH quartile exhibited a 5.52-fold increased mortality risk (heart rate: 6.52; 95% confidence intervals: 2.88–14.7; P <.05) compared to those in the lowest quartile. The relationship was linear (P for nonlinearity >.05). Kaplan–Meier survival curves demonstrated low survival rates in the highest RDH quartile (P <.001). RDH alone showed modest discrimination (AUC = 0.640), while SOFA (AUC = 0.724) and SAPSⅡ (AUC = 0.768) performed better. Adding RDH improved model performance (SOFA + RDH AUC = 0.743; SAPSⅡ+RDH AUC = 0.792) with significant net reclassification improvement and integrated discrimination improvement gains. RDH is an independent predictor of 28-day mortality in ICU patients with AP. Higher RDH values are linked with increased clinical severity and mortality risk.

BackgroundThe ratio of non-high-density lipoprotein cholesterol (non-HDL-C) to high-density lipoprotein cholesterol (HDL-C) (NHHR) served as a novel comprehensive lipid indicator. This study aimed to explore the association between NHHR and the incidence of cardiometabolic multimorbidity (CMM).MethodsThis study included 8191 individuals from the China Health and Retirement Longitudinal Study (CHARLS) database. We used multivariable cox proportional hazards regression, logistic regression, and restricted cubic splines (RCS) analysis to evaluate the association between NHHR and CMM. Subgroup analyses and interaction tests were also performed.ResultsThe incidences of CMM among participants in quartiles (Q) 1–4 of NHHR were 7.03%, 8.3%, 10.06%, and 16.55%, respectively. The NHHR was significantly higher in individuals with CMM compared to those without CMM (P < 0.001). When assessed as a continuous variable, NHHR was independently associated with the risk of CMM, as demonstrated by both multivariable cox proportional hazards regression analysis (HR = 1.05, 95% CI = 1.02–1.07, P < 0.001) and logistic regression analysis (OR = 1.09, 95% CI = 1.04–1.15, P < 0.001). Compared to individuals in the lowest quartiles of the NHHR (Q1), the risk of CMM in the highest quartiles (Q4) was increased by 1.25-fold according to multivariable cox proportional hazards regression analysis (HR = 2.25, 95% CI = 1.73–2.93, P < 0.001) and by 1.48-fold according to logistic regression analysis (OR = 2.48, 95% CI = 1.86–3.31, P < 0.001). This association was consistent across nearly all subgroups. RCS analysis revealed a significant nonlinear association between NHHR and CMM. Additionally, the predictive ability of NHHR for CMM was 0.613, which was superior to that of both HDL-C and non-HDL-C (P < 0.05). Furthermore, the composite variable comprising NHHR and other traditional risk factors exhibited the highest predictive value (C statistic = 0.679).ConclusionA higher NHHR was closely associated with an increased risk of CMM. Further studies on NHHR could be beneficial for preventing and treating CMM.

The present study characterizes the epidemiological situation of Paratuberculosis (PTB) in Europe during the last 24 years, using the information officially reported to the World Organisation for Animal Health (WOAH) by veterinary services of the European countries. The prevalence of PTB at country level was described during the study period. A Cox proportional hazards (PH) regression analysis was implemented to evaluate the notification behaviours. Results from this work indicate that the most affected countries are in Southern and Western Europe, whereas PTB presence appears lower in Northern and Eastern Europe. PTB was routinely declared as a notifiable disease in 65% of the countries. Less than 50% of the countries routinely implemented passive surveillance, and only 19%, reported active surveillance for disease detection. Results from the Cox PH regression indicate that the Gross National Income (GNI) per capita and the application of active surveillance significantly influence the recurrence of PTB reporting. In countries with lower and upper middle income, the hazard of recurrence is 0.13 and 0.18 times lower than in countries with high income. The hazard of recurrence in countries that infrequently and moderately applied active surveillance is 1.99 and 1.65 times higher than in countries that routinely applied active surveillance. Findings from this work highlight an important variation in reporting behaviours, disease status and surveillance across Europe.

