Days Of Inpatient Care Research Articles

The development of psychiatric care after the mental health care reform in Sweden. A case register study

A process of deinstitutionalization and a series of mental health care reforms targeting severely mentally ill persons have taken place worldwide. The objective of this study was to follow-up the volume of psychiatric care after the 1995 Swedish reform and to study if the intended efforts of the reform were fulfilled. In a municipality, during the time-period 1994–2003, the development of number of days of inpatient care, inpatient care episodes, visits to outpatient facilities and the number of unique patients were studied using case registers. The number of persons staying in group homes and nursery homes was also studied. The number of days of inpatient care for persons given a diagnosis of schizophrenia was drastically reduced, but this reduction was quantitatively substituted by the persons staying in different kind of group homes. The implementation of new psychiatric field teams directed towards persons with psychosis and new social service field teams targeting this same group were reflected in the registers. Data supported that the intended efforts of the mental health care reform were in fact carried out, but the prioritizing of the target group of the reform may have influenced the care of persons with other kinds of psychiatric problems negatively.

Forty years of deinstitutionalization of psychiatric services in Canada: an empirical assessment.

To empirically analyze the implementation of the policy of deinstitutionalization of psychiatric services over a 40-year period. We assessed the policy of deinstitutionalization in terms of the following components: 1) population-based psychiatric beds, days of care in psychiatric hospitals (PHs); 2) days of care in psychiatric units in general hospitals (GHs); and 3) per capita expenditures on psychiatric services. There was a rapid closure of beds in PHs in the 1970s and 1980s, but this was associated with an increasing rate of days of care in psychiatric units in GHs (that is, transinstitutionalization). It was not until the 1990s that the overall days of inpatient care began to decrease. Per capita expenditures on community-based psychiatric services increased throughout this period. Standardized rates reveal tremendous variation among the provinces in the timing and intensity of deinstitutionalization.

Health care utilization in dementia patients with psychiatric comorbidity.

The purpose of this research was to determine if differences in service use exist between dementia patients with and without psychiatric comorbidity. A retrospective cohort study was conducted on all Veterans Affairs (VA) beneficiaries seen at the Houston Veterans Affairs Medical Center with a VA Outpatient Clinic File diagnosis of dementia in 1997. The primary dependent measure was amount of Houston VA health service use from study entry until the end of fiscal year 1999 or until death. Of the 864 dementia patients in the identified cohort, two thirds had a comorbid psychiatric diagnosis. Examination of 2-year health service use revealed that, after adjusting for demographic and medical comorbidity differences, dementia patients with psychiatric comorbidity had increased medical and psychiatric inpatient days of care and more psychiatric outpatient visits compared with patients without psychiatric comorbidity. Further understanding of the current health service use of dementia patients with psychiatric comorbidity may help to establish a framework for considering change in the current system of care. A coordinated system of care with interdisciplinary teamwork may provide both cost-effective and optimal treatment for dementia patients.

Day hospital versus admission for acute psychiatric disorders.

Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals. To assess the effects of day hospital versus inpatient care for people with acute psychiatric disorders. We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2000), MEDLINE (January 1966 to December 2000), EMBASE (1980 to December 2000), CINAHL (1982 to December 2000), PsycLIT (1966 to December 2000), and the reference lists of articles. We approached trialists to identify unpublished studies. Randomised controlled trials of day hospital versus inpatient care, for people with acute psychiatric disorders. Studies were ineligible if a majority of participants were under 18 or over 65, or had a primary diagnosis of substance abuse or organic brain disorder. Data were extracted independently by two reviewers and cross-checked. Relative risks and 95% confidence intervals (CI) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise data. Individual patient data were therefore sought so that outcomes could be reanalysed in a common format. Nine trials (involving 1568 people) met the inclusion criteria. Individual patient data were obtained for four trials (involving 594 people). Combined data suggested that, at the most pessimistic estimate, day hospital treatment was feasible for 23% (n=2268, CI 21 to 25) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in number of days in hospital between day hospital patients and controls (n=465, 3 RCTs, WMD -0.38 days/month CI -1.32 to 0.55). However, compared to controls, people randomised to day hospital care spent significantly more days in day hospital care (n=265, 3 RCTs, WMD 2.34 days/month CI 1.97 to 2.70) and significantly fewer days in inpatient care (n=265, 3 RCTs, WMD -2.75 days/month CI -3.63 to -1.87). There was no significant difference in readmission rates between day hospital patients and controls (n=667, 5 RCTs, RR 0.91 CI 0.72 to 1.15). For patients judged suitable for day hospital care, individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n=407, Chi-squared 9.66, p=0.002), but not social functioning (n=295, Chi-squared 0.006, p=0.941) amongst patients treated in the day hospital. Four of five trials found that day hospital care was cheaper than inpatient care (with cost reductions ranging from 20.9 to 36.9%). Caring for people in acute day hospitals can achieve substantial reductions in the numbers of people needing inpatient care, whilst improving patient outcome.

