Community Hospital Group Research Articles

Results From Complex Abdominal Reconstruction at Non-Academic Institution can Favorably Compare to Major Academic Centers: An Abdominal Core Health Quality Collaborative Database Review.

Many complex abdominal hernias are referred to tertiary academic institutions for evaluation and treatment. The purpose of this study was to compare clinical outcomes from complex abdominal hernia repairs and abdominal wall reconstructions at a community hospital vs high volume academic centers participating in Abdominal Core Health Quality Collaborative (ACHQC). Patients undergoing elective complex abdominal hernia repair were identified in our community setting and treated between 2016 and 2019. These results were then compared to Academic centers in the ACHQC database. Complex hernia definition was limited to those who have undergone any myofascial advancement procedure for homogeneity. Informed consent was obtained, and study was IRB approved. All data was de-identified. A total of 180 patients underwent complex abdominal hernia repair at our community hospital. The ACHQC database identified 6299 patients meeting criteria at participating academic centers. Demographics were similar between the two groups including hernia grade, size and wound class. Academic centers tended to have patients with previous component separations (25.7% vs 10.6%) and immunosuppressed (7.2% vs 2.8%), while the community hospital patients included more patients with tobacco use (18.9% vs 12.1%) and hypertension (65% vs 54.9%). Operative times were significantly less at the community hospital, patients requiring >240 minutes of time for repair at academic centers (39.6% vs 5%). Postoperatively length of stay was significantly shorter at the community hospital group averaging 3.7days vs academic centers of 6days (P < .05). Although overall complications were less in the community hospital group (26.5% vs 19.4%). Readmission within 30days was nearly twice as frequent in the community hospital group (14.4% vs 7.7%). Community hospitals can provide comparable care and surgical expertise as major academic centers in regard to complex hernias in a large majority of cases. There is a need for dedicated care coordination and continuous review of supporting staff and outcomes is necessary to assure quality care. There is still a need to identify which patients would benefit from treatment at an academic center as opposed to a community hospital in order to maximize patient access and outcomes at both types of hospital setting. Further investigation needs to be performed regarding criteria for which patients should be transferred to academic centers for their complex hernia care. Identifying patients who would benefit from treatment at Academic Centers as opposed to Community hospitals should continue to be investigated.

Willingness to Select Initial Clinical Training Hospitals Among Medical Students at a Rural University in Japan: A Single-Center Cross-Sectional Study.

PurposeMany countries will be aged societies by 2060. As a super-aged society, Japan may offer a valuable reference point. The number of medical residents and doctors working at university hospitals in Japan has halved since 2004, resulting in serious shortages of doctors in rural areas. This study clarified factors influencing medical students to choose university hospitals as facilities for their initial training or to only choose community hospitals.MethodsThis single-center cross-sectional study was conducted in a typical rural city in Japan from February to March 2021. Data were collected using a questionnaire developed from a narrative review and discussion among four researchers. The participants were divided into those who chose university hospitals and those chose only community hospitals for logistic regression analysis.ResultsOf the 300 students who answered the questionnaire (46.4% response rate), 291 agreed to participate in the study. At the time, 93 students had not decided where to undertake initial training, and were excluded. Of the 198 analyzed students, 113 (57.1%) had chosen university hospitals. Significant factors affecting students’ choices were “good salary or fringe benefits” (odds ratio [OR] 2.6, 95% confidence interval [CI]: 1.3–5.2) in the community hospital group, and “desire to have contact with doctors practicing in a medical setting before starting hospital training in the fifth and sixth grade” (OR 0.4, 95% CI: 0.2–0.8) and “prefer Saga Prefecture for initial training” (OR 0.2, 95% CI: 0.1–0.4) among the university hospital group.ConclusionUniversity hospitals could offer a good salary or fringe benefits to secure residents. Other useful measures include preferential admission of students who pledge to work in the prefecture of their medical school after graduation and facilitating contact between motivated students and senior doctors before starting hospital training.

First medical contact place determines prognosis in a regional STEMI network. Is time the most important factor?

