Hospital Categories Research Articles

Outline for setting up acute postoperative pain service for Indian Hospital

Majority of Indian hospitals still lack the provision of acute postoperative pain relief service. In other parts of the world, field of acute pain management strategy has witnessed a surge in its implementation. Today, acute pain has begun to be recognized not merely as a distressing symptom but also as a precursor of chronic, debilitating pain. This development warrants that we in India address this issue on an urgent basis through the use of analgesic/narcotic combination via parenteral/oral/rectal route as well as by performing regional blocks, to meet the interpatient variability and available facility. In this review article, we have provided the organization and function of acute pain service (APS) program that can be adapted to a wide spectrum of Indian hospitals. We have outlined the role of APS team including the use of easily available analgesic/narcotic drug combinations for various categories of Indian hospitals dealing with different grades of surgical conditions, including those hospitals that are not sufficient in resources and funding. This article has also tabulated possible regional block techniques with their indications for treating acute postoperative pain in combination with parenteral/oral/rectal analgesics/narcotics in the more developed Indian hospitals. Staffing and equipment requirements have also been outlined.

THE QUALITY OF PUBLIC HOSPITALS IN CAN THO CITY, 2016

Background: The criteria set of assessing hospital quality in Vietnam in 2016 was revied from the criteria set in 2013 by the Ministry of Health in order to help hospitals to self-assess towards improvinge quality of hospitals in the international integration context. The study aimed to assess the quality of public hospitals in Can Tho City according to the revised criteria set of the Ministry of Health in 2016 and compare the quality among three hospital ranks (including grade I, grade II, and grade III) via to 5 groups of quality criteria. Methods: A cross-sectional study, using secondary data analysis was applied to assess the service quality of 7 general public hospitals in Can Tho City. Results: The average total score of 7 hospitals is 245 and the average for the criteria of 7 hospitals is 2.99, which is just satisfactory. In the criterion of quality, criterion D and E had the lowest scores compared to the other three groups. There was no statistically significant difference (p = 0.076) among the mean scores for the three hospital categories. Conclusion: The quality of public hospitals in Can Tho city in 2016 only reached moderately good level (2.99). Interventions should be developed to improve the quality of hospitals, with particular emphasis on improving the quality of criteria groups D and E. Key words: Quality, hospital, medicine, health, public, Can Tho

Maternal Opioid Use Disorder and Neonatal Abstinence Syndrome Among Rural US Residents, 2007-2014.

Opioid use disorder (OUD) during pregnancy is associated with poor maternal and infant outcomes, including neonatal abstinence syndrome (NAS), and both maternal OUD and NAS are increasing disproportionately among rural residents. This study describes the trajectory and characteristics associated with diagnosis of maternal OUD or NAS among rural residents who gave birth at different types of hospitals based on rural/urban location and teaching status. Hospital discharge data from the all-payer National Inpatient Sample were used to describe maternal OUD and infant NAS among rural residents from 2007-2014. Hospitals were categorized as rural, urban teaching, and urban nonteaching. We estimated incidence trends by hospital categories, followed by multivariable logistic regression analyses to identify correlates of OUD and NAS among rural residents, stratified by hospital category. Incidence of maternal OUD increased in all hospital categories, with higher rates (8.9/1,000 deliveries) among rural residents who gave birth at urban teaching hospitals compared with those who gave birth at rural hospitals (4.3/1,000 deliveries) or urban nonteaching hospitals (3.6/1,000 deliveries; P < .001). A similar pattern was observed for infant NAS. In multivariable models, the association between maternal OUD and infant NAS diagnoses and hospital category differed by rurality (micropolitan vs. noncore.) CONCLUSIONS: There has been a sustained increase in both maternal OUD and NAS diagnoses among rural residents. Measured sociodemographic and clinical correlates of maternal OUD and NAS differ by hospital category, indicating variability across hospital locations in patient populations and clinical needs for rural residents with these conditions.