Predictors of rehospitalization of military veterans who abuse substances

The study reported in this article is of a systematic random sample of 600 homeless Vietnam veterans, ages 46 to 65, who abuse substances, many of whom are comorbid with psychological afflictions. All of these veterans were in a Midwestern residential program for homeless substance abusers at the time of the interview. Cox's proportional-hazards model was used to estimate the relative rate of rehospitalization (hazard function) across the follow-up interval of two years by the predictors. The ecological predictors include, but are not limited to, demographic characteristics, history of drug and psychiatric treatment, psychological afflictions, abuse before 18 years of age, inner strengths, social support, religiosity, and direct combat experience in Vietnam. The range of ecological factors investigated presents more comprehensive findings for future conceptual models and for more thorough social work intervention. Key words: comorbidity; drug abuse; ecological predictors; homeless veterans; survival analysis ********** Large numbers of homeless military veterans are being treated for substance abuse at Veterans' Affairs medical centers (VAMCs). For example, in 1996, 36 percent of the more than 250,000 discharges of Vietnam veterans nationwide were related to substance abuse (Virgo, Price, Spitznagel, & Ji, 1999). In addition, more than 25 percent of all veterans treated at VAMCs in an inpatient setting in 1996 had a substance abuse diagnosis. Forty percent had a diagnosis of comorbidity, or the coexistence of chemical abuse and other psychological problems. In 1996 one-third of the 10.9 million days of inpatient care provided by VAMCs were for veterans with substance use disorders. Veterans who suffer comorbidity have longer and more frequent hospitalizations than veterans treated in inpatient settings for other reasons (Piette, Baisden, & Moos, 1997). Comorbidity, in fact, appears to be one of the strongest predictors of rehospitalization among veterans (Dixon, McNary, & Lehman, 1997; Marshall, Jorm, Grayson, & O'Toole, 1998; Murray, Anthenelli, & Maxwell, 2000; Rosenheck & Cicchetti, 1998). At the same time, substance abuse historically has been treated in a different system than other psychological or mental health problems. Typically, these systems have had dissimilar, even contradictory, treatment orientations and approaches. Given these dissimilarities, substance abuse frequently is not properly assessed or is overlooked in mental health centers, whereas mental health problems generally are not appropriately diagnosed or treated in drug rehabilitation programs. Often, chemical abusers who suffer other psychological afflictions are shuffled between drug rehabilitation and mental health systems, using scarce resources, without receiving adequate treatment in either system to resolve their problems (Dixon et al., 1997; Nuttbrock, Rahav, Rivera, Ng-Mak, & Link, 1998; Rosenheck, & Cicchetti, 1998). Whereas integrative programs have been designed recently to treat substance abuse and a variety of psychological problems, there are still few of these programs for homeless veterans (Nuttbrock et al., 1998; Rosenheck & Cicchetti, 1998). Moreover, little information exists about what factors predict rehospitalization of homeless veterans who abuse substances (Helzer & Przybeck, 1988; Hoff, Rosenheck, Meterko, & Wilson, 1999; Murray et al., 2000; Olfson, Mechanic, Hansell, Boyer, & Walkup, 1999; Rosenheck & Cicchetti, 1998). Yet, a major assumption underlying the present study is that programs are efficacious to the extent that they target the factors that predict rehospitalization (Andrews & Bonta, 1998). Factors that predict rehospitalization can be categorized into two useful classes for intervention purposes: (1) static factors, which are not alterable by social work intervention, such as age or history of substance abuse, and (2) dynamic factors, which are amenable to social work change, such as self-esteem or depression (Andrews & Bonta). …