BackgroundDespite the well-established morbidity, mortality, long-term effects, and unnecessary extra-cost burden associated with cesarean section delivery (CSD) worldwide, its rate has grown exponentially. This has become a great topical challenge for the international healthcare community and individual countries. Estimated at three times the acceptable rate as defined by the World Health Organization in 1985, the continued upward trend has been fuelled by higher income countries. Some low- and middle-income countries (LMICs) have now taken the lead, and the factors contributing to this situation are poorly understood. The expansion of the private healthcare sector may be playing a significant role. Distinguishing between the public and private hospitals’ role is critical in this investigation as it has not yet been approached. This review aims to systematically synthesize knowledge on the determinants of the CSD rate rise in private and public hospitals in LMICs and to investigate materno-fetal and materno-infant outcomes of CSD in perinatal period, between private and public hospitals.Methods/designWe will include studies published in English, French, Spanish, and Portuguese since 2000, using any experimental design, including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, and interrupted time series. Outcomes of interest are the determinants of CSD and materno-fetal and materno-infant outcomes. We will only include studies carried out in private and public hospitals in LMICs. The literature searches will be conducted in the following databases: MEDLINE, Embase, CINAHL, Cochrane database, LILACS, and HINARI. We will also include unpublished studies in the gray literature (theses and technical reports). Using the two-person approach, two independent review authors will screen eligible articles, extract data, and assess risk of bias. Disagreements will be resolved through discussion with a third author. Results will be presented as structured summaries of the included studies. If possible, a meta-analysis will be conducted and, subsequently, an analysis for heterogeneity will be implemented.DiscussionThe proposed systematic review of the CSD rate rise will provide up-to-date evidence in regard to differences in proportions, determinants, and materno-fetal and materno-infant outcomes in perinatal period, between private and public hospitals in LMICs. We believe that this knowledge synthesis will help to shed light on the evidence and support evidence-informed decision-making with a view to addressing the issue in LMICs.Systematic review registrationPROSPERO CRD42016036871

Background: Tamoxifen is a standard endocrine therapy for both pre- and postmenopausal ER-positive breast cancer patients. Patients with ER-positive disease have a long-term risk of distant recurrence, thus, long-term follow-up studies are essential to understand true treatment benefit. Clinically used tumor characteristics are prognostic 5-10 years after primary diagnosis, however, whether these characteristics are predictive of long-term tamoxifen benefit is largely unexplored. Therefore, we aimed to determine the long-term tamoxifen therapy benefit by the clinically used tumor characteristics in pre- vs postmenopausal patients in the Stockholm tamoxifen (STO)-trials with 20-years complete follow-up. Methods: Secondary analysis of 1242 ER-positive/HER2-negative patients from the STO-trials, randomized to at least 2 years of 40 mg tamoxifen vs no endocrine therapy (control). Premenopausal lymph node-positive patients were allocated to chemotherapy as standard of care and postmenopausal high-risk patients were further randomized to chemotherapy vs radiotherapy. Tumor immunohistochemical analysis was recently conducted. Complete 20-year follow-up was obtained from Swedish high-quality registries. Long-term distant recurrence-free interval (DRFI) was assessed by multivariable Cox proportional hazard regression and time-varying analysis using flexible parametric modelling. Results: Premenopausal patients showed significantly improved long-term DRFI from tamoxifen vs control if they were lymph node-negative (Hazard Ratio [HR]=0.46; 95% CI, 0.24-0.87), PR-positive (HR=0.61; 95% CI, 0.41-0.91), or of genomic low risk (HR=0.47; 95% CI, 0.26-0.85), see Table. In postmenopausal patients, significantly improved long-term DRFI from tamoxifen vs control was seen for all good prognosis tumor characteristics, i.e. small tumor size (pT≤20mm: HR=0.55; 95% CI, 0.39-0.77), tumor grade 1-2 (HR=0.55; 95% CI, 0.41-0.73), lymph node-negative (HR=0.44; 95% CI, 0.30-0.64), PR-positive (HR=0.60; 95% CI, 0.44-0.80), Ki-67-low (&amp;lt; 15%: HR=0.51; 95% CI, 0.38-0.68), and genomic low risk (HR=0.53; 95% CI, 0.37-0.74), see Table. Also, postmenopausal patients with large tumor size (pT&amp;gt;20mm: HR=0.64; 95% CI, 0.44-0.94) and PR-negative tumors (HR=0.51; 95% CI, 0.32-0.81) showed significant long-term tamoxifen benefit. Time-varying analysis in premenopausal patients indicated that tamoxifen therapy benefit diminished over time. Significant tamoxifen benefit until year 5, 10, and 15 after primary diagnosis was observed for PR-positive, lymph node-negative, and genomic low-risk patients, respectively. Postmenopausal patients had a significant long-term tamoxifen benefit if they had tumors of small or large tumor size, tumor grade 1-2, lymph node-negative status, PR-positive status, low Ki-67 levels, or genomic low risk. Conclusions: This study suggests a differential long-term tamoxifen therapy benefit in pre- vs postmenopausal patients. Clinically defined low-risk postmenopausal patients have long-term tamoxifen benefit, whereas the benefit is absent or diminish over time for premenopausal patients. Improved long-term prognostic and endocrine therapy predictive markers in premenopausal breast cancer patients with poor prognosis and long life-expectancy is needed, which could involve molecular tools. Long-term tamoxifen benefit in premenopausal and postmenopausal breast cancer patients by the clinically used tumor characteristics. Table Multivariable Cox proportional hazard regression analysis of 20-year distant recurrence-free interval (DRFI) for patients with ER-positive/HER2-negative tumors, comparing patients randomized to tamoxifen vs patients randomized to no endocrine therapy (control). Adjusted for age, randomization year, tumor size, tumor grade, lymph node status, PR status, Ki-67 status, chemotherapy, radiotherapy, and type of surgery. Citation Format: Annelie Johansson, Huma Dar, Anna Nordenskjöld, Gizeh Perez-Tenorio, Christina Yau, Christopher C. Benz, Laura J. Esserman, Laura Van’t Veer, Bo Nordenskjöld, Olle Stål, Tommy Fornander, Linda S. Lindström. Differential Long-Term Benefit from Adjuvant Tamoxifen Therapy in Estrogen Receptor (ER)-Positive/Human Epidermal Growth Factor Receptor 2 (HER2)-Negative Premenopausal and Postmenopausal Breast Cancer Patients [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-03-11.