Recommendations on telestroke in Europe.

Lack of stroke specialists determines that many European rural areas remain underserved. Use of telemedicine in stroke care has shown to be safe, increase use of evidence-based therapy and enable coverage of large areas of low population density. The aim of this article is to summarise the following recommendations of the Telestroke Committee of the European Stroke Organisation on the setup of telestroke networks in Europe: Hospitals participating in telestroke networks should be chosen according to criteria that include population density, transportation distance, geographic specifics and in-hospital infrastructure and professional resources. Three hospital categories are identified to be part of a hub-and-spoke network: (1) the Telemedicine Stroke Centre (an European Stroke Organisation stroke centre or equivalent with specific infrastructure and setup for network and telemedicine support), (2) the telemedicine-assisted stroke Unit (equivalent to an European Stroke Organisation stroke unit but without 24 h onsite stroke expertise) and (3) the telemedicine-assisted stroke ready hospital (only covering hyperacute treatment in the emergency department and transferring all patients for further treatment).

Analysis of the technical efficiency of the forms of hospital management based on public-private collaboration of the Madrid Health Service, as compared with traditional management.

The study aims to carry out a comparative analysis of the technical efficiency of hospital management based on public-private collaboration, as compared with traditional management. Specifically, we compare traditionally managed public hospitals, public hospitals managed by a private finance initiative (PFI), public hospitals managed through a public-private partnership (PPP), and hospitals managed through other forms of management, during the period 2009 to 2014, in the hospitals dependent on the Madrid Health Service (SERMAS). The study covers all publicly owned general hospitals under SERMAS, consisting of seven PFI hospitals, three PPP hospitals, 11 traditionally managed public hospitals (with the category of general hospital), and four hospitals managed through other forms of hospital management. The technical efficiency indices of the hospitals were calculated using the data envelopment analysis technique. Subsequently, a sensitivity analysis was performed by bootstrapping and variation of model variables to verify their impact on efficiency. Finally, an analysis of the evolution of efficiency in the analyzed period was carried out using the Malmquist Index. In all the analysis models carried out in the analyzed period, the hospitals managed based on public-private collaboration were more efficient than the hospitals under traditional management. The greater efficiency of hospitals managed based on public-private collaboration, as compared with traditional management, could be attributed to greater organizational and management flexibility.

The effects of emotional labor and competency on job satisfaction in nurses of China: A nationwide cross-sectional survey

ObjectivesThis study aimed to explore the status of job satisfaction, emotional labour, core competencies and job stress and the associations of emotional labour and core competencies with the job satisfaction of nurses in China. MethodsData were collected by using a self-designed general information questionnaire, a job satisfaction questionnaire (McCloskey/Mueller Satisfaction Scale), a nurse emotional labour questionnaire, the Competency Inventory for Registered Nurses questionnaire, and a nurse job stressor questionnaire. A total of 13,448 nurses from 92 hospitals across mainland of China were surveyed, and 11,337 respondents (84.3% response rate) completed the questionnaires. ResultsThe survey results indicated that Chinese nurses had average job satisfaction (24.77 ± 5.23), moderate job stress (86.84 ± 21.12), moderate to high emotional labour experiences (55.08 ± 9.63) and high competency (195.77 ± 37.61). Multiple linear regression indicated that surface acting was negatively correlated with job satisfaction (P < 0.01), while deep acting (P < 0.01) and nurses’ core competence (P < 0.01) were positively associated with job satisfaction. Besides, The results also indicated job stress, geographical distribution, hospital category, gender, work shift, only children, parenting status, monthly salary, nursing experience, professional title, hospital area were the influencing factors of job satisfaction (P < 0.05). ConclusionThe improvement of the emotional labour and competency of nurses may help enhance their job satisfaction.