PID2: IMPACT OF CYTOMEGALOVIRUS (CMV)-RELATED READMISSION ON POST HEART TRANSPLANT RESOURCE USE

OBJECTIVES: The incidence and costs associated with the rehospitalization of heart transplant patients for the treatment of CMV infection have not been well documented. Two adult heart transplant centers participated in a Transplant Infection Cost Analysis program that was implemented in several centers covering different solid organ programs. METHODS: A retrospective chart review of all patients rehospitalized within two years post-transplant identified the number of such readmissions, hospital costs and charges for the CMV associated readmission, and the length of stay. Data were pooled for analysis. All dollar amounts were standardized to 1997 dollars using the Medical Care component of the Consumer Price Index. RESULTS: Between 1994 and 1996, the two hospitals performed a total of 163 heart transplants. There were a total of 34 readmissions (21%) to these hospitals associated with a CMV infection. Total direct hospital costs were $740,220 (average $21,771 and range $1,324–$349,224). Total related charges were $1,431,793 (average $42,111 and range $2,323–$698,447). Total days of inpatient care for CMV infection were 371 days (average 10.9 and range 2–95) at an average cost per day of $1,997. CONCLUSIONS: Data from two heart transplant centers demonstrate that CMV infection caused significant readmissions. Use of hospital resources to treat CMV infection one to two years post-transplant was substantial. Total cost of CMV was not captured: readmission to other hospitals, outpatient costs, physician costs, mortality and lost productivity should be included for a complete assessment of the economic burden of CMV infection.

Children of Parapartum Mentally Ill Mothers: A Follow-Up Study

A 2-year cohort of children (n = 75) of hospitalised first-episode parapartum mentally ill mothers in the mid-1970s in Stockholm were studied. The children were followed up during the school-age period from 1982 through 1992, and they were studied with regard to health development, academic achievement and family situation. Comparisons were made with matched controls. Data were collected from hospital case notes, the local tax authorities and school reports. No significant differences were found between the index children and the controls regarding the number of inpatient care episodes or days of inpatient care during the follow-up period. Nor was any significant difference found between the index and the control children regarding academic achievement as measured by the mean of all marks. Four index children and 2 controls were studying in schools for the mentally retarded. Seventy-four percent of the children of the patients were living with their mother, compared to 95% of the controls (p < 0.001). In conclusion, the children of mentally ill mothers in this longitudinal study did as well as the controls. The reason might be the social support provided by society (when needed) for these high-risk families in Sweden.

Can Encouraging Substance Abuse Patients to Participate in Self‐Help Groups Reduce Demand for Health Care? A Quasi‐Experimental Study

Twelve-step-oriented inpatient treatment programs emphasize 12-step treatment approaches and the importance of ongoing attendance at 12-step self-help groups more than do cognitive-behavioral (CB) inpatient treatment programs. This study evaluated whether this difference in therapeutic approach leads patients who are treated in 12-step programs to rely less on professionally provided services and more on self-help groups after discharge, thereby reducing long-term health care costs. A prospective, quasi-experimental comparison of 12-step-based (N = 5) and cognitive-behavioral (n = 5) inpatient treatment programs was conducted. These treatments were compared on the degree to which their patients participated in self-help groups, used outpatient and inpatient mental health services, and experienced positive outcomes (e.g., abstinence) in the year following discharge. Using a larger sample from an ongoing research project, 887 male substance-dependent patients from each type of treatment program were matched on pre-intake health care costs (N = 1774). At baseline and 1-year follow-up, patients' involvement in self-help groups (e.g., Alcoholics Anonymous), utilization and costs of mental health services, and clinical outcomes were assessed. Compared with patients treated in CB programs, patients treated in 12-step programs had significantly greater involvement in self-help groups at follow-up. In contrast, patients treated in CB programs averaged almost twice as many outpatient continuing care visits after discharge (22.5 visits) as patients treated in 12-step treatment programs (13.1 visits), and also received significantly more days of inpatient care (17.0 days in CB versus 10.5 in 12-step), resulting in 64% higher annual costs in CB programs ($4729/patient, p < 0.001). Psychiatric and substance abuse outcomes were comparable across treatments, except that 12-step patients had higher rates of abstinence at follow-up (45.7% versus 36.2% for patients from CB programs, p < 0.001). Professional treatment programs that emphasize self-help approaches increase their patients' reliance on cost-free self-help groups and thereby lower subsequent health care costs. Such programs therefore represent a cost-effective approach to promoting recovery from substance abuse.