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Codi IAM investigators Background Long revascularization times have been associated with worse prognosis in PCI-treated STEMI patients. Thus, efforts have been focused in optimizing revascularization times. In Catalonia, the different first medical contact (FMC) points with the regional STEMI network CODI IAM have been associated with different degrees of delay in reperfusion. Purpose we aim to determine if our regional STEMI network achieves better mortality rates in the fastest circuits than in slower ones by optimizing revascularization times. Methods since CODI IAM network was launched in June 2009, a prospective registry of all attended cases is conducted. We included in the study all patients with final STEMI diagnosis treated with primary PCI from January 2010 to December 2016. Patients were divided in 4 different groups regarding FMC point: primary care center (PCC), community hospital (CH), PCI-hospital (PCI-H), emergency medical services (EMS)). Clinical data, reperfusion times and 30-day and 1-year mortality were analyzed. Results a total of 14,483 patients (PCC 19%, CH 35,7%, PCI-H 12,5%; EMS 32,7%) were included in the analysis. Women proportion was higher in hospital-attended cases (p &amp;lt; 0,001), and so was diabetes (p &amp;lt; 0,001). Previous history of MI, PCI and CABG were more frequent in both EMS and PCI-H groups (p &amp;lt; 0,001). Killip-Kimball Classes III-IV were more frequent in PCI-H and EMS groups (EMS 12,5%, PCI-H 10,4%, CH 7%, PCC 4,6%; p &amp;lt; 0,001). All complications (intubation, ventricular fibrillation, ventricular tachycardia, atrial fibrillation, AV block) in first medical assistance were more frequent in EMS group (p &amp;lt; 0,001). Median time from ECG to reperfusion was shorter in the PCI-H group (74 min (IQR 56-110), p &amp;lt; 0,001) but the shortest median ischaemic time was achieved by EMS group (155 min (IQR 120-215), p &amp;lt; 0,001). Global 30-day and 1-year mortality were 5,8% and 9,4% respectively, significantly higher in PCI-H and EMS groups than in CH and PCC groups (30-day m. CH 4,9%, PCC 3,3%, PCI-H 7%, EMS 7,8%), p &amp;lt; 0,001). After Cox regression adjusted analysis including sex, age, diabetes, anterior STEMI, Killip-Kimball Class and primary VF, 30-day and 1-year mortality remained higher in PCI-H and EMS groups compared to CH group, both without adjusting by time (HR 1,31 (1,01-1,69), p = 0,04 for PCI-H 30-day mortality; HR 1,25 (1,03-1,51), p = 0,025 for EMS 30-day mortality), and after adjusting by time ECG-reperfusion &amp;gt;120 min (HR 1,56 (1,20-2,03), p = 0,001 for PCI-H 30-day mortality and HR 1,48 (1,21-1,82), p &amp;lt; 0,001 for EMS 30-day mortality). Conclusions considering that reperfusion time intervals favour EMS and PCI-H groups, crude between-groups mortality differences might be justified by a selection bias rather than by the pathway itself. Despite this probable selection bias, the STEMI network achieves a reduction of these differences by shortening reperfusion times in EMS and PCI-H groups. Abstract Figure. 1-year mortality curves

Is Youtube a potential training source for total extraperitoneal laparoscopic inguinal hernia repair?

The aim of this study is to evaluate the quality of the most commonly viewed total extraperitoneal laparoscopic inguinal hernia repair (TEP) videos on Youtube, which is the largest social and medical media broadcasting service, concerning educational purposes. A search with the keyword "total extraperitoneal laparoscopic inguinal hernia repair" was performed on Youtube. The first 120 videos among the search results were downloaded and 55 of them were included in the study. A scoring system developed by the authors according to the recent literature was utilized for evaluation of the videos. Video demographics were evaluated for the quality and upload source. Among the enrolled videos, video quality was rated as good in 13 (23.6%), as moderate in 22 (40%), and as poor in 20 (36.4%). Video length, presence of narration, number of likes, and comments were significantly higher in the good group. Upload source was an academic center in 14 (25.5%), a community hospital in 22 (40.0%), and a physician in 19 (34.5%). The mean video score of the academic center group (8 ± 4.095) and community hospital group (8.64 ± 3.259) was significantly higher than the physician group (5.47 ± 2.632) (p = 0.010). Video quality was not correlated with total views or views per day. Total extraperitoneal laparoscopic inguinal hernia repair procedure videos uploaded to Youtube demonstrate considerable heterogeneity in terms of educational quality and the number of good quality videos is significantly low. This heterogeneity is attributed to the lack of peer review process for the evaluation of educational quality of the videos. Therefore, a physician intending to learn and practice a surgical procedure properly (TEP repair in this situation) should not consider a broadcasting service without a peer review process as a reliable training source.