Correlation between serum uric acid to high-density lipoprotein cholesterol ratio and cardiometabolic multimorbidity in China: A nationwide longitudinal cohort study.

Hidradenitis suppurativa (HS) is a chronic inflammatory and scarring disease with a wide spectrum of disease severity. The amount of scarring is proportional to the preceding tissue damage and poses a challenge to patients. Severe HS is most often treatment recalcitrant, but hypothetically avoidable through early biologic treatment. Early prediction of individual risk of disease progression is therefore essential for patient management. To investigate risk factors associated with disease progression and to design an algorithm capable of predicting disease -progression. A prospective cohort study of 335 Hurley III-naïve patients with HS, not treated with biologics, was followed for a median of 2 years. Potential risk factors covered basic demographics, HS anamnestic factors and clinical HS factors collected during physical examination. Two separate Cox proportional hazard regression (CPHR) analyses were conducted. A summated 'progression score' was calculated and used in the predictive algorithm of severe disease. Subsequent bootstrap sampling was used to validate the predictability of the predictive algorithm. The CPHR analysis of Transition to severe disease found that active smoking [hazard ratio (HR) 4.01, 95% confidence interval (CI) 1.71-9.40, P = 0.001]; body mass index (BMI) points > 25 at baseline (each point: HR 1.06, 95% CI 1.02-1.09, P < 0.001); active disease in 2 (HR 4.26, 95% CI 1.23-14.84, P = 0.02) and ≥ 3 areas (HR 6.54, 95% CI 1.89-22.72, P = 0.003) all constituted substantial risk factors. Conversely, the CPHR analysis of Disease progression did not yield results of clinical relevance. A 'progression score' of 3.04 was used as a threshold in the predictive algorithm of Transition to severe disease and achieved the following test specifics: sensitivity = 0.51, specificity = 0.86, positive predictive value = 0.50, negative predictive value = 0.86. We found a disparity between factors increasing the risk of simple Disease progression and those increasing the risk of Transition to severe disease. For the latter, active smoking, BMI points > 25, active disease in 2 or ≥ 3 areas were all shown to be the clinically relevant factors that could be used to construct an algorithm that correctly predicted progression to severe HS in more than half of all instances.