Increased Mortality Rate after Hospitalization Among Chronic Hemodialysis Patients: A Prospective Cohort Study

Background/Aims: Hemodialysis patients are at high risk of hospitalization and their condition may worsen with repeated hospitalization. The aim of this study was to evaluate the impact of the cumulative number of hospitalizations on post-discharge mortality. Methods: This study was a prospective cohort study. We examined 3,359 adult patients on hemodialysis for at least 90 days who participated in the Japanese Dialysis Outcomes and Practice Patterns Study phases 3 and 4 (2005–2012). The patients hospitalized within 3 months before enrollment were excluded. The main exposure was the time-varying cumulative number of hospitalizations during the follow-up period. Hazard ratios (HRs) for all-cause mortality rate after discharge were estimated by time-dependent Cox regressions after adjusting for potential confounders. Results: The median follow-up time was 2.7 years, and 873 (26%) patients experienced at least 1 hospitalization during follow-up. The hospitalization rate was 0.23 per person-year and the mortality rate was 0.036 per person-year. The HR and 95% CI for post-discharge mortality increased as the cumulative number of hospitalizations increased: once, 1.41 (0.99–2.00); and twice or more, 2.27 (1.59–3.23). The cause-specific hospitalization categories, “infectious disease” and “cancer,” affected post-discharge mortality HRs in a similar manner: 2.41(1.32–4.41) and 2.70 (1.23–5.93), respectively. Conclusion: A higher cumulative number of hospitalizations is associated with increased post-discharge mortality in chronic hemodialysis patients. The cause-specific hospitalizations category of “infectious disease” showed an impact on mortality similar to that of hospitalization for “cancer.” Therefore, physicians should pay more attention to reducing preventable hospitalizations.

Risk-Based Hospital and Surgeon-Volume Categories for Total Hip Arthroplasty.

Studies of volume-outcome relationships typically subdivide volume via non-evidence-based methods, producing categories that vary widely among studies, preclude the comparison of results, and possibly obscure the true volume-outcome relationships. The goal of the current study was to use quantitative methods to derive meaningful, risk-based categories for hospital and surgeon total hip arthroplasty (THA) volume based on relationships with mortality, complications, and revision. Using New York statewide patient data (1997 to 2014; n = 187,557), we derived risk-based hospital and surgeon-volume categories for primary THA based on relationships with 90-day complications and mortality and 2-year revision. The following categories, based on relationships with complications, mortality, and revision, were derived for surgeon volume: 0 to 12, 13 to 25, 26 to 72, 73 to 165, 166 to 279, and ≥280 THA/year. For hospital volume, the categories derived were 0 to 11, 12 to 54, 55 to 157, 158 to 526, and ≥527 THA/year. More than 35% of THA cases in New York State were conducted by surgeons performing ≤1 THA/month (0 to 12 THA/year), and these were associated with a 2 to 2.5-fold increase in the risk for complications, mortality, and revision relative to higher-volume surgeons. Similarly, 15% of THA cases in New York State were conducted in hospitals performing ≤1 THA/week (0 to 11 or 12 to 54 THA/year), and these were associated with a nearly 1.5-fold increase in complications and between a 4 and 6-fold increase in mortality. Traditional non-evidence-based quartile categories were concentrated at lower volumes, did not capture the full magnitude of the volume-related differences, and were a poorer representation of the outcome data, as assessed by several model metrics. Thus, quartiles showed only a <2-fold increase in complications, mortality, and revision for the lowest versus the highest surgeon-volume quartile and failed to show the increased risk for lower versus higher hospital volumes. The volume-outcome relationships in THA are more pronounced than previously apparent through standard statistical techniques. Volume-based strategies for improving outcomes in THA should use benchmarks that are evidence-based to achieve optimal results. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

More Is Not Always Better: Understanding the Impact of Volume on the Analysis of Outcomes: Commentary on an article by Jayme C.B. Koltsov, PhD, et al.: "Risk-Based Hospital and Surgeon-Volume Categories for Total Hip Arthroplasty".