The experience of patients with rheumatoid arthritis admitted to hospital.

To describe the experiences of patients with rheumatoid arthritis (RA) when admitted to hospital. A selected sample of 9 women with RA of at least 3 years duration, who had experienced at least 5 days of inpatient care within the previous 2 years, underwent unstructured interviews in this qualitative, phenomenological study. Information from the interviews was analyzed using Colaizzi's 6 procedural steps. Five major themes emerged from the study: uncertainty during the first admission to hospital; the process of becoming an experienced patient on subsequent admissions; the evident experience and knowledge of staff; the effect, both positive and negative, of other patients; and the loss of privacy. These findings throw important new light on the experience of patients with RA receiving inpatient rheumatologic care and have the potential to significantly advance nursing practice within rheumatology.

Convalescent phase outpatient parenteral antiinfective therapy for children with complicated appendicitis.

Children with a perforated or gangrenous appendix become clinically stable after medical and/or surgical therapy but often remain in the hospital solely to complete parenteral antibiotic therapy. This prospective study investigates the outcomes when children who meet specified criteria are discharged to complete parenteral antibiotic therapy at home. Children age 1 to 17 years with appendicitis complicated by generalized peritonitis or intraabdominal abscess were eligible to participate. Subjects whose fever was decreasing, who were able to tolerate oral liquids and for whom further parenteral antibiotic therapy was deemed necessary were discharged from the hospital to receive outpatient parenteral antiinfective therapy (OPAT) with meropenem. Therapy was administered by a family member and supervised by home care nurses. Study personnel visited the home daily to collect data on adverse events, compliance and resource utilization. Pa tients served as their own controls in models of reduced hospitalization and net cost savings. Discharged on average on the fourth postoperative day, 87 children received 4.5 +/- 2.1 days of OPAT. Six (7%) children were subsequently readmitted for complications including bowel obstruction (4 children), intraabdominal abscess (1 child) and pleural effusion (1 child). Another child developed a viral syndrome during OPAT. All other patients recovered uneventfully. Six (7%) children discontinued meropenem prematurely because of rash (4 patients) or diarrhea (2 patients). According to models in which each day of OPAT replaced a day of inpatient care, discharge to OPAT reduced hospitalization by 42 +/- 15% and saved a median of $2908 (10th to 90th percentile range, $1,077 to $4,707) per patient. Convalescent phase OPAT is a cost-effective alternative to continued hospitalization for children with complicated appendicitis who are clinically stable yet require further parenteral antibiotic therapy.

Quality indicators for dementia in vulnerable community-dwelling and hospitalized elders.

Dementia is a leading cause of disability among older adult patients. Appropriate attention to early identification, the assessment of medications and health conditions that may be contributing to ...

Effects of health care cost-containment programs on patterns of care and readmissions among children and adolescents.

This study examined the effects of a utilization management program on patterns of medical care among children and adolescents. From 1989 through 1993, the program conducted 8568 reviews of pediatric patients, ranging in age from birth to 18 years. The program used preadmission and concurrent review procedures to review and certify patients' need for care. This study used multivariate analyses to assess changes in the number of days of inpatient care approved by the program and to determine whether limitations imposed on length of stay affected the risk of 60-day readmission. Concurrent review reduced the number of requested days of inpatient care by 3.2 days per patient. Low-birthweight infants and adolescent patients with depression or alcohol or drug dependence accounted for a disproportionate share of the reduction. Patients classified as admitted for medical or mental health care and whose stay was restricted by concurrent review were more likely (P < .05) to be readmitted within 60 days after discharge. By limiting care through its review procedures, the utilization management program decreased inpatient resource consumption but also increased the risk of readmission for some patients. Continued investigation should be conducted of the effects of cost-containment programs on the quality of care given to children and adolescents, especially in the area of mental health.