Collaboration of community hospital endosonographers improves diagnostic yield of endoscopic ultrasonography guided tissue acquisition of solid pancreatic lesions.

Background and study aims Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is the method of choice for establishing a pathological diagnosis of solid pancreatic lesions. Data on quality and yield of EUS-guided TA performed in community hospitals are lacking. A study was performed to determine and improve the diagnostic yield of EUS-guided TA in a group of community hospitals. Methods Following analysis of the last 20 EUS-guided TA procedures of solid pancreatic lesions performed in each of four community hospitals, a collaborative EUS interest group was formed and a prospective registry was started. During meetings of the interest group, feedback on results per center were provided and strategies for improvement were discussed. Results In the BEFORE team formation cohort, 80 procedures were performed in 66 patients. In the AFTER team formation cohort, 133 procedures were performed in 125 patients. After team formation, the rate of adequate sample increased from 80 % (95 %CI [0.7 – 0.9]) to 95 % (95 %CI [0.9 – 1.0]) , diagnostic yield of malignancy improved from 28 % (95 %CI [0.2 – 0.4]) to 64 % (95 % CI [0.6 – 0.7]), and sensitivity of malignancy improved from 63 % (95 %CI [0.4 – 0.8]) to 84 % (95 %CI [0.8 – 0.9]). Multivariate regression analysis revealed team formation to be the only variable significantly associated with an increased rate of adequate sample. Conclusions Formation of a regional EUS interest group with regular feedback on results per center, and discussions on methods and techniques used, significantly improved the outcome of EUS-guided TA procedures in patients with solid pancreatic lesions in community hospitals.

Pediatric hospitalists in community hospitals: hospital-based generalists with expanded roles.

A few years ago, I was interviewing candidates for a position in our community hospital group. I was telling a resident who was graduating from a highly specialized university program about our range of activities and proudly describing our relationships with community practitioners when she abruptly ended the interview, explaining that she did not want to be what we were; she wanted to be a hospitalist. I was confused. If we were not hospitalists, what were we? “Hospital-based generalists,” she said. Until that exchange, I had no appreciation for a difference between being a pediatric hospitalist and being a hospital-based pediatric generalist. But as I considered her frame of reference, I understood: she was seeking what she knew, a general inpatient niche position within a full department of pediatrics, whereas we aspired to address the care of children everywhere in the hospital as an integral part of a pediatric community providing care for children. The distinction might largely be between the role generally performed by pediatric hospitalists in university/children’s hospitals and what pediatric hospitalists do in community hospitals, activities that may include any or all of the following in addition to inpatient care: newborn nursery care, delivery room resuscitations/stabilization, emergency department consultations, outpatient consultations; procedural sedations, advocacy for the needs of children within an adult-oriented system, and transport medicine. Hospitalists in university/children’s hospitals may perform some of these activities as well, of course, but the expanded scope of activities may well define the unique role of pediatric generalists in community hospitals. The role, or opportunity, …

Cancer Care Ontario Guidelines for radical prostatectomy: Striving for continuous quality improvement in community practice

Objective: Cancer Care Ontario has published an evidence-based guideline on their website “Guideline for Optimization of Surgicaland Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management: Surgical and Pathological Guidelines.” The evidentiary base for this guideline was recently published in CUAJ. The CCO guideline proposes the following: a positive surgical margin (PSM) rate of &lt;25% for organ-confined disease (pT2), a perioperative mortality of &lt;1%, a rate of rectal injury &lt;1%, and a blood transfusion rate &lt;10% in non-anemic patients. The objective of this study was to review the radical prostatectomy practice at the Grey Bruce Health Services, an Ontario community hospital, and to compare our performance in relation to the Cancer Care Ontario guideline and the literature.Methods: We conducted a retrospective review of all radical prostatectomies performed at the Grey Bruce Health Services from January 1, 2006 to December 31, 2007. The following data were obtained from clinical records and pathology reports: patient age, pre-biopsy prostate-specific antigen, biopsy Gleason score, resected prostate gland weight, radical prostatectomy Gleason score, surgical margin status, pathological tumour stage (pT), lymph node dissection status, perioperative incidence of transfusion of blood products and if the patient was anemic (hemoglobin &lt;140 g/L) preoperatively, incidence of rectal injury, and perioperative mortality within 30 days following surgery.Results: Using the method proposed by D’Amico, most patients undergoing radical prostatectomy were intermediate risk (62%), with a minority of low-risk (24%) and high-risk (14%) patients. The overall PSM rate was 37%. The rate of PSMs in organ-confined disease (pT2) was 26%. There was a statistically significant trend between increasing D’Amico risk category and increasing rate of PSM (Cochran-Armitage trend test, p = 0.023). There was a strong correlation between the pathological tumour stage and the rate of PSM (Cochran-Armitage trend test, p = 0.0003). The rate of blood transfusion in non-anemic patients was 6%. There was 1 patient (0.8%) who experienced a rectal injury. There were no perioperative deaths in our study group.Conclusion: Our results show that a community hospital group can appropriately select patients to undergo radical prostatectomy, as well as achieve an acceptable rate of PSMs. We believe that ongoing critical appraisal and reflective practice are essential to improving surgical outcomes and providing quality care.