More Is Not Always Better: Understanding the Impact of Volume on the Analysis of Outcomes: Commentary on an article by Jayme C.B. Koltsov, PhD, et al.: "Risk-Based Hospital and Surgeon-Volume Categories for Total Hip Arthroplasty".

Association between hospital volume and quality of gastric cancer surgery in the CRITICS trial.

Studies investigating the association between hospital volume and quality of gastric cancer surgery are lacking. In the present study, the effect of hospital volume on quality of gastric cancer surgery was evaluated by analysing data from the CRITICS (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) trial. Patients who underwent gastrectomy with curative intent in the Netherlands were selected from the CRITICS trial database. Annual hospital volume of participating centres was derived from the Netherlands Cancer Registry. Hospital volume was categorized into very low (1-10 gastrectomies per year per institution), low (11-20), medium (21-30) and high (31 or more), and linked to the CRITICS database. Quality of surgery was analysed by surgicopathological compliance (removal of at least 15 lymph nodes), surgical compliance (removal of indicated lymph node stations) and the Maruyama Index. Postoperative morbidity and mortality were also compared between hospital categories. Between 2007 and 2015, 788 patients were included in the CRITICS study, of whom 494 were analysed. Surgicopathological compliance was higher (86·7 versus 50·4 per cent; P < 0·001), surgical compliance was greater (52·9 versus 19·8 per cent; P < 0·001) and median Maruyama Index was lower (0 versus 6; P = 0·006) in high-volume hospitals compared with very low-volume hospitals. There was no statistically significant difference in postoperative complications or mortality between the hospital volume categories. Surgery performed in high-volume hospitals was associated with better surgical quality than surgery carried out in lower-volume hospitals.

Quantitative Determination of Potable Cold Water Consumption in German Hospitals

A hospital’s water installations are critical for its function, but the environmental cost is high. This study quantifies the mean potable cold water consumption (PCWC) in 19 hospitals belonging to the German Public Health System. The hospital floor area ranges from 3000 to 151,000 m2 and the number of beds from 45 to 1003 beds. To this end, 60 Eco-Management and Audit Scheme statements were analyzed corresponding to the period 2005–2015 in accordance with their geographic location, heating-degree-days per year, cold-degree-days per year, hospital category depending on the number of beds, floor area, and number of workers. It was found that PCWC is greater in hospitals located in areas with greater heating-degree-days per year. The potential mean annual savings estimated were 8,600,000 m3 of water equivalent to 15,000,000 euros, 4000 MWh energy, and 30,000 tons of CO2 emissions. It was concluded that, to determine the mean annual water consumption, it is preferable to use the number of beds as reference indicator, and the value of the consumption as reference indicator was proposed as 103 m3 per bed per year.

Chinese Anesthesiologists Have High Burnout and Low Job Satisfaction: A Cross-Sectional Survey.

The Chinese health care system must meet the needs of 19% of the world's population. Despite recent economic growth, health care resources are unevenly distributed. This creates the potential for job stress and burnout. We therefore conducted a survey among anesthesiologists in the Beijing-Tianjin-Hebei region focusing on job satisfaction and burnout to determine the incidence and associated factors. A large cross-sectional study was performed in the Beijing-Tianjin-Hebei region of China. The anonymous questionnaire was designed to collect and analyze the following information: (1) demographic characteristics and employer information; (2) job satisfaction assessed by Minnesota Satisfaction Questionnaire; (3) burnout assessed by Maslach Burnout Inventory-Human Service Survey; and (4) sleep pattern and physician-patient communication. Surveys were completed and returned from 211 hospitals (response rate 74%) and 2873 anesthesiologists (response rate 70%) during the period of June to August 2015. The overall job satisfaction score of Minnesota Satisfaction Questionnaire was 65.3 ± 11.5. Among the participants, 69% (95% confidence interval [CI], 67%-71%) met the criteria for burnout. The prevalence of high emotional exhaustion, high depersonalization, and low personal accomplishment was 57% (95% CI, 55%-59%), 49% (95% CI, 47%-51%), and 57% (95% CI, 55%-58%), respectively. Using multivariable logistic regression analysis, we found that age, hospital category, working hours per week, caseload per day, frequency of perceived challenging cases, income, and sleep quality were independent variables associated with burnout. Anesthesiologists with a high level of depersonalization tended to engage in shorter preoperative conversations with patients, provide less information about pain or the procedure, and to have less empathy with them. The anesthesiologists in the Beijing-Tianjin-Hebei region of China expressed a below-average level of job satisfaction, and suffered a significant degree of burnout. Improvement in job satisfaction and burnout might create a positive work climate that could benefit both the quality of patient care and the profession of anesthesiology in China.