Impact of HIV/AIDS on the national economy of India

Background information: Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is a major public health problem in India. In general, it affects mainly young people who are at their most productive part of life. Despite initial fears that AIDS will be disastrous for the economy, recent experience and estimations have shown that there is a need for reappraisal of its economic impact on society. Research question: From the viewpoint of the society of India, what is the total cost and equivalent annual cost of HIV infections for the period 1986–1995 (10 years) in India? Methods: Type of analysis: Cost-descriptive based on predictive modelling cohort analysis using human capital approach. A discount rate of 5% was used. The cost of HIV infections include (i) loss of productivity among HIV patients due to sickness and death, (ii) productivity loss due to caregivers of AIDS patients, and (iii) cost of management of AIDS patients. To estimate the loss of productivity due to premature death attributable to AIDS, a life table approach using two cohorts, one with and one without HIV/AIDS infection at assumed rates was used. The demographic data of 1991 census were used. The difference in the person-years lived in the two scenarios gave the person-years lost due to HIV/AIDS. This was calculated separately for rural and urban areas. To convert this to monetary terms, national per capita income for 1992–93 of Rs. 5529 was used. The data on the days of inpatient care and the cost of management of AIDS patients were based on currently available data and ‘expert opinion’. We analysed, using three different sets of assumptions for determination, the low, medium and high estimates of the impact of HIV/AIDS in India. Some of the costs were not included in the present analysis: (i) use of antiviral AZT, (ii) cost of retraining of new workforce, (iii) cost of strengthening of health care system, (iv) cost of research and development, (v) cost of communication activities, (vi) cost of prevention of vertical transmission, and (vii) the intangible cost of pain and suffering to the patients and their families. Results: The total cumulative number of HIV-infected persons in India until 1995 was estimated to be 1.5 million (low estimate), 2.5 million (medium estimate) and 4.5 million (high estimate). The estimated total annual cost (in billion Rupees) of HIV/AIDS in India under low, medium and high assumptions was 6.73, 20.16 and 59.19, respectively. Cost of treatment of AIDS and loss in productivity were the two major components of the cost. Conclusions: The estimated annual cost of HIV/AIDS appears to be about 1% of the GDP of India if based on high assumptions. However, as mentioned earlier, all costs of HIV have not been taken into account. Its significance has to be assessed in the context of annual growth of GDP (3.5%) and cost of other major diseases in India.

Medical cost for disability: a longitudinal observation of national health insurance beneficiaries in Japan.

To measure the impact of disability on the use of medical care and its costs. A 1-year prospective cohort study of National Health Insurance beneficiaries in a rural Japanese community. Their physical function was examined by the Medical Outcomes Study questionnaire at the end of 1994; medical care and its costs were then monitored for 1 year. Participants were the 49,364 subjects, aged 40 to 79 years, who were beneficiaries of National Health Insurance and lived in the catchment area of Ohsaki Public Health Center, Miyagi, Japan. The subjects were mainly farmers, self-employed persons, housewives, or pensioners. Medical care utilization (number of outpatient visits and days of inpatient care) and the costs for each subject were obtained from National Health Insurance Claim History files. These measurements were collected from January to December 1995, and the relationship between physical functioning levels and medical costs was analyzed. The medical costs per capita increased with poorer physical function. Medical costs among those with limitations in performing self-care increased by 4 times in men and 3 times in women compared with those with no functional limitation. In this cohort, the 4.3% of the subjects who were dependent in self-care used 15% of the total inpatient days and 10% of the total medical costs. Treatment of patients with disability requires a huge amount of medical resources. There is an urgent need for cost-effective intervention programs for disability prevention, which could be offset against the cost for treating the disabled.

The use of specialist palliative care services by patients with human immunodeficiency virus-related illness in the Yorkshire Deanery of the northern and Yorkshire region.