Cancer Care Ontario Guidelines for radical prostatectomy: striving for continuous quality improvement in community practice.

: Cancer Care Ontario has published an evidence-based guideline on their website "Guideline for Optimization of Surgical and Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management: Surgical and Pathological Guidelines." The evidentiary base for this guideline was recently published in CUAJ. The CCO guideline proposes the following: a positive surgical margin (PSM) rate of <25% for organ-confined disease (pT2), a perioperative mortality of <1%, a rate of rectal injury <1%, and a blood transfusion rate <10% in non-anemic patients. The objective of this study was to review the radical prostatectomy practice at the Grey Bruce Health Services, an Ontario community hospital, and to compare our performance in relation to the Cancer Care Ontario guideline and the literature. : We conducted a retrospective review of all radical prostatectomies performed at the Grey Bruce Health Services from January 1, 2006 to December 31, 2007. The following data were obtained from clinical records and pathology reports: patient age, pre-biopsy prostate-specific antigen, biopsy Gleason score, resected prostate gland weight, radical prostatectomy Gleason score, surgical margin status, pathological tumour stage (pT), lymph node dissection status, perioperative incidence of transfusion of blood products and if the patient was anemic (hemoglobin <140 g/L) preoperatively, incidence of rectal injury, and perioperative mortality within 30 days following surgery. : Using the method proposed by D'Amico, most patients undergoing radical prostatectomy were intermediate risk (62%), with a minority of low-risk (24%) and high-risk (14%) patients. The overall PSM rate was 37%. The rate of PSMs in organ-confined disease (pT2) was 26%. There was a statistically significant trend between increasing D'Amico risk category and increasing rate of PSM (Cochran-Armitage trend test, p = 0.023). There was a strong correlation between the pathological tumour stage and the rate of PSM (Cochran-Armitage trend test, p = 0.0003). The rate of blood transfusion in non-anemic patients was 6%. There was 1 patient (0.8%) who experienced a rectal injury. There were no perioperative deaths in our study group. : Our results show that a community hospital group can appropriately select patients to undergo radical prostatectomy, as well as achieve an acceptable rate of PSMs. We believe that ongoing critical appraisal and reflective practice are essential to improving surgical outcomes and providing quality care.

Effects of delays in transfer on independence outcomes for older people requiring postacute care in community hospitals in England

BackgroundIntegration of intermediate care (IC) services, particularly between secondary care and IC, has been regarded as a critical organizational factor for an efficient and effective service but has been poorly researched. MethodsThe effects of time to transfer on outcome were investigated for patients transferred to one of seven community hospitals (a common form of IC in England) as part of a multicenter, randomized controlled trial.Patients admitted to hospital with one of the geriatric syndromes (falls, incontinence, confusion, immobility) were recruited when they were medically stable and if the responsible physician considered that IC was required. Patients were divided into three groups: “early transfer” (<2 days); “late transfer” (>2 days); and “no transfer” (control group).Patient independence at 6 months after randomization as measured by the Nottingham Extended Activities of Daily Living Scale (NEADL) score. ResultsThere was a significant difference between the “early transfer” (n=87), “late transfer” (n=78), and control (“no transfer”) (n=121) groups for changes in NEADL scores from baseline to 6 months using analysis of covariance to adjust for baseline variables (p=0.016). Pairwise comparisons showed a significant difference only between the “early transfer” and control (“no transfer”) groups. Adding time to transfer as a covariate improved the fit of the model, explaining NEADL outcomes, and showed a significant difference in change in NEADL score in favor of the community hospital group (adjusted mean difference, 6.12; 95% confidence interval, 2.59–9.67; analysis of covariance p=0.001). ConclusionThe time window for between-service transfers to IC that optimizes clinical outcomes for frail older people recovering from an acute illness is small. In this study, a delay of more than 2 days was sufficient for detrimental effects on an independence outcome to be observed.