Application of two-step clustering analysis on inpatient satisfaction analysis

Objective To analyze the differences and influencing factors of inpatient satisfaction on hospitals of different types in different regions two years following implementation of the National Healthcare Improvement Initiative. Methods Data of hospitals and inpatient satisfaction survey results were collected from the a third-party evaluation of the National Healthcare Improvement Initiative, and analyzed in a two-step clustering model. This effort aims at learning the subjective feelings of inpatients and impacts of the objective indicators of medical resources allocation on inpatient satisfaction. The analysis helps identify indicators to be included into the clustering model and their correlation with such satisfaction. Results The two-step clustering rounded hospitals into four categories based on the inpatient overall satisfaction. Gaps were found among different categories of hospitals in terms of types of hospitals, location, affiliation and healthcare resources allocation. The inpatient overall satisfaction varied with these indictors. Among the category with the highest inpatient overall satisfaction, 100% were general hospitals, most of which in eastern area (52.38%), and local hospitals (50.00%). Hospitals in this category feature larger scales and stronger medical techniques. The category with the lowest inpatient overall satisfaction were mostly hospitals located in western regions (65.52%), maternal and child hospitals (41.38%) and local hospitals (89.65%). Most of these hospitals were large in scale, but their medical techniques and resources fell behind their eastern counterparts. The strongest correlation with inpatient overall satisfaction was medical behavior (r=0.95), while the weakest was the medical resources allocation (r<0.30). Conclusions There are gaps of inpatient overall satisfactions among different types of hospitals located in different regions. Patients′ subjective perceptions and medical resources allocation affected their overall satisfactions. The non-medical services were important factors towards patient satisfaction. Key words: Inpatients; Patient satisfaction; Two-step clustering analysis; Healthcare improvement

Spatial Epidemiology of Alcohol- and Drug-Related Health Problems Among Northern Plains American Indians: Nebraska and South Dakota, 2007 to 2012.

Despite high abstinence rates, American Indians experience elevated rates of many alcohol and other drug problems. American Indians also predominantly reside in poor and rural areas, which may explain some observed health disparities. We investigated whether geographic areas including reservations or large American Indian populations exhibited greater incidence of alcohol- and drug-related hospitalizations. We obtained inpatient hospitalization records for 2 Northern Plain states (Nebraska and South Dakota) for the years 2007 to 2012. We constructed zip code counts for 10 categories of hospitalization with diagnoses or injury causation commonly associated with alcohol or drug use. We related these to community sociodemographic characteristics using Bayesian Poisson space-time regression models and examined associations with and without controls for whether each zip code was located within an American Indian reservation. Controlling for other demographic and economic characteristics, zip codes with greater percentage of American Indians exhibited greater incidence for all 10 substance abuse-related health outcomes (9 of 10 well supported); zip code areas within American Indian reservations had greater incidence of self-inflicted injury and drug dependence and abuse, and reduced incidence of alcohol cirrhosis and prescription opioid poisoning. However, the analyses generally demonstrated no well-supported differences in incidence associated with local residence percentages of American Indian versus African American. In our analyses, ethnicity or heredity alone did not account for alcohol- and drug-related hospitalizations among Native populations. Aspects of social, economic, and political dimensions of Native lives must be considered in the etiology of alcohol- and drug-related problems for rural-dwelling indigenous peoples.