To examine the use of palliative care services by patients affected by human immunodeficiency virus (HIV) in hospices which do not specialize in the care of HIV patients, a tape-recorded, semistructured interview was carried out in 12 hospices in the UK. The interview explored concerns about such provision, as well as actual issues encountered. The study revealed that all 12 hospices accepted referrals for people affected by HIV and had clear working practices on infection control. between 1990 and 1996, 48 individuals affected by HIV had contact with the hospices. The number of referrals was not related to the size of the hospice. Thirty-nine individuals had a total of 655 days of inpatient care (range 1-35 days); mean length of stay 12.7 days. Twenty-four (62%) died during their first admission. Referrals came from disparate sources and this affected the amount and type of specialist HIV support available to the hospice. The paucity of referrals raised concerns in most of the units as to how to maintain skills. Issues about maintaining confidentiality of diagnosis in a multiprofessional team, and after death were highlighted. All units expressed concerns about the impact on fundraising of HIV-related admissions. Overall it was felt that the hospice units were failing to meet the palliative care needs of the majority of people affected by HIV or acquired immunodeficiency syndrome (AIDS) in the region. Possible reasons for this are given.

A prospective cohort study on National Health Insurance beneficiaries in Ohsaki, Miyagi Prefecture, Japan: study design, profiles of the subjects and medical cost during the first year.

To examine the impact of health-related lifestyle upon medical care utilization and its costs, we conducted a cohort study among all National Health Insurance beneficiaries aged from 40 to 79 years living in the catchment area of Ohsaki Public Health Center, Miyagi, Japan. The baseline survey, using self-completed questionnaire regarding health-related lifestyle, was conducted between October and December 1994. Out of 54,996 eligible subjects, 52,029 (94.6%) responded and formed the cohort under study. Medical care utilization (number of outpatient visits and days of inpatient care) and the costs for each subject have been obtained from National Health Insurance Claim History files since January 1995. The baseline characteristics of health-related lifestyle and medical history at the study subjects were consistent with those at our another cohort subjects (so-called Miyagi cohort study; N = 47,605), which included all the residents aged from 40 to 64 years at 14 municipalities in Miyagi Prefecture, Japan conducted in 1990. The medical costs per capita in this cohort was quite compatible with the national average. This prospective cohort study would quantitatively demonstrate the economic impact of health-related lifestyle, thus would lead us to better provision of cost-effective preventive health services.

Abdominal Adhesiolysis: Inpatient Care and Expenditures in the United States in 1994

Background: Adhesion formation represents a major complication after lower abdominal operations. It is postulated that a shift in surgical practice in recent years toward the use of less invasive techniques, such as laparoscopy, may be associated with a reduction in the incidence of intraperitoneal adhesions and in the rate of adhesiolysis procedures. Using an attributable-risk methodology, this cost-of-illness study was designed to estimate the hospitalization rate and expenditures for adhesiolysis in the United States in 1994 and to examine changes in attributable expenditures since 1988. Study Design: A national hospital discharge data base was used to identify all abdominal adhesion procedures performed in the United States in 1994. Total hospitalization expenditures were based on Medicare payment rates for adhesiolysis hospitalizations and physician services, which were applied to the total number of inpatient days attributed to adhesiolysis. The results were compared with published rates and expenditures attributed to adhesiolysis in 1988. Results: Adhesiolysis was responsible for 303,836 hospitalizations during 1994, primarily for procedures on the digestive and female reproductive systems. These procedures accounted for 846,415 days of inpatient care and $1.3 billion in hospitalization and surgeon expenditures. Conclusions: Although the adhesiolysis hospitalization rate has remained constant since 1988, inpatient expenditures have decreased by nearly 10% because of a 15% decrease in the average length of stay. The increased use of laparoscopy during this 6-year period does not appear to be associated with a concomitant reduction in the adhesiolysis hospitalization rate, suggesting that the causes of adhesion formation warrant further research.

Hospital restructuring and the epidemiology of hospital utilization: recent experience in Ontario.