Virtual slide telepathology for an academic teaching hospital surgical pathology quality assurance program

Virtual slide telepathology is an important potential tool for providing re-review of surgical pathology cases as part of a quality assurance program. The University of Arizona pathology faculty has implemented a quality assurance program between 2 university hospitals located 6 miles apart. The flagship hospital, University Medical Center (UMC), in Tucson, AZ, handles approximately 20 000 surgical pathology specimens per year. University Physicians Healthcare Hospital (UPHH) at Kino Campus has one tenth the volume of surgical pathology cases. Whereas UMC is staffed by 10 surgical pathologists, UPHH is staffed daily by a single part-time pathologist on a rotating basis. To provide same-day quality assurance re-reviews of cases, a DMetrix DX-40 ultrarapid virtual slide scanner (DMetrix, Inc, Tucson, AZ) was installed at the UPHH in 2005. Since then, glass slides of new cases of cancer and other difficult cases have been scanned the same day the slides are produced by the UPHH histology laboratory. The pathologist at UPHH generates a provisional written report based on light microscopic examination of the glass slides. At 2:00 pm each day, completed cases from UPHH are re-reviewed by staff pathologists, pathology residents, and medical students at the UMC using the DMetrix Iris virtual slide viewer. The virtual slides are viewed on a 50-in plasma monitor. Results are communicated with the UPHH laboratory by fax. We have analyzed the results of the first 329 consecutive quality assurance cases. There was complete concordance with the original UPHH diagnosis in 302 (91.8%) cases. There were 5 (1.5%) major discrepancies, which would have resulted in different therapy and/or management, and 10 (3.0%) minor discrepancies. In 6 cases (1.8%), the diagnosis was deferred for examination of the glass slides by the reviewing pathologists at UMC, and the diagnosis of another 6 (1.8%) cases were deferred pending additional testing, usually immunohistochemistry. Thus, the quality assurance program found a small number of significant diagnostic discrepancies. We also found that implementation of a virtual slide telepathology quality assurance service improved the job satisfaction of academic subspecialty pathologists assigned to cover on-site surgical pathology services at a small, affiliated university hospital on a rotating part-time basis. These findings should be applicable to some community hospital group practices as well.

Endoluminal Stent-Graft Placement for Repair of Abdominal Aortic Aneurysms in the Community Setting

To demonstrate that results similar to high-volume academic centers can be achieved in the community setting when treating abdominal aortic aneurysm (AAA) using endovascular techniques, given appropriate volume and skill sets. A retrospective review was conducted of 342 consecutive patients who underwent endovascular aneurysm repair (EVAR) by surgeons in a community hospital group from October 1999 through September 2005. In this population, 245 (71.6%) patients were treated with EVAR and 97 (28.4%) with open surgical repair. Of the 245 EVAR patients (203 men; mean age 73.4+/-9.2 years), 218 AneuRx, 19 Ancure, 6 Excluder, and 2 Zenith stent-grafts were implanted by 2 vascular surgeons to exclude AAAs with a mean diameter of 54+/-11 mm. Patients were followed postoperatively with office visits and computed tomography at 1, 6, and 12 months and annually thereafter. Technical success was achieved in 99.6% (244/245) with 1 intraoperative conversion. Mean operative time was 131+/-57 minutes, with a mean contrast load of 161.6+/-65.5 mL. Thirty-five (14.3%) patients required intraoperative blood transfusion. Length of stay was 2.3+/-4.5 days. Thirty-day mortality was 0.8% (2/245). Secondary procedures were required in 15 (6.1%) patients. Kaplan-Meier estimates of freedom from secondary interventions were 98%, 98%, 95%, and 90% at 12, 24, 36, and 48 months, respectively. At the same time points, freedom from surgical conversion was 99%, 99%, 97%, and 96%, and freedom from aneurysm-related death was 97%, 96%, 96%, and 96%. Endovascular AAA repair provides a less invasive method of managing aortic disease with resultant low perioperative mortality. Results in our community hospital demonstrate that this technology can be applied outside an academic environment in nearly three quarters of the population with excellent short and long-term results.