Paroxysmal sympathetic hyperactivity (PSH) is characterized by episodes of excessive sympathetic activity and is associated with poor outcomes in brain injuries, yet its impact on severe intracerebral hemorrhage (ICH) remains unclear. This study investigates the association between PSH and clinical outcomes in patients with severe ICH. We conducted a prospective observational cohort study of patients with severe ICH from January 2018 to December 2022. Severe ICH was defined as ICH with a Glasgow Coma Scale score ≤ 8 on admission, indicating significant neurological impairment. Patients were assessed for PSH using the PSH-Assessment Measure, and categorized into probable, possible, and unlikely PSH groups. Propensity score matching was used to adjust for baseline differences among three groups. The primary outcome was the 90-day mortality rate. Secondary outcomes included a favorable functional outcome at 90days, defined by a modified Rankin Scale score of 0-2. Statistical analyses were performed using Cox proportional hazards regression and Kaplan-Meier survival analysis. After propensity score matching, 177 patients (59 in each group) were analyzed. The 90-day mortality rate was significantly higher (P < 0.01) in the probable PSH group (67.8%), compared with possible (47.5%) and unlikely PSH groups (35.6%). The Kaplan-Meier survival curve further illustrates a significantly increased risk of 90-day mortality in the probable PSH group (Log rank test P < 0.01). Multivariate Cox proportional hazards regression analysis confirmed that, after adjusting for confounders, the presence of probable PSH (hazard ratio 3.86, 95% confidence interval 2.17-6.87; P < 0.01) was independently associated with a higher risk of 90-day mortality. Functional outcomes at 90days were poorer in the probable PSH group. Probable PSH is significantly associated with worse outcomes in severe ICH, underscoring the importance of early recognition and targeted management strategies.

Approximately 20% of intensive care unit (ICU) patients have cancer, and their prognosis has markedly improved in recent years. In addition to improved treatment in the ICU, this is a result of advancements in cancer therapies, including the use of targeted therapies (TTs), such as antibodies and small-molecule kinase inhibitors. Despite the increasing use of TT, there are currently no comprehensive studies examining critically ill cancer patients receiving TT in the ICU. We studied the clinical characteristics of a multicenter cohort of cancer patients who received TT in the ICU. To this end, we extracted data from the iCHOP Registry, comprising critically ill cancer patients from nine centers in Germany and Austria, and analyzed patient characteristics, cancer therapies, and survival outcomes. We then employed Cox proportional hazards regression and Kaplan‒Meier survival analyses to explore factors associated with mortality. Of the 1,762 cancer patients admitted to the ICU who were analyzed for this study, 106 patients (6%) received TT in the ICU, such as antibody-based treatments, kinase inhibitors and proteasome inhibitors. Although the TT recipients were younger, there were several pronounced high-risk features in the TT cohort, as indicated by a greater proportion of hematologic malignancies and autologous stem cell transplantation (SCT), a greater percentage of progressive disease and fewer patients in complete remission at ICU admission than in patients not receiving TT in the ICU. Despite these more pronounced risk features, TT patients had a slightly longer median OS than did the other patients according to Kaplan‒Meier analysis. The factors associated with mortality according to Cox proportional hazards regression analysis included advanced directives, disease progression, SOFA score, invasive mechanical ventilation (IMV), renal replacement therapy, and duration of ICU and hospital stay. Critically ill cancer patients receiving TT in the ICU had distinct characteristics but had comparable survival outcomes compared to patients receiving any other or no antineoplastic therapy in the ICU. While disease status at ICU admission remains crucial, the present study indicates the feasibility and potential benefits of TT in selected ICU patients.

Individuals afflicted with heart failure complicated by sepsis often experience a surge in blood glucose levels, a phenomenon known as stress hyperglycemia. However, the correlation between this condition and overall mortality remains unclear. 869 individuals with heart failure complicated by sepsis were identified from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and categorized into five cohorts based on their stress hyperglycemia ratio (SHR). The primary endpoints evaluated were mortality within the intensive care unit (ICU), all-cause mortality within 28 days, and all-cause mortality during hospitalization. Cox proportional hazards regression and restricted cubic spline analyses were employed to unravel the association between SHR and mortality. The ICU mortality, in-hospital mortality, and 28-day all-cause mortality were 10.01%, 13.69%, and 16.46%, respectively. Multivariable Cox proportional hazards regression analysis revealed a significant association between elevated SHR and all-cause mortality. After adjusting for confounding variables, elevated SHR was significantly associated with increased risk of ICU mortality (hazard ratio [HR] = 1.67; 95% confidence interval [CI], 1.03–2.70)), in-hospital mortality (HR = 1.53; 95% CI, 1.00-2.33)), and 28-day all-cause mortality (HR = 1.49; 95% CI, 1.02–2.17)). Restricted cubic spline analysis demonstrated a significant U-shaped relationship between SHR and the risk of all-cause mortality. This study revealed that stress hyperglycemia ratio is an independent prognostic factor in patients with heart failure complicated by sepsis. Notably, both very high and very low SHR values were associated with increased mortality risk.