Results of the National Survey on the Treatment of Chronic Anal Fissure in Spanish Hospitals

IntroductionThe treatment of chronic anal fissure (FAC) differs depending on the professional. To come to a consensus, the current situation in Spain should be studied.The aim of this study is to evaluate the current situation of the management of FAC in Spanish hospitals. MethodsDescriptive study, with data from a survey of surgeons of the Spanish Association of Coloproctology. Data was collected according to the doctor's autonomous community, type of hospital and professional category; FAC management data and 3 clinical cases. ResultsResponse was obtained from 152 surgeons. Pharmacological measures stand out as the first therapeutic step (93.38%). In patients with hypertonia and with no risk factors for fecal incontinence (FI), 55.9% use hygienic-dietary measures associated with nitroglycerin ointment (MHG+NTG). The second step is internal lateral sphincterotomy (ELI) (43.4%). MHG+NTG (75.7%) is used in patients with FI risk factors and in case of failure, ELI is used with a prior ultrasound and/or manometry. In young patients with unexplained hypertonia and incapacitating proctalgia with no risk factors for FI, MHG+NTG (55.9%) is used and, if it is not successful, they are treated with ELI (46.1%). ConclusionsThe management of FAC in Spain shows similarities with the international guideline suggestions. Nevertheless, some differences can be seen from the first stages of treatment.

Resultados de la encuesta nacional sobre el tratamiento de la fisura anal crónica en los hospitales españoles

IntroductionThe treatment of chronic anal fissure (FAC) differs depending on the professional. To come to a consensus, the current situation in Spain should be studied.The aim of this study is to evaluate the current situation of the management of FAC in Spanish hospitals. MethodsDescriptive study, with data from a survey of surgeons of the Spanish Association of Coloproctology. Data was collected according to the doctor's autonomous community, type of hospital and professional category; FAC management data and 3 clinical cases. ResultsResponse was obtained from 152 surgeons. Pharmacological measures stand out as the first therapeutic step (93.38%). In patients with hypertonia and with no risk factors for fecal incontinence (FI), 55.9% use hygienic-dietary measures associated with nitroglycerin ointment (MHG+NTG). The second step is internal lateral sphincterotomy (ELI) (43.4%). MHG+NTG (75.7%) is used in patients with FI risk factors and in case of failure, ELI is used with a prior ultrasound and/or manometry. In young patients with unexplained hypertonia and incapacitating proctalgia with no risk factors for FI, MHG+NTG (55.9%) is used and, if it is not successful, they are treated with ELI (46.1%). ConclusionsThe management of FAC in Spain shows similarities with the international guideline suggestions. Nevertheless, some differences can be seen from the first stages of treatment.

National bundle care program implementation to reduce ventilator-associated pneumonia in intensive care units in Taiwan.

This study investigated the impact of implementing ventilator-associated pneumonia (VAP) bundle care on the rates of VAP in intensive care units (ICUs) in Taiwan. A total of 10 ICUs (bed number, 170), including surgical (SICUs) (n=7), cardiovascular/surgical (CV/S-ICUs) (n=1), and medical ICUs (MICUs) (n=2) from 10 hospitals (7 medical center hospitals and 3 regional hospitals) were enrolled in this quality-improvement project. This study was divided into the pre-intervention phase (1st January, 2012-31st July, 2013) and the intervention phase (1st August, 2013-31st October, 2014). Among the 10 hospitals, the overall rates (cases per 1000 ventilator-days) of VAP declined significantly (p=0.005; rate ratio, 0.71) from 1.9 in the pre-intervention period to 1.5 in the intervention period. Significant difference in VAP rates between these periods was found in the regional hospitals (from 1.6 to 0.7; p<0.001) and the SICUs (from 2.1 to 1.4; p<0.001), but not in the medical centers (2.0 vs. 1.9; p=0.0667) or CV/S-ICUs (4.5 vs. 4.5; p=0.5391). However, VAP rate increased significantly (cases per 1000 ventilator-days) in the MICUs between the two periods (from 0.5 to 1.0; p=0.0489). For the VAP bundle care elements, the overall compliance rate was 87.7% with 83.6% and 97.9% in the medical centers and regional hospitals, respectively. Implementing VAP bundle care has effectively reduced VAP in Taiwanese ICUs, but differences in performance and compliance rates of VAP bundle care among the different ICUs and hospital categories did exist.