Post-acute care for older people in community hospitals—a cost-effectiveness analysis within a multi-centre randomised controlled trial

to compare the cost effectiveness of post-acute care for older people provided in community hospitals with general hospital care. cost-effectiveness study embedded within a randomised controlled trial. seven community hospitals and five general hospitals at five centres in the midlands and north of England. 490 patients needing rehabilitation following hospital admission with an acute illness. multidisciplinary team care for older people in community hospitals. EuroQol EQ-5D scores transformed into quality-adjusted life years; health and social service costs during the 6-month period following randomisation. there was a non-significant difference between the community hospital and general hospital groups for changes in quality-adjusted life-year values from baseline to 6 months (mean difference 0.048; 95% confidence interval -0.028 to 0.123; P = 0.214). Resource use was similar for both groups. The mean (standard deviation) costs per patient for health and social services resources used were comparable for both groups: community hospital group 8,946 pounds ( 6,514 pounds); general hospital group 8,226 pounds ( 7,453 pounds). These findings were robust to sensitivity analyses. The incremental cost-effectiveness ratio estimate was 16,324 pounds per quality-adjusted life year. A cost effectiveness acceptability curve suggests that if decision makers' willingness to pay per quality-adjusted life year was 10,000 pounds, then community hospital care was effective in 47% of cases, and this increased to only 50% if the threshold willingness to pay was raised to 30,000 pounds. the cost effectiveness of post-acute rehabilitation for older people was similar in community hospitals and general hospitals.

A cost effectiveness analysis within a randomised controlled trial of post-acute care of older people in a community hospital

Objective To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district...

Favorable Impact of an Infection Control Network on Nosocomial Infection Rates in Community Hospitals

To describe an infection control network (the Duke Infection Control Outreach Network [DICON]) and its impact on nosocomial infection rates in community hospitals. Prospective cohort study of rates of nosocomial infections and exposures of employees to bloodborne pathogens in hospitals during the first 3 years of their affiliation with DICON. Attributable cost and mortality estimates were obtained from published studies.Setting. Twelve community hospitals in North Carolina and Virginia. During the first 3 years of hospital affiliation with DICON, annual rates of nosocomial bloodstream infections at study hospitals decreased by 23% (P = .009). Annual rates of nosocomial infection and colonization due to methicillin-resistant Staphylococcus aureus decreased by 22% (P = .002), and rates of ventilator-associated pneumonia decreased by 40% (P = .001). Rates of exposure of employees to bloodborne pathogens decreased by 18% (P = .003). The establishment of an infection control network within a group of community hospitals was associated with substantial decreases in nosocomial infection rates. Standard surveillance methods, frequent data analysis and feedback, and interventions based on guidelines and protocols from the Centers for Disease Control and Prevention were the principal strategies used to achieve these reductions. In addition to lessening the adverse clinical outcomes due to nosocomial infections, these reductions substantially decreased the economic burden of infection: the decline in nosocomial bloodstream infections and ventilator-associated pneumonia alone yielded potential savings of 578,307 US dollars to 2,195,954 US dollars per year at the study hospitals.

Prevalence of depression among general hospital surgical inpatients

Previous studies report a wide range of prevalence rates of depressive illness among general hospital inpatients, all higher than in a non-patient population. Several factors may have influenced on these results. Mixed study population, depression-prone subgroups and continuous shift in what is a surgical inpatient population due to day surgery treatment are examples. In the present study, 108 patients were assessed with the Structured Clinical Interview for DSM-III-R Non-Patient (SCID-NP) version for current major depression (CMD) and for dysthymia. Furthermore, a patient self-rating scale for depressive symptoms and anxiety, the Hospital Anxiety and Depression Scale (HADS), was applied. CMD was diagnosed among 14/108 patients (13%). Depressive symptoms (HADS-D≥8) were seen in 14 patients. Symptoms of anxiety (HADS-A≥8) were seen in 12/14 CMD patients (86%). Ten of the 14 patients diagnosed as CMD (71%) did not receive any pharmacological antidepressant treatment. After excluding known depression-prone subgroups of patients representing a bias, this study showed that in a community hospital group of adult surgical patients between 18 and 65 years of age, the prevalence of depression is still somewhat higher than in the general population, but not as high as in the previous studies on general hospital patients to which we referred. Thus, this high prevalence of depression in part could be due to increased depression rates in certain population subgroups. However, this hypothesis alone is not sufficient to explain the present results fully.