HIF1α is the key transcriptional regulator of the response to hypoxia in tumors. GLUT-1 is a HIF1α-dependent target gene that is upregulated under hypoxic conditions and enables glucose transport into tumor cells. We sought to identify if co-expression of both of these hypoxia-related proteins, as detected by immunohistochemistry, had prognostic relevance in oral squamous cell carcinomas [OSCC]. Eighty-two OSCC tumor samples were analyzed for their expression levels of both HIF1α and GLUT-1 by immunohistochemistry. Protein expression was assessed using an immunoreactive score system (IRS) and the correlation between gene expression and both clinical and pathohistological parameters were examined. Overexpression of either GLUT-1 or HIF1α was associated with poor overall survival in OSCC patients. Multivariate Cox's proportional-hazards regression analysis (adjusted for tumor size and tumor grade) revealed that moderate expression of GLUT-1 or HIF1α was significantly associated with overall survival (RR=5.07, p=0.002 and RR=4.5, p=0.017, respectively) as compared to the groups with low levels of expression of GLUT-1 or HIF1α. Co-expression of both HIF1α and GLUT-1 were additively and significantly associated with adverse prognoses in patients with OSCC. Patients whose tumors had high levels of expression of both HIF1α and GLUT-1 were found to have a 10.2-fold increased risk of tumor-related death (p=0.001) in the multivariate Cox's proportional-hazards regression analysis. Co-expression of high levels of HIF1α and GLUT-1 is significantly correlated with prognosis in OSCC patients, suggesting that the co-expression of these proteins can be used as both an early diagnostic and independent prognostic marker. Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 448.

ObjectiveTo develop and validate a bone metastasis prediction model based on skull base invasion (SBI) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC).MethodsThis retrospective cohort study enrolled 290 patients with LA-NPC who received intensity-modulated radiation therapy in two hospitals from 2010 to 2020. Patient characteristics were grouped by SBI and hospital. Both unadjusted and multivariate-adjusted models were used to determine bone metastasis risk based on SBI status. Subgroup analysis was performed to investigate heterogeneity using a forest graph. Cox proportional hazard regression analysis was used to screen for risk factors of bone metastasis-free survival (BMFS). A nomogram of BMFS based on SBI was developed and validated using C-index, receiver operating characteristic curve, calibration curves, and decision curve analysis after Cox proportional hazard regression analysis.ResultsThe incidence of bone metastasis was 14.83% (43/290), 20.69% (24/116), and 10.92% (19/174) in the overall population, SBI-positive group, and SBI-negative group, respectively. In the unadjusted model, SBI was associated with reduced BMFS [HR 2.43 (1.32–4.47), P = 0.004], and the results remained stable after three continuous adjustments (P <0.05). No significant interaction was found in the subgroup analyses (P for interaction >0.05). According to Cox proportional hazard regression analysis and clinical value results, potential risk factors included SBI, Karnofsky performance status, TNM stage, induction chemotherapy, concurrent chemoradiotherapy, and adjuvant chemotherapy. Using a training C-index of 0.80 and a validation C-index of 0.79, the nomogram predicted BMFS and demonstrated satisfactory prognostic capability in 2, 3, and 5 years (area under curve: 83.7% vs. 79.6%, 81.7% vs. 88.2%, and 79.0% vs. 93.8%, respectively).ConclusionSkull base invasion is a risk factor for bone metastasis in patients with LA-NPC. The SBI-based nomogram model can be used to predict bone metastasis and may assist in identifying LA-NPC patients at the highest risk of bone metastasis.