Effect of hospital safety net designation on treatment use and survival in hepatocellular carcinoma.

Racial/ethnic minorities with hepatocellular carcinoma (HCC) have worse survival than non-Hispanic whites. Comparing patient outcomes across health care delivery systems can identify biological and care delivery mechanisms contributing to this disparity. We compared presentation, treatment, and survival of HCC patients treated at safety net hospitals (SNHs) and non-SNHs. Patients diagnosed with HCC from 2001 to 2012 were identified in the Texas Cancer Registry. We compared hospital and patient characteristics across three hospital categories: non-SNHs, low-proportion SNHs (l-SNHs), and high-proportion SNHs (h-SNHs). Covariate-adjusted treatment use and overall survival were compared among the 3 hospital categories. Despite comprising only 23% of hospitals, h-SNHs cared for 42% of 17,489 HCC patients and disproportionately delivered care to racial/ethnic minorities and patients of low socioeconomic status compared with non-SNHs. Compared with non-SNHs, treatment use was similar at l-SNHs (45% vs 45%; adjusted odds ratio [OR], 0.97; 95% confidence interval [CI], 0.89-1.06) but significantly lower at h-SNHs (32% vs 45%; OR, 0.64; 95% CI, 0.57-0.73). Similarly, patients with localized HCC were less likely to undergo curative treatment at h-SNHs than non-SNHs (OR, 0.51; 95% CI, 0.40-0.66). Compared with non-SNHs, overall survival was similar at l-SNHs (hazard ratio [HR], 0.93; 95% CI, 0.89-0.98) but significantly worse at h-SNHs (HR, 1.30; 95% CI, 1.22-1.39). Patients at SNHs are less likely to undergo HCC treatment, even when diagnosed at an early stage, which likely contributes to worse survival. System-level differences in care delivery may partly explain racial/ethnic and socioeconomic disparities in HCC prognosis. Cancer 2018;124:743-51. © 2017 American Cancer Society.

The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death

BackgroundAccurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping.MethodsThe study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data.ResultsThe study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%).ConclusionPhysicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.

Air pollution and risk of hospitalization for epilepsy: the role of farm use of nitrogen fertilizers and emissions of the agricultural air pollutant, nitrous oxide.

The link between various air pollutants and hospitalization for epilepsy has come under scrutiny. We have proposed that exposure to air pollution and specifically the pervasive agricultural air pollutant and greenhouse gas, nitrous oxide (N2O), may provoke susceptibility to neurodevelopmental disorders. Evidence supports a role of N2O exposure in reducing epileptiform seizure activity, while withdrawal from the drug has been shown to induce seizure-like activity. Therefore, we show here that the statewide use of anthropogenic nitrogen fertilizers (the most recognized causal contributor to environmental N2O burden) is significantly negatively associated with hospitalization for epilepsy in all three pre-specified hospitalization categories, even after multiple pollutant comparison correction (p<.007), while the other identified pollutants were not consistently statistically significantly associated with hospitalization for epilepsy. We discuss potential neurological mechanisms underpinning this association between air pollutants associated with farm use of anthropogenic nitrogen fertilizers and hospitalization for epilepsy.