The author highlights changes in hospital utilization that have occurred in association with restructuring of Ontario hospitals. The basic features of the epidemiology of hospital utilization described link the analysis of the organizational and structural components of hospitals with a more comprehensive evaluation of the impacts of their restructuring and have implications for international comparative studies. Data from the Canadian Institute for Health Information and the Canadian census were analyzed to provide a population-based description of hospital utilization and care. These hospital data provided information on changes in the patterns of care that occurred during restructuring, based on hospital separations for the fiscal years 1991-1992 through 1995-1996. Analysis of hospital utilization patterns revealed a 30% decrease in the days of care provided per 1,000 population during the period, the result of declines in both the age-adjusted inpatient separation rates and average length of hospital stay. The shift of surgical treatment to outpatient settings contributed to the reduction in inpatient days of care. The decline in utilization was experienced unevenly across age groups, with the elderly experiencing less of the decline than did younger age groups. Individuals living in the poorest areas used more inpatient care than did those living in the richest areas, although the gap in utilization narrowed over the period. International comparisons of the epidemiology of hospital utilization and the impact of hospital restructuring will require the use of multiple data sources and the development of shared evaluative frameworks. Health data systems in Canada support the assessment of the broader impacts of hospital restructuring and offer a framework for developing research projects that can provide useful information on these important changes in health-care policy.

Hospice inpatient care: an overview of NHO's 1995 inpatient survey results.

Hospice inpatient care is currently provided through a variety of arrangements, including freestanding facilities, dedicated units, and contracted beds, but lack of standard definitions of the various types of arrangements has led to confusion about the number and type of facilities actually in operation. This study identified a total of 97 freestanding facilities and dedicated hospice units with a total of 1,165 beds. Fifty-six percent were freestanding facilities; the balance were units located within other facilities, primarily hospitals. Forty-six percent of the units provided mainly acute hospice care, 17% provided mainly residential care, and the balance mixed acute and residential care. Seventy-seven of these facilities were operational in 1994, and these were classified into five facility types. Length of stay for the acute level of care averaged 9.7 days with a median of 6.8 days for the 36 reporting facilities. Length of stay for residential care averaged 33.2 days with a median of 30 days for the 22 reporting facilities. Bed size, total inpatient days of care, average daily census, occupancy rate, and charges are also reported by facility type.

Subfascial Endoscopic Perforator Vein Surgery: A Preliminary Report

Although the open Linton subfascial perforator vein interruption operation succeeded, for the most part, in preventing recurrent venous ulceration, it was associated with morbidity and prolonged hospitalization. We have attempted to obtain the beneficial effects of perforator interruption by the less invasive procedure of subfascial endoscopic perforator vein surgery using laparoscopic instrumentation and limited or no hospitalization. A total of 31 consecutive operations were performed in 30 patients. Sixteen women and 14 men were entered into the study, and all of them had severe chronic venous insufficiency with either open or healed ulcers. Operations were carried out without gas insufflation, in 17 without a hemostatic tourniquet, and in 13 entirely on an outpatient basis. The 18 hospitalizations produced a total of 49 days of inpatient care (mean 2.72 days). One to six perforating veins were encountered in these operations, and veins identified as perforators were electrocoagulated or clipped and sectioned. Sixteen limbs had severe chronic venous insufficiency or healed ulcers, and 15 had open ulcers. In 13 limbs, ulcers were intermittently present for 1 to 5 years. Seven of these healed within 4 weeks of operation and four others within 8 weeks. Two healed more than 8 weeks after surgery. In two limbs with ulcers that were present for 1 to 6 months, healing took place within 4 weeks of the operation in both. Complications included atelectasis in one patient, cellulitis requiring antibiotic therapy in three, wound hematomas not requiring intervention in two, and wound seroma not requiring therapy in one. This preliminary experience suggests that perforator vein interruption can be accomplished using existing instrumentation and a variety of technical modifications to achieve the objectives of the Linton operation without the attendant morbidity. Videoscopic instrumentation obtains benefits of subfascial perforator vein interruption without morbidity of the open operations. This preliminary study suggests that the operative procedure is attended by minimum morbidity without the need for rehospitalization. Long-term observation will be required to assess the procedure definitively, but the short-term objectives can be safely accomplished with minimum use of inpatient facilities.