Purpose of the article: This study was set to determine the influence of institutional framework on service quality in both private and public hospitals. The paper sought to establish the perception of respondents regarding the institutional factors that explain the existence of variations in service quality between public and private hospitals. The institutional framework aspects that were considered in comparing health service quality in public and private hospitals were: institutional culture, control, stability and structure. A descriptive survey design was used because the study sought to know the perception of respondents regarding the factors that influence quality of service in hospitals. Research methods: A multistage sampling method was used to select three public hospitals and three private hospitals from the health service sector. The three public hospitals were Muhimbili referral hospital in Dar es Salaam City, Dodoma regional referral hospital and Geita referral hospital in Geita municipality. Private hospitals included in the study were Bugando referral hospital in Mwanza City, St Francis referral hospital in Ifakara town in Morogoro region and Nkinga referral hospital in Tabora region. Medical doctors, nurses and patients were selected using a systematic random sampling method and patients were selected using a convenience sampling method. The total population for the study comprised 10,650 people (i.e. 2,610 doctors and nurses and 8,040 patients) and the selected sample size, which was determined using McCall’s Table was 400 people. Both primary and secondary data collection sources were used. Analysis of the quantitative data was done using the Statistical Package for Social Sciences (SPSS) and qualitative data were transcribed verbatim, coded and analysed manually. All ethical considerations were observed. Main findings: The findings revealed that private hospitals were better in cleanliness compared to public hospitals and physical arrangement was user friendly in private hospitals compared to public hospitals. There was also more control in private hospitals compared to public hospitals in management of resources and this demonstrates an application of strong institutional framework in private hospitals compared to public hospitals in terms of control, structure and culture. Likewise, there was a more friendly atmosphere in private hospitals compared to public hospitals. However, there was more stability in public hospitals compared to private hospitals in terms of financial stability, affordability of service and medical supplies. It is concluded that quality of service provided in private hospitals is higher compared to quality of service in public hospitals. The possible explanation for the causes for differences in levels of service quality could be the existence of strong institutional framework in private hospitals. It is recommended that for higher service quality, organizations should practice the institutional framework aspects in terms of culture, control, stability and structure.

We report the results of the International Nosocomial Infection Control Consortium prospective surveillance study from January 2004 to December 2009 in 33 pediatric intensive care units of 16 countries and the impact of being in a private vs. public hospital and the income country level on device-associated health care-associated infection rates. Additionally, we aim to compare these findings with the results of the Centers for Disease Control and Prevention National Healthcare Safety Network annual report to show the differences between developed and developing countries regarding device-associated health care-associated infection rates. A prospective cohort, active device-associated health care-associated infection surveillance study was conducted on 23,700 patients in International Nosocomial Infection Control Consortium pediatric intensive care units. The protocol and methodology implemented were developed by International Nosocomial Infection Control Consortium. Data collection was performed in the participating intensive care units. Data uploading and analyses were conducted at International Nosocomial Infection Control Consortium headquarters on proprietary software. Device-associated health care-associated infection rates were recorded by applying Centers for Disease Control and Prevention National Healthcare Safety Network device-associated infection definitions, and the impact of being in a private vs. public hospital and the income country level on device-associated infection risk was evaluated. None. Central line-associated bloodstream infection rates were similar in private, public, or academic hospitals (7.3 vs. 8.4 central line-associated bloodstream infection per 1,000 catheter-days [p < .35 vs. 8.2; p < .42]). Central line-associated bloodstream infection rates in lower middle-income countries were higher than low-income countries or upper middle-income countries (12.2 vs. 5.5 central line-associated bloodstream infections per 1,000 catheter-days [p < .02 vs. 7.0; p < .001]). Catheter-associated urinary tract infection rates were similar in academic, public and private hospitals: (4.2 vs. 5.2 catheter-associated urinary tract infection per 1,000 catheter-days [p = .41 vs. 3.0; p = .195]). Catheter-associated urinary tract infection rates were higher in lower middle-income countries than low-income countries or upper middle-income countries (5.9 vs. 0.6 catheter-associated urinary tract infection per 1,000 catheter-days [p < .004 vs. 3.7; p < .01]). Ventilator-associated pneumonia rates in academic hospitals were higher than private or public hospitals: (8.3 vs. 3.5 ventilator-associated pneumonias per 1,000 ventilator-days [p < .001 vs. 4.7; p < .001]). Lower middle-income countries had higher ventilator-associated pneumonia rates than low-income countries or upper middle-income countries: (9.0 vs. 0.5 per 1,000 ventilator-days [p < .001 vs. 5.4; p < .001]). Hand hygiene compliance rates were higher in public than academic or private hospitals (65.2% vs. 54.8% [p < .001 vs. 13.3%; p < .01]). Country socioeconomic level influence device-associated infection rates in developing countries and need to be considered when comparing device-associated infections from one country to another.