A Longitudinal View of Laboratory Re-Engineering in a Community Hospital Group

Starting with a traditional community hospital laboratory system in one medium-sized and two small community hospitals and with a modest plan for reorganization, the CHS laboratories have embarked on a successful 6-year run of re-engineering.

Rates of disagreement in imaging interpretation in a group of community hospitals

Prospective studies of radiologists' interpretations of selected radiographs reported 20-40 years ago indicated error rates of 30% and higher. The authors retrospectively evaluated the interpretations of groups of radiologists and determined a range of rates of disagreement in interpretation. Quality assessment or recredentialing may add to the importance of such studies in the future. Over a 7-year period, a team of radiologists reviewed imaging interpretations in the radiology departments of six community hospitals. Each review, which lasted about 3 days, included evaluation of the interpretations of a 3%-4% sample of the images read by the radiologists at these hospitals. Reading errors were quantitated and evaluated qualitatively. In a review of over 11,000 images read by 35 radiologists, the authors found a 4.4% mean rate of interpretation disagreement; only one radiologist had a mean rate above 8%. Qualitative analysis of the interpretation errors revealed a mean rate of 3.0% of errors that were considered to be below an acceptable standard of care. Radiologists whose errors included a relatively high proportion of false-positive findings tended to make relatively fewer total errors. Rates of disagreement for a broad range of studies that radiologists interpret in a community hospital setting appear to be far lower than earlier studies on selective radiographs indicated.

Medical student training in the performance of diagnostic laboratory procedures.

A study was conducted to determine what diagnostic laboratory procedures medical students recalled being taught during pre-clerkship training, how well they felt they could perform these procedures on entrance to and exit from their clerkship year, and the estimate of frequency of personal performance during the clerkship year. Surveys were mailed to 223 graduating senior students of a medical school. They were asked to supply data regarding 15 pre-selected procedures. In only seven cases did a majority of students recall being taught a procedure. Higher percentages of students who trained at health science centres and a Veterans Administration hospital recalled being taught procedures compared to students who trained at community hospitals. In general, students who performed their pre-clerkship training at the health science centres rated their ability to perform procedures without assistance on entrance to the clerkship year higher than the other two groups. Students who performed at least one half of their clerkships at a health science centre rated their ability to perform procedures without assistance at the termination of their clerkship year higher than those who performed a majority of clerkships at community hospitals. The former group also reported a higher frequency of performance of the procedures than the community hospital group. Most of the procedures for all groups, however, were performed at a rate of less than one/month.

Continuing medical education

Community hospitals and medical schools have different but complementary resources to carry out continuing medical education. To strengthen the educational capabilities of both, a group of community hospitals has been linked to a medical school in a continuing medical education network. A peripatetic educational development team based at the medical school completes the link by helping community hospital physicians identify educational needs and develop educational responses, using both local and medical school experts as faculty. The educational development team provides skills and staffing which no small or moderate-sized community hospital could afford alone. The program is financially feasible for community hospitals and the medical school, does not consume the resources of either, and conserves the time of the community physician and medical school faculty.

Combined residencies among community hospitals

This is a report of a decade of experience I have had with attempts at coordination of educational programs in a group of community hospitals. It has been imperative to maintain a state of flexibility since the approach has been one of studied trial and error. There have been some significant results. Jacksonville (Fla) Hospitals Educational Program (JHEP) was founded in 1958. The charge in its charter is to "coordinate the training of interns and residents among several member hospitals." The real reason behind the founding of this nonprofit consortium of hospitals is rather difficult to ascertain. I suppose, basically, like most maneuvers, it was aimed at providing a more attractive lure for that most precious commodity, the intern and resident. In this, as in all such efforts, if the attraction of interns and residents remains the sole purpose, then failure will be the result. If on the other hand,